Analysis: Tragedies which unfolded in plain sight
- Credit: Mike Page
The serious case review into the deaths of Cawston Park patients Joanna Bailey, Ben King and Nicholas Briant makes difficult reading.
These were three young people, with learning disabilities, who died on the watch of a care company which was taking thousands of pounds a week to look after them.
Norfolk and Waveney Clinical Commissioning Group was paying Cawston Park hospital, run by the Jeesal Group £26,000 a month to look after 32-year-old Mr King, from Aylsham.
Mr King, who had Down's Syndrome and a learning disability had been sectioned in the private hospital for two years, even though he did not have a mental illness.
Two psychiatrists determined treatment was necessary for Ben’s health and safety or for the protection of others and that appropriate medical treatment was available at the hospital.
When he died, following a cardiac arrest, his weight had increased from 15 stone at admission to just over 18 stone.
The serious case review criticised how there was no structure around people's daily and weekly activities, which meant obese patients were allowed to be "incredibly inactive".
The circumstances of Ben's death, a day after his mother Gina Egmore pleaded for staff to call an ambulance for him, are being investigated by police.
There is no doubt that all three patients were a challenge for staff to deal with.
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But as Margaret Flynn, who authored the serious case review, says, that behaviour could have been indicative of protest against the regime they were incarcerated under.
A regime which took money to look after those patients, but in the words of the report, overmedicated, used excessive restraint, kept 'unaccountably inadequate' records and showed no curiosity in what people's lives were like before they arrived at Cawston Park.
Staff were unskilled and staffing levels inadequate. While there will have been staff who genuinely cared and tried their best to help - the report is unflinching in its criticism of how the hospital was governed.
It is also critical of those who should have ensured the care was appropriate and that the money being used was reflected in the treatment being given.
As far back as 2013, concerns had been raised. The Care Quality Commission was involved, Norfolk County Council was involved and those who commissioned services were aware of issues.
Indeed, they all tried to bring about improvements. Yet, despite issues being in plain sight, three patients died. This was a failing on many levels.
The big issue now is whether their deaths will make a difference. Recommendations have been made.
But recommendations were made after the appalling treatment of patients at Winterbourne View.
Yet 2,000 people are still in units which the government said it would remove them from. There's a long way to go before we can feel confident tragedies like this won't happen again.