Call for major change to 'honour' Cawston Park patients who died
- Credit: The Bailey Family/Ben King's Family/Archant
Major changes in how people with learning disabilities are cared for must be made to "honour" three patients who died in a Norfolk private hospital, say campaigners.
The scathing report into the deaths of the young people at Cawston Park hospital made shocking reading, with patients overmedicated, excessively restrained and ill-treated, with concerns raised by families ignored.
Ben King, 32, Nicholas Briant, 33, and Joanna Bailey, 36, died within just over two years of each other while they were patients at the hospital, near Aylsham.
Ms Bailey, from Romford, died at Cawston Park in April 2018.
She had been sectioned there since 2016. She had learning disabilities and health conditions, including epilepsy and sleep apnoea.
But the jury found CPR was not administered prior to emergency services arriving, there were inconsistent observations, staff had not been ensuring she used a machine which would have helped with sleep apnoea and her care plan was not accessible to staff.
Ben King, from Aylsham, who had Down's syndrome and learning disabilities, died at the Norfolk and Norwich University Hospital in July 2019.
Norfolk coroner Jacqueline Lake concluded Mr King “died due to inadequate weight management and failure to diagnose obesity hypoventilation syndrome and inadequate consideration of the use of promethazine".
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The inquest jury also found that there was a “failure to diagnose obesity hypoventilation syndrome and inadequate consideration of the use of promethazine”, as well as a “failure to identify the seriousness of a life-threatening situation."
His mother Gina Egmore had pleaded, the day before his death, for an ambulance to be called, but it was not.
Nicholas Briant, from London, referred to as 'Jon' in the serious case review, died on October 31, 2019, after swallowing a piece of plastic cup.
He had learning disabilities and a known history of consuming objects. An inquest ruled his death was misadventure
How thousands was spent - with little oversight
Thousands of pounds was being spent each day on the care of those patients, but the serious case review into their deaths was unable to establish how much of the money Jeesal Group was receiving was actually spent on service provision.
Margaret Flynn, the independent author of the report, said it was "astonishing" there was no oversight of how that money was spent.
She said: "Joanna's parents and Ben's mother talked about the thousands that was spent on their care. Joanna's parents thought it was a thousand pounds a day on her care.
"And yet there is no oversight of how that money is spent, which is astonishing when we are so concerned about the funding of our public services."
Dr Flynn called on the government to end the country's reliance on hospitals driven by profit, and warned: "Unless this hospital and similar units cease to receive public money, such lethal outcomes will persist."
What would be the alternative?
Campaigners want to see money used to give people with learning disabilities community support, delivered locally, rather than 'containment' in such units - which can be at the other end of the country from where people live.
Report author Dr Flynn said: "I would want to see individualised support, based on problem-solving with families.
"Just as Ben's mother knew exactly when Ben needed healthcare, she also knew he needed to be occupied. She knew he needed to go for long walks and loved to swim.
"That was the sort of support that he required and wanted and yet the option available to her was Cawston Park Hospital where none of those possibilities were available to him.
"We are looking, not at buildings, but at credible networks around individuals and that takes time to build. It's not going to happen tomorrow.
"We need whole system change. It's going to be long-term. It can't happen tomorrow because of the huge disinvestment in local authority provision, but it must happen.
"It would be right that we honour Joanna, Jon and Ben by ensuring that that results from these bleak events at Cawston Park Hospital."
'People should not be incarcerated because they have learning disabilities'
Emma Corlett, deputy leader of the Labour group at Norfolk County Council, said: "We need radical and rapid change and, as a first step, I agree with the recommendation that we should stop doing business with these people.
"We should not be using people who have overseen such neglect as has happened here.
"The system needs more money, but the health and social care money needs to be taken away from these private hospitals and pooled.
"It should be used for care services which support people and helps them to live independently.
"People should not be getting incarcerated because they have learning disabilities.
"And, most importantly, we need to listen to people with learning disabilities and to their families.
"These were three young people who had aspirations, family members raised concerns and nobody listened to them.
"But just listening will not be good enough - we need to act on what will be hard hitting truths which they tell us."
Ms Corlett said the care model needed to involve intensive support, but also 24/7 crisis services.
Brian Watkins, leader of the Liberal Democrat group at the county council, said: “This must never happen again in Norfolk. The people of Norfolk deserve a robust, well functioning social care system throughout the county that provides the level of services that our loved ones deserve.
"While we accept the recommendations for the national and legal changes that the review sets out, the review has shown widespread failings across the whole NHS and social care system in Norfolk and Norfolk County Council must take a leading role to ensure that the correct lessons are being learnt and applied.”
Jerome Mayhew, Conservative MP for Broadland, who said he was "shocked" at the contents of the serious case review, has organised a meeting with the Norfolk and Waveney Clinical Commissioning Group.
He wants to discuss its response and understand the changes which have been made already - and what more will be done.
Mr Mayhew said: "I don’t want this to be a 'lessons must be learned' type response followed up by little effective change.
"One of the worst aspects that filters through the report is the sense of powerlessness of the families, who could see that need was desperate and acute, yet were simply ignored."
Mr Mayhew said he has also spoken to Norfolk police and made a request for the force and the Crown Prosecution Service to review the evidence around potential prosecution.
Dan Scorer, head of policy and public affairs at learning disability charity Mencap, said: “Ultimately, the only way to stop this scandal is by developing the right support in the community to prevent people from being admitted to these institutions in the first place.
"And that starts with properly funding early intervention and support services in the community, not funnelling more taxpayers’ money into these hospitals.”
Will change happen?
Thirteen recommendations have been made in the report, including that commissioners must do more to scrutinise the services they pay for and that the law over how private companies providing services for adults with learning disabilities and autism are managed and run should be reviewed.
Joan Maughan, who commissioned the report for the Norfolk Safeguarding Adults’ Board, said it had been sent to health secretary Sajid Javid.
She said a meeting with the Department for Health and Social Care had been organised for September 21, while the report has also gone to the Health and Social Care Select Committee, chaired by former health secretary Jeremy Hunt.
However, Dr Flynn acknowledged many of the recommendations from the Winterbourne View inquiry, which she led a decade ago, had not come to pass.
That review uncovered serious abuse of patients which led to the imprisonment of six people and called for fundamental changes in how the care of vulnerable adults be commissioned.
Following that, the government promised to get everyone inappropriately placed in hospitals out.
But the deadline passed. Further targets were also missed and more than 2,000 people remain in inpatient units.
Dr Flynn said there were similarities between Winterbourne View and Cawston Park.
She said: "A great deal of money was put into a transforming programme and yet, here were are 10 years later and we find commissioners are still purchasing places for adults with learning disabilities and autism in these services because there is so little local provision available.
"Until there is a rebalancing of funding and local authorities have the means to provide prevention services, crisis support and counselling... then we will continue to see these places used."
The Jeesal Akman Care Corporation said the care the three received was "far below the standards we would have expected" and apologised that the families had been let down.
The hospital closed in May this year and the owners have said they will never run a hospital again.
The Care Quality Commission and Norfolk and Waveney Clinical Commissioning Group have said they are improving their checks and processes.
The deaths at Cawston Park hospital means it has been added to a shameful list of scandals surrounding such units.
Dr Flynn, who authored the independent report commissioned by Norfolk Safeguarding Adults Board, also led the investigation into Winterbourne View Hospital, near Bristol, a decade ago.
That probe followed shocking footage broadcast by BBC's Panorama, which showed patients at the care home near Bristol being restrained, held down and slapped.
Promises to transfer more than 3,000 patients out of such assessment and treatment units by July 2014 were not met –with more than 2,000 people still in these services.
And in 2019, undercover BBC filming at a hospital for patients with learning disabilities showed staff mocking, intimidating and restraining patients.
Whorlton Hall in County Durham closed afterwards, with a serious case review highlighting a "toxic culture" among some staff, along with failings by watchdog the Care Quality Commission.