Blog spot

The need for raising standards in care. 
23 Sept 2021

The serious case of institutional, physical, emotional and neglectful abuse at Winterbourne View was a scandal that rocked the nation in 2011. Exposed by BBC Panorama, the vulnerable people were let down by those people entrusted to care for them. The abuse exposed failings in safeguarding and found that the staff were undertrained. They were trained in little other than restrictive practises and employing physical restraint techniques, however as trainers, we know that no respectable intervention trainer would ever advocate the behaviour of the staff applying inappropriate and unnecessary force.  

These individuals should have been better protected – a review following the scandal stated: “As much as Winterbourne View fills us all with sorrow and anger, it should also fire us up to pursue real change and improvement in the future”. Lamb, (2012)

Despite the health minister at the time advocating for change, how can we measure that change has occurred, when we continue to observe instances of abuse, neglect and failures in safeguarding?

In 2019, the BBC exposed staff intimidating, mocking and excessively restraining patients with learning disabilities and autism at Whorlton Hall, County Durham. The culture was deviant with evidence of “psychological torture” (Triggle, 2019). Therefore, there is evidence to suggest limited change. These serious cases of abuse, highlight the need for effective training across the care sector to prevent the misuse and abuse of restrictive practises.

Training is required to safeguard vulnerable individuals from harm, and even death. A recent BBC news report highlighted further failings in care, the vulnerable individuals in one setting were let down, the report found:

  • “Excessive” use of restraint and seclusion by unqualified staff
  • Concerns over “unsafe grouping” of patients
  • Overmedication of patients
  • High levels of inactivity and days of “abject boredom”
  • Relatives described “indifferent and harmful hospital practices” and said their questions and “distress” were ignored (BBC News, 2021)

These are all failings that require a safe level of staff training. Chairwoman of the Norfolk Safeguarding Adults Board, said: “This is not the first tragedy of its kind and, unless things change dramatically, it will not be the last” (Joan Maughan, cited in BBC News, 2021).

Residing at this setting, Joanna Bailey had a learning disability, autism, epilepsy and sleep apnoea. The coroner’s report gave her cause of death as sudden unexpected death in epilepsy (SUDEP), primary generalised epilepsy, obesity and obstructive sleep apnoea. Ms Bailey was not checked for two hours the night she died on 28 April 2018, despite 30-minute checks being in her care plan. This is in addition to Nicholas Briant who died of a brain injury following a cardiac arrest and obstruction of his airway after swallowing a piece of plastic cup. He had told staff: “I cannot breathe. I am dying”. The scene was captured on CCTV, and the coroner said staff “did not appear to be doing anything” (BBC News 2021).

These two deaths should and could have been prevented with effective care training, supervision, and knowledge of how to administer first aid and uphold safe, caring, person-centred support.  

Serious cases continue to make for regular headlines; Jessie McKinlay, died on April 21st 2019, as a result of the serious injuries she suffered during a violent assault from another resident. Questions have to be asked about why this happened when supervision should have been maintained, risks assessments in place to manage the behaviour and staff be equipped to manage behaviours that challenge. It was reported: “The court heard Mr Whiteside, who suffered from dementia, was known to be aggressive and had attacked both residents and staff before. He was nonetheless allowed to wander around the home unsupervised, and would frequently go into other residents’ rooms”. This should not have been allowed, if effective care planning and risk assessments were being adhered to. Furthermore, the management went unchallenged by staff. One staff member told the court that the care home’s manager at the time, told staff to “stop logging complaints about Mr Whiteside’s behaviour, and that if they wrote anything about him in their digital reports, those reports would be deleted” (Holmes, 2021). This goes against safeguarding procedures and staff should have the knowledge to challenge this poor practise. Again, another example of a preventable care home death.

What has been learnt then from the Winterbourne View scandal appears to be limited. These recently reported cases above are coming to light now, but happened before the Covid-19 pandemic, what has happened and is happening inside care settings now? What is the current impact of a further crisis in care, staff shortages, limited visitors for the vulnerable people to be additional eyes to safeguard them, absent training, or at best training delivered online, staff worries and stress? This could be considered as a toxic combination that puts those vulnerable individuals at further risks of care failings. If improvements needed to be made prior to covid, what now?!?!