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Cawston Park Hospital: Norfolk Safeguarding Adults Board Review

Volume 701: debated on Tuesday 21 September 2021

Motion made, and Question proposed, That this House do now adjourn.—(Mr Marcus Jones.)

We are here this evening because of Joanna, Jon and Ben. Joanna had autism and was epileptic, Jon was autistic too, and Ben had Down’s syndrome. Their learning disabilities led to mental health difficulties, and they were consequently sectioned under the Mental Health Act 1983 and sent to the private Jeesal Cawston Park Hospital in my constituency. It is an assessment and treatment unit, and assessment and treatment is exactly what was meant to happen to these people: they were meant to be assessed and then treated, the objective being their discharge back into community care. But that did not happen.

Joanna was kept in the hospital for 11 months before she died in April 2018. Jon was kept in the hospital for 24 months before he died in October 2019. Ben was kept in the hospital for 17 months before he, too, died, in July 2020. All of them were in their early 30s, and all of them suffered from neglect. They were neglected through uncontrolled weight gain, through a lack of meaningful physical or mental activities, and through a lack of effective treatment through continuous positive airway pressure—CPAP—machines, which help people to sleep at night. The staff neglected the raising of concerns by members of their families; and, worst of all, they neglected even to attempt to resuscitate them when resuscitation was desperately needed.

Joanna was found unresponsive in her bed. A nurse and five carers—all of them trained—attended, but not a single one attempted resuscitation. Joanna died. Jon had swallowed a piece of a plastic cup. He told staff:

“I cannot breathe. I am dying.”

The CCTV footage proves that the staff just stood there for several minutes without attempting resuscitation. He died.

The day before Ben died, it was obvious that he was extremely unwell. He had blue lips and blue nails because of a lack of saturated oxygen in his blood. His mother was there on a visit and she raised the alarm. She demanded that an ambulance be called, but the hospital refused. Even later that day when Ben’s oxygen saturation levels were measured and found to be 35%, no ambulance was called. He died. The hospital neglected the families, and neglected to use their expertise and experience.

The families describe indifferent, harmful hospital practices, excessive use of restraint and seclusion by unqualified staff, and overmedication. A mother has contacted me in the past week to describe her child’s matted hair, her uncut fingernails and toenails, and the soiled clothing piled in a corner of the room. By chance, CCTV footage reviewed after Ben’s death uncovered a casual physical assault on him by a carer on the day he died. He was pulled down by his arms and then slapped around the head. What have we not seen?

This was supposed to be a specialist assessment and treatment unit, yet records were not even kept by the hospital for prolonged periods. Joanna was at the hospital for 11 months, but there are no records for 179 days of those 11 months. Ben was there for 17 months, but for an amazing 450 days during that 17-month period, no records were kept. So what assessment was undertaken? What treatment was given? My first request of the Minister is this: we need to acknowledge the scale of this scandal and its impact on real people, the most vulnerable in our society. We also need to acknowledge that we should all be ashamed.

This is not unique. We have heard this before. It sounds familiar, and that is because exactly the same thing happened at Winterbourne View Hospital back in 2012. We have had the report. This was another assessment and treatment unit where people with learning disabilities or autism were abused. The 2012 report criticised the development of assessment and treatment units, saying that they were

“not part of current policy, and certainly not recommended practice…Containment rather than personalised care and support has too easily become the pattern in these institutions.”

Of course lessons were learned. Department of Health reports described the abuse of people at Winterbourne View Hospital as “horrifying”. A Department of Health programme of action was agreed, and I have it with me today. Following the statement:

“We the undersigned commit to a programme for change”,

the very first undertaking is that

“Health and Care Commissioners will review all current hospital placements and support everyone inappropriately placed in hospital to move to community-based support as quickly as possible and no later than 1 June 2014.”

That did not happen. Today, in 2021, more than 2,000 patients are still contained in assessment and treatment units. I use the word advisedly: they are “contained”.

This is my second request to the Minister. Will she, on behalf of the Government, recommit this evening to the needed closure of all assessment and treatment units? That is what the coalition Government committed to doing in 2012, but by 2014 it had still not been done. We need to do it now. Why do we need to do it? There is a monumental conflict of interest for these private hospitals. Beyond being merely inhumane, there is a huge commercial incentive to maintain residency, because each of these patients comes with a fat cheque of £26,000 per month.

We can see where the conflict lies and why one family member, when they went to Cawston Park Hospital, was handed a piece of paper on which was written the address of a firm of solicitors. Her statement said:

“Once people are in Cawston Park Hospital you can’t get them out.”

Patients did not leave Cawston Park Hospital, and the problem is structural. If a hospital is paid £26,000 a month to assess and treat a patient, is it surprising that the hospital does not release them?

We have had another review of this latest scandal, and the Norfolk Safeguarding Adults Board’s review of Cawston Park Hospital is excellent. I have read it. It is 105 pages long and there are 13 recommendations. I recommend it wholeheartedly to the Minister, and the Government should apply all the recommendations.

The report has been followed by the usual handwringing responses from the agencies. Action plans have been created and there have been multidisciplinary stakeholder reviews. Profound apologies have been given, and I believe they are profound apologies. Lessons have been learned, but in my submission they have not really been learned, because without a profound culture change in residential care, we will be back here again. We all know it and the public know it.

I am grateful to my hon. Friend for securing this debate on the tragic events in Norfolk and for the powerful case he is making.

One of the most alarming elements of this very shocking report is the final hours of Ben, which my hon. Friend mentioned. Ben’s mum, Gina, said:

“If you ill-treat an animal, you get put in prison. But people ill-treated my son and they’re still free.”

That is completely unacceptable, and the police and the authorities should look again at all the leads and all the evidence to hold those people to account.

My hon. Friend is absolutely right that management teams and owners should personally fear prison as a response to a culture failure. If a culture of neglect is tolerated by their acts or, more likely, by their omissions, there needs to be personal liability. People need to fear prison, because there will be no change without individuals being held personally to account for allowing this culture of indifference. I profoundly hope that the most rigorous investigations are undertaken by the police and the Care Quality Commission, with a focus on individual prosecutions if justified by the evidence. There have been no prosecutions to date.

More generally, and widening the conversation away from the individual, directors need to be held to account if we are to restore public trust in the system. The Law Commission is aware of this, and it is undertaking a consultation on the issue of corporate criminal liability. It is consulting on how we can make improvements primarily, in the first instance, in economic crime, but how much more important is it to get equity where the victims are the most vulnerable in society, people in care, people who cannot argue their own case because of their age, because of illness or because of their condition?

The current rules on the definition of a controlling mind are often too narrow for individual prosecutions to succeed. The legislation has been on the statute book since about 2007, and there have been hardly any successful prosecutions because of that narrow definition. This needs to be changed.

I am meeting the Law Commission in October, along with the authors of the Safeguarding Adults Board review, to press the case for a widening of the definition to make the people who run such hospitals fear personal prosecution, because that is how we will change the culture.

That leads me to my third request of the Minister. If she really wants to prevent a repeat, will her Department commit to making a submission to the Law Commission consultation on criminal corporate liability so that we strengthen the personal responsibility for providers of residential care? The Chinese general Sun Tzu, who is very famous now, said “Kill one, terrify 1,000”, and he was right. The problem is that families of patients are concerned; they are the ones who are fearful and have no confidence in the current system. They fear the consequences and we need to change that; it should be the directors of care businesses. If they allow abuse and neglect, they should be fearful—they should pay with the fear of a prison sentence. Only then will we get change.

I thank my hon. Friend the Member for Broadland (Jerome Mayhew) for securing this debate on this deeply disturbing, upsetting and important topic, and for his continued work on exposing the failings at Cawston Park.

I would like to begin by expressing my sympathy for the families, friends and loved ones of Joanna, “Jon”, as he is referred to in reporting, and Ben. These are three people whose lives were cut short tragically and needlessly. The accounts of their experiences at Cawston Park Hospital, a place that should have been there to care for and support them, are heartbreaking. I can only imagine how distressing it would have been for their families and loved ones to read about the events leading up to their deaths. I send the families of Ben, Jon and Joanna my deep condolences, and I would like to invite them to meet me so that I can understand their experiences directly—I would be happy for my hon. Friend to join me in those meetings.

I would also like to thank those who have shared their experiences of the services and support at Cawston Park, and the Norfolk Safeguarding Adults Board for under-taking the review and preparing the final report. That is essential for shining a light on what has happened. I know that my officials are in dialogue with the board to identify how recommendations can be progressed as impactfully and as quickly as possible. I believe they met today.

The appalling care and practice uncovered at Cawston Park is completely unacceptable. Every person with a learning disability, and every autistic person who needs it, must receive safe and high-quality care, and they must be treated with dignity and respect. Both my hon. Friend and I have dearly loved family members who have Down’s syndrome and know many people with autism, and we are horrified to think that vulnerable people who put such trust in others for support would be treated in such an appalling way.

I recognise and acknowledge the frustration and strength of feeling about the issues raised today. The Department is working with the NHS, local government and the Care Quality Commission to ensure that we identify unacceptable care with urgency and take robust action immediately. I can confirm that Cawston Park closed in May, following action taken by the CQC, and all of the people who were in-patients at Cawston Park have moved either to a supported community setting or to an alternative hospital setting, where immediate discharge was not possible.

I appreciate that everyone listening will want assurance that anyone with a learning disability and any autistic person in one of those hospitals—any one of the 2,000 people he mentioned—is safe. NHS England’s reviews of each individual person’s care arrangements will ensure that there is a clear care plan in place with a clear path to discharge. Such treatment where there were no clear paths to discharge must not happen again.

More broadly, I welcome this opportunity to set out the work that is under way to eliminate poor-quality in-patient settings and properly invest in the community alternatives that people with a learning disability and people with autism deserve.

As the regulator for mental health hospitals, the CQC has a central role in identifying any cases of poor in- patient care and taking immediate action. The Department fully endorses the increased scrutiny by the CQC and its improved inspection approach, which includes spending more time with patients and their families to identify settings that are at risk of developing a closed culture. In particular, the CQC takes more account of what families have to say. The enhanced processes have revealed cases in which quality falls below the standards we expect. Where that is the case, robust regulatory action is being taken. We must not tolerate poor care and treatment, and any provider that cannot meet standards should be tackled immediately, including through closures.

In the report, families describe the excessive use of restraint and seclusion by unqualified staff. Any kind of restrictive practice or restraint should only ever be used as a last resort. The Department is taking action to increase the transparency and reporting of the use of restrictive practices, in response to the recommendations made by the CQC in its review of the use of restraint, seclusion and segregation. Increased transparency is a central aim of the Mental Health Units (Use of Force) Act 2018 statutory guidance, on which we have recently consulted. Work is now under way to commence the Act from November 2021.

As part our longer-term plans to limit the unnecessary detention of people with a learning disability and autistic people, we are seeking to implement once-in-a-generation reforms to the Mental Health Act. Under our proposed reforms, we will limit the scope to detain people with a learning disability or autism for treatment if there is no diagnosed mental health cause for distressed behaviour. To support that, the proposed reforms will create new duties for commissioners to ensure an adequate supply of community services and that every local area understands and monitors the risk of crisis at an individual level. For those who continue to require in-patient care, we are clear that this should be for the shortest time possible, as close to home as possible and the least restrictive possible.

Alongside the longer-term plans to improve in-patient care and support, the situations outlined in the review of Cawston Park highlight the need for urgent action in quicker time. That will require cross-system, cross-Government action in a number of priority areas that have historically presented blockages to progress. The Government are taking action specifically to target such blockages, ranging from identifying best practice models in the community to ensuring that the right workforce with the right training is in place.

In closing, I thank Members for their contributions on this important topic and their commitment to ensuring that people with a learning disability and autistic people receive the high-quality care and support that they deserve. The CQC’s robust inspections are helping us to identify and prevent cases of unacceptable care, such as that of Cawston Park. It is our priority—and my personal priority—to reduce reliance on in-patient care. I have set out today the range of work that is under way not only to reduce in-patient numbers but to drive real change in the care that is available to people with learning disabilities and autistic people, to enable them to live fulfilling lives in the community, as we all want. All our actions will be shaped by the Norfolk Safeguarding Adults Board review report, to ensure that the experiences of Ben, Jon and Joanna are not repeated.

Question put and agreed to.

House adjourned.