I attended a press conference this morning for the release of a Safeguarding Adults Review commissioned by Norfolk Safeguarding Adults Board into the death of three “patients” at Jeesal Cawston Park “Hospital”. I’ve intentionally put patients and hospital in scare quotes, because it’s a term that really shouldn’t be used in my opinion. Personally I’d think the terms prisoners and incarceration warehouses would be factually more accurate.

The press conference was addressed by Joan Maughan, former Chair of the Norfolk Safeguarding Adults Board who commissioned the report, and Margaret Flynn, the report author. I wish to acknowledge at the start how transparent Norfolk SAB appear to have been to this matter. They have named the individuals concerned by their actual names, none of this faux anonymity against family choice. They held a public press conference and spent almost an hour answering questions. They have also published the review in full, not just the summary on their website here. This is noteworthy because it’s exceptional.

I’ve tried to summarise below some of what we learned.

Joan started by introducing Joanna. I had the opportunity of speaking with Joanna’s father Keith, after her inquest concluded. This is what he told me, it’s longer so goes into a bit more detail. We heard how Joanna was kind and loving, from talking with her parents I know she was spirited and determined. She loved music, Michael Jackson and was fond of a disco and karaoke.

Joanna was in Cawston Park for 17mths before she died, aged 36

We know very little about “Jon”. The review could not gather the perspective of his family so it relied solely on records. They described ‘Jon’ as:

“a complex patient with complex needs. His capacity, dignity, wishes and feelings were difficult for commissioners to ascertain”

Can you imagine being described like that? Jon was incarcerated into Cawston Park, in a placement commissioned by NHS England. Except page 101 of the 105 page report includes this footnote:

How is this possible? A Safeguarding Adults Review commissioned in April 2019. Merton CCG wash their hands of “Jon” in February 2020, informing the review team it was NHS England who commissioned the placement, and then a couple weeks ago, after the report was finalised and publication was imminent NHS England inform the Board that they did not commission this placement.

What hope is there for people when they’re passed from pillar to post in death, as well as in life? How can there be any hope of meaningful care coordination or scrutiny, if commissioners are still arguing, just short of three years after he died, about who even commissioned his care?

Jon was incarcerated in Cawston Park for 11 months before he died, aged 33.

Back to the press conference, Joan read from a statement shared by Ben King’s mother Gina, it was heart breaking. She described Ben as a:

“quick witted, bright boy who loved his dogs and chickens and wearing his designer clothes”

He lived with his mum for 30yrs before she was diagnosed with cancer in 2017. Ben was put into a respite placement why she received treatment, he was upset and thought she’d die and smashed the place up. He was sectioned and moved to Cawston Park, despite not having a mental illness.

Ben was warehoused in Cawston Park for 24mths before he died, aged 32.

Joan described how the Safeguarding Adults Board received referrals “already received through the layered process of safeguarding in the local authority” she described how the Board’s duty was to “ensure collaboration between main organisations to protect people from harm”. In March 2019 they received a referral relating to Joanna, a month later they received a referral for Jon.

“Set up some very disturbing factors… events surrounding his death indicated real concerns about facilities being provided at Cawston Park”

She described how they:

“Naturally did a bit more information gathering and were disturbed to find the concerns around Cawston Park were not new. They’d been around from 2013 and in fact Cawston Park had been placed under special measures in Nov 2019. We moved swiftly to agree that a SAR was required and immediately started gathering chronological information from all those organisations involved in Joanna or Jon’s care. We also sought to commission an independent review writer and we sought to commission Margaret Flynn because of her wide ranging and extensive experience of this type of facility and services provided to very complex people with learning disabilities and/or autism”

She described how the Norfolk Safeguarding Adults Board is made up of:

“23 people representing all sorts of organisation in community that have interest and responsibility for safeguarding… It was received with shock and real dismay. Norfolk Safeguarding Adult Board members reviewed the report and these tragic deaths with genuine heartfelt sympathy for families who have lost loved ones”.

She continued:

“That’s not enough, unless there is real change. This is not the first tragedy of its kind and it wont be the last unless real change is secured”

When Margaret Flynn had an opportunity to make opening comments, she focused on the similarities to Winterbourne View.

“Its 10 years since I wrote the review at Winterbourne View Hospital and I want to highlight some of the similarities of conditions that prevailed at Winterbourne View with Cawston Park.

Families really struggled to manage their daughters and sons as they became older and prevention services and support in community diminished. They’ve lived through the impacts of sustained austerity”

She described how families were handed two options, carry on without any support or hand over total responsibility for their loved one. She acknowledged the “very low threshold for using the Mental Health Act” and how “people with a learning disability and/or autism continue to be subject to protracted periods of detention under that act”.

She made reference to how health commissioners “hunted for places” searching for vacancies, not making decisions based on any track record of the service, or any notion of service quality. The report states that Joanna, Jon and Ben all ended up in Cawston Park due to personal and family crises:

“It was the only placement which could be identified by Joanna’s CCG which had previously made contact with 38 other services”.

The lack of detail around funding was also highlighted, however it was not a feature of the review. The three individuals all had their care fully funded by the NHS, but it was not known how much of the weekly fees Jeesal received for their care were actually spent on service provision for individuals. Later in response to a question Margaret Flynn responded:

“I have to be optimistic because it was after Winterbourne View that Private Eye brought their forensic accountants to look at where funding went… what the fee structure was and it was clear how little impact it had on day to day lives”.

I guess that’s fair comment but are we really relying on journalists to hold the State and the social care sector to account on this?

Flynn also highlighted other similarities to Winterbourne View. The inappropriate use of sedatives, restraint and seclusion. Poor quality and failures to conduct observations. Physical health care needs not addressed. Families actively discouraged from visiting, and few allowed access to the places where their loved ones were sleeping. She recalled how families described staff displayed:

“A hurtful lack of interest in the biographies of their relatives”.

It was also highlighted how families had pleaded with staff to provide care to their loved ones. In this BBC piece y can hear Keith Bailey, Joanna’s Dad describe how they felt sure she was going to have a seizure and they begged staff to take care of her.

Margaret Flynn described how “Jon was desperate for purpose. He wanted an ordinary life like most of us aspire to”. The report states:

Jon had aspirations. He made it clear that he did not want to be at the Hospital, he wanted to be near to his family and to live in a bungalow with a computer room. He sought purpose.

Flynn shared how in the months before he died, Jon made good luck cards for staff and residents to sign as he left the hospital, he talked about the food he’d like at party celebrating his leaving. The report discusses this:

After seven months at the Hospital Jon announced that he was leaving. Subsequently, he packed his bags and told staff that he was looking forward to moving closer to his mother. He made cards for peers and staff to sign wishing him good luck. During the month before his death Jon was pleased at the prospect of leaving the Hospital and moving into the community. It was noted that he had “limited understanding as to the timetable of this event.” The credibility of Jon’s belief is not revealed in the records. He planned his leaving party and discussed party food.

Despite Jon’s hopes and dreams to leave, Flynn noted this morning “no one was working towards any date for that man’s discharge”.

Elsewhere in the report it is clearly stated:

All that may be reliably gathered from Jon’s records is that setting a discharge date is a meaningless activity if no attention is given to planning for this; specialist hospitals which are remote from people’s families have unchallenged scope to retain patients; and there are no consequences if Clinical Commissioning Groups responsible for placements are not represented at critical review meetings.

Margaret Flynn described how Cawston Park actively discouraged relationships between people and their families. The review says this about Ben:

Ben wanted to return home to his mother. He became tearful when speaking to her on the phone and at the end of her visits. A month after his admission, the Hospital acknowledged that “a lot of Ben’s distress is driven by his want to be with mum and people he knows…keeping Ben separate from his mum is perpetuating his behavioural distress.” However, it formulated this as “attachment problems…issues”.

Their solution was to limit Ben’s contact with his Mum, in person and on the phone. His care plan included:

“an “appropriate relationship with mother” as an “outcome and success measure.” The rationale is not stated”.

Ben’s mother saw him the day before he died, her statement remembers what she saw:

I went to visit and was told Ben was really unwell. His SATS were 35, which is incredibly low. I urged them to call for an ambulance. They brought him out of a side door and he was slumped and held up by two staff.

He was gasping and couldn’t talk. His hands and lips were blue. He was rocking back and forth. It turned out the GP was called out the previous night and they didn’t call me.

He pleaded with me to take him home. I wish I had put him in the car then. I drove off. That was the last time I saw Ben alive.

The following day, the doctor rang to say Ben was unwell and in the Norfolk and Norwich Hospital. By the time I’d got there, he was brain dead.

I had to turn my baby’s machines off. That was the hardest thing I’ve ever had to do in my life. Ben was my reason to live.

I later saw the CCTV from the night before. It showed staff mistreating him and leaving him to die. This has got to stop. There are other homes like this. This mustn’t happen to anyone else.

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

Margaret Flynn shared how in his final hours Ben was:

“Deprived of elementary decencies of compassion. CCTV images shared with his inquest demonstrate Ben was subject to very rough handling and he was slapped. Those were his final moments”.

It is to my mind frightening that ten years on from Winterbourne View this report could have almost identical conclusions. None of the promised changes from the scores of organisations who fell over themselves to get their logos on the Winterbourne View Concordat have resulted in the promised reduction of reliance on inpatient services. Look at them all….

Chris Hatton routinely updates us on the over reliance, still, on inpatient facilities. The date for change came and went, and there still as many people incarcerated as before, in fact it’s worse because the rate of new admissions has not slowed at all.

Margaret Flynn is mindful of this:

“Whats required is a long term solution, guided by a progressive agenda, shaped most particularly by people with learning disabilities and autism and their families. It’s necessary too that assessment and treatment of the variety so horribly familiar, is excluded from this altogether… in the interim I have suggested some recommendations”.

We’ve been here before, the calls for whole system change, a requirement to focus on human rights. The assurance that this can’t be fixed overnight… but how many more years, how many more deaths are required to actually address this?

I asked the following question at the press conference:

Joan has described how the Norfolk Safeguarding Adults Board were “disturbed to find the concerns around Cawston Park were not new and had been around from 2013” and that members of the Board received the review with “shock and real dismay”.

What are Norfolk SAB going to do to ensure that they have better oversight of ‘care’ provided locally, by the organisations that their Board members represent? How confident are they that others aren’t currently at risk locally? Why did they not know that Cawston Park was in special measures?

Joan’s response didn’t fill me with confidence, much as it was honest:

“Concerns were dealt with within layers of safeguarding provision that exist within all local authorities and clinical commissioning groups. It’s the CCG and NHS England that commission these services, for Ben within Norfolk, for Jon and Joanna from London boroughs.

The reality is that the Board has no particularly authority or powers in terms of regulation with services, it has the ability to investigate as it has done through this review when circumstances arise that meet conditions of the Care Act.

Its a really important point about what the Safeguarding Adults Board can do in relation to having oversight of care. We call people to account… the action plan will be published alongside the report with details of actions taken thus far.

Include number of purposeful actions at a local and national level. Each of the organisations involved will produce their own action plans. Response from NHSE will be published.

How confident are we that others aren’t currently at risk? As confident as we can be by constant checks with our colleagues in the local authority and CCG. Peopll have been moved from Cawston Park Hospital when it closed.

In main for all patients from Norfolk those arrangements have been found within Norfolk. I believe one person may be in a facility in Suffolk. We did know that Cawston Park was in special measures as we started to gather our information”.

From my perspective there is far too much reliance on the system, the same system that funds people being held captive, providing checks and balances of quality – even though report after report after report shows that people are not safe, that learning disabled people are dying premature and preventable deaths.

A local journalist from the Eastern Daily Press asked the former Chair of the Safeguarding Board whether she felt the Care Quality Commission should have acted more rapidly to take away the hospital’s registration. She responded:

“Yes, I think the answer to the question is the CQC should have acted more rapidly. I will add that Norfolk put in place a partnership between safeguarding professionals, in the local authority and in the CCG, that did a huge amount of work to try and help Cawston Park address the issues CQC had raised in their first special measures notice and beyond… there’s credit to be had for that. It doesn’t excuse the managers and directors of Cawston Park, and senior clinicians from largely disregarding all those efforts”

Martin Halle from the Sunday Mirror asked “Do you think as the local safeguarding authority that Norfolk Social Services were negligent in its oversight of Cawston Park?”

Joan’s response was revealing of the inertia and apathy within the system, and how impossible it is to hold anyone to account. She said:

“Norfolk Social Services was not the commissioner of services at Cawston Park… it did have some responsibilities as I said earlier for partnership work around safeguarding across the piece… it could well be argued the number of referrals coming in was high over the last three years, would have indicated some real problems.. I think there was a covid impact on some of that, the eyes and feet weren’t on ground in quite the same way as had been, but there were no easements of safeguarding responsibilities due to covid. Help was put in.

Social services was not in a position, it had no authority to act alone in terms of Cawston Park. It couldn’t affect major change at Cawston Park, that was the responsibility of the Care Quality Commission”

I followed up on this asking the following, what turned out to be final, question:

Do Joan and Margaret feel that the efforts of safeguarding professionals in the local authority and clinical commissioning group to work with Cawston Park while admirable (and required to keep individuals safe), was perhaps misled? Or at least should as much effort be put into developing local community supports so these places can stop being used?

Again the response was one to suggest the local bodies were hamstrung, because they could not close down Cawston Park:

I would find it hard to say the efforts to try and support Cawston Park, given we couldn’t close it, nobody had the authority to do that except the Care Quality Commission… efforts were admirable because they put in a layer of expertise that ensured at least there were some eyes and efforts and work going on that would safeguard people until such times as the CQC made decisions with regards to its future

So I think that was not time wasted in that sense, it clearly didn’t produce the results in terms of re-rating of Cawston Park and if anyone was to ask am I sorry Cawston Park is gone? No, the answer is I’m not sorry and certainly the board is not sorry and none of my colleagues are sorry.

Effort to develop community responses would be significantly different and greater, many of those efforts are going on now, they’ve not ceased because of this. In order to develop the right bespoke services for group with very complex needs takes time and commitment and that is being worked on.

Margaret Flynn’s response was as follows:

Yes George we know that current provision across all agencies has failed to deter or prevent these tragedies.

The Safeguarding Board has very few powers. It can investigate, it can inquire rather, it can make enquiries but in fact this is whole system and safeguarding is one very small part of the whole system.

We do want all levels of the system held to account, including those exporting people to other parts of the country who subsequently do not recall they’re there. I take the view too many patients in ATUs are administrative orphans… very limited contact with commissioning authorities or with their families because of the distance to travel… in turn units do not treat them or uphold their human rights.

We can, and should, do better than this in 2021.

I completely agree, I just have little evidence that we are likely to.

At 4pm this afternoon Merton CCG one possible placing authority for Jon, now the South West London CCG had no announcement or response on their website. Norfolk and Waveney CCG, the placing authority for Ben, had no announcement or response on their website. Newham CCG the placing authority for Joanna, had no announcement or response on their website. Instead their latest news item was bragging about winning a HSJ award, you couldn’t make it up.

As for NHS England, the great and the good, the overseer of all. How did they respond? No announcement or response on their website about the horrific failures at Cawston Park or the premature deaths of Joanna, Jon and Ben. No, they had an announcement that they’d appointed another new National Director of Learning Disability and Autism.

One thing is for sure since Winterbourne View there hasn’t been a slow down in individuals claiming salaries to apparently ‘fix’ the failings in the system. There’s still as much bureaucracy as ever, and still as many people dying premature and preventable deaths.

We should all be ashamed of ourselves.