A major investigation into the deaths of three vulnerable people at a private Norfolk hospital has revealed a string of failings, while police are looking into possible prosecution against those involved.
Ben King, 32, Nicholas Briant, 33, and Joanna Bailey, 36, died within just over two years of each other while they were patients at Cawston Park Hospital, near Aylsham.
Their treatment at the hospital was so shocking that CCTV footage shows one of the dying men being struck by a member of staff.
Dereham-based owners Jeesal Group closed the hospital in May , after Care Quality Commission inspectors, who had put it into special measures', said they were "unable to demonstrate improvements."
But by then three patients were dead and now, a serious case review commissioned by Norfolk Safeguarding Adults’ Board, has found major failures of governance, commissioning, oversight, planning for individuals and professional practice.
Today, review's author called on the government to end the country's reliance on hospitals driven by profit, warning: "Unless this hospital and similar units cease to receive public money, such lethal outcomes will persist".
The review also found:
- Police have been looking at CCTV footage which shows a dying man with Down's Syndrome being struck by a member of staff.
- Staff did not attempt to resuscitate a young woman after an epileptic seizure and were "unduly slow" to respond as a man who had swallowed a piece of cup lay struggling to breathe.
- The hospital's records were "unaccountably inadequate" with no information on patients kept on hundreds of days.
- The hospital did not seek vital information about people’s lives before they moved into Cawston Park.
- There was no structure around people's daily and weekly activities, which meant obese patients were allowed to be "incredibly inactive".
- Staff were unskilled and staffing levels were inadequate – leaving patients under-protected.
- Staff did not do enough to ensure two of the patients who died used a machine to help with sleep apnoea.
- Clinical commissioning groups who placed patients in Cawston Park did not press for, or receive, detailed
accounts of how the hospital was spending the weekly fees on behalf of its patients or whether agreed levels of observations were being honoured. - Even though the hospital was not meeting its contractual
requirements in terms of the levels of supervision provided to patients, commissioners continued to place people there.
Who were the people who died?
Joanna 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.
An inquest found she died of natural causes - sudden unexpected death in epilepsy.
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.
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, but when CCTV footage following his collapse was shown at his inquest, area coroner Yvonne Blake said: "The staff are standing there. Nobody appears to be doing anything.
"There seems to be a long time before any definitive action was taken to assist him. They [the hospital staff] appeared to be milling around."
Ben King, from Aylsham, died at the Norfolk and Norwich University Hospital in July 2019 following the "failure to identify the seriousness of a life-threatening situation".
Police investigated CCTV which showed one staff member striking Mr King, who had Down's Syndrome and a severe learning disability, as he sat slumped in a chair on the day he died, having suffered cardiac arrest.
The report stated that at 6am: "A staff member 'approached (Ben) who was awake in his lounge/second bedroom' and 'rough handled him by pushing him roughly and dragging him down by his arms before hitting his head area with an open hand.' The carer '…then looked up to make sure that there was no one looking and hit (Ben) again in the head area with the back of his hand.'
Further footage shows Mr King slumped over after at about 6.30am – while a carer sits in a chair by the door. The carer then walks off.
A nurse sounded the alarm at 7.07am when she could not rouse him, which was when Mr King was taken to hospital.
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.”
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."
Their deaths have not led to any prosecutions.
A need for change
The latest report states: "The roots of private, specialist hospitals reside in business opportunism and profit-driven priorities.
"These are hospitals in which patients receive neither specialist assessment nor credible “observations” and treatment.
"The deaths of three young adults must plausibly question the “system response” - the Care Quality Commission’s continued registration of such hospitals and their continued use by clinical commissioning groups and NHS England."
The review makes 13 recommendations, including that the Law Commission should be asked to review the current legal position of private companies.
It states: "Given the clear public interest in ensuring the well-being and safety of patients, and the public sponsorship involved, the Law Commission may wish to consider whether corporate responsibility should be based on corporate conduct, in addition to that of individuals."
Another recommendation is for NHS England and the clinical commissioning groups to visit services, host reviews and question providers.
The review also calls for the Care Quality Commission to cancel registration of failing hospitals, if the reasons for them improving are down to intervention by NHS, local authority social care employees and Inspectors, rather than hospital owners.
The report states: "The relatives of the three adults, and those of other patients, described indifferent and harmful hospital practices, which ignored their questions and distress.
“They were not assisted by care management or coordination activities.
"People’s families could not value the unsafe grouping of certain patients, the excessive use of restraint and seclusion by unqualified staff, their relatives’ “overmedication,” or the hospital’s high tolerance of inactivity – all of which presented risks of further harm.
“In addition, these patients did not benefit from attention to the complex causes of their behaviour, to their mental distress or physical health care.”
Who led the review and what does she say?
The review was headed up by independent safeguarding expert Margaret Flynn, who led the review into the Winterbourne View hospital scandal in Bristol in 2011.
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.
And Ms Flynn's report into Cawston Park said little had changed since then - but that the government must now act.
She said: "Joanna, Jon and Ben all had aspirations – they wanted to be near their families, to have friends and jobs or things to do each day.
“Their lives at Cawston Park Hospital were characterised by unhealthy lifestyles of long term under-occupation and were not shaped by their goals or interests.
"The distress of their parents sets an agenda that cannot be ignored.
"To quote Ben’s mum, Gina – ‘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.'
"My report highlights failures of governance, commissioning, oversight, planning for individuals and professional practice.
"It revisits the findings concerning Winterbourne View Hospital 10 years ago."
She said the legal structures of companies responsible for such services needs to be transparent and accountable, to reveal whether and how the public interest and significant NHS investment is represented on their boards.
And she said: "A progressive and non-sectored solution from which assessment and treatment units are excluded altogether remains to be led by Westminster.”
Joan Maughan, who commissioned the report as chair 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.
"There will always be occasions when some people with learning disabilities and/or autism require specialist support for their very complex needs.
“This calls for a determined and robust commitment from all health, social care, housing and other agencies, at both a national and local level, to develop bespoke services matched to the individual - services that ensure safety, respect, care for their physical and mental health wellbeing, stimulating activities, and plans for a meaningful life in the future.”
What the company said
Jeesal Group are being contacted for comment.
The company had previously said standards of care “declined rapidly” as Covid put a strain on the hospital.
They had apologised and said one of the carers seen on the CCTV shown at Mr King's inquest had been sacked for "entirely unacceptable" action.
Chief executive Tugay Akman, previously said "apologies must first go to the families" of the patients, as well as promising lessons had been learned and vowing the company would never again run a hospital.
Mr Akman said: "The loss of these patients to their families is far greater than any pound signs a business may or may not lose. We did not start this business to not take care of people."
Reaction
Organisations which commissioned services and kept watch on them came in for criticism in the report.
Joan Maughan, who commissioned the report as chair of the safeguarding report, said she felt the Care Quality Commission could have removed the hospital's registration sooner.
Deborah Ivanova, CQC deputy chief inspector for people with a learning disability and autistic people, said:
"It is unacceptable for anyone to receive the poor care that Joanna, Jon and Ben suffered at Jeesal Cawston Park.
"Our thoughts are with their families and we welcome the findings of the safeguarding adults review.
“Our monitoring and inspections of this service identified several serious concerns. We reported these to the provider of the service so it knew where it needed improve the quality and safety of its care of people.
“Although there were elements of the service that began to improve, progress was not sustained.
“This led us to preventing it from admitting new people and taking enforcement action to close it. Following this action, the provider and commissioners worked together to promptly find alternative arrangements for people at the hospital.
“People with a learning disability and autistic people should receive specialist care for their mental and physical health, as close to home as possible and delivered by dedicated and expertly trained staff.
"Human rights must be at the forefront of how care is planned and delivered – demonstrating recognition of each person’s value, individuality and humanity every day.
“Sadly, Jeesal Cawston Park did not provide this for Joanna, Jon and Ben.
“We are improving the way we register, monitor and inspect services for people with a learning disability and autistic people. This includes developing more in-depth inspections to scrutinise services’ cultures and understand people’s experiences.”
The report also raised concerns over the level of scrutiny organisations which commissioned such services, including clinical commissioning groups, applied to the care being given.
Melanie Craig, chief executive of NHS Norfolk and Waveney Clinical Commissioning Group, said: “No one can read the report without being shocked and saddened.
"My thoughts are with Ben’s family and the families of the other patients named.
"The care these three vulnerable people received fell well below what they had a right and expectation to receive.
“For all the checks and changes we insisted Jeesal Cawston Park made and the repeated interventions from a number of organisations, the hospital did not maintain improvements and failed to provide consistently safe, high-quality care.
"Alongside Jeesal and its staff, we also had a duty of care to ensure patients were well looked after and for that I am truly sorry and apologise.
“We accept in full the report recommendations that relate to our role as commissioner, and have already made many of the changes including more detailed checks on the progress of vulnerable adults placed in care settings.”
A spokesperson for the Department for Health and Social Care said it had received the report.
They said: "We are focussed on ensuring all patients, including people with a learning disability and autistic people, receive safe and high-quality care, and that they are treated with dignity and respect."
Any former residents of Cawston Park or their relatives who have concerns in the light of the report should call Norfolk County Council's adult social services team on 0344 800 8020.
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