An independent report has urged the Government and local agencies to take action to protect people with learning disabilities, after a series of failings led to the deaths of three people at Cawston Park Hospital in Norfolk.

Norfolk’s Safeguarding Adults Board (NSAB) ordered a Safeguarding Adults Review in 2019 after two people with learning disabilities, Joanna and Jon, died at the hospital. In December 2020, Ben’s case was added to the review, after he died while under the hospital's care. 

Joanna, Jon and Ben, who were all in their 30s, died between April 2018 and July 2020. They had been patients at the hospital for 11, 24 and 17 months respectively.

Cawston Park was placed into special measures by the Care Quality Commission in September 2019 and was closed by its owners, the Jeesal Group, in May this year (2021).

“Indifferent and harmful hospital practices”

While Joanna and Jon had both experienced several out-of-family home placements before being admitted to Cawston Park, Ben lived with his mother for most of his life. They were all admitted to the hospital under the Mental Health Act (1983) following personal and family crises, and were known to display ‘behaviour that challenges.’

The relatives of the three adults (and relatives of other patients at the hospital), described “indifferent and harmful hospital practices which ignored their questions and distress”.

Family members were particularly concerned with the excessive use of restraint and seclusion by unqualified staff, over-medicalisation, the unsafe grouping of patients and the lack of management and coordination of activities.

The report found that patients did not benefit from attention to the complex causes of their behaviour, to their mental distress or physical healthcare.

There was also a distinct lack of documentation during Joanna’s and Ben’s time at Cawston Park, with no information recorded for 179 days of Joanna’s stay and 450 days of Ben’s stay. There was just a single day undocumented during Jon’s stay.

Coroner's report found staff response time to be "unduly slow"

The report found that staff failed to help Jon when he said he could not breath, failed to provide treatment for Joanna's seizures and did not react to Ben’s symptoms from not using his CPAP machine.


Both Joanna and Ben were obese and used Continuous Positive Airway Pressure (CPAP) machines as a result of sleep apnoea. Joanna’s inquest heard that in the last 209 nights of her life, the CPAP had been used only 29 occasions, despite her parents and previous placements prioritising its consistent use. Neither her parents not her Consultant Neurologist, were advised that Joanna had ceased to use her CPAP.

The coroner's report gave Joanna's cause of death as sudden unexpected death in epilepsy (SUDEP), primary generalised epilepsy, obesity and obstructive sleep apnoea. Despite Joanna's care plan stating should be checked every 30 minutes, she was not checked for two hours on the night she died. The report also found that although a registered nurse and five care workers were present after she was found unresponsive, no one attempted first aid or CPR.


Similarly, there were 115 documented occasions when Ben declined to use the CPAP, yet no attempts were made to desensitise either Ben or Joanna to using their CPAPs. 

Ben died after going into cardiac arrest, after his SATS dropped to 35%. The report found that his low SATS symptoms were ignored and his mother’s insistence that an ambulance should be called had no impact.

It was also revealed in Ben’s post-mortem that he had gained nearly six stones in just two years, with a lack of physical activity found to contribute to this weight gain, as well as increasing the risk of high blood pressure, high blood cholesterol, diabetes and heart disease.

CPAP machines also require adjustments as a result of weight gain, but no adjustments were made during Jon's stay at the hospital. 


The coroner's report found that Jon died of hypoxic brain injury following a cardiac arrest, acute laryngeal obstruction, and aspiration of a plastic cup. Staff were seen on CCTV to be "standing there" and "milling around" after Jon had collapsed. The report found the response time from staff to be "unduly slow" despite Jon saying "I cannot breathe, I am dying".

The inquest heard that a staff nurse got oxygen for Jon but it took "several minutes for the defibrillator to be used in the so-called code blue emergency situation."

A need for “bespoke services matched to the individual”

The safeguarding adults report contains 13 recommendations for the Government (the Department of Health and Social Care), NHS England, the Care Quality Commission, Norfolk and Waveney Clinical Commissioning Group and Norfolk County Council’s adult social care department.

The Board concluded such hospitals should "cease to receive public money", and hope the report prompts more reviews into similar facilities, preventing further "lethal outcomes".

The author of the report, Margaret Flynn, said that the report highlights “failures of governance, commissioning, oversight, planning for individuals and professional practice” and “re-visits the findings concerning Winterbourne View Hospital 10 years ago.”

She said that Joanna, Jon and Ben’s lives were characterised by “unhealthy lifestyles of long-term under-occupation” which “were not shaped by their goals or interests”.

“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,” she added.

Dan Scorer, head of policy at Mencap, said lives will continue to be lost until the Government delivers its promise to close hospital beds and develop care in the community instead. 

"The Government, NHS, CQC and local authorities must act on the review’s recommendations. 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​," he said.


Any former residents of Cawston Park or their relatives who have concerns in the light of the report can contact Norfolk County Council’s adult social services team on 0344 800 8020.