Poor management and sustained failings in procedures were at the root of the abuse at Winterbourne View Hospital, the serious case review into the scandal has revealed today.

The review, led by Margaret Flynn, chair of Lancashire County Council’s Safeguarding Adult’s Board and published by South Gloucestershire Council’s Safeguarding Adults Board, also found that other organisations could have done more to prevent abuse, saying that “procedures fell short in commissioning patient care, and in reviewing and safeguarding the wellbeing of patients before and during their stay at Winterbourne View Hospital”.

The Serious Case Review has called for greater investment in local community based care (as championed by Mencap and the Learning Disability Foundation in their new report Out of Sight) to reduce the need for facilities such as Winterbourne View.

Other recommendations put forward in the review include:

  • Outcome-based commissioning for hospitals detaining people with learning disabilities and autism
  • The discontinuation of the ‘t-supine restraint’ technique
  • Better co-ordination and information sharing where hospital admissions and police attendances are concerned, which would lead to earlier action and identification of potential problems.

Safeguarding Adults Board chair Peter Murphy said: “This is a detailed and far-reaching report and a vital blueprint for action and debate on the care and safeguarding of vulnerable adults.

"The organisations which make up the Safeguarding Adults Board, including South Gloucestershire Council, the NHS, Avon & Somerset Police and the Care Quality Commission, deeply regret the shocking events at Winterbourne View Hospital. We fully accept the findings and recommendations of the report, and are determined to work together to ensure that events such as this never again occur in South Gloucestershire.

"We are very grateful to Margaret Flynn for her analysis, which has gone much further than a typical event-focussed enquiry. In this respect, its findings and recommendations point towards a national policy debate with far wider implications for the health and social care system."

David Behan, chief executive of the Care Quality Commission, said: “There is much for all the organisations involved with Winterbourne View to consider in Margaret Flynn’s thorough and comprehensive report. I will ensure that the Care Quality Commission responds fully to all the recommendations for CQC. We will continue to work with other organisations to improve communications and sharing of information to ensure we all protect those who are most vulnerable.”

The full report, including an easy-read version can be found here

Terry Bryan, the man who blew the whistle at Winterbourne View, spoke at the Learning the Lessons from Winterbourne View conference. You can watch his talk here.