Margaret Flynn - South Gloucestershire Safeguarding Adults Board, 2012

After the transmission of the BBC Panorama Undercover Care: the Abuse Exposed in May 2011, which showed unmanaged Winterbourne View Hospital staff mistreating and assaulting adults with learning disabilities and autism, South Gloucestershire's Adult Safeguarding Board commissioned this Serious Case Review. The Review is based on information provided by Castlebeck Care (Teeside) Ltd, the NHS South of England, NHS South Gloucestershire PCT (Commissioning), South Gloucestershire Council Adult Safeguarding, Avon and Somerset Constabulary and the Care Quality Commission; correspondence with agency managers; contact with some former patients and their relatives; and discussions with a Serious Case Review Panel ‐ which was made up of representatives from the NHS, South Gloucestershire Council, Avon and Somerset Constabulary and the Care Quality Commission.

As part of the Serious Case Review, the Care Quality Commission undertook an internal management review into their regulation of Winterbourne View.