Cawston Park Hospital: Norfolk Safeguarding Adults Board Review — House of Commons, 2021-09-21
Topic: Health
Jerome Patrick Burke Mayhew (Conservative, Centre-right): We are here this evening because of Joanna, Jon and Ben. Joanna had autism and was epileptic, Jon was autistic too, and Ben had Down’s syndrome. Their learning disabilities led to mental health difficulties, and they were consequently sectioned under the Mental Health Act 1983 and sent to the private Jeesal Cawston Park Hospital in my constituency. It is an assessment and treatment unit, and assessment and treatment is exactly what was meant to happen to these people: they were meant to be assessed and then treated, the objective being their discharge back into community care. But that did not happen Joanna was kept in the hospital for 11 months before she died in April 2018. Jon was kept in the hospital for 24 months before he died in October 2019. Ben was kept in the hospital for 17 months before he, too, died, in July 2020. All of them were in their early 30s, and all of them suffered from neglect. They were neglected through uncontrolled weight gain, through a lack of meaningful physical or mental activities, and through a lack of effective treatment through continuous positive airway pressure—CPAP—machines, which help people to sleep at night. The staff neglected the raising of concerns by members of their families; and, worst of all, they neglected even to attempt to resuscitate them when resuscitation was desperately needed Joanna was found unresponsive in her bed. A nurse and five carers—all of them trained—attended, but not a single one attempted resuscitation. Joanna died. Jon had swallowed a piece of a plastic cup. He told staff: "I cannot breathe. I am dying." The CCTV footage proves that the staff just stood there for several minutes without attempting resuscitation. He died The day before Ben died, it was obvious that he was extremely unwell. He had blue lips and blue nails because of a lack of saturated oxygen in his blood. His mother was there on a visit and she raised the alarm. She demanded that an ambulance be called, but the hospital refused. Even later that day when Ben’s oxygen saturation levels were measured and found to be 35%, no ambulance was called. He died. The hospital neglected the families, and neglected to use their expertise and experience The families describe indifferent, harmful hospital practices, excessive use of restraint and seclusion by unqualified staff, and overmedication. A mother has contacted me in the past week to describe her child’s matted hair, her uncut fingernails and toenails, and the soiled clothing piled in a corner of the room. By chance, CCTV footage reviewed after Ben’s death uncovered a casual physical assault on him by a carer on the day he died. He was pulled down by his arms and then slapped around the head. What have we not seen This was supposed to be a specialist assessment and treatment unit, yet records were not even kept by the hospital for prolonged periods. Joanna was at the hospital for 11 months, but there are no records for 179 days of those 11 months. Ben was there for 17 months, but for an amazing 450 days during that 17-month period, no records were kept. So what assessment was undertaken? What treatment was given? My first request of the Minister is this: we need to acknowledge the scale of this scandal and its impact on real people, the most vulnerable in our society. We also need to acknowledge that we should all be ashamed This is not unique. We have heard this before. It sounds familiar, and that is because exactly the same thing happened at Winterbourne View Hospital back in 2012. We have had the report. This was another assessment and treatment unit where people with learning disabilities or autism were abused. The 2012 report criticised the development of assessment and treatment units, saying that they were "not part of current policy, and certainly not recommended practice…Containment rather than personalised care and support has too easily become the pattern in these institutions." Of course lessons were learned. Department of Health reports described the abuse of people at Winterbourne View Hospital as "horrifying". A Department of Health programme of action was agreed, and I have it with me today. Following the statement: "We the undersigned commit to a programme for change", the very first undertaking is that "Health and Care Commissioners will review all current hospital placements and support everyone inappropriately placed in hospital to move to community-based support as quickly as possible and no later than 1 June 2014." That did not happen. Today, in 2021, more than 2,000 patients are still contained in assessment and treatment units. I use the word advisedly: they are "contained" This is my second request to the Minister. Will she, on behalf of the Government, recommit this evening to the needed closure of all assessment and treatment units? That is what the coalition Government committed to doing in 2012, but by 2014 it had still not been done. We need to do it now. Why do we need to do it? There is a monumental conflict of interest for these private hospitals. Beyond being merely inhumane, there is a huge commercial incentive to maintain residency, because each of these patients comes with a fat cheque of £26,000 per month We can see where the conflict lies and why one family member, when they went to Cawston Park Hospital, was handed a piece of paper on which was written the address of a firm of solicitors. Her statement said: "Once people are in Cawston Park Hospital you can’t get them out." Patients did not leave Cawston Park Hospital, and the problem is structural. If a hospital is paid £26,000 a month to assess and treat a patient, is it surprising that the hospital does not release them We have had another review of this latest scandal, and the Norfolk Safeguarding Adults Board’s review of Cawston Park Hospital is excellent. I have read it. It is 105 pages long and there are 13 recommendations. I recommend it wholeheartedly to the Minister, and the Government should apply all the recommendations The report has been followed by the usual handwringing responses from the agencies. Action plans have been created and there have been multidisciplinary stakeholder reviews. Profound apologies have been given, and I believe they are profound apologies. Lessons have been learned, but in my submission they have not really been learned, because without a profound culture change in residential care, we will be back here again. We all know it and the public know it.