Friday, 7 December 2012

Positive Behaviour Support – Thoughts In The Light of Winterbourne View SCR

There is no doubt that the lives of Winterbourne View Hospital patients were undercut by terrible treatment which resulted in them feeling blamed and abandoned and being physically harmed. It appears that an excessive emphasis on people’s labels and perplexing behaviour has taken us too far from making sense of their biographies and the complexity of their lives – and from the basics of caring about them and attending closely to their needs and caring for them with capability, respect and compassion.

The Serious Case Review relied on a BBC broadcast of May 2011, information from the hospital’s ex-patients and their relatives and information from a range of agencies, including Castlebeck Ltd, which owned Winterbourne View Hospital. These thoughts rely solely on what we have learned about the circumstances of adults with learning disabilities and autism who have been placed in hospital settings offering “assessment and treatment.” We believe that the practice of physical restraint at Winterbourne View Hospital is a bracing indictment of inadequate management (remote and long distance) and inattentive commissioning.

We suggest that five sets of observations clear a path to viewing the circumstances of adults with learning disabilities and autism in secure settings. We believe that they point to the necessity of developing very different service responses. We begin with a single tragedy:

1. During July 2006, Derek Lovegrove died as he was being restrained. He was a blind and deaf patient with learning disabilities at Cedar Vale Hospital. The Deputy Coroner observed that “…the system was there, the policy, the care plan – but no one seemed to check that it was followed.” Cedar Vale Hospital was owned by Castlebeck Ltd. After the Inquest they stated, “We will take time to fully consider the proceedings of this past week to ensure that any lessons which must be learnt are learnt and acted upon.” Five years before the exposure of the violence associated with restraint at Winterbourne View Hospital, Castlebeck Ltd could have led the way and distanced themselves, and perhaps other services, from the practices associated with Derek Lovegrove’s death. However, during 2009, Castlebeck still had not learned the lessons. A Heathcare Commission visit found shortcomings in Cedar Vale Hospital’s management of serious incidents and patient restraint. The sequel to the BBC Panorama’s expose of May 2011 was broadcast in October 2012. This gave coverage to a recording of a Castlebeck Ltd employee training Winterbourne View Hospital staff in methods of physical restraint. He recalled an occasion when instead of restraining a patient, he “kicked him in the bollocks.” The programme advised that this trainer had been “suspended some weeks ago.” Thus the “learning the lessons” claim apparently did not impact on either the training or practice of harmful means of physically restraining adults with learning disabilities and autism. Heartlessness and amnesia appear to go hand in hand.

2. All policies concerning physical restraint emphasise that it should be the “last resort response.” Castlebeck Ltd’s own policy concerning physical restraint was no exception and yet it bore no resemblance to the practice filmed by an undercover journalist. It was the first line response. We came across no examples of physical restraint being the intervention of last resort. The practice of wrestling patients to the floor and lying across them occurred on a daily and routine basis and yet was not identified as constituting abuse by any professional. Chance determined that there were no tragedies at Winterbourne View Hospital given the filmed evidence of restraint practices and those promoted by Castlebeck Ltd’s own trainer. Records attested to the excessive and harmful use of restraints which involved wrestling adults with learning disabilities and autism to the floor and immobilising them with bodies and objects. These incurred physical pain and injuries, some of which required the attentions of Accident and Emergency services. Even patients who were naked or partially clothed were physically restrained on the floor by staff. It does not appear that exceptions were made for patients whose early lives had been compromised by sexual assaults. Neither was any attention paid to patients’ care plans. As an NHS commissioner observed, “…it is…documented that a mask was used on two occasions. This approach is not written in care plans as being agreed to.”

3. Restraints as practiced at Winterbourne View were pre-emptive. Staff physically overwhelmed patients using whatever means they wanted. Patients were ill-served by their imprecise label of “challenging behaviour.” Staff responded to patients as if self defence was their principal priority.

4. The volume of physical restraints which wrestled patients to the floor and held them there – sometimes for many hours – were under-reported by hospital staff and described in records in fictional terms. Inadequate as these records were, no one took any notice of them. Oblique references to patients “having an unsettled day” and “re-directing patients” were euphemisms for unknown numbers of staff pinning patients onto the floor.

5. It appears that adults with learning disabilities and autism who are patients in hospitals, assessment and treatment and secure services are outwith the protection of legislation. During 2009, it was with some prescience that a Public Protection Unit investigator urged Winterbourne View Hospital to install CCTV cameras. The investigator noted that in view of two incidents, “in which two service users had their teeth knocked out by carers during a restraint situation, both patients appear to have been punched in the face…restraint is usually carried out by two or more people so any allegation of improper or criminal conduct is countered by two people’s word against the victim – the victim always unlikely to make a good witness in a criminal prosecution…no doubt something your staff are aware of…” After the initial Panorama broadcast, staff emphatically denied all allegations made by Winterbourne View Hospital patients which were not captured on film – and even those which were filmed were described by the staff concerned as “horse play…play-fighting…sparring…boxing games…playing.” Accordingly, the Crown Prosecution Service relied solely on film footage provided by the BBC. The Serious Case Review confirmed that Winterbourne View Hospital patients lacked any means of asserting or protecting their rights. They were scandalously silenced.

These findings buttress our concern that adults with learning disabilities and autism have been disproportionately disadvantaged in secure service settings where they may be subject to violence on an unknown scale. Winterbourne View Hospital has taught us about the arbitrariness of cruelty under the guise of restraint and the lamentable lack of interest of all professionals, most particularly Castlebeck Ltd and the commissioners of this service, in ensuring that patients were protected and safe. Such stark findings led us to conclude that there is no place for the practice of getting adults with learning disabilities onto the ground and pinning them there. This form of restraint, as imposed on adults with learning disabilities and autism, in these settings, should not be countenanced.

Margaret Flynn and Vic Citarella

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