Anatomy of failure

“The service shortcomings in this report are almost identical to those that are widely understood and accepted as having led to the Winterbourne View failures.

“There is no reason to believe that Winterbourne View, and the circumstances that surrounded it, were any different to those around any other private assessment and treatment hospital.

“Staffordshire and Stoke on Trent are making significant use of such facilities — use demanded primarily by the inability of local services to support people in appropriate local housing and with NHS back-up and support.

“Unless these shortcomings are addressed, people who challenge and have complex needs will continue to be sent out of area and/or the local health and social care system and the risk of a repetition of abuse — this time involving people from Staffordshire and Stoke on Trent — will continue.”

This was the conclusion of an independent report, written in 2012, on specialist learning disability services in Staffordshire. Other warnings included: a lack of joint working across the system; a “worrying” lack of clarity over responsibility for patients; and a lack of appropriately skilled services.

However, it is a conclusion which sounds depressingly similar to more recent reports on the Transforming Care programme — which is aimed at improving services for people with autism and learning disabilities — across most areas of the country.

The warning to services in Staffordshire eight years ago was stark — improve, or risk putting vulnerable patients with learning disabilities in harm’s way.

Sadly, the experiences of one man from Staffordshire, called Clive Treacy, who died in an out of area private sector unit in 2017, epitomise the failures that were warned about five years earlier.

Ongoing battle

His sister Elaine Treacy told HSJ about years of battling against systemic failures in his care.

Mr Treacy suffered from complex epilepsy, had a learning disability and mental health needs, and a long history of institutional care.

From 2007 to 2012, he was under the care of South Staffordshire and Shropshire Foundation Trust. Ms Treacy described one period between 2007 and 2009 when in-fights by social care and NHS commissioners over funding led to the breakdown of her brother’s community care placement.

In 2010, following a stint in a unit run by Castlebeck Care (owners of Winterbourne View), Mr Treacy was placed back into South Staffordshire and Shropshire FT.

However, the NHS trust was not able to offer care appropriate to his needs and so commissioners needed to seek a provider elsewhere.

St Andrew’s Healthcare acquiesced to commissioner’s requests in March 2012.

Subsequently, Mr Treacy’s family said a nurse at SSSFT raised safeguarding concerns over his care at St Andrew’s, of which they were not informed at the time. These centred around staff’s ability to meet his epilepsy needs and its use of seclusion.

Emails from the time showed further concerns over his care were raised and formally acknowledged by commissioners in 2014.

However, it was only in 2016, following a care and treatment review led by the local Transforming Care programme, that the concerns were escalated.

This was the same year Mr Treacy was told by programme staff that he had been selected as a priority and would be able to return home.

The promise sadly never came to fruition. In January 2017, he died following a seizure in an inpatient unit run by the Danshell Group (the former provider of Whorlton Hall in the north east).

Minutes from commissioning meetings in 2016-17 revealed commissioners were struggling to find providers who would enable him to come back to Staffordshire.

“One of the most horrific things was that Transforming Care came and directly informed Clive that his life was going to change, he was coming home and would not be allowed to be kept in a hospital setting ever again. We always knew that was going to be an ongoing battle,” Ms Treacy said.

She also described how both providers and commissioners refused to listen to the family’s concerns throughout his years in care.

Two years after his death, the family continue to fight for answers. It was only last week, following questions posed by HSJ, that NHS England agreed to review his care under its national LeDer programme.

Looking back at that 2012 report, it said: “There are a number of people that specialist health services in both north and south (Staffs) have been unable to support and, as a result are now in expensive out of county or in county private sector provision, but with little known about the quality of their lives or service in those place.”

Questions should clearly be asked as to why, five years down the line, local services were still struggling to bring home this vulnerable man.

Indeed why, five years after Transforming Care was launched, are there still 2,185 people with learning disabilities and autism in inpatient units with new admissions occurring every month?

Mental Health Matters is written by HSJ’s mental health correspondent Rebecca Thomas. Tell her what you think, or suggest issues she could cover, by emailing her in confidence at rebecca.thomas@wilmingtonhealthcare.com or by sending a direct message on Twitter.