“Out of sight, out of mind” commissioning contributed to the abuse of patients at Winterbourne View Hospital going unchecked for more than four years, a serious case review has found.

The review found there was extensive misuse of physical restraint by nurses and support workers at the hospital for patients with learning disabilities and autism from its establishment in 2007 up until its closure by owners Castlebeck last May.  

At one point the police asked the hospital’s management to install CCTV following two incidents in which patients had teeth knocked out during incidents where they were being restrained by carers.

Author Margaret Flynn, chair of Lancashire County Council’s Safeguarding Adults Board, criticised the primary care trusts placing patients at the hospital for failing to monitor performance against the stated aim of rehabilitating patients.

In 10 of the 44 NHS-commissioned placements at the hospital no check had even been made as to whether Winterbourne View was registered to provide services.

Ms Flynn writes: “The hospital’s existence was dependent entirely on public – principally NHS – contracts; nevertheless, NHS Commissioners did not press for, or receive detailed accounts of how the average weekly fee was being spent on behalf of individual patients.

She added: “There were echoes of ‘out of sight, out of mind’ commissioning at Winterbourne View Hospital.”

Between January 2008 and May 2011, when the hospital closed, South Gloucestershire’s Safeguarding Adults Board, which commissioned the review, received 40 safeguarding alerts about patients at the hospital. However, it treated them as discrete cases and did not pass them on to commissioners.

The review also questions the appropriateness of assessment, treatment and rehabilitation units, such as Winterbourne View, describing them as an “unplanned development” in the wake of the closure of long stay units for people with learning disabilities.

Winterbourne View case ‘a watershed moment’

Concerns about the treatment of patients at the privately run hospital were highlighted by BBC’s Panorama programme last year after it was contacted by a nurse working at the hospital.

The review said the nurse, Terry Bryan, had acted properly in contacting the BBC after first trying to raise concerns with his line manager and then the Care Quality Commission but receiving no response.

The report said the CQC’s registration of Winterbourne View with no conditions in October 2010, could be viewed as “passive complicity”. It came despite outstanding concerns about patient quality of life raised by its predecessor the Healthcare Commission.

It said the “light tough, low cost” regulation practised by the CQC was not suited to “closed establishments” such as Winterbourne View.

In the conclusion to the report, Ms Flynn suggests the company should consider funding the cost of the review and “psychotherapeutic provision” for all former patients of the hospital.

In a statement Castlebeck said it was committed to learning the lessons of the review and had already made “significant changes” including strengthening clinical governance.

CQC chair Dame Jo Williams said Winterbourne View was a “watershed moment” for the regulator.

“We did not respond as we should have and we have taken steps to put things right,” she said. “Among other things, we set up a specialist team to deal with whistleblowers and systems to make sure every such contact is followed up.”