South Gloucestershire Council has published the serious case review into Winterbourne View, looking at the role of the various statutory agencies, as well as the provider of the former service, Castlebeck Limited.

Key recommendations include:  

  • Local adult safeguarding boards, Care Quality Commission (CQC) and all stakeholders should regard hospitals for adults with learning disabilities and autism as high risk services ie, services where patients are at risk of being subjected to abuse and restrictive practices within indefinite timeframes 
  • The DH should consider amending registration requirements to require mandatory visits by the nominated individual for the service and by the board member to whom reports about the service are sent together with public reporting
  • The authors are concerned that managers are not required to be distinct registered professionals individually accountable through a governing body and code of ethics. This is a recommendation that some have speculated may come out of the Mid Staffordshire public inquiry, the report for which is due in October
  • The CQC should ensure that inspections are carried out by sector specialists and experts by experience so that warning signs can be identified earlier 
  • The CQC and the Health Professions Council should work together to describe what effective systems of clinical supervision look like in hospitals for people with learning disabilities and autism. Again, there has been speculation that the Mid Staffordshire inquiry might recommend having a standardised approach to clinical governance 
  • Reducing the use of anti-psychotic medication with adults with learning disabilities and autism requires attention. Commissioners should ensure there are pharmacy led medicines reviews for individual patients as well as the service as a whole. The CQC should also consider using pharmacy led medication reviews in future
  • Commissioners funding placements should ensure that they have up-to-date knowledge of:
    • Adverse incidents/serious untoward incidents, including injuries to patients and staff
    • Absconding
    • Police attendances in the interests of patient safety
    • Criminal investigations
    • Safeguarding investigations
    • The occurrence of Deprivation of Liberty Safeguards applications and renewals
  • Promoting the involvement of relatives and carers and having access to, and provision of advocacy, in particular Independent Mental Capacity Advocates. In relation to informal patients, the authors stress that “adults with learning disabilities and autism, who are currently placed in assessment and treatment units, should have the full protection of the Mental Capacity Act”

This review highlights the importance of corporate accountability, scrutiny and responsiveness. It will be interesting to see what comes out of the Mid Staffordshire inquiry in October and, more importantly, what real changes will emerge from these various reviews in terms of regulation, commissioning and governance generally.