Analysis of Healthcare Practice Gaps and Violations: Winterbourne View

This report examines the Winterbourne View scandal, a case of severe abuse and neglect at a UK private hospital, exposing significant gaps in healthcare practice and violations of safeguarding laws and policies. The report details the abuse, including physical restraints and torture, and highlights the breaches of the Safeguarding Vulnerable Adults Act, Protection of Vulnerable Adults Scheme, Human Rights Act, and Mental Health Act. It explores patient safety issues, such as overcrowding, understaffing, and inadequate staff qualifications, as contributing factors to the abuse. The report also provides recommendations for improvement, focusing on the role of the Care Quality Commission in monitoring and regulating care facilities, improving whistleblowing processes, and ensuring timely investigation of incidents. The analysis emphasizes the need for better safeguarding measures and adherence to ethical and legal standards to prevent future occurrences of such abuse and protect vulnerable individuals within healthcare settings.

Running head: HEALTH CARE
Health Care
Name of the Student
Name of the University
Author Note

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Introduction
Hollins et al. (2019) are of the opinion that there are numerous acts, policies and
guidance in the health and social care services that are used for safeguarding the vulnerable
individuals. Policies and different procedures are designed in order to guide the decision
making process in few important domains of health and social care. However, numerous
reports have highlighted that not all the policies and reports are followed in a way for which
they are designed. Thus for those who are meant to protect suffer of the consequence of same.
The following report will highlight the gaps in healthcare practice and violation of the
healthcare law, policies and guidance under the context of Winterbourne View Scandal
exposed by BBC news. The Winterbourne View Scandal exposed by the Panorama
programme shocked the whole nation. It caused the government of UK to take pledge in
order to move all the people suffering from learning disabilities or autism spectrum disorder
from such inappropriate placement to specialised community care service (Transforming
Care and Commissioning Steering Group 2014). At the end, the report will highlighted few of
the effective recommendations that can be used in order to avoid such events going forward.
Summary of Winterbourne
On 31st May 2011, an undercover agent of BBC Panorama programme exposed the
criminal abuse of the staffs over the patients residing in the Winterbourne View Hospital
located near Bristol UK. The private hospital, founded on December 2006 has an
accommodation of 24 patients. The CCTV footage leaked by BBC news showed that patients
in the Winterbourne hospital were kept under extreme physical restrain, lack of registered
manager along with physical torture and bullying the patients. The TV program also showed
that healthcare staffs are slapping and hurting the patients and forcing them to get on the
floor. At times they used chair to stopped the, from moving, sprinkled water over their face

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and poked their eyes and thereby making their life miserable in the hospital unit (Department
of Health United Kingdom 2014). BBC News reported that 11 defendants (9 support workers
and 2 nurses) admitted 38 different charges of neglect and mal-treatment over five patients
who are suffering from learning difficulties and six were given sentence of imprisonment for
2 years (BBC News 2012).
Laws and policies not adheredSeveral safeguarding laws in health and social care were violated in Winterbourne
case (BBC News 2012). The first law that is being violated is Safeguarding Vulnerable Act
(2006). This act mainly prevents the harm or the risk of harm by restricting people with
dubious character from entering into health and social care focused towards vulnerable
children and adults. However, the Winterbourne View case highlighted that ineligible people
are appointed in the hospital unit who physically abused patients and thereby endangering
their physical and mental health and well-being. Following the Winterbourne case, a new act
was proposed in the year 2012 with the name of Independent Safeguarding Authority and this
was subsequently merged with the Criminal Records Bureau and thereby leading to the
foundation of the Disclosure and Barring Service (DBS). The DBS scrutiny is important
while seeking to work in health and social care profession in UK. The DBS scrutiny also
screens workers (voluntary, social or care worker) based on their previous record of having
attempted to harm someone or harmed someone who falls under the vulnerable group of
individuals like people suffering from mental health complications (Social Care Institute for
Excellence 2013). The second act that was violated in this case was
Protection of
Vulnerable Adults Scheme (POVA). This act was introduced under the Care Standards Act
in the year 2000. The aim of this law was to restrict the entry of any of the working
individuals who have previous case history of abusing or neglecting the individuals having

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mental health complications or other disabilities. POVA also have a stringent list of people
who are banned from working under the care provision of registered home that provides care
for vulnerable group of individuals (POVA 2003). It is questionable in this case whether or
not the employees of Winterbourne View Hospital were stringently vetted for their skills and
qualifications to work with mentally vulnerable group of individuals.
The Human Rights
Act 1998 came into enforcement in the year 2000. Under the European convention on Human
Rights (ECHR), this act vouch for fair and humane treatment for the all the individuals
residing in UK. The fair treatment vouches for rights towards liberty and security, right for
fair trial and fair treatment and freedom from torture and inhumane activities. Any breach to
Human right is subjected for punishment along with financial compensation. However, the
“Human Rights Act (HRA)” is not modulated by parliamentary sovereignty and it cannot
restrict government from introducing new laws of policies like those including infringement
of human rights. The analysis of the case study of Winterbourne highlighted that the basic
Human Rights of the individuals were not abided by the hospital authority as all the residents
were tortured physically and mentally and they also forced to reside an extreme condition like
locking them in room with zero temperature (Equality and Human Rights Commission 2019).
According to Ann Redropp, the head of CPS Complex Case team, the offerings that occurred
in the Winterbourne View undermined the fundamental human rights of the patients by
brutally harassing them with repeatedly abusing. iTV News (2019) are of the opinion that
when an individual feel that their human right is being breached, they are require to lodge
their complain in court. This is however an expensive and time consuming process and the
victims being mentally disabled, failed to lodge complain.
Mental Health Act amended in
the year 2007 is also violated in this case. The Act strengthens the rights of the mental health
patient in availing proper healthcare service irrespective of any discrimination. However he
review conducted over the Winterbourne View Hospital revealed that there is weakness in the

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ability of the justice system for holding the management of the healthcare organization
responsible for endangering the safety of the patient. All the patients in mental speciality
hospital providing residential mental health care service are required to be enrolled under this
act in order to safeguard their rights (National Health Service 2019). However, in case of
Winterbourne view hospital, the patients were initially sanctioned under the term of the
Mental Health Act and did not renew the enrolment after its expiry and still continued to
receive the care in Winterbourne view hospital (Ion, Olivier and Darbyshire 2019). The case
study also highlights violation of Mental Capacity Act of 2005 that provides empowerment to
the individuals who are 16 years and above.
Patient safety issues and outcomes
According to Marsland, Oakes and White (2015), people with learning disability or
with challenging behaviour are prone towards harm, abuse and other exploitation under the
settings in which they are intended to receive the care service. Numerous factors that
contribute towards the abuse over the mental health patient include nature of the abuse,
abused and healthcare organization in which the patients are being kept. Stoltenborgh et al.
(2015) further highlighted that when there is over-crowding of mentally vulnerable
individuals under a same healthcare unit, the probability of getting victimised from physical
or mental abuse increases. This can be a reason behind the high rate of abuse among the
residents of Winterbourne View hospital. The hospital has registered accommodation of 24
residents which is much lower in count in comparison to the total number of resident present
in the hospital at that time. Increased level of sick leaves among the healthcare staffs plus
high rate of employee turnover, deficiency of skilled labour, long working hours, and stress
can also increase the threat over the vulnerable population from getting abused. Ion, Jones
and Craven (2016) are of the there were deficiency in the total number of skilled staffs in the

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Winterbourne view hospital was less than the total number of residents and thus increasing
the probability of the residents getting abused. Concerns are also flagged against the
employing the staffs in the hospital when negligible information is present regarding their
qualification and experience. According to BBC news corrupt and abusive practices can be
justified under the “neutralization of moral concern” where the individual with learning
disabilities are assumed to be less competent than the healthy human being with poor human
rights and values (BBC News 2015). George (2019) stated that disrespectful actions and
threatening behaviour might potentially harm the overall consequences of the disease
prognosis and thereby increasing the threat over the vulnerable population. Conversation
conducted with five-ex Winterbourne View Hospital patients and other 12 different families
of ex-patients revealed how hard it was for them to access professional help. These extreme
conditions in hospital unit were denoted as bewildering and some of them even committed
suicide. Their lives were interrupted with sexual assault and torture.
Recommendation for improvement
Manthorpe and Martineau (2017) reported that the roe of the Care Quality
commission as the main regulator of the in-patient care at Winterbourne View Hospital was
restricted as the light-touch regulation failed to work properly. After the event of
Winterbourne View hospital came to lime-light, CQC took active initiative. Following the
publication of the Care Quality Commission (CQC) review done over the Winterbourne View
hospital in the year 2011, the following recommendation can be proposed.
Recommendation 1
It is the duty of the CQC to highlight the quality and risk profiles (QRP) of the
residential care institutions providing care for the children with learning disabilities or with
behavioural challenges. This is consistent with the DH guidelines on the standard model of

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service delivery. The higher risk status of the residential care institutions will act as an alert
system for the professionals of CQC while looking at the information or carrying out
inspections (Dudley Metropolitan Borough Council 2012).
Recommendation 2
It is the duty of the compliance inspector to record at overall outcome of the
investigations from the assigned compliance managers. In cases where CQC fail to agree with
the outcome of the investigation, the same must be communicated about to the Safeguarding
Adult team (Dudley Metropolitan Borough Council. 2012).
Recommendation 3
The CQC must take the liability of the inherent risk associated with different types of
service provision and the mental health state of the people using the service. This mainly
include collated intelligence about the corporate healthcare provides along woth the
individual locations (Dudley Metropolitan Borough Council. 2012).
Recommendation 4
Although the CQC at present has a definite legislative remit to follow-up on the action
plans and to take necessary actions where there is a lack of scope for the improvement,
further action must be routinely undertaken in order to conduct investigations about the
incidents that are registered under the Regulation 18 (Dudley Metropolitan Borough Council.
2012).
Recommendation 5
CQC must build new rules and protocols for working with the safeguarding adults
team in order to ensure timely conduction of investigation and interventions that are relevant
to the safe guarding alters (Manthorpe and Martineau 2017).

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Recommendation 6
Manthorpe and Martineau (2017) highlighted in their survey that whistle blowing
notification process was not properly addressed by Winterbourne Hospital and not by the
Castle Ltd, irrespective of the fact that the this responsibility was shared with the Castlebeck
Ltd managers. Although connections were framed in the domain of safeguarding the level of
patients’ safety, the response raided by the international organization regarding whistle
blowing through electronic mails was ineffective.
Special safeguarding alerts like blowing the whistle should be developed along with
proper compliance of the guidance proposed by the Mental Health Act Commissioners.
Opinion from second doctor must also be taken in the domain of ensuring patient’s safety.
Not only designing of the tool, the duty of CQC also entails conducting proper scrutiny on
whistle blowing arrangements in order to check whether all the arrangements were in place.
This review must be done after every 6 months. The CQC should also come-forward in
developing protocol about the ways in which we will work for Safeguarding Adult Boards
and other Teams working across. The protocol must take into account of what measures have
worked effectively with the Children’s Safeguarding Boards (Manthorpe and Martineau
2017).
Recommendation by NHS
According to the NHS commissioners, the overall leadership among the
commissioners were poor. The commissioners did not press for nor received details accounts
over how the weekly fees of Winterbourne View hospital was used for promoting
improvement of the overall service quality. Even though the hospital was failing to meet the
contractual requirements, the commissioners continued to admit people there. There were
also limited use of the Mental Health Act 1983 and lack of advocacy service coming from the
NHS leaders (National Health Service 2014). Proper leadership management thus will be

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important in order to supervise the proper quality improvement plans of the residential care
hospital for people with special needs. The role of the leader will also entail on monitoring of
the quality of care given to the residents by the care givers (Alexander et al. 2015).
Additional recommendation
Further recommendation include proper investment in reducing the crisis followed by
commission challenge concerning the ex-winterbourne view Hospital patients. The quality
improvement plan will also include outcome based commission for hospitals that are
detaining people with learning disabilities or autism spectrum disorders and strict
establishment of the Registered Managers as a profession with proper code of ethics and
regulatory body for implementing proper enforcement standards (Richards 2016). There is
also an growing argument that the although it is the right that issues that are affecting people
with learning disabilities are present at the heart of the discussion and debate, this fails to take
active account over the complex, flexible and multiple identities present in the people who
are suffering from learning disabilities and their skills and experiences. It would be more
helpful in understand the lives of these people with proper label of learning disabilities in
comparison to commissioner or a charter (Richards 2016).
Conclusion
Thus from the above analysis of the Winterbourne View hospital and its associated
macabre torture over the people with learning disability or with behavioural challenges, it can
be said that the owner of the hospital, Castlebeck Ltd, failed to abide by the basic rules and
guidelines that are mandate for running such residential hospital units for patient with special
mental needs. The main violated laws that are can be easily highlighted from the critical
analysis of the case study include Several safeguarding laws in health and social care,
Protection of Vulnerable Adults Scheme (POVA), The Human Rights Act 1998, Mental

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Health Act 2007. The critical analysis of the case study also showed that there is lack of
proper whistle blowing strategy in order to highlight the gaps in the service provided. In order
to some of the residents at that time attempted to commit suicide while few of the inmates
suffered from extreme physical and mental health condition, hampering their overall health
and well-being. In order to improve this scenario going forward, the CQC and NHS must
come together with proper set laws and effective monitoring in order to help the overall
standards of care. Proper leaders must also be appointed in order conduct the regulation of the
work of the staffs under the hospital premises in an ordered manner.

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