NORFOLK’s Safeguarding Adults Board (NSAB) on Thursday published an important Safeguarding Adults Review (SAR) into the deaths of three young adults: Joanna, ‘Jon’ and Ben (all in their 30s).
They had learning disabilities and had been patients at the privately-run Cawston Park Hospital. They died within a 27-month period (April 2018 to July 2020).
Joanna, Jon and Ben were admitted to the hospital under sections of the Mental Health Act (1983). Joanna and Jon originated from London boroughs. Ben was from Norfolk.
Their behaviour was known to challenge services and sometimes their families. Joanna and Jon had experienced several out-of-family-home placements. Ben had lived with his mother for most of his life. Their placement at the hospital resulted from personal and family crises.
The NSAB review makes 13 recommendations for critical system/strategic change. In addition it contains the following key learning for practitioners:
- the critical role for professional curiosity and challenge;
- the trauma of transition;
- meaningful support for individuals with behaviours that challenge others;
- critical responsibility for staff to advocate reporting and openness;
- where the victim of abuse doesn’t want to ‘complain’;
- the importance of meaningful occupations;
- making sure attention is given to physical health needs;
- mental capacity.’
SAR Report for Joanna, Jon & Ben – Executive Summary
‘1. During April 2019, Norfolk’s Safeguarding Adults Board (NSAB) commissioned a Safeguarding Adults Review (SAR) concerning the deaths of two adults at a private hospital, Cawston Park.
During December 2020, the death of a third patient was added to the review’s remit. The deceased, Joanna, “Jon” and Ben were in their 30s. They had learning disabilities and had been patients at the Hospital for 11, 24 and 17 months respectively. They died between April 2018 and July 2020.
2. The Hospital is registered with the Care Quality Commission (CQC) for the assessment or medical treatment for persons detained under the Mental Health Act 1983 and the treatment of disease, disorder, or injury. CQC’s website states that it has 57 registered beds across six wards, two of which are locked wards, The Grange and The Lodge. The deceased were placed at The Grange and The Lodge.
3. The purpose of the SAR was to set out the experiences of the three adults in terms of their care management and the care and support services commissioned on their behalf. In particular, the Review considered the impact of the Hospital’s registration, inspections by the CQC, the Hospital’s governance framework, safeguarding referrals, other alerts and the voice of former patients, their relatives, friends, and the relatives of current patients.
The care provider at Cawston Park Hospital is Jeesal Akman Care Corporation Limited, a Private Limited Company providing “other human health activities”. Sally-Anne Subramanian and Tugay Akman are directors and Tugay Akman is the Responsible Individual
4. The Covid-19 pandemic resulted in six virtual meetings of the SAR Panel. Only the initial meeting was physically co-located. The Panel is made up of representatives from the Hospital, the Care Quality Commission, Norfolk’s Adult Social Services Department including its safeguarding team, the Clinical Commissioning Groups (CCGs) responsible for placing the three adults, the ambulance service, the local acute hospital and community care NHS Trusts and the police.
5. As the Review’s accounts of Joanna and Jon’s circumstances was “coming together” there was another tragedy at the Hospital. It was envisaged that adding Ben’s circumstances to the Review would enhance the legitimacy of its findings. A balance prevailed between ensuring that Ben was not shortchanged by being added to a SAR that was reaching its conclusion and ensuring that the SAR should not compromise his inquest.
6. The Review relied principally on the Hospital to provide information concerning the care and treatment of the three adults. It provided partial and incomplete information about their day to day lives.
The Lessons and Findings
7. Joanna, Jon and Ben were admitted to the Hospital under sections of the Mental Health Act (1983). Joanna and Jon originated from London boroughs. Ben was from Norfolk.
Their behaviour was known to challenge services and sometimes their families. Joanna and Jon had experienced several out-of-family home placements.
Ben had lived with his mother for most of his life. Their placement at the Hospital resulted from personal and family crises. It was the only placement which could be identified by Joanna’s CCG which had previously made contact with 38 other services.
8. The relatives of the three adults, and those of other patients, described indifferent and harmful Hospital practices which ignored their questions and distress. They were not assisted by care management or coordination activities.
People’s families could not value the unsafe grouping of certain patients, the excessive use of restraint and seclusion by unqualified staff, their relatives’ “overmedication”, or the Hospital’s high tolerance of inactivity – all of which presented risks of further harm.
In addition, these patients did not benefit from attention to the complex causes of their behaviour, to their mental distress or physical health care.
9. There was no information for (i) 179 days of Joanna’s stay (ii) a single day for Jon, and (iii) 450 days for Ben.
10. Families questioned the Hospital’s undocumented assumptions concerning patients’ mental capacity which appeared to transfer responsibility to patients. For example, Joanna and Ben used Continuous Positive Airway Pressure (CPAP) machines as a result of sleep apnoea.
Joanna’s inquest heard that in the last 209 nights of her life the CPAP had been used on only 29 occasions and that she did not want to use it.
Her parents and all previous placements had prioritised its consistent use and maintenance. Neither her parents nor her Consultant Neurologist were advised that Joanna had ceased to use her CPAP. Similarly, there were 115 documented occasions when Ben declined to cooperate with its use. It does not appear that attempts were made to desensitise either Joanna or Ben to using their CPAPs.
11. Joanna and Ben were obese. Although Ben’s weight reduced to 13.3 stones within two months of his admission to the Hospital, two years later, his postmortem revealed that he weighed 18.10 stones. Their CPAP machines would have required adjustments as a result of weight gain.
Their protracted physical inactivity increased their risk of obesity, high blood pressure, high blood cholesterol, diabetes and heart disease. They did not benefit from being accompanied to outpatient appointments by support workers who (i) were competent in managing their anxieties and (ii) possessed up to date information concerning their health status.
12. The Hospital did not seek vital information about people’s pre-Hospital lives. All that may be reliably gathered from Jon’s records is that setting a discharge date is a meaningless activity if no attention is given to planning for this; specialist hospitals which are remote from people’s families have unchallenged scope to retain patients; and there are no consequences if Clinical Commissioning Groups responsible for placements are not represented at critical review meetings.
13. There did not appear to be any timetabling discipline at the Hospital in terms of people’s daily and weekly activities. Activities in which adults had particular expertise and interests, such as swimming, painting and drawing, for example, were not prioritised.
14. The Hospital is disadvantaged by the absence of accurate and timely information flowing up to managers and directors and down to staff and patients. Although first-person accounts from patients and their relatives are powerful means of establishing the impact of a service and would provide a holistic view of performance, they are absent. Little may be discerned of the Hospital’s corporate and financial governance or the extent to which this is intertwined with clinical governance.
15. A CQC report during 2019 stated “The hospital was not working to the model of an assessment and treatment unit and therefore its operation was not in line with the expectations of the Transforming Care Programme”. Its subsequent reports indicate that the Hospital was mired in familiar stalemate.
16. Norfolk’s SAB should write to the Law Commission proposing a review of the current legal position of private companies, their corporate governance and conduct in relation to services for adults with learning disabilities and autism.
Given the clear public interest in ensuring the well-being and safety of patients, and the public sponsorship involved, the Law Commission may wish to consider whether corporate responsibility should be based on corporate conduct, in addition to that of individuals, for example.
The roots of private, specialist hospitals reside in business opportunism and profit-driven priorities.
These are hospitals in which patients receive neither specialist assessment nor credible “observations” and treatment.
The deaths of three young adults must plausibly question the “system response” – CQC’s continued registration of such hospitals and their continued use by CCGs and NHS-England.
17. There is a crucial difference between the health advocacy of patients’ parents and that of staff, regardless of pay scales. Cawston Park Hospital failed to recognise that its interventions were unequal to aiding patients in their physical and mental distress. It neither built nor sustained trust. It did not serve the larger aims of three people’s lives.
Joanna was supported by staff who were untrained in the use of her CPAP.
They did not begin CPR and a learning disability nurse and two support workers believed that her epilepsy was due to her “playing up and shouldn’t be minded”.
The response to Jon’s breathing difficulties was unduly slow even though he had pleaded “I cannot breathe. I am dying”.
Ben had ceased to use his already underused CPAP and his low SATS symptoms were ignored.
His mother’s insistence that an ambulance should be called had no impact.
Unless this Hospital and similar units cease to receive public money, such lethal outcomes will persist.’