Continuing our week exploring inquiries, today’s post comes from Chris Hatton:
When I was a PhD student, the common room in the research centre where I ‘worked’ (yes, there were such things in the olden days) contained an unremarked upon filing cabinet. One idle afternoon (yes, there were such things in the olden days), out of curiosity, I opened it, to find an anti-Narnia of dusty inquiry reports. The rest of the afternoon went as I started reading through them, my shiny, unthinking bubble of an optimistic perpetual present (what history?) gradually deflating and then popping altogether. I consoled myself that this was all in the sepia-toned, bad, institutional past, though, and people with learning disabilities were on the path to a bright and better future (cue heroic socialist realist poster). As a metaphor for the history of inquiries, it’s so perfect as to be completely unconvincing.
Some quotes (and for more from recent inspections of ‘specialist’ services for people with learning disabilities see here):
- ‘Our investigation found that institutional abuse was widespread, preventing people from exercising their rights to independence, choice and inclusion. One person spent 16 hours a day tied to their bed or wheelchair, for what staff wrongly believed was for that person’s own protection. One man told investigators that he had never chosen any of the places he had lived as an adult’ Full report
- ‘The families of patients at Winterbourne View Hospital had no experience of being regarded as partners, deserving of trust and respect, or even of collaborating with Winterbourne View Hospital staff. Theirexpertise, borne of the lengths to which they had gone to keep their relatives at home and in care services, was not acknowledged by Winterbourne View Hospital. They were excluded from having a full picture of events at the hospital’ Full report
- ‘An unduly casual attitude towards sudden death [and] inadequate systems for reporting incidents’ Full report
- ‘1991: Allegations of assault. Investigations were made and evidence established, but the Inspector chose not to use the enforcement powers of the Act.
December 1992 – April 1993: Allegations of multiple abuse. The evidence of abuse increased and the Inspectors accepted that there was a serious case to be answered. But no assessment of the risk to residents was undertaken nor were the police called in to help. Fearing intimidation of staff and residents, the Inspection Unit continued to rely on announced inspection visits.
1993: Joint Police/Inspection Unit Investigation. There was no common understanding of the strategy to be followed. The Inspection Unit decided to take no action unless and until the Police decided not to prosecute. They failed to assess the evidence as it became available and so suspended their duty to consider whether enforcement action was needed.
1994: The Inspection Unit Investigation. This was an extremely complex investigation for which the Inspectors had little experience. They did not seek help from the Health Authority, renew contact with the Police or use other specialist sources. Complaints about specific aspects of the care regime were never properly investigated. Social workers, families and the police were given no information about specific allegations.
1994: Action on the Inspection Unit’s Report. The advice to Social Services Casework Sub-Committee not to take enforcement action under the Registered Homes Act 1984 to cancel the registrations in respect of the homes, as summarised in the final report which was put to the Social Services Sub-committee, did not reflect the professional judgement of the Inspection Unit’ Full report
- ‘For long periods of time the hospital buildings were neglected and dangerous. They were a patchwork quilt of makeshift repair and poor workmanship. The roof of the main building let in water for many years and the upper floor often had to be evacuated because rainwater poured in and it was feared that the ceiling would collapse. Patients were sometimes soaked as they slept. Buckets and tin baths littered the upper corridor…The standards of hygiene were often appalling and patients and staff alike suffered from demarcation disputes between nursing and domestic staff. Faeces and urine were frequently left unattended for days on end, with consequent risk to health and welfare of patients and staff’ Full report
- ‘Some individuals, as the trust has acknowledged, have suffered abuse including physical, emotional and environmental abuse. The trust’s own investigations at Budock Hospital have shown that some people using its services have had to endure years of abusive practices and some have suffered real injury as a result. For example, one person suffered multiple injuries over time, including a fractured skull after being hit by another person who used the trust’s services. Despite the development of numerous action plans, underlying problems have never been addressed and poor practice has become ingrained within the management of learning disability services and the provision of care’ Full report
- ‘There were examples of individual patients in Winterbourne View Hospital and their families being threatened with the improper use of mental health legislation’ Full report
- ‘All the male wards are seriously overcrowded. The buildings are old and ill-designed. The standards of amenity fall far short of what would nowadays be expected…The staff establishment [of one ward] is half the minimum desirable…’ Full report
- ‘The standard of nursing care was generally extremely low and the quality of life of many of the patients suffered accordingly. Shortage of staff at different levels was at various times a contributory factor, but it was by no means the principal cause of difficulty’ Full report
A few observations from me. First, as the #JusticeforLB #107days inquiry timeline and Katherine Runswick-Cole’s post make clear, these successive inquiries, serious case reviews, independent investigations and inspections (46 years on from Ely Hospital now, almost as old as me!) have not resulted in the eradication of abuse of people with learning disabilities in ‘care’ services.
Second, these inquiries are clear-sighted about identifying the ‘causes’ of the abuse and poor practice reported time and again, but they generally do not try to get to what Sir Michael Marmot in a public health context calls ‘the causes of the causes’. We know that smoking causes lung cancer, but wouldn’t it be equally important to know why people take up smoking in the first place? These inquiries tell us what seemed to contribute towards abusive practices in each place, but not to address what causes these factors to recur, again and again.
The Utopia of Rules by David Graeber (see a long post on my reading of this here for a detailed expansion of the argument) struck me forcibly as providing part of an answer to this question. One of his central points is that bureaucracies can draw on (and indeed rely on) the threat of real violence for their enforcement. So, is the abuse reported in inquiry after inquiry a logical end-point, or a necessary element, of an intensely inhuman, bureaucratic ‘care’ system?
Is it also possible that the ‘failure’ of inquiries to eliminate abusive practices (and not just in services for people with learning disabilities, as this slideset from Prof Kieran Walshe makes clear) is partly because the recommendations they make are all about tinkering with these inhuman bureaucratic systems rather than seeing them as part of the problem and tackling them head on?
So, where might we go from here? Whenever I see a service really working for a person with learning disabilities, there’s always a person with a strong, human commitment to making whatever they’re doing work better for people, no matter what bureaucratic system they’re enmeshed within. Some people just seem to ‘get it’, and have the energy to bend/break bureaucratic systems to create a bubble of humanity within these systems. Why doesn’t this happen everywhere? I used to think part of the issue of ‘scaling up’ good practice was to design systems better so that good practices in a place could survive the committed person moving on. I now realise this was completely wrong-headed and bureaucratic as a way of thinking. Now I think what we need is to find, nurture and support as many ‘humans’ as we can to start to shake and dissolve the inhumanity of bureaucratic systems. A service needs to start without the bureaucratic threat of violence in its back pocket, for genuine, human relationships of trust to develop.
1, 6: Joint investigation into the provision of services for people with learning disabilities at Cornwall Partnership NHS Trust, 2006
2, 7: Winterbourne View Serious Case Review, 2012
3, 8: Ely Hospital Inquiry, 1969
4: Independent Longcare Inquiry, 1998
5, 9: Normansfield Hospital Inquiry, 1978