Norfolk safeguarding review highlights ‘failures of governance’

Posted: 14th September 2021

A report into the deaths of three adults with learning disabilities at a private hospital in Norfolk has called for better collaboration between official bodies when delivering adult social care.

Norfolk Safeguarding Adults Board (NSAB) commissioned safeguarding expert Margaret Flynn to compile a report into the deaths of people – referred to as Ben, Joanna and Jon – under the care of Cawston Park Hospital. Joanna and Jon came from London Boroughs and Ben came from Norfolk.

The hospital was closed in May this year, having been put into special measures by the Care Quality Commission in September 2019.

The report said that the relatives of the three adults, as well as those of other patients, “described indifferent and harmful hospital practices, which ignored their questions and distress”, saying they “were not assisted by care management or coordination activities”.

It said the patients “did not benefit from attention to the complex causes of their behaviour, to their mental distress or physical health care”.

In the case of Ben – who was transferred to Cawston Park while his mother was receiving treatment in hospital –  that the “local authority was seeking a bespoke service … to complement his mother’s care”.

Ben had never lived away from his mother and became distressed when he was initially placed in care while she received her treatment. He was later sectioned, despite having no mental health conditions, and transferred to Cawston Park Hospital.

However, repeated emails from the local authority to the hospital regarding Ben’s care received no reply.

At a press conference today, Ms Flynn said that better collaboration and information sharing between those involved – including Norfolk and Waveney Clinical Commissioning Group, Norfolk CC and the council’s social services department – would lead to more focused, personalised care for those with learning disabilities.

“We need investments and promises, we have to see transformation that is felt by people’s families,” said Ms Flynn.

“I would want to see individualised support [to form] credible networks around individuals”, she added.

The report set out 13 recommendations for NSAB. These include calls for the CCG and county council to review commissioning arrangements to embrace “ethical commissioning”, and transfer of all remaining patients from Cawston Park hospital.

The report also says the CCG and council should rebalance responsibility for Norfolk citizens “away from medical led admissions and social care discharges”.

“My report highlights the failures of governance, commissioning, oversight, planning for individuals and professional practice,” Ms Flynn said.

She called for a “rebalancing of funding” so that local authorities have the means to “provide prevention services and even counselling” for those with learning disabilities who undergo a change in circumstances.

Joan Maugham, the chair of NSAB, called on all organisations involved at both “a national and a local level, to develop bespoke services matched to the individual”.

These should “ensure safety, respect, care for their physical and mental health wellbeing, stimulating activities, and plans for a meaningful life in the future,” she added.

James Bullion, Norfolk’s director of adult social services, said: “The deaths of Joanna, Jon and Ben were tragic and entirely avoidable.”

“This independent report gives the government, the NHS and the CQC and social care the push we need to reform support for the most vulnerable people with learning disabilities and autism,” he added.

Source: Norfolk safeguarding review highlights ‘failures of governance’ | Local Government Chronicle (LGC) ( (September 2021)

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