ire S guard
South Gloucestershire Safeguarding Adults Board
Winterbourne View Hospital
A Serious Case Review
By Margaret Flynn
The Winterbourne View Hospital
Serious Case Review
Winterbourne View was a hospital in South
Gloucestershire for people with learning disabilities
and autism whose behaviour sometimes made their
families and professionals worry.
It was meant to help by assessing and treating
patients so that they could have ordinary lives in their
Winterbourne View Hospital was owned by a
company called Castlebeck. The NHS paid
Castlebeck a lot of money to look after people there.
It had 24 beds.
In 2011, a TV programme showed some staff at
Winterbourne View Hospital slapping and hurting
patients and getting them on the floor. They sat on
them and lay on them so the patients couldn’t move.
Sometimes they used chairs to stop them from
Patients were bullied. They had water thrown at them.
One woman was put in a shower wearing her clothes.
Winterbourne View Hospital has now closed.
The Serious Case Review
The council, the NHS, the Police, the Care Quality
Commission and other organisations work together
to make sure that adults who need help are safe from
harm. They call themselves the Safeguarding Adults
They asked Margaret Flynn to find out what had
happened at Winterbourne View Hospital. They
wanted to make sure it couldn’t happen again. This
is called a Serious Case Review.
Margaret Flynn does research. She has a brother
with a learning disability. She learned about what
had happened at Winterbourne View Hospital from
the people who had been patients at Winterbourne
View and their families.
She talked to Castlebeck, to the Department of
Health, the NHS, the Care Quality Commission and
to the Safeguarding Adults Board.
What did Margaret Flynn find?
Margaret found that lots of patients had been hurt at
Winterbourne View Hospital. Some had been poorly
when they were there.
Some patients had needed to go to Accident and
Emergency because they hurt themselves or they
were hurt by hospital staff.
Sometimes the police had been called when patients
were hurt or had tried to run away.
Some patients had complained to their families,
friends, to staff, the hospital’s managers and to
other professionals about being hurt. They were not
A nurse called Terry Bryan told the hospital’s
manager about patients being hurt at Winterbourne
View Hospital. Because nothing changed he wrote
to the Care Quality Commission. This is called
Terry Bryan then told the BBC and they made a TV
programme about it.
Why did it happen?
Margaret said that even though Castlebeck had rules
about how patients should be treated, staff didn’t
follow the rules.
Castlebeck didn’t train its staff properly and the
hospital’s managers didn’t do their jobs properly.
Sometimes when patients were hurt, the hospital
did not tell their families, the professionals who were
checking how they were getting on, the Care Quality
Commission or local safeguarding staff.
Why wasn’t it stopped sooner?
No one stopped the abuse because they needed the
hospital’s managers and staff to tell them what was
The NHS organisations that put people in
Winterbourne View Hospital thought that patients
were being cared for properly.
The Care Quality Commission, thought that
managers at Winterbourne View Hospital were
following the rules.
The Safeguarding Adults Board didn’t know that
patients were being hurt at Winterbourne View
This was because when the Council’s...
Please join StudyMode to read the full document