Activists ‘horrified’ by Bristol’s third damning report into multi-agency failings in four years

Council, police and other agencies across Bristol have again been found to have repeatedly failed disabled people, in the third such damning report to hit the city in just four years.

This week’s report by Sir Stephen Bubb examined multi-agency failings over many years in relation to three autistic men, two of whom also have learning difficulties.

Sir Stephen, who was commissioned to write his report by Bristol City Council and the Keeping Bristol Safe Partnership (KBSP), said his work proved that Bristol should no longer claim to be an “autism friendly city”.

The report, Building Rights, describes a history of inappropriate placements and ineffective and discriminatory support and safeguarding failures over the last decade – most but not all of it in Bristol – by inpatient mental health settings, young offender institutions, police, prisons, the NHS, supported housing providers, a private assessment and treatment unit, British Transport Police, and Bristol City Council.

It comes only three years after a report that followed the murder of disabled asylum-seeker Kamil Ahmad, and four years after a report into the murder of disabled refugee Bijan Ebrahimi, both of which exposed multi-agency failings across the city.

Sir Stephen said he had “serious concerns” about the treatment of people with learning difficulties and autistic people by the criminal justice system, “and whether their rights are being properly upheld”.

Among his concerns, he found police officers had breached their legal duties on providing an “appropriate adult” to someone who was seen as “vulnerable” after their arrest, ignored medical evidence, failed to assess if someone was fit to be detained and interviewed, and failed in their duty under the Equality Act to provide reasonable adjustments.

He also called for an expansion of community support, and he said he had collected “further evidence of the abusive nature of institutional care and failures to provide effective support”, which he said was a “continuing scandal”.

He added: “Bristol can no longer claim to be an ‘autism friendly city’ and should stop using this slogan.

“This is not to suggest that changes and improvements have not been made, but it is not appropriate to use the slogan when the evidence to support it is lacking.”

The grassroots disabled people’s organisation Bristol Reclaiming Independent Living (BRIL) told Disability News Service (DNS): “We were horrified to read about the system-wide failures that led to these three disabled men being so gravely let down.

“As a city, Bristol needs to reflect about how, and why, it has failed to listen to autistic people and people with learning difficulties for so long.

“It is deeply disappointing that, despite the talk of ‘lessons being learned’ over the 10 years since the Winterbourne View scandal, and after the avoidable murders of Bijan Ebrahimi and Kamil Ahmad in Bristol, there seems to have been a consistent failure to learn from these injustices.

“While we welcome the focus this report will hopefully bring, and the call to support independent advocacy and self-advocacy, it is beyond frustrating that the key recommendation is to remind Bristol that disabled people have rights.”

Laura Welti, manager of Bristol Disability Equality Forum, told DNS that the forum supported the report’s recommendations.

But she said the police force, city council and NHS “need to come up with a clear plan for how they are going to stop criminalising people with certain impairments, just because of those impairments”.

She said the criminal justice system “must stop putting ‘vulnerable’ people into mainstream prison provision and generic probation hostels/post-prison ‘supported’ housing”.

Welti said the report “clearly demonstrates the statutory sector and its services have repeatedly failed to learn from their own experience, and that of others”.

Sir Stephen recommended in his report that Bristol City Council draw up a charter of rights for autistic people and people with learning difficulties which should “underpin all commissioning and provision”, with services then shaped around that charter.

He also called for a new right for autistic people and people with learning difficulties, and their families, to “challenge” any decision to admit them to hospital or keep them there.

And he called for a new independent commissioner who would promote, enhance and protect the rights of people with learning difficulties and autistic people in Bristol, and help deliver a consensus on how to deliver better services and support.

He was also critical of the Independent Office for Police Conduct and called for a more accessible system of making complaints about police officers.

But BRIL said: “Bristol needs more than awareness, or ‘marking its own homework’, by appointing another commissioner.

“We need a radical change in how decisions are made, and for people in power to be accountable.”

The Bristol-based journalism website The Bristol Cable this week spoke to the families of two of the autistic men.

One of them told the Cable: “I will never give up because my son could die today. He’s still being neglected.”

Another parent said: “I’m sick to death of people not being accountable for what they do wrong… I’ll never trust the police again.”

Only three years ago, a safeguarding review commissioned by Bristol Safeguarding Adults Board – which has since been replaced by KBSP – concluded that disabled asylum-seeker Kamil Ahmad had been failed by multiple agencies across the city in the lead-up to his murder by a racist neighbour.

The previous year, another safeguarding review had concluded that Bristol City Council and Avon and Somerset Police were guilty of institutional racism and discrimination in the way they dealt with years of complaints by Bijan Ebrahimi in the years leading to his murder by a neighbour.

The new report also comes seven years after Sir Stephen’s independent report into transforming care for people with learning difficulties in the wake of the abuse at the Winterbourne View assessment and treatment centre, near Bristol, and a follow-up report in 2016, a scandal which also exposed failures by Avon and Somerset Police.

Sir Stephen said this week in his report that it was “time to accept that this type of institutional care by its nature is abusive and must end”, and he called on the government to “make a clear commitment now to closing all such institutions and the transfer of resources into the community” by 2024.

And he said his new report showed “how little has changed” in the “wholly inadequate” system of care and support for autistic people and people with learning difficulties since 2016.

BRIL members questioned why accessible and easy read versions of his report had not been published.

And one autistic BRIL member, James Deane, said the recommendations for a charter of rights, a right to challenge admission to hospital and an independent commissioner were “meaningless language for autistics, and does not have any power.

“Having these rights but with no censure or consequences, or to make people think twice, seems like massaging us into acceptance.”

He called for autism-specific advocacy in Bristol that was designed by autistic people.

A Bristol City Council spokesperson said the council accepted all the report’s findings and that it remained “positively committed to improving the experience of autistic people, and people with learning disabilities in Bristol”, while the report provided “a clear pathway for much needed, system-wide improvements based on people’s real, lived experiences”.

A spokesperson for Avon and Somerset Police said the force had accepted its failings “and carried out a significant amount of work since the incidents referenced in the report”.

She said the force agreed with Sir Stephen that the police “should not always be the first line of response for people experiencing a situation or crisis which may be connected with their autism, learning disability or mental health”.

She added: “We’re committed to continuing our work to improve the experiences of vulnerable adults who come into contact with our officers and staff.”

She said the force had carried out a “significant amount of work” since the incidents described in the report.

This included introducing an autism lead who is himself autistic; delivering an autism training programme for officers and staff; and ensuring that anyone coming into police custody who says they are autistic, or who officers and staff believe may be autistic, will be provided with an appropriate adult “unless they specifically tell us they do not want one”.

But one autistic BRIL member said: “The focus by some on ‘awareness’ will not bring about better treatment of us, nor would any ‘reforms’ of the police… a police officer’s brutality towards disabled persons, like their oppression of BAME folk and their domestic violence rates against women, is institutional to the core.”

Another autistic person from Bristol warned that there was a “wide range of levels of understanding” within Avon and Somerset Police.

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