Review finds multiple agencies failed over Whorlton Hall abuse scandal

Multiple agencies have been criticised by a long-awaited review for failing to expose a regime of physical and psychological abuse at a private hospital for autistic people and people with learning difficulties.

The abuse at Whorlton Hall, near Barnard Castle, County Durham, was only halted after the regime was exposed by undercover footage that featured in a BBC Panorama documentary broadcast on 22 May 2019.

A delayed safeguarding adults review has now described how failings by multiple agencies, including the Care Quality Commission (CQC), Durham County Council adult and health services and Durham police prevented the abuse being halted earlier.

Although the review only focused on a 16-month period between February 2018 and May 2019, concerns about standards at Whorlton Hall (pictured) were first uncovered by CQC in 2015.

The review found there was “insufficient multi-agency working” when safeguarding inquiries were carried out in subsequent years.

When police investigations decided there was not enough evidence for further action, this was wrongly taken by the county council “as evidence that there were no safeguarding concerns or need for protection”.

The review also found that coordination between the council and CQC was “poor”.

The review concludes that if the Panorama documentary had not been broadcast, the council would probably have continued its series of “repetitive stop-start” responses to safeguarding concerns at Whorlton Hall, which had been occurring since at least 2016.

The 87-page review is also critical of some of the health bodies and local authorities that had secured places at Whorlton Hall for disabled people from other parts of the country.

The safeguarding report makes it clear that its conclusions do not reflect any changes or developments that have taken place since April 2022, when its findings were agreed by Durham Safeguarding Adults Partnership (DSAP), which commissioned the report.

The report’s publication was delayed by more than a year by a police investigation and criminal trial.

The review makes seven key “systemic” findings, including the need for closer working between CQC and local authorities on safeguarding inquiries at specialist hospitals.

It also highlights the lack of national standards for provider-led safeguarding investigations into the kind of “toxic, intimidating sub-cultures” seen at Whorlton Hall, which closed in May 2019.

It points to the need for disabled people in specialist hospital settings to have a named, independent professional with whom they can develop a “sustained relationship of trust”.

It also points to the “illusion of advocacy provision” for autistic people and those with learning difficulties who are inpatients in specialist mental health hospitals, which it says is “inadequate” and creates “a false security that advocacy is in place”.

And it says that the absence of national oversight of urgent hospital closures following care scandals means there is “little learning about what is working well and what needs to improve”.

It also criticises the lack of a “clear national approach” that will translate into “real change” for autistic people and those with learning difficulties in specialist hospitals.

The first concerns about Whorlton Hall appear to have been raised in 2015, when a CQC inspection rated it as “requires improvement”. But CQC failed to publish the report, a decision a review for the watchdog later concluded was wrong.

A CQC inspection in early 2018, following whistleblowing concerns, raised some concerns, including about an over-use of restraint, but it failed to carry out a “rigorous investigation” of the so-called “alpha group” of staff, whose members were at the centre of allegations of bullying, cover-up and abuse. CQC also failed to inform the council about the allegations.

There was then a botched investigation by Durham police, and a “misguided” decision by the council to allow The Danshell Group – which owned the hospital until 2018 – to carry out an internal investigation rather than carrying out a statutory safeguarding inquiry itself.

The council’s repeated failure to fully implement the “spirit” of Care Act safeguarding guidance caused “missed opportunities to focus on hearing the voice of people living at Whorlton Hall” and “created particular risks for the people identified as making and retracting allegations of abuse”, the review found.

This also meant that “significant levels of trust were placed in Whorlton Hall management to report accurately on events, evidence and judgements”.

The review draws attention to a “postcode lottery” of service provision that leads to “patients being placed for long periods in large hospitals that claim to be specialist, often at a distance from their family, [which] provides an opportunity for abuse to occur”.

And it is critical of Cygnet Health Care, which took over Whorlton Hall in August 2018, but refused to share the findings of its internal investigation into the abuse or information it had obtained when it bought the hospital from Danshell.

The review was completed in April 2022 but not published until now because of the ongoing trial of nine former Whorlton Hall staff members.

The trial ended in April, with five former members of staff cleared of all charges, but four others found guilty of ill-treating patients. They will be sentenced next month.

Picture by BBC Panorama

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