Source: BBC News published September 9 2021 and published on this site Friday 10 September 2021 by Jill Powell
The deaths of three adults with learning disabilities at a failed hospital should prompt a review to prevent further "lethal outcomes" at similar facilities, a report said.
There were significant failures in the care of the patients at Jeesal Cawston Park, Norfolk, it found.
Norfolk Safeguarding Adults Board concluded such hospitals should "cease to receive public money".
The owner of Cawston Park said it was "deeply sorry" to the families.
The report looked at the deaths of Joanna Bailey, 36, and Nicholas Briant, 33, both of London; and Ben King, 32, from Norfolk, between April 2018 and July 2020.
Police have named Dami Tobi Ayans, 60, as wanted in connection with an investigation into the ill-treatment of Mr King.
Ms Bailey, who had a learning disability, autism, epilepsy and sleep apnoea, was found unresponsive in her bed and staff did not attempt resuscitation, while the mother of Mr King said he was "gasping and couldn't talk" when she last saw him.
Mr Briant's inquest heard he died following cardiac arrest and obstruction of his airway after swallowing a piece of plastic cup.
The report found:
- "Excessive" use of restraint and seclusion by unqualified staff
- Concerns over "unsafe grouping" of patients
- Overmedication of patients
- High levels of inactivity and days of "abject boredom"
- Relatives described "indifferent and harmful hospital practices" and said their questions and "distress" were ignored
The report recommends the Law Commission should review the current legal position of private companies providing services for adults with learning disabilities and autism.
"Unless this hospital and similar units cease to receive public money, such lethal outcomes will persist," author Margaret Flynn said.
The hospital, near Aylsham, closed in May after "consistent failures in meeting standards".
Operator, Jeesal Akman Care Corporation, went into liquidation in June, owing almost £4m.
Joanna Bailey had a learning disability, autism, epilepsy and sleep apnoea.
Her father Keith described her as a happy, fun-loving woman who loved Michael Jackson, musicals and pottery.
The coroner's report gave her cause of death as sudden unexpected death in epilepsy (SUDEP), primary generalised epilepsy, obesity and obstructive sleep apnoea.
Ms Bailey was not checked for two hours the night she died on 28 April 2018, despite 30-minute checks being in her care plan.
A registered nurse and five care workers - all first-aid trained - did not attempt resuscitation when she was found unresponsive in bed.
She used a Continuous Positive Airway Pressure (CPAP) machine for her sleep apnoea, but in the last 209 nights of her life, data showed it had only been used 29 times.
The report said the "failure to ensure its regular use increased her risk of SUDEP".
It also described how hospital records of her care were "unaccountably inadequate".
Ben King had Down's Syndrome, severe learning disability and sleep apnoea.
He weighed 15st 10lb (100kg) on admission in July 2018 but was 18st 1lb (115kg) when he died on 29 July 2020 after an obesity-related breathing disorder was incorrectly diagnosed.
When distressed, he would smear his faeces, which, during his final hours, appeared to "trigger" a staff member.
The report says CCTV footage shows a staff member pushing Mr King roughly and dragging him down by his arms, before "hitting his head area with an open hand".
Norfolk Police said an investigation into Mr King's treatment was ongoing and a "number of inquiries have been carried out in an attempt to trace the suspect".
Mr King's mother Gina Egmore said her son was "gasping and couldn't talk" when she last saw him.
"They brought him out of a side door and he was slumped and held up by two staff," she said.
"He pleaded with me to take him home. I wish I had put him in the car then. I drove off."
An inquest heard that Nicholas Briant died of a brain injury following a cardiac arrest and obstruction of his airway after swallowing a piece of plastic cup.
He had told staff: "I cannot breathe. I am dying."
The scene was captured on CCTV, and the coroner said staff did not appear "to be doing anything".
The Jeesal Akman Care Corporation said: "The care they received at Cawston Hospital fell far below the standards we would have expected.
"We are deeply sorry that we let the families down.
"We closed Cawston Park Hospital and whilst the property is owned by our holding company, we will never run it as hospital again nor will we ever operate any other hospital."
Ms Flynn said "not enough has changed" since she carried out a previous review into the Winterbourne View scandal in 2011, when staff were secretly filmed by the BBC's Panorama programme abusing patients with learning disabilities.
In response, the government initiated the Transforming Care Programme to provide more community-based support to reduce "inappropriate" hospital admissions.
But more than 2,000 people are still in inpatient units like Cawston Park, according to a recent Commons report, which said "they are unable to live fulfilled lives and are too often subject to treatment that is an affront to a civilised society".