Norfolk Adult Safeguarding Board yesterday (10th September) published its report, authored by Margaret Flynn, into the deaths of Joanna, Nicholas (known as Jon) and Ben – three adults with learning disabilities who unnecessarily died in their 30’s whilst being looked after at Cawston Park Hospital.
The RRN has responded in full here.
Cawston Park Hospital is part of the Jeesal Akman Care Corporation Limited and was closed earlier this year (May 2021). Norfolk Safeguarding Adults Board (NSAB) conducted its review using “partial and incomplete information” provided by Jeesal. The review findings are shocking with Ben’s mother, Mrs Egmore, describing the deaths as a ‘scandal’.
Jeesal has said they are “deeply sorry” and the report concluded that such hospitals should “cease to receive public money”.
Joanna died with staff looking over her, unresponsive in her bed. The staff were all first aid trained, yet they did not attempt resuscitation. Joanna was supposed to be checked every 30 minutes as part of her care plan, however staff failed to observe her for two hours on the night that she died.
Ben was “gasping and couldn’t talk” when his mother last saw him. He had previously been hit, dragged and whacked by staff. The offender has not been tracked or prosecuted. Ben’s mother found him being held in “a hideous restraint” by staff at the failed hospital.
She said: “They had him outright with his arms, holding him really tight and his head was flopped down. I think the restraint is called a Crucifix restraint… he pleaded with me to take him home. I wish I had put him in the car then. I drove off”.
Nicholas died after swallowing a piece of plastic cup. CCTV captured his final moments where he had told staff: “I cannot breathe. I am dying”. Staff did nothing. Relatives described “indifferent and harmful hospital practices” and said their questions and “distress” were ignored.
At Cawston Park, and in contravention of the Restraint Reduction Networks Training Standards, unqualified staff used excessive restraint and seclusion to manage people who were simply communicating their utter distress at their appalling living conditions. These people were overmedicated and suffering “abject boredom”.
Alexis Quinn, Manager of the Restraint Reduction Network, activist and Autism campaigner, responded stating: “People’s ‘behaviour’ is communication. We know this. In circumstances such as the ones these poor people were detained in, it is little wonder they were expressing distress. Reading in the report that ‘patients did not benefit from attention to the complex causes of their behaviour, to their mental distress or physical health care’ is completely unacceptable.
“What we really don’t need now is more reports. Instead, the recommendations from the reports written over the past few years, such as the CQC’s ‘Out of Sight’ report, need to be urgently and meaningfully actioned. A step forward would be to regulate commissioners, invest in community-based crisis housing and for the CQC to improve its feedback policies.”
The report rightly highlights that “the deaths of three young adults must plausibly question the systems response. The CQC has recently tightened up their inspection processes. This has meant that we are seeing more and more hospitals being rated inadequate. However abusive hospitals continue to be commissioned by CCG’s and NHS England. This means that remote hospitals, far from people’s families have unchallenged scope to retain patients with no consequences for the abuse they enact. This must be addressed.“
Watch the BBC news report exploring Maria Forwood’s emotional story about her son Adam’s experience at Cawston Park. Maria removed her son from the hospital.
Cawston Park is now closed. The report concludes with a warning, “unless this hospital and similar units cease to receive public money, such lethal outcomes will persist”.
Download the full media statement from RRN here.