An inquiry into a hospital where vulnerable patients received unexplained injuries including bruises, black eyes and broken bones was told staff “systematically bullied” those in their care.
The long-awaited inquiry into the abuse of vulnerable people at Muckamore Abbey Hospital reported “profound and deeply troubling” failures in their care.
Restrictive practices were used inappropriately, and “as needed” medication was overused and “left some patients zombified,” the inquiry report also said.
Inquiry chairman Tom Kark KC told relatives at the hearing in Belfast how the mistreatment of their loved ones by some staff at Muckamore became “normalised”.
Muckamore Abbey Hospital near Antrim in Northern Ireland has been at the centre of the UK’s largest-ever police investigation into the alleged abuse of vulnerable adults.
Police have reported 124 individuals to Northern Ireland’s Public Prosecution Service to date and a number of prosecutions are continuing. The police investigation is running parallel to the public inquiry.
“The people who lived at Muckamore Abbey Hospital deserved better and their families deserved better,” said Mr Kark. The chairman said “unexplained marks and injuries” found on patients included “bruises, grip marks, black eyes and broken bones”.
He said the injuries reported by relatives of patients were “neither isolated nor incidental. They were the visible marks of a systemic failure.”
Glynn Brown said he was told an alleged assault on his non-verbal son Aaron by a staff member at Muckamore was a “one off incident”.
“The one-off incident that involved my son has now proved to be there was hundreds of incidents, there was red flags everywhere, but everybody was wearing blinkers, nobody wanted to see,” Mr Brown told a press conference in response to the report’s publication.
“There’s nobody as blind as those that don’t want to see – that’s an old quote.”
Solicitor Claire McKeegan, who represents several families whose loved ones resided in Muckamore, said the inquiry findings “confirm years of systemic abuse and failure”.
“For years these families were told they were exaggerating, or they were simply not listened to at all,” said Ms McKeegan.
“Today the inquiry has confirmed what they always knew — that their loved ones were abused on a staggering scale, that the failure was systemic, that the warning signs were there to be seen, and that those with the power to stop it did not.”
The report made clear that patients were abused at Muckamore. “It is important to state that bold and simple fact,” it stated. “The abuse did not involve every patient nor every member of staff, nor a majority of the staff.
“But many patients had their lives made miserable by systematic bullying by certain members of staff whose job it was to look after them.”
The inquiry report suggested Belfast Health and Social Care Trust had adopted an adversarial approach during its investigations and expressed “serious concern” as to whether it had the capacity to introduce reforms independently and without external direction.
Jennifer Wels, Chief executive of the Belfast Health and Social Care Trust, “sincerely and wholeheartedly” apologised to families for the care their loved ones experienced at Muckamore.
She added that she understood that the organisation had “lost trust” and said she was determined to rebuild “damaged relationships”.
“I am sorry to say that your loved ones were treated by many staff in the most uncivilised way by people who were there to care, who not only should have known better but more importantly should have behaved better,” she said.
In response to allegations that the trust had been “adversarial” she said: “I’m deeply sorry that proper legal process has been interpreted as something which is adversarial.”
There had been over 119 staff reviewed through disciplinary processes in relation to failings at Muckamore, with 115 concluded, the trust’s director of nursing Olga O’Neill said. She added that 19 staff had been dismissed, nine staff had received final warnings, 11 staff had received formal warnings and one verbal warning has been issued.
The inquiry said that a policy shift in 2001 to move all patients with learning disabilities and autism from hospital into community-based care, was not matched with investment meaning many patients could not be safely discharged due to a lack of capacity in the community.
This led to significant delays in resettlement, heightened distress, and in some cases readmission to Muckamore hospital. There was also “insufficient” staffing at all levels, the inquiry found, leading to unsafe wards, and restrictive practices were used inappropriately.
Some patients were left “zombified” by the overuse of “as needed” medication, also known as pro re nata (PRN) medication, was turned into a tool of restraint. Seclusion was also misused as punishment for so-called “bad behaviour,” the inquiry said.
The inquiry found a “profound catalogue of failures” at the trust, including “ineffective” external inspection regimes, and serious failures in governance within the Belfast Trust that led to the erosion of oversight at the care facility over many years.
Systems and structures in place were “wholly inadequate” to manage the scale of abuse uncovered through a review of CCTV footage in 2017, it said.
Speaking at the publication of the report, Mr Kark paid tribute to the residents of Muckamore and their families for being “central to uncovering the truth”.
“While the publication of this report cannot undo the harm suffered, it is my hope that it will serve as a turning point,” he said.
“The responsibility to act on the recommendations now lies with those who lead, manage, and deliver health and social care services across Northern Ireland.”
He said added: “There should be no delay, no dilution, and no side-stepping in the delivery of the recommendations.”
Stormont’s Health Minister Mike Nesbitt said he was “truly sorry” that vulnerable patients and their families had been “let down”.
“A system which should have ensured the most vulnerable were protected, nurtured, and cared for, failed in that core duty,” he said. “They were let down, and for that I am truly sorry.”
