Learning from Experience Database - Serious Case Reviews

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AB (Kent)

This review focused on the investigation into allegations made against a care worker AB working in an NHS Trust care home for adults with a learning disability. The allegations included physical, psychological abuse and neglect which taken together could rightly be described and institutional abuse. The police voiced concerns that alleged practices did not appear to have been addressed appropriately by the management. Specific allegations concerned 5 named residents and occurred over approx 2 years. Following police investigation AB was charged under section 127 of the Mental Health Act 1983. The charges were later dropped by the CPS just before the case was to be heard in the Crown Court. The reason given for this action was that although the charges could probably have been proven, it was considered not to be in the public interest to prosecute this care worker when more senior staff and managers who had failed to deal with the abusive behaviour had not been prosecuted.

Professional learning:

  • Investigations into institutional abuse must begin with a proper scoping exercise so that the role of management in the aetiology of any specific reported incident is included in the purview of the investigation and its outcomes.
  • Preparation for disciplinary hearings should be undertaken in consultation with and in tandem to the Police investigation.
  • Advocacy should always be available to vulnerable adults in safeguarding investigations. IMCA’s should be provided in cases of this kind where individuals qualify for assistance in making major decisions about accommodation, serious health care or in the wake of abuse if they are un-befriended, or if their family are seen to be acting against their best interests.
  • Standards in services that are designated for re-provision must not be allowed to fall below acceptable standards or to evade regulatory activity in respect of current provision.
  • Liaison between CPS and Police during investigations should be stepped up and include proper debate about the scope of investigation and the potential negligence of management, and/or appropriateness of corporate negligence as well as not, instead of, individual charges.
  • Joint SCR or Serious Untoward Incident Reviews, managed jointly within the Safeguarding Adult multi-agency procedures should be carried out when abuse is uncovered in NHS facilities.

2005 Serious Case Review regarding AB (Kent)