Learning from Experience Database - Serious Case Reviews

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Cornwall Partnership NHS Trust

Cornwall Review (2006): Joint investigation into the provision of services for people with learning disabilities at Cornwall Partnership NHS Trust.  The investigation found that institutional abuse was widespread, preventing people from exercising their rights to independence, choice and inclusion. One person spent 16 hours a day tied to their bed or wheelchair, for what staff wrongly believed was for that person’s own protection. More than two-thirds of the sites investigated placed unacceptable restrictions on people living there. For example, some internal and external doors were kept locked by staff to restrict the movement of people from the services, instead of seeking alternative methods to address perceived problems. In one home, taps had been removed and, in another, light fittings were taken out. The finances of people in supported living services were poorly managed e.g. the pooling of money to a shared household account and the use of people’s money to purchase communal goods and pay for improvements to homes.  There was evidence of physical restraint being used illegally and excessive use of PRN medication to control behaviour.  One person spent 16 hours a day tied to their bed or wheelchair, for what staff wrongly believed was for that person’s own protection.

2006 Joint Investigation into Cornwall Partnership NHS Trust