Learning from Experience Database - Serious Case Reviews

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Long Care Inquiry (Buckinghamshire)

Buckinghamshire County Council report on case of two homes for people with learning disabilities. For 10 years  Gordon Rowe a former social worker beat, tormented, drugged, neglected, indecently assaulted and raped many of the adults with learning difficulties who lived in the homes. The independent Inquiry examined why it took 10 years for the abusive regime to be exposed.  Failings were identified in a wide range of agencies which should have been able to detect and respond to the abuse.  The police investigation highlighted that many of the 26 local authorities with clients at the homes had had little or no contact with them for years and some were not even aware they had clients at the home.  Despite the NHS paying the bills for the care of one resident, nobody visited her to check on her welfare for over 10 years.

Professional learning:

  • Families of residents should be taught how to spot signs of possible abuse
  • Residents placed out of area should be visited and reviewed on a regular basis.
  • Staff, professionals and relatives must be encouraged to speak out about concerns and made aware how to do so. The importance of whistleblowing procedures.
  • Abuse awareness training should be available to all professionals and the professional duty to report concerns highlighted.
  • Prompt and thorough investigations of allegations
  • Police require abuse and disability awareness training
  • Regulators should balance the information gained during inspections to improve reliability.

1998 Independent Long Care Inquiry (Buckingham)