The true measure of society can be found in how it treats its most vulnerable members

Tom Kark KC chaired the Muckamore Abbey Hospital Inquiry, which published its final report in June and echoed the words of Mahatma Ghandi in the report.

For readers in England, this hospital name may not ring any bells but those hailing from Northern Ireland (NI) will immediately recognise it.

Muckamore is the largest hospital in NI which cared for people with learning disabilities (LD) and mental health problems. It was a long stay facility and, while a report published in 2005 advocated resettlement of all people with a LD into the community, there were repeated failures due to lack of investment in local community and social care.

The Inquiry was set up due to the discovery of abuse by staff of patients. This discovery also led to possibly the largest adult safeguarding investigation ever conducted, with criminal trials waiting to start following Operation Turnstone. The Inquiry heard from 235 witnesses.

Tom Kark’s name will be familiar as counsel to the Mid Staffordshire NHS Foundation Trust Public Inquiry. Following that, he was asked to examine the working and effectiveness of the Fit and Proper Person Test which is the statutory test under Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulation 5). His subsequent report entitled A Review of the Fit and Proper Person Test,also known as “The Kark Report”, was published in 2019. As a result of that, he provided a statement about the review to the Thirlwall Inquiry.

The Inquiry report totals over 700 pages and makes 106 recommendations.

We wanted to bring it to readers’ attention for many reasons. The report states that it must inform all other institutions (including smaller institutions and not ones as large as Muckamore) providing care to individuals with LD across NI and hopefully elsewhere. There are take aways in here for those commissioning, operating or investing in LD services. However, there are learning points that go much wider than this setting in terms of risk management. So, whether you are in the public sector or independent sector, in health or social care there’s something in here for everyone.

There are 18 chapters all of which contain points of note which we have summarised below.

Executive summary

• The Inquiry looked at the period December 1999 to June 2021 and found that many of the conditions found in previous abuse inquiries (such as Winterbourne View and Whorlton Hall) existed at Muckamore yet were not identified as signals of heightened risk, despite the setting and the patient care being high risk.
• There were multiple contributory factors.
• Abuse was witnessed but not prevented or reported.
• Concern was expressed by the Inquiry as to the number of occasions that an adversarial, oppositional and confrontational approach was adopted by the NHS Trust involved. It was noted that the Trust’s response to 33 areas of criticism (set out over 57 pages) was 479 pages long.
• In light of these findings, the Inquiry expressed serious concerns about whether the Trust had the capacity to change its approach, noting that this was the second major inquiry into the Trust in six years.
• Some abuse came about due to “the normalisation of deviance”.

Chapters 1 and 2: Patient experience

• Relatives spoke consistently about unexplained injuries, medication and oversedation and lack of basic care.
• Injuries were visible indicators of systemic failure. Dealing with each incident individually resulted in the inability of the organisation to recognise patterns, escalate concerns and protect patients.
• The findings underscore the need for vigilant observation, rigorous investigation, transparent communication and immediate safeguarding action whenever physical harm is suspected within institutional learning disability care settings nationally.
• There are lots of examples here of themes covered in subsequent chapters.

Chapter 3: Care and treatment

• Few patients had positive behaviour support plans and very few experienced psychological interventions. Occupational and speech therapy were extremely limited.
• There was a chronic shortage of suitably qualified professionals.
  Reduction of day care services and activities inevitably had a significant impact on patient boredom and, consequently, behaviour.

Chapter 4: Care planning and record keeping

• Records were split between paper and digital.
• Access to computers on wards was limited.
• Healthcare assistants (HCAs) had limited or no access to full care plans.
• While policies and review practices did exist, they did not describe the quality and depth of content required.
• Records frequently did not reflect the needs of patients, accurately describe the care delivered or its efficacy.

Chapter 5: Information sharing and co-production

• Co-production was neither consistently understood nor systematically practised.
• Care largely remained standardised not personalised.
  The prevailing culture was one of informing families rather than working collaboratively with them.
• Lack of communication with relatives is likely to have led to poorer care.

Chapter 6: Patients’ property and finance

• There were longstanding weaknesses in governance, oversight and transparency in relation to accounting and recording of service user finances.
• The Trust failed for several years to carry out required audits or provide assurance that statutory safeguards were being met.

Chapter 7: Restrictive practices

• Serious and persistent concerns were identified regarding the frequency, rationale, recording and governance of restrictive practices over a prolonged period.
• Policy, staff training and oversight did not keep pace with evolving understanding.
• Seclusion was a particular area of concern, at times being used punitively or as a matter of routine and not a matter of last resort.
• Governance and oversight of restrictive practices were inadequate with limited evidence of senior management challenge, trend analysis or sustained action to reduce use.
• Repeated departures from expected standard were described by the Panel as “normalisation of deviance”.

Chapter 8: Complaints and concerns

• There were systemic weaknesses in complaint handling, oversight and organisational learning.
• There was a lack of information or support about any investigation process.
• There were few formal complaints recorded over the 22-year period covered by the Inquiry.
• Complaints were often handled at ward level and not consistently recorded.
• Fear was a major barrier to complaint raising.
• Too many complaints were not resolved in a timely manner.

Chapter 9: Previous concerns, previous investigations and warning signs

• There were several signs that should have prompted earlier and more decisive intervention.
• Trends were visible through Datix reporting, safeguarding referrals and internal reports but were not translated into a strategic response.
• Better reporting, an explanation often given, was not a sufficient explanation for the rise in incidents.
• Findings from safeguarding were not routinely integrated with complaints data, serious adverse incident reports or incident trend analysis.
• Board level oversight focussed on assurance that procedures existed rather than on whether cumulative evidence pointed to escalating risk.
• Issues fell off Board agendas for extended periods.
• The system failed to connect the dots. There was no attempt to see the bigger picture.
• The failure was not a lack of data but a failure of interpretation, integration and leadership.

Chapter 10: CCTV, 2017 revelations and the response

• CCTV played a pivotal role in uncovering abuse.
• CCTV can be a powerful safeguarding tool in high-risk settings but only if accompanied by clear policy, strong governance, independent oversight and a culture that prioritises transparency and accountability over institutional protection.
• The Trust was unprepared for the consequences of the revelation and failure to manage it well led to multiple suspensions and replacement of staff with HCAs and temporary staff who did not know the patients, many of whom were untrained in caring for patients with severe learning disabilities.

Chapter 11: Safeguarding

• NI remains unique within the UK in lacking detailed adult safeguarding legislation although there is a new Adult Protection Bill passing through the Assembly.
• Safeguarding systems were fragmented and insufficiently integrated within the Trust’s wider clinical governance and risk management arrangements.
• Organisational responses focused on individual incidents rather than on systemic issues.
• The safeguarding system was reactive rather than preventative and insufficiently connected to the Board’s oversight responsibilities.
• Managers failed to recognise the escalating risks between 2011 and 2014, despite data being available via Datix. The clinical governance team failed to highlight these trends and there was limited awareness beyond ward staff.
• There were missed opportunities for the Board to delve more deeply into what was happening and they relied on assurances from executive directors rather than interrogating the data for themselves.
• The Board appeared to confuse risk appetite with risk assessment.

Chapter 12: Staff and ward management

• While resettlement policies gathered pace, Muckamore continued to house a highly complex and increasingly challenging inpatient population. This created a fundamental mismatch between workforce funding models based on a shrinking settled population and the evolving reality of patients requiring high levels of observation, behaviour management and specialist LD expertise.
• Planning for transition was inadequate.
• There was a longstanding practice of recruiting from local families making it harder to challenge unacceptable behaviour. This contributed to a closed culture characterised by loyalty to colleagues over patients.
• Patients lost access to primary care with psychiatrists managing both mental and physical health needs.
• There was no clinical pharmacist for at least ten years prior to 2018.
• All eyes were on the prize of full resettlement and this led to blindness around problems at Muckamore, either wilful or neglectful of the evidence.

Chapter 13: Senior management and Trust Board governance

• Good working governance is fundamental to any large business and even more significant where the care of vulnerable patients is part of the business.
• While extensive governance structures existed, they consistently failed to work to bring relevant information to the Trust Board and to translate information into understanding of risks or into an active response.
• There was an overreliance on executive reassurance, limited interrogation of data and insufficient challenge of clinical and social care risks.
• The Trust focused on governance processes rather than outcomes.
• Incident reporting, safeguarding referrals, complaints and staff intelligence were routinely aggregated at Trust level, masking significant variation at hospital level, thus obscuring patterns of harm at Muckamore.
• Risks were often downgraded or removed as they ascended the risk register hierarchy even when underlying conditions persisted or deteriorated.
• The Trust rarely tested whether mitigating actions were effective in practice or reduced patient harm.
• The governance system failed at multiple levels. It did not integrate information across different assurance routes, failed to identify and act on patterns of harm and lacked the curiosity, expertise and challenge necessary to safeguard highly vulnerable patients.
• There was no evidence that a review of non-executive director (NED) skills had taken place following previous reviews, the Hyponatremia Inquiry or that NEDs were increasingly challenging the executives.
• The failure by management to act upon reports by staff and a consequent failure to change poor practices can easily lead to an acceptance of a culture of “this is the way things are done around here”.
• External concerns were not given sufficient attention.
• The performance of a Board as a unitary team is necessary.

Chapter 14: External agencies inspection and oversight

• Failed to operate as an effective safety net.
• Oversight was reactive rather than preventative.
• External regulation and investigation must extend beyond procedural compliance and episodic inspection.
• Effective oversight requires proactive, risk-based approaches that examine culture, triangulate multiple data sources, engage directly with families (and where possible patients) and act decisively when conditions associated with abuse are present.

Chapter 15: Resettlement

• Targets were repeatedly revised, delayed or abandoned.
• Resettlement targets were hard to achieve due to new admissions occurring at the same time.
• The Inquiry heard from several relatives who described the specific benefits to former patients once they had been resettled.

Chapter 16: Planning and funding of LD services in NI

• There was a persistent gap between stated policy ambitions for community-based care and the practical realities of service delivery, funding and workforce capacity.
• While policy direction was clear, implementation was slow, fragmented and inadequately resourced.

Chapter 17: Managing the delivery of service for people with LD and autism

• The organisational structuring of the Trust placed Muckamore several levels from direct oversight of the Trust Board.
• The governance structures were ineffective and contributed to an environment where individuals at Muckamore were not adequately safeguarded.
• There was a failure to grasp the key principles of assurance as opposed to reassurance.

There's lots to digest here. For more information, please get in touch with our health and care team.

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