Muckamore: Damning review reveals 'missed opportunity' to prevent abuse
A devastating review into Muckamore Abbey Hospital has discovered a "missed opportunity" by "dysfunctional" management to identify and act on institutional abuse committed eight years ago - with almost identical allegations occurring five years later.
The report was released to families of vulnerable patients in a hotel room last night and led to an apology from Health Minister Robin Swann, who confirmed he will now order an inquiry into the scandal. He has not indicated however if this will take the form of a public inquiry.
Ordered by the Department of Health in January, the 'leadership and governance' review into the Co Antrim hospital for adults with severe learning disaiblites discovered the regional facility acted as a "place apart" poorly led by a management team riven with tensions, personality clashes and animosity.
In an extraordinary indictment of the top tiers of the north's biggest health trust, the review authors found there was lack of interest and passion at trust headquarters in Belfast, with "infrequent" visits by those in charge to the hospital, located close to Antrim town.
They found: "The leadership team at MAH was dysfunctional with obvious tensions between its senior members. There was also tension around the intended future of the hospital with some managers viewing its future as a specialist assessment and treatment facility while others perceived it as a home for patients.
"There was a lack of continuity and stability at Directorate level and a lack of interest and curiosity at Trust Board level. Visits of Trust Board members and other Directors to MAH were infrequent. Leadership was not visible.
"The location of MAH at some distance from the Trust and the lack of curiosity about it Trust level caused the Review Team to view it as a place apart. Clearly, it operated outside the sightlines and under the radar of the Trust."
The hospital is currently at the centre of the biggest criminal adult safeguarding investigation of its kind in Northern Ireland - if not the UK - with more than 1,500 crimes relating to one ward over a six-month period between April and September 2017.
Almost 60 staff are suspended following harrowing allegations of physical assaults and mental cruelty of vulnerable adults were captured on CCTV in 2017.
The review team found that had the hospital's senior managers acted properly on previous allegations committed in the all-female 'Ennis Ward' then it could have provided an opportunity to avert the scale of the 2017 incidents.
They describe abuse uncovered on CCTV as "troubling...morally unacceptable and indefensible behaviours".
The findings of the internal confidential Ennis report were leaked to The Irish News last October and laid bare a catalogue of appalling mistreatment of patients with authors expressing concern that "alleged behaviours" were "happening openly in front of visiting staff" on a ward in November 2012.
The governance review team state that an examination of the Ennis scandal was central to their review of the hospital's leadership as well as the trust's policy on CCTV - with staff unaware that cameras were recording.
They also criticised a previous trust commissioned 'Serious Adverse Incident 'report into safeguarding failings carried out in 2018, saying it hadn't "sufficiently" probed leadership and governance arrangements at Muckamore or the Belfast trust.
They state: "The Review Team considered the Ennis investigation to be a missed opportunity as it was not escalated
to Executive Team or Trust Board levels for wider learning and training purposes."
They added: "The Review Team considered the situation at Ennis to be an example of institutional abuse. Learning from Ennis therefore had the potential to identify anyother institutional malpractice at an earlier stage."
Severe criticism of the trust's CCTV policy was also made, with authors finding CCTV cameras were operational in the hospital from 2015 but it took “an inexplicably long time” produce a policy to implement this.
The report concludes that staff were unaware the cameras were recording and singles out the persistence of a concerned parent, Dundonald man, Glynn Brown, who demanded to see the footage following reports that his son Aaron was allegedly assaulted in August 2017/
The team find: "The CCTV cameras had been recording for a considerable amount of time, apparently without the knowledge of staff or management. The discovery of historical CCTV recordings prompted by the intervention of a concerned parent, revealed behaviours which were described as very troubling, professionally and ethically, which were morally unacceptable and indefensible.
"It is apparent from extensive discussion with staff at all levels that there was no awareness that the cameras were operational. The MAH staff member (retired) most likely to be in a position to clarify matters regrettably did not respond to the request to meet with the Review Team."
The team made a raft of recommendations to improve governance at the hospital.
Speaking to The Irish News last night, Mr Brown welcomed the review's damning findings as a "step forward" and vindication of the families' pursuit to get answers.
However, Mr Brown said he was concerned about the lack of co-operation by some senior officials and called for a judge-led public inquiry to be ordered immediately.
"We appreciate the good work that has been done by the team but I have serious reservations about three senior officials who we were told tonight did not co-operate. That is why we need a full public inquiry to compel those individuals culpable to give evidence before a judge about what went on."
Claire McKeegan, a solicitor acting for the group, said the review's findings "only reinforce the immediate need for and the obligation on the minister for health to implement a full public inquiry into systemic abuse at this regional hospital".
"These families have been hurt and damaged by our health service and are entitled to have accountability and answers,"she said.
Mr Swann last night apologised publicly to those affected and said he would call an inquiry.
"I can confirm that it is my intention to establish an inquiry on Muckamore. Thanks to this report, we now know more about why the appalling failings at the hospital occurred. This will help me determine the nature and scope of a future inquiry, which must focus on the questions that remain unanswered and the crucial issue of how we stop this happening again.
"To do so, after considering this report in detail, I want to consult further with families, patients and former patients about the most appropriate terms and format for an inquiry.”
He added: "This was a sustained failure of care, affecting some of the most vulnerable members of our society. Patients and families have been let down and I want to apologise to them on behalf of the Health and Social Care system.
"I also want to apologise publicly to Mr Glynn Brown and pay tribute to his perseverance and devotion to his son. Mr Brown’s determination was central in exposing the truth about Muckamore. It shouldn’t have been left to him to do this but we should all be very grateful that he did."
Belfast Trust's Chief Executive, Dr Cathy Jack also issued an unreserved apology to those patients and their families who had been failed.