- Essex Safeguarding Adults Board

Transcription

Published - March 2013
Safeguarding
Adults DVD
Facilitator Guide
A guide to help you use your DVD training resource
effectively
In March 2013 ESAB published a safeguarding adults training DVD with news clips and abuse
scenarios to help provoke useful conversation when delivering adult safeguarding training.
This guide attempts to help you, as a trainer, to use that DVD effectively.
Safeguarding Adults DVD Facilitator Guide

1
Table of Contents
How much of the DVD should I use in a single session? ..................................................................................2
How should I use the workbook? .........................................................................................................................2
DVD Structure......................................................................................................................................................2
Acted Scenarios ........................................................................................................................................................3
Scenario 1 – Rob’s Social Networking ..............................................................................................................4
Scenario 2 – Visiting Annie ................................................................................................................................7
Scenario 3 – Alan is nervous on the ward ........................................................................................................9
Scenario 4 – Managing Mum’s Finances ........................................................................................................12
Scenario 5 – Carol’s MS Care ...........................................................................................................................15
Scenario 6 – Rob’s Night Out ...........................................................................................................................18
News Clips .............................................................................................................................................................20
Story 1 – David Askew .....................................................................................................................................21
Story 2 – Francesca Hardwick..........................................................................................................................23
Story 3 – Ivy Robinson ......................................................................................................................................25
Story 4 – Nella Black..........................................................................................................................................27
Story 5 – Stafford Hospital ...............................................................................................................................28
Story 6 – Winterbourne View...........................................................................................................................31
Additional Resources ............................................................................................................................................35
Nursing and Midwifery Council films ...........................................................................................................35
Social Care Institute for Excellence films .......................................................................................................36
BBC News resources .........................................................................................................................................38
How should I use the workbook?  1

Safeguarding Adults DVD
Facilitator Guide
A guide to help you use your DVD training resource effectively
How
much of
the DVD
should I
use in a
single
session?

How should I use the workbook?
This facilitator guide should be used by the trainer in conjunction with the DVD for
training purposes. The DVD is intended to support trainers who are delivering
Safeguarding Adults training by encouraging engagement from learners through
discussion of key points from a mixture of acted and real life examples.
This DVD is not
intended to be
shown
as
whole.
Instead
one
or
a
two
DVD Structure
appropriate
The DVD is split into 2 main sections:
scenarios should
be selected by
1) Section 1 contains a series of acted scenarios designed to provoke discussion
regarding the various abuse types, safeguarding concerns and professional
boundaries. Trainers should ensure that they allow a minimum time period
of 20 minutes per DVD scenario in order to fully gain the learning points
the trainer based
upon the needs
of
the
group
being trained.
intended.
Each
scenario
2) Section 2 contains a collection of six news clips all relating to stories covered
will only play
by the national press in the last few years. Each of the stories relates to a
for a minute or
different abuse type – trainers should choose one or two of the clips most
two, but when
relevant to their learning group. News clips may also be a useful example
facilitated
when describing a particular abuse type. Additional useful media coverage
each
scenario
is pointed to under ‘Additional Resources’.
will
generate
well,
substantial
discussion
How should I use the workbook?  2
around potential
abuse or neglect
pointed
to

Acted Scenarios
In this section we look at the background to the six acted scenarios and consider a series of prompt
questions to develop learner discussion. Some scenarios also include further hypothetical situations to
add to the clips to change the direction of group discussions and extract further learning. Symbols have
been used to help you quickly identify different useful resources. The three symbols are identified
below:
This symbol identifies a list of prompt questions which a trainer should use alongside a clip
to generate, develop and lead discussion by learners.
This symbol identifies a list of hypothetical situations which can be used to change the path
of discussion by learners and help to develop thinking. Not all scenarios include hypothetical
situations.
This symbol identifies points we have included for the trainer to note. These points help the
trainer to understand the purpose of the clip. These points are intended to make the planned learning
from the clip clear and identify the types of issues learners should discuss having watched the scenario.
Acted Scenarios  3

Scenario 1 – Rob’s Social Networking
Rob is 20 years old and has mild learning disabilities. He lives in a supported flat. His support worker
Stephen helps Rob to log onto the computer but then Rob can use the internet by himself. He regularly
uses chat rooms and social media to make friends. The scenario looks at whether Rob is being abused
over the internet.
Prompt Questions
After watching the DVD scenario, there are a number of prompt questions below.
 What are the group’s thoughts about the scenario?
 Is any abuse taking place? And from whom?
o
If so what type and what indicates that form of abuse?
 What would you do if you were Stephen in this scenario?
 Who is Sarah? Any concerns about her?
 Who is bud? Any concerns about him?
 Is Stephen doing enough to support Rob?
o
Should Stephen encourage Rob to ‘go out’ more?
o
Should Stephen watch Rob whilst he is on the internet to ensure he is safe?

o
Should Stephen put parental controls over on the computer?
o
Is there anything that can be put in place to enable Rob to safety use the internet?
 Why might Rob not want Stephen to know about Sarah?
 What risks are there to using chat rooms/internet?
 What benefits are there to using chat rooms/internet?
 How would you respond to the comment that Rob was “skint”?
 Are there any other organisations that you would involve?
o
If so who and why?
Hypothetical situations
The group could also start discussing hypothetical situations. Would your reaction be different if;

Rob disclosed he had given Sally £400? For example the iPhone that Rob mentioned he had
purchased from Sally in scenario 6 would, in fact, have cost a substantial amount of money.
(Screenshots from scenario 6)

Rob disclosed Bud was bullying him online?

Rob was arranging and meeting up with women/men?

Rob was accessing pornography?

Points to note
The facilitator should try and elicit from the group the different indicators of possible abuse. It is
important to note that Rob is a 20 year old male and using the internet is part of life. The group should
be dissuaded if their solution to this scenario is to stop Rob from using the internet and/or chat rooms
or control what he can access online. Efforts should be made to give Rob information about the risks to
using the internet and that people may not always be as they appear i.e. Sarah may not be the young
woman that Rob has seen on ‘her’ profile. She could, in fact, be a 50 year old male. Where a crime is
suspected to have taken place, the police should be contacted.

Scenario 2 – Visiting Annie
Annie is 70 years old and lives in her own privately owned house. Annie has difficulty breathing due
to a health condition and has an oxygen tank to help her. Her house is untidy. The scenario looks at
whether Annie is being neglected.
Prompt Questions
o
 What indicators are there of neglect (either self or by others)?
 What would you do if you were the visitor in this scenario?
 Does Annie have mental capacity with regards to her accommodation?
o
If so what indicates this?
 What risks are there to living in the house?
 What benefits are there to living in the house?
 Any thoughts on the visitors’ interaction with Annie?

 What could be done to support Annie?
 What if Annie did not want any support?
o
If so who and why?
Points to note
The facilitator should try and elicit from the group the different indicators of possible abuse. It is
important to note there are no indications that Annie lacks capacity in relation to her living standards.
Principle 1 states that there should be a presumption of capacity unless proven otherwise and principle
3 states that we retain the right to make unwise decisions.
Living in poor conditions which may potentially put an individual’s health at risk is not necessarily an
indicator of lack of capacity; it could be an unwise decision. Not everyone lives according to the same
standards of cleanliness.
Annie may need some support to assist her with daily living due to
deteriorating health or she may have lived this way since she was younger. This situation can be
difficult to deal with if Annie lives in private accommodation and refuses to have any support as there
is little that authorities can legally do, however all efforts should be put in place to support Annie. The
group should also consider whether other professionals should be involved, such as:
 Health service
 Fire service
 Social care
 Environmental health
 Befriending services

Scenario 3 – Alan is nervous on the ward
Alan has been admitted to a psychiatric hospital on a voluntary basis. The scenario looks at dealing
with challenging behaviour as well as abuse between service users.
Prompt Questions
o
 What should be done in this situation?
 Can Allen be prevented from leaving if he is a voluntary in patient?
o
What would the organisation need to do if they felt that Allen is not safe to leave?

 Are there any concerns about how staff dealt with the situation?
o
If so, what should have been done?
o
Could the situation have been prevented/reduced?
o
What difficulties are there in dealing with unpredictable/challenging behaviours?
o
If so who and why?
The group should also consider situations where abuse occurs between service users;

Would you raise a safeguarding concern the first time it happened?

Would it make a difference if the abuse happens more than once?

How should an organisation deal with abuse between two service users?

If you raise a safeguarding concern about two service users, who is the perpetrator?

What is the difference between a complaint and a safeguarding referral?
When going through the answers to these the questions the group should be aware that abuse between
two services users wouldn’t automatically result in a safeguarding alert. Staff should be encouraged to
think about whether the organisation is doing enough to keep both the service users safe and about
looking for any underlying reasons why the abuse may be taking place.

Points to note
The facilitator should try and elicit from the group the different indicators of possible abuse and what
should be done in the situation. The group should think about whether the Deprivation of Liberty
legislation applies to the scenario. As Alan was admitted voluntarily he is free to leave the mental
health setting. Preventing him from leaving would be unlawful. Staff should consider whether other
mental health sections or DoLS could apply.

Scenario 4 – Managing Mum’s Finances
Catherine is 75 years old. She moved into a residential home a year ago following a diagnosis of
dementia. Her husband George and son John regularly visit. The scenario looks at whether Catherine
is being financially abused.
Prompt Questions
o
 Does Catherine have Mental Capacity to manage her finances?
o
What indicates this?
o
If Catherine has dementia, does this mean she lacks Mental Capacity?
 Can John sell the house on behalf of his mum and dad?
o
Has John got Power of Attorney (PoA) over Catherine’s finances?
o
What indicates this?
o
Can this be checked?

o
What can be done if you have concerns about inappropriate use of PoA?
 Any concerns about Catherine’s care?
o
If so who and why?
 What happened to the necklace?
Points to note
The facilitator should try and elicit from the group the different indicators of possible abuse. The
trainer should be familiar with the Mental Capacity Act and the key principles.
Just because Catherine has a diagnosis of dementia doesn’t automatically mean that she lacks capacity,
an MCA 2 would need to be undertaken if there were concerns about a specific issue. Is it clear
whether John is acting in Catherine’s best interests by arranging to sell her house?
If John has got PoA over Catherine’s finances, this would have come into play when she lost capacity to
manage her money (following an MCA 2 assessment). PoA can also be checked through the Office of

Public Guardian (OPG). Staff should always ensure that where someone else is claiming to have PoA
and making decisions on an individual’s health and welfare and/or finances that they see the
paperwork or check this with OPG. If John is not managing Catherine’s finances in her best interests,
this can be challenged through the Court of Protection.

Scenario 5 – Carol’s MS Care
Carol in her 30’s with Multiple Sclerosis (MS). She lives alone and relies upon domiciliary care to help
her with tasks around the house. Carol is clearly disappointed by the amount of time her carer spends
with her. The scenario looks at a short visit by Carol’s carer and is designed to generate discussion
about what abuse, if any, is occurring in Carol’s home.
Prompt Questions

What are the group’s thoughts about the scenario?

Is any abuse taking place? And from whom?
o
o
Is it concerning that Carol is confused about how quickly her tobacco is being used?

Are there any concerns about the carer?

What would you do if you were the visitor in this scenario?

What could be done to support Carol?

If Carol has concerns about her own care, what are her options?

Are there any other organisations that you would involve?
o
If so who and why?

Points to note
group should discuss Carol’s frustration at the lack of time her carer spends with her – however her
appearance does not suggest that she is necessarily neglected - Carol is well dressed and her general
appearance is very good.
The group is expected to question the level of support that Carol necessarily requires and whether
there is more of an issue with loneliness – Carol mentions that “anything is better than staying in this
God forsaken place” which suggests that she doesn’t necessarily go out very often and that she is very
frustrated with her surroundings.
The carer leaves in a hurry leaving Carol outside – but Carol needed to be pushed outside in her
wheelchair. Is she able to get back inside? It is clearly not a warm day because Carol is covered by a
blanket.

The group should also consider a hypothetical situation:

Would it make a difference if the care Carol received was more of a voluntary arrangement i.e.
care was being provided by a family member or a friend?

Is Carol overplaying the severity of her MS? Though she demanded to be pushed outside in the
wheelchair, at the end of the clip Carol moves her foot from the wheelchair, almost as if to
stand. Earlier in the scene a walking stick is in shot which also suggests that Carol’s mobility
may be better than the viewer is led to believe.

Scenario 6 – Rob’s Night Out
Rob is 20 years old and has mild learning disabilities. He lives in a supported flat. In this scenario Rob
goes out to meet some friends with Stephen, his support worker. The scenario looks at professional
boundaries and whether Stephen or others over step any boundaries.
Prompt Questions

What are the group’s thoughts about the scenario?

Is any abuse taking place? And from whom?
o

Any concerns over Stephen, the keyworker?
o
Who is responsible for paying for drinks if they go out?


o
Who is responsible for paying for activities if they go out?
o
Should the keyworker be drinking alcohol whilst working?
Any concerns over Sally?
o
Who is Sally? Should there be any concerns?
o
What is her relationship with Rob?

Is it appropriate to be friends with service users on Facebook?

Is there a difference between being friends and being friendly?

Are there any other organisations that you would involve?
o
If so who and why?
Points to note
group should discuss professional boundaries – what is and isn’t acceptable when working with
service users. The facilitators should explore some of the greyer areas to try and get the group to think
about their professional boundaries.
The facilitator may wish to bring in some hypothetical situations to discuss;

Do personal budgets complicate boundaries between friendships and ‘work’?

Is it appropriate, if you get on as friends, to go out socially with service users?

Is it ever acceptable to accept gifts from service users?

Is it acceptable to do things that would help a service user but that is not in the care plan i.e.
take someone shopping, cut their hair etc.?

News Clips
Section 2 of the DVD contains six news clips all relating to stories covered by the national press in the
last few years. Each of the stories relates to a different abuse type – trainers should try to choose one or
two of the clips most relevant to their learning group. These news clips may also provide a useful
example when describing a particular abuse type. Additional useful media coverage is pointed to
under ‘Additional Resources’.
ESAB has purchased the rights from The Press Association to distribute the six clips on the DVD. Links
to further useful resources on the web, which ESAB does not own the right to share on the DVD, are
shared under ‘Additional Resources’.
News Clips  20

Story 1 – David Askew
The first news clip on the DVD tells the story of 64 year-old David Askew,
a man with learning disabilities who died having endured 30 years of
"torment" by local youths.
Below we have included the BBC’s coverage of the story which provides
further information to support the clip.
7 December 2011
Bullied David Askew unlawfully killed after 'years of
torment'
A bullied man with learning disabilities who was subjected to 30 years of "torment" was unlawfully
killed, an inquest ruled. David Askew, 64, was found dead outside his house in Hattersley, Greater
Manchester, in March 2010.
A pathologist earlier told the inquest an altercation with youths 10 minutes before he collapsed had
been a factor in his death.
South Manchester coroner John Pollard ruled Mr Askew was unlawfully killed.
Mr Pollard said there was a "staggering degree of inertia and complacency" shown by police, the
council and housing associations in dealing with the anti-social behaviour towards Mr Askew.
"The fact that there is 38 separate offences reported against this family within a three-year period
shows the appalling way in which this element of feral youths can bring misery to a decent, vulnerable
family," he said.
'Long-suffering torment'
Pathologist Dr Charles Wilson told the coroner Mr Askew had suffered from ischemic heart disease,
which meant not enough blood got to his heart. He was also suffering from cancer of the oesophagus.
Mr Wilson said the adrenalin released by the altercation with the youths would have made his heart
beat faster, and in turn this could cause heart failure in an already weakened heart.
On the opening day of the inquest, Mr Askew's mother Rose said her son had endured "long-suffering
torment".
She said he had been called "lunatic" and had sticks and stones thrown at him, with eggs and tomatoes
thrown at the family home. She has since moved from the area.
News Clips  21

In a statement made after the ruling, she said: "My life is not the same without David. I feel as if part of
me is gone.
'Hate crime'
"I am still angry about what happened to David but there is no use hating people. Not all teenagers are
like the ones who would target David every day and every night.
"I also want to say how lovely the support has been from the police and other agencies. People often
forget that police officers are human beings and they really care about us."
A spokesman for Tameside council acknowledged all agencies within the borough needed to work
"more closely" together.
"[We need] to identify vulnerable people within our communities, and ensure that we are effective in
protecting them from harassment and hate crime," he said.
A spokesman for Greater Manchester Police said: "We have learned our lessons and made significant
improvements to the way we deal with these crimes."
More on This Story
Related Stories
Victim 'was harassed by youths' 05 DECEMBER 2011, MANCHESTER
(BBC, http://www.bbc.co.uk/news/uk-england-manchester-16067795)
News Clips  22

Story 2 – Francesca Hardwick
Story 2 in this section of the DVD tells the story of Francesca Hardwick
whose mother, Fiona Pilkington, committed suicide and killed
Francesca following years of abuse from neighbours.
28 September 2009
Police criticised by inquest jury
The actions of police and two councils were partly to blame for the deaths of a mother and her
disabled daughter, an inquest jury ruled.
The jury decided Fiona Pilkington, 38, committed suicide and unlawfully killed her daughter Francecca
Hardwick, 18.
The inquest heard the family had endured years of abuse at the hands of neighbours in Barwell,
Leicestershire.
Home Secretary Alan Johnson said the police and councils had "some hard lessons" to learn.
The Independent Police Complaints Commision (IPCC) said it was investigating the police response.
The inquest at Loughborough Town Hall heard that Ms Pilkington,
Sustained anti-social
her daughter and her son, Anthony, a severe dyslexic, suffered
behaviour in a neighbourhood
more than 10 years of abuse from a gang of teenagers living on
over a period of several years has
their street.
contributed to a truly horrific
and tragic outcome
Ms Pilkington is believed to have poured the contents of a 10-litre
Amerdeep Somal, IPCC
can of petrol over clothes in the back seat of the car, and set them alight.
The jury found that Ms Pilkington killed herself and her daughter "due to the stress and anxiety
regarding her daughter's future, and ongoing anti-social behaviour".
The jury foreman said the police's response had had an impact on Ms Pilkington's decision to
unlawfully kill her daughter and commit suicide. He added: "Calls were not linked or prioritised."
News Clips  23

The jury also highlighted lack of action by Hinckley and Bosworth Borough Council and Leicestershire
County Council. Mr Johnson said the family "suffered intimidation at the hands of a local gang,
culminating in a sustained level of abuse that no family should have to tolerate".
"Leicestershire Police and their local authority partners have had some hard lessons to learn about past
failures, which will be the subject of further investigations," he added.
Relatives described how Ms Pilkington had complained for years about youths "taunting and abusing"
her at her home, but six months before her death had told them "I give up".
Temporary Chief Constable Chris Eyre of Leicestershire Police said he was "extremely sorry" that
police failed to help Ms Pilkington and her daughter.
'Truly horrific'
In a statement, the Independent Police Complaints Commission (IPCC) said it would be investigating
the response of Leicestershire Police to calls for assistance made by Ms Pilkington.
IPCC Commissioner Amerdeep Somal said: "This is an extremely distressing case about which there is
understandably a great deal of public concern.
"It appears to be a case where sustained anti-social behaviour in a
neighbourhood over a period of several years has contributed to a
truly horrific and tragic outcome."
She said they would be examining "how seriously the police
responded to her calls for help, whether the action was appropriate
and what actions they did or did not take".
Ms Pilkington's family said it had been a
'terrible time'
Speaking after the hearing on behalf of her family, Pam and David Cassell, Fiona's parents and
Frankie's grandparents, said:
"This has been a terrible time for us and we wouldn't have managed without the love and support from
our friends and family.
"This case has highlighted the difficulties that families with disabled children face. We know that the
agencies involved have looked to see how they can improve the way they work."
(BBC, http://news.bbc.co.uk/1/hi/england/leicestershire/8279106.stm)
News Clips  24

Story 3 – Ivy Robinson
Story 3 in this section of the DVD tells Ivy Robinson’s story. Ivy Robinson’s care
assistant was jailed after physical and verbal abuse was captured on a hidden
camera.
29 August 2012
Abusive Pontefract care home workers caught on CCTV
A care assistant has been jailed for the "sickening"
mistreatment of an 89-year-old woman whose
family recorded the abuse on a hidden camera.
Emma Bryan, 29, hit and shook Ivy Robinson and
verbally abused her at Oakfoss House Residential
Care Home in Pontefract, Leeds Crown Court
heard.
Bryan, of Harewood Avenue, Pontefract, was jailed for four months.
Colleague Katherine Wallis, 45, was given a 12-month community order after also admitting neglect.
The care home's owner said after the hearing it was "devastated" to learn of the ill-treatment and had
immediately contacted police.
Bryan admitted five counts of wilful neglect or ill-treatment while Wallis, of Rhyl Street, Featherstone,
admitted one count of the same offence.
The court heard the pair dragged Mrs Robinson across her bedroom floor which made her scream in
pain before Wallis threatened her with violence.
The elderly woman's family captured the five days of abuse in November last year on a CCTV camera
concealed in an alarm clock after they noticed she was bruised and traumatised.
Richard Butters, prosecuting, said Bryan was filmed swearing at Mrs Robinson and calling her a
"horrible old lady".
The footage also revealed she had failed to give Mrs Robinson her medicine properly and showed her
striking her before swearing at her again.
News Clips  25

The judge described Bryan and Wallis's actions as "unforgivable and unacceptable neglect and illtreatment".
Following the sentencing, Mrs Robinson's daughter and son-in-law, Angela and Simon Wood, said: "To
see what Mum was subjected to sickened and horrified us, this will never leave our memories;
moreover we feel as though we have let Mum down.
'Abhorrent' behaviour
"The decision to install the CCTV came as a last resort and was a culmination of various incidents over
a period of months that could not be explained by staff at Oakfoss.
"The final trigger was when Mum became agitated and frightened when it came time for us to leave on
an evening.
"She would cry and ask us not to leave. No one knows how long this abuse and neglect had been
going on for."
The couple said Mrs Robinson may be moved out of Oakfoss House, dependent on a medical
assessment, and they were considering taking legal action against the home's owner, Denestar
Limited.
Gaynor Saunders, the company's managing director, said: "Providing our residents with excellent care
and quality of life is my number one priority.
"I was devastated to learn that two long-standing, experienced employees who'd been given extensive
training in caring for and safeguarding elderly and vulnerable people had behaved in such an abhorrent
way.
"I immediately notified the police, social services and the Care Quality Commission and have worked
closely with them to ensure the former employees involved face the severest of consequences for their
actions.
"Words cannot express how sorry I am, to the resident and family involved, that they have suffered at
the hands of people who ignored their duty to provide care and show kindness and respect to someone
who was entitled to expect this."
More on This Story
Related Stories
Ivy Robinson care home abuse: Daughter warns other families 30 AUGUST 2012
(BBC, http://www.bbc.co.uk/news/uk-england-leeds-19412723)
News Clips  26

Story 4 – Nella Black
Story 4 in this section of the DVD tells Nella Black’s story. Nella
relied heavily upon Catherine Armstrong for support due to
deafness and blindness. Catherine Armstrong abused that
reliance and admitted 10 counts of theft just minutes before she
was due in court.
Below we have included ‘News & Star’ coverage of the story
which provides further information to support the clip.
Tuesday, 23 August 2005
Brave Nella is lesson to us all
Eleanor Black – known as Nella to her friends – has shown admirable courage in facing up to the con
woman who stole £2,000 from her.
The 92-year-old is housebound and heavily dependent on others. She is blind and deaf and has
considerable difficulties communicating.
Yet she has shown grit and determination in helping the police press charges against the person who
took advantage of her.
Catherine Lowe Armstrong, 52, of Canonbie, admitted 10 counts of theft, minutes before she was due
to go on trial at Carlisle Crown Court.
Nella, despite her frailty, had been determined to help see justice done and had agreed to give
evidence to the court via a video link.
This was a despicable crime. Armstrong was Nella’s care worker charged with – and trusted to – help
with her dressing, cleaning and finances.
Instead she persuaded Nella to sign blank cheques and pocketed the money. Armstrong no doubt
thought she had the perfect cover and had found a victim who was entirely helpless and unable to
defend herself.
Crimes of this kind against the elderly are sadly all too common. Let Nella’s case serve as a reminder
to us all to play our part in taking care of elderly people in our communities and helping them keep such
callous, predatory criminals at bay.
(News & Star, http://www.newsandstar.co.uk/opinion/2.1787/brave-nella-is-lesson-to-us-all1.429465?referrerPath=home/2.1962 )
News Clips  27

Story 5 – Stafford Hospital
Story 5 in this section of the DVD tells the story of a public enquiry into Stafford
Hospital . The hospital was accused of routinely neglecting patients and
providing appalling standards of care.
Below we have included the BBC’s coverage of the story which provides further
information to support the clip.
8 November 2010
Stafford Hospital inquiry to look at 'poor standards'
An inquiry into avoidable deaths at Stafford Hospital will look at why the health care system tolerated a
"terrible standard of service".
A 2009 report condemned conditions at the hospital, which are said to have caused hundreds of
avoidable deaths.
The last government ordered a private investigation, but refused a wider public inquiry.
But in June the coalition government said the families of those who died deserved to know what went
wrong.
Campaigners praised
It is the fifth inquiry into the higher than expected deaths at Stafford Hospital between 2005 and 2008.
Inquiry chairman Robert Francis QC, who will start hearing expert evidence next week, also chaired the
fourth inquiry, which he criticised for its narrow remit.
The inquiries were ordered after the 2009 Healthcare Commission report listed a catalogue of failings
including receptionists assessing patients arriving at A&E, a shortage of nurses and senior doctors and
pressure on staff to meet targets.
The start of Monday's inquiry was delayed after one of the relatives objected because family members
and the media were in a different room from the inquiry chairman and his panel.
In setting out the public inquiry framework Mr Francis said he would not revisit the harrowing cases of
deceased patients brought to light in the fourth inquiry, which was held in private.
Instead he said he wanted to look at the structure of the NHS and the actions and inactions of
management to see how the failings had come about and why they had remained undetected for so
long.
News Clips  28

He also paid tribute to the relatives and campaigners from groups such as Cure the NHS, which was
set up to highlight problems at Stafford Hospital.
He said everyone was there because of the "terrible standard of service inflicted on so many of the
patients who went to Stafford Hospital and their families".
"Last year, in my first inquiry, I sat and listened to many stories of appalling care," he said.
"As I did so, the question that went constantly through my mind was, why did none of the many
organisations charged with the supervision and regulation of our hospital detect that something so
serious was going on, and why was nothing done about it?"
'Serious errors'
Tom Kark QC, leading counsel to the inquiry, said the purpose of the inquiry was to focus not on what
went wrong but how it was allowed to go on for so long.
He said: "Why did no-one act to correct the serious errors that were undoubtedly taking place?
The public inquiry will look beyond the walls of Stafford Hospital at the way the NHS is managed.
Among the million pages of documents there are submissions from doctors, staff and patients from
other parts of the country recording similar experiences.
Key to the inquiry will be the role of the statutory regulators.
Monitor gave the hospital a clean bill of health and made it a foundation trust a month before the
Healthcare Commission began its first investigation.
At the heart of the matter will be how much they talked to each other.
Huge reputations are at stake; David Nicholson, now head of the entire NHS, was in charge in this
region in 2005.
The current chief executive of the Care Quality Commission, Cynthia Bower, took over as head of West
Midlands Strategic Health Authority, with responsibility for measuring quality and safety, from 2006 until
2008.
Ultimately the inquiry's recommendations should change the way safety in our hospitals is monitored.
"Why did those who should have been in the right position to take steps not do so? "
Julie Bailey, who set up Cure the NHS, said: "This will get to the truth. We really believe this will be a
full examination of what went wrong, not just at the hospital but with the regulatory bodies.
News Clips  29

"We believe that if they had done something about it when we first reported concerns, it would have
saved many, many lives within this community," she said.
Problems at Stafford Hospital, run by the Mid Staffordshire NHS Trust, were first exposed by an NHS
regulator in March 2009.
The Labour government then started several investigations.
These included an independent inquiry led by Mr Francis, but it was held in private and did not have the
power to compel witnesses to give evidence.
When it reported in February it said the trust had been driven by targets and cost-cutting.
But campaigners said the failings went far wider than the hospital itself, and the broader NHS and
regulators should have realised there were problems and stepped in.
They demanded a full public inquiry with stronger legal powers.
In June, Health Secretary Andrew Lansley announced Mr Francis would continue the work he had
already done on investigating the hospital by leading an inquiry.
The inquiry will consider more than a million pages of evidence and will hear from dozens of witnesses.
Stafford Hospital management have said they have been working hard to improve patient care over the
past 18 months.
The new chief executive, Anthony Sumara, said they had taken on 140 more nurses, improved training,
and changed procedures in the areas which had problems.
The Mid Staffordshire NHS Foundation Trust Public Inquiry is being held at the offices of Stafford
Borough Council.
More on This Story
Related Stories

Frustration at hospital inquiry 08 NOVEMBER 2010, STOKE & STAFFORDSHIRE

Stafford Hospital crisis 2007-10 08 NOVEMBER 2010, PEOPLE AND PLACES

'Tougher' scrutiny of NHS deaths 04 NOVEMBER 2010, HEALTH

Stafford Hospital 'must improve' 29 OCTOBER 2010, STOKE & STAFFORDSHIRE

Hospital pays £1m over poor care 01 NOVEMBER 2010, STOKE & STAFFORDSHIRE

Inquiry campaigners thank party 05 OCTOBER 2010, STOKE & STAFFORDSHIRE
(BBC, http://www.bbc.co.uk/news/health-11696735)
News Clips  30

Story 6 – Winterbourne View
Story 6 in this section of the DVD tells the story of abuse uncovered by
the BBC’s Panorama filmed undercover at Winterbourne View.
26 October 2012
Winterbourne View: Care workers jailed for abuse
Six out of 11 care workers who admitted a total of 38 charges of neglect or abuse of patients at a
private hospital have been jailed.
Five other workers from Winterbourne View near Bristol were given suspended sentences after the acts
of abuse were uncovered by BBC Panorama.
Ringleader Wayne Rogers, 32, who admitted nine counts of ill-treating patients, was jailed for two
years.
Judge Neil Ford QC said there was a "culture of cruelty" at the care home.
'Vile and inexcusable'
Judge Ford said no attempt was made to provide a caring environment and if the abuse had not been
uncovered by the BBC, it would have continued.
He told the sentencing hearing the home had been "run with a scandalous lack of regard to patients
and staff".
"What happened was a gross breach of trust," he said.
Alison Dove, 25, of Kingswood, was jailed for 20 months as was Graham Doyle, 26, of Patchway. Both
pleaded guilty to seven charges of abuse.
Addressing Dove, Judge Ford said: "You suggested it was born of boredom during long shifts and that
you had viewed patients as playthings."
He also referred to a letter Doyle wrote to him, in which the defendant had described his own behaviour
as "disgusting, vile and inexcusable".
Judge Ford then told Doyle: "You are considered genuinely remorseful and haunted by guilt.
News Clips  31

"But your treatment of Simone Blake was often cruel, callous and degrading. It was always wholly
unjustified."
Prosecutor Kerry Barker QC, said care watchdogs failed to act on repeated warnings of "inhumane,
cruel and hate-fuelled treatment" of patients.
"The so-called restraint techniques were used to inflict pain, humiliate patients and bully them into
compliance with the demands of their carers," he said.
Abuse of five residents at the home featured in footage played to the court during a week of sentencing
hearings.
Among the hours of graphic footage, support worker Rogers is shown slapping patient Simon Tovey
across the cheek before telling him: "Do you want a scrap? Do you want a fight? Go on and I will bite
your bloody face off."
In a statement read outside court after the hearing,
families of the abused patients said seeing the footage
had been "distressing and extremely harrowing".
"The guilty parties were only charged with offences
shown on the Panorama programme and it would be
naive to believe that this monstrous behaviour had not
been continuing for a very long time," they said.
Lawyers representing 17 families say they are now
pursuing compensation in a civil action against Castlebeck, who owned Winterbourne View.
Defendant Jason Gardiner, who received a suspended jail term after admitting two charges of abuse,
said he wanted to apologise for his actions.
"I take full responsibility for everything I have done," he said outside the court.
'Major flaws'
"It was a very difficult place to work, a tough place to work. We were under-staffed and working 12-hour
days without a break.
"All I can do is apologise to everybody for what happened."
Sentencing Gardiner, Judge Ford had said he had heard he was "barely coping" with his remorse and
regret.
James Welch, legal director of human rights campaign group Liberty, said he was "disappointed" with
some of the sentences but thought the judge had been fair.
News Clips  32

The home's owners, Castlebeck, said there had been "extensive changes in board and management"
and new measures introduced to ensure it could not happen again.
The Care Quality Commission, which was heavily criticised after it ignored attempts by whistleblower
Terry Bryan to inform them of the abuse that was happening at the home, said the responsibility for the
abuse rested with the home's owners Castlebeck and individual employees.
Outgoing chair of the CQC, Dame Jo Williams said: "We are committed to do all we can to protect
people whose circumstances make them vulnerable - and since the abuse at Winterbourne View was
uncovered we have made changes to ensure that we are better placed to prevent abuse."
Care and Support Minister Norman Lamb said: "This terrible case has revealed the criminal and
inhuman acts some so-called care workers are capable of.
"It has also shone a light on major flaws in the system which we will address. We will publish our final
recommendations very soon."
Wayne Rogers, 32, of Kingswood, jailed for two years after admitting nine charges of ill-treatment.










Alison Dove, 25, of Kingswood, was
jailed for 20 months for seven counts
of abuse;
Graham Doyle, 26, of Patchway, was
jailed for 20 months for seven counts
of abuse;
Nurse Sookalingum Appoo, 59, of
Downend jailed for six months for
wilfully neglecting patients;
Nurse Kelvin Fore, 33, from
Middlesbrough, also jailed for six
months for wilfully neglecting patients;
Holly Laura Draper, 24, of Mangotsfield, pleaded guilty to two charges of abuse and was jailed
for 12 months;
Daniel Brake, 27, of Downend, pleaded guilty to two charges of abuse and was given a six
month jail sentence suspended for two years and ordered to carry out 200 hours of unpaid work;
Charlotte Justine Cotterell, 22, from Yate, pleaded guilty to one charge of abuse and was given
a four-month jail term suspended for two years. Cotterell was ordered to do 150 hours of unpaid
work and complete 12 months supervision;
Michael Ezenagu, 29, from Shepherds Bush, west London, admitted two counts of abuse and
was given a six month jail sentence suspended for two years and ordered to carry out 200 hours
of unpaid work;
Neil Ferguson, 28, of Emerson Green, admitted one count of abuse and was given a six month
jail term was suspended for two years and ordered to carry out 200 hours of unpaid work;
Jason Gardiner, 43, of Hartcliffe, who admitted two charges of abuse, was given a four month
jail term was suspended for two years and ordered to carry out 200 hours of unpaid work.
News Clips  33

More on This Story
Related Stories

Mum's 'guilt' over Winterbourne View (Watch) 26 OCTOBER 2012, BRISTOL

The abuse that shocked the nation 26 OCTOBER 2012, BRISTOL

Families call for hospital action 26 OCTOBER 2012, BRISTOL

Timeline: Winterbourne View abuse 10 DECEMBER 2012, BRISTOL

Workers forced medicine on woman 24 OCTOBER 2012, BRISTOL

Fresh inquiry into abuse claims 24 OCTOBER 2012, BRISTOL

Care worker's victim 'loved pain' 23 OCTOBER 2012, BRISTOL

Earlier abuse at hospital found 22 OCTOBER 2012, BRISTOL

Arrests after hospital abuse film 01 JUNE 2011, UK
(BBC, http://www.bbc.co.uk/news/uk-england-bristol-20092894)
News Clips  34

Additional Resources
In the creation of this DVD training resource, ESAB has funded the development of 6 adult
safeguarding scenarios and purchased the rights to a small number of news clips which contain a range
of abuse types. Included within this section are a number of additional links to third party visual media
which trainers may find useful when delivering adult safeguarding training.
Nursing and Midwifery Council films
Safeguarding Adults: An introduction (click to watch online)
Downloads:
The discussion guide [PDF]
The transcript [PDF]
The film [MOV, 61MB]
Safeguarding Adults: 28 Weeks (click to watch online)
Downloads:
Safeguarding Adults: Call me Joe (click to watch online)
Downloads:
Safeguarding Adults: Doing our best (click to watch online)
Downloads:
Additional Resources  35

Social Care Institute for Excellence films
Safeguarding adults in care homes (click to watch
online)
This film looks at aspects of good safeguarding
practice in a care home for older people that specialises
in dementia. Staff work in a person centred way,
spending time with residents and getting to know
them well so that they can recognise any changes in
behaviour that could suggest abuse. Residents also feel
comfortable about sharing any worries that they might
have.
Safeguarding adults: a community case study (click
to watch online)
John is a 50 year-old man with Asperger's syndrome.
He was being exploited by a group of young girls in
the community. John has the capacity to make
decisions for himself and clearly felt he was getting
something from his relationship with one of the girls.
He was also giving her money on a regular basis.
Safeguarding adults: a prevention project (click to
watch online)
This short film shows how training for people with
learning disabilities can help them to protect
themselves from abuse. People are helped to recognise
what abuse is and to understand that they can and
should say no.

Safeguarding adults: an independent life after longterm abuse within the family (click to watch online)
The film focuses on the personal story of Philip who
suffered physical, financial and emotional abuse in the
family home for many years. Philip has learning
disabilities and cerebral palsy. When Philip finally
disclosed the abuse, he was supported to leave the
family home. Since then he has gone from strength to
strength.
Safeguarding adults: lessons from the murder of
Steven Hoskin (click to watch online)
Steven Hoskin had learning disabilities and lived
alone in St Austell. He was tortured and murdered by
people who targeted him because of his learning
disabilities. Investigations showed that Steven had
made numerous calls to a number of agencies,
including the police, health and social care services, so
they should have been aware that he was in danger.
Safeguarding adults: preventing abuse through
community cohesion, communication and good
practice (click to watch online)
The film shows how good communication with older
people can improve safeguarding. In residential care it
is important that staff take the time to talk to residents
and to listen to their concerns.

BBC News resources
Listed below is a selection of recent adult safeguarding related stories all taken from the BBC’s news
website.
Care home rapist Stephen Murray jailed for seven years
A care worker who admitted the rape and sexual assault of vulnerable elderly
women in his care has been sentenced to seven years in prison.
Click here to read more…
Home carer Barbara Garvey stole from elderly
A woman supplied by a Kent firm to care for elderly people in their homes stole from
several vulnerable and dying clients, a BBC investigation has found.
Alexandra Hospital neglect: Jeremy Hunt 'disgusted'
Health Secretary Jeremy Hunt has said he is "disgusted and appalled" at accounts
of patient neglect at a hospital in Worcestershire.
Care home boss Rachel Baker jailed for killing
resident
A former care home manager who stole drugs from residents to feed her own
addiction has been jailed for 10 years for killing an elderly woman.

GP Davinderjit Bains filmed sex assaults with watch
A GP has pleaded guilty to a string of sexual offences against teenage girls and
women, some of which were filmed on a camera hidden in his wristwatch.
Nurses arrested in Hillcroft care home abuse inquiry
Six care workers have been arrested in connection with suspected abuse of elderly
residents at a care home near Lancaster, police have said.
Manchester care home worker held over murder
A member of staff at a Manchester care home has been arrested on suspicion of
murder following the death of resident, Ivan Emmanuel Campbell, 73.
Wraxall care home staff arrested after assault allegation
Two care home staff have been arrested on suspicion of assaulting and neglecting
an elderly resident at a home near Bristol.

Care home owners may face ban over 'financial abuse'
An NI couple could be banned from operating care homes after the regulator found
they had been responsible for "significant financial abuse of six vulnerable adults".
Abuse secretly filmed in 'excellent' London care
home
The Care Quality Commission is being criticised for failing to take sufficient action
after undercover filming showed an 80-year-old woman being slapped by a care
worker.
Nurse 'abused' elderly residents at Burnley care home
Elderly residents at a Lancashire care home were clinically, physically and verbally
abused by a nurse, a disciplinary hearing has been told.
'Beast' Devon care home abuser spared jail
A 21-year-old carer who mistreated elderly people at a Devon care home was
branded a "beast" by one of his victims, a court heard.

Stafford Hospital midwife struck off for patient abuse
A midwife who called a dementia patient "an animal" while working as a healthcare
support worker at Stafford Hospital has been struck off.
Carer Ameet Mohabeer 'abused victims' after return to
work
A hospital worker from Luton suspended over an alleged sexual assault was
allowed back to work and abused 14 more victims, a report has revealed.
Whipps Cross Hospital: Three charged over abuse
claims
Three people have been charged with abusing elderly patients at Whipps Cross
Hospital in East London.
Nurse Caroline Gervaise-Brazier found guilty of
misconduct
A panel has ruled a nurse's actions in telling a paralysed patient to shut up or she
would call his family and put him out in the car park was misconduct.

Northamptonshire nurses face abuse and neglect
claims
Two nurses impersonated monkeys as part of a racist campaign against a black
colleague at a Northamptonshire hospital, a panel has heard.
Hemel Hempstead nurse kicked 99-year-old patient
A Hertfordshire nurse who called a 99-year-old patient "evil", kicked him and told
him she would spit in his face has been suspended.
Former Bassetlaw Hospital worker denies sex assaults
A former care worker has denied sexually assaulting elderly female patients at a
Nottinghamshire hospital.
Welwyn Garden City A&E doctor 'sexually abused
patient'
A doctor in an accident and emergency department sexually abused a woman who
had a seizure, a court has heard.

- Essex Safeguarding Adults Board

Transcription

Similar documents

www.fsnb.org.uk - Fresh Start New Beginnings

Super large LCD display to enjoy Multi-format Movies

the dollmaker - Powerful Tools for Caregivers

Windwood Studio is offering a DVD of Theatre on Main`s production

`Let`s Face The Music` – DVD Order Form

DVD Labels

Cyrus Mobasheri - Medienwissenschaft Universität Bayreuth

`How Safe Are You Online` leaflet

here - Downtown Dance Factory

Dítě ohrožené prostředím Týrané, zneužívané a zanedbávané děti