A PUBLIC INQUIRY into the abuse of vulnerable people at Muckamore Abbey Hospital has found “profound and deeply troubling” failures in their care.
The long-awaited inquiry report also found that restrictive practices were used inappropriately, and that “as needed” medication was overused and “left some patients zombified”.
The hospital has been at the centre of the UK’s largest-ever police investigation into the alleged abuse of vulnerable adults and a number of prosecutions are continuing.
The inquiry’s central finding was that a policy shift, beginning in 2001, to move all patients with learning disabilities and autism from hospital into community-based care, was not matched with investment.
As a result, many patients could not be safely discharged due to a lack of capacity in the community.
This led to significant delays in resettlement, heightened distress, and in some cases readmission to Muckamore hospital.
The report made clear that patients were abused at Muckamore. It also found that there was “insufficient” staffing at all levels, leading to unsafe wards, and restrictive practices were used inappropriately.
Staff instability, increased violence, high use of restrictive practices and repeated complaints were “visible and known”.
A lack of activities for patients often led to “frustration, boredom and dysregulated behaviour” and Muckamore became “more functional and less homely” as time went on.
Peer-on-peer abuse “escalated dramatically” and was not recognised as a warning sign, the inquiry said.
It also found that “as needed” medication, also known as pro re nata medication, was overused as a tool of restraint which left some patients “zombified”.
It found that seclusion was misused as punishment for so-called “bad behaviour” and was not properly monitored.
There was a “closed culture” among staff which discouraged reporting of poor behaviour and many families said they were frightened to complain in case it impacted on the care their relatives received.
Systems and structures in place were “wholly inadequate” to manage the scale of abuse uncovered through a review of CCTV footage in 2017.
The inquiry has made 106 recommendations and proposes reforms in response to the “profound catalogue of failures”, including “ineffective” external inspection regimes, and serious failures in governance within the Belfast Health and Social Care Trust (BHSCT) which led to the erosion of oversight at the care facility over many years.
It said the BHSCT treated each complaint in isolation, preventing any recognition of wider patterns emerging over time.
Delivering the findings in Belfast, inquiry chair Tom Kark KC told relatives that the mistreatment of their loved ones by staff at Muckamore became “normalised”.
“The people who lived at Muckamore Abbey Hospital deserved better, and their families deserved better,” Kark said.
Solicitor Claire McKeegan, who represents several families whose loved ones resided in Muckamore Hospital, said the inquiry findings “confirm years of systemic abuse and failure”.
She said those who held power “must now be held to account”, with survivors and families given redress. The solicitor called for all the recommendations set out in the inquiry to be delivered in full.
“For years these families were told they were exaggerating, or they were simply not listened to at all,” McKeegan said.
“Today the inquiry has confirmed what they always knew — that their loved ones were abused on a staggering scale, that the failure was systemic, that the warning signs were there to be seen, and that those with the power to stop it did not.
“This report belongs to the families and to the patients, including those who did not live to see it. They were right. But being vindicated is not the same as receiving justice.”
A memorandum of understanding was entered with the police and the Public Prosecution Service in Northern Ireland to ensure the inquiry did not interfere with the criminal proceedings.