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CQC abuse investigation highlights ‘lack of communication’ with GP surgery

A damning Care Quality Commission investigation into the Winterbourne View abuse scandal has attacked a ‘culture of abuse' at the private hospital, with a GP surgery caught up in allegations of medicines mismanagement.

The CQC's probe into the Bristol private hospital – launched by the NHS care watchdog after a BBC Panorama investigation exposed systematic abuse of patients with learning disabilities - accused Castlebeck Care, the company running the service, of failing to protect the safety of patients or investigate allegations of abuse. The CQC said it was considering ‘further legal action' against Castlebeck.

Staff at Winterbourne View told CQC investigators they blamed a communication breakdown between staff at the GP surgery in charge of prescribing, and said the lack of communication with GPs had, amongst other factors, contributed to failures in one of the standards assessed, medicines management.

‘The dose instructions for some of the medicines given by nurses were not the same as the dosage instructions on the medicine labels,' the report said.

‘Nurses told us that this was because the dose had been changed by the psychiatrist but had not been updated by the GP surgery. The psychiatrist told us that he always sent an email to inform the surgery of any changes. It appeared that discrepancies were not followed up by staff. This could increase the risk of mistakes being made.'

The CQC found that Castlebeck had failed to meet 10 ‘essential standards' of care required by law, including protecting patients from abuse and rigorously investigating staff misconduct.

Winterbourne View closed in June after the CQC withdrew registration for the unit following the Panorama report. Paul Brosnan, the chairman of Castlebeck, resigned before the publication of yesterday's report, which also claimed the company had no systems that were ‘effective  to identify and prevent abuse'.

Amanda Sherlock, CQC's director of operations, said the report was a ‘damning indictment' of the regime at Winterbourne View, but defended the CQC against allegations that the watchdog had ignored a whistleblower who raised the alarm about abuse at the unit.

‘It is now clear that the problems at Winterbourne View were far worse than were initially indicated by the whistleblower.'

‘We now know that the provider had effectively misled us by not keeping us informed about incidents as required by the law. Had we been told about all these things, we could have taken action earlier. We will now consider whether it would be appropriate to take further legal action.'  

Yesterday's CQC report contained no suggestion that GPs, or other doctors who came into contact with Winterbourne View, were aware of the abuse of patients exposed by Panorama. The programme filmed patients being verbally abused, doused in cold water and being pinned down and slapped.

Last month Pulse reported that the GMC was tracking down doctors who had contact with the home. Paul Philip, GMC deputy chief executive, said: ‘There must have been doctors in the vicinity. We are working with Castlebeck, the police and the Care Quality Commission to identify those doctors. So far we have a few names and we will be looking to follow that up.'