Today, an independent safeguarding review was published into the tragic deaths of three young people, Joanna, “Jon” and Ben who had a learning disability and who died at the private hospital Cawston Park owned by Jeesal Group.

The review’s author Margaret Flynn observed that “not a great deal has changed” since the Winterbourne View hospital abuse scandal over a decade ago.

Findings from this review uncovered “excessive use of restraint and seclusion by unqualified staff, “overmedication,” or the Hospital’s high tolerance of inactivity – all of which presented risks of further harm.”

It also found that these three people “did not benefit from attention to the complex causes of their behaviour, to their mental distress or physical health care.”

Responding to the independent safeguarding review’s publication, Dan Scorer, Head of Policy and Public Affairs at the learning disability charity Mencap, said: “The findings in this safeguarding review are extremely damning. Joanna, Jon and Ben were failed by the system that was paid to care for them, and action must be taken now before further lives are lost. 

“It’s over a decade since the Winterbourne View hospital abuse scandal was exposed, and yet these findings clearly show how mistreatment and neglect has continued. It is completely unacceptable that in the 21st century people were being excessively restrained, medicated, and put in isolation; while hospital staff did not always follow their care plans or tend to their mental distress and physical health needs. It is clear that not enough is being done to ensure the safety or wellbeing of the over 2000 people who are still locked away in modern-day asylums at increased risk of abuse and neglect.  

“Further lives will be lost unless the Government delivers the long overdue promises made to close beds in these hospitals and develop social care support in the community instead. The Government, NHS, CQC and local authorities must act on the review’s recommendations. Ultimately, the only way to stop this scandal is by developing the right support in the community to prevent people from being admitted to these institutions in the first place. And that starts with properly funding early intervention and support services in the community, not funnelling more taxpayers’ money into these hospitals.”

Latest NHS Digital data shows that:

  • 2,050 people with a learning disability and/or autism are still locked away in hospitals at risk of abuse at the end of July 2021 – of which 185 are children.
  • There were over 5,000 recorded reports of restrictive practices – like physical restraint, chemical cosh and being placed in solitary confinement – used against people with a learning disability and/or autism in units in May 2021.
  • On average, people with a learning disability and/or autism are locked away for 5.6 years.

While the CQC has identified 34 people with a learning disability and/or autism who have died between 1 March 2020 to 2 July 2021, the majority (23) were not identified as involving confirmed or suspected COVID-19.

Read the full independent safeguarding review online here:

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For further information or to arrange interviews with a Mencap spokesperson or case study, contactMencap’smedia team on:

Notes to editors:

  1. The author of this independent safeguarding report, Margaret Flynn, also conducted the review into Winterbourne View following BBC Panorama’s exposure of systemic abuse at the hospital over a decade ago.
  2. Following the Winterbourne View hospital abuse scandal, the Government promised to get everyone inappropriately placed in these hospitals out no later than 1st June 2014. This deadline passed and in 2015, the Government and NHS England launched the ‘Transforming Care’ programme and the ‘Building the Right Support’ national plan which committed to closing 35-50% inpatient beds by March 2019 and supporting people to return home. This target was missed twice and still has not been met. The Government has since promised to reduce the number of people locked away in inpatient units by 50% by 2024.
  3. Mencap has been campaigning with families on these issues since the abuse scandal at Winterbourne View ten years ago.
  4. Mencap is asking the Government to focus on:   
  • Developing local expertise, support and services  
  • Ensuring there is joint oversight and ownership of the national programme by the Ministers from the Department of Health and Social Care, Ministry of Housing, Communities and Local Government and Department for Education.  
  • Removing the red tape and funding barriers that are preventing so many people from returning home.   
  • A robust plan from leadership for cross-government working.

About Mencap

There are 1.5 million people with a learning disability in the UK.Mencapworks to support people with a learning disability, their families and carers by fighting to change laws, improve services and access to education, employment and leisure facilities.Mencapsupports thousands of people with a learning disability to live their lives the way they

For advice and information about learning disability andMencapservices in your area, contactMencap’s FreephoneLearning Disability Helplineon 0808 808 1111 (10am-3pm, Monday-Friday) or     

What is a learning disability?

  • A learning disability is a reduced intellectual ability which can cause problems with everyday tasks – for example shopping and cooking, or travelling to new places – which affects someone for their whole life;
  • Learning disability is NOT a mental illness or a learning difficulty, such as dyslexia. Very often the term ‘learning difficulty’ is wrongly used interchangeably with ‘learning disability’;
  • People with a learning disability can take longer to learn new things and may need support to develop new skills, understand difficult information and engage with other people. The level of support someone needs is different with every individual. For example, someone with a severe learning disability might need much more support with daily tasks than someone with a mild learning disability.