A public inquiry into the abuse of vulnerable people at Muckamore Abbey Hospital has found “profound and deeply troubling” failures in their care.
The inquiry said some staff inflicted “systematic bullying” on patients.
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”.
Delivering the findings in Belfast, inquiry chairman Tom Kark KC told relatives that the mistreatment of their loved ones by some staff at Muckamore became “normalised”.
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.
Police have reported 124 individuals to Northern Ireland’s Public Prosecution Service to date.
The inquiry report said that CCTV footage was “essential in revealing the truth” at the Co Antrim facility for adults with severe learning disabilities and mental health needs.
“The people who lived at Muckamore Abbey Hospital deserved better and their families deserved better,” said Mr Kark.
The chairman said “unexplained marks and injuries” found on patients included “bruises, grip marks, black eyes and broken bones”.
He said the injuries reported by relatives of patients were “neither isolated nor incidental”.
“They were the visible marks of a systemic failure,” the chairman added.
Stormont’s Health Minister Mike Nesbitt said he was “truly sorry” that vulnerable patients and their families had been “let down”.
“A system which should have ensured the most vulnerable were protected, nurtured, and cared for, failed in that core duty,” he said.
“They were let down, and for that I am truly sorry.”
Responding to the report’s publication, the father of a man with severe learning difficulties who resided at Muckamore said multiple “red flags” on the abuse of patients were not acted on.
Glynn Brown recalled how he was told an alleged assault on his non-verbal son Aaron by a staff member at Muckamore was a “one off incident”.
Addressing a press conference in Belfast, Mr Brown said: “The one-off incident that involved my son has now proved to be there was hundreds of incidents, there was red flags everywhere, but everybody was wearing blinkers, nobody wanted to see.
“There’s nobody as blind as those that don’t want to see – that’s an old quote.”
Solicitor Claire McKeegan, who represents several families whose loved ones resided in Muckamore, 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 106 recommendations set out in the inquiry to be delivered in full.
One of the recommendations includes the introduction of a statutory duty of candour for healthcare providers to be fully transparent in dealings with families of patients.
“For years these families were told they were exaggerating, or they were simply not listened to at all,” said Ms McKeegan.
“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.”
The report made clear that patients were abused at Muckamore.
“It is important to state that bold and simple fact,” it stated.
“The abuse did not involve every patient nor every member of staff, nor a majority of the staff.
“But many patients had their lives made miserable by systematic bullying by certain members of staff whose job it was to look after them.”
Responding to the findings, chief executive of the Belfast Health and Social Care Trust “sincerely and wholeheartedly” apologised to families for the care their loved ones experienced at Muckamore.
Jennifer Welsh said she understood that the organisation had “lost trust” and said she was determined to rebuild “damaged relationships”.
“I am sorry to say that your loved ones were treated by many staff in the most uncivilised way by people who were there to care, who not only should have known better but more importantly should have behaved better,” she said.
The inquiry report suggested the trust had adopted an adversarial approach during its investigations and expressed “serious concern” as to whether it had the capacity to introduce reforms independently and without external direction.
In response, Ms Welsh said: “I’m deeply sorry that proper legal process has been interpreted as something which is adversarial.”
The trust’s director of nursing Olga O’Neill said that people had been “held to account” and there had been over 119 staff reviewed through disciplinary processes in relation to failings at Muckamore, with 115 concluded.
She said 19 staff had been dismissed, nine staff had received final warnings, 11 staff had received formal warnings and one verbal warning has been issued.
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 inquiry 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 (PRN) 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 proposes reforms in response to the “profound catalogue of failures”, including “ineffective” external inspection regimes, and serious failures in governance within the Belfast Trust that led to the erosion of oversight at the care facility over many years.
It said the trust treated each complaint in isolation, preventing any recognition of wider patterns emerging over time.
Speaking at the publication of the report, Mr Kark paid tribute to the residents of Muckamore and their families for being “central to uncovering the truth”.
“While the publication of this report cannot undo the harm suffered, it is my hope that it will serve as a turning point,” he said.
“The responsibility to act on the recommendations now lies with those who lead, manage, and deliver health and social care services across Northern Ireland.”
He said added: “There should be no delay, no dilution, and no side-stepping in the delivery of the recommendations.”
Mr Kark said it was “highly unusual” for a public inquiry to take place simultaneously with a large police investigation and criminal trial proceedings.
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.
PSNI Assistant Chief Constable Davy Beck said: “This remains the largest adult safeguarding investigation in the UK and is the subject of ongoing criminal proceedings.
“The public inquiry has been running parallel to our police investigation. To date, we have reported 124 people to the Public Prosecution Service with the first file submitted in April 2020.
“The protection of our most vulnerable is a priority for the Police Service of Northern Ireland.
“This has been a very detailed and complex investigation and our specially trained officers from our Public Protection Branch, have provided ongoing support to the families whose loved ones are at the centre of this investigation.
“Today marks a significant milestone for them and we thank the families involved for their patience and unwavering support for our investigation.”
