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Our response to the Whorlton Hall Safeguarding Adults Review

14 June 2023

Following the conclusion of the recent criminal trial and four convictions for the ill-treatment of patients at Whorlton Hall in County Durham, the report into safeguarding failures has now been published by the Durham Safeguarding Adults Partnership.

VoiceAbility has contributed significantly to the Safeguarding Adults Review (SAR) report, as we were one of the two advocacy services working at Whorlton Hall – referred to as the Internal Advocacy Provider’ in the SAR report.

The Whorlton Hall SAR report is another powerful call for change. 

Like previous reports and reviews, it adds to the overwhelming evidence that people with a learning disability and autistic people are at high risk of neglect and abuse in mental health hospitals and must be better supported to live a good life in the community. 

The SAR report sets out what happened and why’ at Whorlton Hall, and follows a BBC Panorama exposé which was aired in May 2019. 

Its analysis and recommendations focus on how people can be better safeguarded from abuse in hospitals such as Whorlton Hall. 

It identifies advocacy services as one of the pillars in keeping people safe, but also the systemic weaknesses in its commissioning and provision. 

One of the SAR report’s key conclusions is that:

Current arrangements for the commissioning and oversight of advocacy services and the skill requirements of independent advocates, are inadequate for people with learning disabilities and/​or who are autistic, who are in-patients in specialist mental health hospitals or who are at risk of becoming in-patients.

This leaves people in the most high-risk settings, the least well served and creates a false security that advocacy is in place.

Our involvement

At Whorlton Hall, VoiceAbility was commissioned by the healthcare provider to provide additional (or non-statutory) advocacy services separate from the statutory independent mental health advocacy commissioned by the local authority. 

The SAR report reflects the conclusions of VoiceAbility’s internal review that the advocacy service provided at Whorlton Hall did not meet our own service standards and therefore was not of the quality and effectiveness it should have been. 

Our aim is to ensure people’s voices are heard, their rights are respected and they’re kept safe from harm. We are truly sorry that we did not do this.

The SAR also notes that, prior to the abuse at Whorlton Hall becoming known to us or others, VoiceAbility had already instigated a major programme to ensure our advocacy and safeguarding practice is of consistently high quality. 

Changes made include:

  • the development, rollout and continuing improvement of new safeguarding training, resources and safeguarding process guidance
  • the development of a strong preventative safeguarding culture with specific attention to the challenges in working with people in restricted and closed healthcare environments. This includes regular drop-in sessions to support staff working in high risk’ care environments
  • a Safeguarding Community of Practice to support the identification and dissemination of best practice
  • the appointment of a practice team, including a safeguarding lead, to provide additional oversight and expert guidance in matters of safeguarding
  • improved supervision and quality audit processes, and better use of data and evidence 

What needs to happen now?

In relation to advocacy services, the SAR report concluded that Whorlton Hall is unlikely to be a one-off’ and that systemic change is required in the commissioning and provision of advocacy services.

As well as working to strengthen our own services, we are also contributing to challenging conversations within the wider advocacy sector about what needs to change. 

For example, VoiceAbility published a paper in March 2022 setting out the case for a nationally-commissioned specialist service for people with a learning disability and autistic people in inpatient settings due to the heightened risks of abuse and neglect they face.

Jonathan Senker, VoiceAbility’s Chief Executive, said: 

We know that well-designed and reliably delivered community support is the route to everyone being able to live a good life, free from abuse of human rights in places like Whorlton Hall.

However, whilst there are people with a learning disability and autistic people who remain in hospital, we must do everything we can to improve the support for them.

We believe a specialist advocacy service which is nationally commissioned would provide more effective and consistent support for people with a learning disability and autistic people in mental health hospitals.

The abuse uncovered at Whorlton Hall must lead to urgent change, with strengthening of advocacy services across the country an essential part of this.”