Guest editorial

The Journal of Adult Protection

ISSN: 1466-8203

Article publication date: 2 August 2013



Tozer, C. (2013), "Guest editorial", The Journal of Adult Protection, Vol. 15 No. 4.



Emerald Group Publishing Limited

Copyright © 2013, Emerald Group Publishing Limited

Guest editorial

Guest editorial

Article Type: Guest editorial From: Journal of Adult Protection, Volume 15, Issue 4.

In writing this editorial piece, I am informed by my current responsibilities as the Executive Director of Services at Scope and the Independent Chair of the Southampton Safeguarding Adults Board. But I am motivated to write this piece by my experiences as the former Director of Adult Social Services at Cornwall County Council where, in 2006, I worked to respond to the abuses and systemic failings uncovered in Cornwall Partnership NHS Trust and the murder of Steven Hoskins. The parallels between what happened in Cornwall and the events at Winterbourne View Hospital (WVH) are horribly familiar. Indeed, as stated in the Serious Case Review report of WVH “We have been here before.” (M. Flynn, p. 122).

The events at WVH shocked the country. Adults with learning disabilities, living in a supposed place of healing, were terrorised, degraded and abused in a gross variety of ways, on multiple occasions and by a number of staff. The hospital where the abuse occurred was identified as “the best performing” of Castlebeck's array of services; performance being defined as profitability. Given a clean bill of health by CQC, the regulators failed to respond appropriately to a key whisteblower while local services (including A&E, the police, GPs and the safeguarding team) did not respond to signals that could have resulted in safeguarding action being taken and stopped it from recurring. And NHS commissioners were spending hundreds of thousands of pounds per annum funding “treatment and assessment” that was neither scrutinised for safety or quality nor reviewed for appropriateness. As one of the papers in this edition clearly states – the events at WVH are the product of an “unnoticing environment”.

This edition of the journal contains an array of papers that examine the aetiology, impact and legacy of the events at WVH. They add further volume to the clarion call to action by disabled people and their families that has resounded now for too many years. The action needed includes engaging the expertise of adults at risk in the design and delivery at every stage of the safeguarding process, refocusing professional practice and delivering truly personalised services, delivering evidence informed commissioning, improved governance within and across agencies and better access to legal justice and redress to those who have been abused and neglected. It is notable that the need for more resources is not a central request by any of the authors. The events at WVH did not happen because of a lack of public spend (commissioners spent a fortune there). Rather, the papers in this edition underline the importance of putting compassion at the centre of care – and taking the commodification of care out.

At local levels, the leaders of organisations (be they Executive Directors or Non-Executive Directors, officers or elected members) working with disabled adults and elders play a pivotal role in keeping people safe: they are responsible for the systems that determine access to the range of local resources available to do so. Moreover, local leaders and especially those holding statutory roles, although not personally responsible for safeguarding failures, are always professionally accountable.

So how might local leaders ensure that their safeguarding systems and practices, within and across local organisations are as effective as possible? At Scope's Corporate Safeguarding Board and at Southampton's Safeguarding Adults Board, when we talk about “SAFE” we mean the following.

At the Southampton SAB, for instance, our meetings are organised around these themes and our meetings start with the same “Real Life” agenda item that address the details and structural or systemic issues raised by an individual safeguarding case. In this way, as Board members, we have found that we have become better engaged emotionally with our shared task to lead and deliver effective partnership working in safeguarding adults. Our meetings also have a specific focus on a single agency and how they deliver effective safeguarding practices and governance throughout their organisation. We have developed, and are now reporting on, a multiagency performance framework – with metrics that seek to measure outcomes as well as process and output. And we are in the throes of agreeing, finally, a multiagency budget to ensure that the SSAB has the resources to do its job properly. The Board has several areas to develop, including how we engage – in meaningful and effective ways – with adults at risk and their carers in order to design, develop, implement and evaluate assess the effectiveness of single agency and partnership working in safeguarding adults. I suspect that these sorts of actions are replicated throughout the great majority of SABs across the country.

But in the wake of the events at WVH, we have witnessed a number of equally shocking examples of systemic failures in safeguarding adults: most vividly in the whole systems failures revealed in the Mid Staffordshire Hospitals enquiry and most recently (as I write) in the 17 June 2013 Panorama programme addressing the quality of care in residential care homes for elderly people.

The papers in this edition serve to remind us of the horrors of what went on in WVH, describe the national response that they evoked and detail the unfinished business that remains. At the heart of the subject matter of these articles are a group of adults at risk who staff abused, repeatedly, and who the system failed, repeatedly. I suspect that most people reading this journal will be part of the system that aims to safeguard adults at risk. For me, therefore, my response to the events at WVH have been to make me critically reassess my personal leadership behaviours – in terms of how I help embed an organisational culture of constant watchfulness and enquiry, personalised care and support and zero tolerance toward those who abuse or neglect disabled people. For me, and to paraphrase the feminist credo, the events at Winterbourne are personal.

Carol Tozer

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