- Beth’s parents were never seen as partners in the care of their daughter and over time have moved to a combative position as a consequence of lack of involvement, acknowledgement and voice.
- The lack of diagnosis for Beth, meaningful intervention and management set Beth on a pathway that was foreseen as poor and ended inevitably in institutionalised care.
- The physical environment for a young autistic girl was inappropriate and lacked adjustments to her needs. This led to a cycle of challenging behaviour being met with increasingly restrictive practices. The ethos of care meaning that there was a failure to recognise the communication of unmet needs expressed by such behaviours, and furthermore, normalised profound restrictive practices.
- Issues are identified in relation to numbers of staff, the skill mix of staff, supervision, training and access to information and support.
- Safeguarding issues have not been adequately considered throughout Beth’s life in care. There is too narrow a focus for safeguarding leading to considerations of Beth’s welfare and development not being recognised as safeguarding issues.
- Restrictive Practices: Beth has been subject to restrictive practices from a very early age. There is concern that the legitimisation of such restrictions in the Code of Practice, with limited safeguards and scrutiny, has facilitated prolonged use without external scrutiny. Psychological harm and Beth’s human rights are inadequately considered.
- There has been a lack of follow up of actions from requirement notices and regulatory breaches; a lack of escalation to NHSE of serious concerns and a recognition that there has been inadequate input from carers into regulatory visits.
- Poor cross agency working, in particular with NHSE (Midlands and East Specialised Commissioners); contradictory medical opinions and advice and their interpretation of their ability to effectively challenge due to Beth’s detained status under the Mental Health Act. It is clear that explicit assessment of Beth’s human rights is not undertaken by stakeholders. The current paradigm is one of risk management in dealing with the risk of Beth’s behaviour to herself and others. It is considered that this needs underpinning with an explicit assessment of human rights to support improved care planning.
For recommendations, see here: