Edenfield Centre: Vulnerable patients denied human rights - review

Patients who were filmed being mistreated at an NHS mental health unit were denied "basic dignity and their human rights", a review has found.

Some staff members were sacked or suspended following the 2022 broadcast.

Greater Manchester Mental Health Trust (GMMH) said it was "truly sorry" and committed to a "much-improved future".

The independent report, led by Prof Oliver Shanley OBE, found the trust repeatedly missed opportunities to act on concerns, alongside a culture of "suppressing bad news".

It found the Panorama broadcast exposed the "most shocking abuse and poor care" of vulnerable patients, and that concerns raised by families were "not always taken seriously".

It added that in some services, patients had been denied "basic dignity and their human rights".

During the Panorama investigation, staff were filmed using restraint inappropriately and swearing at and slapping patients, while some of those being cared for endured long seclusions in small, bare rooms.

More than 400 people shared their experiences with the review, which found a "striking level of distress among patients, families, and staff".

The report heard from a patient's family member who tried to raise issues but was ignored.

"The trust seem like they are firefighting and walking from room to room with fire, and petrol already in the room, smoking a cigarette," they said.

The report found several key reasons why the abuse and poor care of patients took place, including:

A number of leaders at the trust were said to have "lacked compassion and empathy", with senior managers fostering "a culture of fear and intimidation" among staff to "maintain performance standards".

The board of the trust had focused on "expansion, reputation and meeting operational targets" rather than the quality of care given to patients, the report found.

But the review's authors also said they spoke to "a great many members of staff who were passionate, evidently talented and highly committed to their patients".

Eighteen months before the Panorama investigation, Rowan Thompson, who identified as non-binary, died in the Gardener Unit on the same site as the Edenfield Centre, in October 2020.

The inquest found observation records had been falsified and hospital blood test results had not been communicated back to the 18-year-old's unit, because phone numbers and email addresses on the website were wrong.

Rowan's father Marc Thompson, who took part in the independent review into the trust, said: "I get angry.

"Those are really basic, lack of detail, mistakes.

"I get really angry that all they do is change the personnel. It doesn't matter if you change the people. You have to change the systems."

He said staff "knew that they had signed stuff that they hadn't done".

"There are other cases within three months where that was a key element to children having serious issues," he said.

"Eighteen months later the same thing is happening within the same trust at a unit on the same site. Where is the learning in that?"

The trust's chief executive, Jan Ditheridge, said: "We are truly sorry for the events described in the report.

"We take the findings seriously and accept the recommendations.

"We cannot change the past, but we are committed to a much-improved future - one in which all service users and carers feel safe and supported, and our people are able to do their best work."

She said an improvement plan would address the issues raised, with some actions already being completed.

"Staff are more supported, leadership and governance is stronger and our culture is getting better," she said, adding the trust had recruited more than 350 nurses in the last six months.

The report outlines a series of recommendations for the trust, which include ensuring patient, family and staff voices are heard "at every level" and creating a culture where quality of care is the "utmost priority".

Other recommendations include a call to adapt to problems caused by staff shortages, to address the poor state of some building, and for a review into oversight to "prevent tragedies like those seen at Edenfield from reoccurring".

The trust, which runs the centre, was downgraded from "requires improvement" to "inadequate" by the Care Quality Commission in July.

Neil Thwaite who had been the trust's chief executive since 2018 stepped down six months after the BBC's investigation in September 2022.

A spokesman for NHS England North West said "immediate action" was taken to improve patient safety at Edenfield after the mistreatment was exposed, including the commissioning of the independent review.

"We now owe it to every patient cared for by the trust and the staff working for them and across the NHS, to ensure the review's recommendations are implemented," he added.

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