Report into shocking abuse at mental health unit found bosses ‘disconnected’ from reality

A report into “shocking abuse” at an NHS mental health unit where patients were filmed being mistreated has found poor leadership, bosses “disconnected” from reality and practices of suppressing “bad news”.

The review of patient care at the Edenfield Centre in Prestwich, Greater Manchester was ordered after a BBC Panorama investigation showed patients being shouted at, humiliated and bullied.

Trust bosses cared more about matters such as expansion and reputation over patient care, the report said.

A BBC undercover reporter posing as a care worker at the unit, filmed patients being abused, physically and emotionally, by some members of staff.

Patients were mocked, humiliated, bullied, restrained inappropriately and secluded for long periods, as shown on the BBC expose broadcast in September 2022.

The trust sacked a number of staff after the TV broadcast and a police investigation is currently ongoing.

NHS England commissioned an Independent Review of the Trust running the unit, Greater Manchester Mental Health NHS Foundation (GMMH).

Professor Oliver Shanley OBE, who led the independent review, on Wednesday published his 155-page report.

It makes 11 recommendations on patient care, clinical leadership, culture, workforce and governance.

Prof Shanley’s report says while many members of staff are passionate, talented and committed to their patients, care at GMMH has, at times, been poor, with patients denied basic dignity and their human rights.

The report states: “There were many indicators that the culture, safety and patient experience in Edenfield and elsewhere in the Trust were poor.

“We have concluded that a large part of what was exposed through BBC Panorama was due to the lack of value placed on the patient’s voice in GMMH, as well as a frequent disregard for the experiences of families and carers.”

Patients and families told the report authors they were not believed when they raised concerns or complained about care standards.

The report also said the board of the trust, “focused more on matters such as expansion, reputation and meeting operational targets rather than the quality of care provided”.

The review found the unit had chronic staff shortages, low morale, a high turnover of staff and workers who felt “exasperated” at not being listened to, with Trust bosses, “disconnected” from reality.

Leadership was also unsupportive of staff along with “unsound” HR practices.

Prof Shanley said the trust had placed “significant resources” into addressing the problems, but these are “long-standing” and not easily fixed, with a culture of improvement needed.

The report concludes: “A fundamental change in emphasis is required to achieve this. Our view is that culture starts with the Board, which dictates the tone of the organisation, what is important, the extent to which staff feel listened to and the priority given to continuously improving services.”

Rupert Nichols, the then chairman of the trust, stepped down after the Panorama broadcast.

Jan Ditheridge, current chief executive at GMMH, said: “We are truly sorry for the events described in the report.

“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.

“Our improvement plan sets out a range of actions that are addressing the issues raised in this report.

“We are working with the review team, partners and colleagues to fully implement the recommendations ensuring our service users and their carers are central to everything we do.”

The full report can be found at: https://www.england.nhs.uk/north-west/our-work/publications/ind-investigation-reports/independent-review-gmmh-nhs-ft/.

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