CBF Statement on the Safe and Wellbeing Reviews: Thematic Review and Lessons Learnt Report

On 21st February 2023, NHS England published a much-delayed report on the safety and wellbeing of all people with a learning disability and autistic people who were detained in inpatient units on 31st October 2021.

This is another report that tells us what we already know – too many people with learning disabilities are in inpatient units where they do not need to be, far from home. Their health needs are not met, their families are not treated as valued partners and oversight and review processes are ineffective. Over 10 years ago these issues were known and the Transforming Care programme was meant to drive change. That change has yet to be delivered.


In September 2021, Norfolk’s Safeguarding Adults Board published “Joanna, ‘Jon’ and Ben”, a Safeguarding Adults Review into the deaths of three people with learning disabilities and behaviour that challenged at Cawston Park Hospital. This review found multiple failings that led to their premature and preventable deaths; the hospital did not listen to or engage with their families, Joanna, ‘Jon’ and Ben were physically assaulted, restrained, and secluded, and their healthcare needs were not met.

Following this review, NHS England commissioned a national review to check the safety and wellbeing of all people with a learning disability and autistic people in inpatient units at that time. This thematic review, which was due to be published in Summer 2022, has now been published (February 2023).


The review found:

  • At least 41% of people with a learning disability or autistic people who are currently detained in inpatient units do not need to be there and could be better cared for in a community setting. The most common reasons for delayed discharges are a lack of suitable housing and care packages in the community (supporting existing data, including the NHS Assuring Transformation and Mental Health Services Data Sets).
  • 57% of people with a learning disability and autistic people detained in inpatient units are in out-of-area placements without support to maintain links with their friends and families, who were excluded from decision-making about their loved ones, not listened to, and not given basic information such as visiting times, or sufficient access to independent advocacy services.

Nearly 12 years ago the abuse of people with learning disabilities and autism at Winterbourne View, a private inpatient hospital, brought these issues to public attention. Many reports and multiple missed deadlines have demonstrated the need for a coherent, funded implementation plan to drive change, which has not yet been produced or delivered. There is just over a year until the revised March 2024 deadline to reduce the number of people with a learning disability and autistic people detained in inpatient units by half.

Vivien Cooper, CEO of the Challenging Behaviour Foundation says “The government is systematically failing people with learning disabilities who are being detained when they could be supported in the community. This is not new, this is yet another review that highlights people being subjected to high levels of restraint, locked in seclusion rooms and overmedicated. People do not have access to adequate healthcare and are not supported to eat healthily and exercise.

On current projections the government will not meet its commitment to reduce the number of people with learning disabilities and autism detained in inpatient units by half. These ‘lessons learned’ should have been learnt before; it is essential that these are now acted upon, and that support is put in place to enable people with learning disabilities to live good lives in the community rather than being locked away in hospitals.”

You can find the full review here: Safe and wellbeing reviews: thematic review and lessons learned (NHS England)

The CBF’s response to “Joanna, ‘Jon’ and Ben” can be found here: Cawston Park Serious Case Review – Challenging Behaviour Foundation


Family Support Service

If you have been affected by any of the issues raised in this statement, you can call the Family Support Service on 0300 666 0126

Or email us at

We are open at the following times:

Monday – Thursday: 9am – 5pm
Friday: 9am – 3pm

We offer information about challenging behaviour to anyone who provides support to a child, young person or adult with a severe learning disability. We can also signpost you to other specialist organisations and sources of information.

Please note we are a small support service so you may not be able to get support straight away. We will support families with urgent concerns as a priority.

Professionals are also welcome to contact the CBF.

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