Joanna, Jon and Ben: a Serious Case Review

The CBF has issued a statement about the Serious Case Review made by Norfolk Safeguarding Adults Board, about Joanna, Jon and Ben who died in Cawston Park private hospital.

Today (9th September 2021) the Norfolk Safeguarding Adults Board published a report about Joanna, Jon and Ben, three people in their mid thirties, who died between 2018 and 2020, in a private hospital called Cawston Park. These individuals died prematurely in circumstances that are shocking in a hospital whose owners were paid thousands of pounds a week to provide specialist and quality care that they did not receive. Our thoughts are with their families and friends – the family accounts within the report show how they and their relatives were not listened to, and how all those in “the system” failed their loved ones which resulted in their premature deaths.

The report exposes multiple serious failures – from the physical assault of patients and failure to meet healthcare needs, to lack of record keeping and even altering records – all in the type of institution that the Transforming Care programme aimed to cease to commission.

The issues exposed in this report are not new – and point again to multiple failures in all parts of the system, from commissioning to inspection and regulation and lack of transparency about how and where public funding is spent. Within the report it is noted that the review heard “the obstacle cited by so many, that is, “there are no community services that can manage people with challenging behaviours.” This Serious Case Review report is published one day after the Care Quality Commission (who are implicated in the SCR report) published examples of good community support Home For Good, proof that it is entirely possible to support individuals with a range of support needs successfully in the community to enable them to lead fulfilling and interesting lives.

The recommendations in the report, if implemented, could make a difference, including adopting ethical commissioning.  But the actions required are not a ‘quick fix’ and require co-ordinated actions and leadership, and long term commitment to address the root causes. The report states: the roots of private, specialist hospitals reside in business opportunism and profit-driven priorities. These are hospitals in which patients receive neither specialist assessment nor credible treatment. The deaths of three young adults must plausibly question the “system response” – CQC’s continued registration of such hospitals and their continued use by CCGs and NHS-England.

It is Joanna, Jon and Ben, and those who loved and cared for them who have suffered the appalling consequences of the failure to transform care, and it seems to many that no-one takes responsibility or is held to account for that.

Support from the CBF

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.

Resources on our website

Please consult the following information section on our website, for information sheets and signposting:

What to do when things go wrong


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