Muckamore Abbey Hospital Inquiry publishes report: CBF statement

Please be aware that some of the content of this statement may be upsetting. If you are a family carer and have been affected by any of the issues raised in this statement, please contact the CBF’s Family Support Service – further details and resources can be found at the bottom of this statement. 

On Thursday 18th June, the Muckamore Abbey Hospital Inquiry published its final report. The Inquiry was established to look into the abuse that occurred at Muckamore Abbey Hospital in Northern Ireland, the circumstances that allowed it to happen, and what can be done to prevent such abuse occurring again – including at other similar institutions in Northern Ireland. 

Our thoughts are with the individuals who experienced abuse, the individuals who are still at Muckamore, the families whose relatives experienced abuse and the families who will always wonder whether their relative experienced abuse. We commend the families who have fought for justice and those conducting the Inquiry for putting their experiences front and centre. The Inquiry report shows the devastating consequences that ensue when people close their eyes and ears to the experiences and voices of individuals and families. 

Muckamore Abbey Hospital was the largest hospital for people with learning disabilities and mental health problems in Northern Ireland. Some of the people at Muckamore were there for many years and many of the children, young people, and adults were non-verbal and displayed behaviours described as challenging. Viewing of CCTV uncovered abuse which took place at the hospital in 2017. Following a fight for justice by families, an inquiry was set up in 2021 to look at events spanning more than two decades.  

More than 90 family members and some of the people who had previously lived at Muckamore gave evidence to the Inquiry. In their evidence, they highlighted the harms they or their loved ones experienced and the culture and practices that enabled this to continue for so long. Among the issues they raised were:  

• failure to listen to people with learning disabilities or their families, or to value their views 

• the overuse of restrictive practices, including restraint, seclusion, and medication (caused in many cases by a failure to understand behaviours that challenge as a sign of unmet need) 

• families being afraid to complain and a failure to act on concerns that were raised 

These have long been recognised as warning signs of a closed or abusive culture, as identified by multiple safeguarding reviews – taking place across the UK and over many years. The issues raised in this evidence are in many cases the same issues that were identified at Winterbourne View, at Cawston Park, at Whorlton Hall and at the settings run by the Hesley Group, among many others. Children, young people, and adults with learning disabilities have time and time again been subjected to abuse, with the systems that should have been detecting and preventing this failing to do so. 

The Inquiry also found serious issues with resettlement (moving people back into the community from hospital). People with learning disabilities who had been at Muckamore were either unable to be discharged, or were later re-admitted, because the right support was not available in the community. Despite a closure date of June 2024, two years on there are still people with learning disabilities at Muckamore because no one has yet found anywhere in the community for them to live. 

The Inquiry’s final report makes 106 recommendations. These recommendations include: 

• Ensuring access to community-based intensive support teams, community forensic teams, and emergency respite services 

• All people with learning disabilities to have a named key individual with responsibility for their care plans, and for communicating with them and their families 

• Increasing access to allied health professionals, such as speech and language therapists and occupational therapists 

• Tackling the use of restrictive interventions by providing human rights-based training and alternative forms of support, improving monitoring of restrictive practices, and conducting external ‘serious event audits’ whenever seclusion is used 

• Formally recognising adult safeguarding as a statutory function and creating uniform standards for conducting safeguarding investigations

We urge the Northern Ireland Department of Health, the Belfast Health and Social Care Trust, and all the other organisations named to implement all 106 recommendations and to do so with urgency to prevent future abuse. 

In his speech introducing the report, the Inquiry’s Chair, Tom Kark KC, stated that the report and its recommendations should not only lead to change in Northern Ireland but beyond as well. With the ongoing reforms to the Mental Health Act in England and Wales, the Department of Health and Social Care must also learn from this Inquiry and implement the recommendations within England and Wales – recommendations which highlight once again the urgent need for a coproduced roadmap to good community support.  

Jacqui Shurlock, CEO of The Challenging Behaviour Foundation, said: 

The abuse of children, young people, and adults with learning disabilities at Muckamore Abbey Hospital was abhorrent. Individuals now live with the pain, suffering, fear, and trauma caused by abuse and families live with enduring guilt for something they are not responsible for. One family carer said “I keep asking myself why did I let this happen to my brother. I blame myself.”  

Some individuals are still living at Muckamore. Many other children, young people, and adults with learning disabilities are also living in other institutions, both in Northern Ireland and across the UK.  

The report is clear that “Institutions caring for people with learning disabilities and autistic people are known to be high risk environments.” This is well accepted in public policy, yet it is still somehow acceptable to spend public money on commissioning places in “high risk environments” for some of the most vulnerable citizens in our society. Across the UK we fail to see any sense of urgency or drive to create good community support. This systemic failure must not be tolerated or action delayed by Ministers or public officials any longer.  

We need community support which values the lives of people with learning disabilities, puts them at the centre of their own care, and supports them as valued members of our community. Listen to individuals and their families, and act now, so that we are not all “learning the lessons” again when the next devastating scandal erupts.

Further information 

• You can read the full Inquiry report here 

• You can read the Plain English Executive Summary here 

Support from the CBF  

Resources on our website  

The CBF has information available for anyone who has concerns about poor support or abuse which can be found here:  

When things go wrong  

Supporting organisations  

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 support@thecbf.org.uk  

We are open at the following times:  

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

We can provide information and support about the needs of your relative with a severe learning disability whose behaviour may be described as challenging. We can also help you navigate the complex health, education, and social care systems. 

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.