A collective moral obligation

Both of us watched the Panorama programme on 28 September on the appalling abuse of residents at Edenfield Medium Secure Unit in Manchester.  The undercover reporter – given only one day's training before working in this challenging environment – revealed persistent bullying and humiliation of the residents by not only unqualified care staff, but also by some of the trained nursing staff, who were also condoning the falsification of care records. This was a truly shocking programme.

How had these abusive practices not been picked up by senior managers and clinical staff? There must be some form of manager and clinical director involved. All of the patients must have been detained under a Section of the Mental Health Act so must have a Responsible Clinician with oversight of their care. Surely there must be a medical consultant, and wait for it... surely some form of psychological input. And the responsibility does not end there: Trust senior officers and members of NHS Trust Boards should be aware of their responsibility to assertively monitor services for the most marginalised.

There is a long literature about how and why institutional abuse occurs, beginning with Barbara Robb's 1967 book Sans Everything. Scandals recur with depressing regularity, despite inspection processes designed to lower their probability. The Mental Health Act Commission was dissolved in 2009 and its role handed over to the generic Care Quality Commission, with its existing rating of Edenfield being 'good'. Inspection does not prevent these scandals, which come from systemic and personal factors that elude sporadic external scrutiny. 

In his book Hospitals in Trouble (1986), John Martin posed two key questions. Why do trained carers behave contrary to professional standards? How have hospitals been arranged so that abuse and neglect have not been prevented?

Martin found that usually other organisational goals (such as staff convenience or public safety) have implicitly usurped goals of caring ('the subordination of care'). He identified six types of 'isolation', which largely address the second question:

• Geographical isolation. Most large institutions were situated away from main town centres, often cut off from local communities.
• Immediate isolation. Wards within hospitals were often isolated from one another, operating as little 'fiefdoms'. Only a small minority of wards within any hospital investigated formed the basis of complaints.
• Personal isolation. Individuals were in charge of large numbers of difficult-to-manage patients. Untrained and isolated staff were left to cope with unbearable conditions.
• Professional isolation. The worst wards were those least visited by '9-5' staff, such as doctors, psychologists and social workers. There was professional abdication of responsibility and lack of leadership from senior staff.
• Intellectual isolation. There was a lack of professional stimulus, staff development and access to training opportunities.
• Privacy. This was a prerequisite for abuse; patients who were regularly visited by relatives were not usually the focus of complaints. (Sunlight is the best disinfectant.)

Martin's checklist offers a starting point to go beyond the 'bad apple' reductionism that police inquiries, or targeted punishment of staff wrongdoing, is likely to favour. Instead, multi-factorial systemic risk has to be kept in mind, alongside the shortcomings of senior staff of all disciplines who should have been aware of these risks and acted to prevent the scandal at Edenfield.

This sickening scenario should prompt those working in similar isolated systems to check that such abuse is not hiding in plain sight under their own watch right now. Psychologists share a collective professional and moral obligation to ensure patient protection. In the past there were laudable whistle blowers at Whittington and Ashworth Hospitals. That honourable tradition should be sustained and not abandoned.

John Hall, Oxford Brookes University
David Pilgrim, Southampton University