Relatives reported being informed by staff that injuries were caused by self-harm, behavioural incidents or peer-on-peer violence. They were told their relative was clumsy or may have fallen in the night. Over time, many families lost confidence in these explanations, especially where injuries were located on areas of the body difficult to self-inflict or appeared repeatedly in similar patterns. Sometimes injuries were unexplained even when a patient was supposed to be under supervision.

The Inquiry also heard evidence of physical abuse captured on CCTV, including forceful handling, dragging, pushing and inappropriate restraint. These incidents provided confirmation that unexplained injuries reported by families over many years could not be attributed solely to patient behaviour or peer-on-peer violence. The presence of injuries alongside incidents captured on CCTV demonstrated that earlier concerns had been justified and should have prompted urgent intervention.

The Inquiry notes that families’ concerns were exacerbated by the lack of communication from staff at the hospital about when patients had been injured, and many complained of significant delays in injuries being reported to them.

The Panel concluded that injuries such as bruises and marks were not isolated or incidental; they were visible indicators of systemic failure. Dealing with each incident individually resulted in the inability of the organisation to recognise patterns, escalate concerns and protect patients, and allowed physical abuse and neglect to continue unchecked, causing lasting harm to patients and profound distress to their families.

Key themes

Key patient safety issues highlighted in this report include:

Information sharing and co-production

• Families described not being informed of their rights when relatives were detained under the Mental Health (NI) Order 1986. Many believed decisions were made without consultation, leaving them feeling excluded from their loved one’s care.
• The Inquiry repeatedly heard that families were informed of decisions rather than involved in making them.
• Families reported not being able to visit during early stages of admission, removing opportunities to share crucial information.
• Many families struggled to identify a consistent point of contact or key worker.

Restrictive practices

• The Panel identified serious and persistent concerns regarding the frequency, rationale, recording and governance of restrictive practices over a prolonged period.
• Seclusion was a particular area of concern. Although policies on seclusion became increasingly prescriptive over time, including requirements for monitoring, the Inquiry heard evidence that implementation was inconsistent, sometimes inadequate and not effectively audited.
• The use of PRN medication as a form of restrictive practice was also problematic. Although guidance emphasised that PRN medication should only be used with a clear therapeutic rationale and as a last resort, families frequently described experiencing their relatives as sedated, disengaged or ‘zombified’. The Panel accepted that this was not necessarily an indication of overmedication by use of regularly prescribed drugs but may have reflected the use of PRN medication to control behaviour when other non-medical approaches had either not been available or not been attempted.
• Governance and oversight of restrictive practices were inadequate. Although data on restraint, seclusion and incidents was collected and reported internally, the Inquiry found limited evidence of effective senior management challenge, trend analysis or sustained action to reduce use.

Complaints and concerns

• Evidence revealed widespread confusion, fear and mistrust among families, alongside systemic weaknesses in complaint handling, oversight and organisational learning.
• Many family members found the complaints system opaque and difficult to navigate, with little clarity about how complaints were investigated, how decisions were reached or what outcomes, if any, resulted.
• Many families reported finding out about injuries, assaults or significant incidents only during visits, or after long delays. Others described communications they perceived as defensive, dismissive or designed to protect the institution rather than investigate the facts. Some believed that staff were effectively ‘investigating themselves’, creating perceptions of bias and eroding confidence in outcomes. Even when complaints were upheld in part, families often felt responses lacked empathy, apology or accountability.
• Fear was a major barrier to complaint-raising. Witnesses described explicit or implicit warnings suggesting that complaining could affect their relative’s care or future admissions. Patients themselves were sometimes frightened to speak up.
• Governance and oversight arrangements were also found wanting. Although complaints data was presented in dashboards and discussed at Muckamore Abbey Hospital management meetings, there was limited evidence of robust analysis, challenge or sustained organisational learning.

Previous concerns, previous investigations and warning signs

• The Panel concluded that Muckamore Abbey Hospital exhibited multiple, persistent and well-documented warning signs long before 2017: sustained understaffing; inadequate specialist supports; unsafe environments; escalating violence and restraint; frequent safeguarding referrals; family complaints; and a geographically and culturally closed institution.
• While individual allegations were often investigated, the system failed to connect the dots. No single mechanism brought together incident reporting, safeguarding intelligence, complaints and workforce pressures in a way that would have revealed the scale of risk

Safeguarding

• The Panel found that safeguarding systems were fragmented and insufficiently integrated with the Trust’s wider clinical governance and risk management arrangements.
• Safeguarding investigations were structurally separated to preserve independence, but this separation limited organisational learning.

Staff and ward management

• The Panel concluded that staffing challenges at Muckamore Abbey Hospital were long-standing, well-documented and increasingly severe, yet were never adequately resolved. These systemic workforce failures significantly increased patient vulnerability and contributed to the conditions in which abuse was able to occur and persist.
• Staffing shortages were persistent from at least 2009 onwards and worsened significantly after 2012, when recruitment freezes and temporary contracts became common due to the anticipated closure of Muckamore Abbey Hospital.
• The ratio of registered nurses to healthcare assistants was frequently below safe levels, and in some wards fewer than half of staff were registered nurses. Healthcare assistants, who provide the majority of direct patient care, had no specialist training requirements and relied heavily on informal learning.
• Supervision of healthcare assistants inconsistent, and clinical supervision arrangements fell far below what would be expected in a high-risk inpatient setting. This created a task-focused culture where staff prioritised basic physical care over personal and therapeutic engagement.
• Throughout this period, senior leadership and the Trust Board repeatedly reassured themselves and external bodies that staffing was safe, even as the regulator and whistleblowers raised escalating concerns.

Leadership

• While extensive governance structures existed, they consistently failed to work to bring relevant information to the Board of Belfast Health and Social Care Trust, and to translate information into understanding of risks or into an active response. There was a resulting lack of insight by the Board into the difficulties faced at Muckamore Abbey Hospital.
• A central failure identified by the Inquiry was the Trust’s focus on governance processes rather than outcomes. Reports to the Board emphasised the existence of policies, action plans and committees but rarely demonstrated whether these arrangements were effective in protecting patients or improving care.
• Incident reporting, safeguarding referrals, complaints and staff intelligence were routinely aggregated at Trust level, masking significant variation at hospital level and thus obscuring sustained patterns of harm at Muckamore Abbey Hospital.
• Risks from Muckamore Abbey Hospital were often downgraded or removed as they ascended the risk register hierarchy, even when underlying conditions persisted or deteriorated. Risks affecting specific services were smoothed out through aggregation and failed to reach the Board as Principal Risks.
• Even after external regulators raised serious concerns, including the issuing by the Regulation and Quality Improvement Authority (RQIA) of Improvement Notices in 2019, the Board continued to accept assurances that care was safe, often disputing regulators’ findings without providing robust supporting data. Senior leaders failed to reconcile contradictory evidence from inspections, incidents, safeguarding reviews and staffing data. Crucially, the Board did not adequately address structural risk factors such as chronic staffing shortages, excessive use of untrained agency staff and inappropriate ward mixes. Reassurances provided by executive directors were not properly scrutinised for any underlying supporting data.

External agencies inspection and oversight

• The Inquiry concluded that, although multiple agencies were involved with Muckamore Abbey Hospital over many years, none succeeded in identifying, preventing or stopping abuse before it was revealed, exposing significant limitations in the external oversight framework.
• Between 2009 and 2019, RQIA conducted over 100 inspections of Muckamore Abbey Hospital, initially at ward level and later using a whole-hospital approach. These inspections frequently identified problems such as staffing shortages, safeguarding weaknesses, excessive restrictive practices and governance failings. However, the inspection methodology relied heavily on documentation review and there was limited involvement with staff, patients and families, providing only a snapshot of practice.
• Inspectors acknowledged that staff behaviour changed when inspectors arrived on the wards and that therefore they were unlikely to observe ‘normal’ ward culture. Despite having statutory powers to do so, RQIA did not review CCTV footage at Muckamore Abbey Hospital, even after CCTV was viewed by the Trust and by Police Service of Northern Ireland and serious concerns were raised.
• Evidence to the Inquiry suggested that families repeatedly raised concerns through various routes but felt unheard, contributing to a loss of confidence in advocacy and oversight mechanisms.
• Overall, the Panel concluded that external inspection and oversight failed to operate as an effective safety net. Warning signs, including staffing instability, increased violence, high use of restrictive practices and repeated complaints, were visible and known but not interpreted as indicators of potential abuse. Oversight was reactive rather than preventive.
• The central lesson is that external regulation and investigation must extend beyond procedural compliance and episodic inspection. For services caring for highly vulnerable people, effective oversight requires proactive, risk-based approaches that: examine culture; triangulate multiple data sources, including where appropriate the use of CCTV; engage directly with families and, where possible, patients; and act decisively when conditions associated with abuse are present.

Planning and funding of learning disability services

• Overall, the Inquiry found there was a failure to align policy, funding, workforce planning and accountability that prevented meaningful transformation of learning disability services. The absence of a coherent, long-term, system-wide approach contributed directly to sustained institutionalisation of individuals at Muckamore Abbey Hospital and to risks in care quality and safety.

Redress

• There is no doubt that patients did suffer as a result of abuse within Muckamore Abbey Hospital but to try to assess the extent of such abuse in relation to individual patients or the nature of the harm caused was deemed as beyond the Inquiry’s capacity.
• In relation to direct redress, including the consideration of financial compensation, however, our recommendation would be that the Department of Health should set up a small working party to consult with patients, service user groups and individuals connected to those who have suffered abuse at Muckamore Abbey Hospital in relation to what form redress might properly take.

• A cross-organisation implementation board oversaw the redesign and initial implementation of the care pathway. Support and oversight from the ICB was time limited, ending before the project had been fully implemented, which impacted on the operationalisation of the service.
• A business case for implementation of the pathway was approved but not fully realised. This created expectations for how the pathway would operate that were not met in practice.
• There was no shared view across organisations about what the redesigned pathway could offer patients in reality. This limited the organisations’ ability to understand the risks across the pathway and to mitigate them to as low as reasonably practicable.
• There was no single guidance document shared between organisations, and there were inconsistencies in the documentation used to support decision making about whether patients should be provided with specialist care.
• Organisations held different perceptions of the risks to patient safety created by the redesign of the pathway. This impacted on clinical decision making and led to disagreements between teams.
• Organisational oversight of the pathway after its implementation was limited due to disengagement among staff and the absence of a collaboratively agreed evaluation plan.
• The data collected about the care pathway differed across organisations and was not routinely shared between them. This led to a difference in understanding about how the care pathway was working in practice and where improvements could be made.
• The ICB had limited ability to support ongoing improvement of the care pathway and had limited access to information about the quality and safety of the pathway in practice.
• Differences in the perceived purpose of the pathway led to barriers to collaborative learning and improvement of the pathway. These included examples of incivility among staff, which is known to impact on staff wellbeing and patient outcomes.

HSSIB suggests safety learning for integrated care boards

Safety learning for integrated care boards ICB/2026/019:

• HSSIB suggests that integrated care boards proactively identify the impact of commissioning decisions on pathways prior to implementation and develop mitigations to reduce any potential impacts on patient safety and equitable access to care.

Safety learning for integrated care boards ICB/2026/020:

• HSSIB suggests that integrated care boards support organisations to effectively evaluate the implementation of new care pathways.

Local-level learning prompts

• HSSIB investigations include local-level learning where this may help organisations and staff identify and think about how to respond to specific patient safety concerns at the local level. HSSIB has developed the following prompts to support local-level learning for NHS trusts when collaborating with other organisations across a regional care pathway.

Safe implementation of the care pathway

• How do you identify and resource dedicated support to implement new care pathways?
• How do you ensure appropriate tools and resources are used to support the design and implementation of the care pathway?
• How do you identify and mitigate unexpected challenges to patient safety arising from the care pathway’s implementation?
• How do you identify and mitigate any mismatch between the expectations of patients, families, carers or staff and what the pathway can deliver in practice?
• How do you ensure that implementation of a care pathway is effectively evaluated to improve safety and learning?
• How do you identify and mitigate potential harm caused when implementing a new care pathway?

The care pathway in practice

• How do you identify and manage incivility between staff across different organisations?
• How do you facilitate shared learning opportunities for staff across different organisations?
• How do you ensure information and documentation used to support the care pathway are aligned across different organisations?
• How do you enable staff to understand the context in which the care pathway may work in different organisations?
• How do you engage staff to understand the different requirements for electronic systems that may exist across the care pathway?
• How do you support interoperability of electronic systems to enable effective information sharing across different organisations?
• How do you enable new technology to be adopted and used across different organisations?
• How do you consider relevant tools and guidance when developing work processes across different organisations?

Oversight of the care pathway

• How do you ensure shared governance forums are appropriately established and resourced, and are effective?
• How do you ensure concerns about the care pathway are escalated and acted on by senior and executive leadership teams across different organisations and the integrated care board?
• How do you ensure consistency in how data is collected and shared across different organisations, including with integrated care boards?
• How do you ensure that risks to the care pathway are identified and mitigated to as low as reasonably practicable across different organisations?
• How do you ensure messages about the care pathway are effectively shared and understood by staff across different organisations?
• How do you identify and facilitate proactive communication with a point of contact at the integrated care board with oversight of the care pathway?

The principles are designed to:

• Strengthen cultural safety, curiosity and respect in practice and education
• Explicitly advance meaningful, sustained anti-racist, bias-aware practice.

The principles are organised around four areas. 

• Culture, equity and inclusion.
• Learning, education and workforce development.
• Community and person-centred practice.
• Assurance, accountability and sector improvement.