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Following revelations in 2017 of the abuse of patients by staff at Muckamore Abbey Hospital, the Minister for Health in Northern Ireland ordered a public inquiry be held into that abuse and related matters. The Inquiry, chaired by Tom Kark KC, and heard from 235 witnesses, including a number of service users, and over 90 relatives of service users. It found that patients had been abused and systematically bullied by staff members at Muckamore Abbey Hospital whose job it was to look after them. The report includes 106 recommendations. The Inquiry heard extensive evidence concerning injuries sustained by patients, particularly bruises, unexplained marks and signs consistent with physical abuse. Some patients were verbal and were able to express that they had been assaulted by staff, but such direct evidence was very limited. 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.

To mark Learning Disability Week 2026, this episode of Voices for Safety explores a critical patient safety issue: the inequalities people with a learning disability face when accessing cancer care. Host Dr Louise Gorman speaks with Dr Oliver Kennedy, an NIHR Clinical Lecturer at the University of Manchester and a Medical Oncologist at The Christie NHS Foundation Trust, whose research uncovers stark inequalities across the cancer care pathway in the UK. Drawing on a large-scale NIHR-funded study of over 180,000 people with learning disabilities, Dr Kennedy explains how they are less likely to be referred for specialist tests, more likely to be diagnosed at a later stage, and around half as likely to receive treatment, resulting in much shorter survival times. Together, they explore why these gaps exist – from communication challenges and diagnostic overshadowing to systemic barriers in screening and treatment – and discuss what needs to change across prevention, diagnosis, and care to create a more equitable system. Released during Learning Disability Week 2026, this episode highlights the urgent need for more inclusive, accessible healthcare systems and the importance of ensuring everyone can receive timely, effective, and safe cancer care. Further reading on the hub: Top picks: Breaking down the barriers faced by people with learning disabilities

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) reviewed the care of adults with a diagnosed learning disability who attended/were admitted to hospital as an emergency between 1st July and 30th September 2024. Care was reviewed using 666 clinician questionnaires, 366 sets of case notes, 144 primary care questionnaires, 199 organisational questionnaires, 832 healthcare professional survey responses and 82 patient/carer surveys. Recommendations Accurately record a person’s identified learning disability in the electronic patient record/clinical notes and in learning disability registers/lists. This information should be accessible across healthcare settings to ensure prompt recognition and proactive care for patients with a learning disability on arrival at hospital. Assess and implement reasonable adjustments for patients with a learning disability. This should be undertaken: proactively if the reasonable adjustments have been flagged, and in place when the patient arrives in hospital; as soon as practicable after arrival/admission to hospital and be reassessed throughout the admission. Use decision support tools to aid healthcare professionals when assessing mental capacity in patients with a learning disability. Consistently and continuously involve people with a learning disability in their care during a hospital admission. This should be from the point of arrival through to discharge. Include:support from carers as appropriate; Reasonable adjustments at all stages, e.g., using communication tools to support conversations. Commission local learning disability support services to enable equitable access to care for patients with a learning disability who attend or who are admitted to hospital. Consider: using multidisciplinary community learning disability services to provide an in-reach service; upskilling all healthcare professionals to care for people with a learning disability; locally assessing how many patients are seen annually to determine the size of the service needed.

A learning disability is a neurodevelopmental condition that affects how individuals process information, often impacting skills such as reading, communication, and memory. While many people with learning disabilities have average or above-average intelligence, they may require tailored support to navigate healthcare effectively. Maternity care should be responsive to every woman’s needs. This Maternity and Newborn Safety Investigation (MNSI) safety spotlight focuses on mothers with a learning disability. Consider these safety prompts: How does your service record that a woman has a learning disability and how it affects her day-to-day care needs? What are the barriers to offering every woman with a learning disability the opportunity to complete a health and care passport? Could tools such as the health and care passport be used more routinely to capture communication preferences, concerns and support needs? How does your service ensure key information about learning needs and social complexities are consistently shared in discharge summaries? Have your staff been supported to undertake the government approved Oliver McGowan mandatory training on Learning Disability and Autism?

This Health Services Safety Investigation Body (HSSIB) report is the second in a series considering the self-administration of insulin by people with diabetes mellitus (diabetes) in community settings. Many people with diabetes manage and administer their own insulin, either by injection or using a combined monitor/pump device (a hybrid closed loop system). However, a disability or impairment may affect their ability to safely manage their own insulin if they are not supported. This can lead to short-term and long-term health problems, which can be life threatening. HSSIB identified incidents where a person with diabetes or their family/carer had administered insulin incorrectly (the patient safety issue of focus). In these incidents, a disability – such as a visual or memory problem – had influenced how someone had administered insulin. The investigation explored the following areas in relation to the patient safety issue: supporting the development of people’s competency – that is, their skills, experience, knowledge and ability – to manage insulin recognising and responding when people’s circumstances change, such as deterioration in a disability assessment of people’s mental capacity to make decisions in relation to insulin. Findings People with diabetes (who require insulin) are at risk of harm through the administration of insulin when pre-existing or new disabilities/impairments have not been recognised or adjusted for. People are not always empowered to become competent to manage their insulin, with assumptions made that a person is not competent to do so because of a disability/impairment. Supporting people to safely self-manage their health, including insulin, requires integrated working across community services. Where this is limited, such as due to resource challenges or limited collaboration, people are put at risk. Efforts to empower and enable people to self-manage insulin are affected by the competing demands on, and the capacity and accessibility of the community services that provide this type of support. Designated and protected resource aimed at supporting the development of insulin self-management skills have shown benefits for patient experience and have reduced demand on community services. There is no national competency framework for the management of insulin by patients and families that supports community services to identify and make reasonable adjustments for a disability/impairment. Administration of insulin by staff in care homes (delegated administration) may reduce demand on community teams but is limited by barriers to implementation, including high turnover of care home staff. Some people with type 2 diabetes may be prescribed insulin without first optimising other diabetes treatments and/or exploring preferences. This means a person may be exposed to the risks of insulin unnecessarily. There are people with diabetes (who require insulin) whose circumstances mean they are not monitored for changes in a disability/impairment, including via long-term condition reviews in general practice. People may not engage with healthcare services to enable the regular monitoring of their condition. Engagement is affected by the ability of services to meet patient needs but may also represent other situations that require a response, such as in relation to patient safeguarding. Electronic systems in general practice may not alert users when people have not requested repeat prescriptions of insulin, removing a potential opportunity to identify patients who need support. Diabetes technology, such as insulin pen devices, are not always designed in a way that supports people to administer insulin when they have a disability/impairment, such as visual impairment or problems with dexterity. There are concerns about the future competence of the healthcare workforce to support the increasing numbers of people with hybrid closed loop systems. Healthcare workers may not identify when a patient’s mental capacity to make decisions in relation to their insulin may be compromised, meaning a more in-depth assessment in line with the Mental Capacity Act (2005) may not occur. Limited education and practical support for application of the Mental Capacity Act (2005) by healthcare staff means its principles are sometimes misunderstood. Patients with diabetes (who require insulin) and who experience fluctuations in their mental capacity, are at risk of harm when services do not proactively plan for a time when the patient may lose the ability to manage their insulin safely. HSSIB makes the following safety recommendations HSSIB recommends that NHS England/Department of Health and Social Care provides guidance to integrated care boards and community providers setting out expectations for service models that empower and support people to manage and administer insulin in community settings. This is to support recognition of models that have safely, effectively and equitably engaged patients, their families and carers, including through the use of modern diabetes technology for self-management. HSSIB recommends that NHS England/Department of Health and Social Care develops a tool for use in community settings to support the assessment of competency of patients, their families and carers to manage and administer insulin and care for people with diabetes. This should include recognition of a person’s circumstances, the impact of disabilities and impairments, and potential adjustments to support administration where safe to do so. This is to support consistency in how competency is assessed for the safe management of insulin within the context of modern diabetes care. HSSIB makes the following safety observation National bodies can improve patient safety by providing clarity on expectations around 1) how staff recognise that a patient’s mental capacity may be compromised in relation to decisions about their self-management of insulin, and 2) the undertaking of a mental capacity assessment by the most appropriate person. This should include clarification on the practical application of the Mental Capacity Act (2005) to situations where a patient’s capacity may fluctuate and where sharing confidential information to support patient safety may be appropriate. HSSIB suggests safety learning for integrated care boards HSSIB investigations include safety learning for integrated care boards where this may help organisations think about how to respond to a patient safety issue that relates to integrated care across a geographical footprint. Informed by the findings in this report, the investigation proposes the following safety learning. HSSIB suggests that integrated care boards develop data-driven approaches to effectively identify the diversity of their populations’ characteristics and social circumstances, and use this data to support community providers to design services that empower and enable people to be involved in a patient’s care, including through supporting self-management of medications and conditions. HSSIB suggests that integrated care boards, through future planning for neighbourhood health services, include consideration of how patients who may be at greater risk of harm from insulin administration due to their specific circumstances – for example co-existing disabilities, social isolation or receiving home-delivered medications – are proactively monitored to identify changes in their circumstances. This may include using technology such as remote monitoring. Local-level learning HSSIB investigations include local-level learning where this may help providers/organisations respond to a patient safety issue at the local level. Informed by the findings in this report, the investigation shares the following local-level learning. How does your organisation create the conditions for staff to empower and enable patients, their families and carers – through a person-centred approach – to self-manage insulin where appropriate? How does your organisation proactively identify the varying needs of people with diabetes in its local population, and ensure these are met to enable their management of insulin? How does your organisation promote patient-centred care and facilitate self-care models that empower and enable patients, such as those with diabetes? Does your organisation allocate specific resources to support patients, families and carers to develop competency to self-manage insulin, and ensure those resources are protected to empower and enable people? How does your organisation ensure that staff supporting the development of a person’s competency have the required knowledge and skills to provide that training and education in relation to diabetes and insulin? How does your organisation support staff to identify and code a person’s disabilities/impairments that may influence their competency to self-manage insulin, and ensure these are considered and adjusted for when deciding whether a person is competent? Does your organisation have systems and processes to identify where patients have not requested their repeat medication prescription, or the frequency of the requests have changed, which may indicate changes in their circumstances? How does your organisation ensure long-term condition reviews reliably take place for patients who may be at a higher risk of deterioration due to their circumstances, for example those with multiple long-term conditions? How does your organisation identify and code patients – who may be more vulnerable to harm from insulin due to their circumstances – for increased monitoring? This may include patients who have their medications delivered to their home, who do not have family nearby, or who are housebound. Does your organisation provide practical training and guidance to support staff to consider the mental capacity of patients to make decisions around their insulin when there are concerns capacity may be compromised? Does your organisation provide practical guidance to staff to help identify when it is lawful, ethical and appropriate to share confidential information about a patient to mitigate risks to their safety, including with family members? Does your organisation have accessible routes via which staff can seek urgent support when they are concerned a patient’s mental capacity to make decisions about their self-care may be compromised, particularly in high-risk situations? How does your organisation support staff to develop ‘crisis plans’ for patients who self-manage insulin to protect their safety at a later point when their capacity to make decisions in relation to their care may change?

Prioritising patient safety is a blog series from the Parliamentary and Health Service Ombudsman (PHSO). Each month, PHSO publish between 70 to 100 of their casework decisions as a way to share learning that will help organisations improve their service and prevent mistakes happening again. This blog shares two cases involving patients with disabilities and the improvements one Trust has made, highlights key themes emerging from PHSO casework and provide updates on patient safety work from NHS Resolution, the Freedom to Speak Up Guardian and the Health Services Safety Investigations Body (HSSIB). 

Cervical cancer is preventable. By 2040 the NHS in England is aiming for a cervical cancer incidence rate of below 4 per 100,000 women (elimination status). To achieve this, we need to increase HPV vaccination rates and improve attendance for routine cervical screening particularly in younger people and underserved communities including patients with learning disabilities. This learning resource from the NHS Wessex Cancer Alliance explains the misconceptions and barriers to cervical screening, the consent and best interest decisions, and the role of the sample taker and the reasonable adjustments that can be made.

This report presents the findings of Healthcare Inspectorate Wales (HIW) from inspections of mental health and learning disability services across Wales between April 2024 and March 2025. During this period, HIW undertook 25 onsite inspections across NHS and independent hospitals, as well as community mental health teams (CMHTs), to assess the quality, safety, and effectiveness of care provided. Of the 25 inspections conducted, 14 were of NHS hospitals and 11 were of independent providers. This total includes two separate inspections of the same independent provider.

In this report, Carer's UK examine the benefits of moving to paid Carer’s Leave, including the positive impact it would have for women and lower paid workers. They also outline the anticipated costs and savings this would result in for HM Treasury.

This policy sets out a framework describing how the Trust and its staff will respond to and learn from deaths that occur under their care.It will provide guidance for all staff involved in the mortality review process ensuring clarity on roles, responsibilities and expectations. Reviewing mortality can help make improvements to the quality of care received by patients at the Trust by identifying care related issues. This enables the identification of learning themes and provides evidence of a high standard of care. Mortality is a fundamental component of clinical effectiveness, one of the three dimensions of quality described by Lord Darzi in High Quality Care for all (2008). The Trusts aims are to: Have continuous improvement of our Hospital Standardised Mortality Ratios (HSMR) and the Trusts Standardised Hospital-Level Mortality Index (SHMI) Achieve a year-on-year reduction in avoidable mortality  Improve learning from mortality reviews Ensure robust and timely governance processes regarding mortality outcomes and reviews Provide assurance of mortality processes in the Trust.

This service model brings together the good practice taking place in local areas, and that  which has previously been described for this group of people. It recognises that improvements  are typically underpinned by visionary leadership, a focus on human rights based approaches,  workforce development, co-production and a preparedness to reflect and learn. It aims to support  commissioners across health and social care to work together to commission the range of services  and support required to meet the needs of this diverse group.

This video made by Health Education England and the Restraint Reduction Network looks at the impact of inappropriately used restraint practices in mental health and learning disability services. Three people with lived experience of restraint discuss the impact it has had on their lives and why they are campaigning for change.

There is an increasing emphasis on, and commitment to, using patient narratives in nursing practice and nurse education. Listening to the voices of those receiving our care is just the beginning. The challenge is to use these narratives to improve practice and the patient experience. This seven-part series in the Nursing Times presents narratives from three fields of nursing: adult, mental health and learning disability. Each article includes opportunities to reflect on the stories presented and consider their implications for practice.