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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.

In 2025 the Department of Health in Northern Ireland held a consultation on the introduction of a new Regional Framework for Learning and Improvement from Patient Safety Incidents to replace the existing Serious Adverse Incident Procedure. This report provides an analysis and summary of the comments made in response to each consultation question. It also covers comments and views shared during consultation events and those in formal consultation response submissions to the Department of Health. Summarising the responses received as part of this consultation, the report states that overall there was strong support for the strategic direction set out in the consultation. It notes that respondents endorsed the proposals as a significant step towards fostering a culture that prioritises openness and learning to improve patient safety and the delivery and quality of care. It advises that the Department will now take time to consider the responses in further detail and will work with partners to consider additions, amendments and refinements that are required to the strategic proposals. This will include ensuring alignment with the implementation of other ongoing policy development in this area including, for example, the Being Open Framework. The report concludes by stating that once considered and approved by the Minister, publication of the Framework, Standards, and Principles will establish the agreed strategic governing framework for learning and improvement from Patient Safety Incidents. A managed transition and implementation phase is anticipated to begin in early 2026. It notes that the Department will keep interested parties informed about future developments relating to the new strategic approach and its implementation.

The Department of Health's Being Open Framework for Health and Social Care Northern Ireland is aimed at supporting a culture of openness, honesty, and transparency across health and social care in Northern Ireland. The Framework provides a standardised, yet flexible, regional approach to help create the conditions where a culture of openness and trust can flourish between those who use our services, their families and carers, health and social care staff and leaders and organisations. Purpose of the framework The Framework aims to promote and support a culture of openness, transparency and accountability reflected through compassionate communication with staff, patients, service users and their families and carers, and where ongoing learning enhances and improves patient safety and quality of care. The Framework will help ensure that all staff understand the expectations and responsibilities upon them to operate in an open, just and learning culture, and that they are supported to do so by health and social care organisations, leaders and managers. It is designed not only to guide staff when things go wrong, but also to promote openness, transparency and honesty as part of everyday practice and patient care, and to create a supportive and psychologically safe environment for all. By supporting an open, just and learning culture, patient safety, public confidence and support for staff will be improved. Aims of the Framework Improve patient safety and quality of care by supporting an open, just and learning culture. Normalise openness as a valued everyday behaviour rather than something that is only important in certain circumstances. Position and frame openness as part of mainstream business, not as an optional add-on. Ensure those who use services, their families, carers and staff are listened to and are treated openly, fairly and with compassion and respect; and their experiences and views are recognised as having a valuable contribution to learning and improvement. Ensure HSC staff experience visible, engaged and inclusive leadership at all levels that demonstrates and promotes an open, just and learning culture – including from those in the most senior leadership positions. Enable leaders at all levels of the organisation to drive cultural improvements. Create psychologically safe spaces for all staff to speak up and to learn. Support a move from blame to balanced accountability, and a focus on system-based learning when an event or incident has occurred or where concerns are raised. Support open and prompt sharing of learning across the organisation and beyond as appropriate, both when things go wrong and when they go well. Ensure that all staff understand the expectations and responsibilities upon them to operate in an open, just and learning culture, and that they are supported to do so. Achieve a sustained focus by leaders at all levels, including senior leaders, on embedding an open culture that is informed by both qualitative and quantitative data. Related reading ‘Being Open’ Framework and Duty of Candour in Northern Ireland: Consultation response (Patient Safety Learning, 28 March 2025)

This report from the Northern Ireland Public Services Ombudsman relates to the care and treatment the Northern Health and Social Care Trust provided to a patient in the Emergency Department of Antrim Area Hospital. The investigation found the Trust’s decision to act to prevent the complainant leaving the hospital grounds for her own safety was reasonable and appropriate and that the actions it took to restrain the patient and prevent her leaving were disproportionate and contrary to relevant standards. The investigation also identified maladministration in the Trust’s handling of the complaint. In particular, the Trust failed to conduct a sufficiently robust and comprehensive investigation into the complaint in a fair impartial manner. It placed too much emphasis on the Nurse in Charge’s statement about the incident, without taking steps to gather other potentially relevant evidence to corroborate or refute her statement. As a result, the Trust failed to give sufficient consideration to the complainant’s account of events, and failed to provide an appropriate response.

This report from the Northern Ireland Public Services Ombudsman relates to the care and treatment the Belfast Health and Social Care Trust provided to a patient during the period of 7 February to 21 September 2022. The complainant believed the Trust misdiagnosed her Temporomandibular Joint Dysfunction1 as muscular, rather than Disc Displacement without Reduction2 and consequently did not provide appropriate treatment. The investigation identified the Trust failed to carry out appropriate radiological investigations in diagnosing the complainant’s condition and clearly communicate the diagnosis in accordance with relevant standards.

This report from the Northern Ireland Public Services Ombudsman relates to the care and treatment the Northern Health and Social Care Trust provided to a patient. The patient, who was 85 years old at the time, has now sadly passed away. The complainant is the patient’s son. He said the Trust provided his father with substandard care, causing him severe bed sores. He found his father in a wet state on several occasions, indicating staff did not meet his toileting needs for extended periods of time.   The investigation founding several failings in pressure damage care and treatment in this case. This included a failure to reassess the patient’s pressure ulcer risk appropriately; a failure to reposition the patient appropriately on several occasions; and a failure to develop an appropriate care plan for managing the patient’s incontinence. Its recommendation is that the Trust apologises to the complainant for the failures and injustice identified and that it provides refresher training on certain aspects of pressure damage care and treatment to relevant staff and reviews its protocol for managing patients’ incontinence.

In March 2024 the Northern Ireland Public Services Ombudsman (NIPSO) brought together a range of voices to help look at ways of improving patient safety and public trust in our health and social care system. With a keynote address from Sir Robert Francis KC, the conference looked at issues such as how to build an open learning culture, and how to design systems which have the interests of patients at their core. The conference report, presentations and recording are available. Conference report (16.3 MB, pdf) Conference programme (18.47 MB, pdf) Opening and keynote address (6.37 MB, pptx) Building an open and just culture (4.57 MB, pptx) Patient-centred safety systems (10.6 MB, pptx) Implementing an effective learning culture (6.22 MB, pptx) Addressing inequalities in patient safety (22.26 MB, pptx) Presentations (3.7 MB, pptx)

At Patient Safety Learning we often get asked by patients and families who have received poor healthcare what they need to do to make a complaint. Although we cannot get directly involved in individual cases, we have put together a simple guide on the steps you can take if you need to make a complaint about NHS care in Northern Ireland. We also have the following guides: How do I make a complaint about my NHS care in England: a simple guide for patients and families How do I make a complaint about my NHS care in Scotland: a simple guide for patients and families How do I make a complaint about my NHS care in Wales: a simple guide for patients and families How do I make a complaint about my private care: a simple guide for patients and families How do I make a complaint: Sources of help and advice If you are a healthcare professional looking at these pages, the NHS Complaint Standards, model complaint handling procedure and good complaint handling guides set out how organisations providing NHS services should approach complaint handling. They apply to all NHS organisations in England and independent healthcare providers who deliver NHS-funded care. If you are unhappy with the care and treatment you have received from health or social care services in Northern Ireland, you have the right to make a complaint. Your concerns could be about any aspect of your care. Step 1: Make a complaint to the practitioner or institution concerned You can speak directly to a member of staff involved in your care about your complaint and ask for a copy of the complaints procedure. If your complaint relates to services provided by a GP, dentist, pharmacist or optician you can contact the Health and Social Care Board’s complaints office. They will then act as a go-between and offer an ‘honest broker’ service. They may also offer conciliation services if appropriate. If the complaint is about a nursing or residential home, you should contact the home directly, addressing your complaint to the home manager. There are six health and social care trusts in Northern Ireland. Details are available on the Northern Ireland healthcare gateway. If the NHS organisation thinks that your complaint has been fully investigated, they should send you a full written response. They should also tell you what to do next if you are not satisfied. If you remain unhappy, you can refer your complaint to the Northern Ireland Commissioner for Complaints (the Ombudsman). The Ombudsman will then consider whether this is a matter they can investigate—see Step 2. Step 2: Northern Ireland Commissioner for Complaints The Ombudsman can investigate: All complaints about health and social care services including hospitals, GPs and dentists. Private sector complaints where health and social care are funding the care or service. Cases of unfair treatment or poor service where the complaint has not been resolved to your satisfaction. Complaints relating to professional judgement of clinical decisions in a healthcare setting, as well as how your complaint has been handled. The Ombudsman cannot investigate. Private medical care. Complaints relating to access to information and the Data Protection Act. If more than six months have passed since the completion of the public body’s consideration of your complaint then the Ombudsman may not be able to investigate. However, they may be prepared to extend the time frame and you should ask for any special circumstances, such as ill health, to be taken in to account You should make a complaint in writing or by using the forms available on the Ombudsman’s website. The Ombudsman can make recommendations about what should be done to make matters right including changes in practice. They cannot award compensation or take disciplinary action against individual members of staff. If you need help to raise your concerns, you can contact the Patient and Client Council’s complaint support officers by telephone, email, letter or through their website. They will listen to your experiences and offer the advice or support that you need. Step 3: Judicial review In some cases, it may be appropriate to use the judicial review procedure, particularly if you need to urgently challenge a decision made by an NHS organisation, for example, a decision not to provide certain treatment. Judicial review is a remedy of last resort and will only rarely be applicable to NHS complaints. You will need a solicitor to offer you specialised advice about whether there are grounds to make an application for judicial review. They will also offer you advice on whether it is worthwhile becoming involved in what can be an expensive and complex legal procedure. The Law Society provides a list of lawyers who specialise in medical matters.

In April 2022, an investigation commenced into the communications provided to patients and/or their carers following placement on a waiting list in Northern Ireland. The primary focus of the investigation is the adequacy of Trust communications to patients, and/or their carers, across various stages of the waiting list process, with significant consideration being given to the content of the Integrated Elected Access Protocol (Department of Health guidance), and its application by the Trusts. The objective was to determine whether or not systemic maladministration has arisen within the communication practices of the Northern Ireland Health and Social Care Trusts (the Trusts) and whether improvements are required. It also aims to publicise what patients and/or their carers should expect from waiting list communications. The Investigative Methodology drew evidence from a wide range of sources. This included extensive queries and information requests to the Trusts and the Department; a General Public survey (with 646 responses); a General Practitioner (GP) survey (with 321 responses); follow up interviews with a number of General Public and GP survey respondents; and a number of Case Study reviews. 

Urgent funding is required to clear waiting list backlogs and drive Northern Ireland's long-term healthcare transformation, the Northern Ireland Audit Office has said in a new report which outlines the health service's "critical situation" after almost a decade of worsening waiting lists for elective care. The NI Audit Office looked at waiting list data from 2014 to 2023. It found the number of patients waiting for elective care has risen by 452,000 during that nine-year period. The Audit Office also said: "Available information suggests waiting list performance levels are significantly worse in Northern Ireland compared with the other UK regions." The report makes a series of recommendations: The very long waiting times across all the main elective specialisms further underlines the range and scale of difficulties facing stakeholders. The Department and trusts should review the key causal factors influencing outcomes across the various elective specialisms and assess if action plans in place to address these need to be radically strengthened. Waiting list pressures are currently particularly acute for Neurology, Dermatology, ENT and General Surgery (initial outpatient appointments) and ENT, T&O Surgery, and General Surgery (hospital admission). To support the introduction of local RTT measurement and targets, DoH must strive to ensure that the Encompass programme remains on course for implementation by its scheduled deadlines, and that it is fully capable of such reporting. In the interim, it should use the December 2022 comparative figures as a baseline and continue regularly monitoring performance on that basis, to determine if the HSC performance gap with England and Wales is narrowing or increasing, and also identify if any best practice there, which has helped ensure performance has not deteriorated to the same extent, can be further implemented locally. Whilst action is underway to try and address issues around trust performance and patient DNAs, and the Department is now trying to centrally drive improvements, the Department and trusts now need to explicitly quantify the increased capacity and activity required to sustainably reduce waiting times, and assess how this can be achieved at each trust, through both improving the efficiency of current operations and progressing HSC transformation. It recommends that the Department identifies the investment necessary to ensure the HSC sector can function more efficiently and sustainably, including reducing waiting times to targeted levels. It should also demonstrate and quantify, in business case terms, if such investment can ultimately secure better longer-term value for money and patient outcomes, and the likely implications of failing to secure such funding. This will help DoH demonstrate how more sustainable funding arrangements can better support its objectives. As DoH and the Trusts seek to incrementally build increased dedicated elective capacity, they should monitor its impact on waiting times, and assess whether the additional facilities are having the desired success and impact. If waiting times are not reducing appreciably, they should assess the extent of further dedicated capacity required across key specialisms. Given the current situation, the Department should firstly confirm the robustness of its estimate of the funding required to fully implement the Framework in preparation for any potential introduction of long-term budgets. Until it has greater certainty on the availability of recurrent funding, it should rank or prioritise the actions likely to have greatest impact on waiting times and allocate available recurrent and non-recurrent funding towards these on this basis. The Department should set revised Framework targets as soon as feasible. The limited implementation of previous strategies means the Department’s regular progress assessments on the Framework is welcome. Going forward, these should identify the specific work which must be progressed over the next reporting period to ensure milestones are met, who is responsible for driving this, progress against targets and timelines, and whether emerging evidence means any actions should be redesigned or reprioritised. Progress should continue being publicly reported, setting out why any actions are behind schedule, and whether, and how, this can be rectified. Close working between the various stakeholders involved in workforce-related issues is required, to ensure stronger elective care workforce planning. The stakeholders should now take stock of how their work is progressing and collectively agree the priority areas which require further attention to ensure the HSC elective workforce has the right capacity and capability to drive HSC transformation. Based on the current situation and workforce deficits, revised projections and plans should be developed, together with targets and strategies for achieving these. Increased use of the IS is likely to be necessary for the foreseeable future to address the colossal patient backlog. In preparation for any progress in approving multi-year budgets, DoH should set out its strategic plans for expanding use of the IS, and continue to clarify with the sector the degree to which it can build additional capacity to help clear the backlogs.

European guidelines advise that patients suffering ST-segment elevation myocardial infarction (STEMI) should be revascularised within 120 minutes of diagnosis. The preferred method of revascularization is primary percutaneous coronary intervention (pPCI). This study in BMJ Heart analysed the Northern Irish STEMI database to establish the proportion of pPCI delivered within the recommended treatment window. It aimed to determine whether there was any difference in long-term survival for patients treated beyond the recommended time window. The authors found that delays that result in primary PCI beyond 120 minutes from diagnostic ECG are associated with a significantly increased risk of mortality following STEMI in Northern Ireland.