Private hospitals should not be used to care for people with autism and learning difficulties, a report into the death of a Collier Row woman has found.
Joanna Bailey, 36, died at Jeesal Cawston Park, Norfolk, in April 2018 after a seizure.
An inquest jury last year found failures in her care on the night of her death.
Author of a serious case review published on September 9, Margaret Flynn, said Joanna’s care records were “unaccountably inadequate”, with only 68 per cent of her time at Cawston Park properly recorded.
The records which do exist show she had asked to be given more activities, but was instead left "inactive” and “sedentary”, causing her to gain weight and potentially worsen her sleep apnoea.
Cawston Park has since been closed.
Following the report, NHS England said it would continue to reduce the number of patients in specialist hospitals and the North East London CCG said it is committed to ensuring the recommendations are met in full.
£1,000 a day
Joanna began experiencing seizures at age 18 and was diagnosed with epilepsy and sleep apnoea.
After her condition deteriorated, she lived in various health facilities, moving to Cawston Park in 2016.
She was placed there by the then Newham Clinical Commissioning Group (CCG), since replaced by the North East London CCG.
Her placement was funded at £1,000 per day, yet her one-to-one supervision was cancelled and she was put under general observation at the often short-staffed facility.
"These private facilities are just making big bucks," said Keith Bailey, Joanna's father. "That money is supposed to be for specialist care and getting people better. But these places are run on a shoestring.
"Her one-to-one was because of her epilepsy, among other things, which was a major threat and ultimately did kill her. They just took the money and didn't do the care.”
Mrs Flynn wrote: “The roots of private, specialist hospitals reside in business opportunism and profit-driven priorities.
She questioned why the NHS continued to use them and why the health watchdog, the Care Quality Commission (CQC), continued to register them.
“Unless this hospital and similar units cease to receive public money, such lethal outcomes will persist," she wrote.
Capacity
Questioned about the removal of Joanna's one-to-one status, Cawston Park's owner Jeesal said she had agreed to it.
But the report questioned whether she had the capacity to make such an important decision.
Mr Bailey said: "She'd had a test done at a hospital prior to her move to Norfolk and they gave her mental age as that of an eight-year-old.”
Joanna was supposed to wear a breathing mask while sleeping to help prevent seizures, but after she died, tests found it was only used 29 out of the last 209 nights.
Jeesal said it was Joanna’s decision not to wear it.
"You're asking a person that doesn't fully understand,” said Mr Bailey, describing the explanation as "disgusting" and "all totally wrong".
Mr Bailey said he believed facilities should have to carry out capacity tests on new patients.
Further deaths
He said he was sad that Joanna's death did not appear to have sparked changes.
"Joanna was the first to die because of all the problems that were going on," he said.
"But they didn't learn - because after that, there were two other deaths in similar circumstances.”
The serious case review found similar failings in the treatment of two other patients who died at Cawston Park – Ben King and Nicholas Briant.
"You would have thought that the CQC would have done more investigation and closed down that place quicker,” said Mr Bailey. “It might have prevented those two other deaths."
The CQC said patients’ treatment at Cawston Park was “unacceptable” and when improvements were not made, it took enforcement action.
The hospital has since closed.
Mr Bailey said: "I think the NHS should go back to looking after people, rather than putting them in private facilities.
"There should be more small, residential care homes for people with learning difficulties. Then they would get the love and the care they need."
The North East London CCG said: "We accept the report’s findings, including the clear failings highlighted in Joanna’s care at Jeesal Cawston Park, and are committed to working with partners to ensure its recommendations are met in full.
"Our thoughts and deepest sympathy are with Joanna’s family and those affected by her loss."
NHS England said it would continue to reduce the number of patients in specialist hospitals and prioritise community care.
Jeesal
The Jeesal Care Corporation did not respond to Archant’s requests for comment, but told the BBC: "The care they received at Cawston Hospital fell far below the standards we would have expected.
"We are deeply sorry that we let the families down.
"We closed Cawston Park Hospital and whilst the property is owned by our holding company, we will never run it as a hospital again nor will we ever operate any other hospital."
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