Good Practice Guide
for Investigating Institutional Neglect

In the summer of 2011, a large scale multi agency investigation into the allegations of neglect at Orchid View Care home in West Sussex revealed wide scale neglect and institutional abuse. Following an anonymous alert to the Police, there was sustained police involvement in the safeguarding investigations and the pursuit of possible criminal offences. After working with the provider organisation for two months, the decision was taken by the multi-agency safeguarding team to assist residents to find new homes to live in, as their safety and well- being could not be guaranteed. An inquest concluded, in October 2013, that five people died from natural causes attributed to by neglect and several others had died as a result of natural causes with “insufficient evidence to show that suboptimal care was directly causative of their deaths”. The suboptimal care caused distress, poor care and discomfort to residents and their families. A serious case review, published in June 2013 commended the multi-agency approach to the investigation and recommended that the processes used should be shared across the country (Georgiou 2014).

As the lead health investigating officer for the Orchid View safeguarding investigation, I oversaw the health involvement of the inquiry, using a model of health focussed investigation that I had developed in West Sussex Primary Care Trust and used in partnership with West Sussex County Council over the preceding five years. The Sussex Institutional Care Risk Assessment Tool © was developed originally in 2008, (Phair 2009) in order to assess the health risks to people staying in any care setting where institutional abuse was suspected. It was used to assess the risks to those living at Orchid View.

Many people suffered because they lived in Orchid View and families suffered and felt enormous guilt because they placed their loved ones into the care of the staff and organisation that ran Orchid View, believing their loved one would be safe.

The publication of this good practice guide is my contribution to share the a small part of the multi-facetted approach we used at Orchid View, to help prevent the suffering of others in the future, and to support health and social care professionals in finding ways to discover the realities of any health related safeguarding concern in an institution, whether that is a care home or a hospital ward.