For readers just joining us - the findings of a public inquiry into the abuse of patients at Muckamore Abbey Hospital have been published.

The inquiry found that patients were abused, systematically bullied by some members of staff and that there was a culture of not reporting abuse.

It also found:

• Ineffective external inspection failed to uncover the abuse and the system failed to function as a meaningful safety net.
• A long-term policy beginning in 2001 to move all patients with Learning Disabilities and Autism from hospital settings into community based care was not matched by necessary investment.
• Prior to 2017, incidents of peer on peer and patient on staff assaults increased even as the patient population was diminishing, indicating a rise in intensity and potential danger.
• Safeguarding arrangements did not provide effective protection for vulnerable adults
• Systems and structures in place were wholly inadequate to manage the scale of abuse uncovered through CCTV review in 2017.
• Evidence from CCTV footage taken from inside the hospital captured patients clinging to wheelchairs, being spat at and so heavily medicated that they'd become "zombified"

Brown says for the families, being vindicated is not the same as getting justice.

His son Aaron was among those whose physical abuse was captured on CCTV.

He calls for support, treatment and counselling to be provided to survivors of the abuse and to families.

He also calls for financial redress that "reflects the gravity and duration of what was suffered".

Brown adds: "The families will not stop until there is real change and meaningful redress for those that were harmed.

"Anything less would be yet another insult to our loved ones."

He calls for the health minister to meet with families urgently.

Families of patients at Muckamore Abbey Hospital says the inquiry's findings are the "the formal confirmation of a truth we have lived and fought to expose for years".

Reading a statement, Glynn Brown whose son was a patient, says families were not believed.

"For years these families were told they were exaggerating.

"Today the inquiry confirmed what we always knew, that their loved ones were abused on a staggering scale and that the failure was systemic, that the warning signs were there to be seen and that those in power to stop it did not.

"This report belongs to the families and the patients, including those who did not live to see it."

Kark says there must be a commitment to ensure that what happened at Muckamore Abbey Hospital can never be repeated.

The report has been formally submitted to Northern Ireland's health minister.

“The inquiry was established to examine what happened, why it happened, and how it was allowed to continue for so long.”

He says recommendations must be implemented immediately and monitored rigorously.

The lessons, he says, are stark.

"This cannot be allowed to happen again. There should be no delay, no dilution, and no side-stepping in the delivery of the recommendations.”

Tom Kark says politicians now need to get on with legislation to implement the inquiry's recommendations.

"We don't do that very well in Northern Ireland," he adds.

Image source, bbc

Kark says one of the things that went wrong at Muckamore was that people "lost sight of the fact that they were dealing with individuals who had personal needs and requirements.

"That led to dysregulated behaviour, and that led to far too much restraint, overmedication and eventually abuse."

Closed circuit television (CCTV) played a pivotal role in uncovering abuse.

In fact the report goes as far as to note that without it, the abuse of patients is unlikely to have been exposed, and the inquiry itself may never have been established.

But, CCTV and its use must be "carefully considered, regulated and monitored".

There was a significant lag between its installation in communal areas and the policy around its use being approved in about 2017.

The pivotal time came in August 2017 after a report that a patient had been struck by a staff member. When CCTV was reviewed "they discovered not only that the incident had been recorded, but that other unreported incidents were visible on the footage".

The panel notes that while it was essential in revealing the truth the Trust was "unprepared for the consequences of that revelation".

The panel concluded that CCTV can be a powerful safeguarding tool in high-risk settings, but only if accompanied by clear policy.

The also report makes it clear that it was not every single member of staff whose behaviour was a problem.

There were "many members of staff who devoted a significant part of their working lives to caring for the patients at MAH and who took no part in the abuse and may not even have been aware of it".

It's "unfortunate" then that the reputations of hard-working and well-intentioned members of staff have been unfairly tarnished by what happened.

The report pays tribute to those staff who behaved with professionalism.

Kark, in his comments, paid tribute those who showed "bravery" in coming forward to the inquiry.

Of 740 patients about 10% were represented in evidence.

The full report has been published on the inquiry's website.

If you would like to read it in full click here., external

Marie-Louise Connolly
BBC News NI Health Correspondent

These findings are shocking and are testament to why what happened inside Muckamore is regarded as the biggest criminal adult safeguarding case in the UK.

Evidence from CCTV footage taken from inside the hospital captured patients clinging to wheelchairs, being spat at and so heavily medicated that they'd become "zombified".

Tom Kark found there was a closed culture and a lack of reporting of what was happening between staff and patients.

Warning signs from as far back as 2012 within the hospital's Ennis Ward were missed after an incident triggered several arrests among staff, one of use resulted in a conviction.

While that case should have triggered questions and further investigations, the inquiry found it didn't and instead some managers stood back and turned a blind eye to what was going on.

Chapter 1 of the report is difficult reading where the inquiry outlines examples of where and how patients were maltreated.

Kark says he found the evidence "very distressing to hear" and it would have been even worse for the families.

"I think what surprised and shocked us most was that there was plainly a culture there," he told BBC News.

"We've referred to the normalisation of, of deviance, in other words, bad behaviour becoming normalised, that people were walking past and allowing this to happen, and neither intervening nor reporting it.

"I think that's profoundly shocking."

Image source, PA Media

Tom Kark says relatives saw their "zombified" loved ones but felt powerless to do anything about it.

He said when the abuse came to light many relatives felt guilty about about placing their loved ones in Muckamore.

"To give that evidence in the full glare of a public inquiry must have been for most and probably all exceptionally difficult," he says.

The report covers the use of restrictive practices with those with learning disabilities and/or autistic people.

It makes the point that some practices once considered "benign" became outdated and staff training did not keep pace with this evolving understanding.

There was a pattern of frequent use of physical restraint, seclusion and PRN (‘pro re nata’) sedation sometimes where the use of "de-escalation or other preventative, person-centred or behavioural interventions" might have reduced or avoided the need for restrictive measures.

Seclusion was a particular area of concern as was the use of PRN medication for restriction.

But families said they often found loved ones sedated, disengaged or "zombified".

The report does recognise that, often, there was an absence of appropriate alternatives such as psychological interventions and the impact of staff shortages on effective de-escalation of challenging behaviours.

The panel concluded that injuries such as bruises and marks were not "isolated" but visible indicators of systemic failure.

Unchecked physical abuse and neglect caused "lasting harm to patients and profound distress to their families".

As well as that personal care and hygiene was often lacking

Descriptions were given of patients being unkempt, with dirty hair and smelling of body odour and urine. On some visits relatives noted that incontinence pads were full or fingernails had faeces under them.

Some patients were dressed in another patient's clothes.

Weight loss and weight gain was also noticed.

Key to finding out what happened at Muckamore was the discovery of CCTV footage with catalogued the physical abuse.

In it the "forceful handling, dragging, pushing and inappropriate restraint" of patients could be seen.

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".

We are told about the "worry and trauma" this caused families, as well as guilt for "exposing their relatives to harm".

"In truth, of course they bear no blame whatever, but the burden for many was expressed clearly through the families’ evidence, which was often and understandably emotional."

Muckamore Abbey Hospital was designed and built as a long-stay facility for people with learning disabilities and/or autistic people, and some were admitted through the criminal justice system into forensic care wards, the report says.

However, the report says their experiences changed over time as the facility changed.

The inquiry heard about people who were admitted as young as six years old and who moved through different wards as they grew older. Resettlement of patients often failed.

Some lived nearly their whole lives there.

"For some it was all they knew and they regarded it as their home for life," the report explains.

The report lays bare the nature of the injuries the relatives saw on their loved ones, many of whom were "non-verbal". Because of this establishing how an injury had been caused was often extremely difficult, the report explains.

"Some patients will have caused injuries to themselves, to other patients and to members of staff," it's acknowledged.

However when abuse was seen on CCTV many relatives "understandably thought the worst and realised the possibility that at least some of the injuries seen upon the patients were a sign of deliberate abuse by staff".

Some relatives commented that patients seemed to receive injuries such as broken bones, black eyes and other bruises at the facility that they had never suffered at home.

There was evidence about "bruises, unexplained marks and signs consistent with physical abuse".

Families saw "bruising to arms, legs, faces and torsos, including what appeared to be grip marks, finger bruises and injuries appearing in clusters".

"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".

The report says many families lost confidence in these explanations.

This is the second major public inquiry into it the Belfast Trust within last decade.

The inquiry found the "adversarial and oppositional approach" taken by the health trust in this case concerning.

It said correspondence from their lawyers was "frequently confrontational" and they were disappointed the trust "did not accept that the evidence given by families and patients should be given equal weight to records held by the Trust".

The inquiry acknowledged that the trust's lawyer recognised on its behalf that it had "failed in its core duties to look after the safety of its patients" at Muckamore, but that it was committed to learning as much as possible through the process.

However, the report says that the "attitude of the trust" seen in correspondence sent on its behalf, during the course of the inquiry gives rise to "serious concern as to whether the Belfast Trust has the capacity to change its ways independently and without external forces brought to bear".

Tom Kark KC says there were clearly warning signs at Muckamore "for many, many years before the 2017 revelations, certainly going back to 2012 and before".

He says senior managers and the board should have identified them as red flags.

"This was clearly preventable," he adds

Kark says "you cure systems by looking at systemic problems, and there clearly were systemic problems here that we've tried to address".

"Patients were abused at Muckamore Abbey Hospital. It is important to state that bold and simple fact."

The report says the revelation in 2017 of the abuse of patients at Muckamore Abbey Hospital "shocked" the relatives of those patients, the health community and the whole of Northern Ireland.

The report also makes it clear that abuse did not involve every patient nor every member of staff, nor a majority of the staff.

But many patients had their lives made "miserable" by systematic bullying by certain members of staff whose job it was to look after them.

Since the investigation began in 2017, the Police Service of Northern Ireland (PSNI) has reported 124 people to the Public Prosecution Service (PPS).

So far, prosecutors have directed charges against 58 people, who are at various stages of the judicial process.

To date, three people have been prosecuted, two cautioned and one case dismissed.

Separately, the Belfast Health and Social Care Trust investigated 192 members of staff.

Of those:

• 19 were dismissed or sacked
• 64 referred to the Nursing and Midwifery Council – unclear how many have lost their registration
• 24 referred to the Northern Ireland Social Care Council
• 52 cases remain outstanding as they await investigation
• Others have left voluntarily with no case to answer