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Coalition for Change

The “Coalition for Change” was launched officially at the Cawston Park SAR progress summit in September 2022, bringing together an initial core group of individuals who have significant experience and interest in relation to people with learning disabilities and/or autism who have been described as having behaviours that challenge and the care they receive.

The overall purpose of the coalition is to bring together people with lived experience, their families or carers alongside professionals from the statutory, private and voluntary sectors to influence service design, policy and practice locally and nationally.

Information about current members can be found here.

19 April 2023

Joint statement in response to a BBC investigation: “Assaults, neglect and a Taser revealed in ‘deeply shocking’ BBC care home investigation”[1] from the authors of safeguarding reviews.

On 13 April 2023, the BBC reported on its investigation into abuse and safeguarding at services in Doncaster. 

The BBC investigation identified serious issues spanning several years, in services for children and adults with learning disabilities and/or who are autistic run by the Hesley Group.  Since little or no learning had taken place, children and adults were at serious risk of harm.

We are mired in a familiar and unacceptable stalemate. There have been multiple safeguarding scandals, court cases, reviews and investigations, some of which have been exposed by the media. They include Winterbourne View Hospital, Atlas Care Homes, Whorlton Hall Hospital, Cawston Park Hospital and now Hesley Group's services. Safeguarding reviews and investigations have identified recurring themes:

  • a widespread failure to design, commission and provide services which would give children and adults with learning disabilities and/or who are autistic the support they need close to home and to reduce or avoid lengthy and inappropriate stays in hospital or residential homes;
  • weaknesses in short-term commissioning with no effective means of assessing the quality of care or outcomes being delivered at many high cost placements;
  • regulation and commissioning failing to recognise or respond effectively to the warning signs of abusive cultures becoming established;
  • failing to listen to and act on concerns raised by individuals and families; and
  • challenges in the system’s ability to hold the directors and shareholders of care organisations to account.

Similarly, their recommendations identify the need to:

  • address the underlying budgetary structures and limitations which militate against person-centred commissioning, the primary purpose of which should be to enable children and adults with learning disabilities and/or who are autistic to lead fulfilling, healthy and safe lives in their local communities;
  • withdraw funding from services which fail regulatory processes and are unaccountable, due to their offshore status and/ or their ability to evade responsibility for harmful care by dissolving their companies;
  • develop different service delivery models which credibly provide supportive, open and positive cultures in which people with learning disabilities and/or who are autistic may thrive and flourish.

However, little has changed, the scandals persist and nothing is fixed.

It is time for a co-ordinated, sustained and resourced re-think and to bring fresh interest to tackling the system-justifying tendencies that perpetuate harm. As the authors of many safeguarding reviews, we commit to working together and networking, to propose a progressive and long-term solution to this heartless cul de sac. People with learning disabilities and/or who are autistic and their families have a far more credible track record in identifying the features of humane services than companies without any corporate social responsibility.  

Dr Margaret Flynn – author of Winterbourne View Hospital SCR and Cawston Park Hospital SAR

Dame Christine Lenehan – Director of the Council for Disabled Children, Lead Reviewer of Hesley Group Safeguarding children with disabilities and complex health needs in residential settings (phase 1)

Dr Sheila Fish SCIE Associate, Learning Together Audits and Reviews, Lead Reviewer of the Whorlton Hall SAR

The Coalition for Change, hosted by Norfolk Safeguarding Adults Board, co-funded by Norfolk County Council and NHS Norfolk and Waveney ICB, is kindly hosting this statement on their website and co-ordinating endorsement and support. 

If you wish to endorse this statement, please click here (it will take you to a new window and ask you a few questions).

Organisations who have already pledged their support can be found here.  

[1] (accessed 14 April 2023)