The UK’s care watchdog has been accused of failing to take action against a scandal-hit hospital before a catalogue of failings led to the unlawful death of a child.
Ruth Szymankiewicz, 14, died on 14 February 2022, two days after she fatally self-harmed when she was left alone at Huntercombe Hospital, in Maidenhead, by an inexperienced care worker who only had a day and a half’s training, and was hired under a fake ID.
In the five years before Ruth’s death, the Care Quality Commission (CQC) published four reports warning about poor care at the hospital, dating back to inspections from 2017, raising concerns over repeated failures to properly monitor patients, reports of staff leaving "blood on the walls" and issues with missing patient records.
It rated the hospital, which was renamed Taplow Manor, “inadequate” in February 2021 but changed this in July 2021, saying improvements had been made.
Now, The Independent can reveal that just 11 days before Ruth died, the watchdog raised fresh concerns over understaffing at the hospital and found staff were not being told what was required of them.
In a joint interview with The Independent and Sky News, Ruth’s parents, Kate and Mark Szymankiewicz, slammed the CQC over its failure to act, despite its own warnings before their daughter’s death.
Mr Szymankiewicz said: “Before Ruth went to Huntercombe, we had been made aware of the CQC reports, which were damning, and to the point we said, ‘No, you cannot send our child to this institution,’ and we were told changes had happened, we were given a lot of assurances to alleviate our concerns.”
Ms Szymankiewicz said: “Regulation is complicated, but why did our daughter have to die before anyone paid attention to make some changes? They knew all of this before she died.”
Charlotte Bird, from Bhatt Murphy Solicitors, who represented Ruth’s family, said the CQC had identified multiple patient safety concerns in the months before her death, but still authorised Ruth’s admission there. She warned: “The period leading up to Ruth’s death and the CQC’s actions subsequently highlight a regulatory framework which is failing to protect patients and deliver accountability.”
It comes as former staff told The Independent and Sky News that the ward where Ruth was being held was understaffed daily before she died, and claimed it was common for patients not to be monitored properly.
One former Huntercombe Group executive, Philip King, speaking out for the first time, said the CQC and NHS England should have closed the hospital years ago.
Ruth’s death came after a 2022 investigation by The Independent and Sky News that revealed dozens of allegations of systemic abuse at the hands of the hospital group spanning more than a decade. Following the reports, its owners, Active Care Group, closed Taplow Manor Hospital in June 2023.
Despite its earlier warnings, Ruth’s parents were told by the CQC that it could not prosecute Huntercombe over her death because a “loophole” in the law prevents it from bringing prosecutions for failures that it has already issued a formal warning notice over.
Ruth’s parents said that despite a jury inquest ruling that Ruth was “unlawfully killed”, there was no justice for their daughter.
Mr Szymankiewicz said: “People often talk about justice for this or that, and we struggle with that because we feel there can be no justice for Ruth; she’s dead, she’s gone. And we’re living with that fallout, which is incredibly challenging… the inquest conclusion really highlights the numerous and systemic failings. Ultimately, Ruth was let down multiple times and in multiple ways... Ruth would be outraged by her story.”
His wife said: “We haven’t really got any faith in the CQC governance that it is going to be making sure those changes have been made. It seems likely the [regulation] process has a lot wanting.”
The couple said that one of Huntercombe’s biggest failings was that Ruth was denied visits by her family, something which caused her huge distress.
They are now urging health secretary Wes Streeting to change the Mental Health Act to protect children’s access to their families while detained in mental health hospitals.
Children's commissioner Dame Rachel de Souza said no parents should have to endure the “horror of knowing their child was failed by the people they trusted to protect her” and warned Ruth’s death was not a "one-off" after hearing stories from other children in hospital.
She said the Mental Health Act needs an "urgent" change to enshrine the rights of patients and allow families to visit whenever they like, adding: “This was cruelly and wrongly denied to Ruth’s parents, so we must act now to stop it ever happening again.”
The calls come as The Independent can reveal that 58 former patients are set to mount clinical negligence claims against around 30 psychiatrists who worked at Huntercombe hospitals over two decades, including at least eight who work for Active Care Group, which owned the hospitals at the time of Ruth’s death.
Mark McGhee, the lawyer representing them, said many had been diagnosed with complex post-traumatic stress disorder because of their experiences at the hospitals.
A campaign group, called First Do No Harm, made up of former patients and families, has urged ministers to “move away from inpatient care that isolates children from the community and their families”.
Dr Arun Chopra, chief inspector of mental health at the Care Quality Commission, said it undertook a number of inspections of Taplow Manor and increased its monitoring after Ruth’s death.
“In March 2022, we issued warning notices to the service provider, which required urgent action. While we saw some improvements in response to these warning notices, we were not satisfied that young people were being kept safe and so we placed the service in special measures, which involved further increasing our monitoring.
“After we rated them as inadequate following an inspection in December 2022, Active Care Group made the decision to stop providing CAMHS care at Taplow Manor and later fully closed the site.
“Although the site is no longer operational, we continue to monitor the safety and quality of services at the provider’s other locations and across mental health services for children and young people. Everyone deserves to receive high-quality care and where we find that this is not the case we take action, including using our enforcement powers.”
Addressing concerns about its inability to prosecute the hospital due to a legal loophole, the CQC said even if it was able to take into account the concerns it flagged in the days before Ruth’s death, there still may not have been enough evidence to prosecute.
Active Care Group said when it acquired the hospital in December 2021, there were “years of well-documented mismanagement”, and it had made significant investments in staff training, recruitment and hospital estate since it took over.
It added that it places quality of care at the heart of its operations and claims it has achieved 100 per cent “good” or “outstanding” ratings from the CQC over the past 12 months.
If you are experiencing feelings of distress or are struggling to cope, you can speak to the Samaritans in confidence on 116 123 (UK and ROI), email jo@samaritans.org, or visit the Samaritans website to find details of your nearest branch. If you are based in the USA, and you or someone you know needs mental health assistance right now, call or text 988, or visit 988lifeline.org to access online chat from the 988 Suicide and Crisis Lifeline. This is a free, confidential crisis hotline that is available to everyone 24 hours a day, seven days a week. If you are in another country, you can go to befrienders.org to find a helpline near you.
For anyone struggling with the issues raised in this article, eating disorder charity Beat’s helpline is available 365 days a year on 0808 801 0677. NCFED offers information, resources and counselling for those suffering from eating disorders, as well as their support networks. Visit eating-disorders.org.uk or call 0845 838 2040
