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MUCKAMORE REPORT PUBLISHED | “This was a sustained failure of care”

The Department of Health has published an independent review of the leadership and governance at Muckamore Abbey Hospital (MAH).



The review was established to build upon the Serious Adverse Incident (SAI) Review into the hospital.


Completed by a professional nurse, social worker and experienced former Chief Executive, the review concludes that while the Belfast Trust had appropriate governance structures in place – with the potential to alert the Executive Team and the Trust Board to risks pertaining to safe and effective care – these systems were not implemented effectively and senior staff did not use their discretion to escalate matters.


The review found that the Trust Board and Executive team rarely discussed MAH and the focus of the Trust leadership was on delivering resettlement targets.  The report also concludes that the annual Discharge of Statutory Functions reports provided by the Trust did not provide sufficient reassurance and were not sufficiently challenged at Trust, Health and Social Care Board or Departmental level. 


The review team confirmed the conclusions of the previous SAI Report that MAH was viewed as a place apart which operated outside the sightlines and under the radar of the Trust.


The report also details:


• challenges and tensions within the management team at MAH, linked to differing visions on the future role of the hospital;

• a lack of continuity and stability at Director level;

• “a lack of interest and curiosity” about MAH from the Trust’s Board; and

• that a previous investigation into allegations of abuse represented a missed opportunity. 


The review team found that CCTV cameras were operational in MAH from 2015 but it took “an inexplicably long time” to produce a policy to implement CCTV in the hospital.


Responding to the report, Health Minister Robin Swann said:


"I want to thank the panel for their thorough report and for their clear conclusions.  Having just received the report, I now want to take the time to study it in detail.


“I can confirm that it is my intention to establish an inquiry on Muckamore.  Thanks to this report, we now know more about why the appalling failings at the hospital occurred. This will help me determine the nature and scope of a future inquiry, which must focus on the questions that remain unanswered and the crucial issue of how we stop this happening again.


“To do so, after considering this report in detail, I want to consult further with families, patients and former patients about the most appropriate terms and format for an inquiry.”


The Minister further stated:


“This was a sustained failure of care, affecting some of the most vulnerable members of our society. Patients and families have been let down and I want to apologise to them on behalf of the Health and Social Care system. I also fully accept that they want much more than apologies. They need and deserve answers as to why this happened and to be confident that this scandal will not be repeated.


“I also want to apologise publicly to Mr Glynn Brown and pay tribute to his perseverance and devotion to his son. Mr Brown’s determination was central in exposing the truth about Muckamore. It shouldn’t have been left to him to do this but we should all be very grateful that he did.”


A copy of the report: A Review of Leadership & Governance at Muckamore Abbey Hospital is available to download on the Department of Health's website at:


https://www.health-ni.gov.uk/publications/mah-review

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