The head of the Belfast Health Trust has expressed “profound regret” at failings in the leadership at Muckamore Abbey Hospital.
A raft of allegations of physical abuse and mental cruelty to patients at the Co Antrim facility are being investigated by police.
An independent review into the running of the hospital by the trust has found that while appropriate governance structures were in place, these systems were not implemented effectively and senior staff did not use their discretion to escalate matters.
Trust chief executive Dr Cathy Jack issued a public apology to patients and their families “who have been failed by this trust”.
“It is clear there were serious failings in leadership and ineffective escalation of serious matters at Muckamore, despite appropriate governance structures,” she said.
“This contributed to an environment which enabled the serious maltreatment of vulnerable people to go unnoticed for so long.
“This is a matter of profound regret and for that I am deeply sorry.”
In a statement, the trust said the review was the latest in a series in recent years, adding that following “significant improvements”, it is “confident that Muckamore Abbey Hospital is much safer today”.
Health Minister Robin Swann confirmed his intention to establish an inquiry into the “appalling failings” at Muckamore as he paid tribute to Glynn Brown, the father of a patient, for his “determination in exposing the truth”.
The review was ordered by the Department of Health last year and follows a Serious Adverse Incident (SAI) Review.
It is three years since allegations around the hospital, which provides facilities for adults with severe learning disabilities and mental health needs, emerged.
Families of patients met with officials on Wednesday evening to be briefed on the findings.
These included that the health trust and the executive team at the facility rarely discussed Muckamore and the focus of the trust leadership was on delivering resettlement targets.
The report also concludes that the annual Discharge of Statutory Functions reports by the trust did not provide sufficient reassurance and were not sufficiently challenged at trust, health and social care board, or departmental levels.
The review team confirmed the conclusions of the previous SAI Report that Muckamore was viewed as “a place apart” which operated outside the sightlines and under the radar of the trust.
Mr Swann said he intends to consider the report in detail before consulting with families, patients and former patients about the most appropriate terms and format for an inquiry.
“Patients and families have been let down and I want to apologise to them on behalf of the health and social care system,” he said.
“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.”
The trust described the review as the latest in a series in recent years to “better understand how such a culture and an environment could have existed and to ensure it can never again be perpetuated”.
In a statement, the trust said: “We acknowledge this is a very painful and lengthy process for patients, families, and carers, past and present. But we are committed to ensuring that the outcomes will lead to better and safer care.
“Since the maltreatment of patients has come to light, significant lessons have already been learned and many improvements have been put in place to protect against this happening again.
“We now have rigorous processes to ensure the safe care of patients and we actively encourage a culture of greater openness amongst our staff and our families.
“Additionally, there have been many significant improvements that are now embedded and we are confident that Muckamore Abbey Hospital is much safer today.”
A major police investigation is ongoing into the allegations, which includes the examination of 300,000 hours of CCTV footage.
Belfast Health Trust said 59 members of staff have been suspended from the hospital.
Police have made seven arrests, but no one has been charged.