What this is
The Independent Longcare Inquiry, commissioned in 1997 by the junior health minister of the day and reported in 1998. It examined two private residential homes for adults with learning difficulties at Stoke Poges, Buckinghamshire, run by Longcare, and how Buckinghamshire County Council regulated and inspected them from the 1980s to the early 1990s. The report was written by Tom Burgner and published by the county council.
Behind it lay a police investigation which found that at least 40 residents had suffered mental, sexual or physical abuse over a decade. A leaked council report exposed it in autumn 1994. Relatives, charities and other councils that had placed people there complained the council had not responded, although police were reported to have been investigating one owner as early as 1983.
What it records
The inquiry found serious mistakes by the council. Evidence of abuse accumulated, and its inspection teams did not act and did not withdraw the homes’ registration.
The minister’s summary of the inspectors was that they were “failing because they were incompetent, they did not listen to patients or their carers and they were neglectful of their duties”.
Its structural recommendation was independent advocacy: people who would go into the homes, befriend residents and report concerns to the authorities.
It also recorded some improvements after the case came to light: better inspection teams, greater openness, better work with the local health authority. The council’s director of social services took early retirement.
Separately, one owner was jailed for 30 months for ill-treatment and neglect, and two former workers were convicted of ill-treatment.
How to read it
The finding is about a function, not an incident. A registration and inspection regime, the only safeguard these residents had, failed continuously for a decade. The record contains no analysis of restraint technique, so this page cannot say what restraint was used on any person.
Read it as a question about your own audit or inspection process. Where evidence accumulates over years and nothing is suspended, escalated or de-registered, what is the regime for? An inspection that can see and cannot act is a filing system with a visiting schedule.
The recommendation is the part most often left out. The inquiry did not answer a decade of silence with more inspection. It answered it with a person whose job was to hear residents, because residents had no route to report what was happening to them.
Where it stops
The report itself has not been published online, and the council has declined to publish it. What is known of its findings rests on BBC News reporting of publication in June 1998 and on academic citations of the Burgner report, so this page is second-hand and should be cited as such.
It is a 1998 document about practice in the 1980s and early 1990s. Nothing in it describes the current inspection system, and no reader should assume the position has improved or worsened since.
It covers one council and two homes, and its findings are about the inspection function, not about individual staff.
Sources
- BBC News, council accused of mistakes over abuse, 23 June 1998
- Disability News Service and Citizen Network (John Pring), Longcare Survivors: The Biography of a Care Scandal, 15 December 2011
If your service supports people who cannot easily tell you what happens to them, our vulnerable and volatile persons training covers de-escalation and the alternatives to hands-on restraint.
Reviewed 20 October 2026.