What this is
A Safeguarding Adults Review commissioned by Norfolk Safeguarding Adults Board, written by Margaret Flynn and published on 9 September 2021. It examined the deaths of three patients in their thirties at Jeesal Cawston Park, a private hospital near Aylsham in Norfolk registered for the assessment or treatment of people detained under the Mental Health Act 1983.
All three had learning disabilities and all three were placed on the hospital’s two locked wards. They had been patients for 11, 24 and 17 months, and they died within a 27-month period, between April 2018 and July 2020. The board commissioned the review in April 2019 and added the third death in December 2020.
What it records
The hospital had 57 registered beds across six wards, two of them locked: The Grange and The Lodge.
The review found excessive use of restraint and seclusion, delivered by unqualified staff. It found unsafe grouping of patients, overmedication, and a high tolerance of inactivity, with days the review describes as “abject boredom”. Families described “indifferent and harmful hospital practices” and said their questions and distress were ignored.
The record-keeping finding is the starkest. The hospital could not evidence the care it gave. There was no information for 179 days of one patient’s stay, a single day for the second, and 450 days for the third.
One patient used a CPAP machine for sleep apnoea. In the last 209 nights of her life it was used on 29 occasions, and neither her parents nor her consultant neurologist was told she had stopped using it.
The review made 13 recommendations for system change. It concluded that hospitals of this kind should “cease to receive public money”, and recommended that the Law Commission review the legal position of private companies providing these services.
How to read it
This is a finding about a system, not a verdict on an incident. No prosecution of the provider is recorded, and the review decides nothing about any individual death.
What it does establish is that restraint and seclusion in this hospital were not a run of isolated failures. They were the model of care: the way the unit was run, staffed and commissioned. Read it that way and the missing records stop being an administrative gap. A hospital that cannot say what happened on 450 days cannot say whether restraint was used, how often, or on whom.
Where it stops
One provider, one review, three deaths, and a document that is a summary rather than an adjudication. The review’s own text was read in part, so detail on the deaths rests on its summary and on press coverage.
Its findings describe England’s assessment and treatment units as they were commissioned and inspected up to 2020. The hospital closed in May 2021 after the Care Quality Commission found consistent failures in meeting standards, and the operating company went into liquidation in June 2021 owing almost £4m. Nothing on this page describes conditions in any service that is open today.
Sources
- Norfolk Safeguarding Adults Board, Safeguarding Adults Review into the deaths of three patients at Jeesal Cawston Park, 9 September 2021
- BBC News, Cawston Park: vulnerable patient deaths prompt hospitals warning, 9 September 2021
If your service uses restraint or seclusion with people who cannot advocate for themselves, our training on vulnerable and volatile persons covers the recording and review that this review found absent.
Reviewed 20 October 2026.