Today, O’Reilly Stewart Solicitors attended the Muckamore Abbey Hospital Inquiry for publication of the Inquiry’s long-awaited report. Claire Hunt and Dearbhla O’Hanlon, Solicitors, represent our clients who are family members of former patients at Muckamore Abbey Hospital, Belfast Health and Social Care Trust. O’Reilly Stewart Solicitors have been representing some family members of those patients since before the Inquiry formally commenced in 2022.
From June 2022 to March 2025, the Inquiry heard from 235 witnesses. Approximately 40,000 documents were provided and considered by the Inquiry during that process.
We heard today from the Chair of the Inquiry, Mr Tom Kark KC, who formally announced the publication of the report. Mr Kark noted this is the second Public Inquiry into BHSCT within the past six years.
Mr Kark outlined the objectives of this Inquiry: to examine instances of abuse at Muckamore, the circumstances in which the abuse happened and to ensure that this does not happen again.
Commenting on the evidence given to the Inquiry overall, Mr Kark stated today that injuries sustained by patients were “neither isolated nor incidental” and the Belfast Health and Social Care Trust “did massive disservice to those it was supposed to look after”. Families of patients were “marginalised and excluded” and there was a “lack of support” when they wanted to lodge complaints in respect of concerns they had about the care and treatment being provided to their relatives in Muckamore.
The report is extremely detailed however a summary of the main areas of criticism is below:
- The Inquiry’s report focused on “systemic issues which gave rise to the circumstances that “allowed abuse and poor care to occur”.
- The patient experience revealed to the Inquiry, most often through the eyes and experiences of the relatives, spoke “consistently of concerns about the appearance of unexplained injuries” such as “broken bones, black eyes and other bruises that they never suffered at home” as well as a “lack of basic care needs”. Those unexplained marks were “signs consistent with physical abuse” and were “visible indicators of systemic failure”.
- The Inquiry found that in retrospect, there was “more than sufficient information available to alert the Trust, commissioners and regulators to the potential for abuse”. Further, “warning signs were present, visible and repeatedly raised, decisive, system-wide action did not follow”. Managers “failed to recognise the escalating risks” and the Clinical Governance team “failed to highlight these trends”.
- Without CCTV “the abuse of patients is unlikely to have been exposed”. Many instances of abuse were captured on CCTV, which showed “forceful handling, dragging, pushing and inappropriate restraint”.
- In 2019, PSNI “lost confidence in assurance that all footage had been reviewed” and subsequently “decided to seize CCTV hard drives to ensure evidential integrity”. Families being informed that CCTV had captured abuse involving their relatives caused “shock, guilt, anger and lasting emotional harm”. Such was the scale of the abuse revealed by CCTV, it led to “unprecedented numbers of staff suspensions”.
- The use of sedation “became normal practice” with many patients appearing in “an overmedicated state”. Supervision was “inconsistent” and “fell far below what about be expected in a high risk inpatient setting”.
- Evidence was found of “physical restraint, seclusion and PRN [sedation] medication”. Families frequently described their relatives as “sedated, disengaged or ‘zombified’”.
- The Inquiry Panel found that “BHSCT failed for several years to carry out required audits or provide assurance that statutory safeguards were being met, despite holding substantial sums of money for individual patients”. BHSCT “did not put in place robust, transparent or consistently applied systems to safeguard patients’ money and property” at Muckamore.
- Dealing with each incident individually resulted in the inability of the organisation to recognise patterns, escalate concerns and protect patients and “allowed physical abuse and neglect to continue unchecked, causing lasting harm to patients and profound distress to their families”.
- Governance and oversight of restrictive practices “were inadequate”. A lack of scrutiny “allowed deviations from policy to become imbedded over time”. As a result, “repeated departures from expected standards” became “accepted as routine”. The Panel found that “BHSCT’s governance system failed at multiple levels”.
- The Panel concluded that MAH exhibited “multiple, persistent and well-documented warning signs long before 2017” – sustained understaffing, inadequate specialist supports, unsafe environments, escalating violence and restraint, frequent safeguarding referrals, family complaints and a geographically and culturally closed institution”. The system “failed to connect the dots”.
- Fear was a “major barrier” to complaint raising, with families fearing that raising concerns would “negatively affect their loved one’s care”. Families felt “intimidated or discouraged from speaking out”.
- It was of “some concern to the Inquiry” on how many occasions an adversarial and oppositional approach was adopted by the Trust to the Inquiry’s methods. With this in mind, the report states that in light of the “adversarial approach” taken to the Inquiry by the Trust, they also considered the position of individual families “attempting to challenge the Trust and how difficult a task that must on occasion have been”.
- The Inquiry also found that “external inspection and oversight failed to operate as an effective safety net”.
The Inquiry’s report outlines 106 recommendations for change.
O’Reilly Stewart Solicitors welcome the findings of the report as well as the recommendations made therein. We would reiterate the comments of the Chair, Mr Kark KC, that “the consequences of allowing the circumstances that led to the abuse and neglect seen by this Inquiry to arise again do not bear consideration” and “there is a high duty to look after the most vulnerable members of our society”, and those with learning disabilities and autism “are entitled to the same human rights as other citizens and deserve to be supported to live full lives with dignity, care, kindness and humanity”.
The Chair, concluding his remarks, spoke directly to the families indicating that “today is not the end of the road for you” and to use the report “as a powerful tool” to “assist you to continue to fight for those you love”.
The 700 page report is now available to access online – https://www.mahinquiry.org.uk/publications/muckamore-inquiry-report-june-2026-0
Speak to our Healthcare Team if you wish to raise a query on info@oreillystewart.com or 028 90 321 000.