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I had to act over abuse - ex-nurse
The nurse who blew the whistle on the Winterbourne View scandal said he acted because no-one would listen to his concerns.
Terry Bryan, a senior nurse at the South Gloucestershire care home, contacted BBC1's Panorama after his fears repeatedly fell on deaf ears. He said that in 30 years' nursing, nothing had prepared him for the "drudgery of daily life" at the private hospital, near Bristol.
"I soon saw that everyone was extremely bored and made to follow the same archaic, institutionalised daily routines," Mr Bryan said.
"Any form of non-conformity was matched by incompetent interpersonal skills from the staff team.
"There would be no bartering, negotiations or waiting. They only ever matched like with like and force with force.
"I saw staff threaten people with cancelled trips out and even a birthday tea on one occasion if they didn't do what was being asked of them.
"Again, with no negotiation skills, the staff were jumping straight from request to order to enforcement. All this escalated in the space of about two minutes.
"When I asked them what they were doing, they explained to me that they were expected to get the people to do what was asked of them.
"This was termed 'The Castlebeck Way'. They said that management wanted it that way.
"I saw staff shouting at individuals and neglecting them when they were desperate for attention.
"I saw people being teased and when I asked the staff about it, they called it 'banter'.
"But what was most apparent to me from an early stage was the complete drudgery of everyone's lives in Winterbourne.
"Everyone was downtrodden and scared, with the staff team operating on autopilot for much of the time. They'd leave morning handover and expect the worst for the next 12 hours.
"When it eventually came, they were ready and willing to react. The uproar of chaos and alarms was relentless."
Mr Bryan, who started work at the private hospital in August 2010, said that staff - due to boredom - provoked incidents with residents in order to use restraint.
"These were the incidents caught on camera," Mr Bryan said. "People were therefore bullied until they did conform. But the bullies didn't hurt all of the service users - they didn't pick on people who would really, really fight back.
"There were one or two individuals whose reputations preceded them and they were not assaulted. Ever.
"But the people caught on camera were able to act with impunity and remain unchallenged; they were volatile individuals who should never have been employed in any care setting, but Winterbourne recruited them."
Mr Bryan said Winterbourne View had become institutionalised with the care staff accepting the noise, chaos and boredom.
"They didn't have the skills to do anything positive about it and were not receiving any positive direction from the nurses and management either," he said.
"Ultimately, they were able to manipulate these failings for their own amusement and entertainment - but only with the more vulnerable members of the group, remember.
"So, there was a bunch of vigilantes in charge of a group of vulnerable people, making them conform to a whole raft of nonsensical routines and facile activities and putting the metaphorical foot down whenever anyone had the temerity to ask why."
In a four-page email Mr Bryan raised a series of concerns with his superiors at Darlington-based Castlebeck Ltd, the firm which owned Winterbourne View.
That email was in turn shared with South Gloucestershire Council's adult safeguarding by a Castlebeck manager but nothing was done.
Mr Bryan then sent his email to the Care Quality Commission (CQC) and, after failing to get any action, he went public.
"I blew the whistle because I had seen bad practice and poor attitudes, staff ignoring people when they were distressed and the threats - staff saying 'If you don't stop banging your head against the wall then you won't see your mum at the weekend'," he said.
"I started recording what I saw and then wrote the email. It was quite low-level stuff, but it was enough to get people suspended.
"It took a secret camera to expose the scale of abuse going on. They wouldn't have done what they were doing in front of me, as they said I was a 'do-gooder'."
Mr Bryan left Winterbourne View in November 2010, having realised that his departure would make no difference. He contacted the BBC the following month.
He said the scale of the abuse filmed by Panorama's undercover reporter shocked him.
"That night, I gathered a group of friends and family at my cottage and we all waited for the programme to start," he said.
"For the next hour, I wept tears like I'd not wept in years. We anticipated an evening where some vicious people were going to get what they deserved but we all soon dissolved into a sea of blank expressions, total disbelief.
"People turned away; no-one was able to look at what they'd captured and what the whole world was now seeing.
"Even as I watched it, I knew that I was witnessing a line being drawn in the sand.
"However, even those harrowing - and now iconic - images did not prepare me for just how much my world would change.
"This was why no-one from the Panorama team had told me what they'd filmed; everyone needed to see this."
Since the programme aired, Mr Bryan, who now lives in Swansea, has been working as an agency nurse while also carrying out inspections for the Care Quality Commission.
Mr Bryan said he was waiting to see the Department of Health's final report on Winterbourne View, which is yet to be published.
"It will take into account the serious case review and provide directives to follow," he said.
"But it has to cut through the rhetoric and actually say what should happen next. The world doesn't need any more truisms - we want details and accountability."