Medway Safeguarding Children Board has this afternoon published the serious case review it commissioned into the abuse of children in G4S-run Medway secure training centre, which was exposed by a BBC Panorama programme in January 2016.
Carolyne Willow, Article 39’s Director, said:
“This review confirms what millions of us watched on the BBC Panorama programme: that G4S failed to protect children from staff violence and cruelty. The new revelation is that the local systems for protecting children in this institution were utterly ineffective and at times expressly working against keeping children safe.
“The extent to which local authorities are left to create their own arrangements for responding to institutional abuse allegations cannot be right. Nor is it acceptable that so much onus is placed on children to know they are being mistreated and to seek help.
“The serious case review highlights that children’s past experiences can affect their recognition of abuse, and their confidence in speaking out. But there are also very powerful institutional factors which influence both children’s and adults’ perceptions of what is tolerable or not, and the actions they take.
“There is a compelling and urgent need for government guidance on keeping children safe in institutions.
“Much is missing from the serious case review, including the alleged sexual abuse found by the local authority and submitted to the Independent Inquiry into Child Sexual Abuse last summer. Only a small number of children were interviewed and parents appear not to have been involved at all. The police went back to 1998 in their investigation, and the Guardian newspaper reported abuse claims going back to at least 2003, yet the serious case review only starts at 2014. Given the very serious and systemic local failure to protect children, Ministers must now revisit their decision to convert Medway secure training centre into their first experimental secure school.”
The serious case review commenced in July 2017, 18 months after the Panorama programme and a year after management of the secure training centre was transferred from G4S to Her Majesty’s Prison and Probation Service. Its time-frame was 2014-2017.
The serious case review shows:
Excessive physical restraint and victimisation of especially vulnerable children
The small number of children who were interviewed as part of the review (13 by telephone and 7 face-to-face) reported “excessive” physical restraint; staff deliberately using physical restraint out of sight of CCTV; and some staff more frequently using restraint which deliberately inflicts pain on children. Children who were especially vulnerable were victimised by staff. The serious case review states: “staff had picked on children who appeared vulnerable. This included children who did not speak English or were comparatively young or withdrawn or had no extremal family support”. Barking and Dagenham local authority reported to the serious case review that one of its children detained at Medway secure training centre had been stopped from seeing their social worker alone.
Reporting of crimes against children “stymied”
Before the police investigation set up after the Panorama programme, “the reporting of crimes committed against children at Medway STC can be described as “stymied” in that their progress had been prevented/hindered”. There was a “limited police response to previous allegations from or about children at the STC”.
Children regularly taken to A&E
90 children were taken to A&E from Medway secure training centre during the three-year period under review (the review does not state whether this was as a result of injuries from restraint or self-harm, or other reasons). A&E staff did not contact children’s next of kin or social workers in respect of children in care; this was left to custody officers to do.
“Erratic and ineffective” local authority oversight of child protection, with “serious and undetected deficiencies”
The local authority designated officer (LADO) function – responsible for monitoring and overseeing investigations of staff working with children – was “erratic and ineffective”. Referrals were not passed to the local authority’s child protection social workers to investigate; instead LADO staff carried out investigations themselves.
The focus “appeared to be proving if the allegation could be substantiated or not, rather than understanding the behaviour of the adult as possibly harmful, criminal or suitable and managing the potential risk of that behaviour towards children reoccurring and causing harm”.
This arrangement – known as the ‘Medway way’ – led to “few [child protection] strategy discussions, interviews with children were not undertaken by those professionals who best knew the child from their home authorities, management oversight and supervision were poor, policies were not followed, regular liaison meetings were not held and responses were slow and did not provide sufficient challenge to the staff and management at Medway STC. There was no operational practice guidance on the management of allegations in the procedures and the approach to the line management of the LADO who may have a specific expertise unfamiliar to most other staff including the line manager appears to have contributed to some serious and undetected deficiencies… It was not until 2016 that these began to be detected”.
Local Safeguarding Children Board did not act on Ofsted concerns from 2014 and 2015 and failed to challenge inadequate arrangements for protecting children in Medway secure training centre
Ofsted recommendations in respect of child safeguarding monitoring and oversight, in 2014 and 2015, “were not apparently followed up in a timely manner and the Medway Safeguarding Children Board did not challenge the quality of the LADO annual reports or other performance information it received”. The “lack of proper analysis of allegations being presented to the [Medway Safeguarding Children Board] was a missed opportunity for challenge”.
Barnardo’s told it couldn’t refer child protection concerns to the local authority
Against requirements in government safeguarding children guidance, a contract between the Youth Justice Board and children’s charity Barnardo’s “expressly did not allow” independent advocates to refer concerns about child protection directly to the local authority. This was only rectified in July 2017 – 18 months after the Panorama programme. When Barnardo’s advocates supported children to make complaints about “how staff acted during restraints”, there was no requirement on G4S to inform the charity of the outcome of these complaints. Barnardo’s advocates were contracted to be in the centre 17 hours a week, yet they were not given a private office in which to meet children.
Barnardo’s advocates no longer see every child after they have been restrained
The year after the Panorama programme, the crucial safeguard of advocates meeting children after each restraint incident, to offer them help, was removed. This protection was first established following a coroner’s recommendation after 15 year-old Gareth Myatt died of positional asphyxia following restraint by three G4S officers in a different secure training centre. Since July 2017, advocates working in Medway secure training centre have not been required to be “physically present to offer advocacy” if a child has been previously restrained.
No recommendations for G4S
The individual management review undertaken specifically in respect of G4S identified not a single recommendation for the security company, which ran the centre between 1998 and 2016, and continues to run two other child prisons – Oakhill secure training centre in Milton Keynes and Parc young offender institution in Bridgend, Wales.
The serious case review makes a general recommendation “that G4S should consider the learning from their own IMR process and the overall learning in this SCR and consider implementation in its other service provision in the secure estate”.
G4S failed to hand over all of its staff records
When the prison service took over the running of Medway secure training centre, G4S failed to hand over “some locally stored staff records” and “local supervision records”. Although not mentioned in the serious case review, this echoes G4S’s failures to hand over information requested by the Independent Inquiry into Child Sexual Abuse last summer.
Youth Justice Board focused on contracts not children
Youth Justice Board monitors focused on contract compliance “as opposed to the safety and welfare of children” and “before December 2015, both internal monitoring and external reports on Medway STC had not signaled concerns about the treatment of children by staff”.
There are very significant omissions in the published serious case review:
- There is no chronology showing when concerns were raised, and by whom; and the nature of concerns.
- There is no overview of the children detained in Medway STC during the three-year time frame – their ages and other demographic information, a profile of their needs, and so on.
- There is no data on child protection referrals, complaints, disciplinary action, restraint injuries and other serious incidents during the three-year time frame.
- It lacks a full description of what was shown in the Panorama programme which led to the serious case review being commissioned, and the STC moving from G4S management.
- We are not told what action the local authority and other agencies took immediately in response to the Panorama programme to safeguard and promote the welfare of the children who were shown on the programme being abused.
- The review states there were no criminal convictions of G4S staff following the Panorama programme, but we are not told whether there was any disciplinary action taken by G4S, the local authority, the Youth Justice Board or any other agencies.
- None of the evidence before the Independent Inquiry into Child Sexual Abuse last summer – including the very serious concerns reported by the social worker appointed by the local authority to, among other things, review the full Panorama footage – is mentioned in the serious case review, let alone considered. This is a very serious omission.
About serious case reviews
Serious case reviews are set up when a child has died or “has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child”.
Statutory guidance on serious case reviews for the time period stated: “when things go wrong Serious Case Reviews (SCRs) are published and transparent about any mistakes which were made so that lessons can be learnt” (Working Together to Safeguard Children, 2015).