Tag: Child protection

Children not safe in St Andrews mental health hospital

The Care Quality Commission (CQC) has placed a mental health hospital for children in special measures.

St Andrew’s Healthcare Adolescent Service in Northamptonshire, which is registered as a charity, has been rated ‘inadequate’ overall and the same for safety, care and leadership following an inspection by the CQC.

Among the many damming findings, inspectors reported:

“On one occasion, staff did not respect a patient’s privacy and dignity when changing her clothing. While female staff were present, there were also male staff there at the time. It was the inspection team’s view that this was uncaring, undignified and disrespectful to the patient.”

Inspectors also found:

  • Between July 2018 and January 2019, there were 1,754 incidents of restraint. In one ward (Meadow), restraint was used 546 times with just 15 children during this period. Inspectors reviewed one incident where “staff had restrained the patient and changed them into rip proof clothing when the patient was presenting as calm and compliant”.
  • Eleven of the 15 ‘seclusion rooms’ did not have furnishings such as a bed, pillow, mattress or blanket.
  • Staff applied blanket restrictions without justification. All wards had imposed set snack times. Other restrictions were placed on access to drinks and takeaways. Children were not allowed to wear shoes on Meadow ward.
  • Staff on Willow ward locked en-suite rooms which meant children had to request staff to unlock them.
  • Staff shortages sometimes resulted in staff cancelling escorted leave, appointments or ward activities. Staff on Fern, Maple and Willow wards said the high use of bank and agency staff impacted on patient care.
  • There were sharp edges on door frames in ‘seclusion rooms’ and ‘extra care suites’, blind spots in ‘seclusion rooms’ and pieces of exposed sharp metal in ‘extra care suites’.
  • Staff did not always check emergency equipment and medicines.

Helen Donohoe, Assistant Director at Article 39, said:

“It is incomprehensible that such systematic abuse of children’s human rights can go on in an institution funded by the NHS. The denial of dignity and privacy and the failure to ensure basic levels of safety reveal a toxic environment that conflicts wholly with the care that children need to thrive and be well.

“It is clear from the CQC report that staff levels and the frequent use of agency staff was a factor in the poor care. This is a recurring issue and one that Article 39 is deeply concerned about.” 

Article 39 will be seeking information about the post-inspection actions taken to ensure the rights, dignity and safety of the children and young people in St Andrew’s Healthcare Adolescent Service. The inspection took place in March-April 2019.

We are especially keen to find out how children and young people are supported by independent advocates and how they are made aware of their rights. A review of 25 records found that nearly a third (7) failed to show that children had been informed of their rights either on admission or at the point of their detention.

Read the full inspection report.

End child imprisonment

A joint campaign to end child imprisonment – run by a steering group of Article 39, the Centre for Crime and Justice Studies, Howard League for Penal Reform, INQUEST, Just for Kids Law, the National Association for Youth Justice and the Standing Committee for Youth Justice with leading independent experts – launches a week of action today.

We begin with a new mini-documentary produced by The Open University and will launch a joint publication at the end of the week.

The week of action is timed to mark the 15th anniversary of the death of Gareth Myatt. It follows February’s report from the Independent Inquiry into Child Sexual Abuse. The inquiry’s Chair Alexis Jay said she is “deeply disturbed by the continuing problem of child sexual abuse in these institutions over the last decade. It is clear these children, who are some of the most vulnerable in society, are still at risk of sexual abuse.

Gareth Myatt loved riding his bike and watching South Park and the Simpsons. He was academically very able and his favourite game was chess.


Fifteen years ago, on 19 April 2004, Gareth Myatt was fatally restrained by three officers in Rainsbrook secure training centre in Northamptonshire. Gareth was aged 15; he weighed just 6½ stone and stood less than five feet tall.


Medway child prison will be site of experimental secure school, despite history of failure to protect children

Last month, Article 39 and 35 others wrote jointly to the Ministers responsible for child protection and child prisons urging them to abandon plans to open an experimental secure school on the site of Medway secure training centre.

A serious case review showed substantial failure both within the institution, and among local and national agencies, to keep children safe. This was followed by an inspection report, published on 29 January 2019, which revealed children had been recently unlawfully inflicted with pain as a form of restraint. The secure training centre transferred from G4S to Ministry of Justice management in July 2016.

We received a letter this week – see below – from Edward Argar MP, responsible for child prisons. He said he was also replying on behalf of Nadhim Zahawi MP, whose Ministerial portfolio includes child protection and safeguarding vulnerable children.

Given our joint letter was wholly about the safety and welfare of very vulnerable children, many of them in the care system, it is very disappointing that Minister Zahawi did not, at the very least, countersign the letter.

But the most astonishing part of the response is the Government’s explanation for using Medway secure training centre as its first experimental secure school:

“Medway STC stood out for several reasons – including location, our ownership of the site and the absence of any need to go through a potentially protracted and expensive planning application.”

Edward Argar MP, Youth Justice Minister

On location, official data published by the Ministry of Justice shows 58 children from the South East region of England were detained in December 2018. However, 228 children were detained within the region – meaning that 170 children were from outside the area. Over a quarter (27%) of children in custody are sent to the South East region. The Government’s own data therefore shows that extra provision is not required in this location.

Moreover, one of the documents produced by the Ministry of Justice to encourage companies to apply to run the first experimental secure school notes that there are no secure settings in England’s Eastern region – yet 77 children from that area are detained, according to latest figures.

That the Ministry of Justice owns the prison site has no credibility as a reason for choosing it as the place to pilot an institution meant to be completely different from existing child prisons.

There is a very long history of the prison service’s ownership of land, as opposed to children’s needs, determining where institutions are built. The location of Medway secure training centre itself was selected in the late 1990s because the prison service ran the nearby Cookham Wood young offender institution and Rochester prison.

Prior to its opening in 1998, Medway secure training centre was known as Cookham Wood secure training centre – showing its links to the adjacent prison. Its other neighbouring prison, Rochester, was once called Borstal prison, and was the site of the first ever experimental child prison – which opened in 1902.

Similarly, the Government’s avoidance of having to “go through a potentially protracted and expensive planning application” makes no sense if Ministers genuinely want to abandon penal institutions for children. Whenever a local authority or health body wishes to open a new residential service, for children or adults, they must go through the planning process.

Article 39’s Director, Carolyne Willow, said:

“The Minister’s response signals his department continues to be trapped in a cycle of failure with the perpetual remodelling of child prisons. The first experiment in child prisons started in the same geographical location as the planned secure school. That was 117 years ago.

“If Ministers are truly behind replacing young offender institutions and secure training centres, they must surrender their dependence on prison land and prison property.

“And if they genuinely want secure schools to be secure children’s homes, as their promotional literature says, then why not build upon and develop the best of existing provision run by local authorities as part of their wider services to children and families?”

The Minister’s letter can be read here.
Our joint letter to the minister can be read here.

In December 2016, the Government announced it shares the long-term vision of Charlie Taylor (Chair of Youth Justice Board) to replace juvenile young offender institutions and secure training centres with secure schools.

Systemic and serious child protection failures – G4S and Medway Safeguarding Children Board

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).

Article 39 threatens legal action to protect vulnerable children

Article 39 has written to the Secretary of State for Education and government lawyers threatening a judicial review if a misleading document about local authority duties towards vulnerable children is not withdrawn.

The document, produced by the Department for Education’s children’s social care innovation programme, claims to expose myths in common understandings of council legal obligations towards vulnerable children. But Article 39, together with other children’s law experts, has identified numerous errors and misrepresentations of the statutory framework for children’s social care.

For example, councils are advised that they can reduce visits to children in long-term foster care to twice a year, yet the law states this is only permissible if the child gives their consent. This ensures young children, and other children unable to understand the implications of relaxing council monitoring of their care, continue to be visited regularly by social workers.

Most of the so-called myth-busting topics concern the protection given to children in care such as the frequency of visits from social workers, who is responsible for planning and supervising children’s care and the support given to foster carers. A series of questions are posed with advice from the Department for Education about the minimum actions they are allowed to take.

Freedom of information requests made by Article 39 have revealed that Ofsted disagreed with the innovation programme’s advice on council duties in respect of providing children and foster carers with their own social workers in the case of long-term placements (where a child has lived with the same family for at least a year).

Ofsted told the innovation programme that “The interpretation of all local authorities to date of the statutory guidance is to have two social workers – one supporting the child and the other the foster carers”, and that to reduce this to one would be “removing a significant safeguard for children in foster care”.

Despite this warning from the children’s social care regulator, the document was published with advice to councils that statutory guidance does not require them to give fostered children and foster carers different social workers.

An earlier draft of the document said it was agreed by Ofsted but this text was diluted to “in consultation with Ofsted” following the clash.

Elsewhere the document states that children who have run away should be offered an interview with someone independent after they return, yet existing statutory guidance is stronger than this because it says this safeguard must be offered.

Statutory guidance states that foster carers must receive at least one unannounced visit at home each year in addition to other visits and support from social workers. Clearly in conflict with this, the ‘myth busting’ document refers to just one visit a year as the minimum.

A joint letter was sent to the Children’s Minister Nadhim Zahawi MP last year, setting out the legal inaccuracies in the document. Fifty charities and social work experts urged the Minister to withdraw parts of the document that conflict with existing legislation and government guidance, because of the serious risks to children.

Labour’s Shadow Children’s Minister Emma Lewell-Buck MP also challenged the Minister in the House of Commons, accusing him of “cutting vulnerable children adrift”.  A further request that the Minister withdraw the document or at least meet with concerned charities was rejected.

Carolyne Willow, Article 39’s Director, said:

“It is not good enough for the Minister to say there have been no changes to the law and statutory guidance while at the same time leaving in circulation a document which indicates otherwise. Council duties towards vulnerable children cannot exist and not exist at the same time.

“We are a small charity and taking legal action is inevitably risky financially but we cannot stand by and leave it to vulnerable children to have to go to court to defend the rights that Parliament and successive governments have given them.”

Copies of emails released by Ofsted show that the myth busting document originated from a meeting of the innovation programme, Ofsted and a small number of local authorities in 2017. That year the Department for Education sought to press through legislation which would have allowed individual councils to opt out of their social care duties towards children and families.

Over 108,000 members of the public signed an online petition opposing what came to be known as the exemption clauses in the Children and Social Work Bill. Peers voted them out of the legislation but a revised set of clauses were inserted when it returned to the House of Commons. These were removed from the Bill in their entirety after the then Education Secretary Justine Greening MP added her name to opposition amendments to delete them, in the face of widespread criticism that the plans undermined the rule of law and child protection.

Article 39 is represented by Oliver Studdert, Partner in Public Law at Simpson Millar, and Steve Broach, barrister at Monckton Chambers.