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Lost in Care - Report






  55.01  A major benefit of this Inquiry has been that the evidence of 259 complainants, of whom 129 gave oral testimony, has been heard in public. For the vast majority of them this was the first opportunity for their accounts of their periods in care to be publicised and very many of them have expressed satisfaction that this has now been achieved. We are very conscious of the burden that giving evidence, in whichever form, imposed upon these witnesses; and that burden was generally most obvious when some of them were subjected to necessarily severe cross-examination by Counsel for those against whom they made specific allegations. We believe, however, that the satisfaction in their minds of knowing that they have been listened to will substantially outweigh the disadvantages of providing that evidence[897].

  55.02  For the "Salmon letter" recipients the Inquiry has been a particularly anxious time: that has been unavoidable, given the nature of the allegations against them. The anxiety has been mitigated, as far as it was permissible for us to do so, by the Tribunal's anonymity ruling for the period of our hearings in respect of any person against whom an allegation of physical or sexual abuse had been or was likely to be made[898]. For reasons that we have explained in paragraph 6.14 of this report, that ruling could not properly be applied to the report itself but, we have exercised restraint in "naming names" and have done so only where we have considered it to be necessary in order to fulfil the purposes of this public inquiry.

  55.03  Particular burdens upon the "Salmon letter" recipients (other than those against whom the allegations were limited to abuse) and Counsel who represented them were the wide range of matters with which they had to deal and the scale of the documentation involved. Whereas in conventional litigation between parties the issues are narrowed by statements of each party's case and there is ample time to study relevant documents, the ambit of our inquiry and the necessary timetable of our hearings did not permit these refinements. We acknowledge the additional strains that were imposed by the inquiry on those "Salmon letter" recipients and their Counsel and are grateful to them for their co-operation in accepting them. They are factors that we have borne in mind in reaching our conclusions.

  55.04  We have outlined our approach to the evidence submitted to us in Chapter 6 of this report, in which we referred to the special difficulty of investigating a very wide range of events, most of which occurred many years ago[899]. Although it may be obvious, it is necessary to stress also that an inquiry of this kind cannot emulate, for example, an investigation by the police. The resources of the Tribunal and its mechanisms inevitably limit its ability to seek out new witnesses and to interrogate them. Thus, in the course of probing the existence of an alleged paedophile ring, we have been unable to do more than hear what the relevant witnesses known to us have been prepared to say on the subject and there has been very little documentary evidence to assist us. These limitations, as well as the lapse of time, should be borne in mind when the report is read because they are reasons for the lack of specificity in some of our conclusions.

  55.05  At the beginning of the period under review, 1 April 1974, there were 542 children in care in Clwyd and 290 children in care in Gwynedd. At that date, 203 of the Clwyd children were in residential care and 212 were boarded out whereas in Gwynedd about 80 were in residential care compared with 122 boarded out. The period under review ended on 31 March 1996 and the latest (1995) figures that we have show that the children in Clwyd now described as looked after children had been halved, to 244, of whom 190 were fostered. In Gwynedd the changes had also been substantial, if less dramatic, because by 31 July 1995 the number of children looked after was 157, of whom 18 were in residential care and all the rest were fostered.

  55.06  Our inquiry has focussed upon the children's homes and foster placements that were the main subject of complaints by former residents. The comparatively few other complaints have not been investigated for a variety of reasons such as lack of identification of the abuser, the fact that the alleged abuse occurred outside the period under review, closure of the home early in that period and/or the fact that the complaint was an isolated one unsupported by any significant body of other complaints in relation to the same home.

  55.07  The result has been that we have examined in detail the histories of nine local authority homes in Clwyd[900] (of 23 that existed from time to time) and one voluntary children's home[901] (of four). We have also investigated complaints emanating from a local authority residential school and a National Health Service residential clinic[902]. In the private sector we have examined residential homes/schools in Clwyd run by three organisations[903], namely, the Bryn Alyn Community, Care Concern International and Clwyd Hall for Child Welfare, embracing not less than eight establishments on different sites. Thus, the detailed Inquiry has covered 20 residential establishments in Clwyd over substantial periods as well as the investigation of complaints about seven foster homes[904].

  55.08  On the same principle we have examined the histories of five local authority homes in Gwynedd[905] (of ten that existed from time to time). The only other establishments that required investigation in the light of the complaints were in the private sector and we examined particularly one that belonged to Care Concern International and three run by Paul Hett[906]. Thus, the Inquiry covered nine residential establishments in Gwynedd and eight foster homes[907].

  55.09  It is our hope that, despite its length, this report will be read fully and widely by policy makers, members of the social services profession, administrators and all others who have responsibility for the welfare of looked after children. We draw attention specifically to the fact that many of the children in the residential establishments that we have discussed and in North Wales foster homes were placed there by English authorities. The accounts that we have given of the residential establishments reveal not only how sexual and physical abuse of children can arise and fester but also the extent to which many of these establishments have failed to provide an acceptable minimum standard of care for children in dire need of good quality parenting. The report discloses also widespread shortcomings in practice and administrative failings in the provision of children's services, including failure to apply basic safeguards provided for by regulation, which must be addressed if local authorities are to discharge adequately the parental responsibilities imposed upon them in respect of looked after children. The Children Act 1989 has provided a springboard for many improvements in children's services but the need for vigilance and further positive action remains if the ever present risk of abuse is to be minimised.

Summary of our conclusions

  55.10  The following is a summary of the major conclusions that we have reached, as indicated earlier in this report:


Sexual abuse

    (1)  Widespread sexual abuse of boys occurred in children's residential establishments in Clwyd between 1974 and 1990. There were some incidents of sexual abuse of girl residents in these establishments but they were comparatively rare.

Local authority homes

    (2) The local authority community homes most affected by this abuse were (a) Bryn Estyn, where two senior officers, Peter Norman Howarth[908] and Stephen Roderick Norris, sexually assaulted and buggered many boys persistently over a period of ten years from 1974 in the case of Howarth (paras 8.03 to 8.22) and about six years from 1978 in the case of Norris (paras 8.23 to 8.34) and (b) Cartrefle, where Norris[909] continued, as Officer-in-Charge, to abuse boys similarly from 1984 until he was arrested in June 1990 (paras 15.05 to 15.18).

    (3)  The Tribunal heard all the relevant and admissible evidence known to be available in respect of the allegation that Police Superintendent Gordon Anglesea committed serious sexual misconduct at Bryn Estyn but we were not persuaded by this evidence that the jury's verdict in his favour on this issue in his libel actions was wrong (para 2.31 and Chapter 9).

    (4)  In addition to the abuse referred to in (2) there were other grave incidents of sexual abuse of boy residents by male and female members of the residential care staff between 1973 and 1990 at five local authority homes in Clwyd, namely, Little Acton Assessment Centre (para 12.10), Bersham Hall (paras 13.14 to 13.20), Chevet Hey (paras 14.32 to 14.45), Cartrefle (paras 15.21 to 15.25) and Upper Downing (paras 17.08 to 17.14).

Private establishments

    (5)   There was widespread sexual abuse, including buggery, of boy residents in private residential establishments for children in Clwyd throughout the period under review. Sexual abuse of girl residents also occurred to an alarming extent.

    (6)  The most persistent offender in the Bryn Alyn Community was the original proprietor himself, John Ernest Allen, who was the subject of complaint by 28 former male residents and who was sentenced to six years' imprisonment in February 1995 for indecent assault on six former residents (paras 21.23 to 21.47). One other member of the staff was convicted in 1976 of sexual assaults on boys (paras 21.48 and 21.49) and another was under police investigation for alleged sexual abuse during the Tribunal's hearings and until his death in August 1998 (paras 21.52 and 21.53). The Deputy Headteacher of the Community's school was also convicted in July 1986 of unlawful sexual intercourse with a girl resident under 16 years and sentenced to 6 months' imprisonment (paras 21.50 and 21.51).

    (7)  Richard Ernest Leake, formerly of Bersham Hall, who was the first Principal of Care Concern's Ystrad Hall School from 1 July 1974 and later Director of the organisation, is awaiting trial on8 November 1999 on charges of indecent assault on boys between 1972 and 1978 (paras 22.07 and 50.31(6)). The Tribunal is aware of 16 male former residents of Ystrad Hall School who have complained of sexual abuse by members of the staff (six have been named). The Deputy Principal, Bryan Davies, was convicted in September 1978 of three offences of indecent assault against two boys and placed on probation[910] (paras 22.10 to 22.14). We were unable to hear the evidence in respect of Leake because of the continuing police investigation and the evidence that we heard in respect of other members of the staff was insufficient to justify a finding, except in respect of Davies (paras 22.15 to 22.19).

    (8)  There was persistent sexual abuse, including buggery, of not less than 17 boy residents at Clwyd Hall School between 1970 and 1981 by a houseparent, Noel Ryan, for which he was sentenced in July 1997 to 12 years' imprisonment (paras 23.17 to 23.27). Richard Francis Groome, the former Officer-in-Charge of Tanllwyfan, who was Head of Care and then Principal at Clwyd Hall School between November 1982 and July 1984, has been committed for trial oncharges of sexual offences against boys, some of which relate toformer boy residents at these establishments. His trial will take place early in 2000.

    (9)  There was yet again persistent sexual abuse of boy residents of Gatewen Hall, which was a private residential school prior to its sale to the Bryn Alyn Community in 1982[911]. The abusers were the two proprietors from 1977 to 1982, Roger Owen Griffiths and his then wife, now Anthea Beatrice Roberts, who were convicted on 4 and 5 August 1999 in the Crown Court at Chester. Griffiths was sentenced to eight years' imprisonment and Roberts to two years' imprisonment[912].

Voluntary homes

    (10)   There were complaints of sexual abuse from six former boy residents of the only voluntary home that we investigated, namely, Tanllwyfan. They were directed against a former care assistant at the home, Kenneth Scott, who was there from 1974 to 1976 and who was sentenced in February 1986 to eight years' imprisonment for buggery and other offences against boys committed in Leicestershire between 1982 and 1985. We have no reason to doubt the accuracy of the two complainants who gave evidence of indecent assaults on them by Scott during his period at Tanllwyfan (paras 18.12 to 18.16). There is one charge against Richard Francis Groome in respect of his period as Officer-in-Charge of Tanllwyfan (para 18.30).


    (11)   Allegations of sexual abuse during the period under review at Gwynfa Residential Unit or Clinic, an NHS psychiatric hospital for children, were made by ten former residents to the police and involved four members of the staff. One former member of staff was convicted in March 1997 of two offences of rape of a girl aged 16 years committed in 1991, when she was a resident but not in care (paras 20.12 and 20.13). Allegations against another member of staff, Z, were being investigated by the police in the course of the Tribunal's hearings and some of them were made by former children in care but the decision has now been taken that Z should not be prosecuted (paras 20.16 and 20.19 to 20.24). We have not attempted to reach detailed conclusions in relation to Gwynfa for reasons that we explain (para 20.28).

Physical Abuse

    (12)  Physical abuse in the sense of the unacceptable use of force in disciplining and excessive force in restraining residents occurred at not less than six of the local authority community homes in Clwyd, despite the fact that it was the policy of Clwyd County Council throughout the period under review that no member of staff should inflict corporal punishment on any child or young person in any circumstances (para 30.04). It occurred also at most of the other residential establishments for children that we have examined.

Local authority homes

    (13)   Such abuse was most oppressive at Bryn Estyn, where Paul Bicker Wilson was the worst offender. There was a climate of violence at the home in which other members of the staff resorted to the use of impermissible force from time to time without being disciplined for it. Bullying of residents by their peers was condoned and even encouraged on occasions as a means of exercising control (Chapter 10).

    (14)  Physical abuse was less prominent in the five other community homes referred to in (12), namely, Little Acton, Bersham Hall, Chevet Hey, Cartrefle and South Meadow, but was sufficiently frequent to affect a significant number of residents adversely. The use of force was often condoned and its effects were aggravated by the fact that some Officers-in-Charge from time to time, such as Peter Bird, Frederick Marshall Jones and Joan Glover, were themselves the perpetrators (Chapters 12 to 15 and paras 17.17 to 17.40).

Ysgol Talfryn and Gwynfa

    (15)   Physical abuse occurred also from time to time at a local authority residential school, Ysgol Talfryn, and at the NHS residential clinic for children, Gwynfa (paras 19.04 to 19.19 and 19.27; 20.10 to 20.28).

Private establishments

    (16)   Physical abuse was prevalent in the residential schools/homes of the Bryn Alyn Community in its early years and to a lesser extent at Care Concern's Ystrad Hall School. John Ernest Allen himself was a prominent offender in this respect at the former but impermissible force was used by other members of the staff quite frequently (paras 21.59, 21.60, 21.61 to 21.106 and 21.133; 22.20 to 22.27 and 22.32).

Abuse in foster homes

    (17)  There were comparatively few complaints of abuse in foster homes in Clwyd but the evidence before the Tribunal disclosed major sexual abuse in five such homes, in respect of which there were convictions in four of the cases (the fifth offender hanged himself before his trial) (Chapters 25 and 26, paras 27.20 to 27.35 and 27.43 to 27.52).

Failings in practice etc

Complaints etc

    (18)   It was a serious defect nationally that complaints procedures were not introduced generally until the late 1980s. In Clwyd, there were no complaints procedures in any of the residential establishments that we have examined in detail between 1974 and 1991 when the major incidents of abuse occurred (paras 29.49 and 29.50).

    (19)  Few resident children made complaints of abuse (except at Park House, where long term residents felt freer to do so). Those who did complain were generally discouraged from pursuing complaints and recording of complaints was grossly defective (paras 30.15 and 30.31 to 30.35). It was, however, the complaint of a boy resident at Cartrefle to a sensitive member of staff that led to the first convictions of Stephen Roderick Norris (paras 15.12, 15.14 and 29.27).

    (20)  There were no procedures in any of the establishments to enable members of staff to voice matters of concern and, in many of them, complaints by staff were strongly discouraged.

    (21)  The worst exemplar of the "cult of silence" on the part of staff was Bryn Estyn, where there were grounds for suspicion and gossip about Howarth's "flat list" activities for many years but the Principal, Arnold, threatened staff with dismissal if they gave currency to the rumours. Arnold was responsible also for covering up the true circumstances in which a resident had been injured and both he and Howarth were seriously at fault in failing to deal with Wilson's oppressive conduct (paras 8.11 to 8.22, 11.02 to 11.06 and 29.51 to 29.57).

The quality of care

    (22)   The quality of care provided in all the local authority homes and private residential establishments examined was below an acceptable standard throughout the period under review and in most cases far below the required standard. Those well below the standard were Bryn Estyn (paras 11.49 to 11.58), Little Acton (para 12.51), Bersham Hall (paras 13.66 and 13.69), Chevet Hey (paras 14.80 to 14.83), Cartrefle (paras 15.39 to 15.50), Park House (para 17.95), the Bryn Alyn Community (paras 21.107 to 21.132) and Clwyd Hall School (paras 23.11 to 23.14 and 23.31). The quality of care was also well below standard at Ysgol Talfryn by 1993 (para 19.25).

Secure units

    (23)   There was misuse of the secure units provided (but not approved for use as such) at Bryn Estyn (paras 11.07 to 11.25) and Bersham Hall (paras 13.61 to 13.65).


    (24)   The provision of education was inadequate in all the local authority community homes with educational facilities (paras 11.26 to 11.41, 12.46 to 12.48, 13.67) and in the private residential schools at Bryn Alyn (paras 21.116 to 21.125) and Clwyd Hall (paras 23.11 to 23.14).


    (25)   There were many breaches of approved practice in the appointment of residential care staff, most notably at Bryn Estyn, where several members of the staff were recruited informally without references and without any adequate investigation of their past records (paras 30.09 to 30.14).

    (26)  Manifestly unsuitable residential care staff were appointed to some vacant senior posts in community homes without any adequate assessment of their suitability for those posts. This was most blatant at Cartrefle with the successive appointments of Stephen Roderick Norris and Frederick Marshall Jones (paras 29.14, 29.15, 14.19, 15.51 and 30.27 to 30.29).

Police checks

    (27)   Checks upon the records of potential employees and foster parents held by the police, the Department of Health and the Department of Education were not made routinely before appointments were confirmed. In the particular case of the foster parent Roger Saint the North Wales Police were at fault in failing to explain to the Social Services Department the narrow limits of their check on Roger Saint's record of convictions in August 1978; and the Department itself was at fault subsequently in failing to make a further check in 1982 at the request of Tower Hamlets and in failing to take any appropriate action when informed of his conviction in 1988 (paras 10.43, 10.63, 10.66, 10.68, 10.125, 24.08, 25.15 to 25.18, 25.75 and 25.77).


    (28)   Training opportunities and practice guidance for residential care staff were grossly inadequate and no instruction was given to them in proper measures of physical restraint (paras 30.06 and 30.37 to 30.42).


    (29)   The recording of events within residential establishments was frequently of poor quality and on occasions knowingly false (paras 30.31 to 30.36).


    (30)   Visiting by field social workers was in too many cases both irregular and infrequent and recording standards were very variable; in general, the quality of contact was poor (paras 29.60 to 29.64 and 31.16 to 31.21).

Care planning

    (31)   There were deficiencies in care planning and in the statutory review process for each child on a similar scale. Too often reviews were paper exercises carried out without the involvement of the child and much later than they should have been (paras 31.04 to 31.06 and 31.11 to 31.16).

Leaving care

    (32)   There were no adequate arrangements for preparing children for leaving care (paras 31.22 to 31.30).

Supervision by other authorities

    (33)  The supervision of children from outside Clwyd by the placing authorities, whether in a residential establishment or in a foster home, was generally inadequate (paras 21.124, 21.131, 25.47 to 25.74 and 25.78).


    (34)  The arrangements for the oversight of the operation of the Social Services Department at the most senior levels in the County Council were inadequate (paras 28.50 to 28.54).


    (35)   The Social Services Department failed to provide at the most senior level effective and positive leadership to ensure that, in relation to decisions affecting each child in their care, first consideration was given to the welfare of the child and to foster a climate in which that principle was followed (paras 28.55 to 28.62 and 31.31 to 31.32).


    (36)   The senior management of the Social Services Department in relation to children's services was subjected to frequent changes and remained confused and defective without adequate expertise at the highest level and clear lines of responsibility and accountability (paras 28.56 to 28.62).


    (37)The Social Services Department failed to establish any strategic plan for the provision of residential placements following the demise of the Regional Plan for Wales (paras 31.07 to 31.10).

Inspection and monitoring

    (38)   There were no coherent arrangements by Clwyd Social Services Department for the management, support and monitoring of the authority's community homes and for supervision and performance appraisal of residential care staff for most of the period under review. This grave defect had its most serious impact on Bryn Estyn where, despite the existence of a management committee charged with responsibility for it and two other Wrexham community homes, the Principal was left to run the home without any effective supervision or guidance (paras 29.65 to 29.85 and 29.88).

Complaints and discipline

    (39)   The response by senior management, particularly by Geoffrey Wyatt, to complaints was discouraging and frequently inappropriate; and the implementation of disciplinary procedures was fundamentally flawed (paras 30.15 to 30.30).

Response to reports

    (40)   The Social Services Department failed to respond positively to successive adverse reports on individual community homes, most of which were of county-wide relevance in relation to the management of the residential sector and the state of the community homes (paras 12.06 to 12.08, 15.42 to 15.50, 17.46 to 17.52 and 17.79 to 17.87 and 32.04 to 32.34).

Information to the SSC

    (41)   The information supplied to members of the Social Services Committee by officers, including the contents of reports on inquiries, was inadequate and, on occasions, positively misleading (paras 32.09, 32.12, 32.20, 32.21, 32.23, 32.24 and 32.27).

The role of councillors

    (42)   Members of the Social Services Committee prior to 1990 failed to discharge their parental responsibilities to the children in their care by informing themselves adequately about the state of children's services in the county and insisting that officers supplied appropriate information to them about matters of concern (paras 32.01, 32.02 and Chapters 29 to 32 generally).

Visits by councillors etc

    (43)   Visits to community homes by councillors and headquarters' officers were grossly inadequate for most of the period under review (paras 29.65 to 29.85).

The Cartrefle and Jillings reports

    (44)   Clwyd County Council cannot fairly be blamed for failing to publish the Cartrefle and Jillings reports before it ceased to exist, having regard to the continuing police investigation at that time and its contractual duty to its insurers; but it is desirable that the Law Commission should consider the legal issues that arise in relation to the conduct of inquiries of a similar kind initiated by local authorities or other public bodies and publication of the reports of such inquiries (paras 32.24 to 32.63).


The reason for the inquiry

    (45)  Without Alison Taylor's complaints about Nefyn Dodd there would not have been any public inquiry into the alleged abuse of children in care in Gwynedd (paras 45.06 and 49.57 to 49.70). In general terms, she has been vindicated.

Complaints generally

    (46)  Of about 120 complainants to the police who were former residents of one or more of the five local authority community homes in Gwynedd that we have investigated, about half (58) made complaints that they had been abused by Nefyn Dodd; and all but six of the latter alleged abuse by him at Ty'r Felin.

Sexual abuse

Local authority homes

    (48)   We have not received acceptable evidence of any persistent sexual abuse in any of the local authority homes in Gwynedd (paras 33.56 to 33.59, 34.08, 35.18, 35.19, 36.13 and 37.05). We did, however, hear perturbing evidence of incidents of alleged sexual abuse at different times by two women members of the staff (X and Y) at Queens Park community home involving one (different) resident only in respect of each. The allegations against X were inadequately and inappropriately investigated and, in effect, suppressed. The allegations against Y were not made until 1996. In the absence now of any supporting evidence in respect of either set of allegations we are unable to find that they have been proved (paras 36.14 to 36.39).

Private establishments

    (48)   There were some isolated incidents of sexual abuse at two of Paul Hett's establishments, namely, Do®l Rhyd School and Ysgol Hengwrt. The five alleged abusers were all male members of the staff involved with one victim each; three of the victims were boys and two were girls. Four of the abusers left the staff shortly after complaints had been made but the fifth was not the subject of complaint until 1993, over four years after the victim had run away (paras 39.42 to 39.49).

Physical abuse

Local authority homes

    (49)   Physical abuse in the sense that we have defined it in (12) occurred frequently at Ty'r Felin during the regime of Nefyn Dodd as Officer-in-Charge between 1978 and 1990 but was less frequent in the last three or four years of that period. There were 75 complainants to the police who alleged physical abuse there. The worst offenders were Nefyn Dodd himself (paras 33.60 to 33.85) and John Roberts (paras 33.93 to 33.108). We have not been persuaded that either June Dodd or Mari Thomas was guilty of physically abusing residents (paras 33.87 to 33.92 and 33.109 to 33.113).

    (50)  There was no persistent physical abuse at any of the four other local authority community homes in Gwynedd that we have investigated and comparatively few complaints of such abuse were made to the police about Ty Newydd (paras 34.08 to 34.12), Queens Park (paras 36.42 to 36.46) and Cartref Bontnewydd (paras 37.05 to 37.10). There were more (11) complainants to the police who alleged that they had been physically abused by a named abuser at Y Gwyngyll and four of them named Nefyn Dodd; but any incidents of physical abuse that occurred were isolated and were not the subject of complaint until many years afterwards. We accept, however, that Nefyn Dodd did use excessive force to residents at Y Gwyngyll on a limited number of occasions (paras 35.18 and 35.20 to 35.28).

Private establishments

    (51)   We did not receive any complaint of physical abuse at Hengwrt Hall School but there were complaints by the Spastics Society in 1988 and by a Senior RCCO in 1990 of incidents of alleged abuse, which gave rise to concern (paras 38.14 to 38.30).

    (52)  15 former residents of Paul Hett's establishments complained of physical abuse by identified members of the staff but most of their complaints related to Ysgol Hengwrt between 1986 and 1990. We have no doubt that excessive force was used to residents quite frequently by largely untrained staff in the absence of any clear guidelines (paras 39.51 to 39.58).

Other abuse

Nefyn Dodd

    (53)   The regime imposed by Nefyn Dodd and, to a lesser extent, John Roberts upon staff and children at Ty'r Felin was autocratic, oppressive and contrary to the best interests of the residents (paras 33.30 to 33.49 and 33.132).

Abuse in foster homes

    (54)  Both sexual and physical abuse of children in care occurred in a small number of foster homes in Gwynedd during the period under review.

    (55)  Complaints of sexual abuse were made by four foster children placed in Gwynedd, but two of them were placed there by Clwyd Social Services Department. One of the foster parents of a Clwyd child (Malcolm Ian Scrugham) was sentenced to ten years' imprisonment in April 1993 for rape and other offences against the foster child (paras 42.03 to 42.17). Gwynedd foster child C1 was sexually abused by the eldest other child in her foster home, for which he was fined in 1984 (paras 42.25 to 42.29). We are not satisfied that the two other foster children were sexually abused (paras 42.19 to 42.24 and 42.37 to 42.45).

    (56)  Two foster children placed by Gwynedd were subjected to physical abuse in their foster homes. In the case of M, the foster father and one of his two sons were eventually convicted in July 1993 of assaults many years after they occurred; but there were many breaches of good practice by the Social Services Department earlier in dealing with M's complaints (paras 41.09 to 41.63). It is likely also that C1 and her two brothers were subjected to bullying in the foster home (paras 42.30 to 42.35).

Failings in practice etc

Similarities to Clwyd

    (57)   Although the extent of abuse of children in care in Gwynedd was much less than it was in Clwyd the failings in practice were of a similar order or degree.

    (58)  The following failings in practice mirrored those in Clwyd:


    (1) There were no complaints procedures in any of the residential establishments between 1974 and 1991 (paras 45.14 to 45.16).

    (ii) The few residents who complained were discouraged and their complaints generally suppressed (paras 41.31 to 41.54 and 45.17 to 45.19).

    (iii) There were no procedures for staff to voice matters of concern and complaints by staff were strongly discouraged (paras 33.120 to 33.122 and 45.20 to 45.23).

The quality of care

    (iv) Quite apart from the oppressive nature of Nefyn Dodd's regime at Ty'r Felin referred to in conclusion (53), the quality of care provided in all the local authority community homes was below an acceptable standard (paras 33.115 to 33.125, 34.06, 35.29 to 35.35, 36.47 to 36.50 and 37.11 to 37.13).


    (v) The provision of education at Ty'r Felin was inadequate (paras 33.54 and 33.55).


    (vi) Visiting by field social workers was in too many cases both irregular and infrequent and the quality of contact was poor (paras 46.16 to 46.20).

Care planning

    (vii) There were serious and persistent deficiencies in care planning and in the statutory review process (paras 46.03 to 46.05 and 46.10 to 46.15).

Leaving care

    (viii) There were no adequate arrangements for preparing children for leaving care (paras 46.21 to 46.28).

Supervision by other authorities

    (ix) The supervision of children from outside Gwynedd by the placing authorities, whether in a residential establishment or in a foster home, was generally inadequate (paras 38.37 to 38.39, 42.05, 42.10 to 42.17 and 43.25).

    (59)  Monitoring by social workers of the quality of individual boarding out placements was inadequate and there was confusion of responsibility for this (paras 43.37, 43.39, 43.43, 43.44 and 46.08).

    (60)  The child protection procedures and the provisions of the Boarding Out Regulations 1955 were not used for that purpose in some cases (paras 41.56, 41.63 and 43.22).


Retention and advancement of Nefyn Dodd

    (61)   Major causes of Gwynedd's failure to eliminate abuse in its residential homes for children were the failure to recognise Nefyn Dodd's shortcomings as Officer-in-Charge of Ty'r Felin and his advancement to a position of control over all the county's community homes (paras 33.22 to 33.50 and 45.06 to 45.13).

    (62)  As in Clwyd:


    (i) The Social Services Department failed to provide at the most senior level effective and positive leadership in the provision and monitoring of children's services (paras 44.67, 45.24 and 46.49).


    (ii) The senior management structure of the Social Services Department in relation to children's services was subjected to frequent changes and was confused and defective without adequate expertise at the highest level and clear lines of responsibility and accountability (paras 44.63 to 44.67).


    (iii) The Social Services Department failed to establish any strategic plan for the provision of residential placements (paras 46.06 to 46.09).

Inspecting and monitoring

    (iv) There were no coherent arrangements for inspecting community homes and for monitoring the performance of residential care staff for most of the period under review. The effect of this was to leave Nefyn Dodd in sole control, accountable to himself alone (paras 45.09 to 45.16 and 46.32).

Response to complaints

    (v) The response by senior management to complaints, in particular to those made by Alison Taylor, was discouraging and generally inappropriate (paras 45.17 to 45.23).

Response to reports

    (vi) The Social Services Department failed to respond to successive adverse reports on the community homes, most of which were of county-wide relevance in relation to the residential sector and the state of the homes (paras 46.29 and 46.30).

Information to the SSC

    (vii) The information supplied to members of the Social Services Committee by officers was inadequate and, on occasions, positively misleading (paras 46.31 and 46.35).

The role of councillors

    (viii) Members of the Social Services Committee failed to discharge their parental responsibilities to the children in their care by informing themselves adequately about the state of children's services in the county and insisting that officers supplied appropriate information to them (paras 46.31 to 46.35 and 46.45 to 46.49).

Visits by councillors

    (ix) Visits to community homes by councillors were grossly inadequate (paras 46.45 to 46.47).

Financial allocation to children's services

    (63) Inadequate financial resources were allocated by Gwynedd County Council to children's services throughout the period under review and the adequacy of the allocation was never re-appraised by reference to children's needs (paras 44.55, 44.60 and 46.36 to 46.44).


    (64) Prior to 1991 the managerial arrangements at the most senior levels in the County Council were outdated and failed to provide an adequate oversight of the operation and performance of the Social Services Department in relation to children's services (paras 44.46 to 44.48, 44.51, 44.53 and 44.59).

The Welsh Office and Central Government


    (65) Too many changes were imposed in the organisation of local government in Wales and of social services in too short a time span (paras 47.59 and 47.60).

Leadership and guidance

    (66) At a time of major upheaval in local government in Wales and in the organisation of social services, the Welsh Office failed to provide leadership and guidance to ensure that the provision and administration of social services were given appropriate priority and failed to inform itself adequately about what was happening in relation to those services in North Wales (paras 47.63 and 47.64, 47.68 to 47.71 and 48.42).

Bryn Estyn's change of status and control

    (67) The Welsh Office failed to give Clwyd County Council (or its predecessor, the then Denbighshire County Council) any guidance in relation to the management, administration, supervision and running of Bryn Estyn Community Home following its change of status from an approved school controlled by the Home Office (paras 47.61 and 47.62).


    (68) The policy and inspectorate branches of the Welsh Office were inadequately staffed with officials of sufficient experience in children's services to support and monitor the provision of those services by local authorities in Wales effectively (paras 47.13, 47.69, 48.09, 48.39 to 48.42).

Strategic planning

    (69) Following the demise of regional planning in 1984, the Welsh Office failed to ensure that there were adequate strategies for the provision of residential accommodation for children in care in North Wales (including placements outside Wales) and that such strategies were implemented (paras 47.32, 47.38 and 47.64).

Private children's homes

    (70) Central government failed to take any action before the Children Act 1989 to regulate private children's homes despite the provision for this in the Children's Homes Act 1982 on the initiative of a Member of Parliament (para 47.65).

Regulation and inspection of residential establishments for children

    (71) The regulatory and inspectorial regimes for community homes and for private residential schools were defective and the findings of inspectors were insufficiently publicised (paras 48.39 to 48.42).


    (72)Insufficient priority was given to the need for appropriate training for residential care staff (including guidance on appropriate methods of physical restraint), despite a succession of reports drawing attention to the need for such training (paras 47.66 and 47.67).

Alison Taylor's complaints

    (73) Although the Welsh Office did not become aware of allegations of mistreatment of children in care in Gwynedd until September 1986 and of persistent sexual abuse in a Clwyd community home[913] until August 1990, its response to Alison Taylor's complaints was inappropriately negative and inadequate (paras 49.57 to 49.70).

The North Wales Police

Investigations generally

    (74) Save for the investigations in Gwynedd from 1986 to 1988 of Alison Taylor's complaints, there was no significant omission by the North Wales Police in investigating the complaints of abuse to children in care that were reported to them prior to 1990 (paras 50.06, 50.07 and 50.13). This finding includes the investigation of Gary Cooke (and Graham Stephens) in 1979 (paras 52.66 and 52.67).

    (75)  The evidence before the Tribunal does not justify severe strictures on the police for their response to individual alleged complaints by children in care, including absconders, but it does underline the need for vigilance and sensitivity by police officers when dealing with such complaints (para 50.33).

1986/1988 investigations in Gwynedd

    (76) The investigations in Gwynedd between 1986 and 1988 of Alison Taylor's complaints were defective in many respects and may fairly be described as "sluggish and shallow". The role played by Detective Superintendent Gwynne Owen was inappropriate and the size of the investigating team inadequate. There was no liaison with the Social Services Department and relevant documents were not seized. The reports on the investigation were one-sided and regrettable in tone; and the oral report to the Director of Social Services was inadequate (paras 51.29 to 51.33 and 51.79).

The Cartrefle investigation

    (77) The investigation of sexual abuse at Cartrefle in 1990 led by Detective Inspector Cronin was thorough and he pursued it as far as could reasonably be expected on the basis of the information before him; but the mode of access to social services files afforded to the police was unsatisfactory (paras 51.35 to 51.39).

The major investigation from 1991

    (78) The major police investigation of child abuse in Clwyd from 1991 onwards was carried out thoroughly (para 51.59). It was also carried out sensitively according to most of the complainants, although a small number were critical of the method of approach to them (paras 51.47 to 51.58).

An outside force

    (79) The decision by the Chief Constable not to request that an outside police force should take over the major police investigation was justified (paras 51.60 to 51.78).

Re-opening the Cooke 1979 investigation

    (80) The decision of the senior investigating officer not to re-open the 1979 investigation of Gary Cooke (and Graham Stephens) was also justified (para 52.68).


    (81) Freemasonry had no impact on any of the police investigations and was not relevant to any other issue arising from our terms of reference (paras 9.24 and 50.41 to 50.47).

Inter-agency review of major police investigations

    (82) It would be timely now to arrange a comprehensive inter-agency review of the conduct of major police investigations into the alleged abuse of looked after children (para 51.81).

Paedophile ring

    (83) During the period under review there was a paedophile ring in the Wrexham and Chester areas in the sense that there were a number of male persons, many of them known to each other, who were engaged in paedophile activities and were targeting young males in their middle teens. The evidence does not establish that they were solely or mainly interested in persons in care but such youngsters were particularly vulnerable to their approaches (paras 52.84 to 52.90).

The Successor Authorities

Need for co-ordinated action

    (84) The number and size of the new local authorities responsible for social services in North Wales give rise to special problems, some of which can only be solved by co-ordinated action (paras 54.09 and 54.30).

New management structures

    (85) The new management structures for social services in some counties do not all provide a single officer at senior management level who is both dedicated to and responsible for children's services and who is of sufficient seniority to influence adequately the allocation of resources to those services (paras 54.06 and 54.07).

Financial resources

    (86) There is cause for continuing concern about the adequacy of financial resources allocated to children's services. A fresh assessment of the needs of these services on an All Wales basis is highly desirable (paras 54.04, 54.28 and 54.29).

Recruitment at managerial level

    (87) Difficulties are being experienced by some authorities in recruiting officers of appropriate ability and experience in child care services at senior and middle management level and there has been little cross-fertilisation of ideas and practice (paras 53.04, 53.45, 53.46 and 54.05). Provision for appropriate management training is required (para 54.31).

Recruitment of residential care staff

    (88) The recruitment of suitable residential care staff for children is a widespread problem that needs to be addressed urgently (para 54.05).

Residential care establishments

    (89) The provision of residential care establishments in North Wales is inadequate and needs to be reviewed, together with the use of out of county and private establishments, with a view to co-operative action (paras 54.19 to 54.22).


    (90) There is a shortage of foster parents with requisite skills and a similar review of the availability and quality of fostering services is needed (paras 54.13 and 54.23 to 54.25).


    (91) The present organisation of inspection units needs revision. Any National Unit should have a local base within North Wales (paras 54.10 and 54.11). Inspection should include also the provision and quality of fostering services (paras 54.23 to 54.25).


    (92) There is real danger that the discouragement of "whistleblowing" may persist and positive action is required to ensure that the new procedures are implemented conscientiously and that any fear of reprisals is eliminated (para 54.16).

Independent visitors

    (93) The need for independent visitors requires re-assessment, as do the pre-conditions for their appointment (paras 54.17 and 54.18).

Awareness of signs of abuse

    (94) Vigilance by everyone who has contact with looked after children is of great importance and this applies particularly to teachers, members of the medical profession and police officers (para 54.26).

Leaving care

    (95) The problems for children leaving foster care may well be as severe as those facing children leaving residential care and the forms of assistance that they need may be wide ranging. The implementation of leaving care strategies will need continuous monitoring (para 54.27).


  55.11  This inquiry has revealed that many of the aspirations of policy makers in the 1960s in relation to children's services were not realised in the following two decades. Reorganisation of local government and social services led to a dissipation of specialist skills and knowledge in child care, which were not replaced. Moreover, the intention of the Children and Young Persons Act 1969 that delinquent children, whose misbehaviour was seen as a consequence of deprivation and disturbance, should receive the same programme of care and treatment as children who had suffered similarly but who had not offended was not effectively implemented.

  55.12  It must also be said that, in terms of crime prevention, the care system in Clwyd and Gwynedd was notably unsuccessful. From the records available to us in respect of all but two of the 129 complainants who gave oral evidence to the Tribunal, it appears that 52 had convictions before they entered care but 85 were convicted of offences whilst they were in care and 85 are known to have been convicted after they left care; and the figures for both counties were proportionately broadly similar. It would be a mistake to attach great importance to unanalysed statistics of this kind but they do underline the gravity of the problems that local authorities face.

  55.13  One of the many explanations for this sorry record may be that delinquent children saw themselves as being more severely punished than their predecessors because they were now subject to orders that could continue up to the age of 18 years instead of orders for shorter specified periods. On the other hand, some children who had not offended before were introduced to delinquency and to harsh regimes in which they were treated by some staff as "little criminals". Neither category of child received a service that could be described as remedial or therapeutic and some regimes encouraged absconsion and increased offending. It is not surprising in the circumstances that many regarded themselves as lost in care.

  55.14  Despite what we have said, however, a significant number of children regarded life in care, even at Bryn Estyn, as distinctly better than life at home and did not want to return to their family of origin. They were fed and clothed regularly and preferred a more predictable life to the unstable and sometimes dangerous one that they had known. We do not subscribe, therefore, to the view that children should be kept out of care at all costs, even though radical improvements in children's services may take some years to achieve.

897   See Appendix 5 for the report of the Witness Support Team. Back

898   See paras 1.08 to 1.10. Back

899   See paras 6.01 and 6.02. Back

900   See Chapters 7 to 17. Back

901   See Chapter 18. Back

902   See Chapters 19 and 20. Back

903   See Chapters 21 to 23. Back

904   See Chapters 25 to 27. Back

905   See Chapters 33 to 37. Back

906   See Chapters 38 and 39. Back

907   See Chapters 41 to 43. Back

908   Sentenced to 10 years' imprisonment in July 1994 and died on 24 April 1997. Back

909   Sentenced to 3.5 years' imprisonment in June 1990 for indecent assaults at Cartrefle and to 7 years' imprisonment in November 1993 for buggery and lesser offences at Bryn Estyn. Back

910   See para 2.07(3) for the full order of the Court. Back

911   See para 21.05(d). Back

912   See para 50.32(1). Back

913   Cartrefle: see Chapter 15. Back

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Prepared 15 February 2000