CONCLUSIONS AND RECOMMENDATIONS
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.
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.
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.
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
(of 23 that existed from time to time) and one voluntary children's
(of four). We have also investigated complaints emanating from
a local authority residential school and a National Health Service
In the private sector we have examined residential homes/schools
in Clwyd run by three organisations,
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.
55.08 On the same principle we have examined
the histories of five local authority homes in Gwynedd
(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.
Thus, the Inquiry covered nine residential establishments in Gwynedd
and eight foster homes.
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
(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
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,
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).
(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
(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.
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.
(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).
(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).
(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
(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
(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).
(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).
(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).
(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).
(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
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
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.
(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.
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).
(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).
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).
(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).
(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).
(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).
(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
(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
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).
(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
(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
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
(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).
(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).
(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
(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
(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
(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).
(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
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
See paras 1.08 to 1.10. Back
See paras 6.01 and 6.02. Back
See Chapters 7 to 17. Back
See Chapter 18. Back
See Chapters 19 and 20. Back
See Chapters 21 to 23. Back
See Chapters 25 to 27. Back
See Chapters 33 to 37. Back
See Chapters 38 and 39. Back
See Chapters 41 to 43. Back
Sentenced to 10 years' imprisonment in July 1994 and died on
24 April 1997. Back
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
See para 2.07(3) for the full order of the Court. Back
See para 21.05(d). Back
See para 50.32(1). Back
Cartrefle: see Chapter 15. Back