You don’t have to look for bad news about children’s social care, it finds you. For the last 40 years, stories of child protection failures and institutional abuse have reached living rooms, workplaces, and communities. 

 

I joined the children’s social care workforce in February 1976 not long after the childcare system in the UK had been rocked by the death of Maria Colwell at the hands of her mother’s violent partner, after she was returned to her mother’s care when the courts discharged the care order. At that time concerns about child protection, children ‘drifting’ in care for long periods of time with no hope of returning home, and debate about how to deal with young offenders was heavily influencing legislators, policymakers, and practitioners.  

 

Three decades later I was employed in the private sector as a care director with responsibility for a group of small children’s homes and schools. I was by then a registered social worker who had foster children in their 40’s and had witnessed the North Wales child abuse scandal, ‘Pin Down’ in Staffordshire, the founding of ‘Child Line’ during the 1980s, and the trials of Frank Beck in Leicestershire and Ralph Morris in Shropshire. I had uncovered institutional neglect, professional misconduct, and serious fraud believed to be in the region of half a million pounds in today’s money during the 1990s and at the beginning of the New, Millennium had welcomed the introduction of National Minimum Standards for Children’s Homes. I had seen the diminishing use of residential care, been involved in two working parties looking into child sexual exploitation, and experienced the transfer of regulatory responsibility from the Commisision for Social Care Inspection (CSCI)  to Ofsted on 1 April 2007. 

 

In recent years, the shift from public and voluntary sector providers to private care providers has often been blamed for our failing care system but in my experience informed opinion, failure is not sector-specific. It is about organisational culture, people, and behaviour and it is undeniable that the care system in England and Wales had been failing for a very long time before the shift to private sector commissioning. Also, that it continues to do so in spite of the attention given by ‘expert’ advisors, politicians, regulators and the ever-increasing number of professionals involved in the life of a ‘looked after child’ which has not translated into positive outcomes for far too many.

 

Following the introduction of National Minimum Standards for Children’s Homes and the first joint Chief Inspectors report on arrangements to safeguard children at the beginning of the new millennium, I was shocked to uncover the use of dangerous and unauthorised physical intervention in children’s homes that I became responsible for in 2009. Particularly, as there was undeniable evidence in logbooks and inspection reports showing inspectors and social workers had overlooked for some considerable time the excessive use of physical intervention, the dangerous use of prone restraint by untrained staff, and failure to seek medical attention for injuries suffered. Records showed that between July 2005 and July 2007 one young woman was physically restrained 107 times for periods of up to 14 hours, her liberty was restricted, she suffered injury and complained. On 2 occasions she was restrained in a prone position for 62 and 65 minutes respectively and was eventually admitted to inpatient psychiatric care. 

 

“The home records all sanctions and physical intervention appropriately, sampling these documents supported appropriate interventions and sanctions were being deployed.” (Ofsted inspection report 11.09.2007)

 

This report was published just ten weeks after the inquest into the restraint related death of Gareth Myatt who died at Rainsbrook Secure Training Centre in April 2004 recorded a verdict of accidental death and made sweeping criticisms of the Youth Justice Board.

 

When bringing my concerns to the attention of Child Protection Services, The Children’s Rights Director and Her Majesties Chief Inspector, and revisiting it again with her successor following the first social care lecture hosted by Ofsted on 1 February 2012, did not trigger an inquiry I raised them with The Children’s Minister and The Children’s Commissioner. The Office of The Children’s Minister agreed, “… it is essential that evidence of past abuse is thoroughly investigated…” and was hopeful that the introduction of a new inspection framework would mean future inspections would be much better at identifying and tackling poor practice. The Children’s Commissioner also agreed the issues raised were extremely serious and suggested I “should consider approaching the Local Government Ombudsman to request an inquiry…” 

 

The Local Government Ombudsman advised that only complaints made by the young people concerned can be investigated. 

 

I was dumbfounded that beyond the vindication of Alison Taylor, the children’s home manager who was sacked when she bravely blew the whistle on physical and sexual child abuse in Wales, and in spite of masses of undeniable evidence, that vulnerable children were still expected to know they are being abused, be capable of pursuing a complaint and have the understanding and tenacity to do so. Worse still, was the ‘catch 22’ created by this particularly as there had been countless stories of unchallenged wrongdoing by those in positions of power and whistleblower’s being treated as ‘troublemakers’ since the 1980s. The most famous of these being the allegations of sexual abuse against Jimmy Saville that were finally exposed around the same time and led to the Independent Inquiry in Child Sexual Abuse. 

 

By the time the IICSA was announced by Theresa May on 7 July 2014 I was aware of allegations against a childcare worker accused of sexually abusing three girls while working at three different children’s homes. Two of these girls and the homes where they lived at the time of the alleged abuse were known to me, as was the accused. I had attended the first child protection strategy meeting and prepared a report advising why I believed the allegations to be true.  

 

When the defendant was described in court as a good person with an impeccable work record, collusion had already been introduced as a motive for malicious allegations. The jury had been told that two of the three victims went to the same school but it was not made clear that this was at different times. Shocked by the inaccuracy of this, I protested the omission of evidence from the defendant’s personnel file, relevant child protection records including information sent to the local authority designated officer and the school’s register. It was obvious this was news to the barristers who uncomfortably explained that new evidence could not be introduced during the trial despite this meaning the potential miscarriage of justice created by this could not be avoided. My concerns were heightened still further when no attention was paid to the ‘under oath’ testimony of a witness who admitted she had not reported a previous related disclosure. And, even more so when barristers advised this serious child protection failure was not a matter for the court, and letters to Chief Constable and the Police commissioner were not answered and remain unanswered to this day. 

 

Unsurprisingly, the defendant was found not guilty of all offences against two of the three girls, but the jury failed to reach a verdict on charges in relation to the third girl. Sadly, any hope that this disastrous miscarriage of justice could be lessened in any way by a retrial was destroyed a few months later when the victim understandably refused to go through it again. 

 

The trauma of this trial will never leave me as I have no doubt these three girls like so many more were betrayed; serious child protection breaches were confessed, no action was taken against those responsible, and taxpayer's money was completely wasted on a prosecution destined to fail. Worse still was the complete failure to seek an explanation at the time these serious concerns were raised. As a result of this ‘wrongs’ were not corrected, harm caused was not appeased and lessons were not learned.

 

It felt like history had repeated itself and the emotional price of remaining silent had become too costly when faced with false allegations of professional misconduct I finally wrote to the Independent Inquiry into Child Sexual Exploitation (IICSE) on 29 July 2017. I viewed the inquiry as a ‘safe place’ to tell the story of a ‘gagged’ caregiver and I held on to a glimmer of hope that the cult of silence that hides wrongdoing, ignores truth, and allows dangerous people to remain in the children’s workforce would finally be exposed. But, this was swiftly extinguished when I was politely invited to appreciate that it was “not possible to investigate every allegation of institutional failure” in response to the professional experiences I brought to the attention of the inquiry. 

 

“There may be times when we are powerless to prevent injustice, but there must never be a time when we fail to protest.” Elie Wiesel

 

Soon after, with the support of The Consortium for Therapeutic Communities and The Care Leavers Foundation, I organised the first Your Life Your Story workshop for care leavers with literary aspirations. The event, facilitated by care experienced authors Rosie Canning, Lisa Cherry, and Paulo Hewitt was an inspirational experience that led to Your Life Your Story becoming a small charity. YLYS now brings care experienced adults and caregivers together with published authors, artists, and poets to share stories and learn the techniques of storytelling through the arts. Stories are corroborated, past injustices are revealed, supportive relationships flourish and wisdom emerges. 

 

A year after, the first Your Life Your Story workshop the first Your Life Your Story inspired book was published. The author was known to me as a young teenager in care and our paths had crossed again the year before his 50th birthday. The joy of this ‘meant to be’ reunion will never leave me - it was the best reward ever. Knowing that a young person has survived inconceivable childhood trauma, an ill-informed care system, and lived a good life beyond it, is more than any caregiver could hope for. As we caught up on the last 30 years the significance of our shared history emerged and along with it an aspiration to amplify the collective voice of care experienced adults and caregivers. In doing so, we hoped to contribute to the improvement of children’s social care by handing down lessons and knowledge from one generation to the next through storytelling and the arts.

 

David had grown up in the care of the state during the ’60s, ’70s, and 80’s where he suffered inexcusable abuse, and he left believing nobody cared about the wrongdoing he had experienced. His efforts to speak out were punished, and he was silenced until now. His book ‘Oi’ tells a story that in many ways mirror’s my own, it is a personal journey through decades of a harrowing childcare system.

 

Although it is true care fails too many, it is equally true that by far the majority of caregivers do not deliberately fail children and they are not the child abusers they are too often portrayed to be. In fact, the vast majority try extremely hard to care for children seriously harmed by acute trauma, neglect, and abuse, suffered long before the care system intervened. But it is the horror stories that reach the media not stories of the valiant efforts of caregivers to keep them safe. At the height of public outrage about the sexual exploitation of girls in Rochdale, there was no interest in stories about staff repairing trauma-driven destruction, mopping up the blood of self-harm, and walking the streets in the middle of the night looking for missing children. Or those following cars driven by unstopable men who were brazenly picking girls up at the front door of children’s homes, girls pleading with staff to go back because there was a gun on the back seat, or the numerous occasions when the police refused to assist.  

 

“There is no greater agony than bearing an untold story inside you” Maya Angelou

 

Yet every time there has been a major scandal there has been a hunt for ‘scalps’ and calls for more regulation in the hope this will solve the problem despite research that proves more rules and hard enforcement just does not work. During a recent conversation with a program maker I pointed out that most people want to do the right thing but because enforcement thinking is geared to the punishment of deliberate rule-breakers and does not differentiate between those who try to behave appropriately and those who do not there are unintended consequences. Evident in placement breakdowns, persistently poor outcomes and over-representation of care experience within the prison population, street homelessness, drug addiction centres, psychiatric wards, infants removed from care experienced mothers, early death amongst care leavers, and the impact of mistrust and on the workforce.

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If regulation is driving improvement as claimed by Ofsted surely there is a need to understand why outcomes refute this. 

 

On 23 January 2019 Amanda Spielman informed the Commons Public Accounts Committee Ofsted was seeing an increase in legal challenges to its reports and in a particular rise in the number of tribunals involving children’s homes. She said it is understandable but frustrating that, “people will throw everything they can at critical reports”, and added that winning a Court of Appeal case against an academy trust that challenged its damning inspection report was “a lovely Christmas present”. The legal bill for the academy trust was in excess of £700,000, Amanda Spielman could not say how much Ofsted was spending on legal fees when asked, but this publicly celebrated win confirms my worst fears about the dominance of the ‘prove it game’ in regulation. 

 

A year later, observations made in close proximity to Ofsted judgments and decision-making practices, in particular, the ‘fit person’ process, have reinforced this view, resurrected historical concerns, and re-opened old wounds. Of course, it goes without saying that it is essential for a registered provider or manager of a children’s home to be a person of integrity and good character, suitably qualified and experienced. But ominously any applicant who is refused registration becomes disqualified from fostering a child privately, having a financial interest, being involved in the management or employed in a children’s home, or working as a childminder without written consent from Ofsted even though they are not proven guilty of any wrongdoing.  

 

Previously in situations where it was likely that Ofsted would refuse to register a manager (or refuse a registration), the inspector would inform the applicant of the likely outcome. This gave the applicant time to withdraw their application, which they are well within their rights to do and Ofsted has to accept the withdrawal. Ofsted says this practice was discontinued because in a small number of circumstances they come across people whom they do not believe should be operating within social care and want to be able to ‘refuse’ them without giving them the opportunity to withdraw. 

 

Given the lack of protection against unemployment imposed by this, it is incredible that Ofsted is allowed to use an exemption in data protection law to refuse an applicant access to the ‘untested’ evidence relied upon by inspectors to reach a ‘behind closed doors’ decision with such far-reaching implications. Then to impose a 28-day time limit on an appeal when GDPR allows up to 3 months for the release of information needed to defend the decision. Most significantly because the impact of refused registration is immediate, the right to a tribunal appeal is delayed, the emotional and financial cost is prohibitive, and the harm caused is irreversible.

 

Power corrupts and absolute power corrupts absolutely. Lord Acton 1834 - 1902

 

My concern is that what Amanda Spielman described as a lovely Christmas present and the rise in the number of legal challenges has not raised alarm. The willingness to accept that this is explained by bad people just trying to hide a critical report or wilful opposition of authority  is as dangerous as the willingness to accept that 96 people “caused their own deaths” at Hillsborough in 1989 and the victims of widespread organised child sexual exploitation were “making a lifestyle choice.” 

 

When I joined the children’s workforce in 1976 children were not being listened to and terrible abuses were perpetrated against them, many of their stories were reflected in the publication of ‘Handle with Care’ the report of an investigation into the care system undertaken by Harriet Sergeant. I was at the commissioning conference in 2006 when Harriet presented her findings to a room full of professionals, many in fractious denial of what I knew to be true. It was my thirtieth year as a caregiver and I had witnessed first-hand the failures so well documented in her report. 

 

Sadly 14 years later I still see a system that is failing and a workforce under attack. Stories about careers being terminated, providers being put out of business, and good people being pushed into resignation, unemployment, bankruptcy, destitution, and despair are not being heard and the part regulation is playing in this does not appear to be on the government's radar. Poor inspection reports terminate careers and close homes,  fear of poor inspection reports ends placements and puts good outcomes at risk, and dubious GDPR exemptions legitimise covert decision-making processes, make challenge difficult and justice impossible.

 

Of course, this is not to say that when wrongdoing is identified perpetrators should not be held accountable and punished or that ‘unfit’ individuals should be allowed to work in childcare. I am simply saying that it is my firm belief that transparency keeps everyone safe and when things go wrong we need to learn from our mistakes. But we can only do that if we can share openly why the mistake happened and identify the cause.  To do this there needs to be an open trusting relationship between the regulator and the regulated that removes the incentive for hiding negligence and wrongdoing, stands up to public scrutiny, and does not pillory people for making a mistake or worse still for someone else’s mistake. 

 

The problem as I see it is that the relationship imitates one of parent-child with inspectors putting themselves in a position of actual and moral authority over caregivers and providers and preference for rule-focused ‘tick-box compliance and petty enforcement will prevent good behaviour rather than promote it. There are without doubt individuals working in childcare that we all think should not be there and examples of caregivers and providers who have escaped accountability for negligence, in some cases serious wrongdoing and even criminal behaviour. But this does not justify hidden processes that adversely affect innocent staff, managers, and stakeholders and assume that public authorities,  specifically inspectors, always behave ethically and treat those they regulate fairly. 

 

Common threads running through the perennial maze of children’s social care are the misuse of power, the avoidance of accountability, and the absence of apology.

 

When I reached out to the Independent Inquiry into Child Sexual Abuse (IICSA) on 29 July 2017 I did not know that Phil Frampton of the Survivors of Organised and Institutional Abuse (SOIA) and founder of The Care Leavers Foundation had formally withdrawn his support from the inquiry seven weeks earlier. Ironically, I also didn’t know that amongst the concerns that led to this decision was the absence of an investigative approach and the failure to include “whistleblowers” in the Truth Project led by the inquiry. 

 

By then I had resigned my position in regulated children’s services and reported the allegation of professional misconduct threatened against me to the Health and Care Professionals Council and the Information Commissioners Office. Even though no action was taken against me the cost of protecting evidence the allegation relied upon ran into tens of thousands of pounds and put a very big hole in my retirement fund. Without a doubt, defending the truth had demanded a high price but unlike Alison Taylor who lost her career in the 1980s, I have not spoken publicly about my experiences until now.   

 

Why now…?

 

We know that the number of children being separated from their parents is higher now than at any point since I joined the children’s workforce and paradoxically, we also know that too many children in care suffer harm and care leavers are still over-represented in all marginalised groups but we don’t know why. Unfortunately, the search for answers to these failures has led to scapegoating and a regulatory system that is designed around people who deliberately break the rules and must be deterred by punishment.

 

But regulation has not delivered the improvements promised and there have been unintended consequences. Not least, fear of poor inspection ratings fueling placement breakdowns and increased demand arising from anxiety elsewhere in the system has led to the use of unregistered provisions for young children and vulnerable teenagers recently exposed by the media.  Worse still good people are being expelled from the workforce whilst unethical and dangerous practice remains hidden and for some accountability is escaped.

 

Shortly after Your Life Your Story 2019, the Independent Inquiry into Child Sexual Abuse announced its final investigation into Effective Leadership of Child Protection. In doing so it will consider the evidence of “whistleblowers”, recommendations from inspectorates, serious case reviews, and similar reports. It will also take into account learning from past institutional failures and “think” about embedding a “learning” not a “blaming” culture. But I have not been contacted by the inquiry team with any queries about the evidence I submitted in 2017 as suggested in the letter received when I expressed dissatisfaction after being advised that it was not possible to investigate every allegation of institutional failure. 

 

So, it remains to be seen whether IICSA proves to me and other “whistleblowers” that it is any more than the ‘tick box exercise that led Phil Frampton to withdraw his support. Or a “talking shop” for highly paid academics and lawyers to produce endless glossy reports as it was described, by the late Anna Racoon, a staunch defender of liberty, freedom, and most of all the truth, who wrote about this shortly before she died. 

 

At the very least I hope that it triggers change not just another review and in the meantime, I will live in the hope that the narrative of lived experience and the collective voice of care experienced adults and caregivers will be heard and lessons are learned.

 

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Amanda Knowles MBE

(first published 24 January 2020)