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IICSA Independent Inquiry into Child Sexual Abuse

Sexual Abuse of Children in Custodial Institutions: 2009-2017 Investigation Report

D.2: The Inquiry’s findings on culture

The current culture within custodial institutions

3. From all the evidence we heard, there are a number of cultural factors within custodial institutions which inhibit the proper prevention, exposure and investigation of child sexual abuse.

4. The position was summarised by Professor Nick Hardwick, formerly HM Chief Inspector of Prisons, that there are very serious risks that children in custody may be subject to sexual or other forms of abuse, and that the reasons for this are linked with the following cultural factors within custodial institutions:

  • These are closed institutions, where the normal scrutiny of parents, friends and visitors is not possible. It is very difficult for a person from outside to see what is actually happening, other than what they are shown. As an example, abusive behaviour by staff at Medway STC was hidden from inspectors and official visitors in some cases.
  • There is a power imbalance between staff and children. Staff are trained to use force, including pain compliance techniques. In addition, the child is dependent on staff for every part of day‐to‐day life, including access to privileges, status, food, unlock, visits and more.
  • Children in detention often lack credibility because of their offending behaviour, mental health or age.
  • If staff are encouraged to create an ‘unpleasant experience’, this makes poor behaviour normal. In Professor Hardwick’s view, there was likely to have been a direct link between the policy to create an ‘unpleasant experience’ and the brutality and sexual abuse that followed at HMP Medomsley, echoed in some of the language of juvenile custody. He thought there was a similar subculture between staff at HMP Medomsley to that at Medway STC.

Overall he described children in custody as “very vulnerable children in a very dangerous place”.[1][2]

5. There was a focus on achieving a closed and controlled environment rather than welfare in YOIs and STCs. The Medway Improvement Board (established after the January 2016 Panorama documentary regarding Medway STC, discussed below in greater detail) had concluded that the culture at Medway was focussed on control and contract compliance at the expense of child welfare.[3][4] Pam Hibbert, a social worker and former Chair of the National Association for Youth Justice,[5] believed that children in custody have become more vulnerable because institutions have become more closed and the protective factor of contact with the outside world has reduced.[6][7][8] Dr Laura Janes, Legal Director of the Howard League for Penal Reform,[9] described the culture in custody as a generally punitive one. [10]Matthew Brazier, an Ofsted special adviser on looked‐after children, said the key difference between SCHs and STCs/YOIs is that SCHs tend to be much more child‐centred.[11] These characterisations of the secure estate were borne out by the evidence concerning how SCHs operate compared to YOIs and STCs.

6. Complainants regarded physical and sexual abuse as inextricably linked. Witnesses described physical violence making them so frightened they submitted to sexual abuse and were too afraid to complain about it. Effectively the culture of violence contributed to the opportunities for sexual abuse to occur and go undetected.[12][13][14][15] Angus Mulready‐Jones, the lead inspector for children in detention for HM Inspectorate of Prisons, agreed that today there remains a link between violence and sexual abuse. One consequence may be that children are less likely to trust the institution to protect them if they report sexual abuse.[16]

7. There seems to be a perception of detained children as somehow “undeserving” and not reliable historians. In Pam Hibbert’s experience, children in custodial institutions are considered offenders first and children second; they are seen as malicious or different from other children. Her examples included a member of STC staff saying it was okay to refer to children in custody as “animals”, and other staff expressing the view that children made false allegations. To disclose abuse, a child must feel they will be believed and that something would happen as a result; however, the children Pam Hibbert had spoken with did not believe the staff who looked after them would put their interests before those of the establishment.[17][18][19] As Carolyne Willow, a social worker and founder of Article 39,[20] highlighted, a child in custody has a “tarnished” reputation before they even enter an institution.[21]

8. This is exacerbated by feelings of powerlessness experienced by the child in custody, which are made worse still by practices such as strip searching and pain compliance. As Dr Janes explained, it is a fact of detention that children often are in positions where they feel vulnerable, lonely and afraid. This, coupled with the acute and inherent power imbalance, puts them at greater risk of abuse.[22] Pam Hibbert also suggested there is a link between power dynamics and abuse. Many children in custody have already experienced neglect, abuse and chaotic lifestyles, and some have been involved in gangs. As a consequence, the dynamic in which “the strongest person wins” might be replicated in custody.[23][24][25] In Carolyne Willow’s view, practices such as strip searching and pain techniques to induce compliance or facilitate restraint are the antithesis of what children need to feel safe and cared for.[26]

9. These broad themes were reflected by others. Mark Johnson, founder and CEO of User Voice,[27] explained the power imbalance between adults and children in the community was amplified in custody and children are reliant on the systems and people within the institution to protect them.[28] Angus Mulready‐Jones said staff need to take positive action in many aspects of how detainees are treated. For example, only 25 percent of children in YOIs said their emergency cell bell was answered within 5 minutes. If the institution cannot guarantee basics, it will undermine the child’s confidence in reporting, including incidents of abuse.[29] Such an approach is also likely, in our view, to make a child feel powerless.

10. The friendships, intimacy and sexual activity that would be normal in the community are likely to be absent from the custodial environment. Dr Janes noted there were no authorised sexual outlets and no opportunities to develop relationships in custody. Parents not being allowed to hug their children during visits and teenagers in detention being punished for masturbating creates an artificial state of “untouchedness”, as well as a secretive and unhealthy atmosphere around sexuality. These factors make it harder for children to know what is normal and what is abusive.[30] Mark Johnson commented that the very nature of excluding people from normal sexual activity, the volatility and social immaturity of children in custody, and gang or other peer pressures all increase the risk of sexual abuse occurring. They also reduce the likelihood of a child disclosing abuse in custody.[31]

11. Finally, according to Steve Gillan, General Secretary of the POA,[32] there are a number of matters which limit the time staff can spend building trusting, professional relationships with children, leading to fear that they might be deterred from coming forward to discuss concerns.[33]

12. Alan Wood, the independent expert appointed to advise the Inquiry, considered these cultural issues at some length.

  • He described various potential risk factors for the occurrence of sexual abuse in custody, including the use of drugs, gang membership and violence committed by other children, although there are many variables that could cause a child to become isolated and at risk.[34]
  • He noted that in the community the possible symptoms and signs of abuse may be detected by a wide range of people with whom a child interacts, whereas children in custody are dependent on the professionals they come into contact with to recognise those signs. In a custodial environment, some of the signs associated with past or current abuse[35] may be present because the child is reacting to custody.[36]

  • One of the strongest protective factors for children is having a positive educational experience, which feeds into their self‐esteem, self‐awareness, positive peer contact and ability to build trusting relationships with adults. Despite the importance of education, he noted from the Review of the Youth Justice System in England and Wales by Charlie Taylor in 2016 (Taylor Review) that children were only accessing 17 hours of education per week, rather than the expected 30 hours. He explained that children need to be given information about what is abusive or neglectful behaviour so they can identify it, as they might not realise they are being harmed or their prior experiences may have skewed their idea of what constitutes consensual activity. He thought children should be given practical information in an age‐appropriate way about what would happen if they made a disclosure.[37]

  • In Mr Wood’s experience, the most successful ways to enable children to disclose abuse have involved creating a culture where there is access to a trusted and close professional (eg social worker) as well as other independent people. However, his view was that once a disclosure is made, achieving the necessary multi‐agency response is more complicated in custody than in the community.[38]

  • In the context of the case studies analysis relating to Medway, he described an incident when staff members failed to protect another child who was being assaulted and having his clothes removed by other detainees. He expressed concern about the effect this would have had on children’s expectations of the protection they would receive from members of staff.[39]

13. Chief Constable Simon Bailey, the National Police Chiefs’ Council lead on child protection, was more optimistic. He thought that while the culture within custodial institutions may well be such as to operate as a barrier to disclosure, the culture and working relationship between the police and prison service is improving, and there is now a greater understanding about how to meet the current challenges.[40]

14. On behalf of the Youth Custody Service, Sara Robinson recognised that the environment in custodial environments is not always conducive to staff being able to create a culture of enabling children to have positive outcomes and not re‐offend, albeit there were many staff who worked hard and wanted to make a difference.[41]

Proposals to reform culture

15. Various witnesses gave their views as to what cultural change is needed within custodial institutions for children.

16. Dr Janes suggested a common set of rules and standards based on the rights of children is required.[42] Children in custody need to be treated with great care but, in her view, they also need to be empowered to take responsibility for their own futures and to demand to be treated with respect and dignity.[43] Recommendations to this end have been made by a number of experts. For example, the Bach Commission report The Right to Justice (2017)[44] recommended that “all matters involving children should be brought back into the scope of funded legal aid”.[45][46]

17. Experts in this area, including Pam Hibbert and Dr Tim Bateman,[47] have expressed disappointment that the government rejected the recommendation of the Taylor Review[48] that the focus should be on the child first and offending second. Pam Hibbert considered that there needed to be a “fundamental rethink” about children in custody, and that they should be removed from Prison Service responsibility.[49]

18. Professor Hardwick told us “the most important factors in reducing risk are sufficient well trained professional staff, a child-centred culture and a management culture which encourages challenge and discussion”. He shared the view that child detainees should not be the responsibility of the Ministry of Justice but rather of the Department for Education or Department of Health or somewhere else. Overall the protection of children should be at the top of the list of important aims; the bedrock has to be safety and protection of children from abuse.[50][51]

19. Of the key themes Mr Wood identified, those relating most directly to the reform of culture were that the need for a child‐centred approach and that issues of trust are key.[52]

20. Phillip Noyes of the NSPCC indicated there were a number of ways that professionals and non‐professionals could make it easier for children to disclose abuse, including:

  • being aware of, recognising and responding appropriately to emotional distress, behavioural changes and other signs;

  • asking sensitive questions;

  • using age and developmentally appropriate words and communication styles;

  • giving children a safe space to talk and tell;

  • giving children a sense of control over the process of disclosure;

  • taking prompt action to protect children; and

  • giving children better information.

To help children disclose sexual abuse sooner, Phillip Noyes thought cultural change in organisations was needed; in summary, the key change needed is “kindness”.[53]

21. Sara Robinson said that the Youth Custody Service was looking at developing a code of practice on the management of behaviour across the sectors. She agreed they ought to consider whether the clear quality standards relating to children that apply in the SCH context[54] can be carried over to YOIs and STCs.[55] Sara Robinson said, generally, all the steps the Youth Custody Service is undertaking are aimed at creating an improved and more child‐centred culture in custodial institutions.[56]

22. Peter Savage, formerly of the Youth Justice Board, stressed the importance of “porous boundaries” in youth custody, where a range of different organisations and individuals come into the establishment who are independent of HMPPS. He thought this was an area where HMPPS needed to continue to do more.[57]

23. Jonathan French, governor of Medway, told us about the attempts he has made to change the culture at Medway STC since taking over in early 2017. He has, for example, introduced a “rewards-based approach”, as a foundation for the behaviour management policy. The previous regime had been overly punitive and was ineffective. The new scheme gives children points for positive behaviour.[58]

24. Likewise, Peter Gormley, the former governor of HMYOI Werrington, told us that at the institution they had tried to create a reward culture for good behaviour, rather than a punitive one for poor behaviour.[59]


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