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IICSA Independent Inquiry into Child Sexual Abuse

Children in the care of Lambeth Council Investigation Report


C.5: Other concerns arising from the case studies

Increased risk of sexual (and other) abuse of children with communication difficulties

22. Children with complex needs are at significantly greater risk of sexual abuse.[1] As Dr Emily Phibbs set out in her report to the Inquiry (dated May 2020):

Children with intellectual disabilities may struggle to access memory and cognitive functioning in a way that allows them to clearly define what has happened to them in a coherent narrative.[2]

Expressive language may also be impacted in the case of certain disorders. Children may lack the means to describe what has happened and are especially vulnerable to being targeted by sexual offenders as a consequence.[3]

23. Children with complex needs have varying abilities to communicate, often as a result of their developmental stage and the child’s ability to adapt to their environment with social communication skills (cognitive and adaptive functioning). Communication is further hampered if adults lack the skills to overcome these difficulties.[4] Children in residential care depend on a number of carers knowing them and their method of communication. Children who communicate non-verbally – through behaviour, idiosyncratic movements or signing – may convey the trauma of sexually abusive experiences through changes in their behaviour or day-to-day functioning.[5]

24. As we saw, the inability of some adults to communicate with LA-A26 was crucial in the initial dismissal of her complaint of sexual abuse. In the 1980s, no specific guidance existed about obtaining complaints from children with communication difficulties.[6] Nevertheless it was open to both Lambeth Council and the Metropolitan Police Service in their early investigative processes to obtain specialist expert assistance, as Lambeth Council went on to do within the context of its management investigation in respect of LA-F12. Instead LA-A26’s ability to provide an account of sexual abuse was discounted at an early stage.

Medical examinations of children

25. The medical examinations of children housed at Monkton Street in 1986 were inappropriate. Some were conducted at the police station, others at Monkton Street. No attempt was made to interview the children prior to any decision about the need for an examination. Relevant background material, such as each child’s medical records, was not requested by the Metropolitan Police Service or supplied by Lambeth Council before the examinations were conducted.[7]

26. As recognised by the Monkton Street management investigation, the use of physical force during the examinations, particularly for children with complex needs and communication difficulties, caused them to be “frightened, upset or confused” and itself “constituted a form of child abuse”.[8] Detective Inspector Simon Morley explained that, today, the approach of the police would be to hold an initial interview with the child at a specialist facility, with the assistance of intermediaries and working in partnership with other experts to enable the very, very best evidence possible to come forward”.[9] (See Part J.)

Inadequate staffing and the consequences

27. Children with complex needs require a higher staff-to-child ratio in order to provide suitable and safe care. This should have provided protection for children, limiting the opportunities for a single member of staff to have access to children out of sight of their colleagues. However, as early as 1968, Lambeth Council identified difficulties in recruiting residential staff.[10] In November 1981, its Children’s Homes Sub-Committee of councillors recorded their “extreme concern” about staffing levels at Ivy House, Monkton Street and Chestnut Road. The staffing levels at these three specialist homes for children with complex needs were described as “inadequate”.[11]

28. By 1988, all Lambeth Council’s homes were “running at below 60 percent of full operational capacity due to staffing shortages”.[12] The shortage appears to have remained particularly acute in the case of specialist homes, where higher ratios of staff-to-children were needed. The officer in charge of Monkton Street, Herbert Botley, resigned in January 1989 in protest at the staffing crisis:

I felt unable to maintain a service that was not safe and, without some assurance of imminent practical support, my resignation was immediate.[13]

By February 1989, the staffing levels at Monkton House were described as in “crisis”.[14] This should have triggered an immediate response by senior staff in children’s social care in Lambeth Council to take steps to protect these especially vulnerable children.

Regulation of care workers within children’s homes more generally

29. In both the Ivy House and the Monkton Street case studies, members of staff who had been the subject of unproven allegations remained in employment. LA-F12 was provided with a reference for a role involving access to adults with complex needs. At a meeting with the SSI, Mr Osmond is recorded to have made it clear that “it was not possible in terms of employment legislation to refer to this matter if a reference from the Council was requested”.[15] Ms Annie Hudson, strategic director for children’s services at Lambeth Council from May 2016 to March 2020, confirmed that the position remains the same today.[16] Where an allegation is made against an employee but found to be unsubstantiated, false or malicious, in accordance with the London Safeguarding Children Board Child Protection Procedures (the London-wide Procedures) any reference provided by Lambeth Council will not refer to that allegation, to ensure fairness towards an employee.[17] This underlines the importance of taking allegations seriously, and conducting careful and considered disciplinary proceedings.

30. It also highlights the importance of carrying out appropriate recruitment checks, to reduce the risk to all children in care. Children with communication difficulties who require additional support reporting sexual abuse are placed at increased risk when cared for by those with a history of abusive behaviour. This was evidenced in the report commissioned by Lambeth Council in March 2000 into the closure of Chestnut Road children’s home. It included a section entitled ‘Employment Practices – dangerous employees and the paramountcy of the welfare of the child’.[18] One employee, LA-F39, appointed by Lambeth Council in April 1990 subject to references, police checks and medical clearance, was later revealed to have committed seven offences between 1971 and 1979, including robbery, unlawful wounding, burglary and theft – with one offence resulting in a five-year prison sentence. Despite being made aware of his convictions, Lambeth Council took the extraordinary decision to confirm his appointment as a care worker working with vulnerable children – a decision which was authorised by the appointing officer.[19] LA-F39 took up a post at South Vale children’s home and, while there, it was alleged he used physical force against the children, although the subsequent investigation was “inconclusive” because witness statements were not consistent.[20] When South Vale closed in 1995, LA-F39 was offered a post at Monkton Street; then in 1996, when Monkton Street closed, he was relocated to Chestnut Road, where allegations of sexual abuse were made against him. He was suspended following:

complaints from parents that something had happened to their children whilst receiving respite care at Chestnut Road. The first child made a complaint to his mother and the second parent came forward after a letter to all parents regarding [his] suspension. Both cases were investigated, although complicated by the children’s difficulty in communicating what had happened to them. The result was again inconclusive and the Child Protection Report found no firm evidence to form the basis of either criminal prosecution or a disciplinary hearing … It was agreed that references would be ‘minimal’.[21]

31. In the Inquiry’s Interim Report in April 2018, we recommended regulation of the children’s homes workforce.[22] The Department for Education is yet to respond to that recommendation. Such regulation has been in place for several years in Scotland, Wales and Northern Ireland, but not in England. Lord Kamlesh Kumar Patel, chair of Social Work England (which is responsible for the regulation of social workers), was asked if there were any plans for children’s homes workforce regulation. He replied:

So I think we’ve got two very concrete plans, I think, that are really important to this Inquiry. I believe there’s approximately 35,000 social care workers in children’s homes, and they’re not regulated by anybody. I absolutely believe that we have the infrastructure, the processes, to be able to register those 35,000 individuals and give them the same conditions that we give social workers in terms of their professional standards, of their continuing professional development.[23]

The second plan related to students. In Lord Patel’s view, student social workers should also be registered, “not only for the pipeline and the better quality and raising standards, but for the protection of the public”.[24] Lord Patel went on to say that the Department for Education and the Department of Health and Social Care would have to “give us those powers to regulate the children’s care workforce”.[25]

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