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IICSA Independent Inquiry into Child Sexual Abuse

Children in the care of Lambeth Council Investigation Report


F.7: Deaths in care and cover‐up

42. It is difficult to overstate the significance of the unlawful killing of a child in the care of a local authority. Tyra Henry was 22 months old and suffered appalling injuries. Her father had grievously injured her brother, when he was a toddler, prior to Tyra’s birth. The Tyra Henry public inquiry report chronicled the circumstances that led to Tyra living with her father despite the fact that she was in Lambeth Council’s care. The report noted, in stark terms, that “Lambeth’s own position as Tyra’s legal parent was effectively forgotten” during the course of her short life.[1] The inquiry brought with it external and detailed public scrutiny of failures by individual staff, of systems and of the committee system. It should have been an impetus for change, but it was not.

43. In 1993, a report into the death of Mia Gibelli, who was killed by her mother when she was just seven weeks old, also led to criticisms about Lambeth’s Social Services directorate.[2] Staff had known that her mother had previously injured a sibling by throwing the child from a third-storey window.

44. In December 1992, after the death of Mia Gibelli, when it became known that Lambeth Council had retained Carroll in the face of his conviction for the sexual assault of a child, when there were investigations into South Vale and when it was known that Lambeth Council had one of the highest numbers of unallocated cases in London, as leader of Lambeth Council Mr Whaley signed a letter to Mr Lambert of the SSI. The letter welcomed a full inspection of homes by the SSI or an independent inquiry into care arrangements. The letter also stated:

During the last few months, the Council has been working closely with the SSI and the police investigating what had been happening in the past … We have improved our practices during the last two years with better management and procedures and are confident that we are providing a high standard of care for the children we are responsible for.[3]

45. Mr Whaley said that this letter would have been written by the director of social services. He accepted in oral evidence to the Inquiry that when this letter was written practices had not improved.[4] He said that Lambeth Council spent a lot of time not being transparent and that problems were covered up. He thought that it was a culture amongst staff, but perhaps also between councillors. It was a defence against criticism, a tendency to try to avoid the issues, to hide the facts and to try to find a way of putting a positive spin on it.[5] Mr Whaley also accepted that this pointed towards the reputation of the council being prioritised over concerns about what was happening to children in care in Lambeth.

I think by the time we got to the point where we had started to recognise the sheer chaos which we were operating under, I think, just the size and scale of everything did mean that the particular issues within childcare in the children’s homes were not seen as being as important as the bigger picture of meltdown and corruption, and I think that’s something which we have to accept and bear responsibility for.”[6]

46. Tyra Henry and Mia Gibelli were only two of a number of children to have died in Lambeth Council’s care in the period considered by the Inquiry.

47. In 1975, a baby died in a Lambeth children’s home in shocking circumstances. She was found dead, harnessed to a top bunk bed in a children’s home. There was an internal inquiry but no independent inquiry (save for a limited coronial process) and there was no police investigation.[7] Her brother, Russell Specterman, told the Inquiry that “to this day” neither he nor his family have received a full explanation as to what happened to his sister. This lack of understanding causes him “overwhelming pain”.[8]

48. A child in Lambeth Council’s care was placed at Birtley Farmhouse in Surrey in the early 1990s. Birtley Farmhouse was for teenagers with therapeutic needs. The child Lambeth Council sent to live there was seven years old. He was supposed to be there on an emergency basis but he stayed for five months. Before he was placed there, Surrey County Council wrote to Lambeth Council setting out concerns about Birtley Farmhouse. The child made allegations that he had been sexually abused there. An affidavit from his social worker suggested that he was still living in Birtley Farmhouse when he made the disclosure. An alternative placement was found for him but he was not moved immediately. He took his life some years later, while still a child in Lambeth Council’s care. A review following his death referred to a “lesson in the potentially disastrous consequences of failure to plan/implement plans for children in care.[9]

49. As set out in Part B, LA-A2 (who was taken into care in the 1960s) was found dead in the bathroom of a Shirley Oaks cottage, having given evidence two years earlier in the trial of his house father Donald Hosegood. LA-A2’s sister recommended to the Inquiry that:

when a child or adolescent dies whilst being looked after in care, whether the death is suspicious or not, professional agencies should be completely transparent when communicating details with parents or guardians and family members.”[10]

50. In 1998, Helen Kenward (an independent consultant in child protection with 37 years’ experience) came to Lambeth Council to lead the Children’s Home in Lambeth Enquiry. One of her first tasks was to try and secure the records of children who had been in homes. She gave evidence to the Inquiry of the sheer difficulty involved even in this task because of the ways files were treated. She regarded the treatment of children’s files (which contained the record of their life stories) as emblematic of the chaos and the disrespect for children’s lives as well. She found a total lack of respect and extraordinary things written in those files. Professional curiosity should have meant that these were investigated – this was just basic social work. She regarded it as “not necessarily criminal, just basic social work was lacking”.[11] Ms Kenward found evidence of people lying about files, hiding them, denying working with or knowing individuals being investigated. She confirmed that workers who had been involved in the previous investigations were resentful and had to be reminded of a social worker’s duty of care. There were some who were subversive and withheld files, hiding them in drawers and cupboards.[12]

51. Ms Kenward agreed that there was a culture of withholding, hiding and concealing information that was difficult. She also thought that there was a culture of lazy social work; she did not suggest that it was “all necessarily malevolent but … there was a lot of laziness about it”.[13] The files reflected that, and Ms Kenward suspected that social workers were reluctant to let CHILE look at the files because files had not been supervised and scrutinised in the normal social work way.

52. A statutory duty to report all child deaths in care to the Department for Education (and its predecessors) did not come into effect until the early 1990s. It was not until the Children Act 2004 that a child death review process was introduced.[14] In response to a request from this Inquiry, Lambeth Council identified 15 known cases of children who died in its care between 1969 and 1992. It was unable to confirm if this figure was accurate or that its summary about those 15 children was comprehensive.[15] This figure is markedly different from the 48 deaths between 1970 and 1990 that were cited by Ms Gillian Delahunty (a senior training officer for residential child care from 1990 to 1991) in her 1992 dissertation.[16] Ms Delahunty told us that:

Statistics were required to be kept by local authorities and sent to the Department of Health on a range of things, including admissions to childcare and reasons for discharge, and they had a set of codes for each of the reasons for discharge, and one of the set of reasons for discharge was included deaths of children in care, and I collated those into this 20-year table and, you know, those were the figures that it came to. I’m sure I would have double-checked them, because, particularly for the years ’74 and and ’75, they did appear, you know, and do appear, particularly high. But unfortunately I no longer have the background papers.[17]

53. In the absence of underlying documents it is not possible to reconcile the two figures, 15 and 48. It is indicative of the chaotic record-keeping (even without an obligation to report all child deaths) and the lack of value placed on a child in care’s life that Lambeth Council was unable to provide this Inquiry with accurate and comprehensive figures and details for children who lost their lives whilst in the care of Lambeth Council.

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