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IICSA Independent Inquiry into Child Sexual Abuse

Children in the care of the Nottinghamshire Councils Investigation Report

E.5: Institutional responses

34. There is little information now available about the approach adopted by children’s social care or the police towards harmful sexual behaviour for much of the 1970s and early 1980s. Some incidents were recorded in children’s social services files but treated as behavioural problems or adolescent exploration.[1] As Professor Hackett commented, while even good carers and professionals may not have understood harmful sexual behaviour at this time, they should still have been concerned about the sexual wellbeing and behaviour of children in care.[2]

35. The County accepted that it had “let down” a number of children who had been sexually abused by other children.[3] To explore the institutional response, we have reviewed five internal enquiries, carried out between 1988 and 1995, into allegations of harmful sexual behaviour at different community homes in the County.

Harmful sexual behaviour in residential care

Amberdale (1987–1988)

36. In December 1987, two female residents of Amberdale alleged that they had been forced into oral sex by a male resident, aged 15. Their allegations were investigated by the police.[4] In January 1988 the same male resident attempted to sexually assault another female resident, and three further allegations of harmful sexual behaviour followed over the next few days. As a result, there were “real fears for the safety and security of females in the unit”.[5] Despite this, no steps were taken by residential staff or social care managers to address the immediate risk of sexual abuse of other children and the harmful sexual behaviour was regarded as simply part of a pattern of disruptive behaviour.[6] In March 1988, the child was removed from the unit and placed outside of Nottinghamshire.[7]

37. In 1988, NO‑A117, a 13‑year‑old male resident at Amberdale, made allegations of rape and oral sex against another male resident of the same age.[8] The child alleged to be exhibiting harmful sexual behaviour had been admitted to Amberdale following allegations that he had committed buggery and murder. As children in the secure unit were closely supervised, no special arrangements had been considered necessary to separate children exhibiting harmful sexual behaviour from other residents.[9]

 38. NO‑A117’s allegations were escalated to children’s social care, the placing local authority for each child, the police, councillors and the Department of Health Inspectorate. The child alleged to be exhibiting harmful sexual behaviour had allegedly threatened to kill NO‑A117 if he told anyone of the abuse. Steps were taken to divide the unit to separate the two children. This proved to be unsustainable and the child alleged to be exhibiting harmful sexual behaviour was moved.[10] Despite supportive medical evidence and a consistent statement from NO‑A117, the police concluded there was insufficient evidence to proceed “in the absence of any corroborative evidence”.[11] The internal enquiry commenced in December 1988. In interview, staff said that they did not believe NO‑A117. The investigation concluded that “the truth will probably never be known”, but that children’s social care’s response had been “appropriate” and “in keeping with good child care practice, embracing important principles guiding work with sexually abused children”.[12] Recommendations included training and guidelines “to assist residential staff when they have to deal with allegations of sexual abuse between children and young people in residential care”.[13] Although the findings and recommendations were endorsed by councillors,[14] they were not passed on to Amberdale staff.[15] Recommended training did not take place[16] and guidelines were only introduced in 1991[17]  (by which time further harmful sexual behaviour cases in residential care had been reported).

Greencroft Community Home (1990)

39. In May 1990, children’s social care management and residential staff from Greencroft Community Home (which could accommodate up to 12 children, up to 17 years old)[18] met to discuss “kids being abused by kids”.[19] They discussed possible ways to protect children, including the need for ongoing counselling, for children’s inductions to include a discussion about sex and sexuality, and the deployment of waking night staff.

40. In July 1990, at which point eight of the nine Greencroft residents had been sexually abused previously,[20] two incidents of harmful sexual behaviour, three weeks apart, were reported. The first incident involved a 15‑year‑old male resident allegedly sexually abusing four girls aged between seven and 16 in one night.[21] The police were involved and recommended charging the male resident.[22] The second incident involved one of the same four girls being sexually assaulted by a different male resident.[23]

41. One of the victims, D31 (then aged 12), told us that these were just two of a series of five incidents of harmful sexual behaviour to which she was subjected by the same male residents and others.[24] She had been placed at Greencroft with much older children[25] which, along with a failure to monitor risks posed by other children and a lack of guidance for staff,[26] left her at risk of abuse.

42. An internal enquiry reported, in September 1990, that “widespread changes” were needed across all children’s homes to contain “the problem of child abuse” and give children “the protection and help they need”.[27] Children’s social care were “overburdened” and responses to child sexual abuse had “fallen far short of what is needed”.[28] It was “unacceptable” and dangerous to mix together sexually abused children with children exhibiting harmful sexual behaviour,[29] and there was no guidance on how to deal with either group.[30] More generally, advice on the response to abuse was “based on a premise of trained, skilled professional staff, whereas less than 10% of the staff are trained and many are temporary and inexperienced”.[31] The report made 20 recommendations, including that:[32]

42.1. steps be taken to “separate abused children and perpetrators” and “priority … given to providing separate Homes for abused and abusers[33] and 

42.2. children’s social care issue guidance to residential staff on dealing with harmful sexual behaviour[34] and establish a system for monitoring and evaluating sex offenders in residential homes.

The Social Services Committee approved separating victims of sexual abuse and children exhibiting harmful sexual behaviour, with one community home to be designated for work with children exhibiting harmful sexual behaviour and another exclusively for sexually abused girls.[35] These recommendations were not fully implemented by the County.[36]

Sandown Road Community Home (1990–1991)

43. In 1990, in the course of a police investigation, two residents at Sandown Road Community Home admitted sexually assaulting and raping other residents at the home. One was cautioned and the other was given a supervision order.[37] One of their victims (NO‑A120) had also been anally raped by a different resident six months earlier. A safe and secure placement for the victims could only be found outside the County.[38]

44. The County failed to prevent or respond appropriately to widespread sexual abuse at Sandown Road. A 1991 internal enquiry into the quality of child care at Sandown Road by senior social workers from the County found that children’s social care staff:

“were very concerned by the sense of inevitability that any child admitted was subject to sexual abuse or involved in inappropriate sexual activities. In one 12 month period, every child admitted was involved in sexual abuse incidents whether they had been previously abused or not. This does not appear to have been a problem since April of this year.”[39]

Staff had reported concerns about the management of disclosures, that staff meetings had not addressed how to manage abused children and “the needs of the individual children in terms of counselling and protection were forgotten”.[40] Social workers were concerned that “staff had not been able to prevent” the “high levels of sexual abuse”.[41] Requests for training and support for staff had not been responded to by Paul Bohan, Senior Professional Officer within the County at the time.[42]

45. Sandown Road was temporarily closed that year, in line with the report’s recommendations. Although the Social Services Committee were informed of the closure, there is no record of how much they were told of the abuse suffered by some of the children and staff concerns.[43]

46. There is no evidence of anyone within children’s social care considering this report alongside the Greencroft and Amberdale reports despite those reports raising similar issues. Co‑author of the Sandown Road report, Sue Gregory (Senior Social Worker at the time), told us that when writing the report, she was unaware of the similar issues that had been raised in the Greencroft report the previous year.[44] This lack of information sharing was poor practice.

Hazelwood Community Home (1991–1994)

47. A former resident of Hazelwood (another community home), NO-A89, alleged in 1991 that he had been raped by three other residents at the home in 1985.[45] The other residents were aged between 11 and 15 years old.[46] It was known to staff in 1985 that NO‑A89 had suffered serious physical abuse by other residents “with potentially sexual content”.[47] At the time, the other residents had remained at Hazelwood and staff were not warned of the risk they posed to other children.[48]

48. Tony Dewhurst (a children’s social care manager in the County, whose role at the time included supervision of and advice to management at Hazelwood) was said to have been aware of the rape according to NO‑A89’s social worker at the time,[49] although Mr Dewhurst told us that he could not remember being informed about it.[50] Mr Dewhurst had also allegedly described one incident involving NO‑A89 as “normal adolescent behaviour”,[51] however it is unclear whether this related to the rape or to physical abuse suffered by NO‑A89. He did notify the Social Services Inspectorate (SSI) of the allegation in November 1991, saying that “lessons … have been learnt”. The SSI responded that “The general question of whether community homes in Nottinghamshire are safe places in which children can live is clearly the most important factor.[52]

49. In 1992, NO‑A89’s social worker and his key worker at the time of the 1985 assaults voiced their “extreme concern” to David White, the Director of Social Services, about the abuse and the response to it, including the disappearance of files, the failure to investigate staff and children’s social care’s failure to take responsibility for the harm caused to young people in the care system.[53]

50. At a meeting in August 1992 between County legal and insurance officers and a children’s social care manager, they agreed that: 

“there was basically no discipline in this particular home, no action was taken against the perpetrators, there was no psychological help for [NO‑A89] and the records of all the incidents have since been destroyed”.

It was agreed that a working party within the County should consider various issues, including “segregation of abusers and abused or males/females” and the reporting of incidents of abuse[54] but no such group was set up. 

51. One of the three residents was convicted in 1992 and sentenced to five years’ imprisonment. The judge commented that “if the home had been run better by social services the offence could not have been committed”.[55]

52. An internal enquiry was ordered by David White. Its report concluded, in 1993, that it was not possible to determine whether senior staff had been aware of the harmful sexual behaviour incidents at the time due to a lack of records.[56] However, it concluded that insufficient control had been exerted by staff, so that “powerful boys” had created a culture of “intimidation and violence”.[57] The report also identified failures by staff to take action to prevent the abuse by responding to persistent and serious bullying of NO‑A89 and to respond appropriately afterwards. Its recommendations did not address harmful sexual behaviour in community homes but did recommend training on the support needs of children who had suffered abuse and their vulnerability to abuse from other children. This was implemented.[58] 

Farmlands Community Home (1995)

53. In March 1995, a fifth enquiry was carried out, following a complaint that a resident at Farmlands Community Home, D46, was at risk. It concluded that “particularly difficult children some with problems of sexually abusive behaviour have tended to end up in Farmlands[59] and there were a number of complaints of sexual abuse between residents. The report identified a failure to move D46 and one of the children exhibiting harmful sexual behaviour, despite this being recommended by case conferences and the police. It concluded that the County failed to protect D46 by exposing him to both physical and sexual abuse. There was:

“no strategy dealing with the sexualized behaviour of adolescent boys. No consistent therapeutic approach and there are limitations to the service that is provided at the moment … The Child Protection Policy within residential care is both inadequate and unclear. Therefore it is recommended that a clear procedure be laid down and staff be made aware of these.”[60]

This was compounded by there being “no overall strategy across the County”.[61] 

54. The Service Standards Unit annual report for Farmlands that year commented:

“resident/resident abuse has occurred and the inspecting officers were very concerned about child protection issues in their widest sense. These concerns have been the subject of a confidential document sent to the Director of Social Services.”[62] 

We have not seen this document nor any documents setting out the children’s social care response to the report into D46. 

Wider consideration of these investigations

55. While each investigation covered different institutions and raised its own issues, they were all commissioned by the County’s children’s social care service about children in their care in their establishments. However, children’s social care do not appear to have considered these investigations together or their wider implications. There is no record of the Sandown Road report or the Farmlands report being considered by senior managers within children’s social care or by the Social Services Committee. Knowledge and learning were not shared across the County; each report was considered, if at all, in isolation, with no reference to the findings or recommendations in the preceding reports.

56. There was also no apparent attempt to disseminate those findings or recommendations to staff in children’s social care. For example, Margaret Stimpson (the County’s Children’s Service Manager in the early 1990s, responsible for a number of other residential homes) was unaware of the risk to children in care of harmful sexual behaviour and was never briefed about events at Amberdale, Greencroft, Hazelwood and Sandown Road or the reports.[63]

Other cases of harmful sexual behaviour in residential care 

57. Between 2001 and 2005, there was a series of disclosures of harmful sexual behaviour in children’s homes that were by that time the responsibility of the City: 

57.1. In 2001, NO‑A483, a resident at Beckhampton Road[64] disclosed to staff that he had been raped by his roommate, who was then arrested and remanded to secure accommodation.[65]

57.2. In 2002, L43 alleged that another resident at Beechwood had indecently assaulted him.[66] L43 told staff but felt like he was “talking to a brick wall”, and was discouraged from pursuing the matter with the police.[67] He told us that sexual activity between children at Beechwood happened “pretty much daily” and staff did nothing about it.[68] L43 was seen as a “management problem” for staff.[69]

57.3. The same year, the National Care Standards Commission (NCSC) concluded that Beechwood was “an environment where vulnerable young women, and men, were liable to be sexually exploited by each other”.[70] Michelle Foster (a staff member) told us that there was no guidance or training on harmful sexual behaviour.[71] Understaffing meant they could only manage and monitor sexual activity.[72] 

57.4. In late 2003, NO‑A479, a Beechwood resident, disclosed that she had twice been pressured into having sex with a male resident and thought she might be pregnant. The male resident should have been supervised closely by staff, having committed sexual offences against young children, but this had not been possible because of staff shortages. The NCSC were notified[73] and visited Beechwood.[74] The Assessment and Early Intervention Panel assessed the ongoing risk posed by the male resident as “very high” and supported a prosecution “should there be sufficient evidence”.[75]

57.5. In October 2003, NO‑A480, a resident of Beechdale Road, disclosed he had been forced to perform oral sex and masturbation by two other residents. There was a joint investigation.[76] One of the children allegedly exhibiting harmful sexual behaviour was removed, but the other remained in the home despite a recommendation to reconsider this by the Assessment and Early Intervention Panel. No charges were brought against the two residents[77] and the one who remained at Beechdale Road was subsequently involved in another “very similar incident” with a different victim, which also did not proceed to charge.[78] 

57.6. In 2004, strategy meetings were held amid concern about sexualised behaviour of 10 children in City children’s homes, including allegations of rape.[79] The meetings were “to try and establish whether the incidents constituted child-on-child sexual abuse, and if so who were the victims and who were the perpetrators”.[80] Two of the children had been charged with sexual offences against children, but there had previously been separate strategy meetings for the individual children, so only “assorted information” had come to light. It was concluded that intensive sex education was needed for all children, and that all of the City’s children’s homes needed to liaise with each other regarding the children’s activities. 

However, it does not appear that any steps were taken to address these cases at a senior management or political level.

58. Staff lacked sufficient guidance or training on harmful sexual behaviour.[81] Glynis Storer, the City’s Practice Manager for Young People who Sexually Harm in the 2000s, said she never trained residential staff on harmful sexual behaviour.[82]

Harmful sexual behaviour in foster care

59. Few studies have been conducted on harmful sexual behaviour in foster care.[83] Research shows a lack of information provided to foster carers about allegations of harmful sexual behaviour made against children placed with them, and the risks associated with their behaviour. This has impeded foster carers’ ability to identify or respond to harmful sexual behaviour.[84] 

60. We received evidence of four cases of alleged harmful sexual behaviour in foster care between 2002 and 2007: one in the City and three in the County. These involved multiple rapes, sexual assault and forced oral sex. There was a significant difference in age between the children allegedly exhibiting harmful sexual behaviour and the complainants in most of the allegations. We have seen no documentary evidence relating to the response to any earlier instances of harmful sexual behaviour in foster care, but the absence of records does not mean that earlier abuse did not occur. 

61. In each of the four cases, the police were notified. In three of them, steps were taken to reduce the risk of further abuse, either by ensuring no unsupervised contact[85]or by moving the child allegedly exhibiting harmful sexual behaviour.[86] 

62. However, in one case an alternative placement could not be found for a child allegedly exhibiting harmful sexual behaviour so he remained in the same placement as the complainants.[87] In another, the police did not pursue allegations of harmful sexual behaviour in one foster home until the same complainant made allegations relating to another child two years later. By this time the complainant did not want to pursue her original complaint.[88] In that case, the City also failed to properly assess the risks posed or support needed by the child allegedly exhibiting harmful sexual behaviour, despite procedures at the time requiring them to do so.[89]

Recent years and ongoing issues

63. Since 2010, a number of cases have raised issues about the way in which the Councils respond to allegations of harmful sexual behaviour. In the City, a serious case review in 2011 highlighted the need for clear governance in addressing incidents. The review also called into question the effectiveness of its Assessment and Early Intervention Panel. In the County, the variable responses to allegations showed a continuing lack of understanding amongst residential care staff of the complexities in individual cases, and the challenge in knowing what to do in practice, despite the guidance and procedures in place. 

64. The 2011 serious case review followed the suicide of a child in the care of the City[90] who had suffered sexual assaults by other residents and had displayed harmful sexual behaviour himself. It described children who sexually offend as “one of the most vulnerable groups of children”, who needed “robust processes” to assess their “levels of need, vulnerability, risks posed and appropriate interventions”.[91] It recommended that the process of assessment should be reviewed and strengthened: 

“to ensure that these children have a full assessment and intervention plan that supports their own vulnerability and safeguarding needs. This will include the development of clear governance and performance management arrangements”.[92]

In spite of these recommendations, in the 2013 annual review of the Assessment and Early Intervention Panel, it was noted that meetings of the group responsible for overseeing the work of the City’s AEIP had “not taken place for some time”.[93] 

65. In 2012, the County failed in its response after a four‑year‑old in foster care with the County, NO‑A605, was forced to perform oral sex on a 13‑year‑old child in care who was visiting the foster home.[94] The AIM assessment was delayed due to a lack of trained social workers. The chair of the series of strategy meetings said that the County’s response “could be seen as negligence”.[95] When an assessment finally did take place,[96] it identified that the 13‑year‑old had been involved in an earlier incident of harmful sexual behaviour with another child which was not investigated. It was agreed that children’s social care should complete a learning review into the case, but there is no evidence of what, if any, lessons were actually taken forward.[97]

66. There were also failings by the County in 2014, when a resident in a County children’s home, NO‑A588, was subjected to forced oral sex and masturbation by another resident.[98] This led to an internal investigation, carried out by an independent investigator under the County’s complaints procedure following a complaint made on behalf of NO‑A588,[99] which found that “staff at the care home failed in their duty of care”.[100] There had been no assessment prior to placement of whether the victim would be safe at the home, and staff had not been informed about the known risks posed by the child exhibiting harmful sexual behaviour. Following the abuse, risk assessments were carried out, the complainant was moved to ensure his safety and the child exhibiting harmful sexual behaviour was closely supervised before moving to a therapeutic placement.[101] However, the investigation found that it was unclear “how well the incident … was investigated and how seriously it was taken in respect of lessons that could be learned from what happened”.[102] Although it was recommended that the County acknowledge their failings and consider an apology and appropriate redress to NO‑A588, it was not until 18 months later that the County made an “unreserved apology” for the failings which resulted in him being abused.[103]

67. In November 2016 and May 2017, allegations of harmful sexual behaviour were made at a children’s home run by a private company, Homes2Inspire.[104] Homes2Inspire had its own safeguarding policy specific to harmful sexual behaviour.[105] This required any concerning behaviour to be referred to social workers and other relevant agencies.[106] Staff were only to conduct an internal investigation if the local authority gave permission and the allegation either did not meet the threshold for police involvement or the police had concluded their enquiries.[107] In practice, whilst the Deputy Manager at the home was clear that staff would not question children, he was confused as to the distinction between an investigation and how this differed from initial fact finding.[108] 

68. NO‑A136 alleged, in October 2016, that she had been sexually abused in her previous foster placement by the foster carers’ son.[109] At the time, she was 11 years old and the alleged perpetrator 21. Nonetheless, the Deputy Manager noted that NO‑A136 “hasn’t stated if this was consented or not[110] despite the fact that consent would have been irrelevant.[111] 

69. Allegations of sexual abuse made against NO‑A136 by a male resident in November 2016[112] and by NO‑A136 against another male resident in May 2017 were handled appropriately. In the former case, the police decided it was not in the public interest to proceed;[113] in the latter, they concluded NO‑A136’s complaint was “a hoax”. In any event, proactive steps were taken to protect the children and a detailed safety plan was put in place. This included increased supervision, extra staff, sex education, a sexualised behaviour tracking log, preventing children from going into each other’s rooms and trying to ensure a family atmosphere in the home.[114] Staff also received specific training on harmful sexual behaviour and sexualised behaviours as a result of the second incident.[115]


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