1. Children detained in a custodial or secure setting are often the most vulnerable children in our society. Some are detained for their own welfare (unconnected to criminal activity) and others because they are on remand or have been found guilty of crimes and sentenced by a court. Serious criminal activity may, understandably, not always attract public sympathy but behaviours giving rise to these kinds of state intervention tend to reflect unhappy and disruptive childhoods, caused by others, and over which these children have had little control.

2. Children are particularly vulnerable when placed in a closed institution where access to the outside world is necessarily restricted and those in authority are distrusted by the children themselves. It is all the more difficult to escape an abuser when there is nowhere to hide.

3. The problem of child sexual abuse is by no means uncommon across the secure estate, which encompasses young offender institutions (YOIs), secure training centres (STCs) and secure children’s homes (SCHs). The Inquiry’s analysis reveals 1,070 alleged incidents of child sexual abuse from 1 January 2009 to 31 December 2017. There were more alleged incidents per year in 2016 and 2017 (203 and 205 incidents respectively) than in any other reporting year. The majority of allegations related to members of staff. It was troubling that the institutions had less reliable data than the Inquiry.

4. The barriers to reporting an incident of sexual abuse for a child are strikingly similar across all institutions on which the Inquiry has reported. The prevalence of violence, the power imbalance between staff and children, a prevailing culture of disbelief when a child complains and the child’s distrust of authority figures all feature significantly. These elements are exacerbated in custodial and secure settings by the absence of normal friendships and intimacy, and the risk factors arising in a confined environment connected to drug use, gang cultures and violence committed by children.

5. In order to report sexual abuse to someone who can take the appropriate action, a child must feel safe. There has been a shocking decline in safety in the secure estate in recent years. This has been caused by management instability and staffing losses. There is some evidence that these have been linked to budget cuts. Inspectorate reports by HM Inspectorate of Prisons have been critical of YOIs and STCs and improvements have been slow to materialise. There is little doubt that YOIs and STCs were in crisis by the end of the Inquiry’s investigation period.

6. The Youth Custody Service is taking action to professionalise the workforce in YOIs and STCs and there are clear signs of progress. There are no requirements, however, for minimum qualifications or levels of experience before staff are recruited. In contrast, SCH staff are normally required to have qualifications specified by the Children’s Home Regulations 2015. Similarly staff supervision is not subjected to minimum requirements in YOIs and STCs and again compares unfavourably with SCHs.

7. Staff turnover for operational officers in YOIs and STCs was high, at 11.2 percent in 2017/18, compromising the ability of the workforce to meet the challenges of the environment and having a negative effect on the children’s feelings of safety and ability to form positive relationships with staff members. A culture of respect for whistleblowers has not yet been embedded across all the institutions. The Youth Custody Service is working to tackle these issues.

8. Understanding the child’s history is an important factor in ensuring the child feels safe and is properly protected. The Comprehensive Health Assessment Tool (CHAT) and the Youth Custody Service’s ASSETPlus systems are designed to identify children most at risk of sexual abuse in custody. CHAT assessments, however, are not always completed in YOIs and STCs. These issues are compounded by missing health records, depriving the institution of a full health history of the child. New IT systems are intended to correct these problems but it is difficult to underestimate the importance of ensuring that the right information is available at the right time to support decision‐making about the best interests of the child.

9. Knowing the history of the child and their particular vulnerabilities is important when force is applied in a custodial setting. Custodial institutions are authorised, in certain circumstances, to apply physical restraint or strip search children. Force may be authorised to impose ‘good order and discipline’. Force and strip searches, however, should only be used when absolutely necessary. Greater awareness is needed of children who have been sexually abused so that staff understand the impacts of these techniques and manage the consequences effectively. The problem is compounded when there are failures to document these events properly, making it difficult for custodial institutions to account for their use.

10. In addition to the application of restraint and strip searching, pain compliance techniques are currently permitted in YOIs and STCs (but not in SCHs). The use of these techniques, however challenging the behaviour of the child, normalises pain for staff and children. This, in turn, prevents staff from building trusting relationships and inhibits a child from reporting sexual abuse. The use of pain compliance, although authorised as a last resort, has attracted criticism from a number of informed commentators. Pain compliance contributes to a culture of fear and has the effect of silencing the child at a time when it is important that the child feels safe to speak out about aspects of their lives, including sexual abuse.

11. Environmental factors play an important part in developing a safe place for a child. Evidence about room‐sharing, CCTV cameras and body‐worn cameras for staff painted a mixed picture about the potential benefits of these initiatives and illustrated the difficulties of balancing the child’s right to privacy and potential risk of harm in unmonitored situations. A greater understanding is required of the advantages and disadvantages of these issues, particularly in relation to body‐worn cameras. The use of CCTV cameras is well‐established, particularly in areas of common access. When properly located to achieve the maximum coverage of these areas, they are regarded by some as helpful.

12. Evidence that children who had engaged in sexually harmful behaviour were placed alongside children who were in SCHs for welfare reasons gave rise to concern.

13. In YOIs and STCs, investigations into child sexual abuse were undertaken without the involvement of a social worker within the institution. The allegation was rarely referred to the police or the local authority. The lack of involvement of independent institutions gives rise to concerns about the rigour of the investigation and the expertise of the investigator, who may not have had relevant training or experience in dealing with these types of cases. When considered alongside the Inquiry’s prevalence analysis, the institutions would find it difficult to provide an adequate account of their performance in responding to sexual abuse. The absence of data about allegations and limited auditing obscures the true picture.

14. There are a number of ways children can report sexual abuse: in writing, externally to friends or family (suitably modified mobile phones have been provided), and to members of staff (where positive relationships have been developed). Not enough social workers are involved with children in YOIs and STCs to provide an alternative trusted adult to whom children could disclose sexual abuse. It is notable, however, that the Department for Education 2015 guide, which applies to SCHs, states that children should be loved, valued and nurtured, and “staff should strive to build positive relationships with children in the home and develop a culture of openness and trust that encourages them to be able to tell someone if they have any concerns or worries about their safety”. ^[1] The regulations, policy and contracts governing YOIs and STCs contain less about building positive relationships, trust and confidence, although the Youth Custody Service is seeking to address these issues.

15. Throughout this investigation, the differences between the YOIs and STCs, and SCHs became increasingly obvious. SCHs were more focussed on the interests of the child and adopted a less punitive approach. Staff training was subject to regulation and use of pain compliance was prohibited. The cultural barriers to disclosure were less apparent in SCHs. Such an environment creates a better climate in which a child potentially will feel safer and more able to disclose sexual abuse. In SCHs the staff/child ratio is higher than the ratio in YOIs and STCs, with more opportunities to build positive relationships with children.

16. The underlying reasons for the differences in regimes almost certainly lie with the departments of state involved. The Department for Education has responsibility for setting the overall policy and legislative framework and ultimate oversight for SCHs; the Ministry of Justice has ultimate oversight for STCs and YOIs. These departments have very distinct roles in serving the public interest, the former focussing on education and social care and the latter on the justice system.

17. Inevitably the cost of keeping a child in a SCH is much higher than other custodial institutions, principally because of the higher staffing ratios. Cost alone, however, cannot be the main factor determining where a child is placed, particularly when the child custody population has considerably reduced over the years.

18. The Youth Custody Service proposes to develop secure schools as an alternative model for child custody. The development of this initiative is welcome but it is important to ensure that secure schools are not an exercise in relabelling. A genuine child‐centred focus must be introduced with comprehensive education standards and effective safeguards. Greater local authority involvement for these ‘looked after’ children is essential. The new system should be brought in with speed and efficiency.

19. Finally, the number of children who were remanded in custody prior to trial, and were therefore unconvicted, comprised around one‐third of the child custody population. This number of children exposed to the risks associated with custody seemed very high.