A national review into safeguarding children with disabilities and complex health needs has revealed serious failures at 3 residential special schools registered as children’s homes. The independent review looks at the experiences of 108 children and young adults living at Fullerton House, Wilsic Hall and Wheatley House, located in Doncaster and operated by the Hesley Group.

The report shows a culture of abuse and harm, including evidence of physical abuse and violence, neglect, emotional abuse and sexual harm. There was also evidence that medication was misused and maladministered, an over-use of restraints, and unsafe and inappropriate use of temporary confinement. The children affected were placed at these homes from 55 local authorities across the country and there is a complex abuse investigation underway by the Doncaster Safeguarding Partnership, which includes a concurrent criminal investigation by South Yorkshire Police.

Given the severity of the allegations and evidence uncovered, the Child Safeguarding Practice Review Panel has issued an urgent action to all local authorities to ensure all children with complex needs and disabilities currently living in similar children’s homes are safe and well.

Panel Chair, Annie Hudson said:

This national review seeks to make sense of how and why a significant number of children with disabilities and complex needs came to suffer very serious abuse and neglect whilst living in 3 privately provided residential settings.

Our evidence shows that the system of checks and balances which should have detected that things were going wrong simply did not work.

While there are many skilled professionals who work with children with disabilities, we are concerned that these are not isolated incidents. That’s why we have asked all local authorities and Ofsted to take urgent action to ensure all children living in similar circumstances are safe and well.

Lead Panel Member for the review, Dr Susan Tranter, said:

Children with disabilities and complex health needs are some of the most vulnerable in our society but they are too often overlooked and forgotten.

Following allegations that a significant number of children who were living far away from home, often with limited communication skills, were trapped in settings where systemic and sustained abuse was inflicted with no respite, we spoke to those responsible for placing the children in these settings and for checking on their welfare to understand exactly what went wrong.

It is clear to us that the standards of practice in care are failing to meet the needs of children with complex needs. The second phase of this national review will explore the systemic issues in children’s social care, health and education that must be addressed to ensure we learn from these horrific incidents and to prevent this from happening again.

Dame Christine Lenehan, Strategic Director of the National Children’s Bureau and Council for Disabled Children, said:

This review demonstrates that the residential settings responsible for taking care of these children did not have a clear vision to safeguard them from abuse. The lack of accountability across the residential care system means there is too little ownership for the safety of children with complex needs and, as a consequence, many have suffered, or are at risk of suffering, harm and abuse. We urgently need a shift in thinking, so that these children’s rights to live safely in supportive and nurturing homes is guaranteed.

While the complex abuse investigation will hold to account those directly involved in the harm of these children, the national review found that the safety net that should have identified and responded to this abuse failed to act on concerns.

The phase one report sets out that Ofsted had received a number of complaints dating back to at least 2015, expressing concerns over staffing levels, staff conduct and possible abuse of the children. These complaints had promoted additional monitoring visits and an emergency inspection, but the review has found these were insufficient as both settings had been judged ‘good’ by Ofsted at the most recent inspection visit. In light of the most recent allegations, Ofsted conducted emergency inspections of the settings in March 2021 and notices of suspension of the service were served.

Additionally, local authorities and partner agencies placing children at these homes put great reliance on the reports provided by the settings despite professionals in different roles having separate information indicating concerns. The processes in place for bringing together information from a range of sources to analyse the pattern of safeguarding concerns was not effective.

To address these, the panel has requested local authorities and Ofsted to undertake urgent action:

• local authorities should review complaints and concerns relating to the workforce in each individual residential special school registered as a children’s home over the last three years, and ensure these have been appropriately actioned
• OFSTED should conduct an immediate analysis of their evidence around workforce sufficiency focusing on suitability, training and support

The panel has been assured that the urgent actions will be completed by the end of November 2022. A second phase of this review will be published in early 2023, setting out the progress against the urgent actions and providing recommendations to government to improve safeguarding in the residential special school and care system.

The independent national Child Safeguarding Practice Review Panel is an independent body that was set up in July 2018 to identify, commission and oversee reviews of serious child safeguarding cases. It brings together experts from social care, policing, health, education and the third sector to provide a multi-agency view on cases which they believe raise issues that are complex, or of national importance.

On 5 March 2021, the Doncaster Safeguarding Partnership agreed to initiate a complex abuse investigation (Operation Lemur Alpha) into the 3 specialist residential settings run by the Hesley Group. This was in response to information gathered following a whistleblowing referral reporting 12 allegations of abuse and concerns for children in Fullerton House, which was received by the Doncaster Children Services Trust on 26 February 2021. Further information about the criminal investigation should be referred to South Yorkshire Police, and about the wider complex abuse investigation should be referred to Doncaster Council – contact details available on request.

These matters were formally reported by the Doncaster Safeguarding Partnership to the Child Safeguarding Practice Review Panel in September 2021. The review was formally launched in January 2022. The terms of reference for the Child Safeguarding Practice Review Panel: review into safeguarding children with disabilities and complex health needs in residential settings is available on GOV.UK. The panel has worked in close co-operation with Doncaster Safeguarding Partners to deliver this phase one review report.

Any families who have concerns about a child can find more information on the Council for Disabled Children’s website.

The cases were brought by the Environment Agency to Northampton Magistrates Court on Monday 24 October.

Kevin Mallard from Rowley Regis was found guilty of fishing without a licence on 25 May 2022 at Lodge Farm Reservoir at Netherton, near Dudley.

In a separate case Aaron Butler from Smethwick was found guilty of leaving his fishing rod unattended with bait or hook in the water at Highley on the River Severn in Shropshire on 28 June 2022.

Kevin Mallard, 35, was proved guilty in absence and ordered to pay a total penalty of £619. The penalty includes a fine of £440, costs of £135, and a victim surcharge of £44.

Aaron Butler, 35, was also proved guilty in absence and ordered to pay a total penalty of £443. The penalty includes a fine of £220, costs of £135, and a victim surcharge of £88.

Nichola Tomlinson, Fisheries Enforcement Team Leader at the Environment Agency, said:

We’re pleased to see how seriously the courts take these offences. Kevin Mallard and Aaron Butler have both been rightly punished for fishing illegally on separate occasions. While Aaron Butler had a licence to fish, leaving his fishing rod in the water unattended meant he was unable to exercise sufficient control over it.

Illegal fishing undermines the Environment Agency’s efforts to protect fish stocks and make fishing sustainable.  Money raised from fishing licence sales is used to protect and improve fish stocks and fisheries for the benefit of anglers and, for those caught cheating the system, we will always prosecute.

We hope these penalties will act as a deterrent to anyone who is thinking of breaking the laws and byelaws we have in place across England.

Any angler aged 13 or over, fishing on a river, canal or still water needs a licence to fish. A 1-day licence costs from just £6, and an annual licence currently costs from just £30 (concessions available). Junior licences are free for 13 – 16-year-olds. Licences are available from www.gov.uk/get-a-fishing-licence or by calling the Environment Agency on 0344 800 5386 between 8am and 6pm, Monday to Friday.

The Environment Agency carries out enforcement work all year round and is supported by partners including the police and the Angling Trust. Fisheries enforcement work is intelligence-led, targeting known hot-spots and where illegal fishing is reported.

Anyone with information about illegal fishing activities can contact the Environment Agency incident hotline 24/7 on 0800 807060 or anonymously to Crimestoppers on 0800 555 111.

Background

Kevin Mallard was charged with the following offence:

At 2:12pm on 25 May 2022 at Netherton Reservoir (known as Lodge Farm Reservoir, Netherton) in a place where fishing is regulated, fished for freshwater fish or eels by means of unlicensed fishing instrument, namely rod and line. Contrary to Section 27(1)(a) of the Salmon and Freshwater Fisheries Act 1975.

Aaron Butler was charged with the following offence:

On 28 June 2022 at Highley on the River Severn, left a rod and line with its bait or hook in the water unattended or so that the person shall be unable at any time to take or exercise sufficient control over said rod and line. Contrary to Byelaw 10 of the Environment Agency National Byelaws which came in to force on 27 May 2001 made pursuant to Section 210 and Schedule 25 of the Water Resources Act 1991 and Contrary to Section 211 of the said Act.

Victims of crimes like domestic abuse and sexual assault will be better protected following arrests of perpetrators under new provisions collectively known as ‘Kay’s Law’, Safeguarding Minister Mims Davis announced today (25 October).

The reforms, which will come into force this week, will mean police have a duty to take into account the views of victims before releasing someone on bail. Police will be encouraged to use pre-charge bail instead of releasing suspects under investigation, where it is necessary and proportionate.

Kay’s Law, named after a victim of domestic violence, is one of many measures the government has taken to support victims, bring perpetrators to justice and protect women and girls across the country. This includes the ‘ENOUGH’ campaign to tackle violence against women and girls, the second phase of which has launched today (25 October).

The campaign aims to provide bystanders with a range of safe ways to intervene if they witness an incident of violence against women and girls, ranging from sexual harassment on the street, public transport or at work, to unwanted touching, sharing intimate images of someone without their consent and coercive control in a relationship.

The Minister for Safeguarding, Mims Davies said:

There is no place in our society for cowardly acts of violence against women and girls.

Abuse comes in many forms, and by standing against all of them, and holding perpetrators accountable, we can create a society where women and girls are safe.​

This campaign, as well as our crucial reforms to pre-charge bail under Kay’s Law, is part of this vision. However, there is more to be done, and I am committed to continuing this vital work.

‘Kay’s Law’ is named after Kay Richardson, who was tragically murdered by her estranged husband after he was released under investigation, following his arrest for sexual offences against Kay. In 2019, the government launched a review of pre-charge bail legislation which led to the reforms being implemented this week, including the new duty which aims to provide better protection for victims like Kay. The measures were introduced as part of the Police, Crime, Sentencing and Courts Act.

Following the publication of the government’s Tackling Violence Against Women and Girls Strategy in 2021, the government launched the ‘ENOUGH’ campaign in March 2022.

The second phase of the campaign includes television adverts, billboards, social media and radio advertising which highlight different forms of violence against women and girls and the simple acts that anyone can take to challenge perpetrators of abuse.

Deputy Chief Constable Maggie Blyth, National Police Chiefs’ Council Violence Against Women and Girls Coordinator said:

Policing has a key role of going after the violent people who commit these awful crimes but we cannot arrest our way out of the societal issues that lead to this behaviour. If we are serious about long-term change then we need to prevent harm and violence to women and girls by changing attitudes and behaviour across society.

Deniz Uğur, Deputy Director of the End Violence Against Women Coalition (EVAW), said:

We welcome this next phase of the government’s Enough campaign to tackle male violence against women and girls, something the End Violence Against Women Coalition has campaigned for for years. We know that without shifting the attitudes behind male violence against women, this violence won’t end.

We’re pleased to see the Enough campaign focus on what everyone in society can do to end violence against women, because too often, campaigns are targeted at women and wrongly place the responsibility on us to ‘keep ourselves safe’. But ending violence against women is everyone’s business. We want to see men and boys actively engaged in this conversation, because we should all be able to take action and hold each other accountable.

Preventing violence is always better than waiting until harm has been done to act. Achieving this requires a genuine commitment, because this work takes time and needs dedicated and long-term resourcing.

Farah Nazeer, Chief Executive of Women’s Aid said:

We were pleased to help support the development of the Home Office’s Enough campaign, to raise awareness of violence against women and girls and encourage people to stop everyday abuse and harassment. Everyone has a role to play in ending violence against women – whether it takes place in the home or in public – and we must all step up and play our part. By changing public attitudes and challenging everyday misogyny and sexism, we can all help to make society a safer place for women and girls.

Graham Goulden, international leadership and bystander trainer and retired Scottish police officer said:

The Enough campaign provides focus on a very important group of people who can make a difference. Bystanders are often present in the build up to incidents, at the time of an incident or afterwards.

When one person speaks up they signal that a behaviour is wrong. They also make it ok for others to intervene as well. Therefore it’s important we communicate this message as well as giving friends, colleagues, neighbours and other bystanders the tools to act.

One person can make a difference. The Enough campaign will make a difference.

Through the campaign, the department is working with organisations involved in the night time economy and fitness industry, like gyms, as these are places where violence against women and girls can often occur.

The violence against women and girls Enough campaign has information and examples of how to intervene safely if you witness violence against women and girls. It also provides information on support services, how to report violence to the police and offers guidance for individuals worried about their own behaviour.

Over the coming weeks, the website will include a dedicated page for teachers with educational materials for use in schools on violence against women and girls.

The campaign has been developed with an advisory group of over 40 voluntary sector organisations, survivors and academics who have given their expert insight.