An official inquiry has lifted the lid on comprehensive failings of governance and oversight at RNIB, which placed some of its beneficiaries at undue risk of harm and allowed harm or distress to come to some children with complex needs.

In a report, published today, the Charity Commission sets out systemic weaknesses at RNIB that allowed serious safeguarding breaches to take place, and which meant these were not picked up or addressed by senior levels of the charity at an early enough stage. It is highly critical of the charity’s leadership at the time for allowing these and other failures to take root, and considers there was a breach in RNIB’s duty to take all reasonable steps to protect the charity’s beneficiaries from coming to harm.

Concerns resulted in the regulator sanctioning RNIB with an Official Warning and issuing it with a legal Order that holds the trustees to account against an Action Plan requiring wholesale change to its governance, management, culture and processes. The charity remains under ongoing statutory supervision until it has implemented all of the required reforms.

Serious safeguarding weaknesses put children at undue risk

The regulator launched its investigation in March 2018, prompted by serious concerns about the services provided at the RNIB’s Pears Centre children’s home in Coventry and Ofsted’s notice of intention to cancel the registration of the facility.

The inquiry and independent reviews which supported the inquiry, corroborated these concerns. The reviews found a catalogue of failings at the charity including:

• a culture that was too insular and dismissive of external criticism from Ofsted, CQC and parents
• a disproportionately high number of basic medication errors at RNIB Pears Centre
• inadequate staff training, an issue compounded by an over reliance on agency staff
• poor recruitment practices which did not adequately protect beneficiaries
• inadequate oversight and interim management arrangements of staff and services allowed a working practice to develop that was not child centred

Today’s report also details several incidents where harm or distress occurred to some children at the RNIB Pears Centre.

The inquiry considered that the seriousness of these shortcomings, particularly at RNIB Pears Centre, was exacerbated by many of the beneficiaries having learning and communication difficulties, and therefore they and their families being heavily reliant on RNIB. Children at the RNIB Pears Centre had needs and disabilities so complex that in some cases, a placement at the centre was an alternative to a hospital stay. However, the charity’s safeguarding processes and oversight did not reflect the high level of care and attention that was required.

The inquiry concluded that families affected by these failings were badly let down by RNIB.

Ineffective and dysfunctional governance

The inquiry found evidence of ineffective and dysfunctional governance at the charity. At one stage trustee committees that were meant to oversee the regulated establishments did not meet for a period of 10 months, something the inquiry finds to have been “wholly inadequate”, and an independent review criticised a committee for providing “superficial scrutiny”.

The same independent review found that “no single person had direct qualifying experience” in the chain of senior managers, various committees, senior executives and the trustee board which oversaw the regulated establishments catering for children and/or adults with complex needs.

The inquiry was told that between 2016 and 2017 trust had broken down between some of the trustees and executives. It also heard that there was “a dysfunction in leadership and governance over many years”. The inquiry is critical of the charity’s board for failing to ensure its governance arrangements appropriately matched the complexity and scale, and associated risks, of its activities and structure.

The inquiry concludes that these failings contributed to beneficiaries across RNIB’s specialist care and educational centres being placed at undue risk of harm – and some suffering actual harm or distress. It considered that some of the failings identified by the inquiry and the associated reviews amount to misconduct and that collectively, they amount to serious mismanagement in the administration of the charity.

Helen Stephenson CBE, Chief Executive of the Charity Commission, said:

This is one of the worst examples we have uncovered of poor governance and oversight having a direct impact on vulnerable people. A catalogue of serious failings were allowed to occur, because the charity’s governance was simply too weak for the trustees in charge of the charity to do the job that beneficiaries needed them to do.

No child should ever be put at risk of harm, and this case is all the more troubling because it happened in the care of a charity.

Providing services to children with complex needs is a significant responsibility, and when charities provide such services, the public expect rightly these to be delivered with compassion, selflessness and empathy, as well as competence.

Charity trustees should therefore ensure that systems of governance and management help, rather than hinder their charity from delivering on its purpose and meeting the needs of those it is set up to help.

I am concerned that what happened here lets down all those doing good work in so many charities to care for people to high standards.

After issuing its Official Warning and Order, the Commission approved an Action Plan submitted by RNIB involving a 2-year reconstruction programme. The regulator also exercised other powers to support refinancing of debt the charity had incurred and the appointment of new trustees.

During the inquiry RNIB reassessed its provision of regulated services. It is now part-way through the transfer of all its regulated older people’s care homes, and its schools and colleges, to new specialist providers.

The charity is also making good progress against the Action Plan. The charity remains under the Commission’s statutory supervision. The regulator will closely monitor its progress to ensure the required changes are made.

Helen Stephenson added:

RNIB has long been an important national institution, and, for many people with sight loss, it provides a lifeline that they should be able to trust. I am encouraged by the charity’s commitment to address its shortcomings and hope that it will get back to that position of trust. We are determined to ensure that it does.

Alert to large service delivery charities

The failings at RNIB had a significant impact on the charity, including financially, and the regulator is clear that the mistakes made at this charity must never be repeated. It is the third in a series of recent high-profile failures by household name charities; the Commission is concerned about damage to the public’s trust in the charity sector should another large charity fail in its key responsibilities in running a charity.

As a result, the regulator is today issuing a regulatory alert to leaders of large, complex charities that directly support beneficiaries or provide amenities or facilities to the public. The alert will remind charities of the importance of suitable oversight that takes into account the complexity, scale and nature of their activities, in order to help avoid potential harm to their beneficiaries, finances or reputation. This matters all the more in a period when charities are playing a crucial role in the Coronavirus response, and with many charities under severe financial strain.

The full inquiry report is available on GOV.UK.

Ends.

Notes to editors

1. The Charity Commission’s full report is available on GOV.UK and includes a foreword from the Commission’s Chair, Baroness Tina Stowell.
2. If service users, and their families, of RNIB have any concerns they should contact the RNIB Helpline on 0303 123 9999.
3. In March 2018 RNIB, through its group structure and the subsidiary charity, operated a total of 18 regulated services in England and Scotland. These services included 2 schools, 1 sponsored academy, 1 college, 1 children’s home, 5 care homes, 2 supported housing services, 3 supported living services, 2 day support and assessment centres, and 1 holiday scheme. These services were collectively regulated by the Care Quality Commission (CQC), the Office for Standards in Education, Children’s Services and Skills (Ofsted) and the Care Inspectorate.
4. The RNIB Pears Centre site was transferred to Warwickshire County Council in December 2019.
5. RNIB is one of the UK’s leading sight loss charities. Its charitable objects, as set out in its Royal Charter, are “to promote the better education, training, employment and welfare of blind and partially sighted people and generally to watch over and protect the interests of blind and partially sighted people and to prevent blindness.”
6. The regulation of activities relating to the provision of education and care standards in the school and children’s home is undertaken by Ofsted and the Care Quality Commission in this particular case. The Commission, as charity regulator, has an important regulatory role in ensuring that trustees comply with their legal duties and responsibilities in managing their charity. In the context of safeguarding issues, it has a specific regulatory role which is focused on the conduct of trustees and the steps they take to protect beneficiaries and other persons who come into contact with the charity.
7. The Charity Commission is the independent, non-ministerial government department that registers and regulates charities in England and Wales. Its purpose is to ensure charity can thrive and inspire trust so that people can improve lives and strengthen society.

Sweeping reforms will see more victims of domestic abuse given access to separate building entrances and waiting rooms as well as protective screens to shield them from their alleged abuser in court. 

Ministers will also make it easier for judges to issue barring orders which prevent abusive ex-partners from repeatedly dragging their victims back to court – which can be used as a form of continuing domestic abuse. 

The move comes after an expert-led review into how the family courts handle domestic abuse and other serious offences raised concerns that victims and children were being put at unnecessary risk.

Justice Minister Alex Chalk said:

Every day the family courts see some of the most vulnerable in society and we have a duty to ensure they are protected and not put in danger.

This report lays bare many hard truths about long-standing failings, but we are determined to drive the fundamental change necessary to keep victims and their children safe.

But this is not all we’re doing. Our landmark Domestic Abuse Bill will transform society’s response to this destructive crime – protecting victims and pursuing perpetrators more than ever before.

The expert panel was made up of representatives from charities, the judiciary, family law practitioners and academia, and took the views of more than 1,200 individuals and organisations.

It found that an adversarial process in the family courts often worsened conflict between parents, which could retraumatise victims and their children.

Fundamental reform of how the courts hear cases, through a new investigative approach, will be trialled as part of the Integrated Domestic Abuse Courts pilot – these consider family and criminal matters in parallel in order to provide more consistent support for victims. Emphasis will be placed on getting to the root of an issue and ensuring all parties are safe and able to provide evidence on an equal footing – without the retraumatising effects of being in court with an abusive ex-partner.

Additionally, Ministers will launch a review into the presumption of ‘parental involvement’ that often encourages a child’s relationship with both parents, unless the involvement of that parent would put the child at risk. It will examine whether the right balance is being struck between the risk of harm to children and victims, and the right of the child to have a relationship with both parents. The government welcomes this key recommendation which requires careful consideration to implement correctly – further details about the review will be announced in due course.

Nicki Norman, Acting CEO at Women’s Aid, said 

This report marks a major step forward in exposing what women and children experiencing domestic abuse have been telling us for decades.

The culture of disbelief identified by the panel is a barrier to courts making safe child contact arrangements in cases of domestic abuse. The result is that, all too often, survivors and their children experience the family courts as failing to effectively protect them.  

This welcome report must now deliver change. Guaranteeing special measures in the family courts is a critical protection which survivors have long called for. As a member of the expert panel, I look forward to seeing the government and family judiciary adopt all of the recommendations to change the culture of the family courts and deliver a safe and just contact system for survivors and their children.

The measures form part on an Implementation Plan published by Ministers today which sets out immediate and longer-term steps to better protect victims in the family courts.  These include:

• Trialling an investigative, problem-solving approach in private family law proceedings as part of an upcoming pilot of Integrated Domestic Abuse Courts. This could see judges decide what evidence to investigate, rather than both parties presenting their cases against each other.
• Giving automatic entitlement for special measures in the courtroom for victims of domestic abuse going through the family courts – such as separate waiting rooms, entrances and screens – via a further amendment to the Domestic Abuse Bill.

• Reviewing the presumption of ‘parental involvement’ and whether the right balance is struck between the risk of harm to children and victims, with the right of the child to have a relationship with both parents.

• A commitment to change the provision on ‘barring orders’, which prevent abusers repeatedly dragging ex-partners back to court over child arrangements. Ministers will review whether this is best done through legislative or non-legislative means.
• Inviting the Domestic Abuse Commissioner and Victims’ Commissioner to monitor and report on private family law proceedings involving victims of domestic abuse.

Sara Kirkpatrick, CEO Welsh Women’s Aid

Welsh Women’s Aid welcomes the publication of Ministry of Justice panel’s report on assessing risk of harm to children and parents in private law children cases.

Critically the report’s recognition of alignment with the Welsh devolved context is vital to ensuring the whole system delivers maximum protection, safety and support for all survivors of abuse.

Domestic Abuse Commissioner Nicole Jacobs said:

Problems in the family court are the single most common concern raised with me as the Domestic Abuse Commissioner, and I am glad to see this report published in time to implement its recommendations through the Domestic Abuse Bill.

I welcome the work of the panel, and the breadth of evidence and expertise that has gone into this report, and in particular thank those victims and survivors who shared their experiences as part of this process.

 Dame Vera Baird QC, Victims’ Commissioner for England and Wales said:

This panel of experts has dug deep to understand, and address, the serious harm to domestic abuse victims and their children caused over many years by the presumption of contact, and the intensely adversarial process present in the family courts.

With children’s voices rarely heard in these proceeding and even more rarely heeded, victims and children are in need of better protections from abusive perpetrators.

 I welcome the report, its recommendations, and the implementation plan which will help to address these, and other concerns. It has my full support. And I call on the government to action this as a matter of urgency.

The changes build on the landmark Domestic Abuse Bill, currently before Parliament, which transforms our response to dealing with perpetrators and protecting victims. Key measures in the Bill include:

• creating a statutory definition of domestic abuse, emphasising that domestic abuse is not just physical violence, but can also be emotional, coercive or controlling, and economic abuse
• establishing a Domestic Abuse Commissioner, to drive the response to domestic abuse.
• introduce new Domestic Abuse Protection Notices and Domestic Abuse Protection Orders to further protect victims and place restrictions on the actions of offenders
• place a duty on local authorities in England to provide support to victims of domestic abuse and their children in refuges and other safe accommodation
• prohibit perpetrators of abuse from cross-examining their victims in person in the family courts in England and Wales
• enable domestic abuse offenders to be subject to polygraph testing as a condition of their licence following their release from custody
• place the guidance supporting the Domestic Violence Disclosure Scheme (‘Clare’s law’) on a statutory footing

The Bill is backed by £35 million to support victims and their children – with an additional £76 million extra funding announced in May to support vulnerable victims during the Coronavirus pandemic, including victims of domestic abuse and sexual violence.

Notes to editors

• The Report ‘Assessing the Risk of Harm to Children and Parents in Private Law Children’s Cases’ was published today after a review by a panel of independent experts. The panel have made a series of recommendations for the government and the wider family justice system.
• Alongside this, the Ministry of Justice has published an Implementation Plan outlining our response to those recommendations.
• Further details on the key changes:
  • Introducing a government amendment to the Domestic Abuse Bill so that victims of domestic abuse will be automatically eligible for special measures in the family court. The Domestic Abuse Bill provides this in criminal proceedings however the new amendment will be extended to the family and civil courts.
    • Special measures are a range of provisions that the court can provide to support parties in providing evidence. These can be things such as screens in court so that a party cannot see another party when giving evidence, the option to provide evidence through video link, and separate entrances and waiting rooms in the court building.
  • Reviewing the law on barring orders to ensure that parents and children are protected where further proceedings would risk causing them harm, particularly where proceedings could be a form of continuing domestic abuse. The Government will immediately explore whether this aim can best be achieved via an amendment to the Domestic Abuse Bill, through other primary legislation, or through non-legislative means.
  • Review of the provision of Domestic Abuse Perpetrator Programmes
  • Commitment to further research on the long-term effects of domestic abuse on children
  • In recognition of the need for better understanding of domestic abuse, a commitment to improve existing training packages for all professionals across the family justice system, and to introduce new training where appropriate.
• The panel was chaired by MOJ but comprised of independent experts from the family justice system. Those who made up the panel are:
  • Melissa Case & Nicola Hewer, Joint Directors of Family and Criminal Justice Policy, MOJ (Chair)
  • Professor Rosemary Hunter FAcSS, University of Kent
  • Professor Mandy Burton, University of Leicester
  • Professor Liz Trinder, University of Exeter
  • Neil Blacklock, Development Director, Respect
  • Eleri Butler, former Chief Executive at Welsh Women’s Aid
  • Lorraine Cavanagh QC & Dierdre Fottrell QC (joint representatives), Association of Lawyers for Children
  • Mr Justice Stephen Cobb, Judiciary
  • Nicki Norman, Acting Co-Chief Executive, Women’s Aid
  • District Judge Katherine Suh, Judiciary
  • Isabelle Trowler, Chief Social Worker for England (Children & Families)

Defence Secretary Ben Wallace thanked the nation’s Reserves for their commitment. He said:

Today is Reserves Day and I personally thank the 35000 reservists supporting our Armed Forces, balancing civilian life with a military career.

Some 2000 stepped up to support the fight against coronavirus recently, displaying commitment, discipline and selfless dedication. An admirable feat and one which highlights the sheer versatility of out Armed Forces.

Reservists from the Royal Navy, British Army and Royal Air Force have shared their stories:

Louise Tunnicliff, Army Reservist

“I am a Civil Servant, completing my final year of the Fast Stream in the Department for International Trade. In my spare time I am also an officer in the Army Reserves serving with 68 (Inns of Court and City Yeomanry) Signal Squadron, 71 (City of London) Yeomanry Signal Regiment based in Central London.”

“During the COVID-19 outbreak, the Army decided to mobilise certain Reserve elements and my Regiment quickly released a call for individuals who were not considered key workers and who would like to volunteer.”

“Following a quick turnaround, I was mobilised at the start of April to command a troop of 27 Reserve soldiers from across my Regiment to support 1 Signal Regiments efforts in the West Midlands area. This experience required me to adapt my leadership approach to the challenge of bringing together individuals from different squadrons, to get to know each other and organise ourselves all via virtual platforms.”

“It has been phenomenal to see the determination and spirit of people coming together from across society and all walks of life to help the most vulnerable, those affected by the virus and their families.”

Ross Ewing, Royal Navy Reservist

“I joined the Royal Naval Reserve in my first year at the University of St Andrews, having previously been a member of the RAF Air Cadets. The RNR was a fantastic way to do something different while studying at university. It gave me the opportunity to travel, train, stay fit, acquire valuable skills and earn money all in one go. I am extremely proud to serve in the Royal Navy part-time.”

“I am currently mobilised as a submarine advisory team (SAT) watchkeeper aboard HMS Queen Elizabeth. My main role is to facilitate the safe and effective operation of a submarine in support of the UK Carrier Strike Group (UKCSG).”

“For me the best thing about the Reserves is the range of diverse opportunities on offer. In my short career I have supported national exercises involving submarines, delivered training to new recruits, travelled to France, Gibraltar and Belgium and been mobilised in support of the UK Carrier Strike Group. I have also developed my leadership and management skills and am now responsible for the delivery of initial naval training at HMS Scotia.”

“I became an officer at the age of 18, and I think one of the biggest challenges for me was proving that — despite my age — I could be an effective leader and team player. I would encourage anyone interested in joining the Reserves to kick-start their application and get involved. The more you put in, the more you get out.”

Polly Moore, RAF Reservist

“Prior to joining the Reserves, I wouldn’t even give eye contact to anyone. I am now, however, far more confident and eager to learn. The Reserves pushes you in various elements such as leadership, confidence and organisational skill, and this in turn can help enhance you in your everyday life.”

“There is also the ‘cool’ factor! Coming from a somewhat ‘nerdy’ childhood, the ability to say I have shot a rifle, flown a glider, camped out in the woods, socialised with Canadian Soldiers in France, Nordic-skied up a mountain larger than Ben Nevis, certainly piques the interest of those I talk to!”

“I am very proud to be part of an organisation that I believe is truly a force for good in the world. I also enjoy the camaraderie within our Squadron — Reserves are a mix of many individuals from different backgrounds.”

Reserves of Faith: Royal Navy Chaplain

Simon Chapman is a Chaplain at a UK boarding school by day, a Chaplain with the Royal Navy in his spare time and is now mobilised with the coronavirus effort.

Working with servicemen and women in the Royal Navy brings different challenges to working in a school.

“My skill as a vicar has been greatly enhanced by the training and experience that I have received in the Armed Forces.”

“The great part about being a member of the Royal Navy is that I never feel that I am on my own. When I encounter a situation with an individual that is complex, I can immediately call on the assistance of medical staff, mental health professionals, welfare support workers and the individual’s chain of command.”

Simon has had a diverse career: he acted as a Chaplain in Afghanistan during Herrick, where he held a weekly Church of England service, ran the Easter services, and vigils and repatriation services in times of tragedy. Being able to travel with the troops in Afghanistan and assist in a range of roles, has been the marker of a career that is never the same two days in a row.

Inside the Red Zone: Royal Navy medic tackling coronavirus

Hon. Midshipman Christopher Storer is a Royal Navy medical bursar studying medicine at Brighton & Sussex Medical School. Since teaching stopped due to lockdown, he has been working as a Healthcare Assistant (HCA) in A&E in the Royal Sussex County Hospital.

“I’d just completed my second-year presentation in March, when we received the email telling us that the COVID-19 outbreak had been declared a pandemic, and that teaching was suspended immediately. I’d already been working at the Royal Sussex County Hospital for almost a year at that point and so as lockdown was announced I was able to immediately book in to work the next day.”

“In A&E, like the rest of the hospital, the facilities had been split into “red” and “green” zones — with red being the areas where Covid-positive patients were receiving treatment, and the green zones being protected areas which would be kept Covid-free.”

“By the end of March, the effects of lockdown had made the hospital significantly quieter. There was a constant sense that a tidal wave could hit at any moment. Nothing was left to chance, and staff were taking full advantage of the initial quiet to prepare. Extra training was provided to refresh skills, and within a couple of weeks I was able to work in the patient ambulatory triage, assisting the nurses by putting cannulas in, taking bloods and other tasks. It was a high-pressure, fast-moving environment but I felt incredibly well supported by the emergency department staff.”

“In April, with a good amount of experience working at the front of A&E, I began working in the red zone. Areas were set up to put on the full PPE: a surgical gown, the tight-fitting masks, a visor and scrub caps. I remember feeling anxious the night before my first red zone shift– the name conjures up images of red lights and closed off wards, looking like something on a submarine from an old war movie. But the reality was nothing of the sort. While access in and out was highly restricted to prevent the spread of the virus, it was a normal hospital environment.”

“It was hard work, but there were so many morale-boosting moments working on the emergency department team. The local community really come together to support the NHS. We’d receive donated scrubs and knitted ear protectors to help with the sore marks you get from wearing the surgical masks daily. At the Easter weekend, we received over 200 donated Easter eggs. It seems like such a small thing, but to the staff working there it means so much.”

“Looking back, I feel incredibly privileged to have worked as part of the A&E nursing team providing frontline care to patients. I’m glad to have been able to play a small part in helping during the COVID-19 outbreak.”