“The reports generated by these investigations and inquiries demonstrate that Lambeth was determined to explore the reasons underlying service failure but despite the numerous useful recommendations, there is little evidence to demonstrate that these recommendations were consistently implemented. “It is therefore unclear what Lambeth learned from these eight reports as the council appears to have been unable to put in place, and sustain, the changes required to keep children safe” – Annie Hudson. (2.9)
SECTION 17: THE ZEPHYRINE REPORT {1990)
lntroduction
In 1989, an internal management inquiry was commissioned by the Director of Social Services in response to allegations of poor practice and misconduct on the part of staff at South Vale Assessment Centre. [AH1-5/2d]
The subsequent report, ‘The Report of the Enquiry into the South Vale Assessment Centre’ (the Zephyrine Report) is dated January 1990. [AH1-5/4]
South Vale Assessment Centre was a purpose built children’s home designated as Lambeth’s observation and assessment centre, providing emergency placements, a reception function, and an on-site education facility, with a capacity between 30 and 40 places. It was open between June 1967 and April 1993. Whilst the unit was primarily responsible for children in the care of Lambeth, some children from other boroughs may have been accommodated on an emergency basis. (17.1 to 17.3)
In my view, the key issues that this inquiry highlights is a failure of child focused practice and a lack of professional concern in relation to the care of children in Lambeth, relating to both drift and delays in care planning and a failure to meet the needs of black children in care. Finally, the inquiry regrettably did not consider in sufficient depth important issues about the protection of children from sexual abuse. 17.4
Background
On 11 December 1987, at a meeting of the Children’s Homes Sub-Committee concern was expressed by Councillor Cecilia Motley about possible sexual abuse of two children placed at South Vale. The Chair of the Sub-Committee, Councillor Phyllis Dunipace, indicated that this would be dealt with by the Child Abuse Team. [AH1- 17/1] The outcome of this referral is unknown and was not referred to in the Zephyrine Report.
In 1989, Estella Knight, a Team Leader at South Vale, met with Teresa Johnston, Children’s Home Officer, to discuss her concerns about South Vale. Ms. Knight expressed concern about the treatment of black children, the poor standard of child care, and instances of racism from the senior staff.
She raised issues about the management style of senior staff, and said that she felt unable to raise any of her concerns about bad practice with the (Name redacted). She also recalled (Name Redacted’s) treatment of particular children, including singling them out and taking them upstairs to his flat for several hours at a time. [AH1-5/5] 17.7
In 1989, Beverly Clarke, another Team Leader at South Vale, also met with Teresa Johnston to discuss her concerns, having been advised by Estella Knight to do so. Beverley Clarke raised similar concerns to Estella Knight, including the lack of awareness of the needs of black children, the use of physical restraint, and instances of racism and sexism. She also noted the way the (redacted) favoured some staff, and his practice of singling out individual children for special treatment. [AH1-17/2] 17.8
At a meeting of the Children’s Homes Sub-Committee in (month redacted) 1989, it was reported that six members of staff had been suspended from South Vale in the previous three weeks. 17.9
It was within these circumstances the Director of Social Services commissioned the internal management inquiry in July 1989. The panel was chaired by Edgar Zephyrine Principal Manager, Community and Voluntary Services. 17.10
Ultimately the Report concluded that whilst there were breaches of practice in terms of racism, sexism and poor management, there was no disciplinary case to answer. 17.12
No allegations of abuse, either sexual or physical, are recorded despite the wide remit to investigate in the Terms of Reference . Given the numbers of former residents who have now come forward to make allegations of abuse and the references to inappropriate behaviour, brutality and favouritism within the Report, it is easy to conclude that the investigation was insufficiently rigorous, or was not focusing on the right issues. 17.14
The Report made 36 recommendations, some of which related specifically to South Vale, whilst some were more generally related to management structures, equal opportunities and implementation of child care policies. 17.28
There is reference made by Ainsley Forbes (then Assistant Director, Children and Young Persons) to moving forward from the enquiry and a management action plan being prepared following the Zephyrine Report, however it has not been possible to locate this. Without this plan, it is difficult to determine what actions were taken in response to this Report. 17.29
_________________________________________________________________________________________-
SECTION 20: THE CLOUGH REPORT {JUNE 1993)
In February 1993, the Council was directed by the Under Secretary for Health Tim Yeo MP to commission an independent inquiry into why Michael Carroll, a former Lambeth employee, had been allowed to continue working in a children’s home after the Council discovered he had a conviction for an offence against a child which he had failed to self-declare on two occasions. The inquiry also considered the circumstances in which the Council supported an application in 1987 by Carroll and his wife to foster two children in the care of Lambeth, and alleged interference by a Lambeth Councillor and Officers in that fostering application process. [AH1-5/8] 20.1
Michael Carroll worked at two children’s homes, Highland Road and Angel! Road, between 1978 and 1991. Highland Road children’s home was a residential home for the purpose of preparing children for rehabilitation home, fostering, adoption, or independence. Angel! Road children’s home operated as a pre-fostering and adoption unit while Michael Carroll was employed there. 20.2
In my view, the Clough Report highlighted a number of concerning issues, including understanding and assessing risk as well as the ongoing prioritisation of staff over vulnerable children. Lambeth’s failings in understanding and prioritising these issues are starkly demonstrated in the responses of both the Director of Social Services, David Pope [AH1-20/3] and the Chief Executive, Henry Gilby to the Clough report [AH1-20/2] 20.3
Background
In (month redacted) 1978, Michael Carroll was appointed as Deputy Officer-in-Charge of Highland Road children’s home after satisfactory references, medical clearance and a check with the Department of Health in line with the Home Office Circular.
In 1980, he applied for and was appointed as Officer-in-Charge at Angel! Road children’s home where he remained until his dismissal in 1991 for fraud. For both roles he failed to declare a criminal conviction for indecent assault of a child in 1966 in his application forms. 20.4 to 20.6
At the same time June Mellor, who later was to become John Carroll’s wife, was appointed as Deputy Officer-in-Charge in (month redacted) 1977 at Highland Road children’s home.
In (month redacted) 1984, an anonymous letter was addressed to the Director of Social Services concerning John Carroll’s misconduct at Angel! Road. It was found that he had been using a Lambeth letterhead to gain a discount for a charitable organisation that he was a member of. As set out in the Clough Report, he was instructed that “on no account in the future was Lambeth notepaper to be used for these purposes.” 20.8
In (month redacted) 1986, the Carrolls made an application to the London Borough of Croydon to become foster carers. It was during checks conducted by Croydon that his criminal conviction from 1966 came to their attention. In (month redacted)1986, Croydon alerted the Director of Social Services Robin Osmond, and as a result Lambeth arranged a disciplinary hearing in (month redacted) 1986 to consider two charges of gross misconduct for firstly, failing to disclose his previous conviction on two occasions and secondly, that his actions undermined the trust of the local authority. 20.9
At that hearing the first charge was found to be proven but a decision was not reached on the second charge, as the Disciplinary Panel wished to obtain more evidence in relation to Michael Carroll’s mitigation statement. 20.11
On (date redacted) 1986, after a number of postponements, the disciplinary panel reconvened and found the second charge proven, so decided that he should be issued a final warning. He continued to work as the Officer-in-Charge at AngelI Road until his dismissal in 1991.
Application to Foster Lambeth Children
ln 1987, the Carrolls expressed an interest in fostering two boys aged 14 and 12 placed at Nottingham Road children’s home where June Caroll worked. In line with Council procedures, In the same year Lambeth asked the London Borough of Wandsworth to undertake the fostering assessment of the Carrolls. During that assessment process in 1998, Wandsworth contacted Croydon and discovered their previous refusal. In 1988 Wandsworth rejected the application. On (date redacted) 1988, Lambeth was advised by Wandsworth by telephone that the fostering application would be rejected for “clear legal reasons”. 20.13
On (date redacted)1988, Verley Chambers, Assistant Director Community Services, wrote to the Carrolls formally advising them that Lambeth could not consider their application to foster the two boys. Despite this, on (date redacted) 1988 permission was granted by Verley Chambers for the two children to stay with the Carrolls for a fortnight over the Christmas period. The two boys continued to have contact with the Carrolls who were eventually paid an allowance to act as “aunt and uncle” to the boys. [AH1-5/8] 20.14
ln (month redacted) 1991, a disciplinary hearing was held for charges against Michael Carroll in relation to false claims for overtime, purchasing alcohol and cigarettes with Council funds and breaching financial procedures. All charges were proven and the disciplinary panel recommended Carroll’s dismissal. Michael Carroll appealed against the decision and as part of that process Cllr Anna Tapseil was asked to chair the appeal panel hearing. However, Michael Carroll did not proceed with the appeal and as a consequence Lambeth dismissed him without notice on (date redacted) 1991. 20.15
Having considered the papers for the appeal, Councillor Anna Tapseil became concerned about the circumstances of his continued employment, despite his previous conviction, and his suitability to work with children. ln (month redacted) 1992, she raised concerns with the then Chair of the Social Services Committee Cllr Graham Nicholas and the Director of Social Services, David Pope. She followed this up on (date redacted) 1992 as no progress had been made in the six months since she raised her concerns, by copying in the Chair of the Social Services Committee and the Leader of the Council, Cllr Steven Whaley. It is not clear as to the reasons for the considerable delays and the lack of responsiveness from the Chief Executive and Chair of the Social Services Committee. [AH1-20/2] 20.16
As detailed in the Report of Henry Gilby presented to the Social Services Committee on 6 August 1993,“on 30 September 1992, Cllr Tapsel/ wrote directly to the Department of Health SSI raising her concerns, after informing the Leader of the Council, Cllr Steven Whaley of her intention to do so. The Department of Health SSI responded and on 13 October, Cllr Tapsell advised them, there was no concern with the letter dated 30 September being provided to the Directorate of Social Services. On 11 November 1992, she wrote to Cllr Whaley, Leader of the Council, and indicated her view that these matters could only be dealt with by an external independent inquiry, preferably by the SSI”. 20.17
ln 1992, there was local press interest surrounding Michael Carroll with articles being published on (dates redacted) 1992 in the South London Press. The (date redacted)1992 article, stated that Health Minister, Tim Yeo, commented that “This is a very serious matter and obvious/y employment practices at Lambeth Council are not adequate. There wilI be an immediate and urgent investigation, starting straight after the festive season, in Lambeth Council’s children’s homes by the Social Services lnspectorate”. [AH1-20/1a] [AH1-20/1b] 20.18
On 14 December 1992, the Minister wrote to the Leader expressing concern and asking for Lambeth to arrange for an independent management review into the circumstances of the employment of Michael Carroll as the Officer-in-Charge of Angel! Road children’s home, indicating that the Terms of Reference of the review were to be discussed with the SSI and required his ratification. This letter also noted an intention for a full inspection of Lambeth’s residential care services to be carried out in the New Year. [AH1-20/1c] (The resulting SSI inspection report, which was published during June 1993, is discussed in section 21 of Annie Hudson’s corporate report – Ed.). (20.20)
Richard Clough, MBE, who was then the General Secretary of the Social Care Association, was commissioned to undertake the inquiry with the agreement of the SSI. 20.21
Findings of the Clough lnquiry
Clough commenced his inquiry on 22 February 1993 and presented his report to the Chief Executive, Henry Gilby, on 18 June 1993. [AH1-5/8] Henry Gilby also prepared a report for the Social Services Committee both of which were considered at a special meeting of the Social Services Committee on 6 August 1993. [AH1-20/2] 20.23
The Clough Report does not make any explicit recommendations. Henry Gilby noted this in his response, and stated “white this may be disappointing, it is understandable given the nature of the matters under investigation and the timing of some of the incidents, despite the fact that an independent inquiry has been undertaken.” [AH1- 20/2] 20.24
The Report concluded by saying, “although the terms of reference give the opportunity for recommendations to be made their emphasis was on examining and commenting. The inquiry hopes that this has been done in a manner that will prove helpful.
No specific recommendations are made but the report indicates some general approaches for the future. It is now unlikely that any Schedule 1 offender anywhere would be permitted to remain in employment in such a sensitive post or to be considered as a foster parent whether in the private or statutory sector.
The climate in the present day leads to a much more rigorous approach and it is reasonable to expect the London Borough of Lambeth to take such an approach in the future. The authority has already taken some steps to fighten up and improve its procedures in relation to the selection of staff and the use of council money in pretty cash accounts and comments have been made within the report which will hopefully help further .. .The calibre and ability of senior management wi/I dictate to a very large extent the service that is offered.” [AH1-5/8] 20.25
Michael Carroll failed to declare his offence on two occasions during his employment at Lambeth. Clough concluded that the decision of the disciplinary panel was incorrect and legitimised Michael Carroll’s position as a carer in whatever setting. This was not supported by David Pope who remarked that the decision was finely balanced and that on the information available it would seem the balance taken weighed in favour of Michael Carroll. I note that David Pope was also the Chair of the disciplinary panel and furthermore I have noted that this was not prominently declared in his response, as it surely should have been. 20.29
The Chief Executive noted that there were a number of issues that, had they been presented to the disciplinary panel, would have precluded Michael Carroll continuing as an Officer-in-Charge. 20.30
Whilst David Pope’s application of the relevant local authority circulars was technically correct, my view is that that he exercised his discretion incorrectly. Michael Carroll was in a very clear position of trust and authority, who was responsible for managing a home caring for vulnerable children. The decision making does not seem to have paid sufficient regard for the power and authority that he held. The offence was of a sexual nature against a child and given Michael Carroll’s role in working in a children’s home, having significant contact with children, the decision was at best, flawed and failed to put the safety and welfare of children first. 20.31
It is concerning that David Pope endeavoured to provide a rationale for his decision making in terms of the regulatory framework, i.e. that the regulations which disqualify Schedule One offenders from acting as private foster carers did not apply when the local authority placed children in foster care and children’s homes.
It is my view that this evidenced the failure to priorities the protection and well-being of children in care, despite being the most senior Council Officer responsible for children services. His response to Clough, seven years after the event, even with the benefit of hindsight, served to defend his actions and lacked critical reflection and insight. This is of concern and perhaps surprising given the developments in approaches to child protection that had taken place by the time of the Clough inquiry (for example, the Cleveland report in 1988). 20.32
Clough concluded that Michael Carroll’s application to foster was flawed from the outset; that he made the fostering application to Wandsworth so soon after Croydon had made it absolutely clear his offence disqualified his application. 20.35
Clough noted that the Foster Children Act 1980 specifically disqualified individuals that have been convicted of a Schedule One offence and some Lambeth officers clearly felt it was unlawful to allow Michael Carroll to foster, but it was unknown why such a situation was allowed to develop.
He further commented that Wandsworth felt that due to Michael Carroll’s senior position at Lambeth, they should proceed with the application, and “at one stage it looked like it was being regarded as a formality to a/low the fostering”. 20.36
Clough concluded that there was no evidence to support any impropriety between Wandsworth and Lambeth staff, and between elected Members during the fostering application. 20.37
David Pope in response maintained that the Foster Children Act 1980, which disqualified persons from privately fostering children if they had been convicted of a Schedule One offence, was only applicable to private fostering arrangements and not the placement of foster children by a local authority.
There was other guidance, such as Boarding-Out of Children Regulations 1955, Boarding-Out of Children (Foster Placements) Regulations 1988 and the Charge and Control Regulations 1988 that did not automatically prohibit Schedule One offenders from applying. The discretion was with the local authority and it was expected that local authorities consider any offences as one of the factors taken in consideration when assessing the suitability of applicants. 20.38
(One of Clough’s terms of reference was: To examine and comment upon any conflict of interest between consideration of the welfare of children in Lambeth’s care and the interests of the Council’s staff, as applying to this case.)
Clough raised a number of concerns in relation to this Term of Reference which demonstrated significant tension between the weight given to the welfare of children in Lambeth’s care and the interests of the Council’s staff, with the balance often tipping in favour of the staff. 20.45
In my view, this isa key point and demonstrated, once again, a failing by Lambeth to prioritise children and their needs over those of staff. 20.46
Clough concluded that had Michael Carroll not been an employee of Lambeth and had the decision made at the disciplinary hearings in 1986 concluded in his dismissal, he would have been ruled out at the outset of his fostering application.
Whilst Lambeth maintained that decisions made in relation to the care of the children were in their best interests in the circumstances, Clough was of the opinion that the actions taken were an attempt to fit with the decision from 1986 to allow Michael Carroll to remain in employment.
It was felt that the situation was allowed develop as it involved Council employees and that the interests of Council staff were given undue preference. He pointed out that at no stage were the Carrolls, or any staff facilitating the visits, informed that they could be subject to disciplinary action if they allowed unauthorised visits to continue. 20.47
An Area Team Manager, Patricia Orton, questioned at the time whether the newly introduced regulations, Accommodation of Children (Charge and Control) Regulations 1988, applied to the placement of the two boys with the Carrolls. In further correspondence, Patricia Orton stated that the Carrolls would need to be assessed under the new regulations, and which would need to include a police check.
A response was received from Verley Chambers, Assistant Director Community Services, in which he stated that the regulations did not apply in the “strietest sense” in this case because Michael Carroll had “already been /egitimised (carer) … I see no useful purpose”.
During this time the children had been living with the Carrolls on an “unofficial basis” with the full knowledge of the social worker with permission being granted by Jack Smith, Principal Officer Social Work.
Jack Smith also chaired the Fostering Panel and made a written statement in support of Michael Carroll’s fostering application. According to Clough, Jack Smith should have been strictly neutral and his actions constituted gross unprofessionalism. I endorse this finding. 20.48
Chief executive Henry Gilby concluded it was of serious concern that the interests of the Council’s staff were given undue preference and that management’s decisions were overridden, yet no disciplinary action was taken in connection with any of the staff involved. He felt that it was difficult to understand how a situation was allowed to develop where a member of staff, who was disbarred from fostering children, was placed by Lambeth in the position of having the children often staying with him and having a boarding-out allowance paid. 20.52
Action Plan in response to Clough Report
An Action Plan responding to the Clough Report was combined with recommendations arising from two other reports presented to the Social Services Committee on 28 September 1993. The Social Services Committee received a report which provided a ‘comprehensive and co-ordinated plan with monitoring procedures’. [AH1-20/3a] 20.55
Two actions within this Plan related to specific issues raised in the Clough Report.
a) The Director of Social Services was to immediately provide written guidance to Personnel, training and line managers to ensure that no degree of risk to children or vulnerable adults is acceptable and that disciplinary panels must consider as a minimum the transfer of staff to an alternative service area. The plan noted that this had been completed in August 1993;
b) The references supplied in 1977 did not make mention of the offence and there were no records of the agencies involved being contacted by Lambeth in 1986 to bring the omission of the offence to their attention. The Director of Social Services was to write to those agencies immediately. The plan noted that this had been completed in August 1993.
Conclusion
The Clough Report highlighted poor practice in Lambeth. David Pope’s response to the Clough report raises important concerns about the quality of management decision making at that time. It indicates an intention to justify and rationalise the decisions relating to Michael Carroll over which he had oversight; moreover, the passage of time and changing approaches to child protection did not seem to have caused important critical reflection. 20.57
The response document lacks any real acceptance on his part of the key failings, nor does he take responsibility for them. This is further demonstrated by the prepared statement issued by Luton Council during 1999 where David Pope worked after he lefl Lambeth which stated, “In 1985, Mr Pope chaired a Lambeth Council disciplinary panel that made recommendations about Michael Carroll to the then Director of Social Services, Mr Rabin Osmond. Those recommendations were appropriate to the evidence avai/able, and, at the time, there were no grounds to believe Michael Carro/I was a danger to children”. [AH1-20/4] 20.58
This document goes some way to demonstrating why institutional change in Lambeth Social Services Directorate was problematic. It demonstrates a continued focus on the interests of employees rather than on the primary responsibility to protect and safeguard children’s welfare and a tendency to downplay the potential for abuse, even when there was clear evidence of this. 20.59
David Pope’s response purports to accept the criticisms made by Clough when it clearly does not. At the heart of the issue arising from these events is the failure by the most senior managers in the department to prioritise the needs of children first and foremost. 20.61
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THE HARRIS REPORT 1993:
There is evidence that the problematic and dysfunctional aspects of the Council’s organisational culture during the 1980s and 1990s unwittingly facilitated the potential for the abuse of power by officers in relation to children and other vulnerable people. Evidence of this organisational culture was highlighted in the Harris Report. This investigated alleged breaches of the Council’s equal opportunities policies in the directorate of housing services (DHS); the Report produced in 1993 found:
a) There was a long-standing culture of sexual harassment and assault of employees with work and management practice being racist and sexist and sexual harassment passing unchallenged for many years and that, “”cronyism” and “favouritism” were widespread and perceived to f/ourish as the ‘de facto’ norm uti/ising the very mechanisms that the Council has developed to avoid these. These same mechanisms within DHS a/so served to sustain organisational racism and sexism”.
b) That there was a system of widespread malaise eroding perceptions of proper work conduct and confidence in senior management dealing with issues in this area and that the managerial context was discriminatory and unacceptable. [AH1-4/8]
SECTION 23: THE HARRIS REPORT (1993)
lntroduction
In October 1993, the Director of Housing, Peter Camp, established an internal panel to investigate allegations regarding:
- The exchange of pornographic material between housing officers and elsewhere;
- That the Senior position (Name Redacted) had deliberately and improperly interfered with the process of an investigation.
These allegations had arisen in the course of a previous disciplinary hearing within the Housing Directorate. 23.2
The Report, dated 22 December 1993 was presented in four separate parts:
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- The first section dealt with the general context and background of the Housing Directorate;
- The second section dealt with the investigation into specific allegations;
- The third section dealt with equalities issues, particularly racism and women’s equality issues; and
- The fourth section highlighted other issues which arose during the course of the investigation and set out recommendations for further action in response to these. [AH1-4/8] 23.4
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In this section I discuss the remainder of the allegations raised in the Harris Report in relation to the distribution of pornography, and any connection there may have been to convicted perpetrator Les Paul whom I discussed in section 6. (Please see: Background to the news – THE ABUSERS: “The total number of people abused as children will never be fully known as there are many reasons why victims and survivors may not come forward and Lambeth council do not hold complete records of all those who did”
Findings and Recommendations of the Report
The Panel received evidence that pornographic material was held and loaned on Council premises, that these films may have been home produced by staff or their associates and that they may have contained ‘hard core’ pornographic material and content of a paedophilic nature. 23.7
The Panel found that there was a network of exchange of pornographic videos that existed and that there was wider knowledge within the Housing Directorate about this matter than the Panel was able to ascertain. 23.8
In particular, the investigation noted “Most seriously, on one occasion, a letter to one of the staff was intercepted by two more senior staff. The letter offered further pornographic video material to the employee and referred to providing children. No management action was taken on the letter which was returned by the more senior manager.” 23.9
The investigation also noted that a person named “Les” had also been in possession of computer pornography at work. It was the view of the Panel “that the LP mentioned may have been LP who is thought to have links with same of the suspended people”. 23.10
Les Paul, was employed by the Council between 1979 and 1992. He was dismissed from the Council on (date redacted) 1992 following a disciplinary hearing for possession of pornographic material relating to children. He was subsequently convicted for sexual offences against children in 1994, 2002 and 2016.
It is unclear whether this is the same person that the Panel were making reference to, however, the Panel did note that they had examined personnel records of staff within the Social Services Directorate. 23.11
The Panel recommended that allegations in relation to possession of pornography “may warrant police investigation” which should be done in tandem with any management action taken by the Council. It was recommended the Housing Directorate further investigate the existence of computer pornography across the Directorate. 23.12
Whilst it is noted that Les Paul had been dismissed by the date of the Harris Report, assuming he was the same “Les” referred to in the Panel Report I would expect given the findings of the Panel that the Director of Social Services would have commissioned further inquiries within the Directorate to consider the serious issues raised. 23.14
Lambeth has not been able to establish what was done in response to these recommendations, so in their absence it is not possible to comment on how Lambeth responded to the Harris Report. 23.15
This investigation concerned deeply disturbing events within the Council’s history. The wider findings of the Harris Report demonstrate an atmosphere of fear and favouritism which existed within the Housing Directorate of the time.
The report highlighted that there was little or no corporate oversight of what was taking place, an organisational inability to address serious allegations of misconduct, ill treatment of staff, particularly women and black people and a failure to investigate complaints properly.
It would seem that at the time in Lambeth it was very difficult for staff to raise complaint; the Report highlights that employees were inhibited from reporting issues of concern relating to matters such as the use of pornography because they did not believe that anything would be done in response. 23.16
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APPLEBY: Five years later the Appleby Report set out a catalogue of cultural, financial and organisational failings and mismanagement. This Report goes some way to explain how the Council was incapable at that time of securing necessary improvements because of systemic structural failings and chronic staff shortages. Appleby also highlighted a culture of dishonest employees, members and contractors where corruption could go unchecked. Whilst the Appleby Report makes no particular findings in relation to these issues within the Social Services Directorate, it provides evidence of a prevailing organisational culture which protected staff to the detriment of service delivery; it also indicated that trade unions had, “fartoo much influence and control over the parly and the Council.” [AH1-4/1] 4.48
Appleby highlighted streng links between the political leadership of the Council and the trade unions. The report indicated that contributed to a corporate culture which sought to privilege the interests of the workforce over other considerations and most particularly, in the context of this inquiry, over duties to safeguard interests of children. There is evidence of a significant number of situations where the Council’s responsibilities towards children became secondary to its promotion and protection of staff interests. For example, there instances where employees who were the focus of allegations of child sexual abuse were not removed from the workforce but instead were transferred to other service areas, exonerated or allowed to leave without any disciplinary action taken. 4.49
4.50 Between 1993 and 1995, there was no permanent Chief Executive in place which further underlies Appleby’s findings that there was neither sufficiently clear leadership nor strategic will to ensure that there were the right systems and oversight in place to deliver quality services across the council. In addition, I note that there was a significant turnover in senior management staff within Social Services. This was highlighted by Barratt who noted that at the time of Celia Pyke-Lees’ appointment as the permanent Director of Social Services in 1996, all previous Directors, relevant Assistant Directors, the Child Protection Co-ordinater and the Child Protection and Quality Assurance Manager had left. Regrettably, this meant that there was no clear corporate child care, or institutional memory, left within Lambeth Council.
2.6 This was followed by the ‘lnquiry Report of Miss Elizabeth Appleby QC’, known as the Appleby Report, published in 1995, which exposed the dysfunctions which existed within Lambeth Council during the 1980s and early 1990s. The Appleby Report reveals a catalogue of systemic structural, cultural, financial and organisational failings, which partly explain why Lambeth Council was incapable fora lengthy period of time of making improvements, and provides evidence of a prevailing culture which protected staff to the detriment of servi ce delivery. Appleby referred to Lambeth at that time as, “an appalling financial and administrative mess with non-existent or incompetent management.” (section 24)
4.3
There is evidence from the reports of Elizabeth Appleby (1995) and John Barratt (1999) [AH1-4/2] [AH1-4/6] that during the 1980s and 1990s there was a lack of political and corporate leadership and governance in Lambeth. The Administration was severely criticised by Appleby where she observed that, “Lambeth’s ru/ing party was intent on obstructing the implementation of government policy in a number of areas ...the result is that Lambeth is an appalling financial and administrative mess with non-existent or incompetent management.” [AH1-4/1]
SECTION 24: THE APPLEBY REPORT {1995)
lntroduction
Between 1991 and 1993, the Chief Executive, Herman Ouseley produced a series of reports in his capacity as the Monitoring Officer of the Council, which investigated and identified serious concerns regarding contracts entered into by the Council, including the subcontracting of contracts awarded to the Council’s Direct Labour Organisation (“DLO”). These reports, together with concerns raised about the prevalence of Freemasonry within Lambeth, led to press coverage alleging serious financial mismanagement and potential corruption within the Council’s DLO. 24.1
When presenting his report to the Policy, Resources and Performance Review Committee on 27 September 1995, Herman Ouseley described himself and corporate management as whistle blowers, and referred to the threats and intimidation he received from officers involved in the investigation. 24.2
Taken with the widely publicised allegations against senior officers within the Housing Directorate following the Harris Report, the Council resolved in January 1993 to commission an independent inquiry into the history of all the issues raised within Herman Ouseley’s report including the financial and legal procedures in operation within the Council. 24.3
In February 1993, the Council appointed Elizabeth Appleby QC, to conduct an independent inquiry into Lambeth Council and produce a report…24.4
Findings and Recommendations of the Report
Whilst Appleby was instructed to focus on a number of specific areas, she noted that given the widespread nature of Lambeth’s problems, it would paint a false picture if she were to limit herself to specific areas.
The overarching conclusion produced in her Report dated July 1995 illustrates the institutional culture that had developed in Lambeth from the late 1970s to the early 1990s. ‘The financial contra/ of Lambeth is such that vast amounts of money are wasted, and, in consequence, services are severely prejudiced. What is so surprising is that many of the defects in Lambeth’s administration have been identified time and time again by internat audit, by the district auditor and by independent reports. It seems that white the conclusions and recommendations f/owing from the audits and the reports have been readi/y accepted by chief officers and the politica/ /eadership, Lambeth has been total/y unable or unwilling to translate its plans and ambitions into positive action.”
The following conclusions within this report are of importance in understanding the political and corporate culture at Lambeth and give some insight into the reason why investigations and inquiries within the Social Services Directorate were similarly incapable of being translated into positive actions and improvements. Appleby’s conclusions are of very great significance in making sense of the broader political and corporate culture in Lambeth at that time; they provide helpful insight into the reasons why the outcomes from, and recommendations of various investigations and inquiries were not coherently and consistently translated into concrete actions and improvements. These issues therefore had a major impact on the quality of management and oversight of children’s homes in Lambeth.
Appleby opens her Report by tracing the genesis of difficulties at the Council back to the late 1970s and 1980s when the seeds were sown for the problems Lambeth was facing by 1995. She noted that, “/ am satisfied that in the 1980s Lambeth’s ru/ing party was intent on obstructing the implementation of government policy in a number of areas. The facts c/early indicate that it had little or no regard to reducing public expenditure …that it embarked on a policy of protecting its own workforce at all costs...Lambeth appeared to apply a recruitment policy that led to staff being recruited who were not only unqualified and inexperienced but totally unsuitable for the job given to them. Recruitment … bore signs of nepotism” and concluded by stating, “Lambeth is in an appalling financial and administrative mess with non existent or incompetent management.” 24.9
She made a number of comments regarding the financial state of Lambeth, noting, “As at October 1994 if one takes account of the arrears of council tax, community charge, rates, non-domestic rates, debts, housing rents, temporary accommodation and mortgage arrears Lambeth is owed over f:200 million. This is an appalling record and appalling mismanagement”. 24.10
She noted that the Council seemed to stumble from one crisis to the next with the policies and actions of Lambeth contributing to a perfect atmosphere for abuse of processes by people working within Lambeth and outside the Committee structure; the use of the urgency procedures were yet another example of this mismanagement. 24.11
Appleby makes a number of observations about Lambeth, in particular:
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- Recommendations from previous inquiries failing to be implemented or, in some areas, ignored;
- Animosity between Directorates is high and rather than working as a team are independent and jealous of one another. No Directorate can be free from criticism;
- The system of Lambeth was incapable of implementing any substantial changes without the appointment of independent, outside permanent Chief Executive;
- In the 1980s, the Lambeth ruling party was intent on obstructing government policy and had little or no regard to reducing public expenditure;
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Members are not clear as to their role in setting policy objectives and making decisions within that framework. 24.12
It should be noted that although Appleby stated in the Report that during the course of her investigation she received numerous allegations as to the cause of Lambeth’s problems, including the influence of Freemasonry, a “Mafia” exerting pressure over officers and a pornographic ring holding officers and Members to ransom, she stated that she had received no evidence to substantiate these allegations. 24.13
Heather Rabbatts was appointed as a permanent Chief Executive on 3 April 1995, replacing a series of acting Chief Executives in the preceding two years. Prior to her appointment, Appleby had formed the view that, {{Lambeth had no officer capable of leading the restructuring that must take place if Lambeth is to overcome its problems. The difficulties facing Mrs Rabbatts are substantial.” 24.14
The report concluded by setting out a series of steps to be taken to achieve change and that if a system of efficient management was established, then risks of fraud, dishonesty or abuse of the system would be removed or at least be capable of being identified and proved. 24.16
Lambeth’s response to the Appleby Report
The Council responded robustly to the Appleby Report. Exhibit AH1-24/1 sets out a statement of Heather Rabbatts, dated for publication 28 July 1995 where she said: “We are here this morning to announce the publication of the Appleby Report on the management, organisation and operations of Lambeth Council. It outlines a catastrophic litany of mismanagement and, in same cases, fraud. The events which it describes amount to a betrayal of the people of Lambeth. There are very real social and economic problems in the Borough and it is these which should have benefitted from the money frittered away through waste and corruption. 24.17
In response to the human resources issues, competency assessments of staff were undertaken which led to a number of staff leaving and over 100 cases of disciplinary action in relation to fraud being undertaken.
Steps were taken in order to address the issue of uncollected funds owed to Lambeth which also resulted in a Budget Strategy Group being established as the Acting Director of Finance took steps to examine all aspects of the Finance Department. Additionally, an Anti-Fraud team was established. 24.24
The Appleby Report provides very relevant and important narrative and analysis of the corporate culture in Lambeth during the late 1980s and early to mid 1990s. It highlights the lack of good governance, political and corporate leadership and oversight which are very likely to have contributed to the quality of services to children in care in Lambeth and in particular to increasing the risks of harm to them.
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BARRATT REPORTS
John Barratt was subsequently commissioned to undertake two investigations – ‘The Lambeth Independent Child Protection lnquiry 1991: Part One’ and ‘Two Lambeth Independent ChiId Protection Inquiries 1999 – 2000: The Final Report’. The first report investigated the case of lLA-A29 ja looked after child who had been severely let down by the Council; and the second into the failure to carry out police checks on foster carers.
His First Report in 1999, referred to an, “unavoidable legacy of general organisational incompetence” and his Final Report in 2000 concluded that the Council had, “repeatedly failed to fulfil both its statutory duties and its own policies relating to the care and protection of children” …and, “repeatedly tried but repeatedly failed to create an effective Department and Division.” (section 26)
4,4
It is clear that during the period from the late 1970s to the early 1990s there were severe and significant shortcomings in the quality of management and leadership, most particularly at senior levels. A picture of “organisational incompetence” emerges, a phrase coined by Barratt in his Report. He evidences failings in both leadership and governance at Lambeth which significantly contributed to the Council being unable to properly safeguard the children in its care. [AH1-4/6]
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EVANS: The final report discussed in this section is the ‘Events and Circumstances Associated with Changes to Services at a Home Providing Residential Respite Care for Children with Disabilities’, known as the Evans Report (2000), which investigated events at Chestnut Road respite home for children with disabilities. The Evans Report highlighted the failure of Lambeth’s own lnspection Unit to inspect Chestnut Road children’s home, and raised serious concerns about the perceived conflict between the necessity to protect the needs of children and the employment rights of staff. (section 27)
SECTION 27: THE EVANS REPORT (2000)
lntroduction
Respite care services for children with disabilities in Lambeth, moved to Chestnut Road children’s home on 16 September 1996, after the closure of Monkton Street children’s home. Chestnut Road provided respite placements for children with learning disabilities of all ages and was initially managed by Lambeth’s Adult Services division. It was the last remaining Lambeth children’s home which closed in February 2000. 27.1
Following political and public interest in the reduction of services at Chestnut Road, during 1999/2000, an independent review was commissioned by Lisa Christensen, Executive Director of Social Services. Richard Evans, who was an ex-Director of Social Services at another local authority, was commissioned to review the Directorate’s analysis of previous difficulties at Chestnut Road, the reasons for them and the management actions taken in response. Furthermore, Evans was to comment upon the robustness of the proposed action plan formulated by the Directorate to deal with the managerial difficulties identified. [AH1-4/17] 27.2
In my view, this inquiry highlights a further example of Lambeth’s continued failure to implement sustained change and adhere to accepted standards for caring for its most vulnerable children within a residential provision. 27.3
The home was not inspected by Lambeth lnspection Unit until 1997. The lnspection Unit had been “unaware that Chestnut Road was operating as a children’s home because no-one had informed them of this.” Further, as the lnspection Unit was under-resourced, a decision had been made by the Chief lnspector that inspections of Chestnut Road would be a “discretionary matter” and would not take place until there would be further resources provided. The Report commented that it was not clear whether this decision was founded on the ambiguity about Chestnut Road’s legal status. This decision was contrary to the recommendations in the 1994 SSI report, that the lnspection Unit inspect all the Council’s children’s homes. [AH1-4/17] 27.6
Findings of the Evans Report
The Report identified a number of managerial issues whilst absolving the Service Manager and Unit Manager from any responsibility for the failings, due to their recorded attempts to raise issues with the Department. In addition to the failings in respect of the inspection process. There were a number of human resources issues that had implications for good child protection practice.
The Report highlighted the number of staff employed at Chestnut Road whose employment history was unsatisfactory, including staff that had been employed despite having criminal convictions. A number of staff had been suspended for lengthy periods.
The managerial inactivity in resolving employment issues had resulted in cases where it appears it had proved difficult to discipline staff who were then ‘managed out’ in other ways. There was also a break in where a staff member alleged she was raped. It appears the unit was fundamentally unsafe. 27.11
The Inspection Process
Lambeth failed in its duty to inspect the home until 1997, because the Council’s lnspection Unit had not been made aware of the purpose and function of Chestnut Road. Additionally, the managers of the home were unaware of the statutory guidance. 27.12
Recommendations of the Evans Report
The Evans Report made a number of recommendations which considered the role of the lnspection Unit in relation to inspecting homes for children with disabilities; recommendations in relation to recruitment, vetting and personnel practices for staff and proper guidance regarding dealing with children with disabilities. 27.18
The second set of recommendations related to the management of human resources at Chestnut Road and was directed specifically at the Executive Director of Social Services. It was recommended they undertake retrospective police checks on all staff involved in the care of children and that guidance be issued in respect of procedures relevant to staff to access personnel/human resources information. Finally, it was recommended the Executive Director of Social Services also instigate a review of the arrangements and guidance on staff discipline (including suspensions). 27.20
Lambeth’s response to the Evans Report
In relation to staff recruitment, it was noted all prospective candidates were now required to give a full employment history on their application form, including clarifying gaps in their employment. All successful candidates that would have substantial contact with children, would be police checked and any staff with convictions, would be referred to the Head of the Children’s Division on whether to offer them employment. He noted all existing staff had been police checked, with checks being renewed on a three yearly basis. 27.26
Conclusion
Many of the issues the Evans Report highlights, constitute repetition of concerns and risk factors identified in the other reports discussed within this section. 27.29
The Evans Report identifies examples of human resources and management practices where the impression was given that for some senior managers’ fairness towards the employee appeared more important than the safety and the welfare of the child. This was completely at odds with both the spirit, and letter of the Warner and Utting Reports. Correlations can be drawn back to the serious criticisms in Appleby’s Report regarding Lambeth’s inappropriate recruitment of staff. 27.32
The home was staffed by unqualified residential staff from other Lambeth homes and the staffing complement (large numbers of staff and minimal management oversight) was in breach of both the Children’s Homes Regulations 1991 and good practice. 27.33
Also concerning was the fact some staff were not police checked, which, from 1986 was required for all new staff working in children’s homes and from 1997 was a statutory requirement under the Police Act 1997. It was also Lambeth procedure to ensure staff working with children were appropriately vetted. High risk adults were, therefore, employed to care for extremely vulnerable young people in the care of Lambeth. 27.37
The review highlights the case of LA-F39 as particularly illustrative of this.
When LA-F39 !began working for Lambeth in 1990, within his application form, there were a number of omissions including no referees provided and failing to declare a11 of his prior convictions Despite this, he was appointed as a Residential Social Worker at South Vale on (date redacted) 1990, conditional upon references and satisfactory police checks.
A police check received on 18 June 1990 detailed seven offences (redacted – marked as sensitive/lrrelevant in report) which resulted in a prison sentence of five years. Later, on (date redacted) 1990, his appointment was authorised. 27.38
Upon South Vale closing, he was offered a post at Monkton Street and subsequently Chestnut Road. This redeployment process did not include disclosure of his previous convictions. Therefore, his new managers, at both Monkton Street and Chestnut Road, were unaware of his history. 27.39
He was suspended from Chestnut Road in [_D_PAi1998 following an allegation of sexual abuse bya child in the unit. He was ultimately made redundant and accepted a ‘standard’ reference confirming his dates of employment in 1999. 27.40
There had been a failure to recognise the significance of employee offences and the Department had been oblivious to the danger that he might pose to vulnerable children given his convictions. The chronology suggests that the fact that LA-F39_did not return to work with children was attributable to the persistence and integrity of the Service Manager rather than to the policies and procedures of the Council. 27.41
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CHILE / MIDDLETON 2.11
The statement goes on to consider the impact of the Children’s Homes in Lambeth Enquiry, known as CHILE, established by the Council in 1997 to support the Metropolitan Police’s Operation Middleton into allegations of abuse in Lambeth homes. (section 32) Whilst CHILE was considered a successful example of inter agency working with the police at the time, the Council now recognises that CHILE was a missed opportunity to reflect upon any lessons arising from the investigation, and therefore failed to apply any consequent learning to improve social work practice to better safeguard children. This is particularly disappointing as the contemporary inspections and reports (Barratt and Evans) clearly indicated that Lambeth’s child care practice needed to improve.
The review of the documents discussed in the corporate statement has led the Council to conclude that the institutional failings catalogued within it can be categorised into four overarching themes. These are: firstly, the lack of leadership and failure of governance at both political and officer levels, compounded by the political legacy, financial pressures and the rapid turnover of senior staff as evidenced in the Appleby, Harris and the Barratt reports. The second theme is the overall poor quality of practice, both within Social Services for children and more broadly across the Council, in such areas as Personnel Management/Human Resources. This is illustrated by the South Vale Report, the Barratt Report, and others, as well as examples of failures to discipline staff properly. The third theme is that of the inadequate recruitment and vetting practices adopted by Lambeth over the years when the Council operated its own children’s homes, as documented in the Clough Report among others. The final theme is the Council’s inability to implement the recommendations from investigations, inquiries and inspections, leading to failure to effect any meaningful change. 2.15
At the end of 1998, the Metropolitan Police investigation known as Operation Middleton, supported by CHILE, was set up into allegations of abuse of former Lambeth children’s homes. Operation Middleton concluded in 2003. I discuss this investigation and CHILE in section 32. 4.37
- In the introduction to the ‘Children’s Homes in Lambeth Enquiry Summary 1998 – 2003’, prepared by Helen Kenward, she observed, “The financial constraints imposed by Lambeth brought the enquiry to a premature end”. [AH1-32/5] I find this surprising given the function of the CHILE team and how closely that related to assisting Operation Middleton.
We have not located any other material that supports this comment by Helen Kenward and Lambeth’s internal reports in respect of Operation Middleton do not identify financial constraints as an issue. There were references to the need for an ‘exit strategy’ and there was undoubtedly a need to ensure that wider and general lessons from the inquiry were addressed and a coherent improvement plan drawn up and implemented. 32.55
NEWS FROM CRYSTAL PALACE 