The Scottish Government

Borders Reports

Full text of statement to Parliament by Peter Peacock, Education and Young People Minister, on Thursday, May 6, 2004

In March 2002, a woman with learning disabilities was admitted toBordersGeneralHospitalhaving suffered extreme levels of physical and sexual abuse over an extended period.

In September 2002, three men were imprisoned for this abuse.

Following these events Scottish Borders Council commissioned respectively David Stallard, Anne Black and Peter Bates to undertake separate pieces of work to help them in identifying actions necessary as a consequence of the issues that had come to light.

Following examination of the first two reports to Scottish Borders, the Social Work Services Inspectorate recommended to me that they conduct a full inspection into the department of Lifelong Care of Scottish Borders Council and their handling of this case.

Euan Robson and I agreed to that inspection and today I am publishing the SWSI Report.

In addition, I am today publishing a joint statement from SWSI and the Mental Welfare Commission that includes the recommendations from a separate report the Mental Welfare Commission undertook at their own volition into the case, looking at the Health Service dimension.

In all my experience in public life, dating back over 20 years and from my experience of dealing with social welfare issues for a National voluntary organisation over many years, I have never come across a more harrowing, appalling case as this.

So horrific are many of the incidents that Parliament will understand that details of the individuals and what happened to them should not and will not be revealed.

As MSPs and the wider public will see the SWSI report is a damning verdict of a catalogue of repeated and significant failings by individuals and key managers within the Social Work Service in the Borders.

The Mental Welfare Commission' has highlighted failings in health services.

Both reports show that there are also some issues the police need to address.

These failings are not of recent origin - they span a prolonged period - those involved had their first contacts with Social Work back in the early 1970s.

The conclusion of the report is that a number of other individuals were the subject of neglect and abuse as well as the individual admitted toBordersGeneralHospital.

Over a period of three decades those individuals variously suffered severe forms of:

• Physical and emotional neglect
• Sexual abuse and exploitation, and
• Financial exploitation

The report concludes that much of the abuse and exploitation over - I repeat - three decades - could have been avoided had appropriate action been taken by the agencies involved.

The report graphically illustrates not just individual failings, but also failings in:

• Comprehensive assessment and care planning
• The understanding of provisions for guardianship
• adherence to local policy and national guidelines
• a failure to follow Scottish Social Services Council Codes of practice
• Failings in Information sharing between agencies
• Grossly inadequate recording practices in casework
• Failings of key managers at key times
• Inadequate supervision of and monitoring staff performance

It is a depressingly familiar tale which resonates with the findings of all too many inquiries down the years into child abuse cases across theUK.

This case itself started as a child abuse case - those children were failed by the system, just as they were subsequently failed as adults.

As I have indicated, the report graphically illustrates the failings - I refer to a number of extracts from the report.

I quote:

"The repeated failures of social work to act effectively in response to allegations of abuse over some three decades undoubtedly contributed to the serious sexual abuse of at least 3 individuals and to the serious physical neglect of another.

"Unequivocal prompts to act occurred routinely over the decades prior to March 2002. Between 1976 and December 2001, 28 allegations of physical and/or sexual abuse were reported to Social Work.

"Between December 2001 and24 February 2002, there were 16 separate contacts or referrals by the individuals themselves, members of their family or social work staff expressing concerns. Each one of these events should have initiated decisive action, but none did."

Most disturbingly of all Presiding Officer - and again I quote:

"The repeated horrific sexual and physical abuse for which 3 men were convicted in 2002, could have been prevented had the department acted on mounting evidence available over the previous two decades."

I could go on making such references from the report, but its full contents are available for Members to read for themselves.

The report is, as I have said, a damning verdict of a catalogue of repeated and significant failures.

SWSI - and separately the mental Welfare Commission make a number of key recommendations.

Those recommendations - 42 in all - are directed at Scottish Borders Council, NHS Borders and Police, as well as recommendations specifically for the Scottish Executive to follow up.

The recommendations span many issues:

Of the SWSI recommendations, two are specific to the individuals in the case.Twenty one relate to Scottish Borders Council and span recommendations to:

• Review all cases involving vulnerable adults
• Comply with Scottish Social Services Codes of Practise
• Improve Training for Mental Health Officers
• Develop better risk assessment methods
• Improve case recording & case review mechanisms
• Introduce random case monitoring processes
• Reform case transfer arrangements
• Share information more effectively

And a range of other related issues.

The Mental Welfare Commission recommendations reflect all of these critical issues.

In addition the SE is specifically recommended to take forward our existing work to reform, support and develop Social Work practice through:

• Reviewing the role of the Chief Social Work Officer
• Making provision to record all abuse allegations in new data base frameworks we are developing
• Auditing local guidelines to protect vulnerable adults
• Introducing a vulnerable adults Bill
• Reinforcing the need for compliance with SSSC Codes

We accept all the recommendations and will take all the necessary actions to ensure they are acted upon.

The SWSI report is based on a process which involved the trawling of files for all of the period during which the individuals involved had been known to the Social Work Service.

Inspectors also had access to the other reports commissioned by Scottish Borders Council, to staff disciplinary and training records and transcripts of interviews with key staff from the earlier investigations.

A detailed chronology, drawing heavily on case notes and this wider evidence base was produced as Findings of Fact upon which to agree the facts with the agencies and base the SWSI report.

The published report is an anonymised version of the "Findings of Fact" which themselves cannot be published in order to protect the identities of the victims and what, in detail, happened to them.

I met yesterday with Scottish Borders Council and with the Chief Constable of Lothian and Borders Police and with the Chief Executive and Chair of Borders Health Board.

Scottish Borders Council and the other agencies have accepted without reservation the Findings of Fact and the conclusions and recommendations of the SWSI Report.

My purpose in meeting with the Council in particular, but with the others also, was to impress upon them the extremely serious nature of the findings and to get their absolute assurance they:

• accepted the findings
• would take immediate steps to address the remaining needs of the victims, and
• would take all the necessary actions to ensure such failings would not occur again.

I can tell Parliament that I have received those assurances.

I can also tell Parliament that I will ensure ongoing liaison between my officials and Scottish Borders Council, as will colleagues in Health and Justice in relation to NHS Borders and the Police.

I have asked Scottish Borders Council to submit their plans to address all the issues raised in the report to SWSI.

SWSI will carry out a follow up inspection to ensure the action plan is fully implemented and the necessary change is brought about.

As members will be aware Scottish Borders Council has a number of recently appointed officials in key positions, not least a comparatively new Chief Executive and an acting Director of Lifelong Care following the departure of the previous Director.

Scottish Borders Council have a major set of changes they need to make to the culture and operation of their services and they will need dedicated effort and clear political commitment to bring that change about.

I can tell Parliament that they are fully aware of the challenges they face and have started the process of change that is necessary by allocating additional resources and implementing, for example, the recommendations of the Bates Report to the Council.

In the short term the Council still have a lot they must do to support the individuals at the centre of this case who have suffered so much.

Those individuals are still extremely vulnerable, but are making significant progress in their lives in new settings.

We too, in this Parliament, in the conduct of our deliberations and proper scrutiny of events, need also to protect those individuals from unnecessary exposure or hurt as a consequence of that scrutiny.

In which regard I urge members not to refer to this case by the former label as it is known to cause distress to the individual concerned.

Beyond these particular individuals Scottish Borders Council also has a duty to ensure no other individuals with similar learning difficulties are suffering as a consequence of systems or individual failings.

They require - and are undertaking - an immediate audit of cases to ensure adequate protection and support for any such individuals.

The findings and recommendations in the SWSI Report directed at Scottish Borders Council and the Police and Health services have a relevance to every other Social Work Service, Police force and Health Board inScotland.

I am writing today, together with Justice and Health Ministers, to every Scottish Local Authority, Health Board and Chief Constable to draw the report to their attention and to ensure they ask themselves:

• could this happen in my area?
• and asking them to work together to audit their services to adults with learning disabilities
• based on the Inspectorate's and Mental Welfare Commission's recommendations.

Where that audit identifies areas needing attention agencies should produce timetabled action plans identifying how they will address these issues.

Parliament recently made clear its intention to raise standards in Social Work practice.

We have created the Scottish Social Services Council to register Social Workers and required them to publish Codes of Practice setting out standards of conduct for social workers and social work employers.

I have been deeply troubled and am deeply concerned by what is revealed by this report by way of systems and individual failings.

I am very clear I have a duty to act on those concerns as they relate to systems and to the actions of individuals.

I believe the proper way to deal with this is to refer the SWSI findings and conclusions to the Scottish Social Services Council.

I expect them to take these into account as they develop standards of registration over time but also as they go about their task of registering individual Social Workers.

Parliament should be in no doubt about my intentions here.

I expect the SSSC to exercise their statutory duties and use the evidence we supply them to decide if any individual is failing to meet the required standards and is therefore not fit to be registered.

This would enable any potential employer to know that they were unsuitable, and thereby protect the interests of vulnerable clients.

I do not believe Parliament or the public would expect any less than that assurance from me.

Practising Social Work is one of the most demanding and complex tasks we ask any group of professionals to conduct on our behalf.

Today, as we speak, there are Social Workers across the length and breadth ofScotlandconfronting extraordinarily challenging circumstances.

There are many, many social workers and health staff and social work and health managers in Scottish Borders and elsewhere exercising sound judgement, assessing difficult situations, making the right interventions and improving the lives of vulnerable citizens.

We will hear little or nothing of their good work on society's behalf.

But when things go wrong we have a duty to act, to learn the lessons and ensure accountability

As an Executive and as a Parliament we also have a duty to ask critical questions of whether we are doing everything we can to be clear about what we expect of Social Work in the modern era.

We have decided it is now the time to take a more fundamental look at social work. We need to ask, as Ministers and Parliamentarians what is the task we are asking social work to do for our society in this ever changing world.

We need to be clear what we expect in this early part of the 21 ^st century - so different from the 1960s when social work as we know it today found its statutory basis.

We need to be clear where it fits and how it relates to others in the complex landscape of public, voluntary and private agencies.

We need to be clearer about the contribution we want and need social work to make as we move through this early part of the century in order to strengthen that contribution.

We are already active on that agenda.

• We have introduced a new social work honours degree,
• set minimum standards for CPD,
• run successful campaigns to attract new people into the sector and introduced a fast track scheme for graduates to boost by a third the number of social workers qualifying over the next 3 years.

But it is clear we need to go further and beyond what we are already doing.

For example - UNISON have recently written to my officials stressing the importance they attach to the task of identifying exactly what a social worker does.

I will return to Parliament before the summer recess to set out more fully the Executive's thinking to progress the consideration of the issues.

In the meantime it is important to take action now to improve services.

I am therefore immediately making changes in the Social Work Service Inspectorate which will now concentrate on inspection activity alone.

Its former policy role will stay within my Department, but the Inspectorate will sit at arms length from Ministers reflecting the arrangements put in place in relation to Schools Inspection two years ago.

The reports published today also raise issues relevant to police, health, education and social work.

One of the first tasks for the revamped SWSI will be to develop with other inspectorates and regulatory bodies a joint inspection of learning disability by the end of the year.

That inspection will monitor the audits by services providers I have already mentioned.

I have emphasised the importance of the Scottish Social Services Council and the Codes of Practice in raising standards and protecting vulnerable people.

We have already agreed to protect the social worker title through the Regulation of Care Act.

I now intend to take further action to strengthen the statutory basis of the Codes of Practice.

It is critical that agencies share and act on the right information. The presumption must be to share information but too often this does not happen.We must challenge this approach, particularly when it involves vulnerable children and adults.

I will now make sure that the databases being developed by the Scottish Consortium for Learning Disabilities in partnership with local authorities include a field for abuse and neglect.

Malcolm Chisholm is also asking the Health Department to develop national guidelines to strengthen the protection of vulnerable adults.

This will complement local guidelines recommended by the report, the same as you?

We will also introduce legislation to complement the statutory measures that already exist to protect vulnerable adults under the Adults with Incapacity Act and the Mental Health Act of 2003.

As I said in opening this statement, the SWSI Report is a damning catalogue of failings.

As I read the report I was not only profoundly moved and deeply affected by what happened to the individuals, but I became increasingly incredulous and angry that such things could have been allowed to happen over such a prolonged period of time.

But, I also became more and more committed and resolute in my determination to do anything I can to bring about the changes that are necessary.

Everyone must deeply regret what has happened to the individuals involved, but apologising or regretting does not go anywhere near far enough.

We need to take the actions we have set out to seek to ensure we are doing all in our power to prevent a repeat.

No one in this Parliament or more widely should doubt the steely determination of this Executive to ensure widespread action and change flows from this report adding to all we know from the past.

Today marks a watershed in the way we need to think about social work - we will ensure all the big questions are asked in our determination to ensure Social Work can make a stronger contribution to meetingScotland's modern needs.

And we will take whatever actions are necessary to ensure - as far as it is humanly possible to do so - thatScotland's vulnerable adults are not let down in this way again.