Lord Carlile of Berriew was asked to look at services at Doncaster Council by Education Secretary Michael Gove following the publication of the full serious case review into the brutal attack on an 11-year-old and a nine-year-old by two brothers, aged 10 and 11, in Edlington, South Yorkshire, in 2009.
His report, published today, coincides with a highly critical inspection report by Ofsted on the town’s child protection services.
Lord Carlile’s report prompted Mr Gove to say that more children should be taken into care more quickly to rescue them from “a life of soiled nappies and scummy baths, chaos and hunger, hopelessness and despair”.
Mr Gove said too many children were living in “physical and moral squalor”, being allowed to stay with neglectful or abusive parents for too long.
And he said more backing should be given to social workers “who rescue children from homes where they are left in their own urine and faeces for days, left to forage for scraps of food and drink and denied warm, clean bedding and clothing”.
At a speech in central London, he strongly backed assertions made in a report by Lord Carlile, who said in his report: “I found that Doncaster today is not faced with the shambolic situation of early 2009.
“However, there remain weaknesses, which have been highlighted by the consequences of a severely critical report following an Ofsted inspection in October 2012 of the arrangements in Doncaster for the protection of children.”
The council has admitted services have not improved enough since the events of 2009, saying “features of that systematic failure remain today”.
Mr Gove ordered the Carlile Report into the background to the Edlington incident after he concluded the serious case review published in March did not “meet his expectations” and showed the current system of serious case reviews is “failing”.
The incident which sparked the controversy was a savage attack in which the two brothers lured their victims to a secluded spot and subjected them to 90 minutes of violence and sexual humiliation.
The victims, who are uncle and nephew, were strangled, hit with bricks, made to eat nettles, stripped and forced to sexually abuse each other.
The older boy was seriously injured when a piece of ceramic sink was dropped on his head.
The attackers were locked up in 2010 for a minimum of five years and will be released at the end of their sentence only if the Parole Board believes they are no longer a danger to the public.
The brothers had been placed with foster carers by Doncaster council shortly before the attacks. They had grown up in an extremely violent home in a different part of Doncaster, where they watched ultra-violent movies and pornography and were exposed to drink and drugs.
An executive summary of the serious case review was published in January 2010 and prompted a political row over whether to publish the full version.
But when the full, if heavily redacted, report was published in March, Mr Gove called in Lord Carlile.
The serious case review concluded the attack was “a preventable incident” and identified “more than 30 opportunities that could, with different and clearer judgment and action have reduced the harm suffered by *(the brothers) and their harm to others.”
Doncaster Council said in March that it was taking disciplinary action against five members of staff and had referred one former employee to the General Social Care Council, the social care regulator.
The council said in a statement that 279 members of staff were involved with the brothers’ family over a 15-year period.
Doncaster Council’s director of the children and young people’s service Chris Pratt said: “It is clear that we have not yet fully recovered the systematically broken services that we previously had, and as Ofsted says, features of that systematic failure remain today.
“The reports do acknowledge progress has been made - and Lord Carlile’s reporting states Doncaster is not faced with the shambolic situation of early 2009 - but I’m acutely aware our progress hasn’t yet come far enough.
“As a result of better child protection work, we are now actually working with an overwhelming number of children - including three times as many more child protection investigations compared to two years ago.
“Together with huge difficulties in attracting experienced social work professionals to work in Doncaster, this has put tremendous pressure on our services and meant our journey of recovery hasn’t coped as well as we had planned.
“However, these are not excuses and we can and must do better to improve services.
“We are using these reports as a major opportunity to up our game and are determined to rejuvenate our improvement plan to speedily put in place the changes that will provide maximum protection for all our children and young people.”
The Ofsted report found that all areas of Doncaster’s child protection services were inadequate.
The report said Doncaster could not be confident that all children known to the children and young people’s services were safe.
It said: “In too many cases, professional practice was poor, management oversight ineffective and risk to children not identified or progressed.”
Lord Carlile said his report summarises more than 100 important events affecting the brothers who committed the assault between May 2005 and April 2009.
He said in the report: “It is simply shocking to reflect that, over 100 events after the first, the two boys were out on the streets uncontrolled to the extent that they very nearly ended the life of a boy of their own age.”
The QC said: “With those events in mind, including their sheer volume, it hardly requires a report like this to note with regret that the Doncaster social and other relevant services failed to co-ordinate any realistic attempt to address the problems caused by, and of course faced by (the brothers).”
Lord Carlile said there needed to be a “radical look at the way interventions are assessed” and said he had encountered disquiet over the current presumption that a child should be kept with its natural parents if at all possible.
He said in his report: “I recommend that we need to take a radical look at the way interventions are assessed and dealt with.
“Some old assumptions may not be as sound as has been suggested.
“There has been a degree of disquiet suggested to me at the length to which the system sometimes acts to uphold a key principle in the Children Act 1989 that a child’s best place is with the natural parents wherever possible.
“I have considered how one might address this.”
He said: “For example, for cases where there have been three police reports of criminal behaviour (or comparable trigger events) on the part of a child in a given period, consideration should be given to placing the burden on the parents and the child’s legal representatives in any ensuing court proceedings to show that the child’s welfare and best interests are served by leaving him/her in the family home.”
The Ofsted inspection team looked at issues of the effectiveness of the help and protection provided to children, young people, families and carers; the quality of practice; and leadership and governance.
All areas were deemed to be inadequate.
The report said the inspectors found 244 unallocated child in need cases.
In a number of these, it had not been recognised that the children involved experienced, or were at potential risk of, serious harm.
The report said Doncaster children’s services immediately set up a social work team to take responsibility for the unallocated cases.
This was the second unannounced Ofsted inspection since the Secretary of State issued an improvement notice in March 2009 due to systemic failures across children’s services.
At the time of this inspection, 508 children were the subject of a child protection plan - the highest ever recorded in the borough.
The British Association of Social Workers said staff in Doncaster had been subjected to “draconian conditions and within a bullying culture”.
It also said social workers across England were facing “excessive bureaucracy, deep cuts to support staff and rising caseloads”.
Acting chief executive Bridget Robb said: “No assessment of the standards of social work practice in Doncaster is complete without an understanding that social workers in the local authority have been working under draconian conditions and within a bullying culture.
“Staff there were recently issued with a ‘signed or be sacked’ ultimatum to accept cuts to their pay and conditions, so it is no surprise that Doncaster has problems recruiting and retaining staff, and has subsequently been downgraded by Ofsted.
“These unacceptable issues in Doncaster are exacerbated, there and elsewhere, by the single biggest issue currently facing the majority of child protection professionals in England - that social workers are simply not getting time to see children.
“GPs are not expected to cure people by filling in forms instead of seeing patients, yet social workers remain chained to their desks unable to spend time with vulnerable children who need their support.
“Excessive bureaucracy, deep cuts to support staff and rising caseloads mean that few local authorities in England can say their social workers operate in a suitably safe and acceptable environment.
“Social workers are already at the front line, they know the problems, and they know the solutions, but their voice is still being overlooked by ministers in favour of advice from highly paid consultants, who often lack both experience and expertise.
“We hope that any reforms will properly consult with frontline social workers and enlist their support, rather than be presented as another dictat imposed on an already beleaguered workforce.”
Lord Carlile recommended family court judges should be brought in to advise on all serious case reviews (SCRs).
He said this would help with a number of problems, including the way in which redacted reports fail to read as a coherent story.
The QCs said the published Edlington SCR contained all 619 paragraphs of the original but with many passages blacked out.
He said: “The effect of this is to give the impression of concealment, or at best to interrupt the narrative in a way that makes parts impossible to read.”
Lord Carlile said: “I recommend the production of SCRs in two forms, open and closed: the open version would be a fully informative document, without redactions.”
And he said: “In every area of the country there is at least one designated family judge, a Circuit Judge who specialises in family and children’s issues.
“These judges are expert in their field. I recommend that a designated family judge should be asked to participate as an adviser in every SCR.”
The lawyer also pointed to lack of involvement and leadership from elected officials in Doncaster ahead of the 2009 incident.
He said: “It did not occur in Doncaster before 2009, and is not being achieved now in a satisfactory or accountable way.
“The almost unchallenged description I have received discloses that in the period 2005-09 there was an unparalleled level of dysfunction in Doncaster.”
The report found that the high number of child in need cases without a named social worker meant the local authority could not be confident the children had their needs met or were protected.
It said: “There are systemic and unacceptable delays in ensuring that their needs are met in an effective and purposeful way.”
The report added that children at potential risk were not always identified due to management oversight which was “inconsistent” and “lacks rigour”.
In too many cases, there was not appropriate intervention or effective protection of children.
In some cases, delays in planning meetings led to children being left in unsatisfactory and risky circumstances for too long.
An increase in the number of cases in the last 12 months had put extra pressure on staff and impacted on services.
The report made a number of recommendations to improve children’s services in Doncaster.
It also highlighted a number of areas of improvement, some of which were rated as being adequate or good.
It said: “While progress is marked in some areas, the council acknowledges that children and young people’s services remains fragile and features of the historical legacy of failures are still evident in some significant aspects of child protection work.
“The significant increase in the volume of contact, referrals and the number of children on child protection plans over the past 12 months has severely impacted on capacity and further weakened services to children and young people and families.
“Consequently, a significant number of children known to Doncaster Metropolitan Borough Council are potentially left at risk.”
In his speech in London, Mr Gove said: “Anyone reading both reports will appreciate that the problems Doncaster faces are not amenable to a quick fix. Nor is there any single individual - or group - who we can say are alone responsible for the problems Doncaster faces. But the situation is unacceptable, and needs radical change and improvement.”
The Education Secretary said: “I’ve taken a particular interest in child protection in Doncaster because I, like many, was horrified by the events a few years ago in Edlington, a village within the Doncaster local authority area, which resulted in two innocent children being horrifically abused by other children who were themselves the victims of parental abuse and neglect.
“I had the opportunity to meet the parents of those victims and was deeply moved by their courage and also determined that lessons be learned.”
Mr Gove said he is due to meet the town’s MPs next week when he will announce the action he intends to take.
On the Carlile Report, he said: “Reading his report, I have found his overall argument compelling.
“There are a series of specific recommendations, many of which I am instinctively drawn to and all of which deserve careful consideration. The Government will respond formally to all the recommendations in due course.”
He said: “And one of the first arguments where I want to hear how people respond is the case Lord Carlile makes that we should be much more assertive in taking children out of homes where they are at risk.”