The inquiry was announced in May last year after an investigation by the Independent revealed emotional and physical abuse at the children's home near Abergavenny, Gwent, and that Phillip Knight, a boy of 15 who killed himself in Swansea prison, had attempted suicide at the home. According to his social workers, his suicide attempt was not taken seriously by staff at the home, who sought to punish him for it.
The investigation revealed that 17-year-old Leslie Clements, who also committed suicide last year, made five attempts on his life before he was moved to a psychiatric unit where he could be treated. Leslie told the Independent that he was woken each morning by a member of staff who told him: 'You're going to fail.'
Alex Saddington, of the National Associaton of Young People in Care, said that while the report singled out the former director of social services, Roger Perkins, for 'autocratic, verging on dictatorial' management style, the report failed to focus on the abuse of children and young people by members of staff.
'Lord Williams, the inquiry chairman, spoke of 'low level violence' and said young people accepted punishments such as being 'knuckled' on the head, but I don't believe they did accept it. The language of the report seems to qualify the violence,' he said.
'Slaps and knuckles were part of it, but there was much more. There was punching and there was emotional and psychological cruelty. It misses what Leslie Clements talked about. Staff telling him he was 'shit' and that he would never do anything with his life. The report does not address this and does not particularly say anything. It is nowhere near as informative as the Staffordshire pin- down inquiry.'
The inquiry report found that 'neither Ty Mawr nor its staff could be fairly blamed' for the death of Leslie Clements and that while the home was an 'inappropriate placement for him', staff treated him with 'affection'.
There was also disappointment in Dyfed with the report's finding that Ty Mawr staff could not be criticised for their handling of a suicide attempt by Phillip Knight in June 1990. The report says: 'There is no fair basis upon which staff at Ty Mawr or employed by Gwent County Council could reasonably be criticised in respect of Phillip's treatment at Ty Mawr.'
Dewi Evans, Dyfed's director of social services, said he stood by his social workers' reports that staff at the home had called police instead of an ambulance when they discovered the damage Phillip had caused to his room. A Dyfed social worker said: 'Staff were more interested in damage to property than to life and limb.'
Mr Saddington said he was surprised that the inquiry report had rejected criticism levelled at the home's use of secure unit cells by the Social Services Inspectorate. Its report published in June last year criticised the home for locking up children for 'prolonged and persistent' periods in 1989.
The report also stated that while the secure unit was intended to protect children from harming themselves, young people at the home believed it was being used as a punishment.
The report criticised staff for poor record-keeping, which made it difficult for inspectors to check how long children were being kept in solitary confinement. But the inquiry report found there was 'no abuse of secure accommodation' at Ty Mawr.
'We are pleased that Ty Mawr is to close and that the management has been heavily criticised, but I'm disappointed. I don't think Leslie Clements would have been happy with it,' Mr Saddington said.
He also claimed members of the inquiry had refused to disclose how many young people had given evidence and how many were allowed legal representation. He said this information would highlight the scope of the inquiry.
The great irony was for all the Government's guidelines on 'listening to children', the two most important witnesses, Leslie Clements and Phillip Knight, were not heard. They were dead before the inquiry began its work.
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