The abuse of children at a secure training centre could have been stopped if procedures had been followed effectively, a report has concluded.
A serious case review has today been published into failings at Medway Secure Training Centre (STC), in Sir Evelyn Road, Rochester.
In January 2016 the STC was the subject of a BBC Panorama documentary in which an undercover reporter revealed abuse at the G4S-run facility during his time there the previous autumn.
John Drew, chair of the Medway Safeguarding Children board, admitted many lessons will be learned
He filmed staff using excessive force to restrain children, inappropriate language, and shouting and bullying at the centre, home to 76 12 to 18-year-old offenders.
Footage shows one member of staff coming up with excuses to attack a boy and another bragging about stabbing a trainee before later saying he was "properly trying to break" a boy's skull.
In July 2017, following two Medway Local Safeguarding Children Board reviews, children's social work expert Alex Walters was appointed to head up an independent review into practices from September 2014, when Ofsted judged the STC to be 'good'.
Mrs Walters said having conducted interviews with children who were at the centre it was "clear they were a highly vulnerable group... who required the most skilled work force... to enable them to lead productive lives and become adults who do not continue to cost the state in terms of their future health needs and potential offending."
G4S was awarded a contract to run the STC in 1998 on a 15-year PFI deal, which was extended twice.
At the time of the incidents there was a very high staff turnover rate at the centre.
This meant employees who had not previously worked with children were put to work in the centre without adequate supervision.
Staff were subject to appropriate checks and training, although the seven-week course was class room based.
There were also concerns about the whistleblowing process which required staff to provide contact details and therefore eroded trust.
There were also reports of managers asking staff to effectively play down incidents at the centre in an effort to meet targets.
G4S was paid £10 million to run the centre, one of three such facilities in the country, in 2014-15 and would be fined if they 'lost control', leading to a situation where it paid to lie about incidents.
In the run up to the filming G4S had already had its contract at Rainsbrook, another STC, terminated because of abuse.
As part of the review 14 key agencies involved in the centre, including Medway Council, Medway NHS Foundation Trust and Kent Police, carried out Individual Management Reviews.
This process led to various concerns being flagged up with procedures in place at the centre.
Staff at Barnardo's, who acted as 'advocates' at the STC and handled concerns from children, said they received some complaints about restraints but not on the scale exposed by Panorama and not concerning the same staff.
But children interviewed described the 'barrier of visibility and identification' of being seen by staff talking to an advocate and having to ask staff to speak to an advocate.
Even if advocates did have serious concerns the contract with G4S meant they were not allowed to independently contact the Local Authority Designated Officer (LADO), who was responsible for dealing with allegations, independently.
'Had a number of arrangements been more effective there [would have been] opportunities to prevent the abuse of children...' — Alex Walters, who chaired the review
The LADO role itself was branded "erratic and ineffective".
"Policies were not followed and responses were slow," Mrs Walters noted.
The priority of the service, he said, "appeared to be proving if allegations could be substantiated" rather than looking into them further.
It was also revealed Kent Police did not deal with allegations made by children effectively.
The review notes: "It is clear the limited police response to previous allegations from or about children at the centre combined with an ineffective LADO role resulted in an ineffective response."
In the three-year period of the review there were 90 presentations from children from the STC at Medway Maritime Hospital's A&E department.
Hospital staff did not inform their next of kin of these visits, instead relying on STC staff to do so.
Similarly follow up appointments were often missed but medical staff did not notify the child's family or home authority.
Children interviewed by Mrs Walters were negative about lock downs being used for varying periods due to staff shortages and also reported some staff were more "heavy handed" than others.
There was a view that staff picked on vulnerable children — those who were young, did not speak English or had no family.
They also described incidents of staff deliberately confronting children out of sight of CCTV cameras.
On one occasion during the Panorama documentary a member of staff forces a mentally ill 14-year-old to the floor and digs his thumbs into his neck and head simply because the boy insulted Liverpool football club.
He does this in a spot he knows is not covered by CCTV.
Three key areas for improvement were identified around recruitment, handling of allegations or concerns and 'creating safe working cultures', which includes setting up whistleblowing procedures and improving training.
In total 38 recommendations were made.
Mrs Walters concludes: "Had a number of arrangements been more effective there [would have been] opportunities to prevent the abuse of children...
"The absence of a safe organisational culture combined with the fact the processes to monitor the STC were not effective in identifying and responding and monitoring allegations of abuse meant children were not kept safe."
Independent Chair of the Medway Safeguarding Children Board John Drew said: “I was deeply shocked by the way the children were treated by staff at Medway Secure Training Centre; they had a duty of care to those young people in custody and put them in a vulnerable position.
“It is clear from the conclusions from the extensive review that there are many lessons to be learnt by a number of agencies. The board fully accepts and adopts the independent reviewer’s recommendations and will ensure that the necessary improvements are made as a matter of priority. However, it is encouraging to see that agencies have already started toaddress some of the initial concerns raised and make improvements within their organisations.
“On behalf of the board, I would like to thank Alex and particularly all of the children who were brave enough to come forward and assist us with the review.”
In the wake of the programme airing police probed conduct at the STC dating back to 1998, when G4S took over, and identified 23 suspects and 39 victims.
Sixteen people were arrested and nine were charged — seven were cleared and jurors couldn't reach verdicts on two. The Crown Prosecution Service decided a real trial was not appropriate.
The STC was transferred into the care of Her Majesty's Prison and Probation Service in April 2016 and last year, following three poor Ofsted inspections, the government announced a £5 million investment in the site, which will see it open as the first 'Secure School' in late 2020.
Director of children and adults services at Medway Council Ian Sutherland said: “We take concerns around children’s welfare extremely seriously and the footage from the documentary was deeply concerning.
“We fully accept the recommendations in the Serious Case Review and will be addressing these as a matter of priority. Substantial changes have already been made to the LADO service and these changes, which were made in 2017, addressed many of the points raised following external inspection and reviews. It is also encouraging that the review recognised the ‘significant change and improvement’ in the way our LADO team responded to allegations at the centre.
“To ensure efficient support is provided to protect the welfare of children and young people, we are working even closer with our partner agencies to share and address safeguarding concerns. This helps give our safeguarding professionals access to all available information for consideration before making any assessments or decisions.
“It is also important that young people feel confident to address their concerns directly with us and we have made changes within the safeguarding service to help improve the access and support they are offered. We will continue to learn from the findings and address the recommendations in the Serious Case Review to ensure all vulnerable children and young people are safeguarded.”
Managing director of G4S Custodial and Detention Services Jerry Petherick said: “The behaviour of some of our staff at Medway in 2016 was completely unacceptable, and in stark contrast to our training and values.
"The well-being of those in our care is of the highest priority, and the lessons learned from Medway have been at the forefront of our management of the Oakhill secure training centre in Milton Keynes. Ofsted inspectors recently noted the positive work at the centre around staff retention, continuity of care, and education, and we’ve also made significant investments in CCTV and body worn cameras to enhance the safety of the young people and our staff.
"I am confident that we are an organisation that learns and improves, and the good work of the team at Oakhill demonstrates that.”
Influential prison reform campaign group The Howard League received more than 50 calls in respect of about 40 children at the STC during the three-year period the review focused on.
Chief executive Frances Crook said: “No one who watched the Panorama documentary on Medway will ever forget its most distressing scenes. Today’s report reveals in yet more detail the harmful culture that has festered there for decades.
“The Howard League opposed the creation of secure training centres in the 1990s and warned that children would be damaged and hurt in these institutions. For many years independent inspectors’ findings have underlined that this is a failed model of detention. After more than 20 years of children being mistreated and their life chances damaged, it is time to put an end to this.
“The government has plans to convert it into a ‘secure school’, but a renaming exercise is not going to deal with the fundamental toxicity of this institution. Medway must close and it must close now.”