8. THE NATURE OF ABUSE
Glasgow' City Council's investigations
8.1 The conclusion of Glasgow City Council investigators, as we noted at paragraph 2.2, was that a core of around 40 staff was involved in abuse and a much larger number colluded over a long period of time. The publicity given to this conclusion, and the inferences drawn as to the nature of the abuse, brought a strong reaction from many former Kerelaw managers and staff. Many expressed disbelief and shock, on their own behalf or on behalf of others. Some remain angry about what was reported, expressing disdain for Glasgow City Council and the investigation that continues to be aired in the media and various public forums.
8.2 These strong reactions are not confined to those who were subject to allegations and implicated in abuse. Some who left Kerelaw with an unblemished record consider that they have been branded guilty by association. Others, whose involvement was to place young people in Kerelaw, worry about the extent to which they may have colluded in abuse without knowing. Many who were the subject of unsubstantiated allegations are angry about the Glasgow Report. Others are concerned that the report adversely affects the whole residential child care sector, undermining confidence and casting doubt on the ability of anyone involved to care properly for young people. The Inquiry notes that a significant number of ex-staff who were interviewed told us that they had not read the report at all, some commenting that it was hardly worthwhile, given its short length.
8.3 Some former residents have also expressed concerns about what has been said about Kerelaw. It was home for a time to a great many young people over more than 30 years and some who felt that they had a good experience have been upset by the negative commentary on Kerelaw and the people who worked there. Such commentary has caused concern to families and friends, and to organisations involved with the survivors of abuse.
8.4 Although it was not the Inquiry's remit to consider individual cases, we took the view that we should test the Council's conclusion and look closely at what the abuse was. This revealed a more complex picture than might be inferred from the brief Glasgow Report. The report stated that a range of allegations of abuse resulted in disciplinary proceedings against 23 of 38 staff who were subject to fact-finding investigations. The allegations constituted a substantial list and included physical assault, some of it arising from the inappropriate use of restraint, including pain compliance, sexual misconduct, excessive horseplay, and aggressive behaviour. Investigations were also said to have uncovered examples of emotional abuse in which young people were denigrated and disparaged.
8.5 While the Inquiry was able to confirm from the records we checked that 38 people had been subject to fact-finding, we identified 29 individuals who by the end of 2008 had in fact been disciplined. We are aware that disciplinary action continued after the Glasgow Report was published and this may account for the disparity between the Inquiry's figure of 29 and the Council's figure of 23 at August 2008, although we were unable to confirm this. The disciplinary actions resulted in 14 dismissals and 13 individuals received other disciplinary outcomes, including written warnings and management discussion followed by return to work. Most of those who were dismissed appealed, but only one appeal was upheld by the Council's Appeals sub-committee, with a reduced penalty of a final written warning. Some then went on to Employment Appeals Tribunals which deemed dismissal to be unfair in the case of the Principal and the Deputy Head (Open School). The Council conceded two Tribunals on procedural grounds. Two have lapsed or been withdrawn by the appellant and three remain active.
8.6 Many who gave evidence to the Inquiry disputed the picture painted by the Glasgow Report and by the media coverage of the Court cases involving the art teacher and the unit manager. Those included supporters of both men, ex-employees, former sessional workers and academics. Some ex-staff accepted that physical abuse may have taken place, but argued that it was not intentional or that it was not regarded as abuse at the time.
Sexual abuse
8.7 Some of the criticism of the Glasgow Report was strongly expressed, notably in relation to the inference that might be drawn that sexual abuse was widespread, systematic and longstanding. Many former staff who gave evidence found it hard to believe that sexual abuse had occurred, but accepted that convictions had been secured. Some with hindsight questioned whether they themselves had been sufficiently observant. There was agreement by witnesses that sexual abuse is by its nature secret and, as a result, difficult to secure sufficient evidence to prosecute; and there was recognition that sexual abuse beyond that which came before the Court in 2006 might have occurred, without their being aware of it. A small number of witnesses were unwilling to accept the verdicts of the Court.
8.8 The Inquiry is not in a position to say whether sexual abuse occurred on a larger scale or over a longer period than established by the convictions of two former employees. The Inquiry was not charged with looking at individual allegations and we did not seek any out. We note that beyond the three ex-employees who went to Court on sexually-related charges, there have been no further prosecutions for sexual abuse at Kerelaw so far. At the time of writing we understand that there are no current police inquiries into allegations of sexual abuse at Kerelaw, although the possibility of further complaints of criminal conduct and police inquiries cannot be ruled out.
8.9 We also note that, although the Glasgow Report refers to sexual, physical and emotional abuse, sexual abuse and misconduct accounted for a small proportion of the allegations made to investigators and followed up by them. This is consistent with research into large-scale abuse in residential settings. According to Barter 12 (2003) writing on the abuse of children in residential care:
Within US research no clear pattern has emerged regarding the type of abuse children in residential facilities most commonly report. Both US research and the limited number of UK studies suggest that sexual abuse is not the most commonly reported form of institutional maltreatment.
8.10 On the other hand, according to Barter:
……there may exist substantial differences between what abuse occurs and what is reported. Due to the secretive nature of sexual abuse there may be fewer opportunities for external individuals to witness and subsequently to report the incident. Children themselves may be particularly reluctant to report sexual abuse, feeling embarrassed or that they may not be believed.
8.11 While we cannot form a view of the scale of sexual abuse at Kerelaw beyond what has been established in the Court, only 21 cases of alleged abuse of different kinds were referred to the Procurator Fiscal. These included those with a sexual element. It would therefore be very unfortunate if the inference drawn from the broad-brush conclusions in the Glasgow Report and the associated media coverage was that all of the core of staff to which the Report referred were involved in sexual abuse.
Physical abuse
8.12 The question of what constituted physical abuse and how widespread it was is complex. The proposition that there had been physical abuse as suggested by the Glasgow Report was challenged by a number of staff who had been subject to investigation and by others who came forward to the Inquiry. The most robust denial was from some of those who had been disciplined, although there was also recognition that certain practices which had once been acceptable had become unacceptable with the passage of years, as child protection policies and regulation had developed and as societal sensitivities to violence against children and young people had strengthened. Some witnesses - ex-residents and staff alike - seemed able both to deny that abuse took place and at the same time describe practices that were abusive.
8.13 Glasgow City Council's investigators interviewed employees of the school prior to its closure, past employees, former and current residents, parents and associated professionals, and scrutinised a large number of records and logs. The Inquiry received oral evidence from all but one of the 13 people who were at one time or another directly part of the investigation team and accessed written records of their interviews with over 90 young people and 100 staff during their two-year investigation.
8.14 Not all the residents or former residents interviewed by the Council's investigators made allegations. A number said that their experiences at Kerelaw had been positive. Some appeared to accept violence against them as a normal part of their lives or in some cases had concluded that it was justified by reference to their behaviour at the time. Some took the view that the good things offset bad things that happened to them. It was, however, possible from the records of the interviews to build a picture of an institution where - irrespective of whether specific allegations against particular individuals were in all respects substantiated - maintaining staff control over young people had a high priority, and where physical restraint played a significant part in many young people's lives. The Inquiry received evidence from former staff and others which confirmed this picture, and which was described by some witnesses as the result of a legacy of Kerelaw's origins as a List D school. We shall return to this in Chapter 9
8.15 A number of witnesses put it to the Inquiry that, as Kerelaw was required to manage a difficult client group, staff had to be in a position to maintain order, for their own safety as well as that of the young people. We acknowledge that appropriate levels of control are necessary in a volatile environment if staff are to feel safe and secure in the workplace, and if young people are to be protected, sometimes from themselves. This may from time to time require physical intervention. Order is also important if constructive work is to be done with a potentially disruptive client group. But it is neither acceptable nor productive if physical intervention becomes the first or indeed the "normal" response to actual or potential disruption. Nor is it acceptable if physical intervention is used as punishment, or takes place outside approved procedures, or is disproportionate to the circumstances to which it is a response.
8.16 Evidence from the Council's investigations and from ex-employees and young people to the Inquiry suggests that for some staff at Kerelaw physical intervention was a first, rather than a last, resort in dealing with difficult behaviours. This appears to have been an approach that became particularly favoured by certain individuals as the client group's behavioural problems became more challenging. Young people who had been restrained in other residential establishments, and who had experience of how restraint should be carried out, often complained to investigators that on many occasions it was not practised in accordance with the approved procedures. The evidence also suggests that practice could vary from unit to unit and be dependent on which staff were in charge at the time. An ex-teacher put it to the Inquiry that if physical intervention was followed properly:
then it is fine but there were concerns it was being used for swearing for example…it seemed to depend on who your unit manager was…
Therapeutic Crisis Intervention
8.17 Precipitate use of physical restraint in an actual or potential incident would have been inconsistent with the policy of "Therapeutic Crisis Intervention" introduced by Strathclyde Regional Council in 1995 and adopted by Glasgow City Council after local government reorganisation. Skinner (1992) saw training in conflict avoidance and managing violent behaviour as essential for residential care workers. He observed that for children to feel safe in care there needed to be clearly set limits to acceptable behaviour. Physical restraint remains a controversial area and one which many children complain about. National guidelines Holding Safely13 were finally published in 2005, and a number of different methods of managing challenging behaviour, including restraint, are used throughout Scotland.
8.18 TCI is a system for preventing and managing challenging behaviour in young people. Although it provides for physical restraint to be employed and sets out guidance on how this should be done, it is in fact a system intended to reduce the use of restraint. The system was developed by Cornell University in Ithaca, New York in the early 1980s, following research that indicated young people and staff were being injured through the use of restraint in residential facilities. This was seen as a consequence of restraint being used too readily and of an absence of training in safe methods. TCI was introduced in the UK in 1993 and is now used by around 70 agencies.
8.19 All staff at Kerelaw were required to undertake training in TCI and a programme to enable them to do so was introduced in the mid-1990s. Records confirm that staff did undertake training although, as this required a minimum of 4 days away from post, finding time could be difficult. The current version of TCI, which dates from 2001 and is being revised, stipulates that refresher training should take place every 3 to 6 months, a significant resource commitment. In the 1990s the frequency of refresher training was advisory, rather than compulsory, and at Kerelaw it fell behind badly.
8.20 The TCI student workbook is a substantial document. Some two thirds of it is devoted to management techniques aimed at stopping escalating behaviours and helping the young person regain control, with the intention of avoiding physical restraint if at all possible. Training must be carried out by certified trainers and must cover the full system, not simply the physical restraint elements. The strong emphasis on TCI as a "system" is important, and its designers recommended that senior management receive training as well as operational staff so that it is supported by appropriate leadership, supervision and monitoring.
8.21 The introductory pages of the workbook describe TCI as a crisis prevention and intervention model for residential child care facilities which assists organisations in preventing crises from occurring, de-escalating potential crises, managing acute physical behaviour, reducing potential and actual injury of children and staff, and teaching young people adaptive coping skills. TCI recognises that physical restraint may be necessary in the interests of safety, but notes that the physical techniques presented in the training should never be seen as an end in themselves.
8.22 The workbook spells out very clearly what physical intervention does not do, in the following terms:
It is not used for retaliation, discipline, or punishment. It does not intentionally inflict pain, injury or harm to the young person. It is not physical abuse. Techniques such as hitting, yanking, or pushing are not applications of physical restraint.
8.23 We were told in evidence that most staff broadly welcomed the training in TCI. Prior to the introduction of TCI many staff had little or no training at all in safe physical interventions, and were expected simply to handle crises as best they could. Some staff had undergone training in the 1980s and 1990s at Gartnavel hospital in physical restraint involving pain control techniques, more akin to that used by the prison services and secure psychiatric hospitals. Many staff were uncomfortable with that. For them TCI was a welcome development, and we heard evidence that there were examples of good practice in TCI at Kerelaw.
8.24 For others it was a less welcome development, with some unconvinced as to its suitability for use across the board. Some appear to have misunderstood that TCI was a systemic approach to reducing the need for physical intervention, seeing much of the instruction in de-escalation as the "theory", and restraint as the practice. Others appear to have been more overtly hostile. We were told by one ex-staff member that some staff:
had a less mature attitude to the use of restraint and the impact on young people. At training many showed a dissent to learn and presented a dismissive attitude by reading the newspaper and asking when the training would finish. Some would get up and walk out or skip parts that they did not like.
8.25 This should have been picked up both by trainers and management and followed up. There is evidence that for some staff shaking off the legacy of training in pre- TCI pain- compliant methods was difficult. It was put to the Inquiry by one observer that:
Staff had been trained in painful holds. Then they were taught TCI and told not to use the old method. A lot of staff struggled with TCI……
and by a practitioner that:
the aftermath of the Gartnavel training was still present in how staff behaved……… people went too quickly to the last stage.
8.26 That some staff struggled to grasp the point of TCI is not surprising when one considers this extract under the heading "Discipline/Care Control" from a Kerelaw School and Secure Unit document in 1997:
On occasions young people in secure lose all personal controls and act out in an extremely violent fashion. In order to maintain the safety of themselves and others measures of restraint have to be used. A number of staff have been trained to cope with these incidents, and by June 1996 all staff had completed this training. The social work department has endorsed this training which is the programme of behavioural management approaches and techniques known as Therapeutic Crisis Intervention.
8.27 An ex-Kerelaw employee, reflecting frankly to the Inquiry on his own practice, admitted that there were many inappropriate restraints and that he quickly became part of the culture and took part. His view was that at Kerelaw:
they talked about TCI as a restraint technique rather than as a wider method. At Kerelaw there had not been an emphasis on TCI as a way of avoiding restraint... When restraint did occur people ended up reverting to old techniques.
8.28 This explains the emphasis laid by the developers of TCI on leadership by management, supervision, monitoring, and refresher training. However, there is a debate to be had as to whether de-escalation would be effective in all circumstances, particularly where the safety of a young person or persons, or staff members, was at immediate risk. If harm, including self-harm, is imminent, there may be very little time to de-escalate, and no alternative to a quick, but proportionate, physical response. The Inquiry saw reports of violent incidents, which provide a vivid picture of the kind of behaviours and aggression which staff often had to manage. One former staff member summed up his difficulty. He did not consider that:
TCI assists you to stop a young person going for another young person with pool balls in a sock, for example……nothing teaches you how to intervene to stop this happening and if necessary restrain the child.
8.29 There were occasions when de-escalation techniques provided for in TCI were used successfully at Kerelaw, and we heard witnesses refer to them. There were also occasions when proportionate, physical intervention to prevent harm was employed by staff at Kerelaw in a professional manner, with best intentions. This was confirmed by a number of young people. However, the volume of concern raised by residents and former residents with Council investigators about the way in which restraint was used and carried out by certain members of staff at Kerelaw, and the consistency of their statements across successive "intakes", do lead to the conclusion that many restraints involved painful holds and inappropriate locations or surfaces. Some of those restraints resulted in injuries to residents, including bruises, carpet burns, and in at least one case damage to a limb, and did not reflect observance of TCI. Some resulted in injuries to staff as well. One young woman summed up her experience of restraint at Kerelaw in the following terms:
[she] was restrained a lot of times by various staff but did not think usually it was done the way it should be done - they pushed her face in the carpet, pulled her arms back, put their knees into her back to keep pulling her legs up…… it felt like they were pulling her body apart. This could happen if somebody was in a bad mood - she just had to say the wrong word and they would restrain her.
8.30 Disturbing though that description is, it does not mean that in all cases of inappropriate restraint the staff involved set out to cause injury to a young person. As noted earlier, TCI requires staff regularly to refresh their training, in all aspects of the system. They are also supposed to be re-tested annually, although the Inquiry was told that prior to 2001 it was only the physical part that was tested. While new Kerelaw staff would receive TCI training, there is ample evidence from the Glasgow City Council investigations, from North Ayrshire Council inspection reports and from paperwork seen by the Inquiry that staff did not receive refresher training or testing as they should have.
8.31 In May 2000, following analysis of Violent Incident report forms, the Head of Service raised in writing with the then Principal the question of TCI refresher training for Kerelaw staff. In the Autumn of 2000, a North Ayrshire Council Inspection Report on the Open School concluded that TCI refresher training needed to be developed. In early 2001, North Ayrshire Council reported on an inspection of the Secure Unit and noted that TCI refresher training was an issue there, as it was in the Open School, and that this training had "slipped". A year later, in its February 2002 report of a follow-up inspection of the Secure Unit, North Ayrshire Council again noted that TCI refresher training was overdue. In May 2003 the Principal issued a policy statement on TCI to staff, but it appears that it was not until after more robust external management arrangements put in place over the Summer of 2003 had identified a range of shortcomings in the use of restraint, poor recording practice, and inconsistent responses to incidents, that attention finally turned to TCI refresher training.
8.32 In the absence of regular refresher training, staff may well have lost sight of the main purpose of TCI, which was to reduce the need for physical restraint, even if they had clearly understood that in the first place. Nor would knowledge have been updated. For example, the Inquiry learned that there may have been confusion over whether TCI sanctioned the physical removal of a young person who was being disruptive to another place. Techniques for staff physically to "remove" or "escort" a young person were taken out of the 2001 version. While their intention had been to permit small movements within a given space, some practitioners saw this as licence to remove a young person from, for example, a communal area to a bedroom, where actual restraint might then be carried out. A common allegation by young people was that they were often manhandled or dragged upstairs to their rooms where " TCI" - or, more accurately, physical restraint - was then applied.
8.33 We saw a written assessment in the files of what was required so far as TCI training was concerned:
The 1-day refresher course run at Kerelaw is inadequate to update staff who were trained over a year ago (some staff did the course as far back as 1995/96). The TCI System has been considerably updated and amended in recent years and it is important that staff are fully refamiliarised with this. During refresher training some staff are still referring to outdated TCI books and holds which are no longer used….. the two day refresher course designed for use in GCCSWS Units should be used for all future updates done annually……More attention should be given to ensure that the TCI System is integrated into general practice, particularly de-escalation techniques, behavioural management approaches and appropriate use of the LSI [Life Space Interview]. TCI is a broad-based system for general practice in residential child care and needs to be integrated into the wider management of and operations at Kerelaw.
8.34 The assessment, dated 2003, included a query as to whether teachers needed to be "refreshed" as well. It appears that they did, and it was decided that all education staff should be called in for retraining. This required approval from education managers in HQ to close the school for a week. The training was described to the Inquiry by one manager at Kerelaw as a "disaster", with many managers and staff failing to attend at all or with attendance subsequently tailing off. The trainers were internal to Kerelaw, but were said to have stopped the training on occasion because of problematic conduct by participants. The Inquiry was told that the legacy of the event was the emergence of increasingly divisive practices, with teaching staff unwilling to implement TCI, instead preferring to call the police.
Intentional harm
8.35 Without proper refresher training and testing, any confusion in the minds of staff as to what was and was not acceptable under TCI would not have been addressed. Similarly, and despite what we heard about the attitudes of certain employees, some physical interventions by staff which they thought were TCI-compliant may have been carried out clumsily, thus resulting in pain and injury, but without an intention to harm. In her directions to the jury at the trial of the teacher and the unit manager, the trial judge, Lady Paton, sought to clarify the importance of intentional harm in determining whether a non-sexual assault had taken place. She suggested among other things that if a restraint was imposed for "cheek" or a "bad attitude" then it was imposed with "evil intent". ("Evil intent" is the intention necessary for assault.)
8.36 Some staff against whom allegations of physical abuse were made successfully argued to investigators or at disciplinary hearings that there was no intention to harm (ie "evil intent") in their actions at the time, and this was repeated in evidence to the Inquiry. This defence was prayed in aid not only in response to allegations of heavy-handed physical restraints but also in relation to what some former employees and Unison have described as "horseplay".
8.37 "Horseplay" is easier to recognise than to define, but might be described as rough and tumble, perhaps including "play fights", arm-wrestling, prodding, tickling, and other apparently non-threatening, light-hearted physical contact. This may be a commonplace in many ordinary private households. Where horseplay involves adults interacting with young people in residential care, its defenders may argue that it can have a beneficial effect in terms of relationships and trust, and that it simply reflects interactions which take place in stable and nurturing family settings. The opposing view is that it reinforces the unequal relationship between adults and children and in a residential setting provides adults with a means to demonstrate power and control, which can be abusive, and which in certain circumstances might also provide cover for inappropriate sexual contact. Horseplay may well conceal an intention to harm.
8.38 In an October 2007 paper responding to Glasgow City Council's conclusions about Kerelaw, Unison argued that horseplay was an issue on which staff were judged by standards that had changed and were different in 2005-6 from what had been acceptable years before. There may be some basis for that view so far as the period prior to that covered by the Inquiry is concerned. However, although horseplay might in the past have been accepted in residential settings, that had ceased to be the case by the mid-1990s. The Council's Care and Control Policy for residential establishments, which was re-issued in March 1998, was explicit that staff must not engage in horseplay. Moreover, a number of young people complained to investigators of physical contact from some staff members which, although disguised as "horseplay", went beyond what would at any time have been considered acceptable.
8.39 The most benign assessment of inappropriate behaviours at Kerelaw during the period covered by the Inquiry is that a number of staff were responsible for poor practice, either through what they regarded as horseplay or in the way in which they applied physical restraint. This poor practice then either went unremarked or was not sufficiently challenged by colleagues or managers. In either interaction there may or may not have been an intention to harm, but even if there were not, poor practice should have been challenged and addressed: the absence of intention to harm does not make poor practice acceptable.
8.40 It was suggested to the Inquiry that, as the Procurator Fiscal decided to prosecute for physical assault in only 2 of the 20 cases put to him by the police as a result of Operation Chalk, there was no intention to harm and that therefore physical abuse was exaggerated in the Glasgow Report. It is neither possible nor appropriate for the Inquiry to comment on decisions of the Procurator Fiscal, or on the specifics of the cases put before him. The allegations reported to the Procurator Fiscal were thoroughly investigated, before being reported to Crown Counsel who considered the full facts and circumstances of each individual case before making a decision. Before any decision to prosecute could be taken, Crown Counsel had to be satisfied that there was sufficient admissible, credible and reliable evidence to prosecute. There requires to be corroborated evidence to establish that a crime has been committed and to prove the identity of the perpetrator. That is a much higher standard than that of the balance of probabilities test which would apply in consideration of a child protection intervention or in the context of disciplinary action against an employee.
8.41 It is against the latter test that Glasgow City Council drew the conclusions that it did and proceeded with disciplinary action against particular individuals. From the employer's point of view, intention to harm would not have had to be established to proceed with a disciplinary hearing, although it might have had a bearing on the outcome and on the disposal. Non-compliance with Council policy could be a disciplinary matter, and a number of young people, again drawn from different age groups who were not at Kerelaw at the same time, complained to investigators that physical restraints took place that did not comply with approved guidelines. They also alleged that restraint was used by some staff as a first rather than a last resort, and that it was often used to deal with "cheek" or "bad attitude". A young woman 's experience of this in the late 1990s was recorded in the following terms:
If there was one thing that should have changed it was the way restraint was done at Kerelaw. Restraint was used too quickly, sometimes just for swearing…it wasn't done properly. They would deck you too quickly. They used to put your arms up your back. It was also common for staff to say horrible things to you while you were being restrained……this included references to[ her] adoptive parents and how they would not want [her ]back. There was always someone being restrained.
8.42 That restraint was not confined to dealing with physical aggression, or employed as a last resort in compliance with TCI, was confirmed by some former staff members, for example in relation to the "zero tolerance" policy in the Millerston Unit. That being so, if Lady Paton's test is taken as a guide, the actions of some staff were on occasion consistent with an intention to harm.
8.43 A more troubling assessment of what took place at Kerelaw is that there was a complex set of behaviours and motivations. These ranged from poor practice, a lack of compliance with TCI and the clumsy application of approved restraint procedures, to physical handling and treatment which were outside the scope of the approved procedures, and which in many cases amounted, on the balance of probabilities, to deliberate assault. Evidence available to the Inquiry does not lead us to conclude that it would be right to interpret the Glasgow Report as saying that a core of 40 people came daily into work at Kerelaw determined to inflict pain and punishment on young people. Some may have been very willing to do so, some may have resorted to doing so under pressure, and some may have been sucked into a culture in which showing who was the boss was important. Others may have inflicted pain through misunderstanding or misapplication of procedures. To some extent that complexity was recognised in the range of outcomes for individuals following the investigations and the subsequent disciplinary action, where that took place. But whatever the motivations, we believe that physical abuse did occur at Kerelaw, a significant core of staff was involved, and a number of others did not challenge it as they should have.
Emotional abuse
8.44 All forms of abuse carry an element of emotional abuse, the more so if the abuser is in a position of trust. Throughout our evidence-taking we heard from ex-employees and others that Kerelaw was treated as a "dumping ground" for particularly difficult children who had "failed" in other residential placements and for whom Kerelaw was the "end of the line". As we note at paragraph 12.24, Kerelaw was indeed the destination of last resort for many difficult, disruptive and damaged young people whose placements elsewhere had not been successful, and the records of incident reports illustrate well the challenge many of them posed.
8.45 However, that does not excuse poor treatment or abuse. The language of failure and dumping, though never far from the surface, seemed to gain increasing currency among some managers and staff as the proportion of children from Glasgow rose, as the numbers of those aged 16 and over, and problems associated with drugs, grew. A paper entitled "Improving Services to Young People" prepared by the Principal in June 2004 acknowledged that:
certain members of staff had developed negative attitudes to young people
and that recent events - a reference presumably to the Millerston investigation:
had highlighted the difficulties associated with keeping young people safe… when there is not an ethos and culture that values and respects young people
8.46 The negative attitudes and culture were not conducive to the creation of the caring therapeutic environment to which Kerelaw's plans and statements of purpose referred. The paper said that there was a need to ensure that all staff worked with young people through building relationships that respected and valued them as individuals. Had this been more fully recognised, communicated and embraced by all staff, more young people's experience of Kerelaw would have been positive; so too the experience of more staff.
8.47 A number of former employees told Glasgow City Council's internal investigators that certain employees referred to residents in very disparaging terms. The Inquiry was also told, by other sources, that it was common for young people to have their troubled histories used against them by staff who should have been working to enable them to move forward with their lives. One external advocate for young people's rights told the Inquiry that in her opinion Kerelaw staff were fairly consistent in the approach that they were dealing with "bad" children, and not children with challenging behaviour as a result of difficult or abusive family backgrounds. She stated that these attitudes were displayed openly in front of young people and other professionals. Another witness to the Inquiry was clear that:
negative attitudes to the young people at Kerelaw were held by both those staff working at Kerelaw and other staff………the attitude to young people at Kerelaw was terrible.
8.48 A frequently quoted example was of young people being discouraged from complaining by being told that because of their past they would not be believed. It was put to us that staff undermined the complaints and testimony of young people by referring to their personal histories and reasons for being in care. A witness to the Inquiry who pursued a complaint on behalf of a particular individual heard a staff member undermining the testimony of a young person on the grounds that he had "said his stepfather hit him all the time and they never proved that either".
Conclusion
8.49 The Inquiry believes that physical and emotional abuse of young people took place at Kerelaw over a period and was associated mainly with a particular core of staff. Although this was a concern for some of their colleagues, it went largely unchecked. Not all staff engaged in abuse and those who physically abused young people will not have done so all the time. Some may not have believed that what they were doing was abuse. Nevertheless, it was abusive and should not have occurred.