The consultant responsible for an independent review of how public bodies dealt with an abuse scandal at a day centre has defended her decision to ignore a string of key issues in her report.
Gill Poole’s serious case review for Doncaster Safeguarding Adults Partnership Board (DSAPB) was published today (Thursday), but omits nearly all of the concerns highlighted by Disability News Service (DNS) since it began investigating the Solar Centre scandal in 2010.
During those four years, DNS has highlighted serious failings by South Yorkshire police, the Crown Prosecution Service (CPS), the Care Quality Commission (CQC), and Rotherham Doncaster and South Humber Mental Health NHS Foundation Trust (RDaSH), which runs the Solar Centre, on the edge of Doncaster.
All of these news stories were emailed to Poole by DNS – and were received by her – but her report includes almost no criticism of the authorities.
Instead, it merely suggests that investigations into the abuse took “too long”, that knowledge of legislation was “an issue” for both the police and CPS, even though both organisations had to be told about relevant offences under the Mental Health Act by DNS.
She also found that there was “little evidence of a person centred approach or culture in the safeguarding process”, while the agencies “did not effectively engage the victims or their families”.
But the concerns were far more serious than that. Because of police and CPS failures, it took six years – and two unsuccessful investigations – for the case to reach court, even though an RDaSH report had suggested that 18 people with learning difficulties, high support needs and physical and sensory impairments had been abused.
In an interview with DNS, Poole admitted that she had failed to include concerns that the trust had been warned by other staff members about the Solar Centre abuse long before a whistleblower eventually disclosed allegations to an RDaSH manager in March 2007.
Poole, now a consultant but with a background in nursing, health visiting and senior management within the NHS, said there had been “some talk” about these other whistleblowers, but there was “nothing on paper anywhere” within the trust.
She said: “This was part of the discussions that were had with RDaSH but this report was about the investigations ‘post’ [the abuse being disclosed]and not what happened before.”
She said she had mentioned these claims to RDaSH and why it had taken so long for the abuse to be halted – it began in 2005, and probably earlier – but “they said there was nothing that proved it, no evidence of it”.
She admitted that she had accepted RDaSH’s word that there had been no earlier warnings, and so did not mention these claims in her report.
Poole also admitted that she had failed to mention that a report handed to relatives of the disabled people who had been abused at the Solar Centre did not include the true scale and seriousness of the abuse that had been detailed in individual safeguarding reports compiled on each of the adults who had been abused.
DNS revealed in August 2010 how the trust had left out nearly all of the detail that would have shown how serious the abuse had been, before handing the report to families.
The report given to the families omitted to mention that one day centre-user had been grabbed and forced to the floor, pricked with needles around his eyes, and pinned to a wall and hit around the head.
Another, Richie Rowe, had his wheelchair kicked “from one side of the room to the other causing Richie to crash into patients and the walls”, while on another occasion he was lifted out of his wheelchair and thrown onto the floor.
But none of this was included in the report handed to relatives, which detailed just four alleged incidents at the day centre – in which a disabled person was locked in a store room, two others were hit, and another was slapped in the face and threatened – and some incidents on a trip in a minibus.
She admitted that communication with families was “poor”, but when DNS suggested that her failure to include these points in her report amounted to a cover-up, she said: “Well, that’s terminology.
“That wasn’t what I was looking at. I was looking at the lessons that were learned subsequently to that. Had there been a change in practice.”
Then she added: “It not that I wasn’t looking at it. I was looking at the whole, and all of the communications with the families. I didn’t feel that that was part of what I was looking at.”
Poole also admitted that there was no mention in her report that South Yorkshire police had only reopened its investigation in 2010 after being threatened with a judicial review.
And she made no reference to the fact that DSAPB had to be threatened by one of the families with a judicial review before it would commission the serious case review.
Also, Poole left out any mention of how one of the nursing assistants who was suspended after being accused of abuse at the Solar Centre was then able to work for a care agency for nearly a year, even though she should have been barred from all care work with adults.
Poole said she did not even talk to the agency, and added: “The disciplinary investigations were not part of what I was investigating. It was the safeguarding stuff.”
When DNS asked why this was not a safeguarding issue, she said that problems with vetting and barring care and health staff were “not an issue at the moment” because a new organisation – the Disclosure and Barring Service – was now carrying out that work.
Concerns about the Care Quality Commission were ignored because that organisation had now “completely changed” the way it regulated trusts, she said.
CQC – which took over the regulatory duties of the Healthcare Commission in April 2009 – had been so impressed with the standard of care at RDaSH that it was “named and famed” as one of 44 high-performing trusts in October 2009.
She also failed to mention that CPS had made no attempt to persuade the judge in the trial of four former Solar Centre staff members – two of whom were convicted – to treat the abuse as disability hate crime.
Poole said this was because “CPS had apologised for the way that they dealt with the case as a whole and the training and the awareness and supervision of the solicitors involved in these sorts of cases is very different now, and I believe that there has been a change in practice and that was what I was looking for”.
Poole also apologised for failing to mention in her report the significant role of the media in securing justice for the Solar Centre service-users.
The scandal only became public knowledge because a local newspaper published details of RDaSH’s leaked report, and the four former staff members only faced trial because a DNS campaign persuaded CPS to reconsider its decision not to bring any charges.
Poole’s 25-page report, which took more than six months to write, contains little or no criticism of the police, CPS, the safeguarding board, or RDaSH itself.
Instead, she concludes: “The organisations and the processes seem to have lost sight of the 19 individuals who were abused; and the impact that the abuse and subsequent investigations have had on the victims and their families.”
Poole said she “fundamentally” disagreed that she had given the public bodies “a clean bill of health”.
The first of seven terms of reference for her serious case review says one of its aims was to “establish the lessons to be learned from the circumstances at the Solar Centre in relation to the way in which local professionals and agencies worked together to safeguard vulnerable adults”.
A second of the terms of reference says another aim was “to improve practice by acting on learning”.
Nursing assistants Susan Murphy, aged 44, and James Hinds, aged 59, were found guilty in May last year of a total of 25 charges of ill-treating people with learning difficulties, physical impairments and high support needs at the Solar Centre.
The two other defendants, Julie Burge and Michael Barnard, were cleared of all charges.
The service-users had suffered more than two years of abuse from Hinds and Murphy, who intimidated other staff into silence.
17 July 2014