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Background:

41.01  M, who was born on 7 March 1974, was the youngest of five children who were admitted into care on 11 January 1978 pursuant to a matrimonial care order[540] made by His Honour Judge Meurig Evans in divorce proceedings. M's mother lived at Holyhead and he was placed initially in Ucheldre Community Home at Llangefni before moving on to Y Gwyngyll at Llanfair PG on 19 January 1979[541]. He was first boarded out (separately from his half-brothers and half-sisters) with foster parents at Carreglefn in Anglesey on 5 October 1979 and he remained there until 11 November 1980, but the placement was not successful.

41.02  Speaking of this period in his life when making a statement to the police in March 1992, M said that his first recollection then was of Y Gwyngyll, about which he had no complaints to make: he was treated very well there. He said also that he had no complaints to make about the way in which he had been treated by his first foster parents.

  41.03  M made a statement to representatives of the Tribunal in January 1997, in which he said that he was willing to give oral evidence to the Tribunal. However, when the time came for him to be called as a witness, he was not available and we admitted in evidence, therefore, his five statements to the police made in 1992 and his statement to the Tribunal.

  41.04  M's second placement with foster parents lasted over five years, from 11 November 1980 to 11 April 1986, after which he returned to live with his natural mother on trial, with the intention that he should do so permanently. He was discharged from care on 10 June 1988, at the age of 14 years, when the care order was revoked.

  41.05  M's second foster parents were Norman and Evelyn Roberts, who lived on a smallholding at Gwalchmai, in the centre of Anglesey. Norman Roberts was said to be a self-employed farm-worker, who also ran a mobile grocery business, although he described himself as a quarryman at his trial. Evelyn Roberts was a former SRN with two years' experience of nursing children (other than her own). They were approved as foster parents on 9 October 1978 and they were described as "most impressive" by the senior social worker who recommended them to the fostering panel.

  41.06  Mr and Mrs Roberts had two sons and a daughter of their own aged in 1980 approximately 21, 17 and 16 years respectively. The two sons married in 1982 and left home. The daughter married in 1985.

  41.07  During the period when M was fostered with them, Mr and Mrs Roberts had three other foster children staying with them. A boy (N) born on 15 February 1973 and his half-sister (O) had been placed with them briefly in 1979, and returned on a long term basis from 17 September 1981; and another girl (P), born on 15 November 1971, was placed with them on 25 May 1983.

  41.08  When M was placed with Mr and Mrs Roberts the intention was that he should be fostered for a short period of nine to 12 months to provide him with individual attention, which (it was thought) would have an ameliorative effect on him. He remained with them from about early 1982, however, on a long term fostering basis.

The allegations of abuse

  41.09  In his statement to the police made on 10 March 1992 M alleged that he had been treated cruelly, like a slave, throughout his period with Norman and Evelyn Roberts. He had been required to get up at 6 am daily to feed the animals in all weathers. False allegations of theft of food had been made against him and Norman Roberts had punished him by beating him across the hands with a bamboo type cane or by whipping him about the body with a horse whip. The whippings had occurred about three times a week and he had been made to have a cold bath after some of them.

  41.10  M complained also of being undernourished throughout the period of his stay with the Roberts family. One type of punishment was to make him eat dry dog biscuits and this had occurred with similar frequency to the whippings.

  41.11  Whilst M was fostered with the Roberts, he attended Gwalchmai Primary School and then latterly Bodedern School. He claimed that friends at the former saw marks of the whipping and that he showed marks later to two teachers at Bodedern School, who reported the matter to his social worker. He was too scared then to tell the latter what had happened but he was taken to hospital and a doctor photographed his injuries. Later, when his social worker and the Area Officer visited the foster home he said at first, in the presence of the foster parents, that a schoolboy was to blame; but he managed to speak to his social worker on her own just before she left and told her that it was his foster parents. He thought that she had then replied that it was "a bit too late to say that now". In the event nothing else happened: he continued to suffer the same treatment until his mother eventually managed to have him back home.

  41.12  In further statements to the police in 1992 M said that two horse whips were used by Norman Roberts when whipping him and he identified the whips to the police. He said that he was always whipped on the bare skin and alleged that on occasions Ian Roberts (the elder son) would hold him upside down with his feet roped when Norman Roberts whipped him. But he was usually whipped when he was standing up. M also explained 14 photographs taken at the smallholding to illustrate findings there. He said that, on the occasion when he was taken to hospital, he had been whipped three or four days previously by Norman Roberts. At the school and at the hospital he had told different stories about what had happened and he had told the Area Officer, who took him to the hospital, that boys had caused the marks by hitting him with a ruler. This was because he was afraid of being whipped again by Norman Roberts if he told the truth. However, he did tell the Area Officer that Norman Roberts was responsible when they sat in a car park eating chips immediately after the visit to hospital.

  41.13  M first alleged that Ian Roberts had whipped him in the last of his statements to the police, made on 27 November 1992, which was the occasion when the photographs were shown to him. In that statement he enlarged on aspects of the whipping and explained that the photographs had helped him to remember. M's allegation against Ian Roberts was that on some occasions he had used a small whip to hit M over his clothes on his back and on his bottom. On other occasions, when Norman Roberts had whipped M, Ian Roberts had held him hanging upside down (as previously said) over a beam.

  41.14  Other allegations by M were that, when he wet the bed or soiled himself during the night, Norman Roberts would take him outside immediately, sometimes in the dark, and would hose him down over his pyjamas for about five minutes before ordering him upstairs to wash himself.

  41.15  In relation to Evelyn Roberts, M made a number of separate allegations. A major complaint was that she gave him insufficient food to take to school to eat at dinner time so that he was forced to scavenge. He alleged also that food generally in the foster home was inadequate for him and that presents and clothes supplied for him by his mother were distributed by Evelyn Roberts amongst the other children without any authority or justification.

  41.16  The charges laid in 1993 against Norman, Evelyn and Ian Roberts were based essentially on these statements of M and he gave evidence at their joint trial in June 1993 at Mold Crown Court. The two foster parents were charged with cruelty to M between 10 November 1980 and dates in 1985 and 1986 respectively. Norman Roberts was charged also with assault occasioning bodily harm on M in respect of the incident that led to the hospital visit, which was alleged to have occurred between 1 and 13 September 1985; and Ian Roberts was charged with common assault upon M between November 1980 and 31 August 1985 on the basis that he assisted his father in roping up M and suspending him for whipping. Both foster parents were acquitted of the cruelty charges on 1 July 1993 but Norman and Ian Roberts were found guilty of the assault charges.

  41.17  When His Honour Judge Gareth Edwards QC sentenced Norman and Ian Roberts the following day he ordered that both of them should be conditionally discharged for a period of two years and that both should pay £1,000 towards the costs of the prosecution. The judge regarded the offences as grave but took into account the fact that they had occurred many years before, that the defendants were of previous good character and that they had to live with the disgrace brought upon them by the highly publicised case. He expressed the view also that an inquiry should follow the trial and that it should look "not only at the events of 1985, but at the period from 1980 to 1985".

  41.18  In the course of the trial a considerable body of oral evidence was called and it has been neither necessary nor appropriate for that exercise to be repeated before this Tribunal. In addition to the evidence of M, there were numerous witnesses from his school and from the Social Services Department; the other foster children (of whom only P supported the evidence of M) and various friends and neighbours of the Roberts' were called; and the paediatrician who examined M on 13 September 1985, a consultant pathologist and a divisional police surgeon gave medical evidence. Finally, all three defendants gave evidence, repeating their previous denials to the police of any ill-treatment of M. One of the planks in the defence of Norman Roberts, in particular, was that the whip that he was alleged to have used to beat M in September 1985 had been purchased by him at the Royal Welsh Show in July 1986.

  41.19  We received evidence from Norman, Evelyn and Ian Roberts in the form of written statements. These statements repeated the substance of what they had said at their trial in response to M's allegations. Norman Roberts said that he remembered being told by a social worker and the Area Officer about injuries to M's bottom in September 1985 but that he did not cause them and knew nothing about them until then. The only whip that he had in 1985 was a very long lungeing whip, which is not meant to strike anything with. Ian Roberts said that he was on holiday in Scotland between 8 and 11 September 1985, when M was alleged to have been injured. Evelyn Roberts dealt, in particular, with M's conduct and eating habits and difficulties that she experienced with P. She said that she had always regarded M as continuing to be a friend of the family and pointed out that, although N is now grown up, he still lives with the Roberts family and has chosen to make his home with them.

  41.20  It is clear that the trial jury had much fuller oral evidence before them in the case of M than we ourselves have heard and we have not received any evidence that persuades us that the jury's verdicts were wrong. In order to avoid any misunderstanding, however, it is right to say that, on the basis of a question of law asked by the jury after they had retired to consider their verdicts, the trial judge inferred that they were not satisfied that Ian Roberts had played any part in whipping M, although they accepted that Ian Roberts had assaulted M by suspending him.

  41.21  The activities of the Social Services Department in relation to M between 1978 and 1988 were subjected to minute scrutiny by the inquiry team who produced the Walton report and no useful public purpose would be served by repeating all the detail here. Bearing in mind our terms of reference and the trial jury's verdicts it is necessary, however, to consider the performance of Gwynedd Social Services Department in relation to M in three phases, namely, 1980 to 1985; September 1985 and the response to the evidence then; and 1986 to 1988.

Surveillance of M's placement between 1980 and 1985

  41.22  We do not think that it is appropriate for us to criticise the original placement of M with Norman and Evelyn Roberts. In November 1980 they were held in high regard by the Social Services Department and we are not aware of any adverse reports at that time.

  41.23  There is some confusion about the plan for M in November 1980. It is arguable that assessment in a residential home would have been appropriate for him on the breakdown of his first fostering placement but the Walton inquiry was told by an Assistant Director that there was no residential home in Gwynedd with appropriately qualified staff to make assessments at the time, a comment with which we agree. A six monthly review of M on 4 November 1980, a week before he was placed with the Roberts', is said (in the Walton report) to have assumed that a long term placement was in M's best interests but the initial plan seems to have been to work towards rehabilitation with his mother, following upon rehabilitation of his half-sisters. This plan was changed quite soon because of a combination of circumstances.

  41.24  Without going into unnecessary detail it appears that M had developed a number of problems by 16 February 1981, when a further review of him took place. These problems (soiling, vomiting etc) were attributed by a child psychiatrist to M's contact with his mother and the upshot was that M had no further contact with her for the next year. Meanwhile, there were separate concerns about the mother's position and her ability to cope, following the birth of her sixth child (a boy) in 1981. In January 1982 it was said that the placement was to be considered long term fostering and the prohibition on contact with the mother continued, apart from a visit home by M on 8 March 1982. Yet the child psychiatrist did not attend a review until 17 January 1983. It was not until the mother had been seen by the psychiatrist in February 1983 that a pattern of two monthly access visits by the mother was established.

  41.25  One of the causes of concern considered in the Walton report was the number of field social workers involved with M from time to time in this period and the pressure on the Area child care team, which increased from 1980 onwards because of the number of referrals. It was said by the Area Officer in February 1983 that "using the caseload weighting system as a guideline, the system indicates that only three-quarters of all child care cases are securing the attention that they should"; and he urged that the team establishment should be restored to its original 1979 figure of six and a half team members.

  41.26  Between November 1981 and August 1985 three different field workers were allocated to the case of M in succession. The first was responsible until June 1982; the second took over after a gap of five months and was then responsible until September 1984, when she started maternity leave; and the third was an unqualified temporary member of the staff who took over in November 1984 until August 1985. There was then another gap before the fourth social worker took over: she was on leave when the September 1985 bruising was reported but appears to have taken over on her return from leave, when she visited the foster home with the Area Officer and saw M. The latter's comment in his Tribunal statement was that the fourth was "OK" but that the others did not help him at all.

  41.27  The evidence suggests that there were some complaints or suspicions of physical abuse of M during this period prior to September 1985. M's mother alleged at Christmas 1980 that he had been sent home in "tatty clothes and covered in bruises". This allegation was made in a letter from the mother to the foster parents, who reported it to the Social Services Department. An emergency duty officer examined M, who did not know where or when he had suffered the two small bruises that were observable. M's social worker subsequently visited the foster home and M's mother, who agreed that the marks on M were consistent with a fall. Evelyn Roberts did take M to a doctor, who gave evidence at the trial, but there was no evidence of social worker contact about this.

  41.28  At the Roberts' trial a retired school canteen lady at M's school alleged that on one occasion she had seen red marks on M's buttocks and that her finding had been reported via the cook to the Headmaster and thence to the Social Services Department. There was no documentary evidence, however, to substantiate this allegation.

  41.29  There were indications in April and July 1983 that M was telling school friends that his foster parents were hitting him. These reports emanated, at least in part, from Evelyn Roberts, who said that M was seeking attention and pity. The social worker told Evelyn Roberts that she had heard this also from the police school liaison officer. It was assumed that M's allegations were lies or fantasy and no action was taken to investigate them.

  41.30  The conclusions of the Walton report were critical of social work practice in the period 1980 to 1985 because there were no records on file of any six monthly reviews of M for two years between August 1984 and August 1986; and the reviews that were held before that appeared to have been carried out in a routine manner without reappraisal of M's long term future (they were preoccupied with narrow treatment of his behaviour problems and issues of access). They were critical also of the failure to visit M as regularly as the rules required and/or to record visits on the departmental forms. There was little evidence that, when M had been seen, his feelings and wishes on such matters as his long term future had been discussed; and there had been a major gap in the contact log, with no records of boarding out visits on file, between late 1984 and the autumn of 1985.

The response to the events of September 1985

  41.31  It was the Deputy Headmistress of Bodedern School who reported on or about 11 September 1985 that M had disclosed bruises on his body to some of his schoolfellows, claiming that he had been hit on his bottom by his foster father. The school was told that there was no social worker for M but that his new social worker would be starting her duties the following Monday and would investigate; but the school requested an immediate investigation.

  41.32  The Area Officer, who was the only member of the staff with knowledge of the case available, visited the foster home late that evening, on the return of Norman and Evelyn Roberts from a family celebration, and saw M in their presence. The Roberts' denied all knowledge of the bruising. M gave two different explanations for his bruises. The Area Officer did not examine them, but he asked the foster parents to make arrangements for M to see his general practitioner.

  41.33  On 12 September 1985 the Area Officer visited Bodedern School and talked with M, who said that he had alleged that he had been pushed downstairs and hit by Norman Roberts in order to gain sympathy from his teachers. The Area Officer saw M's injuries and arranged for him to see the consultant paediatrician that evening at Ysbyty Gwynedd, the nearest major hospital. Two doctors examined M and took photographs for teaching purposes. They regarded the injuries as "classic": in their view they had been inflicted deliberately, probably seven or eight days earlier. M drew a picture of a leather horse strap with metal studs, claiming at one point that it was used by Norman Roberts to chastise him but later denying this, saying that he had fallen downstairs.

  41.34  The Area Officer told the inquiry panel that he took M for fish and chips after the hospital visit but his account of the conversation differed from that of M, who alleged that he (M) told the Area Officer then that he had been whipped about three or four days previously. According to the Area Officer, M said that P had tried to blame his foster father for the injuries and that he wished to return to his foster home, where he was happy. The Area Officer had arranged a fall back place for M at Ty'r Felin and told M that he need not return to his foster home. On their return to Gwalchmai, the Area Officer told Mr and Mrs Roberts of the extent of the injuries. Norman Roberts admitted slapping M with a soft slipper but did not offer any other explanation of M's injuries.

  41.35  The Area Officer sent a Notice of Accident form dated 17 September 1985 to the Director of Social Services, accompanied by the following memorandum:

"Your records will indicate that M is a boy in care fostered with Mr and Mrs Norman Roberts. Neither the boy, foster parents or school are able to identify the exact nature and cause of M receiving the blows to his buttocks. The two social workers supervising the children in this placement will, of course, monitor the situation. I will leave it to you as to whether you feel the police should be advised."

  41.36  The Notice of Accident form described the injuries sustained by M as:

"Two or 3 strap marks about 6 inches long across both buttocks. Confirmed by Consultant Paediatrician as 3 successive blows to the buttocks with a hard object. Photographs have been taken."

  41.37  There is a considerable conflict of evidence about the responsibility for the subsequent inaction by the Social Services Department with each senior officer blaming another. What is clear is that, whatever errors had occurred prior to 17 September 1985, there was a lamentable failure to take appropriate action from then onwards for which several senior officers must bear some of the blame. There were also, in our judgment, deliberate failures to inform the police and to report the facts fairly and accurately to the Chairman and members of the County Council's Children's Sub-Committee.

  41.38  We do not propose to rehearse here every step that followed or all the allegations and counter-allegations that have been canvassed before the inquiry team and in evidence before the Tribunal, because to do so would be disproportionate to the original events in the context of our inquiry. It is sufficient to draw attention to the main sequence of what occurred.

  41.39  The Notice of Accident Form and memorandum were sent to Gethin Evans, then a Principal Officer but who was to become Assistant Director (Children) from 30 September 1985. Gethin Evans passed them to Larry King, the Principal Officer responsible for child abuse, who signed the Notice of Accident Form and sent it to the County Treasurer. The latter then questioned on 26 September 1985 the relevance of the notice to the insurers and King responded with the following note:

"Note: this is being dealt with by Area as non-accidental injury to be fully discussed shortly. Has already been (coord) tentatively informed so no urgency."