Gwynfa Residential Unit

4.06 Another establishment having much of the character, but not the status, of a community home was administered latterly by the Clwydian Community Care NHS Trust. This was Gwynfa Residential Unit (or Clinic) (20), Pen-y-Bryn Road, Colwyn Bay. 

It was opened in 1961, for up to 16 children of both sexes from two to 13 years of age; and it was to serve as a centre for the investigation, assessment and treatment of children, from North Wales or elsewhere, showing severe emotional maladjustment, difficulties or abnormalities in personality development, or psychiatric disorder. 

As a rule, children who were considered capable of a definite degree of improvement were admitted on a short term basis for up to one year. At some stage the Unit accommodated up to 25 children and young persons and the age range was extended to 17 years. 

Until 1974 there was no consultant psychiatrist and the medical management of a child resident remained the responsibility of the child psychiatrist who referred the child. 

In April 1974, however, the Gwynedd child psychiatrist was designated as the co-ordinating consultant, providing two sessions per week; and a resident child psychiatrist was employed from 1981. The Unit was managed initially by the Clwyd and Deeside Hospital Management Committee but there were several changes of management structure in the following 30 years until the present NHS Trust took over the responsibility for the clinic on 1 April 1993. 
Gwynfa's functions were transferred to a new unit at the edge of Colwyn Bay (Cedar Court) in March 1997.

Background
20.01 This unit was established in 1961, as an NHS psychiatric hospital for children, in an Edwardian house with substantial grounds situated in Pen-y-Bryn Road in Upper Colwyn Bay; and there was a school on the site. The residential unit, also known as a clinic, was administered by the Clwyd and Deeside Hospital Management Committee and the school by Denbighshire County Council. 

In 1981 a child psychiatrist, Dr Barry Kiehn, was appointed specifically for Gwynfa and the concept of a therapeutic community was introduced. The object was to offer the patients opportunities to develop, and to bring about positive behavioural changes; and the emphasis shifted towards working with families. Group and individual psychotherapy were provided and clinical psychologist and social work posts were established, whereas previously such professionals had merely visited the unit from the Child Guidance Service in Old Colwyn.

From 1982 to 1993 Gwynfa was administered by the Mental Health Unit of Clwyd Health Authority, which became the Community and Mental Health Unit from 1991. The 18 bed unit (as it had become) was visited by the Hospital (later Health) Advisory Service (HAS) in 1987 in the course of its review of services for mentally ill people in Clwyd and found evidence of declining use, in conformity with a national tendency. However, referrals from Gwynedd were increasing and accounted for 50% of referrals. In 1987 as a whole there were 47 admissions and the average length of stay was 104.7 days. There were eight qualified nurses, six other nurses and four psychologists. The HAS recommended that, due to the high cost of the unit, the new clinical management team should evaluate the need for Gwynfa against the increased need for non-residential services. 

In April 1993 the Clwydian Community Care NHS Trust took over the responsibility for administering Gwynfa, which continued to provide residential care for up to 18 youngsters, but in the older age range of 12 to 18 years (it was often referred to as an adolescent unit). It continued to serve Clwyd and Gwynedd with some referrals from Cheshire and northern Powys. About 40 of the larger number of children referred were being admitted annually and the average stay was five months.

In March 1996, at the end of the period under review by this Tribunal, Gwynfa had 12 in-patient places and six day places but it closed a year later, in March 1997, when the services it offered were transferred to a new unit with better facilities, called Cedar Court, on the outskirts of Colwyn Bay.

The local education authority (now Conwy) has continued throughout to provide education on the site.

Staff
The person with immediate overall management responsibility for Gwynfa was the (Principal) Nursing Officer, later called Senior Nurse for Child and Adolescent Services, who was responsible for the recruitment and selection of staff, even after the appointment of a full time child psychiatrist in 1981. 
This officer was also responsible for routine and discipline, subject to consultation with the psychiatrist about children. 
Prior to reorganisation in 1974 he reported to the consultant psychiatrist but thereafter he reported to the Divisional (later Unit) Nursing Officer, based at the North Wales Hospital in Denbigh, who visited Gwynfa monthly and who had to be consulted about any suspension or dismissal of a nurse. This officer was latterly known as Director of Nursing Services.

The holder of the senior nursing post at Gwynfa from November 1972 to March 1990 was Nigel Mannering Berry, who had already been employed there for nine years, successively as a staff nurse and then a charge nurse; and he had been Acting Nursing Officer for a year before he became established in the post. He was then 37 years old and had qualified as a registered mental nurse in or about 1959 after service in the RAMC between 1954 and 1956. 
Prior to his transfer to Gwynfa he had been employed at the North Wales Hospital but had been seconded to Clatterbridge Hospital for two years during his period of training. He does not appear to have had any specific training in dealing with disturbed children and adolescents but he had attended management courses at a technical college and Abergele Hospital before his appointment as Nursing Officer.

Previous investigations
20.10 During the period covered by our inquiry there were five internal investigations or reviews of the conduct of specific members of the nursing staff at Gwynfa.

The first investigation, in 1986, was into an allegation by a boy patient that he had been head-butted by a male staff nurse. The complainant was interviewed by the Divisional Nursing Officer and the outcome was that the nurse received a final warning. He was also transferred from Gwynfa to another hospital to perform services for adults.

20.12 In August 1991 the relationship between a 16 years old girl patient, P, and a 45 years old male nursing auxiliary was investigated following the discovery of a letter in an article of her clothing. This girl, who gave oral evidence to the Tribunal was not in care but was suffering at the time from a depressive disorder. Unfortunately, despite considerable efforts by the clinical staff, they were unable to obtain full details of what had occurred from the girl. 
The auxiliary, Robert Martin Williams, had previously been counselled about his behaviour towards other patients because of concerns expressed by other members of the Gwynfa staff. He denied committing any offence against the girl when interviewed under the Clwyd Health Authority's disciplinary procedure but then resigned before he could be dismissed.

It was not until January 1996 that P felt able to disclose to the police what had occurred (she had refused to do so when seen by them in September 1993) but a copy of the highly incriminating letter, which we have seen, was still available. According to P, Williams had befriended her at Gwynfa, which she had welcomed, but he had then had sexual intercourse with her against her will twice within the space of a few days. In the event Robert Williams was charged with two offences of rape upon P. He was tried in Mold Crown Court, when P gave evidence, and he was convicted on 14 March 1997 of both offences, for which he received concurrent sentences of six years imprisonment.

Following the appearance on television in September 1991 of a former Gwynfa patient, who is identified as A in the preceding chapter, a review of Gwynfa's records from 1975 to 1981 was undertaken by Irene Train, then the Divisional General Manager (North) of Clwyd's Community and Mental Health Unit. 
The major police investigation had begun and, when the Train report was written for the Health Authority Board, the police had asked for the addresses of 14 former patients and seven past and present members of the staff.

It became evident by July 1993, in the course of the police inquiries, that allegations of a more serious nature were being made against some members (again past and present) of the Gwynfa staff. 
A selected member of the NHS Trust that had by then become responsible for Gwynfa saw the relevant statements that had been obtained by the police; and by letter dated 26 July 1993 Detective Superintendent Ackerley was invited to conduct a fuller investigation into Gwynfa. Appropriate documentation and information were supplied to the police, which enabled them to carry out an investigation by sample of all admissions to Gwynfa in the period of our own review to 1993 (and of some earlier admissions).

At some stage the NHS Trust became aware that seven former patients of Gwynfa had made serious allegations to the police against a then current member of the staff (Z). The Trust therefore asked the North Wales Police to obtain permission from the authors of the relevant statements for their statements to be released to the NHS Trust for use in the latter's own inquiry and disciplinary procedures. 
Only four of the former patients gave that permission with the result that the NHS Trust had to investigate the matter on an incomplete basis. The legal advice that the NHS Trust's Board received was that the available evidence was insufficient to justify summary dismissal and it was decided, therefore, to transfer Z to a Psychiatric Day Hospital, where he would not be expected to nurse children. 
At that time a decision not to prosecute Z had been taken. Later, further allegations were made against Z and he was again suspended from duty in July 1997 pending a decision as to whether he was to be prosecuted. By March 1999, the Crown Prosecution Service had advised that a prosecution would not be justified but as far as we are aware he remained suspended at the time that this report was signed.

Allegations of abuse
20.17 By the end of the Tribunal's hearings, there were 27 complainants who were known to have alleged that they had been abused whilst they were at Gwynfa, but of these three left there before the period of our review began. The latest known date when any of the 24 other complainants left Gwynfa (except P who left on 27 August 1991) was 17 July 1987. 
Thus, a total of 23 former patients made complaints relating to the period 1974 to 1987; and the evidence is reasonably clear that 13 of these were in care at the time when they were resident in Gwynfa.

Seven of the relevant 24 complainants made allegations of physical aggression in varying degrees by unidentified members of staff; and one other former girl resident, who was in care, alleged that she had been indecently assaulted by an adolescent male fellow-patient. The remaining 16 made allegations against one or more of eight named members of the staff but ten of them named Z and only one other member of the staff (not Robert Williams) was the subject of allegations by more than two complainants.

In view of the continuing police investigation into allegations against Z whilst the Tribunal was sitting, we heard evidence from one complainant against him only (when his legal position was not clear to the Tribunal) and none from Z himself. 
It would be inappropriate, therefore, for us to make any further comment about the allegations save for the brief reference in the next paragraph and paragraph 20.23.

20.20 Allegations of sexual abuse have been made against four members of the staff, including Z and Robert Williams, but they do not suggest a pattern of such abuse amongst the staff, bearing in mind the length of the period under review. 
They are allegations of sexual abuse in different forms committed by individuals separately from one another. 
Half of the allegations against Z are of this type of misconduct and they remain to be adjudicated upon; and the only sexual allegations against Robert Williams are those of P, in respect of which he has been convicted. 
As for the other two members of staff, one is alleged to have been guilty of indecent "groping" in 1978/1979 by a girl patient then 13 years old, who did not report the matter; the other is alleged to have committed buggery with a 17 years old male patient in 1979/1980, but the allegation did not come to light until the complainant was interviewed by the police in August 1992. 
A decision not to prosecute the alleged offender was taken in the autumn of 1993.

The Tribunal received evidence in the end from 14 of the former patients of Gwynfa, of whom three gave oral evidence. These three were P, A and the witness who made allegations against Z so that not a great deal can be added here. None of them was in care at the time of his or her stay at Gwynfa but A was received into care later in his youth and the third was in and out of care. 
P did not make any other complaint about conditions at Gwynfa. She had been abused earlier by another man when she was ten years old and suffered from low self esteem; she had cut herself, made herself sick and taken overdoses before her admission to Gwynfa. However, she found the staff at Gwynfa approachable. 
There was a complaints system but she thought it was for more trivial things such as arguments and she did not feel able to resort to it in respect of Robert Williams' conduct.

A was more critical of Gwynfa. He had behaved disruptively as a day boy at a private school in Llandudno but he had thought that he was entering Gwynfa as a hospital for an investigation of a heart condition. 
He regards his year at Gwynfa as wasted and blames it for his subsequent inappropriate placement at Ysgol Talfryn. 
He did not receive the medical attention that he thinks he needed and he criticised the educational arrangements because they were not geared to meet the needs of patients staying longer then six weeks: after that period it was repetition. 
He was frightened initially, until he made some friends, and he had personality clashes with some of the staff. He complained, in particular, of two alleged assaults by male members of staff. The first occurred after a "bandage fight" when two of them made a harness with rubber rings and pulled him up on a door. It was very painful but he did not make a complaint: they said that he should learn to take it "in good spirit". 
On another occasion one of the two dropped him outside from a ground floor window after some play fighting. He landed on his back, which hurt a great deal. He was also wrongly blamed at Gwynfa for two incidents.

20.23 Finally, the third oral witness went to Gwynfa from her foster home when she was nearly 14 years old and in danger of being excluded from her school. She was at Gwynfa for four and a half months in 1975. 
She was assessed as of below average ability and was not thought to be bright enough to learn new behaviour patterns through the Gwynfa type of therapy. 
Later in the year she was admitted in care to Little Acton and Cartrefle successively and she had been in residential care or fostered from the age of three and a half years. 
She complained about the pyjama punishment (being required to wear pyjamas) then in use at Gwynfa but thought that the school there was very nice. 
She said also that she told her social worker that she did not like Z but her social worker (a woman) told her not to be silly, that he was nice. When she persisted the social worker said that she was just seeking attention.

20.24 Of seven other main complainants whose evidence was read, only one was able to identify the member of staff who was the alleged aggressor. 
That witness alleged one specific physical assault by Z and we say no more about it. Another complained of bullying by fellow residents rather than by staff. 
She was only eight years old when she was admitted to Gwynfa in 1977 and her complaints were that 
(a) members of staff saw her being bullied
(b) she reported other incidents of bullying to them but nothing was done to stop it. On one occasion she was pushed through a ground floor window by a named girl, who was much bigger then her, and she was taken to the local hospital by a staff member to have her left arm stitched. She was not, however, able to name any of the members of staff alleged to have been at fault.

The remaining five of these main complainants alleged various physical assaults by unidentified members of staff in the overall period from 1976 to 1984. One, for example, complained of being gagged on half a dozen occasions with elastoplast by a female member of the staff and he said that removal of the gag left him in considerable pain. Another complained of being put in a dog collar, when he was about seven years old, and led around with an attached piece of string for several days by an older resident because he had run away. The third complained of being grabbed and hung out of a window by a staff member who also hit him on the back of the head with a pool cue on another occasion and who used to assault him about twice a week for no reason. Finally, the other two complainants in this group complained respectively of open-handed slaps to one and clips around the ear to the other but the first said that, generally, Gwynfa was well run and the latter said that the clips were no more than he deserved at the time.

Four other witnesses whose evidence was read touched upon their stays at Gwynfa in statements mainly directed to other matters but they did not add anything of substance to the evidence given by other witnesses. Two of them were critical of the regime, one complaining of being bullied and also of being beaten up by one member of the staff and the other comparing it to a prison. But another, who had a drink problem at the age of about 15 years in 1981, said that his time at Gwynfa was good: he got on well with all the staff, he was not abused or assaulted in any way, and his drinking problem was sorted out.

The opening submission on behalf of the NHS Trust disclosed that two forms of punishment, known respectively as "pyjama therapy"273 and "bed therapy" were discontinued on unspecified dates many years ago. The former involved putting children in pyjamas for a specified period following absconding or repeated aggressive behaviour towards other residents. The latter meant taking away the resident's pyjamas (and thus confining them to bed for practical purposes) but it was used only for repeated absconders for specified short periods and when a resident was considered to be significantly at risk of deliberate self harm. 
It is accepted by the NHS Trust that such practices would be questionable by today's standards although it suggests that "they were acceptable at the time".

Conclusions
20.28 The picture that we have received of conditions at Gwynfa has been incomplete for a variety of reasons but most notably because we have not been able to investigate the activities of Z, who was on the staff of Gwynfa from April 1974 until he was suspended in July 1993, pending the outcome of an internal inquiry. 
We have not attempted therefore to reach detailed conclusions about the regime at Gwynfa. It is clear from what we have said, however, that sexual abuse did occur during the period under review. We accept also that on occasions unjustified physical force was used by staff members and sometimes inappropriate methods of punishment or restraint. 
The evidence that we have heard does underline the vulnerability of young children when they are living in a residential clinic like Gwynfa, whether or not they are formally in care at the time. The problem of protecting them from abuse is closely akin to that which arises in community homes and, in our judgment, similar measures to stamp out abuse and to prevent its recurrence are appropriate for both kinds of establishment.

In view of the similarities between a residential clinic for children who may be emotionally or behaviourally disturbed and some community homes there is a strong argument for greater social service involvement in the former, particularly when a substantial proportion of children admitted to the clinic are already in care. We are not persuaded that it is necessarily right to leave the care of such children over periods that may be a year or longer in the hands of nursing staff alone. 
The nursing staff at Gwynfa appear to have been recruited from mental nursing resources (often male) and many of them had little or no experience of dealing with disturbed children. It is strongly arguable, therefore, that some trained residential care staff ought to be introduced into the staff establishment and that the senior staff at the residential unit, whether or not they are nursing officers primarily, should have an appropriate qualification in residential child care.

It must be said, however, that, in her written evidence to the Tribunal, Irene Train said that there have been considerable developments at Gwynfa (and its successor). She referred specifically to an on-going programme to improve the training of individual members of staff and continuing efforts to increase the involvement of parents in the care of their children. 
For some years before its close children were being admitted to Gwynfa on a four day week basis, returning home at week-ends. As for child protection, confidential free telephone facilities have been provided for patients to obtain independent counselling and child advocacy services are being established. 
Moreover, child residents are now informed by means of a bi-lingual leaflet of their right to have complaints dealt with by the Chief Executive with a right of appeal to a non-executive director of the NHS Trust. It is said also that steps have been taken to strengthen staff recruitment procedures and to ensure that staff "are appropriately qualified to work with children".
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