The events with which I am concerned tonight relate to the death of a 12-year-old boy in my constituency called Wesley Neailly, who was reported missing on
Of course, nothing can bring back Wesley Neailly. Nothing can heal the hurt of his mother, his grandfather and other members of his family. But there are lessons to be learned from the circumstances that led to this dreadful tragedy, and I know that Wesley Neailly's family want those lessons to be learned. They want the bad practice and bad management that is evident in the history of this dreadful affair to be put right once and for all.
I wish to place on record my thanks to my right hon. Friend Mr. Clarke. When he was a Minister at the Home Office, he met Wesley Neailly's family with me, leading to the early implementation of the Sex Offenders Act 1997. I also wish to thank the northern region health executive for commissioning the central report that was published last week dealing with the history of this dreadful affair.
There are only a limited number of cases each year in which young people between the ages of 10 and 18 commit violent or sexual offences. They make up a small, very disturbed group of young people. Very few go on to commit homicide—murder—in the way that occurred in this case.
The report demonstrates that there are early signals which could, if the organisation was right, prevent some of the disasters that occurred in this affair. Wesley Neailly was a 12-year-old boy in my constituency. Most of my constituency is very diverse. It comprises a mixture of people living together, of different races, religions, life styles and age groups, and has a very mobile population of the kind that one sees in any big city in which people find themselves and, sometimes, lose themselves.
Dominic McKilligan arrived in Fenham, just one such part of my constituency, at the age of 18, to lose himself and, tragically, to find others. When he came to Fenham, he was already highly intelligent, manipulative and disturbed, a practised abuser of long standing with a long-established capacity for wicked threats and acts for which he showed no remorse. He sought out young Wesley Neailly, befriended him, led him away and murdered him. The circumstances that led up to that tragedy are the subject of the reports and they are a source of great concern to me. I was very shocked and disturbed by their contents.
For example, when Dominic McKilligan was placed in the Fenham area of my constituency—he did not just arrive there, he was placed there—no outreach programme was set up for him. The report says in cold and chilling terms that the consequences of the lack of action in respect of the young man's discharge into my constituency were that no agency that had been responsible for his care when he was discharged from the Aycliffe unit in County Durham had any formal plan in place to visit and support him in the place where he was going to live. No statutory agency in the area in which he was going to live was made aware of his presence until two and a half months after his discharge from Aycliffe and six days after the ending of the care order which might have been the basis of some preventive action. The first time that Northumbria police have any record of knowing about Dominic McKilligan's presence in the area was when he himself chose to report to the local police information about the disappearance of Wesley Neailly.
The failure of agencies to share information with each other, with the local community and with the local police is at the disastrous heart of that dreadful tragedy. The report documents in chilling detail the lack of documentation regarding McKilligan's treatment in his first year at the Aycliffe centre. Those records apparently cannot be found. That is a shocking fact, and something that the Aycliffe unit must investigate thoroughly.
It took 10 months from McKilligan's arrival at Aycliffe from Bournemouth for him to receive a full assessment. Why did it take so long? The Kolvin unit at the then Newcastle city hospitals trust, which had the clinical supervision of McKilligan's care, deemed him—at times only two months apart—to be a high risk and a low risk. There must be some inquiry into the conduct of the Kolvin unit and why that confusion of analysis occurred. What other confusions of analysis may have occurred at other times?
The report contains clear evidence not merely of lack of co-ordination between Bournemouth, where McKilligan originated, the Aycliffe unit in Durham where he was cared for, and Newcastle, where he was placed, but of conflict between the caring agencies and of a failure to share information. The arguments between the agencies were more centred on money and finance than they were on the substance of the case.
The record keeping was lamentably poor. There should have been seven recorded reviews of McKilligan's progress, care and treatment at Aycliffe. Only three can be found. McKilligan decided that he would leave Aycliffe after an incident in which he flirted with another boy and was threatened with the child protection board. That triggered his decision to leave Aycliffe. During his time at Aycliffe, a unit under the control of Durham county council, 15 very serious incidents are logged concerning his behaviour, 13 of which were of a clearly sexual nature. The unit's policy was that it did not encourage sexual behaviour and activity between those who were being cared for at Aycliffe. None the less, inadequate action seems to have been taken to deal with this matter.
The report records, in chilling terms, that specialist units—Aycliffe at Durham and the Kolvin unit at the Newcastle city hospitals trust—understandably feel the need to succeed and that behaviours can thus too readily be justified. The report documents 16 agencies as having had the care of Dominic McKilligan, involving 200 members of their staff. Several professions were involved. As I said, there was a failure to share information; there was conflict between some of the caring agencies and there were rows about money and the responsibility for supervision. There was extremely poor record keeping at the Aycliffe centre.
Finally, I point out that McKilligan came to Newcastle to follow a music course at Newcastle college. I want to record my deep understanding of what the professionals at the college—who had no knowledge of that young man and his history—must feel about the period in which he was under their care. I have a great deal of sympathy for them.
It is clear from the report and from a similar report produced by Newcastle and North Tyneside health authority that the Kolvin unit at Newcastle city hospitals trust failed adequately to carry out the duty of supervision of that young man that it had agreed to undertake. Durham county council, which is responsible for the management of the Aycliffe unit, did not take adequate action. We must explore the need for further inquiry both by the mental health trust that has taken over responsibility for the Kolvin unit from Newcastle city hospitals trust, and by Durham county council into its actions.
Is there a need to identify the staff responsible and perhaps to carry out disciplinary action or to provide additional training? We must certainly demonstrate to the people of the north-east that the failures recorded in such chilling detail can never be repeated. General words of comfort and general assurances will not do. I hope that my hon. Friend the Minister of State will make clear her desire that such inquiries should be carried out speedily and robustly, and that if they are not undertaken by Durham county council and the mental health trust, she will herself ensure that the necessary corrective action is put in hand.
Some important lessons for the Government emerge from this matter. There has been no proper calculation of the number of young people who need that specialist care. There are no consistent standards for care arrangements, for assessment and treatment, for clinical oversight and accountability and for the training of staff. There is no single regulatory inspection system for units that care for such deeply disturbed young people.
Furthermore, there is no geographical consistency or equity of provision. There is a grave shortage of places. That is how Dominic McKilligan, who lived in Bournemouth, came to be placed in a unit in County Durham. Had there been better, and better spread, provision, that would never have happened. There must be co-ordination of the protocols and policies that link all the caring agencies—social services, health, education and, of course, the custodial services that deal with young offenders—so that they will think and act together. They must co-ordinate their records and share information, especially if children and young people leave their home area and switch between responsible authorities, so that those young people can benefit from co-ordinated, specialist support.
The reports highlight the enormous need for nationwide specialist assessment facilities and for skilled remand facilities. There should not be 1,000 young people in that age group in the care of prisons. There should be skilled treatment facilities, including secure treatment facilities, so that other communities can be protected in a way that my community in Newcastle was not.
The Government should take responsibility for the regulation of what is an extraordinary array of different facilities, some run by the NHS, some run by voluntary agencies, some even run for profit by the private sector and some, such as Aycliffe, run by local social services agencies and the county council.
The treatment facilities should be provided on nationwide basis, so that it will never again be necessary for a deeply disturbed young man to be taken from his home community—where there was a great deal of knowledge about him, his family and his early life, with all the signals that that gave about his later behaviour—and placed at the other end of the country, where some of that knowledge sadly does not appear to have arrived or to have been properly shared.
At present, there are a very limited number of specialist facilities for young sex offenders. Those that exist are spread across that wide range of different agencies, without nationally agreed standards of care. I hope that alongside the necessary, robust corrective action that must be taken by Durham county council and by the mental health trust, which now has responsibility for managing the Kolvin unit, there will be a programme of national action to correct the deficiencies in the system that the reports highlight—Wesley Neailly's family expect no less.
The death of any child is desperately sad, but the death of Wesley Neailly was particularly tragic, and I should like to take this opportunity to express my sympathy to his family.
As my hon. Friend has said, Dominic McKilligan was only 18 when he murdered Wesley. Dominic was a damaged young man who had exhibited very dangerous behaviour and had had a great deal of contact with statutory agencies over several years. He had significant contact with social services, mental health services and the criminal justice system. As a child, he was the subject of a care order to the local authority, and following his conviction for sexual offences as a young teenager, he received treatment for his offending behaviour.
Dorset, and then Bournemouth social services, however, had lead responsibility for Dominic's welfare and were ultimately responsible for ensuring that his care plan encompassed all aspects of his treatment and that there was very careful planning for his discharge from the care system on turning 18.
My hon. Friend is absolutely right to say that, given the risks that Dominic presented, a very high standard of assessment, planning, intervention and review was absolutely essential, but there was clearly a failure in this case. Let me make it clear, however, that the requirement for thorough assessment, planning, intervention and review is nothing new. The Arrangements for Placement of Children (General) Regulations l99l, under which local authorities are required to draw up care plans, and the Review of Children's Cases Regulations 1991, under which reviews are required to take place to enable the plan for the child to be reconsidered and any necessary changes to the care plan to be made, are in operation.
Wesley's death rightly gave rise to very serious questions about how effectively the agencies responsible had worked together to plan and provide for Dominic's care and treatment. Without doubt, there are important lessons to be learned from this case for a number of agencies. They include how to ensure that people and the current systems work correctly and that people and resources develop to minimise the possibility of such an event happening again.
It was because of the clear need to learn from this tragic case that the responsible area child protection committees—ACPCs—for Bournemouth, Durham and Newcastle decided to carry out a serious case review, under the "Working Together to Safeguard Children" guidance, into the management of the care and treatment provided to Dominic McKilligan. In parallel with this review, Newcastle and North Tyneside health authority, which is the host commissioner for the Kolvin unit that oversaw Dominic McKilligan's treatment programme at the Aycliffe centre in Durham, commissioned an independent inquiry into the health care and treatment of Dominic under the terms of the health service guidance in circular (94)27. As my hon. Friend said, the report of the inquiry was published, along with a summary of the serious case review, on
Both the serious case review and the independent health authority inquiry have identified specific issues for local authorities, the NHS, and their partner agencies to address through their ACPCs. The serious case review, which makes recommendations to the three ACPCs that commissioned the review, concludes that Wesley Neailley's death could not have been predicted. However, it highlights how important it is for the key professionals involved with young people who have committed violent or sexual offences to carry out, on a multi-agency basis, effective assessments of young people's needs and the likelihood of such offences being committed in the future; to use current research findings to inform professional judgments and decision making; and to ensure responsibility and accountability for the implementation and reviewing of plans across agencies.
Those, along with other recommendations, have been the subject of detailed action plans drawn up by each of the ACPCs and the NHS trust involved in this case to take forward the review's recommendations.
My hon. Friend made an important point about how we monitor implementation and future progress. The implementation of these plans will be rigorously monitored by the Department of Health, through its regional offices and the social services inspectorate.
Key recommendations from the independent health inquiry included the premise that the Department of Health should issue further guidance which reinforces the requirements of agencies responsible for young people that need mental health treatment; and that the Department should review existing guidance to local authorities and provide written notification to other agencies when young people are discharged from care and placed in other areas.
The Department will consider seriously whether any additional guidance is required. My hon. Friend made an important point about the failure of the discharge process in this case. In terms of planning for discharge, since
As my hon. Friend pointed out, we know that Dominic left care at the age of 18 already a deeply troubled young man, and that he then became lost to the system. The provisions of the Act, had they been in force at the time, might have gone some way to preventing this tragedy. Dominic would have left care at 18, but the Act imposes a new duty on local authorities to keep in touch with care leavers until they are at least 21 and to make sure that they receive the support to which they are entitled.
My hon. Friend asked for further work to be done in relation to the health responsibility and, in particular, to the responsibility of the Kolvin unit. I am glad that Newcastle and North Tyneside health authority and Northumberland Mental Health NHS Trust, which is now responsible for the Kolvin unit, have taken action to review their involvement in supporting treatment programmes that are undertaken by other organisations, so as to ensure that responsibilities for clinical oversight are clear. In future, any arrangements for the provision of specialist treatment programmes or of training support to other organisations that are delivering such programmes will be unambiguous with regard to the important issue of clinical responsibility, and will have clear standards against which the programme can be monitored. Under the Health Act 1999, the Commission for Health Improvement has responsibility for inspection of NHS provision. I hope to comment further on inspection and common standards.
I am grateful to my hon. Friend for going through these matters and take heart from the changes that she mentions. However, she will recognise that the report illustrates that the procedures of the time were not properly carried out. Does she know whether the action plans relevant to Durham county council, Bournemouth social services or the Kolvin unit have resulted in disciplinary action or acceptance of responsibility by the staff?
I do not know whether the action plans have led to disciplinary procedures. As I emphasised, they are a key part of the response to such problems and will be closely monitored. Durham social services department has carried out an internal inquiry. Perhaps I could write to my hon. Friend on that specific issue.
The serious case review also made the important recommendation that area child protection committees should make representations to Ministers, and highlighted the urgent need for a national strategy to be developed for the management and treatment of young, violent and/or sex offenders. My ministerial colleagues in the Home Office are giving that careful consideration.
The youth justice board is preparing an effective practice strategy for working with young people who sexually abuse. To inform that, a number of pilots are being conducted in the community, with plans to extend them to the secure estate. The board is also ensuring that all youth-offending team staff receive appropriate training and that work is monitored and quality assured to measure effectiveness. The Department of Health is also closely involved in those discussions.
Dealing effectively with the most dangerous individuals, including young people, is a key part of modernising the criminal justice system and making it more responsive. We have made substantial improvements to the way in which we treat and rehabilitate young people in particular. It may reassure my hon. Friend to know that if a 14-year-old boy were to be convicted today of the same crimes as Dominic McKilligan committed as a 14-year-old, he would be required to register with the police under the provisions of the Sex Offenders Act 1997.
Multi-agency public protection panels exist in every area of the country, bringing together agencies with a statutory duty to co-operate to manage high-risk offenders. As Dominic approached 18 years of age, he would have been the subject of one of those meetings, which would in turn have been part of the pathway planning process because he was a child leaving care. A senior member of staff from Newcastle college would have attended that meeting and been part of the discharge planning process. I recognise my hon. Friend's concern that a college that has not been properly notified is unable to take the necessary action.
An inter-agency inspection of safeguards for children is scheduled for this winter. The inspection will focus on the range of safeguarding measures that are in place in council areas. It will incorporate judgments about services that are provided by social services, health, the police, probation officers, education and custodial establishments, and the courts, and it will consider the agencies' individual effectiveness as well as their effectiveness in the corporate arena, such as in area child protection committees and the community safety forum.
It is part of our investment in mental health services to ensure that we increase the number of secure placements. It is crucial to get better co-ordination between the services. I made clear how the Government are addressing some of those issues, and we will learn the lessons that my hon. Friend spelled out.
The motion having been made after Ten o'clock, and the debate having continued for half an hour, Mr. Deputy Speaker adjourned the House without Question put, pursuant to the Standing Order.
Adjourned at Eleven o'clock.