Closure of the New School Butterstone: independent review report

The Deputy First Minister and Cabinet Secretary for Education and Skills commissioned this independent review, conducted by James Martin CBE, into the closure of the New School Butterstone to consider the procedures and circumstances which led to the closure.

Chapter 3: February to December 2017

3.1 The overview below is set out in chronological order. It specifically covers critical periods where interactions with, and between, the Relevant Bodies have been evidenced and correlated.

3.2 This period principally covers the time that Head of School A was in post. The Head of Care referred to in this report was in post throughout the period of this Review.

February 2017

3.3 On 20th February 2017 a student took their own life while attending the School, only weeks after a former student of the school had also taken their own life. The aftermath of this event had a considerable impact on all those connected with the School, particularly those staff who had gone to the young person's assistance.

3.4 The pupil had attended the School for the previous two years. Not long before their suicide, Perth and Kinross Council had written to confirm that they would not support the pupil's attendance at the School for a third year. It is not within the Terms of Reference of this Review to investigate what caused this young person to make the decision they did. Now, three and a half years after the young person's tragic death, I am told that the Significant Case Review is now underway. In my view, and I acknowledge this is also outwith the terms of the Review, this delay shows a considerable lack of respect for the young person's family, and for those members of the school staff who were directly responsible for trying to assist the pupil and to manage the School in the aftermath of this tragic event. I am grateful to the family of this pupil for their support of this Review.

3.5 Following the death, on 22 February 2017, HM Inspectors and the Care Inspectorate visited the School to satisfy themselves about the arrangements within the School for the safeguarding of pupils. Some weaknesses were noted. On 27 February 2017, Scottish Ministers placed 5 conditions on the running of the School in accordance with section 98E(1)(a) of the Education (Scotland) Act 1980 (the 1980 Act). The Conditions referred to: the updating and accessibility of young people's files; a review of all care plans for the School's young people; staff awareness of care plans; and a review and update of school Information and Communications Technology (ICT) policies.

3.6 The Care Inspectorate issued a requirement at the beginning of March 2017, compelling the School to: update all young people's care plans; ensure that accurate dates were kept in the files; and that the files were kept in a more accessible place. These interventions on safeguarding matters were to be the first of many over the course of the next 20 months or so, all of which have been set out at Annex C. In all, between February 2017 and November 2018 on a further 9 occasions, conditions, requirements or recommendations were made on safeguarding issues by Ministers, HM Inspectors or the Care Inspectorate

3.7 In addition, Perth and Kinross Council in early March 2017, and without prior appropriate discussion with the School, sent a list of demands to the School about future working arrangements. While there was some discussion around individual cases, this was the first indication the School had of a change in the Council's general requirements. The tone of this letter, while offering condolences, was at best insensitive, took no account of the impact of events on the staff of the School, or the challenges they faced in trying to manage a small School through a traumatic event. The manner in which the Council engaged with the School, or failed to engage, had a negative and damaging effect upon the working relationship between the School management and the Council, which was to play out over the rest of the period under review.

3.8 It is accepted, both by those from the School and the Council that I interviewed, that over a period of years, relations between Perth and Kinross Council and the School at the level of officials and management had not been good. There was an atmosphere of hostility and mistrust on both sides, which was to grow in intensity over the next two years. I deal with some of the other serious incidents later in this Review, and there were certainly faults on both sides. However, in this instance, the manner in which Perth and Kinross Council officials sought to redesign the relationship with the School at this time, without first discussing their requirements with the School management, could be interpreted as being opportunistic and an attempt to micro-manage a school in which they had regularly opposed placing requests.

3.9 All of the conditions and requirements, including the new reporting regime required by Perth and Kinross Council, were accepted by the School's Board and, over the next few weeks, the School's management team worked to meet them within the timescales set. Of the five conditions imposed by the Scottish Ministers, four were found to have been satisfied and revoked in April 2017. The final condition imposed by the Scottish Ministers was revoked in June 2017.

3.10 In the days and weeks following the pupil's suicide, pupil care plans were reviewed by the School and a small number of placements were terminated. These decisions were taken following discussion between the School and external agencies given the possible effect on the young people concerned.

3.11 This was undoubtedly a time that impacted heavily on the family of the pupil concerned and the wider School community. Submissions I have received, meetings conducted, and documentary interviews viewed all reflect an overwhelming sense of loss. It is therefore understandable that from this point a number of concerns were raised with HM Inspectors, and others, regarding the wellbeing of the School's staff. Immediately, and after consultation with the Head of School, the Board contracted counselling support for all those who wished to access it.

3.12 It is clear that the impact of this incident on some staff, particularly the Head of School A and Head of Care, was significant and long lasting. These members of staff, and others, believe that this should have been recognised earlier by the Board and that additional resources should have been brought in to support staff at a very difficult time. This support was described as being required for the additional work that required to be undertaken, particularly by senior staff, to meet the conditions set by Ministers, the requirements of the Care Inspectorate and the new reporting regime demanded by Perth and Kinross Council. Staff have also told me that while offers of support from the Registrar, Care Inspectorate and HM Inspectors were welcomed, this did not provide the hands on specialised assistance that was required. The Board has told me that it supported staff by authorising expenditure on external counselling services, increasing staff hours and in the creation of a new role of Senior Health and Wellbeing worker, as requested by the Head of Care in September 2017.

3.13 It is not surprising that a small School of this type did not have access, or the finances available, to provide supporting resources in the way a local authority or a larger independent school might have. Furthermore, providing hands on support and shadow direction is not the role of the Care Inspectorate, HM Inspectors, the Registrar, or Perth and Kinross Council. The Board did recognise that there would be a need for support and provided access to counselling. But the staff considered that they did not engage as fully as they might have to understand the needs being expressed by their staff at this difficult time. The Board has told me that in addition to support being given at Board and Education and Care Committee meetings, both the Chair of Governors and the Chair of the Education and Care Committee were regularly present at the School and kept in very regular contact with the Head of School A by phone and email.

3.14 There is little doubt that the suicide and its aftermath had a long-term effect on the management team in the School, and particularly on external relationships. However, staff had a high (and perhaps unrealistic) expectation of what could, or should, be delivered by each of the Relevant Bodies and may not have properly understood the extent of the remit of each organisation. Nevertheless, the impact on the management team of the School, particularly in a small school like this, may not have been fully appreciated by the School's Board.

March to May 2017

3.15 March and April 2017 was a difficult time for the staff and Board of the School, who were working hard to meet Scottish Ministers' conditions and the Care Inspectorate requirement, while attempting to provide a normal school environment for the pupils. During this period the School's Head of Education was involved in a very serious accident, which led to a prolonged absence and difficult recovery period. The School adapted its existing staff duties to cover their departmental responsibilities, but the loss of a key member was a blow to the School's senior management team, who were under great pressure over this period

3.16 In early May 2017, the Care Inspectorate undertook an unannounced inspection and HM Inspectors visited the School to assess the School's progress in meeting Scottish Ministers' conditions. Despite the trauma and pressures of the previous three months, the outcome was generally positive.

The Care Inspectorate grades awarded mirrored those of the previous inspection in September 2016:

May 2017

Care and Support

(5) Very Good


(4) Good


(5) Very Good

Management and Leadership

(4) Very Good

A number of recommendations were made, as is normal after any inspection, and on this occasion they focused on: the School's consistency of approach to planning across care plans; a review of supervision policy; and improvements to the quality assurance process. The Care Inspectorate also provided a short update following this concurrent inspection and although action was required, real progress was noted.

3.17 It was not until a year later, after a similar inspection in May 2018 dealt with at length later in this report (see section 'the inspections of May 2018' from point 4.13), that some doubt emerged over what was actually assessed in the May 2017 inspection. In response to challenges about a reduced grading in the May 2018 inspection, the Care Inspectorate wrote to the School to clarify that safeguarding at the School had not been part of the 2017 inspection. Specifically, this correspondence set out that:

"… every inspection is different. We focus inspection based on intelligence, inspection intensity, and changes within the service that have taken place throughout the year. That may be in relation to changes in staffing, management and leadership or other factors which have had an impact. At this inspection [for clarity, May 2018] we had a clear remit to look at safeguarding and care planning. Sometimes things we find at inspection lead us to further scrutiny.

The Care Inspectorate has made changes to grading evaluation criteria, which will be available on our website imminently. These changes give better clarification of grading criteria."

Furthermore, correspondence stated that:

"We made recommendations about care planning and quality assurance in the 2017 report, we said:

We made some suggestions about how some of the plans could be more specific in order to guide new staff who may not know the young person. We also suggested that further work need to be done to ensure a consistent approach to planning across all care plans.

Recommendation: We made some suggestions about how some of the plans could be more specific in order to guide new staff who may not know the young person. We also suggested that further work need to be done to ensure a consistent approach to planning across all care plans."


"Whilst we saw some quality assurance systems in place, we felt that there was a need to develop a more structured and systematic approach to quality assurance with clearly defined roles and responsibilities, and details of how aspects of the service will be evaluated and improved. This should include better quality assurance of case files to bring a level of consistency to content and quality.

Recommendation: Managers should develop a more structured and systematic approach to quality assurance with clearly defined roles and responsibilities, and details of how aspects of the service will be evaluated and improved.

We followed up on both of these at this inspection. We did not find the level of improvement we would expect, which has led us to making requirements and further recommendations on these areas at this inspection.

Balanced alongside this were other factors such as safeguarding which resulted in the grade awarded at this (2018) inspection. For example, we were not aware (either from intelligence or from the school) of any child protection situations which were needing to be followed up at the 2017 inspection. Therefore we could not comment on the quality of actual practice. At this inspection there were a number of potential safeguarding incidents which we looked at in depth. We report on these at this inspection. As stated above, inspections are led in different directions dependant on what we are finding."

3.18 Given the events of the previous few months and the resulting intervention by the Care Inspectorate, and visits by HM Inspectors, it is understandable that in May 2017 the Trustees and staff took comfort from the outcome of the inspection.

It seems incomprehensible to me that in making its decision to conduct an unannounced inspection of the School so soon after the death of a pupil, which led the Care Inspectorate to make requirements of the School, that the Care Inspectorate would not consider safeguarding as part of the inspection. However, that was the Inspectorate's position. The School Board and Management had a reasonable expectation that, given the timing of the unannounced inspections, they could take comfort from the outcome.

3.19 There is a clear learning point here for regulatory and inspection bodies on the need for clarity in their own processes and what is, and is not, the subject of inspection and assessment.

Training and external relations

3.20 The year between the inspection of May 2017, and the subsequent inspections of the School in May 2018, was a difficult one for the School. This period also coincides with the remaining tenure of the then Head of School A, who retired at the end of March 2018. The recurring theme of that year, gathered from the information submitted to the Review, was the continual raising of concerns about the School's ability to manage its requirements to implement appropriate procedures for safeguarding the young people in its care.

3.21 Before looking at important events around safeguarding and Child Protection in this period, and in the rest of 2018 until the closure of the School, a number of issues need to be addressed to set them in context.

3.22 In written submissions and in interviews, it has been put to me by former staff members, parents and young people who attended the School that one of the main strengths of the School was that pupils felt safe in the atmosphere created at the School by staff, and in the School's environment, and that one of the differentiators of this school from other schools, particularly mainstream local authority schools, was its unique ethos and the trust that was built between individual students and staff. However, concerns were also expressed in submissions and interviews, by both the School's own senior staff and by external bodies, about the ability of the School's management to understand and manage the requirements placed upon the School and to ensure that appropriate policies and procedures were in place, followed and, equally importantly, administered effectively and well.

3.23 There was an uncomfortable balance between the tacit ethos of the School, that the young people responded well and felt safe in a more relaxed environment, with the more rigorous child protection procedures that anybody responsible for the safety of young people must put in place. In other words there is a significant difference between the way children and young people 'feel', and the obligations on schools to have processes in place, which ensure their safety. At times throughout the period of this Review, it is clear that this distinction was missed and that the difference was not wholly appreciated by the School.

3.24 At an early date, the Head of School A raised concerns about the School's ability to meet the child protection and safeguarding responsibilities placed upon it. Furthermore, Head of School A suggested to the Board that a senior appointment be made of a Child Protection Manager to address what they saw as a risk, that continuing to embed that responsibility within the Head of School's role may lead to problems. They argued that the seriousness of these responsibilities merited a standalone role. Head of School A also raised concerns that there was insufficient expertise among the Trustees on safeguarding and child protection matters, and that this should also be addressed by the Board.

3.25 The Board accepted the Head of School's proposal and approved the creation of a new Senior Health and Wellbeing Worker role at its meeting in September 2017, with an individual being appointed by the Head of School A following interview in December 2017. The Board were content that the Trustees did have among their number a member with recent experience of running a large boarding school, and a member with experience of the Children's Hearings System and former Chair of the Scottish Children's Reporter Administration. This gave the Board comfort that the Trustees' skill set was appropriate. The Board were also of the view that, should the need arise, they could consider bringing in external help and advice as required to support both staff and the Board. The Board did in fact seek legal advice on a safeguarding matter from the School's solicitors in March 2018.

3.26 However, I was told that at various times over this period, the School's Head of Care, who had been appointed both Head of Care and Child Protection Officer in December 2016, also raised concerns with the Head of School A and the Board that their role was too large and that they had received insufficient training and support in this role. That the Head of Care was prepared to be so open about these concerns is to their credit. The Head of Care told me that they felt confident in delivering the reporting required for the School, but did not feel they had the skill base, or capacity, to deliver wide-scale change. They also went on to say that this was ultimately raised officially at the Board's Education and Care Committee meeting at the end of 2017, with the Board recording that the Head of Care felt their role incorporating Child Protection Co-ordinator, Head of Care and Registered Manager was too much. Furthermore, in a report to the Education and Care Committee dated September 2018, a month before the School closed, the Head of Care advised that she had attended a two-day training course run by Perth and Kinross Council, which was not adequate and that they would like to access further training related to the Child Protection Coordinator role.

3.27 Despite these requests, the Head of Care role was not revised, though the minutes of the meetings of the Education and Care Committee, and the Board, state that the Head of Care's proposal for the creation of a new position of Senior Health and Wellbeing Worker role to the care team was approved in September 2017, and the appointment of another member of the care team as Deputy Child Protection Coordinator was approved by the Board on 26 April 2018. Furthermore, the Head of Care did not receive appropriate training, other than generic training provided by the National Society for the Protection of Cruelty to Children (NSPCC). The Board told me that they considered that identifying the need for training, accessing it and monitoring it was the responsibility of the Senior Leadership Team, with the Education and Care Committee receiving regular reports on training and the Board authorising specific spending.

3.28 These concerns being expressed by the two members of the School's senior staff responsible for delivering on the School's safeguarding and child protection policies about their ability to effectively meet their responsibilities should have raised alarm bells at Board level. This was a missed opportunity.

3.29 The Head of Care also approached the Care Inspectorate, under both Head of Schools' leadership, seeking guidance on basic elements of policy and how they, in their role, should manage procedures. There was a fundamental misunderstanding not only on the Head of Care's part, but of the senior team at the School generally, of the role of the Care Inspectorate. The Care Inspectorate is a Regulatory body, charged with ensuring that the bodies under its jurisdiction are operating effectively and within the regulations and procedures laid down for them. It is not a training agency, nor is it a helpline for managers. The senior management team at times, seemed to rely on the Inspectorate as a management resource. Indeed the frequency with which the senior management team approached them for the answers to questions, which it would be reasonable to expect a competent management team to be able to answer for themselves, should have raised more concerns within the Inspectorate about the competence of the senior team in safeguarding and child protection matters. This would become a serious issue under Head of School B's headship. Further information on safeguarding and child protection is covered in the section 'child protection incidents' at 4.41.

3.30 Over the final eighteen months of the School's operation, the School's approach to Safeguarding and Child Protection procedures was a constant cause for concern to Perth and Kinross Council, the Education Authority in which the school was located and the largest of the School's seven placing authorities, and to the Registrar, HM Inspectors, the Care Inspectorate, and latterly to Witherslack. The Care Inspectorate, HM Inspectors and the Registrar continued to be made aware of other pupil related incidents.

3.31 Over this period, around a dozen incidents involving young people at the School were reported to the Care Inspectorate by the School, Perth and Kinross Council and some parents. It is to be expected that, given the nature of the School, a number of reportable incidents would be expected. However, as will be seen later in this report (see section on 'complaints and concerns' at 4.2), there were serious concerns expressed as to whether the senior management at the School fully understood their responsibilities for monitoring and reporting incidents to the Care Inspectorate. I raise this matter here, because in seeking to understand what was happening at the School and its interactions with outside organisations, it is important to recognise that there were day-to-day matters around safeguarding and protection which were being encountered, as well as the more 'set piece' interventions such as inspections and visits. Some of that concern came to light as a result of the events leading up to, and the outcome, of the May 2018 inspection of the School.

3.32 Furthermore, policy related areas of work were also under scrutiny. For example, a further requirement was placed on the School by the Care Inspectorate that all service users should be supported appropriately when their placement ends, with plans agreed and recorded to deliver the best possible ending. This was in response to a complaint about the School in August 2017, where it was felt the School wrongly advertised itself as being able to offer 'lifelong inclusion achievement and self-belief'.

3.33 Between the inspections in May of 2017 and 2018, the relationship between the School senior management and Perth and Kinross Council officials had all but broken down. Over this period the Council raised a number of complaints and concerns about the School with the Registrar, HM Inspectors, the Care Inspectorate and the SSSC. In turn, the School raised complaints with the Council about some of its officials. There was little trust evident on either side. This broken relationship made the normal informal and formal discussions one would expect to see between a placing authority and a receiving school all but impossible to conduct positively. At one point, the Head of School A issued an instruction to his staff that all contacts between themselves and Perth and Kinross Council officials should be recorded and transcribed.

3.34 The officials of Perth and Kinross Council had little confidence in the School's ability to meet their requests around safeguarding and reporting, and there was a view among the School's staff that Perth and Kinross Council officials were out to make life as difficult as possible for the School in the hope that it would fail.

3.35 In February 2018, on the advice of HM Inspectors, the Registrar of Independent Schools recommended that the School and Perth and Kinross Council enter into mediation with a view to improving their relationship. As far as I have been able to establish, this approach was unprecedented. This of itself should have given the School and Council officials pause for thought. While on the face of it, each agreed to proceed to mediation, the mediation process itself became the subject of dispute and delay. In the end mediation never took place as set out in the section 'the decision to close the School' at 4.39.

3.36 Neither the senior management staff of the School, nor Council officials, come out of this well. It appears to me that, over the piece, neither was prepared to accept that the other was acting in good faith. Having spoken to most of those directly involved over the course of this Review, I have concluded that these views are still strongly held and that, in some cases, professional disagreements appear to have become personal. I am certain that these poor relationships had a bearing upon the events of 2017 and 2018 set out in this report.



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