A while ago I was delivering training and speaking with passion (I think) about a local Serious Case Review that had thrown up a number of insights. As I have said many times before, so much of my own continuing professional development is gained from reading Serious Case Reviews which tragically examine the death or serious harm of a child from abuse with regard to possible lessons learned. The participants on this course, many who had been receiving my newsletters for years, requested that I should use the format of my newsletter to focus periodically on specific cases, basically because when we shine the light on particular cases, there is so very much to learn. Putting a name and a face to real children also helps us to remember that it is they that lie behind the all headlines, statistics and guidance. Real children who were failed by those safeguarding processes that we adults put in place to protect them. And that cannot help but to engage us in the work and concentrate our efforts to effectively safeguard children.
Accordingly in this piece I am going to focus on a real case of child abuse and tell the story of Dennis O’Neill. Dennis was the subject of the first ever Public Inquiry on children’s safeguarding in the UK which took place in the last months of World War II, and led to many early legislative changes regarding the protection of children. In that time, the sad death of Dennis at the hands of his abusers was as much a talking point for the society at that time, in much the same way as Victoria Climbie, Baby P and the victims of Child Sexual Exploitation in cities like Rochdale and Rotherham have been for us in recent years.
On 9 January 1945, a boy called Dennis O’Neill was found dead in his foster home in a remote farm in the county of Shropshire. His foster mother had phoned the local doctor at 1pm and told him that Dennis was having a fit. When the doctor arrived at 3.30pm he found that Dennis was dead and in an appalling physical condition. A post-mortem later revealed that he had suffered cardiac arrest as a result of heavy blows to the chest. He also had been beaten severely on his back, his feet were covered in sceptic ulcers and he was severely malnourished. A post-mortem examination revealed he had been starved for months and weighed just four stone. Dennis was just two days shy of his 13th birthday.
On 3 February 1945, his foster parents Reginald and Esther Gough were arrested. Reginald, 31, and Esther, 29, were charged with manslaughter, ill-treatment, neglect and exposure likely to cause suffering. At their subsequent trial in March 1945 they both pleaded not guilty.
Dennis and his two younger brothers, Terry and Freddie were all born in Newport. They had been removed from their parents’ care in 1939, but since then they had been in and out of foster homes. In July 1944, a foster home was found for all three boys in Shropshire, but at the last moment only the youngest, Freddie (7) was accepted. The Goughs lived at the nearest farm and were persuaded to take on the older boys Dennis (12) and Terry (9) as a matter of urgency.
Paid nearly £2 per week to look after the boys, the Goughs pledged to uphold the Children and Young Persons Act, which was effectively a promise to bring them up as one of their own children and to provide them with proper food, washing and lodging. Evidence at the trial revealed that the couple fell very short of that promise. The most crucial witness for the prosecution was Dennis’s younger brother, Terry, who gave evidence over 3 days. Too small to sit in the witness box, he sat instead on a bench at the front of the court. As Terry’s sad story unfolded before a packed courtroom, his words were so horrific that women at the back of the court couldn’t hold back their tears. One woman is recorded as crying out, “Oh God, oh God!” after hearing some of the evidence. It became clear that Terry and his older brother had been the victims of neglect, grotesque bullying and sadistic punishment at the hands of their foster parents and in particular from Reginald. He spoke of their terrible hunger, how he and Dennis were often given just three slices of bread and butter to eat all day and were so ravenous that they risked a beating by sneaking into the pantry and stealing food. Dennis was sometimes so hungry that he would suck milk from a cow’s teat. The physical punishment suffered by the brothers was unremittingly grim. Every day the boys were beaten with a stick, often up to 100 whacks each.
The night before Dennis died he was thrashed for taking a bite from a swede. The following day he was stripped naked and tied to a bench by Gough, and thrashed with a stick so hard that it broke; Gough then thrashed him with another stick until his legs were blue and bleeding. He was unable to stand up, and was then locked in a cubbyhole in the kitchen. His feet were by now in a terrible condition, and Gough hit him with his fists in his chest to try to make him stop crying. He died soon after.
Eirlys Mary Edwards, a clerk with the Newport Education Committee, also gave evidence. With no training or experience in matters of child welfare, Eirlys had visited Bank Farm on December 20, 1944. She found Dennis pale and withdrawn and although neither boy spoke out against the Goughs, she recommended in her report their ‘immediate removal’ from the farm. Authorities responded with little urgency, the report being put aside for an officer to deal with on his return from annual leave on January 10 – the day after Dennis died. Eirlys also urged Esther to have Dennis checked medically, but the first doctor Dennis saw, in the six months he spent at the farm, was the one who declared him dead.
Esther Gough gave evidence against her husband, relating how he had punched and beaten her. Reginald had been convicted for common assault against Esther in 1942, and she had left him, but then returned. “I am afraid I had not time to think of loving him,” she said when asked at trial how she felt about Reginald. “You cannot love someone you are afraid of.” She confirmed Terry’s story of her husband’s brutality, describing how Dennis lost weight because Reginald would not allow him to eat with everyone else at the table, but would make him stand and watch them. Esther also described how, the night before Dennis’s death, Reginald had made him go outside into the freezing January night with no clothes on and then hit him on his head as well as punching him on his chest and back.
Along with personal testimonies, there were 16 police exhibits in court, including the bench described by Terry as the one to which his brother had been strapped and beaten.
The jury took 20 minutes to return a guilty verdict. The judge took into account Reginald’s mistreatment of Esther before sentencing her to six months in prison. Reginald was initially sentenced to six years. This caused an outcry among the public, who felt that it was far too lenient given the brutality of his actions and eventually an appeals court found him guilty of murder, extending his sentence to 10 years.
The nation was not just shocked by the Gough’s actions but also by the failure of the local authorities to watch over the two young boys in their care. The questions in particular were:
- Why were two young boys placed with a man who was not only a known to the police as a bully, and with a conviction for violence?
- Why was the welfare of the boys not properly supervised or monitored whilst in his care?
- Why had no inspection of the boys’ welfare was made until they had been with the Goughs for six months?
- Why had the professional carrying out a visit received no training in child welfare?
As a result of the O’Neill case, on 22 March 1945, the Home Secretary announced that a public inquiry would be held into the case, conducted by Sir Walter Monckton. Monkton’s Inquiry reported later that year, and identified a string of failures by staff and agencies. There had been confusion between the two local authorities responsible for the boy’s foster placement, conflicting reports by childcare staff about his wellbeing, staff shortages and miscommunication.
On 1 January 1947 the new Home Office and Ministry of Health regulations on the boarding-out of children came into force as a direct result of the Monckton Report. The principal requirements were:
- Each local authority was required to appoint a boarding-out committee, at least three of whose members were to be women and which had to meet at least every three months. The committee was to be responsible for finding suitable foster homes and to exercise supervision over all the authority’s foster children.
- An official was required to visit every foster child within a month of their being placed and thereafter at least once every six weeks. They were required to submit a written report, taking into account any complaint made by the child.
- A doctor was to be appointed for every foster child and was to examine the child within one month of their being placed and at least once a year thereafter.
- No child was to be fostered or remain fostered by a person with any criminal conviction rendering them unsuitable to be a foster parent or in any environment likely to be detrimental to them.
The case was a significant contributory factor leading to the Children Act 1948. This imposed new duties upon local authorities which resulted in childcare services working more closely with families, encouraging professionals ‘to view children as individual human beings with both shared and individualised needs, rather than an indistinct mass.”
The key themes of child centred practice, training and management of safeguarding professionals, professional accountability, checking on the suitability of adults who look after children and information sharing between statutory agencies are important factors which have repeated sadly in many high profile child abuse cases since then.
In 1947 Agatha Christie wrote a radio play called Three Blind Mice loosely based on the case. This eventually developed into the long-running play The Mousetrap.
In 2010, a book by Terry O’Neil describing his childhood experiences was published, entitled ‘Someone to Love Us’. Despite his horrific experiences as a child, Terry became part of a large and loving family of his own. The book was dedicated to his brother Dennis.
If you are interested in finding out more about the safeguarding training I offer, please don’t hesitate to contact me. At the current time, all my training is being delivered via Zoom. I offer a range of inhouse safeguarding children training to settings, and a number of scheduled open courses in partnership with Delegated Services.
