Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome Ms Catherine Fox and Mr Glynn Brown, representatives from Action for Muckamore.

Ms Catherine Fox (Action for Muckamore): Hello, everybody.

The Chairperson (Mr McGuigan): You are very welcome. Thank you very much for taking the time to come before the Committee. The Committee is very engaged with what is going on with the Muckamore inquiry. We have a keen interest in that. We thank the families for shedding light on some of the horrific issues that have come to light, and a lot of what the Bill is doing follows on from that inquiry. Today is specifically about the Bill, so we should keep as close as possible to the Bill and the lessons that we can learn in supporting some of the things that you, as families, have encountered.

I will hand over to you for some opening remarks, and we will then go around Committee members for questions.

Mr Glynn Brown (Action for Muckamore): We had so much in our mind that we have committed it to paper so that we do not get waylaid, miss out bits and come out of the meeting saying, "I should have said this. I should have highlighted that". Without further ado, we will commence.

Chair and Committee members, thank you for the opportunity to speak today. We speak on behalf of Action for Muckamore, which is a group formed by families whose loved ones were patients at Muckamore Abbey Hospital. We are here because what happened there was not an isolated failure; it was the predictable outcome of a safeguarding system that does not enforce its own rules.

We support the introduction of the Adult Protection Bill. The need for such legislation has been clear for many years. As far back as 2014, following failures at Cherry Tree House care home, the Commissioner for Older People called for stronger adult protection. More than a decade later, families are still describing the same failures, the same gaps and the same harm.

Today, we want to focus on four areas that must be strengthened if the Bill is to genuinely protect vulnerable adults: CCTV; culture; independent advocacy; and training, investigations and adherence to procedures with proper oversight. Before addressing those areas, it is essential to be clear about the core problem in adult safeguarding in Northern Ireland. Northern Ireland already has a regionally agreed adult safeguarding policy and operational procedures. The policy was introduced in 2015, with procedures following in 2016. The failure is not the absence of policy, but the absence of enforcement, oversight and accountability. The 2020 independent review of adult safeguarding at Dunmurry Manor found that each health and social care trust was operating differently despite those agreed regional procedures. That finding mirrors exactly what families experienced at Muckamore Abbey Hospital. Evidence to that effect was given directly to the Muckamore Abbey public inquiry. The staff were using different forms and different processes and were working without consistent supervision. That level of inconsistency is not merely inefficient; it is dangerous.

When procedures are not followed, investigations are not robust. Timelines drift, meetings are missed, safeguarding plans are weak or absent, and vulnerable adults are left exposed during the very process that is there to protect them. Today, there is no effective oversight, monitoring or regulation of adult safeguarding investigations across Northern Ireland. Safeguarding investigations can take months or years to conclude, and, during that time, there is no assurance that procedures are being followed and no guarantee that required meetings are happening, nor is an independent body routinely checking the quality of the process.

There is no organisation above the trusts that systematically checks whether adult safeguarding is being done properly. That is an extraordinary gap. The Regulation and Quality Improvement Authority (RQIA) has an important role, but it does not oversee adult safeguarding investigations being carried out by trust safeguarding teams. It inspects environments and staffing, but it does not examine safeguarding files, audit timelines or check compliance with procedures. If the Adult Protection Bill is to succeed, it must include the statutory oversight of the safeguarding process itself, not just the services where harm occurs.

CCTV is important, but it is only one tool. It must be set within a system where incidents trigger proper safeguarding procedures, those procedures are followed consistently and investigations are overseen externally. Without that, CCTV risks becoming another unmanaged safeguard. Families have talked about CCTV in care settings for well over a decade. It is time for action that actually protects people.

Culture is the biggest problem in the system. For years, we have listened to the Committee discuss culture reviews and culture change, yet at no point during those reviews has anybody spoken to us, the families who have lived through the consequences of that culture. For over 10 years, families have sat in meetings with senior learning disability management, and what we have experienced in those rooms has been a disgrace. A culture that allows procedure to be ignored is a culture that tolerates risk. Culture changes not through reviews alone but through enforcement, accountability and consequences.

I will now read a short quotation from a public statement made by Geraldine O'Hagan, a Belfast Health and Social Care Trust social worker, that is available on the Muckamore Abbey Hospital inquiry website.

When safeguarding systems fail, families and advocates become the only protection that vulnerable adults have. Independent advocates must be properly trained, properly empowered and genuinely independent. Advocates should never have to fight simply to ensure that basic safeguarding procedures are followed. Training without oversight is meaningless; investigations without regulation are unsafe; procedures without enforcement are just paperwork. The Bill must ensure that mandatory training, standardised investigations and external scrutiny have compliance.

We are not here simply for our loved ones. Behind us are families of children and young people with learning disabilities who are still in the children's system. They are watching the process closely, because their children will soon transition into an adult social care system that is not fit for purpose. They should not inherit the same failures, culture and risks that families before them have endured. If the Bill does not address culture, enforcement and oversight, nothing fundamentally changes, and, if nothing fundamentally changes, the next Health Committee will sit here in five or 10 years' time hearing the same evidence, commissioning another review and responding to another preventable failure.

The Dunmurry Manor review confirmed what families already knew: adult safeguarding in Northern Ireland fails not because policy does not exist but because no one ensures that it is followed. The Bill is an opportunity to break that cycle; an opportunity to move beyond statements of regret and commitments to learn lessons; and an opportunity to put enforcement, oversight and accountability at the centre of adult protection. If that opportunity is missed, families will continue to pay the price; vulnerable adults will be exposed to harm; and the system will continue to fail the people whom it is meant to protect. Please do not let the Bill become another promise without protection.

Action for Muckamore supports the use of CCTV in care settings as a safeguarding measure. We want to be clear that CCTV is not about punishment or surveillance for its own sake. It is about protection, transparency and accountability, particularly for people who cannot speak for themselves. However, it is also important to say that the drafting of legislation is not our area of expertise. We do not pretend to know the correct legal wording or structure for CCTV provisions. That is a matter for legislators and legal drafters. However, we know that CCTV in care settings has been talked about for a long time. There have been reviews, consultations and discussions for years. At this point, it is time to make a decision; to set up a properly resourced task force; to agree a clear approach; to work on a defined time frame; and to implement what is agreed on. CCTV cannot remain an idea that is discussed endlessly but never delivered.

CCTV was the catalyst for exposing the large-scale abuse at Muckamore Abbey Hospital. The footage showed behaviour that should never happen in any care setting. However, it is also important to say that CCTV was not needed for people to know that something was seriously wrong in Muckamore. The failings at Muckamore were visible long before the CCTV footage was viewed. They were evident in the culture, staffing issues, injuries, complaints and repeated safeguarding concerns. Members of Action for Muckamore were raising concerns with the Department of Health, the Health Minister and the regulator long before the CCTV footage came to light. The warnings were there, but they did not act on those warnings. Therefore, while CCTV is an important safeguarding tool, it must be set within a wider system that listens to families, responds to concerns, follows procedures and has proper oversight. CCTV should support adult safeguarding, not replace it.

We have studied and discussed CCTV repeatedly. Action for Muckamore believes that trying to deal with the nuances of CCTV in the Adult Protection Bill is fundamentally the wrong approach. CCTV in care settings is not a simple clause that can be slotted into the wider adult safeguarding legislation; it is a major, complex policy that requires dedicated legislation. The reasons are clear: CCTV involves multiple competing rights, including the right to privacy, the right to family life, the right to dignity and autonomy and the right to protection and scrutiny. Balancing those rights requires detailed regulation, consultation, case law review and strong legal drafting, and that cannot be achieved by a few paragraphs in a broader safeguarding Bill.

CCTV varies across care environments, such as hospital wards, respite units, care homes, day centres, supported living, private bedrooms and communal areas. Each setting has different risks, different layouts and different legal considerations. One generic clause in the Adult Protection Bill cannot cover all settings safely or lawfully. The operational standards for CCTV must be extremely detailed. Stand-alone legislation must address storage and retention periods; encryption and cybersecurity; who can view the footage; auditing systems; triggers for mandatory reviews; rules for covert versus overt cameras, i.e. the Regulation of Investigatory Powers Act 2000 (RIPA); clarity on consent and capacity; and safeguarding thresholds. Those are not side issues; they are the core issues that will determine whether CCTV protects or creates new risks. The Northern Ireland Assembly should not attempt to deal with such a complex safeguard in a subsection. CCTV deserves the same legislative quality and scrutiny as is given to major systems, such as mental capacity, social care and carers' rights.

CCTV was a lifesaver in Muckamore, but it was completely mishandled. The catastrophic way in which the CCTV was installed, stored and mismanaged there demonstrates exactly why Northern Ireland needs detailed stand-alone legislation. The CCTV at Muckamore was not covert; it was overt. However, nobody in the health service had a clue about the status of the overt CCTV, despite its having been installed for adult protection purposes in 2015. I note that there were signs all over the facility: you could hardly walk 10 feet without seeing a sign stating that there was 24-hour surveillance. The CCTV installation and CCTV management at Muckamore was a clear example of how not to do it. Look at the huge cost to the public purse and the huge cost to families caused by the Muckamore CCTV fiasco. The footage was not monitored; time frames were ignored; the staff bullied anyone who questioned it; and there was no audit system, no guidelines and no triggers for action. The governance had collapsed.

The Adult Protection Bill cannot correct those failings with a few brief clauses. Only a dedicated CCTV in care settings Bill can do that. The Adult Protection Bill is already overloaded, and adding complex CCTV regulations risks delaying or weakening the Bill. Two separate Bills would mean stronger adult protection, stronger CCTV regulation and more effective scrutiny. They complement each other; they should not be forced together. We strongly support CCTV, but it is too important an issue to be squeezed into a single clause in a wide-ranging Bill. Northern Ireland needs separate, stand-alone legislation on CCTV in care settings, because the issues involved are far too complex to be treated as an add-on. The Adult Protection Bill should focus on oversight, enforcement and safeguarding standards, and CCTV should be given the full legislative attention that it requires.

England does not have dedicated CCTV legislation for care settings, nor do Scotland and Wales. They all rely on patchy guidance, data protection rules and inconsistent practice. Northern Ireland has the chance to lead. Action for Muckamore believes that Northern Ireland can become the first jurisdiction in these islands to introduce stand-alone, world-leading CCTV legislation for care settings that is clear, safe, detailed and enforceable. We could be the first jurisdiction to get it right.

Ms Fox: We are not finished. When Action for Muckamore talks about culture, we are not talking about abstract values or mission statements; we are talking about how people behave when things go wrong, how concerns are received and how families and staff are treated when safeguarding issues are raised. At Muckamore, the culture allowed abuse to happen, to continue and to go unchallenged. However, that culture did not exist only on the wards; it existed at management level and across the wider system. A healthy safeguarding culture is one in which concerns are welcomed, not resisted. At Muckamore, concerns were treated as problems to be managed rather than warnings to be acted on. Families who raised concerns were viewed as difficult, and staff who tried to do the right thing were isolated. That is not a safeguarding culture; that is a defensive culture.

We want to be clear that culture is not changed by writing new policy. Northern Ireland already has a safeguarding policy. What was missing was a culture that enforced that policy. Culture is revealed by actions, not words. At Muckamore, actions showed that reputation was prioritised over safety and control over transparency. The evidence heard by the public inquiry showed that people who spoke up were not supported. Some were marginalised, some were ignored and some felt actively discouraged from raising further concerns. That is why Action for Muckamore believes that culture cannot be left to goodwill or leadership style. It must be shaped by law, oversight and consequences. If there are no consequences for ignoring safeguarding concerns, the culture will not change. If families can be excluded without challenge, the culture will not change. If investigations can be delayed for years without scrutiny, the culture will not change. The Adult Protection Bill must, therefore, do more than describe good practice; it must create conditions in which the wrong culture cannot survive. That means having independent oversight, mandatory procedures and accountability when those procedures are not followed.

Culture affects many members of Action for Muckamore as older carers who have experienced years of stress, fear and exhaustion because of how they were treated when they raised concerns. The way that carers are treated is a direct reflection of an organisational culture. Action for Muckamore is not asking for blame for the sake of blame; we are asking for a culture in which safeguarding is taken seriously from the first concern, not after the harm has been proven.

The Committee has heard many times that culture needs to change. Today, we say that culture will change only if it is reinforced by law, oversight and enforcement. The Adult Protection Bill is an opportunity to hardwire a safeguarding culture that protects people, listens to families and supports staff who do the right thing. If culture is not addressed properly in the Bill, the same behaviours will continue, even under a new framework. Culture is not a side issue but is central to whether the legislation succeeds or fails.

Mr Brown: That leads us to independent advocacy. When Action for Muckamore talks about independent advocacy, we are talking about the presence of a voice that is separate from the health trust, separate from the care provider and focused solely on the interests of the adult at risk and their family. Many of the people cared for at Muckamore could not speak for themselves. Some had limited communication; others had none. Some lacked capacity to understand many issues. Some were entirely dependent on others to raise concerns on their behalf. In such circumstances, independent advocacy is not optional; it is essential.

At Muckamore, families were often the only advocates, yet they were excluded, marginalised or treated as a problem when they raised concerns. An advocate must be independent not just in name but in practice. Advocacy that sits within the system that is being scrutinised is not independent. Independent advocates must be able to challenge decisions, question delays and escalate concerns without fear of retaliation or instruction. Action for Muckamore believes that independent advocacy should not depend on whether a family knows how to navigate the system or has the strength to keep pushing on. Older carers in particular should not have to fight complex systems on their own while dealing with stress, ill-health and exhaustion. Independent advocacy must be available early, not introduced after harm has occurred. Advocates should have access to information, meetings and documentation, because, without access, advocacy just becomes symbolic rather than meaningful.

At present, advocacy provision is inconsistent. Some people receive support, others do not, and families are often unclear about what advocacy exists or how to access it. The inconsistency leaves vulnerable adults exposed and places an unfair burden on their families. Action for Muckamore believes that advocacy must be embedded in the safeguarding process, not added on as an afterthought. Advocates should have a recognised role in adult safeguarding investigations, Mental Capacity Act 2005 processes and care planning decisions. Advocacy must also be properly resourced, as an underfunded advocacy system cannot provide an effective challenge. We also believe that advocates should be trained in learning disability, safeguarding and trauma-informed practice. Independent advocacy protects not just the adult at risk but the integrity of the safeguarding system. Without independent advocacy, the system relies on families to be persistent, resilient and knowledgeable, which is neither fair nor safe.

The Adult Protection Bill must therefore make independent advocacy a core component of safeguarding, not a discretionary extra. If advocacy is not guaranteed in law, the same patterns of exclusion and imbalance of power will continue. Independent advocacy is all about balance. It ensures that the most vulnerable people are not left voiceless in systems that hold power over them.

Ms Fox: You will be glad to know that we are coming to the end. The final area is training, investigations and adherence to procedures. When Action for Muckamore talks about training and investigations, we are not talking about box-ticking or compliance on paper; we are talking about whether safeguarding works in practice when concerns are raised. Northern Ireland has adult safeguarding policies and procedures. The problem has never been that they do not exist but that they are not followed consistently. Training without enforcement is meaningless. Staff can be trained, but, if there are no consequences when procedures are ignored, behaviours do not change.

At Muckamore, safeguarding procedures were in place, yet abuse continued, which tells us that training alone is not enough. Investigation must be timely, thorough and independent. Delays of months or years undermine safeguarding and cause significant harm to families and carers. Action for Muckamore has seen adult safeguarding investigations drift without clear timelines, clear leadership or effective scrutiny. When investigations are poorly managed, the focus shifts away from protection and accountability and towards process management and delay.

Procedures exist to protect vulnerable adults, not to be selectively applied or adapted for convenience. One of the most serious failings in the system is the lack of oversight of investigations. There is no routine external check that procedures are being followed correctly, and, when procedures are not followed, there are often no consequences.

That creates a system in which poor practice can continue unchecked. Therefore, training should be tied to clear expectations and accountability. Staff need to know that safeguarding procedures are mandatory, not optional.

Investigations must also be standardised. People should not receive different levels of protection depending on which trust area they live in. Action for Muckamore believes that investigations should be subject to independent monitoring, quality assurance and audit. Without oversight, even well-written procedures fail in practice. Families and advocates should know what the safeguarding process looks like, what stage it is at and what should happen next. Lack of transparency in investigations increases stress and erodes trust. The Adult Protection Bill must ensure that training, investigation and procedures are embedded in law, not left to guidance. It must make clear who is responsible, what must happen and what happens when it does not. If procedures remain optional in practice, the same failures will continue under a new legislative framework. The Bill is an opportunity to move from guidance to guarantees. Training, investigations and adherence to procedures are not technical details; they are the backbone of effective safeguarding.

Thank you for listening.

Mr Brown: For context, I will add something about CCTV. Obviously, the trust owns up to nothing. Nobody knew about Muckamore. It was a case of, "Nobody told me. We are all innocent. How were we to know?" — never mind the hundreds of confirmed adult safeguarding investigations that were proven. That should have been a massive red flag. However, besides that, the trust position will be, "Things have moved on", and it will wring its hands, look sad and say, "Lessons have been learned. Reassure the public".

I want to explain something to you, but I will talk in the broadest and vaguest terms so that I do not identify anybody. I have permission to speak on this person's behalf. Somebody moved into a facility several months ago and got resettled. After a while, that person could speak and told their parents, "I am being ill-treated". The parents went to the facility and said that the person — male or female — said that they were being ill-treated. The response was, "a lot of rubbish". It went up the line, and it was, "Problem family. These staff are super and brilliant". They were totally not believed.

The family pushed and pushed and then said, "I'll tell you what. Play the CCTV. If it shows that all is in order, we will walk away quite happy and contented. If it shows that all is not in order, we expect action". It was agreed to play the CCTV. Muckamore's story was, "We never knew that the CCTV was switched on". At this facility, they said, "Play it", and the response was, "Oh, it is not switched on". There was a CCTV facility that was not switched on, and it was a case of, "Well, it had better be on from now on". The facility then switched the CCTV on. Bear in mind that that was only a few months ago. The individual was still making complaints about ill treatment, so the parents raised the concerns on that person's behalf. It is somewhere in Northern Ireland, but I will be vague so that nobody can tie down who it is or where it was. They complained again, right to the top, and the response was, "Problem family, blah blah blah" — the usual. They said again, "Play the cameras. Let us see what is happening. If there is nothing untoward, we will walk away". They played the cameras, and 12 people were dismissed and one was prosecuted by the police.

Eight years after the Muckamore scandal, the same people are in safeguarding positions, and there is the same attitude of, "It cannot be happening. My staff are great. Do not believe them. This is rubbish. They are a problem family". Then, when the footage was played, it was, "Frigging hell. What are we going to do now?". What has been learned?

Ms Fox: That was an ex-Muckamore patient who was resettled in the community, and there was further abuse and neglect. We do not feel that, from Muckamore to the community, any lessons have been learned. The safeguarding is not fit for purpose. Margaret Kelly, the ombudsperson, publicly announced in 2023 that it was not safe and that adult safeguarding was not fit for purpose. Nothing has changed.

The Chairperson (Mr McGuigan): I will stop you there. The example that you have given us to end your evidence is particularly harrowing. It is disconcerting to hear that, particularly given the experience of Muckamore and what we are here to discuss.

I thank you for giving your evidence, which was very forthright. It is important to us that we hear it. The Committee will certainly view your experience as important as part of the evidence that we are gathering. The Adult Protection Bill is important, and it is vital that we get it right. What we have heard today will be useful to us in our continued deliberations.

We will have questions from members.

Mr Brown: May I just say something in one sentence? The whole point of that was, again, as in Muckamore, that, without the CCTV, you were not believed. That is still going on.

Ms Fox: Families were made out to be troublesome families. That is only one case, but we could go on to tell you about lots of others. That is just an example. The point is that families are not believed when they raise concerns. Of course, I am sure that the majority of families want to protect their loved ones. When we come up against that treatment and false allegations are made against families, it is because we are seen as troublesome. That is unacceptable. [Interruption.]

I am sorry; my phone is ringing. I thought that I had turned it off. Go ahead.

The Chairperson (Mr McGuigan): You are all right.

Both of you covered a number of issues, including oversight, culture, independent advocacy and CCTV. Those were the four primary issues. I am sure that members will focus on those matters and will give you ample opportunity to expand on some of the things that you have talked about.

You talked quite a lot about culture. You seem to be saying that culture cannot change unless it is legislated for and reinforced by enforcement. What do you think needs to be included in the Bill that is not currently there? You said that some aspects that could be included in guidance need to be shifted into legislation. Is that what it is, or is there more? Are there specific things that need to be included in the Bill that are not currently there and would help with your families' experiences of culture in the trusts?

Ms Fox: This is only part of it, but, when we talk about culture, for example, I was raising concerns back in 2015 and 2016 about Muckamore. My daughter and I felt that I was not listened to. I do not know why, but it is almost as if there is a culture that, where people raise concerns, those are not taken seriously. All the people to whom you reach out, who are there as part of adult protection, ignored it. As a mother, you are trying to protect your loved one. You go back and will not go away, and then you are accused of being a difficult family. There could be false allegations made against you on the basis of no proof. That is the culture. There is a power imbalance.

The Chairperson (Mr McGuigan): Would strengthening independent advocacy help in that scenario?

Ms Fox: I definitely do. I believe in independent advocacy. For example, I could be given an advocate, but, while my personal advocate is good, is she trained in all the policies and procedures? Can she support me? She should know all the policies and procedures and be trained in the different stages of the adult protection process (APP) from APP1 to APP7. She should know about those and be able to say to the designated adult protection officer (DAPO), for example, "Catherine needs to be involved in stage 4. You have now done your investigation at stage 3. At stage 4, the family should be involved and should hear the findings of the adult safeguarding procedure".

The Chairperson (Mr McGuigan): Glynn, you said that the advocates have to be resourced properly. Some evidence that we are getting is potentially giving us concern that resources may be a difficulty, even if we get perfect legislation. There is a worry, in a constrained budget, that there may not be the resources. In your view, would that have a detrimental impact?

Mr Brown: Yes. That goes to the core of every problem that government has. If you do not resource what you are trying to achieve, it will become a farce. The police said it; we watched them online. If you go in piecemeal fashion to introduce something — you bring one bit in and bring another bit in — and it is not properly resourced, it will end up being a shambles.

Everybody — every Department, the police and the RQIA — is under the financial cosh. The RQIA is meant to have an oversight of adult safeguarding, but it has told us that it is not resourced to do that. It might gurn that your light switches are a bit dirty and tell you to change them, but it is not resourced to check and enforce the crucial issues. That is a critical failing. It should have oversight from start to finish. If I am going to inspect a facility and many safeguarding investigations have been proven in that facility, do I need to give it closer scrutiny, or will it come up smelling of roses?

Money will be at the core of everything that we are trying to do here. If it is not provided in adequate amounts, it will end up being a shambles.

Ms Fox: May I jump back to the independent advocacy point? Advocates need to be fully trained in all the policies and procedures. They need to be confident in their job and not be afraid to challenge. There needs to be a healthy culture of not being afraid. For example, they can have oversight and be part of the safeguarding and, if they believe and know that the procedures are not being adhered to, they should not be afraid of any repercussions if they speak up. In the past, while at Muckamore, advocates have said to me, "I have to be careful about what I challenge, because, after all, it is the Belfast Trust that is paying me". There should be no fear in challenging. They should be fully qualified and trained and know and be confident in supporting people like me or others.

The Chairperson (Mr McGuigan): Absolutely.

The Committee has heard a raft of evidence about CCTV. Most people are sitting on the fence with regard to CCTV because they see it as a difficult thing to potentially get right. You have gone a stage further in your position, which, hopefully, I am getting right. You say that you agree that there should be CCTV but that, because it is so difficult, it cannot be dealt with properly in the context of the Bill: am I right in saying that?

Mr Brown: Yes. There should be a stand-alone Bill. We agree that one paragraph should be included to implement it, but, for the mechanisms and structure and everything that surrounds it, one size does not fit all. For instance, my son has no speech whatever. He cannot tell me anything regarding Muckamore, whereas somebody else could be able-bodied, lack a lot of capacity but still be able to speak and discern things. Therefore, you cannot implement a system that suits A but is detrimental to Z.

It needs a lot more work by people beyond our capability. We are not legislators. We do not draft law, so we do not know. Check with the jurisdictions in other places: what is good practice, what works and what does not work? Body-worn cameras come into it. What legislation are you using for that?

We are realistic about it. We are not in a dream world where you just snap your fingers and it will happen. It is hugely complex, and it needs to be dealt with in a timely and definitive manner.

The Chairperson (Mr McGuigan): Thank you.

We have a set amount of time. This is emotive, and I completely understand that. If members try to be concise in questions and answers, we will get round everybody.

Mrs Dodds: Thank you for your evidence. It is really important.

To go back to the issue of CCTV, last week, I lamented the fact that we had heard a lot of evidence about CCTV but nobody said what they wanted really or nobody would give us, "This is my definite direction". Your evidence is powerful and important because you recognise the inherent difficulties of CCTV for an individual's privacy. For the individual who lives in that establishment, that room is their home. CCTV could be a real invasion of privacy. It could, on the other hand, be a huge protection, so I am struggling with that.

I appreciate the fact that you have been clear around CCTV, saying that a clause in a Bill is probably not enough to do it. The clause states that it would enable regulations to be made on CCTV; it is enabling. Would that be enough, or does it have to be absolutely separately scrutinised legislation?

Mr Brown: Our group and I would prefer legislation.

Mrs Dodds: OK.

Mr Brown: We have had loads of procedures: nobody follows them.

I was in RQIA getting information from someone on an issue. At the same time, somebody from the trust phoned me and said that I was not entitled to the information that I wanted. Beside me was my advocate, who was well genned up on procedure — I cannot remember the page — and said to turn to page 49, paragraph 6 and quote to the manager:

I said, "That's your policy". That manager said to me, "I never knew that".

Mrs Dodds: That does not surprise me.

Mr Brown: If she is the manager, she is, in theory, forcing her underlings to comply with the policy, but she admitted that she did not have a clue. I thought, "My God. How many breaches of the system are there?". I can pull a bit out — I am doing this, and I am not doing that — and there is no comeback. Who cares? We need somebody to say, "Right, there have been 500 adult safeguarding issues this month. We will pick a sample of 10. We will start at phase 1 and go right the way through to see whether it was handled properly, whether there is learning that we can give back to the trust, and whether it is willing to learn". That is another question.

Mrs Dodds: Yes. Your point on culture is well made. Any of us who advocate on behalf of our constituents or for people who write to us will understand that culture is a real inhibitor to progress and, in your case, to the safety of your loved ones. The point that you make about culture is really important. I will make a note that regulation is not sufficient, that CCTV requires separately scrutinised legislation and that, if you have to wait a little longer, you are happy to do that.

Mr Brown: Right.

Mrs Dodds: We have got that right. OK.

Mr Brown: To be honest, culture in any organisation, as they will all tell you, is hard to change, no matter the organisation.

Mrs Dodds: Yes, and it takes years to change, and it needs really strong leadership to change it. That is important.

Do you have any views about the adult safeguarding board?

Mr Brown: If you take Muckamore, there was RQIA, the Health and Social Care Board and the Belfast Trust — all those strata of governance and oversight — but none of them worked. Our worry is that all those things are great on paper, unless you have an inquisitive mind and start challenging, "Why are so many people going into seclusion? Is there not better, less restrictive practice? How come there are so many proven adult safeguarding allegations?". Does nobody say, "My God, one of our facilities must be way off the rails"? Nothing seems to trigger anybody to be curious about anything.

It will be a question of how vigilant a person is. You need people who are driven about adult safeguarding and passionate to see massive change. It seems to be that someone goes from the RQIA to a senior post on the board and from a senior post on the board to the RQIA. All those positions are interchangeable.

Ms Fox: It is like pass the parcel.

Mr Brown: Yes.

Ms Fox: Nobody takes responsibility, picks up the gauntlet and moves forward.

Mrs Dodds: Can you legislate for culture? We have legislation that we have to try to improve. I agree with you: I have done a lot of work on the cervical cancer issue, and nobody looked back over the records there either. Nobody had the curious mind that you talked about. Nobody did the investigation until a new person started work and noticed that something was not right.

Ms Fox: Things and patterns emerged at Muckamore. There were red flags, warning signs and a lot of failed and missed opportunities. I am an ordinary person, but I could identify and feel in my gut that something was radically wrong. However, all the professionals could not pick up on that. I do not believe that for one moment. I will never believe that. The problem is about identifying and recognising it in the early days. It is about listening to people who come forward with concerns and being open to the reality. Just because the person is a nurse, a manager or in any other role in the profession, it does not mean that they cannot do harm. The culture of them protecting themselves and the NHS needs to go. They need to be open, honest and transparent. That needs to be part of the culture.

Mrs Dodds: Thank you very much. That is very powerful.

Ms Fox: Thank you.

Mrs Dodds: You have experienced it, and it is powerful.

Mr Brown: I call it the musical chairs of mayhem. This is the fifth major inquiry into the health service, and that alone should tell you that something is tragically wrong. If you look at the scandals, you see that person A is in a position in one scandal, they then move to a more senior position in the next scandal, and they become quite senior in the next scandal after that. All they do is leave wreckage in their wake. In any other job, if you preside over a disaster, you get the bullet. The big problem with Muckamore, as with all the inquiries, is that it involves the Civil Service, and nobody is ever to blame. Nobody knew anything, and nobody will be sacked. There is not a hope in hell of that.

Accountability must be built into the system. We are not talking about somebody making a genuine mistake; we are talking about catastrophic failure, when everyone walks away and says, "It is not my problem. I knew nothing".

Mrs Dodds: I think that most members of the Committee would agree. I do not pretend to speak for everybody, but accountability is one of the biggest issues that we find in the health service.

Ms Fox: 100%.

Mr Brown: Absolutely.

The Chairperson (Mr McGuigan): On the point about separate CCTV legislation, we have the ability to make secondary legislation that complements the primary legislation. That also receives full Committee scrutiny and public consultation. Depending on the final version of the Bill, that is a potential avenue for an additional CCTV aspect.

Ms Fox: We would welcome being invited back to the Committee to speak about that and to help in any way that we can, given our experiences.

Mr Brown: Again, the process has two plebs at the bottom of the pile —

The Chairperson (Mr McGuigan): Not plebs; they are important and valid experiences.

Mr Brown: — who are being asked about making changes. Where is the senior management? Where are their constructive proposals on protection? What is their view on CCTV? Let us see them drive something forward. Let us see them do something right for a change. It should not be up to the parents, as usual, to expose the scandal, the cover-up and the suppression of information.

Ms Fox: To fight for a public inquiry.

Mr Brown: The senior people had to be ordered to do their job. They said that they were going to watch 25% of the footage of the worst scandal in UK history: we said, "No, you are going to watch 100% of the footage". They said that they moved eight people who watched the alleged abuse to another ward: we said, "No, you are going to suspend them". I say, "You had to be ordered to do your job. The boss sets the tone for the organisation, and, if that is your response, that says it all to me".

The Chairperson (Mr McGuigan): I should say —.

Ms Fox: Sorry; I want to say one more thing in relation to what Glynn said. For example, in Muckamore, the investigation was a joint protocol with the police and the Belfast Trust. The Belfast Trust should not have been investigating itself, because it was not independent. As we know, within the first two years, it was found to be totally incompetent, and that was horrendous. That should also be looked at: there should be an independent body, and the trust should not be allowed to investigate itself. There is a conflict of interest, and, of course, it will try to protect itself; that is exactly what happened. The truth about Muckamore has not yet been revealed because of the ongoing legal process and whatever. The trust should not be allowed — no one should be allowed — to investigate itself.

The Chairperson (Mr McGuigan): Absolutely.

Mr Donnelly: I will pick up on something that Diane said. Around the room, we heard you describe yourselves as "two plebs" — not at all. Your lived experience in this area makes your views, evidence and opinions invaluable to us, and it informs how we view the legislation: it is absolutely priceless. Your presentation today was detailed and comprehensive, and I thank you very much for that.

Ms Fox: Thank you.

Mr Donnelly: It will shape this work as it goes forward.

You gave us strong opinions on CCTV. I had a couple of questions about that, but you have kind of answered them. We know that CCTV has already played a massive role in exposing the abuse. You have come out strongly in favour of it. I have heard differing views from families of people with complex needs. There are concerns that such people would not be safe without CCTV, but there are also people who are disabled and would see it as an invasion of privacy. There is a battle of rights, as it were, that you alluded to. How do you see those rights being balanced? Is it about having a detailed framework of legislation?

Mr Brown: To be honest, it is so complex that it would be presumptuous of us to say, "We believe CCTV should be there". There might be a small facility with six people, three of whom are totally non-verbal and would benefit from that. There might be others who have limited capacity, with parents who are naive. People confide in me about the scandal, saying, "What happened to you is terrible, but thank God that it never happened to my child". Four weeks later, there is a knock on the door with the news, and they say, "What?". People's perception changes when they are behind the eight ball. You might not be keen on CCTV now, but, if there is a safeguarding challenge down the road with your loved one, and you are trying to get access —.

That is another thing: at some facilities, parents are not allowed to view the footage. If you have a safeguarding concern, you are told, "I've checked that; it's all OK", and you have to accept that official's view. You need access to the footage yourself, with an independent advocate. You need access to documentation. Eight years down the road, I am still fighting the trust for access to documentation on my son. I use FOI now. I was told at the start by Sean Holland that a parent should not use FOI to access information that the trust should provide over the counter because, "We are open and transparent". I want to choke someone when I hear that, because, every time people use that phrase, they do the exact opposite. Eight years down the road, I am still trying to access information on my child, and now, in the heel of the hunt, they say, "Your son has no capacity, so we can't now give you the information that you require, because we don't know whether he would really want that".

They have been giving me information for eight years, but the minute I ask for it on the 350 adverse incidents outside Operation Turnstone, all the obstacles are put up. I am being honest when I tell the public, "Do not believe them; they are not open and transparent, and they will frustrate you at every corner". It needs to be written in to the law that parents have access to all relevant documentation for their loved ones' safety. There are so many things wrong with this country, to be honest, on adult safeguarding.

Mr Donnelly: The example that you gave was highly concerning and very recent: three months ago, you said.

Mr Brown: I did not say that it was three months ago. What happened was —

Ms Fox: A couple of months ago.

Mr Brown: — a few months ago. I am trying to be vague so that no one can start beavering away to see —.

Ms Fox: Sorry, Glynn. That is what I was —.

Mr Donnelly: I hope that that person is safe now and in a safe environment.

Ms Fox: Yes.

There is CCTV in some facilities, and, as I said, that has proved to be beneficial.

While we understand that it cannot be mandatory because there are too many nuances, we must look at the most vulnerable, the non-verbal and maybe those who have no capacity. It may well be that it is done on an individual basis, and it may come down to choice, but I do not think that anybody would disagree that CCTV is effective.

It can also be used for positives, such as, for example, positive behavioural support (PBS). Do you understand that? No? Right. I will not give you a lesson at the moment. If CCTV records an incident, the PBS practitioner might view it, look at the behaviour of the staff — we are not talking about negatives — and learn from that observation. They might say, "Maybe I could have approached the service user or spoken to them in a different way". That would eliminate the trigger. It could be used for other reasons as opposed to safeguarding, in my opinion.

Mr Brown: There is one other thing that I would like to draw to your attention on the issue of CCTV. The situation at Winterbourne View was followed by the situation at Whorlton Hall. That facility was being bought over by a different provider, and covert cameras were used by the 'Panorama' team. The scary thing there was what the abusers call "clotheslining". As a patient went by, an abuser would put out their fist, catch them in the throat and drop them down. However, they were saying amongst themselves, "We are being recorded. A new provider is talking about installing CCTV in this facility because of the allegations". Some of the abusers — this is chilling — said, "It does not matter. We will not abuse them any more in the communal areas or the hall. We will do it in their bedroom or the toilet where there are no cameras". That shows you the mentality of an abuser.

Mr Donnelly: An issue raised with us is that people will find areas not covered by CCTV. As you say, the mentality of the abuser is horrific. I remember those images.

Ms Fox: Exactly. To go back to what we said previously, we believe that the oversight, scrutiny, governance and monitoring should come from the RQIA. There should be early detection and warning signs, as was the case in Muckamore. Preventing abuse is better than having to deal with it when it happens. All those mechanisms, if they are more robust and monitored and audited on regular basis, can be tools to pick up warning signs. CCTV will then be only one tool in the box of safeguarding.

Mr Donnelly: Absolutely. I appreciate that. Thank you very much.

Mrs Dillon: Thank you both for your presentations. I want to say one thing: you are far from plebs. Your presentations were articulate, easily understood and really important in our scrutiny, because, at the end of the day, you are the people who have experienced it and who have the lived experience. Therefore, you are the most honest voices in this whole process, because you are saying, "This is what we have lived through and experienced". You have skin in the game, but your skin in the game is to protect people, and that is what this legislation is about. It is not about protecting any organisation or individuals who have done or may potentially do harm.

Your point about culture is very important. Diane asked whether you can legislate for culture. It is about a duty of candour. That is what it comes down to.

Mr Brown: Individual and statutory. Yes, absolutely.

Ms Fox: It is about accountability and duty of candour. An individual duty of candour would be a great deterrent.

Mrs Dillon: It allows for some of the stuff that you both talked about, and you, Catherine, in particular, on the issue of protecting staff who are afraid to speak up. The duty of candour encourages and protects. I know that it is not in this legislation, but it is important. We have asked other people their view, and you have made yours very clear.

Separate legislation on CCTV would mean taking more time. I could not confidently tell you that it would be just a little more time. I am just being honest with you because I have seen what the legislative process entails. We wait for legislation to come from Departments, and the Bill Office is under extreme pressure as well. However, if you think that that is the best way to do it, we absolutely need to consider it.

Chair, in the light of what has been said, we could look at the legislation that has been used. I speak as a member of the Policing Board as well as of the Health Committee. Police officers use body-worn video. That has been a process in itself. It was optional whether officers turned it on, but, more often than not — I think that it was wrong — the body-worn video was not turned on. That has changed, but the culture has had to change for that to change. However, making it mandatory will change the culture as well.

You are right: rules need to be put in place in order to change the culture. It will not change of its own accord; that is not realistic. That is not what happens. We see it. Accountability and scrutiny are really important.

Chair, maybe we can get some information on body-worn video. Nurses are now wearing it in Antrim Area Hospital.

Ms Fox: There is a pilot scheme operating currently. That might form a basis.

Mrs Dillon: It does not necessarily involve having CCTV watch every move that the service user makes, but it watches every interaction with staff members and maybe that gives some protection. I do not know. I am throwing it out here. We need to look at it, or we need to ask departmental officials,

Another thing that we need —.

The Chairperson (Mr McGuigan): Just to cut into the conversation, we visit Antrim Area Hospital next week specifically to look at the body-worn cameras and CCTV and the operation of it. We will have that conversation next week with those who operate it in Antrim.

Mrs Dillon: That is a good opportunity to ask those questions.

Ms Fox: Sorry, I presume that the pilot scheme was brought about because the staff needed to be protected and to substantiate the truth about incidents that may happen. That is no different from how we feel. We want our loved ones protected as well, so we are strongly advocating for CCTV. How many years will it take the Bill to —?

Mr Brown: Four, they claim, from the drafting.

Ms Fox: Probably much longer. We realise that CCTV cannot be mandatory and that it does not fit all situations. However, at the same time, I am concerned at how long we would have to wait for separate legislation on CCTV. I strongly believe that it is a good tool for deterring harm and for protecting vulnerable people.

Mrs Dillon: It also protects staff.

Ms Fox: Exactly.

Mrs Dillon: Nobody should be afraid of oversight if they know that they are doing the right thing. I made that point to police officers when they were wearing body-worn video. It protects them from false accusation and it can show the full course of events.

Ms Fox: If you have nothing to hide, you have nothing to fear. That is my motto. If everything is open, honest and transparent, then why not? As I say, when we walk down the street there is CCTV. I get the nuance around privacy and confidentiality. Unfortunately, however, the mere fact that we are discussing CCTV says it all because of the failures to protect the most vulnerable in our society. Muckamore Abbey Hospital was the largest ever adult safeguarding case in the history of the NHS. Otherwise, we would not be discussing it.

Only for Glynn Brown pressing forward and uncovering the CCTV, the abuse at Muckamore might still be continuing. That is the reality. It needs to be used as a part of safeguarding. I understand the many nuances around it and that it cannot be made mandatory. However, it is an important tool in safeguarding.

Mr Brown: Just to refresh your memory, a previous Health Minister, Edwin Poots, after the Winterbourne scandal, wrote to all the heads of trusts.

Ms Fox: In 2014.

Mr Brown: He said that they would have to reassure him that this catastrophe could not happen on our watch. They all wrote back to say, "We are on the ball. We are aware of it and on top of it. Do not worry; things are sweet." Then you get a litany of failures, and Muckamore is just the end result of them. Everybody always wrings their hands and say, "There is another scandal. We did not know."

The Chairperson (Mr McGuigan): That is why this Bill is important. I have two more members wanting to ask a question. The witnesses for our next presentation have arrived, so I want to move on to allow members to ask their questions. Sorry, we may have three members.

Miss McAllister: Thank you, Catherine and Glynn. Sorry that I cannot be there in person, but I am a bit under the weather. I hope that Aaron and Alicia are doing well, and I want to thank you for the fight that you have been putting up for the past few years. The Bill has been a long time coming. I notice that the Sharps are also in the Public Gallery, and I hope that all is well with Laura. Thank you all for coming here today.

I have a few questions. I understand your concerns about putting CCTV into the Bill in a generic clause, and I hope that you can get the sense from the Committee that it is not something that we would seek to do. However, by putting it in a clause, the Department could then have secondary legislation. We have heard from different organisations about why it would be better in the Bill, as opposed to having secondary legislation. A point they raised was accountability, being able to scrutinise it and, as you both have mentioned, being able to come back.

However, my concern is that if we do not deal with CCTV in any shape or form in the Bill now, it will be five-plus years down the line until we do. It is about trying to balance the best way forward. What is your view on having the option open for CCTV in the Bill -- not necessarily mandatory, as it is, as you say, nuanced -- or is your preference that it is just not dealt with at all in the Bill?

Mr Brown: No, we would prefer it to be in the Bill and bolster it with secondary legislation, as and when it could be drafted in a professional manner.

Miss McAllister: That is helpful for us.

Ms Fox: Some facilities have CCTV. Therefore, it would have to be monitored appropriately. We agree that it needs to be included in this legislation, but that it needs to be a stand-alone.

Mr Brown: It needs to be beefed up.

Miss McAllister: Maybe with a clause dealing specifically with it. It has definitely given the Committee a lot of scope for how we deliberate on the issue.

My second question is about the independence board that is being set up and the independent advocate for the adult involved. I listened to your submissions. With regard to the advocate, are you content with that and feel that it is as strong as it needs to be for the individual? If it were your child, would the independent advocate be the way forward?

Mr Brown: It is the way forward if they are appropriately trained. From my experience of the system, you did not know who was an advocate, and when you found one, you used them as an independent witness. They were not conversant with the procedures. Along the way, I found an expert on the procedures, and that is when things started to change. I began to gather information because my efforts were directed in the right direction, and I asked the right questions.

There is no sense in giving me an advocate to hold my hand: I do not want somebody to hold my hand. I want an expert in policies and procedures who can provide guidance to help me to protect my loved one. I do not want somebody to hold my hand. It is crucial that those who do that job are proficient and confident, so that no matter what fur flies as a result of pushing back against the system and highlighting the failures of the wrong people, they feel confident that their organisation will get on with it.

Ms Fox: They will not be afraid.

Mr Brown: We have been subtly reminded about who pays for our organisation, which is a subtle way of telling me to pull my horns in.

Ms Fox: They could also be an essential part of safeguarding. If they are educated on the policies and procedures in the trust, they should not be afraid of the repercussions of challenging them. What is the point of being given an advocate unless they can truly support us to protect our loved ones?

Miss McAllister: I agree with that statement, and it is helpful. You may need a moment to think about my next question. What adult safeguarding works well for you now as the parents of children with complex needs? What works well now that you do not want to change? It may be the family liaison, or any other issues associated with their care. What works well for you that you do not want the Bill to change?

Mr Brown: Environment plays a big part in your child's behaviour. If you are in Muckamore, and there is chaos — alarms sounding, response teams coming into the ward using force to trail you away to seclusion — and there is mayhem around you because of the various patients' natures, that is bound to be reflected in your behaviour. If you move to a quieter setting with no smashing glass, and no response teams to manhandle you, and you are treated in a civil manner, your behaviour will be affected. Their behaviour is affected by the placement, the manager who oversees the risk assessments, the staff's behaviour and their competence in the right to report .

For example, in a three-month period at Muckamore Abbey Hospital, my son was medicated 48 or 50 times, and he was dosed with heavy drugs and put into seclusion about 48 times -- 48 times that were recorded. He then moved to a facility in a certain place, and, over six years, he has only had hands placed on him five times. One of those incidents lasted 13 seconds and another 24 seconds. The new facility does not have a consultant psychiatrist, a registrar, a cabinet full of heavy drugs, a response team, and there could be three girls looking after him. They have only been hands-on five times in six years, whereas in Muckamore, he had hands placed on him every day of the week and was repeatedly put in seclusion. The girls looking after him now are not learning disability nurses. The environment that you are placed in and how you are treated in it will be reflected in how you behave. The new placement has been done well, but the adult protection part?

Ms Fox: Unfortunately, while I am not saying that some things have not been positive, in my experience, environment is very important. For example, families may advocate for supported living, and the person may be assessed for supported living. If they are put in the wrong environment, they will not progress; they will regress. They could be financially inhibited.

Their quality of life will be impaired. It is so important that families are listened to in those situations. Moreover, just because supported living is not available does not mean that it is acceptable to put someone into a care home. When people who are quite capable are put into the wrong environment, it will never be right unless the environment is right. I can look at the failures and see what would work better, but I do not believe that anybody is really listening to my opinion.

Mr Brown: That is where the individual duty of candour will be important. All those people who obstruct you will have to comply, tell the truth and provide documentation. If you treat people properly and give them access to information, you may be able to assuage their fears on a range of issues.

Ms Fox: As families, we want people to work alongside us, to help us, because all we are interested in is the well-being and best interests of our loved one. Unfortunately, in my experience, and in the experience of people I speak to, it is almost as if they do the opposite. Again, that comes back to the culture. It is very frustrating. When you challenge them on the fact that they are not adhering to the policies and procedures, there is a backlash from them. That is the truth. That is what many, many families have experienced. That culture needs to stop. When they are held accountable for not adhering to their own policies and procedures, then, and only then, things might start to change.

Mr Chambers: Abusing vulnerable people is cowardly and inhuman, and those carrying it out are inadequate bullies. It is a heinous crime.

If someone were brought before a judge for slapping somebody in the face on the street, they would get a heavy fine. If a really bad injury incurred, they might get a suspended sentence. If somebody from Muckamore was caught on CCTV for just one offence of slapping somebody on the face, the same judge cannot do very much more than impose the same sentence as that on somebody who had slapped somebody in the street, yet the two things are so, so different.

Can you see a case for a parallel change in justice legislation that would create an offence of abuse in a care setting? It would not even have to be specific, just a catch-all: you have abused a vulnerable person in care. Judges should have a heftier sentence at their disposal to deal with it.

As Danny says, those people will find a corner, a blind spot, where they will carry out their psychopathic actions. The way to defeat that is by having deterrents. If there were a specific sentence for the abuse of vulnerable people in a care setting, they might think twice before lifting their hand to a patient in those settings. Is there a case for heftier sentencing as a deterrent to try to stop that happening and to try to change the culture?

Mr Brown: Would they argue that the Mental Health (Northern Ireland) Order 1986 allows for ill treatment from a cleaner right up to a director? I am all for heftier sentencing, but, to play devil's advocate, a judge will take into consideration mitigating factors and aggravating factors in your individual case. An aggravating factor would be that that adult whom you assaulted had no capacity and was minding his own business, and that that was a gratuitous assault. I am all for it: separate legislation and more robust sentencing. The public at large generally scratch their heads when they see somebody up for a serious crime on a number of fronts, and they go, "Is that what he got? He knocked £300,000 and got a suspended sentence".

Mr Chambers: Or community service.

Mr Brown: Or community service. I do not know the ins and outs of cases, but if somebody drafted legislation and made a robust sentence for the serious abusers, that would definitely be on the wish list.

Ms Fox: Someone who has been put in a position of care has a duty of care.

Mr Chambers: It is a breach of trust.

Ms Fox: It is a breach of trust. Moreover, they are trained and should be qualified to raise concerns and protect. They then become the perpetrator because they are in a position of trust. It is not like Joe Bloggs out in the street hitting me a slap in the face. That is the difference that you are trying to make. I agree: if you are entrusted in the care sector to keep someone safe and you have a duty of care, the sentence should be stiffer.

Mr Chambers: Thank you.

Mr Robinson: I will be brief. I am conscious of the fact that we have gone well over time.

I have no shame in admitting that I found some of the previous sessions quite complex and technical. Today, however, as others have said, I felt that this was an incredibly powerful presentation and probably one of the best sessions that we have had to date in refining the Bill.

If there were future opportunities on the Interim Adult Protection Board for people with lived experience, I do not think that there are two better people here who could sit on that board or two better people who could be independent advocates with that suitable training. You have been exceptional today in helping us to better understand some of the issues that I have found very complex, detailed and technical.

You focused heavily today on independence and concerns that we all expressed about trusts and the Department marking their own homework. However, I note in your response that you have called for a review of the operation within a three-year period, and at fixed intervals thereafter, to be built into the Bill. Given that you have focused heavily on independence today, how independent would those reviews be?

Ms Fox: Exactly.

Mr Brown: As with everything, it is who you pick. As with any public inquiry, whoever you pick to run it will dictate the format, the scope and the terms of reference. Is whoever is picked to do the reviews totally independent? What makes us suspicious is that people in senior positions float between organisations. You are in charge of one trust, you get ripped to bits only to jump over and take a senior position in RQIA: poacher turned gamekeeper, and you think, "How is that allowed to happen?"

Ms Fox: Or you could be made the chair of a panel.

Mr Brown: Sure, you have employment rights. Fair enough. We get all of that, but it does not look good. What is the pillow talk? You were mates with all those senior officials, and now you are meant to be enforcing action against them. It makes you wonder

Ms Fox: The question is, "How independent are they?" How can we have someone above them who is totally independent and scrutinises and monitors?

Mr Brown: Nobody from the trust. It should be an outsider: somebody from the mainland with a solid, proven record.

Ms Fox: Or down South.

Mr Brown: Or down South. Somebody competent and independent, whom everybody will look at and say, "That boy has achieved a lot in his own sphere; he will be good".

Ms Fox: Someone not afraid to challenge or ask questions.

Mr Brown: You cannot have someone from the old boys' club here. You cannot have someone from the trusts overseeing the board to see whether it is independent.

Mr Robinson: Your input today has been invaluable. We thank you very much for it.

Mr Brown: Thank you.

Ms Fox: Thank you, everybody.

The Chairperson (Mr McGuigan): Catherine and Glynn, that has been really useful to all of us. We have had a number of sessions, and we will have a number to follow this. I am sure that we will use some of what we have heard today in our conversations with the Department. We want to get the Bill right, and we are hearing a lot of competing evidence. We will have to work our way through all of that, but you have definitely given us much food for thought. We appreciate your coming and passionately putting forward your views.

Ms Fox: As I said, we are willing to come back and help in any way, because, ultimately, if the truth be told, when Glynn and I met, we had the same thought: we need to do something so that this can never happen again.

The Chairperson (Mr McGuigan): Absolutely.

Ms Fox: What happened to our loved ones and others cannot happen again. We have the power, if we have the drive to get it right.

The Chairperson (Mr McGuigan): Thank you very much.