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Commission of Inquiry into the Care of Young People 4 May 2006

On 15th October 2004 Mark Everall QC was appointed by the Council of Ministers on the Isle of Man to conduct a Public Inquiry into the care and support given to Samantha Barton and George Green and into the care and support for children and young people with emotional and behavioural problems.

The Terms of Reference of the Inquiry are;

  1. to inquire into the level and effectiveness of the care and support provided by the government and the agencies of government to Samantha Barton and George Green and to determine whether they had any relevance to the circumstances surrounding and leading to their deaths
  2. to inquire generally into the level and effectiveness of the care and support systems, including through care, provided to children of secondary school age or above on the Isle of Man who have emotional and behavioural problems, taking account where considered necessary, of care and support in their early years. In so doing the Inquiry will take into account all relevant influences on such children
  3. to make recommendations as to how the welfare of such young people may be safeguarded so as to avoid as far as possible, a similar tragedy occurring in the future

On 4th May 2206 Mr Everall formally submitted his report to the Council of Ministers. The report contains 132 recommendations.

Mr Everall expressed his sympathy to the families of Samantha and George for their loss. He said

“All involved cannot fail to be conscious of the horror of the murders, and the continuing grief suffered by the families of Samantha and George.”

In his report Mr Everall also stated

“that those working with troubled children with emotional and behavioural problems have a difficult task and they all deserve the understanding and support of the wider public.”
He paid tribute to the dedication of many of the staff he met from a range of agencies including the voluntary sector during the course of the Inquiry.

However, the Report makes recommendations relating to a range of political, managerial and professional concerns. It concludes that public services on the Isle of Man must work more closely together to deliver effective outcomes for children. It calls for a more rigorous scrutiny and assessment of the quality of public services by politicians and senior managers.

The Report identifies shortcomings in the care and support of Samantha and George, both of whom were in care, by social services and education. It finds there has been a failure by these services to make sufficient progress in the care and support of children with emotional and behavioural problems in their policies, procedures and practice since the deaths of Samantha and George.

The Report highlights the need for consistently high standards in government and government agencies in the provision of social care and also in education and health care provision for all children especially those with emotional and behavioural problems. Regular and thorough scrutiny of all these services by political and managerial oversight and by internal and external inspection is not yet at an acceptable level.

The Report welcomes the new Children and Young People’s Strategy, but it raises concerns about the lack of consistent implementation of new policies and ideas in the Isle of Man. Mr Everall commented

“There is no shortage of ideas, good intentions and positive initiatives on the Isle of Man, but I am concerned that they are inconsistently implemented across the Island.”

The Report recommends that a Minister for Children and a Children’s Commissioner be appointed to ensure that the Children and Young People’s Strategy and the Report’s recommendations are consistently and effectively implemented It calls for a formal external review after 12 months to assess and publicly report on the implementation of the recommendations of the Report.

Mr Everall stated

“The deaths of Samantha and George are tragedies .The failures in the care and support for Samantha and George, despite their own individual difficulties, reduced their opportunities in life .The recommendations of the Inquiry and the proposals of the Children and Young People’s Strategy must be implemented effectively and consistently so that the opportunities for other young people with emotional and behavioural problems are not avoidably undermined.”

The Report is published on the Inquiry website at

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