Malcolm was my first child, born on October 12th 1967, he was the oldest of my four children. Malcolm was born with severe mental and physical disabilities. With three younger children to care for it became increasingly difficult for me to provide the care that Malcolm needed. When Malcolm was ten he moved into the care of Salford Social Services. This was a very difficult and painful decision for me to make. The consoling factor for me was that Malcolm would receive the individual care and attention I could not give him and no matter what happened to me Malcolm would be safe in the care of the experts, Social Services. How wrong could I have been!

People who did not know Malcolm saw him as a disabled person who had nothing to offer. This was far from the truth. Malcolm had a wonderful sense of humour and the most infectious giggle. With his big blue eyes he would melt your heart with his smile. The love that Malcolm gave to those in his life was completely unconditional and was given with the innocence of a child. Malcolm was not a disabled person; he was a person with disabilities.

On July 18th 1998, the day Malcolm drowned, there were two 'carers' on duty, Sarah Peters and Barbara Mather. They were responsible for the care of just three clients, adequate staffing levels. Sarah Peters undressed Malcolm, placed him in a hoist, lowered him into a jacuzzi and added bubble bath. She then left him alone, lying flat on his back in a jacuzzi full of foaming water while she went to have a cup of tea with Barbara Mather. Malcolm was later found dead under the water. Malcolm was mentally and physically disabled, he suffered from epilepsy and had the physical capabilities of a four-month-old baby. He could not speak, use his hands or sit up. Malcolm had no choice but to lie and wait while the water covered his face and killed him As was later testified by an Independent Investigator "Malcolm quite simply had no capacity for self rescue".

An inquest into Malcolm's death was opened in December 1999 at Salford Coroner's Court. At the inquest it was established that Social Services did not have Risk Assessment procedure in relation to the bathing of individuals in their care. Nor it appears did they have Risk Assessment procedures for other risk-related activities. There had been no training for staff in relation to the use of a jacuzzi, or in the bathing of people with profound learning and physical disabilities. If a Risk Assessment had been carried out in relation to Malcolm, and staff had been trained appropriately, Malcolm would not have been left alone, and the possibility of him drowning would have been eliminated.

Brian Grant, manager of Malcolm's home stated he was "unaware of the practice of leaving clients unattended in the bath". Salford Social Services did not provide adequate staff training or supervision and left staff to their own devices. They had a duty of care towards Malcolm and they failed in their duty by failing to ensure Malcolm's safety.

The reason given for leaving Malcolm alone in the bath was "a profound respect for Malcolm's right to privacy and dignity". Malcolm paid for that right with his life.

The Coroner stated that Malcolm relied on his carers for his every need. Malcolm had to be fed, toileted, bathed and dressed. The Coroner suggested that Malcolm had no concept of 'privacy or dignity' and that the carers had distanced themselves for their own benefit and not out of respect for Malcolm's dignity. A jury returned a verdict of Accidental Death to which Neglect Contributed. In essence this verdict incorporates neglect and effectively states that Malcolm's death would not have happened if it had not been for neglect.

The Health and Safety Executive found that Salford Social Services were in breach of Health and Safety Law and in April 2000, at Salford Magistrates Courts, the Health and Safety Executive prosecuted the City of Salford on two counts.

1) On 18th July 1998, the City of Salford contravened the requirements of Section 3 (1) of the Health and Safety at Work etc Act 1974.

2) On 20th July 1998, the City of Salford contravened Regulation 3(1)(i) of Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995.

The City of Salford pleaded guilty to both charges. Magistrate's powers are limited to a fine of £20,000 for the first charge and £5,000 for the second charge. The Magistrates recognised the seriousness of the offences and deferred the case to the Crown Courts who have unlimited fining powers.

In July 2000 at Manchester Crown Courts the judges imposed the following fines on the City of Salford.

1) For failing to ensure Malcolm's safety, £100,000

2) For failing to report Malcolm's death by the quickest possible means £15,000

The City of Salford was ordered to pay costs of £7,938.

This was a prosecution for breach of Health and Safety Law and not a prosecution for Malcolm's death. It should be noted that payment of the fines imposed does not come from Social Services insurance but is paid by the public out of their taxes.

It is now more than two years since Malcolm died within the care of Social Services and as yet no one has accepted responsibility or been charged with his death. Legal experts advise that a private prosecution would be an option but this is a financial impossibility for me, or for that matter any ordinary working person. Is there now a price for justice?

Sarah Peters stated that after leaving Malcolm alone in the bath she returned to the bathroom to get a bowl. She noticed the bubbles rising excessively around Malcolm so she dropped a bar of soap into the water to disperse the bubbles, she then left the bathroom immediately. If only she'd bothered to wait just one minute to ensure the bubbles subsided? Neither carer has been sacked, reprimanded or disciplined in connection with Malcolm's death and both Sarah Peters and Barbara Mather still work for Salford Social Services "caring" for the disabled. This sends the wrong message to our care workers. Although Risk Assessments are a legal requirement under Health and Safety law, experienced staff should not need training or a Risk Assessment for them to recognise the the very obvious danger of leaving someone with Malcolm's disabilities unattended in a bath. There was no special training needed in the bathing of Malcolm, you bathed him in the same way, taking the same precautions you would with your own child who has the same level of physical capabilities as Malcolm. It just required caring, compassion and common sense.

If Social Services suspect that neglect or abuse of a child is occurring within a family home they have powers to remove that child from the home and the parents can be prosecuted. Salford Social Services ignored the neglect that was occurring in one of their own residential homes. The neglect cost Malcolm his life.

A doctor who did not know Malcolm told me to think of his death as a "blessing in disguise". If we justify Malcolm's death in this way, do we then sanction drowning people as a form of euthanasia? Malcolm was not unhappy, he wasn't sick or in pain and his disabilities were not life threatening. Where was the blessing? As an individual with disabilities Malcolm had the same basic right to life as any other individual. If we ignore Malcolm's death by denying him justice, then we ignore the value of his life.

The week that Malcolm died my husband, Fred, went into a heart failure and as a result died eight months later. Fred spent the last months of his life supporting me. He calmed me down when I screamed with anger and frustration and held me when I thought my heart would break. I believe that the stress of those eight months contributed to Fred's death. The past two years have been very difficult for my children and I. The fight for justice for Malcolm has taken over my life. My children have not only lost their brother and father, but their mother also. They acknowledge the importance of Malcolm's life and the injustice of his death by never complaining. With their love and support I will continue to fight for Malcolm until he receives his right to justice.