What DID they do to my boy?
Mail writer Christopher Stevens’ son David is so severely autistic he had to go into residential care at 13. But after his home was taken over by private equity, standards went through the floor. Soon he was covered in livid bruises, being fed Haribo for
THIS is the stuff of nightmares. Blood on the walls. Rotting food trodden into the floor. Torn bedding and dirty toilets. Over-flowing bins. Broken furniture. The sound of shrieking and sobbing.
My adult son had to exist in this sheer squalor for a nightmare year. The care home on the outskirts of Cardiff where he had lived for eight years descended into hellish conditions that defied belief.
My wife Nicola and I made ceaseless, desperate efforts to rescue our son and restore good care. Yet his situation remained so horrific that for many months we lived in dread and expectation of a phone call to tell us that he had died.
Even if this was an isolated case, it would be disturbing. But it is far from unique.
What happened to our son is a direct result of a broken care system.
Nationwide, migrant workers with little training, less English and no motivation are increasingly being employed on contracts below the minimum wage, while managers are rewarded for undercutting budgets.
Conscientious staff are undervalued and overworked, and all too often leave, exhausted and disillusioned. Any who speak out risk being dismissed and silenced.
David is 27 and profoundly autistic. He is unable to use language with much meaning — he can’t tell you where he has a pain, or answer any basic question such as, ‘What did you do today?’ Though he can parrot words, he doesn’t really understand what they mean.
Despite this, he has always been a happy, affectionate young man. He’s sweet-natured with a mischievous sense of humour, and a passion for Disney VHS videos. But he has no sense of danger and, after a series of serious incidents as a child, including a house fire, he could no longer safely remain at home. After five years at a residential school from the age of 13, he moved to adult care in 2015, at a home called the Old Vicarage in Cardiff.
When he arrived, the facility was run by Orbis Education and Care, a small independent company. At first the care was excellent, but the Old Vicarage was bought up in 2017 by a private equity investment company, August Equity, and the turnover in management was frequent.
WE WERE assured that this would have no significant effect on the day-to-day running of the home, but it gradually became apparent that increased pressure on budgets was having a disastrous impact.
Many of the longer-serving carers left, some of them telling us that working conditions were becoming unbearable. We saw an increased reliance on temporary staff from agencies who had little time to get to know our son or understand his needs.
David kept his spirits up, even during the upheaval of Covid. But his behaviour changed completely in September 2021, when he began to self-harm violently — smashing his head against walls, windows, lampposts and other hard objects.
The head-banging was so hard and frequent that thick layers of contusion built up on his forehead. At the back of his head, the hair was worn away from repeated blows, and the skin was split, bleeding daily.
Previous limited instances of self-harm had only ever indicated pain, such as toothache — it isn’t normal behaviour for David, and it isn’t ‘caused’ by autism.
We assumed he was in pain again, but repeated medical examinations and even a brain scan could find nothing physically wrong with him — and David was unable to tell us what was upsetting him so badly.
But after a visit to our home the next month, the intensity of his headbanging was worse than we had ever seen.
It erupted as he left. With his carer in the driving seat and David in the back of the car, he started smashing his skull against the rear window so hard that the whole door buckled outwards.
Less than an hour later, two police officers knocked on our front door. My first thought, when I saw the uniforms, was that there must have been a crash.
In fact, a member of the public had called 999 to report a suspected abduction involving David’s car (a Motability vehicle registered to our address).
While the car was stopped at traffic lights, our son was screaming in the back seat,
thrashing his head and feet against the windows. A passer-by assumed David was fighting to get out and escape.
The headbanging continued for months, and a psychiatrist employed by Orbis recommended doses of lorazepam, a heavy-duty tranquilliser, to be given as required. This was in addition to a cocktail of other drugs, administered to manage his behaviour rather than to understand it.
The more heavily he was sedated, the more confused he became, and the bouts of headbanging could last for three hours or more.
He began sobbing uncontrollably in the mornings, fat tears rolling down his face. This was something he had never done before.
One carer who had known him for years, and who was deeply distressed to see him like this, witnessed David having a fit or panic attack that left him trembling all over.
Two years on, we can quote the health watchdog guidelines: ‘Abuse should always be considered as a cause of unexplained emotional or behavioural change.’ All behaviour is a form of communication — and David’s behaviour was unlike anything he had shown in his life before.
It was now that bruises began to appear all over his body. By the summer of 2022, we were seeing purple marks that lingered for weeks on the back of his legs and his upper arms.
He was covered in bruises — what looked like grip marks up and down his arms, and shoe prints on his legs. When we begged to be told what was happening to him, we were invariably told these were self-harm injuries. David was certainly self-harming, by banging his head, though we never saw him pinch or grip himself, or stamp on his own legs.
Affectionate: A young David with his dad Christopher
We asked whether David was being restrained — held down, for example, in the prone position by two staff — and we were repeatedly assured that this never happened (though a BBC report in June 2021 had made allegations of prone restraint at another Orbis home, with the online headline ‘Whistleblowers claim children with autism “abused” at care home’).
Searching for answers, we pleaded for outside assistance. Social services, who had funded the placement from the beginning, refused to take any interest in him. After much urging and intervention, specialist nurses and therapists were assigned.
But by now, David was almost catatonic — sleeping all day, awake but hiding in his bed or bathroom during the day. And then it got worse.
A new manager was appointed, and the standards of care became atrocious. David appeared unwashed and unshaven. His bedding was rags, with a pillow that had been torn open and shredded, though not by David. According to daily diet sheets that we obtained later, he was being given Haribo sweets and fries for breakfast and lunch.
EVERY day staff recorded what David was given to eat and drink. This was called ‘my food and fluid record’. On one typical Wednesday in July 2022, the record shows: ‘Breakfast— 1x jam tart, 1x Rolos, 1x Haribos, 4x Jaffa Cakes. Lunch — 2x fries, 2x Quavers, 2x cookies. Dinner — 2x fries, 2x jam tarts, 3x Jaffa Cakes. Supper — declined. Fluid throughout the day: 1x milkshake, 2x Fruit Shoots, 5x squash.’
After repeated requests from staff for ‘pocket money’ for David, we asked to see the accounts. Our son’s own money had been used to buy bedding, apparently for other residents, including a pillow that supposedly cost £50 (€58).
When we visited, we often found a staff member sitting idle outside his bedroom door. The filth inside the room was indescribable. Some communication aids, the symbols on walls that help David understand the daily routine, were defaced — horns and a moustache drawn on one photo, for instance.
At the same time, the unexplained injuries were getting worse. We tried to photograph them, but David had recently become very distressed when a phone camera was pointed at him.
Of course, he isn’t able to explain why this was so upsetting. On one occasion, we did manage to take a picture of what looked like a shoeshaped bruise on the back of his badly contused legs. We also took pictures of livid little bruises in pairs, the size of grapes, on his arms and abdomen.
On another visit, my wife Nicky noticed David was limping badly. She pointed this out to the manager, who told her: ‘David has always walked like that.’
When we insisted on a medical examination, the GP diagnosed heavy bruising or a possible bone fracture in the upper groin area. Again, we were assured this had been sustained during a bout of self-harm.
NOW David began shutting himself in his bathroom for days on end. Staff responded by using the toilet as a table, placing food and drink on the lid and leaving it there. Spillages were left untouched for days. The toilet itself was sometimes in a foul state.
He beat his forehead until it bled, leaving rows of bloodstains all around the walls of his bedroom. These remained there for many weeks because, in spite of our constant complaints, no one saw fit to wash them off or paint over them.
One visiting occupational therapist observed that David was physically inactive almost all the time, and left the house for only 1 per cent of the time. His weight ballooned by more than 40lb. Previously, he was active and fit, with daily outings — shopping, swimming, walks, even horse riding.
But however much we pleaded for better care, we were met with indifference, excuses and an increasingly hostile attitude. Another manager was appointed, yet standards remained atrocious.
We sent photos of the squalor to senior executives at August Equity, the private equity company that owned the home. That did bring a reaction: an investigation by the Orbis ‘independent quality adviser’, Alan Rosenbach.
I did not think his findings could be called ‘independent’, since they were submitted to both the Orbis senior management and the August Equity board members before we were able to see them.
Among his conclusions were cautious admissions that ‘there had been erroneous use of David’s funds due to failure to follow policies arising from a lack of training and oversight’ and ‘the care and support for David and
the management of his environment has at times fallen short of acceptable standards’.
The CEO of Orbis at the time, Suzanne Lawrence, also wrote to offer ‘sincere apologies’ and to accept responsibility: ‘I am 100 per cent accountable for each and every instance where care has fallen short within Orbis,’ she stated.
Standards of hygiene, she admitted, were ‘clearly unacceptable and would not have been tolerated by us in our own homes and therefore should not have been in David’s home’.
By now we were searching constantly for an alternative home that could meet David’s needs. One seemed promising but fell through. Others were too far away. We visit David weekly at least, and frequently more often than that. We wanted him closer to home, not further away.
We continued to hope that we could force improvements. We made multiple allegations to the council safeguarding team that David was suffering poor care and neglect, documented by multiple images.
But then a truly chilling fact became plain. On the rare occasions that David left the home, he was willing to walk or drive away from it — but his protests on the way back to the house were frantic and desperate.
After a trip to the dentist, he refused to leave the clinic for hours. Back at the house, he wedged himself into the car and would not come out. Then he began lying down in the care home’s back garden, clinging to the large wooden swing and screaming if staff tried to move him.
David was terrified of going into the Old Vicarage building. He couldn’t tell us why, but he was doing everything possible to make people understand. Shortly before Christmas 2022, we sought advice about his bruises from his GP, who advised us to call the police and the safeguarding services.
On Christmas Eve, we were contacted by the safeguarding team, asking if we wanted to remove David immediately, that night, but no suitable alternative placement was available.
Orbis’s own ‘positive behaviour support’ care plan emphasised that David was not to be manhandled or physically restrained. Despite this, one junior staff member was alarmed to see a male carer, senior to her, seize David by the upper arms and push him backwards across a room. She phoned the Old Vicarage manager who came in, on her day off.
The end result was that the male carer was exonerated but told, at our insistence, not to work with David again. The female carer left Orbis shortly afterwards.
While Newport police investigated our fears, David spent almost every day and many whole nights curled up on that swing in the garden, rather than consent to go into the care home. He was subject to constant sedation, with doses of the tranquilliser lorazepam administered up to three times daily.
Despite this, if he had to go inside the house, he headbanged with such force that we were afraid he might fracture his skull. Consequently, a ‘best interests’ meeting decided it was safer for him to remain outside, even at night in sub-zero temperatures.
ATENT was erected over the frame of the swing. Conditions inside were as squalid as they had been in his bathroom. On one occasion we found food and soiled clothes scattered inside and outside the tent, and a plate smeared with mud — while two temporary staff members sat in a nearby wooden hut, looking at their phones. They ignored us and appeared not to understand us when we addressed them.
By the end of February, Orbis managers served notice on David. They claimed their relationship with us, David’s parents, had broken down. We were told that, by involving the police, we were upsetting staff, and were given four weeks to find a new placement for David — despite Alan Rosenbach’s written assurance to us, less than three months earlier, that there was ‘no intention of serving notice’ on our son.
This appears common in the care sector. Relatives are often too afraid to complain about poor standards, for fear that their loved one will be evicted.
Thanks to diligent efforts by nurses, therapists and commissioners, whom we cannot thank and praise enough, another placement was found for David. He transferred there at the end of June 2023, and the staff at his new home have made extraordinary efforts to win his trust and help him to feel safe.
The police were unable to find any conclusive proof that David had been physically abused.
Orbis have always strenuously denied that he was subject to physical restraint or abuse, and insisted that all the bruising on his body was due to self-harm.
David will never be able to tell us what was really happening. All we know is that, literally from the day he arrived at his new home, there have been no new bruises. The grip marks on his arms, the black-andblue discoloration on his legs, the livid little bruises like pinch marks around his stomach, all vanished and have not returned.
Our son is being patiently nursed back to health in a setting that truly deserves to be called a ‘care home’. His cheerful, affectionate, mischievous character is re-emerging and he is happily enjoying a range of activities.
Some mornings, though, he wakes up screaming and shaking.
The carers talk to him and comfort him until he calms down. They believe he is having nightmares.