Despite innumerable inspections, a catalogue of "significant failure in leadership and management" blighted children and staff at Kerelaw School for troubled youngsters.
The results of an independent inquiry into the running of the school amount to a devastating critique of a regime which led to allegations of serial abuse against the children in its residential and secure units. Although it was in Stevenston, North Ayrshire, the school was run by Glasgow City Council, which inherited it from Strathclyde Region after local government reorganisation in 1996. The open school and the secure unit have now closed.
An investigation by the city council reported in 2007 that there were between 350 and 400 allegations from 159 people complaining of emotional, physical or sexual abuse over a period of years.
But the handling of this investigation came in for heavy criticism. Although the council dismissed a number of staff, including senior management, only two staff were convicted of physical and sexual abuse, and one of physical abuse. A further case involving alleged sexual abuse was found not proven.
Despite that outcome, an eloquent foreword in the report by Eddie Frizzell, the former head of enterprise and lifelong learning under the previous Scottish Executive, who chaired the inquiry, spares none of those in charge of Kerelaw.
"In carrying out this inquiry, the team gained an insight into a world which few people care to think about, far less enter," he writes. "We saw what can happen when staff lack direction, when leadership is inadequate, when appropriate values are not upheld, and when poor attitudes are not challenged. We saw the impact of relative neglect of an institution by senior managers 30 miles away preoccupied with reorganisation, budgets, high-level policies and internal disputes.
"The impact on those who were abused at Kerelaw was devastating. A number of ex-residents will require support for some time to come; for others, it is an experience to put behind them as best they can. Some, who were not abused, have had what was a positive experience for them besmirched.
"For many former staff, the consequences have also been devastating. We interviewed a number of broken people - ex-workers as well as ex-residents - and we heard from others working with young people who felt a stigma from Kerelaw had affected them and all residential child care workers."
The inquiry emphasised the importance of having well-qualified and trained staff, which prompted Adam Ingram, the Children's Minister, to stress that the Government was moving to improve training and upskill the residential child-care workforce through the National Residential Child Care Initiative, due to report to ministers later this year.
The report by Mr Frizzell, who once headed the Scottish Prison Service, is a reminder that this is not the first such effort. Strathclyde Region introduced "therapeutic crisis intervention" in 1995 to deal with challenging behaviour among young people. But the inquiry found that some staff ignored it and that weaknesses in training for TCI "contributed to poor practice that was often abusive."
The inquiry, which Glasgow City Council agreed to commission along with the Scottish Government, also found shortcomings in the complaints system at Kerelaw, which it said was "key to safeguarding young people in residential care." It notes that there is now a "listening to children" strategy in Glasgow, but it also notes there are funding pressures on the Children's Rights Service.
Among the many astonishing features of the case is the revelation of the number of inspections to which Kerelaw was subject but which made little or no difference. Among the cast of characters were North Ayrshire Council (which carried out annual inspections), HMIE and the Social Work Services Inspectorate (which inspected every three years), the Care Commission and the then Scottish Executive Health Department.
The Frizzell report acknowledges that residential child care has moved on since the events at Kerelaw, and protection for young people has improved. But, it adds: "There is no room for complacency."