Nursery 'ideal environment for child abuse'
The review into the scandal at Little Ted's in Plymouth said there was a "complete lack of recognition" that Vanessa George's increasingly strange behaviour after the break-up of her marriage had crossed boundaries.
But it concluded that no professional could have reasonably predicted the self-styled "paedo whore mum", who was jailed indefinitely last year, might be a risk to children.
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Hide AdGeorge took photographs on her phone of her abusing toddlers and shared them with fellow paedophile Colin Blanchard.
There was weak management at Little Ted's, which closed immediately after George's arrest, according to the summary of a serious case review commissioned by Plymouth Safeguarding Children Board.
The nursery "provided an ideal environment within which George could abuse" and Ofsted inspections failed to spot shortcomings, the review said.
Management culture allowed the abuse to take place and lessons must be learned, but "ultimate responsibility for the abuse must rest with George", it concluded.
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Hide AdThere was a lack of safe recruitment procedures, an informal recruitment process and lack of formal staff supervision, and the nursery did not provide a safe, positive environment for children in its care, the report stated.
It was not seen as significant that George began using a cubicle to change nappies instead of the general changing area, and staff did not report concerns about her openly discussing her sex life or showing them inappropriate images on her mobile phone.
"The escalation of George's behaviour should have prompted a response by the manager of the nursery, but it did not do so," the report said.
"There appears to have been a complete lack of recognition of the seriousness of the boundary violation and a culture within the nursery where explicit sexual references in conversation were the norm."
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Hide AdA culture developed at Little Ted's where staff felt "increasingly uncomfortable" but they were unable to challenge her inappropriate behaviour.
George came into contact with almost 200 children while working at the nursery, police believe, but she has refused to identify her victims.
The working mother-of-two fell into a life of depravity following the breakdown of her marriage.
She met Blanchard, 40, of Rochdale, on Facebook and became part of a paedophile ring.
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Hide AdA colleague found pornographic pictures on his computer, which resulted in a police investigation that led them to George, Angela Allen, 40, of Nottingham, Tracy Dawber, 44, of Southport, Merseyside, and Tracy Lyons, 40, from Portsmouth.
George exchanged more than 7,000 explicit messages, emails and calls with Blanchard until his arrest in June 2009.
She admitted seven sexual assaults and six counts of making and distributing indecent pictures of children.
The Department for Education said an ongoing review is looking at whether standards for protecting young children should be strengthened.
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Hide Ad"This was a shocking case of abuse of children," a spokesman said. "The (report) identifies important lessons that all early years settings need to learn from so that vulnerable children are better protected in future."
One mother said: "I want to know how it happened, how no-one ever knew what went wrong and what changes are going to (be made) to make sure it can't happen again."
Main findings of the review
Ofsted inspections not rigorous enough
Ideal environment for her to abuse children
Staff felt unable to challenge her behaviour
Management culture allowed abuse to happen
Lack of recognition of her inappropriate actions
Explicit sexual references normal in conversation