Individual at Lancaster Farms

Investigation into the circumstances surrounding
the death of a boy at HMYOI Lancaster Farms
in November 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2009
This is the report of an investigation into the circumstances surrounding the death of
a young boy at HMYOI Lancaster Farms in November 2007. The boy was found
hanged in his cell. The pathologist who conducted the post mortem examination
confirmed that the cause of death was hanging.
The boy was 15 years and eight months old when he died. During his short life he
suffered much unhappiness. His father died when he was three. His mother, having
become addicted to drugs, drifted away from him. I find it particularly distressing that
the boy’s uncle and aunt, who were his legal guardians and who had cared for him
as surrogate parents for half his life, have had to suffer the agony of his loss. That
the boy died in a prison, and at such a young age, must be especially shocking and
difficult to come to terms with. I offer my heartfelt sympathy and condolences to the
boy’s uncle and aunt, and to their daughters who have in effect lost a brother. My
sympathy also goes to all those affected by the boy’s loss, including his mother and
sister, and those who knew and cared about him, including staff at Lancaster Farms
and at St Helens Youth Offending Service.
The investigation was a complex one as is the report that now follows. They have
taken many months to complete. I am very conscious that the first anniversary of the
boy’s death has now passed. I apologise for the added distress that the time needed
to conclude the investigation will inevitably have caused his family.
I appointed a team of four investigators to examine the circumstances surrounding
the boy’s death. The team was led by my investigator. He was ably assisted by 3
other investigators. My Senior Family Liaison Officer was the contact point with the
boy’s family.
I also commissioned a clinical review of the management of the boy’s health needs
while he was in custody at Lancaster Farms. This was initially conducted by a panel
of specialists led by the Assistant Director, Commissioning and Performance, at the
North Lancashire Teaching Primary Care Trust (PCT). The final signed version of
that review was not despatched to my office until 28 October 2008. The review was,
in my view, inadequate. Its brevity did not reflect the complexities that arose during
the investigation. At consultation stage, the Chief Executive of the PCT expressed
his surprise at the delay in the submission of the report by the clinical reviewer and
at its inadequacies. The Chief Executive of the PCT subsequently decided to
commission a review of the evidence and statements collected by the initial panel
and to provide me with a revised clinical review. I am grateful to the Chief Executive
of the PCT for his personal intervention. The revised version is appended to this
report.
My thanks go to the Governor and his staff at Lancaster Farms for their assistance
and cooperation during the investigation, particularly the Principal Officers who acted
as liaison officers. I also appreciate the help given to my investigation team by the
Youth Justice Board, the St Helen’s Local Safeguarding Children’s Board, the Youth
Offending Service and the Head of Young People’s Team in the National Offender
Management Service (NOMS). I am also indebted to the Lancashire Constabulary
for the invaluable help and support they gave to my investigators throughout, despite
their own very heavy workload.
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The investigation into the boy’s death came at a time when the inquest into the death
of another young person at Lancaster Farms was in progress. I had also
investigated this earlier death. Both cases raise questions about the wisdom of
sending vulnerable youngsters to prison. Given resource constraints and operating
pressures within NOMS and the Youth Offending Service, there are no easy
answers. However, if the practice is to continue, the recommendations I make in this
report must be effectively implemented. This is the second time I have made
recommendations about the Personal Officer scheme at Lancaster Farms. I am also
very troubled by the culture of mental bullying witnessed by my investigation team,
and this is something NOMS must not allow to prevail.
Such has been the scale of this investigation that I have made a total of 32
recommendations to the key agencies involved in the boy’s management: Lancaster
Farms, the Youth Justice Board, NOMS, and the North Lancashire Primary Care
Trust. (I have also made a number of other proposals in the text, short of formal
recommendations.) The recommendations relate to a range of issues, the most
critical of which include a failure in the application of the Personal Officer scheme for
the boy, and a failure to arrange a sentence planning meeting for him within
prescribed timescales. I am also utterly dismayed by the failure to attempt to revive
the boy as soon as he was found hanging, despite the fact that his body was still
warm, and by the failure to call an ambulance promptly.
I also note that the boy’s death occurred three months after a major disturbance at
Lancaster Farms which necessitated the temporary closure of the two juvenile units.
Once the damage caused during the disturbance had been repaired and the
accommodation became usable once more, there was an influx of new arrivals in a
very short period. Although the Youth Justice Board attempted to control the pace at
which the numbers built up, there is no doubt that some aspects of the
establishment’s regime for juveniles, including the induction process, were placed
under considerable strain.
I understand that a decision has recently been made to change the role of Lancaster
Farms into a single site for young offenders and that of HMYOI Hindley into a single
site for juveniles, and that the change of role for each institution will have been
completed by April 2009. I welcome that decision. But I urge NOMS and the Youth
Justice Board to work together to ensure that the lessons learned from both my
investigations at Lancaster Farms are given urgent consideration in all sectors of the
secure estate for children and young people. Many of the recommendations in this
report relate specifically to the management of young people at Lancaster Farms.
Although, from April 2009, juveniles will no longer be sent there, I have chosen to
retain the recommendations as they stand because I believe they might assist the
Coroner’s inquest into the boy’s death. I also believe they have a wider application
across the juvenile estate. The recommendations should be read in that light,
therefore.
In line with my normal procedure and good practice, a copy of this draft report was
issued to NOMS in the first instance because named individuals have been
criticised. This was to enable representations to be made and considered.
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This final version takes into account the responses received from NOMS, Youth
Justice Board, St Helens Youth Offending Service, North Lancashire Primary Care
Trust and the boy’s family solicitor.
It need scarcely be said that this is a painfully sad story.
This version of my report, published on my website, has been amended to remove
the names of the boy who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2009
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CONTENTS
Summary
Investigation process
The management of children in custody
HM Young Offender Institution Lancaster Farms
Red Bank Secure Children’s Home
Key events
Issues
Family concerns not covered in main body of report
Summary of findings and conclusions
List of recommendations
1. HMCIP, Juveniles in Custody: A unique insight into the perceptions of young
people held in Prison Service custody in England and Wales
2. St Helens Safeguarding Children Board Annual Report, 2006-2007
3. Brochure on Red Bank Secure Children’s Home
4. Further miscellaneous information relating to the boy’s time in custody prior to
his arrival at Lancaster Farms
5. HMYOI Lancaster Farms’ local contingency plans managing self-harm or
illness
6. Lancashire Ambulance Service Patient Report Form on the boy, November
2007
7. HMYOI Lancaster Farms’ strategy for tackling anti-social behaviour
8. CD Roms x 3: CCTV footage of events of 28/29 November 2007
9. Prison Service Order 3550: Clinical Services for Substance Misusers
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SUMMARY
The boy’s tragically short life began in Liverpool in March 1992. Three years after
his birth he lost his father. As his mother had severe problems of her own, the boy
had to live thereafter with his grandmother. After her death not long afterwards, the
boy was taken into foster care. In 1999, at the age of seven, the boy’s aunt and
uncle became his legal guardians. Although he tried to maintain contact with his
mother, the boy looked upon his aunt and uncle as his parents.
The boy’s education was interrupted by frequent truanting. Whilst still very young,
he took to drugs and drank alcohol excessively, often returning home drunk. He
soon began to break the law. On one occasion he had to be admitted to hospital
after taking an overdose of drugs. The boy’s family told my investigator that he went
out of his way to please his peers at any cost. They also said they believed that
much of his reckless behaviour was due to the influence of two girls who lived
nearby, and who they thought coaxed the boy into committing crimes. The boy thus
became known to the Youth Offending Service from 2006.
In May 2007, the boy committed four separate acts of theft from a shop and one of
assault. On each occasion he had been drinking alcohol. After appearing in court,
the boy was remanded to Local Authority Care in Liverpool. On 5 June, his case
was heard by St Helens Youth Court where he was given a Supervision Order.
Three days later, he subjected a shopkeeper to a torrent of abuse for which he was
arrested the same day. The boy again appeared at St Helens Youth Court and was
given a four month Detention and Training Order (DTO) which required him to spend
the first half of his sentence in custody and the remainder under supervision in the
community. Whilst in police custody prior to his court appearance, the boy used a
spoon to inflict minor cuts on his arms and other parts of his body. He was placed at
HMYOI Thorn Cross on 11 June. This was the boy’s first experience of custody. An
ACCT (Assessment, Care in Custody and Teamwork) form was opened the following
day because staff were concerned about his recent history of self-harm. (ACCT
procedures are a process used by the Prison Service to monitor and support those
prisoners who are thought to be at risk of self-harm.) Although the boy did not harm
himself at Thorn Cross, the ACCT form remained open throughout his brief time
there. As the boy was subject to further charges, he was considered to be
unsuitable for the open unit at Thorn Cross. His ability to cope in a prison
environment was also questioned. As a result, the boy was transferred to Red Bank
Secure Children’s Home near Warrington. In the initial stages of his time at Red
Bank, the boy’s risk of self-harm was closely monitored, although not by means of
the ACCT form which is only used by the Prison Service. The boy remained at Red
Bank until 10 August 2007, when he was released to serve the remainder of his DTO
in the community. However, three weeks later, he appeared at Liverpool Crown
Court on an outstanding charge of affray. The boy was given another four month
DTO and returned to Red Bank where he remained until 22 October.
The boy failed to comply with the curfew element of the supervised phase of the
DTO. Consequently his YOT (Youth Offending Team) worker recommended to the
courts that he had formally breached his licence conditions. Just two weeks after
leaving Red Bank, the boy therefore returned to court on 7 November and was
ordered to complete the remainder of his DTO in custody. In spite of his
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vulnerabilities and his known fear of being sent to prison, the boy was placed at
Lancaster Farms the following day (8 November). On 28 November, the boy was
transferred from Buttermere Unit to Windermere Unit upon completion of his
induction period. At 7.10am the following day, the boy was found hanging in his
single cell. He had been due for release on 22 December.
I am critical of some individual members of staff at Lancaster Farms and I draw
attention to systemic failures that, in my view, impaired the quality of care given to
the boy. The investigation found that the decision to place the boy at Lancaster
Farms was not informed by any current assessment of his ability to cope with the
macho environment of a prison establishment. Detailed information about the boy’s
experiences at Red Bank was not passed to Lancaster Farms. During the reception
process, little attention was paid to the information available in the boy’s Asset form
(a standard assessment document used throughout the Youth Justice System to
measure young people’s risks and vulnerabilities).
In my opinion, the boy’s induction process was mechanistic and more suited to the
establishment’s needs than to those of the individual young person. His first night
interview was conducted in an open area within earshot of other young people.
During his time in the induction unit, the boy hardly left his cell. Although he told his
family he was frightened by the possibility of being bullied, he did not bring this to the
attention of staff. The boy did not complete all the induction modules, but
nevertheless was deemed ready to transfer out of the induction unit on 28
November. That day, despite the fact that all young people had to be locked in their
cells to enable staff to attend a training programme, the boy transferred to
Windermere Unit.
There was a significant systemic failure regarding the allocation of a Personal Officer
for the boy. The member of staff assigned to him in this role on 9 November was on
leave followed by night duty when allocated, and could not therefore engage with the
boy until his return to daytime duty on 25 November. No alternative Personal Officer
was allocated in the meantime. This is the second time I have had cause to criticise
the Personal Officer scheme at Lancaster Farms in the course of investigating a
death.
Lancaster Farms failed to organise a sentence planning meeting within the required
target of ten working days of the boy’s arrival. Instead, a meeting was scheduled for
4 December 2007. Sadly, by this time, the boy had died. Had the meeting taken
place on time, arrangements might have been made to involve the boy’s family in
assessing his vulnerabilities and to help him plan constructively for his resettlement.
When the boy was found hanging on the morning of 29 November, the staff in
attendance found that his body was still warm although they thought he was dead.
They made no immediate attempt to resuscitate him. This was despite the fact that
Prison Service Order 2700 clearly states that, in such circumstances, an attempt at
resuscitation should be made immediately unless rigor mortis has set in. After a
delay of nearly four minutes, one member of staff realised that he and his colleagues
had a duty to try to revive the boy. Cardio pulmonary resuscitation was therefore
commenced. There was a delay of a further three minutes before an ambulance
was called.
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Numerous young people gave statements to the police after the boy’s death. They
claimed that others in nearby cells had shouted to him through their windows during
the night of 28/29 November telling him that, if he did not hang himself that night, he
would be beaten up the following morning. The police conducted a thorough
investigation into the claims but found no evidence to raise criminal charges against
any individual. The staff on duty in Windermere Unit that night told my investigators
they did not hear anyone taunting the boy.
Neither my own investigation, nor that of the Lancashire Police is able to prove
whether the boy was bullied, mentally or physically, at any time at Lancaster Farms.
However, my investigators visited Windermere at night. None of the young people in
the unit was aware of their presence. My team witnessed at first hand a sustained
and concerted exchange of frightening and disgusting insults between a number of
young people in their cells. They were targeted principally at one individual. This
exchange had been preceded by the loud banging of cell doors by numerous young
people. On that occasion, there was no effective reaction by the on duty staff. If this
is the sort of behaviour the boy experienced, I have no doubt that he would have
been frightened. I am persuaded that his death was probably triggered by the
mental bullying to which many young people testified afterwards. Although the
Governor had put some measures in place to tackle this problem before the boy’s
death, they were manifestly unsuccessful in reducing the problem at night.
I make recommendations to Lancaster Farms, the local Primary Care Trust, NOMS
and the Youth Justice Board that I hope will help prevent further deaths in the secure
estate for children and young people. I have also recommended that a copy of this
report is shared with the Secretary of State for Justice.
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INVESTIGATION PROCESS
1. On the morning of 29 November 2007, I was a guest at the conference of the
Prison Service’s North West Area. When the news of the boy’s death came
through, I agreed with the Area Manager that I would attend Lancaster Farms
straightaway. I was able to receive a personal briefing from the Deputy
Governor and make an initial assessment of the situation. I also read the
boy’s prison file. As the police were present, I did not open the investigation
formally at that point.
2. On returning to London, I appointed a team of four of my colleagues to
investigate the boy’s death on my behalf. A family liaison officer was also
appointed.
3. At midday on 3 December 2007, two of my investigators attended a strategy
meeting chaired by a senior manager in the Safeguarding Children Unit at
Lancashire County Council. My two investigators were able to explain the
nature and scope of the Ombudsman’s investigation and meet those involved
in the boy’s management both in the community and in custody. At 3.00pm
that day, one of my investigators met the Governor of Lancaster Farms and a
number of his senior managers, two representatives of the local Independent
Monitoring Board, a representative of the local branch committee of the Prison
Officers’ Association, and the investigation liaison officer. At the meeting, my
investigator explained the purpose and style of the investigation. Notices
were issued the same day to staff and to the young people in the
establishment inviting anyone with concerns or information relating to the
boy’s death to make themselves known to the investigation team. The
Governor made a point of asking his Diversity Manager to explain to all young
people who were foreign nationals the content of the multi-lingual notice
issued. No-one came forward.
4. After the meeting, my investigator took the opportunity to familiarise himself
with Buttermere and Windermere, the two units at Lancaster Farms in which
the boy was placed. He also examined the cell in which the boy died.
5. My investigator met the Police Liaison Officer for Lancaster Farms on 4
December to agree a protocol for sharing information.
6. My investigator briefed those who attended the Governor’s weekly
management meeting on 5 December about the nature and scope of the
Ombudsman’s investigation.
7. On 6 December, my two investigators visited the headquarters of the Youth
Justice Board in London and met the Senior Strategy Adviser for the Youth
Justice Board, in order to explain the purpose of and methodology for the
investigation. My two investigators also interviewed the Head of Placements
at the YJB, during the course of the investigation.
8. In all, 32 people were interviewed by my investigators, including staff at St
Helens Youth Offending Service. Numerous witness statements were
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received from the police relating to the events of the night of 28/29 November
when the boy was found hanging, and to claims that he had been taunted that
night.
9. I also commissioned a review of the management of the boy’s health needs
while he was in custody. This was initially conducted by a panel of specialists
on behalf of the local Primary Care Trust. The panel comprised:
The Assistant Director, Commissioning and Performance, North
Lancashire PCT
Child Protection, East Lancashire PCT
A Consultant Forensic Psychiatrist, Greater Manchester West Mental
Health NHS Foundation Trust
National Treatment Authority North West
A Consultant Anaesthetist, Royal Lancaster Infirmary, University Hospitals
of Morecambe Bay NHS Trust
The Corporate Services Manager, North Lancashire PCT.
10. I was disappointed that the final, signed and dated version of the clinical
review was not despatched to my office until 28 October 2008. Moreover, the
brevity of the review report was not, in my view, in line with the complexity of
the issues. At consultation stage, the Chief Executive of the PCT expressed
his surprise at the delay in the submission of the review by the Assistant
Director and at its inadequacies. The Chief Executive of the PCT decided to
commission a review of the evidence and statements collected by the initial
panel and to provide a revised clinical review to my office. .
11. On 4 December 2007 my senior Family Liaison Officer (FLO), made initial
telephone contact with the boy’s uncle and aunt who were his legal guardians.
The FLO and my investigator met them at their home on 9 January 2008 to
discuss the concerns they wanted the investigation to address. These
matters are dealt with in this report.
12. My investigation team visited Red Bank Secure Community Home on 15
January 2008 in order to familiarise themselves with the environment in which
the boy was managed there, as well as to compare its ethos and regime with
that of Lancaster Farms. My investigator later visited HMYOI Hindley in order
to examine aspects of the environment, culture and regime in place for young
people there.
13. My investigator attended a meeting of the Local Safeguarding Children’s
Board serious case review on 8 July 2008 in order to share information with
the panel members.
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14. On 16 July 2008, my investigator discussed matters of policy for the
management of young people with the Head of Young People’s Team in
NOMS.
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THE MANAGEMENT OF CHILDREN IN CUSTODY
Youth Justice Board
15. The Youth Justice Board (YJB) is a non-departmental public body set up by
the Crime and Disorder Act (section 41). From April 2000, the YJB became
the commissioning and purchasing body for all forms of secure
accommodation for children and young people. The YJB is also ultimately
responsible for allocating young people to appropriate secure establishments,
taking into account recommendations made by staff in Youth Offending
Teams. The YJB monitors the youth justice system and advises the
Secretary of State.
16. The basis of the Board’s relationship with NOMS, as the main provider of
custodial accommodation, is a strategic partnership. A five year agreement
between both parties sets out how the strategic partnership should operate
and develop. It also defines roles and responsibilities. The partnership
agreement is supported by a Service Level Agreement (SLA) which sets out:
- the number of beds purchased by the YJB
- the financial framework adopted
- the standards/levels of service required across the juvenile estate
- the action that can/will be taken in the case of non-compliance with the
requirements set out in the agreement.
Youth Offending Teams
17. The Crime and Disorder Act 1998 (section 39) requires local authorities with
responsibilities for Social Services and Education to establish Youth
Offending Teams (YOTs), in partnership with the Police, Probation Service,
Health Authorities and Social Services. The role of the YOTs is to work with
young offenders and those at risk of offending in the community in order to
help turn them away from crime. The teams co-ordinate the delivery of a
range of youth justice services including bail support and the supervision of
community sentences and of young people released from custody. The
manner in which these services are to be delivered and funded locally has to
be set out in an annual youth justice plan, drawn up by the local authority in
consultation with other agencies, and submitted to the YJB for approval and
publication. Local custody providers should be consulted in drawing up the
plan.
Local Safeguarding Children Boards
18. In the context of the management of children who are offenders, the term
“safeguarding” refers to the process of protecting and maintaining their safety
and welfare. Section 13 of the Children Act 2004 requires each children’s
services authority to establish a Local Safeguarding Children Board (LSCB)
for their area. It requires the Governor/Director of any prison in the area of
the authority to become a partner of the LSCB and co-operate fully with the
authority. The Act defines the LSCB’s objective as:
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“… to co-ordinate what is done by each person or body
represented on the Board for the purposes of safeguarding and
promoting the welfare of children in the area of the authority by
which it is established; and to ensure the effectiveness of what
is done by each such person or body for those purposes.”
The Detention and Training Order
19. Section 73 of the Crime and Disorder Act 1998 (now section 10 of the Powers
of Criminal Courts (Sentencing) Act 2000), established a new custodial
sentence, the Detention and Training Order (DTO) for young people aged
under 18. The new sentence was devised to rationalise the sentencing
arrangements that previously existed for those aged under 18 and to make
custody more effective in preventing re-offending.
20. The only DTO sentences available to the courts are those of 4, 6, 8, 10, 12,
18 and 24 months. Half of the sentence is served in custody and the other
half under supervision in the community. The DTO is designed to ensure that
the most appropriate form of training is provided for each young offender to
help prevent further offending. This might typically be education in numeracy
and literacy, a parenting skills course, or NVQs in decorating and plastering.
The secure estate for children and young people
21. There are three types of secure accommodation in which a young person can
be placed. These are:
- a Secure Children’s Home (SCH)
- a Secure Training Centre (STC)
- a Young Offender Institution (YOI).
Secure Children’s Homes
22. Secure Children’s Homes focus on attending to the physical, emotional and
behavioural needs of the young people they accommodate. They are run by
Local Authority Social Services Departments and are overseen by the
Department of Health and the Department for Children, Schools and Families.
They accommodate young people involved in the criminal justice system as
well as those outside it.
23. Secure Children’s Homes provide young people with support tailored to
individuals’ needs. To achieve this, they have a high ratio of staff to young
people and are generally small facilities, ranging in capacity from six to 40
beds. There are 14 such facilities in England.
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Secure Training Centres (STCs)
24. Secure Training Centres (STCs) are purpose built centres for young offenders
up to the age of 17 years. They are run by private operators under contracts
which set out detailed operational requirements. There are four STCs in
England. They are:
- Oakhill in Milton Keynes
- Hassockfield in Consett, County Durham
- Rainsbrook in Rugby
- Medway in Rochester, Kent.
25. Each centre normally holds between 58 and 87 young and vulnerable people
who have been sentenced to custody or remanded to secure accommodation.
STCs provide a secure environment in which they can be educated and
rehabilitated. They differ from Young Offender Institutions (YOIs) in that they
have a higher staff to young person ratio and are smaller. As a result,
individual needs should be more easily met.
Young Offender Institutions (YOIs)
26. Young Offender Institutions (YOIs) are run by NOMS and can accommodate
15 to 21 year olds. The YJB web site shows that YOIs generally have lower
ratios of staff to young people than STCs and they accommodate larger
numbers. Consequently, they are less able to address the individual needs of
young people, and are generally considered to be inappropriate for vulnerable
young people with high risk factors such as mental health or substance
misuse needs. The 16 YOIs in England can accommodate up to 2,874 young
people under the age of 18 years.
Placement
27. The YJB is responsible for the allocation of young people to the most
appropriate custodial establishment, based upon:
- vulnerability, as assessed by the Youth Offending Team (YOT)
- specific needs, such as a disability or a particular programme
- competing demand for available beds
- location
- age.
28. The vulnerability of a young person is determined by an assessment,
completed by the YOT, known as Asset. This is a structured assessment
system in place throughout the youth justice system in England and Wales.
Its aims are:
- to identify the key factors contributing to offending by young people
- to provide a prediction of reconviction
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- to help identify young people who may present a risk of serious harm to
others
- to identify situations in which a young person is vulnerable to being
harmed
- to identify issues where more in-depth assessment is required.
29. The YOT notifies the YJB of the details of Asset. In turn, the key factors from
this assessment influence the placement decision. These factors might
include:
- risk of self-harm
- having been bullied
- separation, loss or care episodes
- risk taking
- substance misuse
- other health related needs
- the ability to cope in a YOI or other custodial establishment.
30. The YJB tries to place a young person sentenced to custody in an
establishment that is near his family and home and that provides an
environment that is suited to his needs based upon the information in the
Asset.
31. The following table, taken from the YJB website, shows the method of
determining the most appropriate type of establishment:
Gender, age and Status Type of establishment
vulnerability
Males and females aged Court ordered secure Secure Children’s Home or
12 to 14 remand or sentenced to STC
custody
Vulnerable males aged Court ordered secure Secure Children’s Home or
between 15 to 16 remand or sentenced to STC
custody
Non vulnerable males Court ordered secure YOI
aged 15 to 16 remand or sentenced to
custody
National Standards
32. National Standards for the management of children and young people at high
risk of offending are set by the Justice Secretary on advice from the Youth
Justice Board and in accordance with relevant legislation. National Standards
apply to Youth Offending Teams and secure establishments, but partner
agencies in the youth justice system have responsibilities for helping to
ensure that they are met through agreed good practice. National Standards
make requirements of organisations as a whole, not just of individual
members of staff. The National Standards are currently under review and are
due to be re-issued in 2009. I hope that the learning from this investigation
will inform the revision of this document.
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Prison Service Order 4950
33. The policies for the management of young people in prison are set out in
Prison Service Order (PSO) 4950, the most recent version of which was
issued in December 2006. Other PSOs also apply, such as PSO 2700 which
gives guidance on managing risk of self-harm and suicide.
34. The purpose of the PSO is to define the principles upon which Governors
must operate the regimes for young people, their key features, and what they
must achieve. Its purpose is not to prescribe in great detail but to provide
sufficient guidance and clear direction in order to ensure consistency. Scope
is left for Governors to determine how the regimes are to be delivered and
their operational detail.
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HM YOUNG OFFENDER INSTITUTION LANCASTER FARMS
35. Lancaster Farms is located a few miles from the centre of Lancaster. It is a
closed Young Offender Institution. At the time of the boy’s death, it could hold
up to 527 sentenced and remanded offenders although its normal capacity
was 480. Approximately half were likely to be young people (aged between
15 and 18), and half were young offenders aged between 18 and 21.
Buttermere and Windermere are the units for young people under the age of
18. They are both divided into two sub-units. Buttermere 1 and 2 each hold
up to 65 young people. Buttermere 1 is the main residential unit. Buttermere
2 is the first night centre. Windermere 1 and 2 units are two further residential
units, each holding up to 60 young people.
36. All young people must by law engage in full time education. They also have
access to vocational training such as bricklaying, painting and decorating and
joinery. Physical education is available - there is a large gymnasium and an
outdoor sports area. Other courses include industrial cleaning, catering,
farms and gardens and media skills. The establishment also provides a
number of offending behaviour groups and interventions, including the young
persons’ enhanced thinking skills course. The chaplaincy team offers
religious services each Sunday as well as pastoral care on an individual
basis.
37. Healthcare at Lancaster Farms is provided by the local Primary Care Trust.
Mental health services are provided by Lancashire Care NHS Foundation
Trust. GP services are provided by Owen Road GP surgery. Out of hours
GP services are provided by Baycall. Nursing and dental services are
provided by the local Primary Care Trust. At the time of the boy’s death there
were beds for 12 inpatients. There is also a care and separation unit (a
segregation unit) for those who ask to live separately from the mainstream
population, or who are under punishment.
38. The following table shows the young persons population at Lancaster Farms
in November 2007:
Average population (overall) 227
Average population (Buttermere) 103
Average population (Windermere) 116
Number of new receptions in 64
November
Number of discharges in November 40
According to data provided by the Youth Justice Board, 27 young people aged
15 were at Lancaster Farms on 28 November 2007. There were 23 in the
establishment on 31 October 2008.
39. The following table shows how many young people were subject to
Assessment, Care in Custody and Teamwork (ACCT) - suicide and self harm
monitoring - procedures at Lancaster Farms on 29 November 2007:
17
Unit ACCTs
Buttermere 1 3
Buttermere 2 4
Windermere 1 2
Windermere 2 0
Other 1
Totals 10
Her Majesty’s Chief Inspector of Prisons’ Report
40. Lancaster Farms was last inspected by Her Majesty’s Chief Inspector of
Prisons in October 2006. The Chief Inspector’s concluding remarks in her
report were as follows:
“Lancaster Farms was once the flagship young offender institution
in the prison system and, after a period in the doldrums, it
appears to be improving. Much has been done recently to
enhance the safe and respectful treatment of the challenging mix
of young people in the establishment’s care, and particular
progress has been made in addressing resettlement needs.
There is still much to do, particularly in terms of getting young
people out of their cells and into purposeful activity.”
41. In the context of this investigation, I was particularly keen to examine the
appropriateness of the culture in place at Lancaster Farms. In 2006, the
Chief Inspector of Prisons wrote:
“Survey results regarding staff-prisoner relationships were good,
and comments in discussion groups with young people were
positive. Most staff were at ease with their role in assisting young
people towards a better future. There was good interaction
between staff and young people during association and at other
times out of cell. We found staff to be fair and tolerant in their
dealings with young people, and that they generally set a good
example to them. Although not all staff knocked on doors before
entering cells, they were friendly enough and greeted the
occupants courteously.”
Independent Monitoring Board (IMB) Report
42. Every Prison Service establishment has an Independent Monitoring Board.
This is a panel of local people appointed to monitor the way prisoners are
treated. Boards are required to report their findings annually to the Secretary
of State for Justice.
43. In their report on Lancaster Farms for the period February 2006 to January
2007, the IMB wrote about the following issues which required a response
from the Secretary of State:
“Purposeful activity remains a big problem. Many young persons
spend too much time in their cells. We have now changed to
18
Education classes of shorter duration, designed to enable all
young persons to be out of their cells every day. Whilst we are
now seeing an improvement in class attendance it is still not at an
acceptable level. Some classes may have only two, three or four
young persons present when there should be at least eight.
“The issue of young persons being a long way from home and
family has not been improved and has been exacerbated by
recent prison population pressures.
“Staff shortages throughout the prison due to high levels of
absence have placed continual pressure on the delivery of
programmes and activities. We have found far too many
occasions of ‘dining in’ cells this year, usually ascribed to this
reason.
“Throughout the year we have had late arrivals in reception. In
October 2006, we closely monitored arrivals and had a total of
109 arrivals after 7.00pm, 11 after 8.00pm and six after 9.00pm.
This puts tremendous pressure on reception staff. We are
concerned that the first night care cannot be as it should be,
especially when a young person arrives after 9.00pm and is a
long way from home and may have been travelling for over six
hours.
“The number of young persons who arrive at Lancaster Farms
with mental health issues is very high and yet healthcare staff
maintain that they are not suitable for treatment and cannot be
located on the healthcare ward. Nevertheless, many of them
cannot cope with being on the wings either.
“During the reported period the effects of short stay Young
Offenders and Juveniles have not diminished. Custody staff and
Prison Management are expected to carry out the task of
rehabilitative care whilst offenders are in custody but with such a
short stay this is impossible. Staff are doing a good job with great
difficulties.”
44. I also record here further extracts from the IMB report as I believe them to be
relevant to the investigation into the boy’s death:
“Windermere and Buttermere
“Buttermere 1 is the reception wing for Juveniles and first night
care is in operation. The IMB have a 15 minute slot every week
to speak to the young persons, explaining how they can make an
application to see a member.
“There is a monthly Juvenile Forum with two young persons from
each of the Juvenile wings, Buttermere and Windermere,
19
attending. The meeting is a good ‘talking shop’ and young
persons bring their thoughts and ideas. For example, if they think
there are issues with menus, a member from catering attends.
This gives everyone a chance to discuss the food available,
something which is seen as a big problem.
“Windermere 1 and 2 houses Juveniles. All Juveniles are now
financed by the Youth Justice Board. We now have two safer
cells (i.e. cells in which the fittings and furniture are such as to
reduce the presence of ligature points) on Windermere which can
be used when a young person is on intermittent watch (i.e. when
he is considered to be at risk of self-harm and therefore needs to
be observed intermittently). The Youth Justice Board has
financed a further 8 safer cells to be installed in 2007.
“Reception
“Reception staff often stay late to get through the late arrivals and
the procedure for first night care. The late arrival of escorts
continues to test their forbearance, as does the intake of
prisoners who arrive unannounced, some with very little personal
information.
“Suicide prevention
“The Suicide Prevention Team has met regularly throughout the
year. Due to transfers of duties, the team has twice changed
chair. During this time, however, the changeovers have gone
smoothly showing a good team spirit where everyone knows their
responsibilities and what is required of them.
“Concerns have been expressed about the number of juveniles
and young offenders with mental health problems being sent to
Lancaster Farms. Healthcare staff look after these young people
to the best of their ability but prison is not a suitable environment
for them and there is great difficulty finding vacancies in other
establishments where more appropriate treatment can be given.
“We are fortunate that our staff are so dedicated and qualified to
care for these young people. The number of ACCT (self-harm
monitoring) forms opened has been of some concern at times
during the year. There are currently 23 open (5.12.06). Reviews
are done on a regular basis although the IMB are not always able
to attend because times are often changed at the last minute.
“Training for assessors has taken place during the year and
recruitment is ongoing for more assessors. As mentioned
elsewhere in the report, the distance from home and family only
adds to the stress some of these young men are under, a fact that
is frustrating for both prison staff and the IMB.
20
“Violence reduction
“The committee has met on a monthly basis throughout the year.
The number of fights, particularly between juveniles, has been of
great concern and the staff are to be commended for the sensitive
way that they have handled the problem and the implementation
of the new minor reports process.
“It is hoped to launch the new anti bullying strategy early in 2007.
The launch had to be held over from the autumn because of staff
shortages and change of management. A close watch has been
kept on the situation when groups of trainees and young
offenders from Merseyside and Manchester have transferred into
Lancaster Farms as they do not always see eye to eye.”
YJB Monitoring Report
45. Each secure establishment’s performance is monitored by a YJB performance
monitor who works with the establishment to ensure that the YJB’s
requirements are being met and that it is complying with its contract. Monitors
also work with the establishment to offer support to improve performance. In
her report dated 24 April 2007 the monitor responsible for Lancaster Farms,
summarised her findings on the subject of safeguarding as follows:
“Safeguarding arrangements were monitored on 23 April 2007
using information from the Safeguards team, case file samples,
cell sharing risk assessment, discussion with casework team, In-
Reach team, and Governor for Juveniles. Data received from the
Placements team via the monthly report indicated 34 vulnerable
admissions during the month of March with 9 young people being
identified as having a history of self-harm. First night alert forms
were also used to sample relevant case files. As indicated in the
main body of the report, although there has been a significant
improvement of T1:Vs [the name given to the form which has to
be completed whenever a young person’s initial custodial
assessment is conducted], in some cases vital information is not
included … It is understood … that the issue of Healthcare not
having access to the Asset has now been resolved and that from
now on, Healthcare will evidence that they have had sight of the
Asset and, in particular, substance misuse, emotional, mental
health and physical health sections.”
46. On 22 October and 1 November 2007, the performance monitor visited
Lancaster Farms in order to undertake a review of the Behaviour Management
Code of Practice. The monitor chose this theme in the aftermath of the
disturbance that occurred at the establishment in August that year (see my
comments at paragraph 54 below), and because there had also been a
separate, gang related incident. The table below contains relevant extracts
from the monitor’s report of those visits.
21
Code of Practice Indicator Assessment by monitor
Systems should be put in place to monitor From a sample of eight wing files, evidence of a
the risk in individual cases. cell share risk assessment was found in all cases,
though the level of detail on some was limited.
The completion of T1:V vulnerability assessment
does however remain an area of concern. From a
sample of six case files, only three had adequately
recorded information from documents received. In
one case, although the initial T1:V was completed
very well, there was no T1:V-R [the form used to
update the T1:V] completed when important
information relevant to risk eventually arrived.
In previous monitoring visits, it had been pleasing
to see that the T1:V had been included in wing
files giving officers insight into any specific issues
of vulnerability and risk. However, none were
seen on this occasion and, disappointingly, it
would appear that practice has not been sustained
in this area.
All interventions to be driven by From the six case files sampled, all provided some
assessment. evidence that interventions had been driven by
assessment. Particularly good evidence was seen
of remanded young people having objectives set
which were relevant to their own individual
behaviour. The introduction of the Tackling Anti-
Social Behaviour system (TAB) has resulted in
those young people who are identified as requiring
specific intervention due to bullying or other
negative behaviours being monitored by intensive
observations. Whilst there appears to be progress
in terms of addressing particular negative
behaviours, sampling of live TAB documents
found no planned action to address negative
behaviour.
Where identified risk or need exists, As identified above, the new TAB document has
integrated co-ordinated behaviour been introduced in order to address bullying and
management arrangements must be in other anti-social behaviours within the
place. establishment. Whilst this is seen as real
progress, there continues to be a need to produce
more individualised behaviour management plans
[sic] for those young people with particularly
challenging behaviour such as assaults on staff,
other young people and cell damage. The TAB
documents seen on Buttermere 2 Unit and on
Ullswater (the segregation unit) appeared to
monitor behaviour but does not address the
presenting issues through a plan.
Previous death at Lancaster Farms
47. In January 2005, another young person took his own life at Lancaster Farms.
The inquest into his death was being heard when the boy died. In my report
of the investigation into that earlier death, I made 16 recommendations to the
Governor of Lancaster Farms who accepted all but one (which was found not
to apply to the establishment). One of those recommendations was about the
22
Personal Officer scheme. Although efforts had been made to improve the
Personal Officer scheme thereafter, I am disappointed at having cause to
make another such recommendation in this report.
Disturbance
48. In August 2007, a serious disturbance took place in the young people’s units
at Lancaster Farms during which a large number of young people damaged
their cells. As a result, both units were temporarily closed while the damage
was repaired. When the units were re-opened, the influx of young people was
such that staff felt that reception and induction procedures were placed under
some strain. The establishment was still trying to cope with the effects of that
pressure at the time of the boy’s death.
23
RED BANK SECURE CHILDREN’S HOME
49. Red Bank is situated in Merseyside on the border of the town of Newton-le-
Willows. The home has been managed by St Helens Social Services since
1992. It provides specialist care and education for 40 children, aged between
ten and 17 years, in three secure units and three open units. Education is
provided for every child in residence.
50. The secure provision comprises three houses: Newton, which accommodates
14 boys; Willows, which accommodates seven boys; and Vardy, which
accommodates eight girls. The Children’s Home Health Team looks after all
the mental health and associated needs of the children, and the site nurse
caters for their primary health needs. Leisure activities within the units include
table tennis, crafts, cookery, computer games, board games, television and
video.
51. All staff are social work trained. They are supported by a Children’s Home
Health Team comprised as follows:
a general manager
an art therapist
a secretary
a registered mental health nurse
a speech and language therapist
a music therapist
a consultant psychiatrist in young people’s and forensic services
a registered mental health nurse specialist practitioner
a psychologist.
52. Many of the children will have experienced placement breakdowns and
changes in carers which in turn may have led to behavioural problems,
disruption to education and mistrust of adults. The children’s home staff help
them to develop socially, emotionally and intellectually by providing high
quality residential care and educational services tailored to individual needs.
Great importance is placed upon communication in order to monitor children’s
well-being and progress. Staff handovers, regular staff meetings, children’s
meetings, and reviews are all vital components of the communication process.
Arrangements for reviewing cases are in line with national guidelines issued
by the Youth Justice Board. A care plan is formulated for each child in secure
provision in conjunction with all relevant professionals.
53. Residents are able to access facilities within the secure perimeter which
include a large sports hall, fitness suite, a games area and all-weather activity
court. Where applicable, access to facilities outside the secure perimeter is
planned and monitored for each resident via their care plan and risk
assessment procedure. This may allow access to open facilities off campus.
54. Individually and together, the team members aim to meet the children’s health
needs during their time in the home. Approximately 90 per cent of the
children present with needs in at least one of the following areas:
24
mental health, including depression
anxiety
onset of psychosis
deliberate self-harm
emergent personality disorder
substance misuse
development disorders including ADHD (Attention Deficit Hyperactivity
Disorder)
autistic spectrum disorders
dyspraxia,
disorders of communication and other congenial or acquired difficulties, such
as hearing or learning disabilities.
OFSTED inspection
55. In a report of an OFSTED inspection carried out on 28 November 2007, Red
Bank achieved an overall ‘good quality’ rating. The inspectors found that
relationships between staff and residents were positive and friendly. The
approach by staff was child centred. They skilfully used positive professional
relationships and appropriate humour to persuade the residents in their care
to comply with their instructions.
56. The children were told of the procedures for making complaints when they
were admitted to the home. The complaints procedures had improved to
enable them to use external procedures if they chose to do so. The home
offered a number of meetings and opportunities for the residents to raise
issues within the daily routines. One example was the food council which
gave children a chance to meet the managers and catering staff to discuss
meals and make suggestions about menus.
57. The OFSTED inspectors found that there was a clear anti-bullying policy in
place that was known by staff and residents. They reported that there was a
well developed incentives and bonus scheme that allowed the children to
obtain incentives such as extra telephone time, increased pocket money and
later nights.
58. A detailed risk assessment was carried out for all children at the point of
admission to the home. The assessment of risk and vulnerability was very
comprehensive and was ongoing. Procedures for dealing with those
attempting suicide or self-harm were linked to the risk assessment and risk
management plan.
Visit to Red Bank by investigation team
59. My investigation team visited Red Bank on 15 January 2008 in order to
compare the ethos and culture with that of the juvenile units at Lancaster
Farms. The team’s impressions matched the findings expressed by the
OFSTED inspectors. There was a clear ‘family’ atmosphere in the home. My
investigators were told that there was one member of staff for each of the
25
residents. First name terms were used. Both staff and young people
routinely wore civilian clothes. The rooms – not cells – were well decorated
and comfortable. The residents seemed proud of their environment. They
were encouraged and supported in maintaining links with their families and
friends outside. Each of them was closely supervised at all times during the
day, and interaction between staff and residents was intense and continuous.
My investigators spoke to two boys and one girl. Each gave positive and
optimistic responses to the many questions posed, and each confirmed their
opinion that they were given appropriate support by staff.
26
KEY EVENTS
Background
60. Prior to his admission to Lancaster Farms on 8 November 2007, the boy had
already amassed a number of court appearances. The first of these, following
his arrest for shoplifting, had taken place a year earlier. Thereafter, the boy
continued to re-offend on numerous occasions, each time for similar crimes.
The youth courts before which he appeared handed down a variety of
community based punishments, none of which seemed to have had any
deterrent or rehabilitative effect.
61. In May 2007, the boy committed four separate acts of theft from a shop and
one of assault. On each occasion he had been drinking. On 26 May, he was
remanded to Local Authority accommodation at Willowfield Care Home in
Croxteth, Liverpool.
62. On 5 June, the boy’s case was heard by St Helens Youth Court. The
following extracts from a report to court submitted by a member of staff of the
Youth Offending Service drew attention to concerns relating to the possible
impact upon the boy of a custodial sentence:
”The boy is currently residing at Willowfield Care Home in
Croxteth, Liverpool following a remand to Local Authority
accommodation on 26 May 2007. However, dependent on the
outcome of today’s sentencing, the boy will hopefully be moving
back to live with his legal guardians. The court will be
concerned that the boy is a persistent young offender and is
before them once again in such a short period of time.
“I would assess the boy’s vulnerability as being low to medium.
Although the boy stated at his interview there had been a recent
incident of self-harm (within the last 3-4 weeks) I have no
evidence of this. The boy will receive ongoing support from
Child and Adult Mental Health Service (CAMHS) and a range of
other professions/agencies. The boy is aware and immensely
fearful that the court may be considering imposing a custodial
sentence today. The court will be aware of the adverse effects
of custody upon a young person.”
63. The boy was given a Supervision Order as part of the Intensive Supervision
and Surveillance Programme (ISSP). During the early evening of Friday 8
June, when the boy was still subject to the requirements of that order, he
allegedly made racial insults to a shopkeeper and threatened him. He was
arrested at 7.25pm that day. He remained in police custody over the
weekend. The boy was taken to St Helens Youth Court from St Helens police
station at about 8.30am on Monday 11 June. The Prisoner Escort Record
(PER) for the journey carried a notation that he was at risk of self-harm
because he had cut his wrists a month earlier. A concern was also raised
about his mental health.
27
64. At court, the boy was given a four month Detention and Training Order (DTO).
A Youth Offending Team (YOT) worker and Senior Practitioner for the ISSP
sent a Vulnerability Alert to the Youth Justice Board in which she drew
attention to the following concerns about the boy’s risks:
“History of self-harm/suicide attempts. Most recent whilst in
police custody on 9 June 07. (self-harm). First time in custody
and extremely fearful and anxious about this.”
65. In a post-court report, another YOT worker wrote:
“The boy has never been into custody before and is fearful. He
has a history of self-harm, the most recent incident being this
weekend whilst in custody at police station. The boy needs the
most intensive support package available. I feel he will attempt
self-harm again and is at risk of bullying. Please monitor
carefully.”
66. The YJB decided that the boy was to be placed at HMYOI Thorn Cross and
issued a placement confirmation to that effect on the same day that the boy
was sentenced. The placement confirmation carried an alert that the boy had
previously self-harmed.
67. The boy arrived at Thorn Cross at about 9.40pm on 11 June. A suicide/ self-
harm warning form was completed by a Prisoner Custody Officer (PCO) who
was tasked by Global Solutions Ltd to take the boy from court to prison. The
warning form carried the notation that the boy had self-harmed within the
previous month. The source of this information was quoted as the Prisoner
Escort Record. No other details were recorded.
HMYOI Thorn Cross 11-20 June
68. Upon his arrival at Thorn Cross, the boy underwent a reception health screen.
The following note of the screen was made in his clinical record:
“Arrived at Thorn Cross late in the evening on 11 June.
Reception screen was completed but all information entered onto
system one [his electronic medical record] the next day due to the
lateness of the hour. The boy was nervous being his first time in
prison and it was noted that he caused superficial scratchings and
cuts to his arms, neck and chest. He says this was an impulsive
act following the distress at being in custody and is now regretful
of the incident. He reported that there had not been any other
attempts to harm himself and denied the comments about an
overdose in the Asset form (Nov 06). The boy also reports that
his biological mother was also in a prison and was due to see her
next Monday for the first time in nine years. Both of them are due
for release in July. He has a visit due this week from his social
worker and YOT worker. He is demonstrating that he is thinking
28
positively about the future and seemed reassured about being in
custody following the support he was getting on DCU [Direct from
Court Unit]. Referred for mental health assessment and will see
doctor routinely tomorrow. No immediate concerns in terms of
health needs.”
Cell sharing risk assessment
69. During the reception process, each new arrival must be assessed as to his
risk of harming other prisoners. The assessment informs the decision as to
whether it is safe to allow him to share a cell. The risk of a person harming
others has to be balanced against the risk of harming himself if he were to
occupy unshared accommodation. The boy was considered by the reception
officer to present a medium risk of harming others. This was because of the
nature of his offence and because he had admitted that he was a person who
quickly became angry and frustrated. In practical terms, the fact that he was
judged as presenting a medium risk meant that there was no immediate risk
of harming others but the boy would have to be kept under review.
70. The cell sharing risk assessment process includes an assessment by a
member of the healthcare team. In the boy’s case, this was completed by a
prison nurse. The nurse wrote:
“The boy self-harmed in police cells. Superficial cuts to arms,
neck and chest. Feels regretful. No plans to self-harm further.
Planning for the future. Currently relaxed and at ease. Denies
previous self-harm in Nov 06.”
71. The prison nurse concluded that there was no evidence of a risk of harming
others and that the boy was therefore suitable for multi-cell location.
Form T1:VR
72. As part of the normal reception procedures, the prison reception officer
completed a form T1:VR. This form is used to assess the vulnerability of
newly arrived young people. In answer to the question, “Having interviewed
the child/young person, do they give you any cause for immediate concern?”
the prison reception officer wrote as follows in the boy’s form:
“Yes, due to cuts on arms neck and chest. The boy appears a
very nervous individual, which may be a result of this new
environment, but on observation he displays low self-esteem, is
difficult to interact with and appears quite withdrawn.”
73. However, the prison reception officer also recorded that the boy told him he
had no concerns at that point. The boy was nevertheless placed in a safer
room for his first night. (Safer cells are designed to make an act of self-harm
or suicide as difficult as possible. This is achieved primarily by reducing
ligature points as far as is possible. Anti-ligature furniture and fittings are
installed as an integral part of the cell fabric. The design also takes account
29
of the physical needs of the prisoner and the necessary robustness required
in the construction of all fixtures and fittings.) The prison reception officer
recorded his view that the key points that required follow-up action were an
in-depth mental health assessment and safeguarding during the process of
his induction assessment.
74. In answer to the question, “Does the child/young person’s attitude appear to
make them a victim of bullying/victimisation?” the prison reception officer
wrote:
“Easily led by peer group. The majority of previous offending
linked to alcohol abuse and peer group pressure. The boy is of
slight physical stature and current physical scarring may result in
him being recipient of verbal/physical abuse.
“Has presented as vulnerable in the past and although there is
little evidence of being victimised, this will need to be monitored if
placed in open conditions.”
75. The prison reception officer believed that the nature of the boy’s crime was
significant. He wrote:
“Racially linked crime. Peer group pressure. Self-harm history.
Should others become aware of it, could lead to heightened
vulnerability.”
76. During his first night at Thorn Cross, the boy was observed in his room once
every hour, a standard practice for all newly received young people. The
entries made in his first night observation and support record show that he
gave none of the staff any cause for concern. He had his breakfast on the
morning of 12 June and interacted with the other boys in his unit. On the
same day, the following entry was made in the boy’s prison record:
“During next day induction, whilst talking about bullying issues
and racially motivated previous convictions, the boy became very
agitated, placing both arms up inside his shirt, wringing his hands
together and pulling at his shirt. As soon as we moved on to
easier subject matters he visibly calmed down.”
Assessment, Care in Custody and Teamwork (ACCT) form opened
77. At 5.20pm that day (12 June 2007), a decision was made by a prison officer to
open Assessment, Care in Custody and Teamwork (ACCT) procedures.
(The ACCT process is a means whereby staff can work together to provide
individual care to prisoners/young people who are in distress in order to help
diffuse a potentially suicidal crisis and to help individuals with long term needs
- such as those with a pattern of repetitive self-injury - to better manage and
reduce their distress. Anyone working in a prison who has concerns about a
prisoner/young person with whom they are in contact must talk to the person
30
about their concerns, listen to what they have to say and, if still concerned,
open an ACCT plan.)
Concern and keep safe form
78. The reasons for opening the document for the boy were recorded on a
“Concern and Keep Safe” form as follows:
“The boy states he has a history of both self-harm and attempt
suicide. The boy states he last self-harmed in police custody on 9
June 07 when awaiting sentence. He states he used a spoon to
cut his arms, throat, chest and body. The boy also states the last
attempt suicide was two months ago when he cut his wrists.
Asset also details further attempt suicide in November 06 when
he required hospital admission. Currently on first custodial
sentence and was using excessive amounts of both alcohol and
class A and B drugs. History of mental health support (ongoing).
“During discussions, the boy appeared quite happy but would
become extremely uncomfortable particularly in discussions about
family. Has not met his mother in nine years. Given the above,
the boy will be very vulnerable and will require close monitoring to
ensure safety whilst in Thorn Cross.”
Immediate Action Plan
79. As part of normal ACCT procedures, an Immediate Action Plan was drawn up
for the boy. The purpose of this plan is to record the most appropriate
environment and regime required to support the prisoner prior to his first ACCT
case review. The actions listed for him were as follows:
The boy was to remain in the Direct From Court Unit in a safer
cell until a full assessment was made.
He was to be subject to “15 minute observations maximum at
irregular intervals and spoken to if awake”. Five observations
were to be recorded every hour.
A visit with a carer (i.e. a parent or guardian) was to be arranged
for the following evening.
The boy was to be reminded that he could speak to staff at any
time if he felt the need to do so.
80. The investigation found no evidence to show whether the visit by a carer took
place.
ACCT assessment interview
31
81. The next day, the boy underwent an ACCT assessment interview. He told his
assessor that he usually self-harmed when under the influence of alcohol
because in this condition he would become emotional. He said his distress was
mostly related to his father’s death and the fact that his mother was in prison.
The boy said he was also affected by the death of his uncle and aunt’s son five
years earlier.
82. The boy explained that when he was in police custody on 9 June, he had
broken a spoon and used it to make superficial cuts to his arm, throat, chest
and body. He told his assessor that this behaviour was a coping mechanism
rather than a suicide attempt. He said he felt relieved after cutting himself but
did not want to die. He admitted that he had started to harm himself two years
earlier but could not remember what had triggered this behaviour. He said he
usually self-harmed by cutting himself rather than by overdosing. The boy said
he used alcohol to block out bad memories and took drugs such as cocaine,
ecstasy, LSD and cannabis for recreational reasons.
83. As to his risk of killing himself, the boy told his assessor he had no feelings of
hopelessness, no persistent low mood, no lack of interest in work or play, and
did not feel increasingly tired. His appetite was normal. He said he did not
want to be dead and therefore had no intention or plans to kill himself. He
realised his time in prison was brief and that support would be available from
family and friends when he was released. The boy was also offered
bereavement counselling but he declined as he said he already had a
counsellor in the community from whom he expected a visit whilst in prison.
First ACCT case review
84. On 13 June, the boy’s first ACCT case review was held. The panel
comprised his assessor and his unit manager. The boy was present
throughout. The review was summarised as follows:
“During the course of the case review, the written information
provided by the assessor was discussed along with the issues
that were raised by the prison officer from Safeguarding. On
speaking to the boy, he appears to be happy to be here rather
than at a closed establishment. This was also the case of the
staff in attendance who feel that closed conditions would not be of
any benefit to the boy. He appeared to be fine at the moment but
below the surface there are a lot of issues that need to be
addressed.”
85. The panel considered that the boy’s risk of further self-harm was low and
decided that he should be observed five times each hour. (I consider that this
level of observation is more appropriate for someone whose risk is thought to
be much higher.) A contemporaneous record of each observation was to be
made. The panel also decided that it was appropriate for the boy to move from
a safer room to an ordinary room.
32
86. On 18 and 19 June, consideration was given to the boy’s readiness for open
conditions at Thorn Cross. The following email was sent to Cheshire Police:
“The boy is expected in St Helens Magistrates Court on 4 July.
He is on technical bail (i.e. on bail for this offence but already in
custody) for an offence of Affray. He has submitted no plea. The
case is expected to go to the Crown Court. In order for the
Governor to review the boy’s suitability for open conditions, we
need as soon as possible further details: i.e. the seriousness of
the boy’s involvement in the offence and the approximate length
of sentence he is expected to receive.”
87. The police replied as follows:
“The offence for which he is charged is affray, using racially threatening
words/behaviour. The offence took place on 8 June 2007. Having looked at
his convictions and the fact he is in custody on other matters he may get a
custodial sentence. My thoughts are that until a trial date is fixed and the
formal remand is in place, he is not suitable for open conditions.”
88. On 19 June, the following entry was made in the boy’s core prison record:
“Spoke to YJB placements ref the boy having to be transferred at
the soonest possible moment. Message from the Governor the
placement had to be a secure unit not a prison environment due
to his previous self-harm and an outstanding court appearance of
a serious nature. All this was related to YJB placements.”
(At consultation stage, the St Helens Youth Offending Service pointed out that
the boy was deemed not suitable for open conditions only because there
were outstanding matters at court and not because of his vulnerability.)
89. The next day, the boy was transferred to Red Bank with his ACCT form still in
force. The PER for the journey to Red Bank made this clear. The last entry in
his ACCT ongoing record was made at 9.30am on the day of his transfer. The
author wrote, “Transferred to Red Bank. He seems quite happy to be going.”
The boy arrived at Red Bank at 10.00am.
Red Bank: 20 June-10 August
Initial custodial reception assessment
90. As soon as the boy arrived at Red Bank, a form T1:V (Initial Custodial
Reception Assessment) was completed. The aim of the assessment was to
consider the boy’s current risks. The following table shows the principal
conclusions drawn from the assessment with regard to his risk of self harm:
Question Answer Comments
Has the detention in a secure Yes Asset suggests that the boy is extremely
facility increased the child’s at risk when in custody. Self-harmed
risk of self-harm or suicide? whilst in custody and suicide attempt in
33
Nov 06. The boy is only 1 week into a 4
month DTO and has been transferred
from Thorn Cross to Red Bank due to the
high risk of self-harm.
Is the child a potential victim? Yes Due to the boy’s past regarding self-harm
and his slight build.
What action will the secure The boy will be put on 5 min nightly
facility take to reduce the checks. He will notbe allowed any items
child’s anxiety, vulnerability or in his room until he has been fully risk
risk of self-harm or suicide or assessed. The boy’s behaviour on the
the risk they pose to others? unit will be closely monitored.
91. A week after his arrival at Red Bank, the boy was described as “still finding his
feet” with other young people. He seemed to get on well with staff other than
those working in the education department. There were no concerns about
his health, except in relation to a foot injury he sustained on 22 June. He
maintained regular contact with his guardians by telephone and received a
visit from them.
92. On 4 July, the boy appeared at St Helens Magistrates Court where he was
committed for trial at Liverpool Crown Court for his charge of affray.
93. Later that month, on 20 July, the following letter was written by the Senior
Social Work Practitioner, Safeguarding Team at Thorn Cross, to Red Bank:
“I am writing to you as the Social Worker based in Thorn Cross
who interviewed the boy on 12 June 2007 following his arrival. As
a result of my interview, a number of concerns became apparent
which, whilst you may already be aware of, I feel I need to draw
your attention to:
“The boy’s history of self-harm and attempted suicide,
A self-harm incident in police custody whilst awaiting placement in
Thorn Cross,
“The boy’s previous heavy reliance upon alcohol and drugs and
the impact of the loss of these apparent key coping mechanisms.
“The loss of his father at a young age, his previous history as an
armed bank robber and the boy’s feelings regarding this;
The abandonment by his mother also at a young age and the
recent information about her current whereabouts and the boy’s
wishes to make contact.
“As a result of my concerns regarding the boy’s vulnerability, an
ACCT was opened to increase the level of monitoring and the boy
remained within the Direct from Court Unit (DCU) whilst further
enquiries were made.
“A meeting was arranged at Thorn Cross on 15 June to
discuss these concerns with the boy’s Social Worker, his
CAMHS worker and key staff at Thorn Cross. Following that
34
meeting, it was agreed that the boy should remain in the DCU
whilst he continues to settle and make a gradual transfer to
open conditions. It was also agreed that his social worker
would make further enquiries regarding developing contact
with his mother and explore how, and at what pace, any
contact should take given the boy’s current circumstances.
His CAMHS worker agreed to carry on supporting the boy by
continuing her weekly visits and providing any additional
assistance he may require following contact with his mother.
However, following the realisation that the boy had additional
charges, he was transferred to your establishment and no
further action could be taken with regard to the issues
identified.”
94. On 23 July, the boy was due to appear at Liverpool Crown Court on the
charge of affray but the case was adjourned. The boy was remanded in
custody and returned to Red Bank.
95. By the end of July, the frequency of observations made upon the boy had
reduced from five to 15 minute intervals during the night. Although he had
generally settled, his behaviour was at times demanding. The following
report, written on 31 July, reveals both the positive and negative aspects of
his conduct at that stage:
“The boy has been very positive during his placement at Red
Bank. He has followed the routines appropriately and progressed
well on the incentives scheme, gaining very high points totals. He
does struggle in attending PE sessions and will try to avoid these
at any cost. The boy has handled the situation with his mother
and personal issues very well and has resumed contact with her
although he would now like to meet with her and receive visits.
However, this has led to a deterioration in the relationship with his
uncle and aunt.”
96. In his final review on 3 August, the boy was described as having made good
progress at Red Bank. A week later, he was released on licence under the
Intensive Supervision and Surveillance Programme (ISSP). The licence
conditions required him to conform to curfew arrangements monitored by an
electronic tag. For the following two weeks, the boy lived with his aunt and
uncle.
Red Bank: 24 August-22 October
97. Three weeks later, on 23 August, the boy appeared again at Liverpool Crown
Court to answer the charge of affray. In her pre-sentence report to court, the
boy’s second Youth Offending Team (YOT) worker wrote:
“The boy has been involved with the Youth Offending Service
since 2006. He has been subject to various community orders
and has responded positively to interventions. However, he has
35
breached orders where there has been an additional curfew
element. It is with regret that I must inform the court that the boy
has placed himself in breach of his current Notice of Supervision.
The boy was released on 10.8.07 with a condition to comply with
the ISSP including an 8.00pm to 7.00am curfew. He is required
to undertake 25 hours of supervision and be subject to the curfew.
The boy has kept all but one of his supervision appointments.
However, he has unfortunately breached the curfew element.
This incident happened on the evening of his release when he
was not available for the equipment to be fitted. A further attempt
was made to install the equipment but the boy was absent from
home for this visit. As such, he does not have an electronically
monitored tag at the current time. The breach case is currently
being processed and has to be heard before the Youth Court.
However, plans to proceed further will depend upon the outcome
of today’s case.
“Regardless of today’s outcome, the Youth Offending Service
will remain involved with the boy on a statutory basis whether
that is via a community based order or a DTO. Objectives for
supervision/sentence planning would be for the boy to:
- improve his understanding of the effects of crime by
participating in victim empathy and consequential
- thinking skills sessions,
- reduce his levels of alcohol use,
- participate in positive activities thus reducing the risk of
- involvement in further offending,
- improve his understanding of the links between peer
pressure and his offending,
- improve his coping skills via continued specialist mental
health service interventions,
- make reparation for the harm he has caused by his
offending by engaging in regular reparation sessions.”
98. The second YOT worker recommended to the court that the boy could be
given a further ISSP supervision order. However, instead he was given a
further four months Detention and Training Order. The boy was initially taken
to Newton Aycliffe Young People’s Centre in County Durham, but the next day
he was transferred to Red Bank, some 150 miles away. In a post-court
report, a YOT worker pointed to the boy’s vulnerability to self-harm and
advised of the need to monitor him closely in the early stages of custody. The
boy’s admission proforma carried a notation that he was at risk of self-harm or
suicide. The following comments were recorded:
“From Asset – He has self-harmed in police custody recently (cuts
to arms). If loses contact with mum, risk of vulnerability
heightened. Risk at high level. Suicide attempt (2006) overdose.”
The boy’s attitude towards education
36
99. The following table contains extracts from later sections of the admissions
proforma and shows the boy’s attitudes towards compulsory education:
Question Answer
Do you think it is important to get an education? No
What do your parents/carers think about your Aunt and Uncle have no say.
education?
Do you go to school regularly? No
Do you, generally, like school? No
Have you ever been suspended or excluded from Yes, for poor behaviour.
school?
Did you get into trouble at school? Yes, for smashing things and
bullying.
Have you ever been a victim of bullying? No
Are you working towards any GCSEs? Supposed to be working towards
7GCSEs but not going to.
Whilst you are at Red Bank you will have to Not happy but will try.
attend education classes. How do you feel about
that?
100. On a keywork session recording sheet completed on 29 August, the boy’s
keyworker made the following comments:
“Generally, the boy is familiar with the rules and regulations
governing the unit. The boy has settled in well and is having no
trouble from his peers. The boy has to admit when he is wrong
and face up to his actions. He can’t just bury his head in the
sand. All those with a vested interest in the boy believe him to
have the ability to do well in his education. It is up to him to prove
it.
“The boy is keen to contact his mother who he says is currently
‘missing’. Has spoken to his sister who is trying to find mum.
Also his aunty is trying to make contact and, if successful, will
inform the boy accordingly.”
101. A week later, the boy had a further review with his keyworker. The record of
the review shows that the boy asked to be transferred, though no further
details were recorded. It also shows that the boy had been successful in
making contact with his mother by telephone and that she was due to visit
him at Red Bank on 6 September. It is not clear from the record whether this
visit took place. It was reported that the boy had attended some education
classes but not PE. He told his keyworker he was adamant that he would not
attend PE whilst at Red Bank.
102. The documents presented to my investigation team contain summaries of
further review meetings held on 21 September, 29 September and 15
October. It is not clear whether additional meetings were held on other dates.
The available evidence shows that there was an improvement in the boy’s
attendance at classes towards the end of his time at Red Bank but this
improvement was not matched by his general behaviour. Between 22 June
37
and 11 October, a total of 26 control measures (minor punishments) were
invoked because of the boy’s poor conduct. On 2 October, the boy received
a visit from a family member to whom he became abusive. He was also
abusive to staff and had to be restrained. Shortly afterwards, he cut his arms
superficially. As a result of his poor behaviour, the boy was not allowed to
use the television in his room for four days. There is no evidence to show
whether his risk of further self-harm was monitored. However, the boy did not
in fact self-harm again.
Release from Red Bank
103. At 9.40am on 22 October, the boy was released from Red Bank to serve the
remainder of his DTO under supervision in the community. He attended St
Helens YOT that day to confirm that he understood the conditions of his
supervision, including compliance with the curfew element of his release.
This came into effect at 8.00pm that day when the boy was required to be
available for the installation of the monitoring equipment. At 6.32pm, an
engineer from a security firm arrived at the boy’s home to install the
equipment. The boy was not at home. A further visit was made by the
engineer at 8.00pm. On this occasion, the boy was present but he was under
the influence of alcohol and in bed. Three unsuccessful attempts were made
to wake him. This incident was classed as a significant violation of the
conditions of his supervision. A formal notice to this effect was issued.
104. The monitoring equipment was installed some time later. During the first
week of his release, the boy complied with the supervision element of his
licence but accrued two further curfew absences on 27 and 28 October.
Thereafter, the boy’s behaviour deteriorated further. He refused to engage
with the YOT interventions, and failed to attend school or comply with his
curfew. On two occasions, he stayed out all night and was reported to police
as a missing child. As a consequence, the YOT became increasingly
concerned at his risk of re-offending and his vulnerability, and decided that he
had breached the conditions of his licence. As a result, a court hearing was
arranged for 8 November. As the second YOT worker thought she might still
be able to recommend community supervision, the option of recommending
his recall was delayed until the last minute. In light of the fact that the boy
failed to engage during the two week period between his release from Red
Bank and the court hearing, the second YOT worker decided that she had no
option but to recommend recall.
Placement alert
105. The role of Placements and Casework at the YJD is to place young offenders
appropriately within the young people’s secure estate. During interview, the
Head of Placements and Casework said the YJB placements process is
reliant on receiving accurate information from YOTs.
106. The Head of Placements and Casework explained that YOTs send a
Placements Alert form to the YJB, ideally a day before the young person is
due to appear in court. In the boy’s case, his second YOT worker had
38
prepared the alert form and tried to fax it through on 7 November. However,
as a result of a technical problem, the second YOT worker was unable to fax
the form to the YJB until the morning of 8 November, the day of the boy’s
court appearance. The alert form should provide the latest information about
a young person, including any risk factors that should be considered by the
YJB Placements team or by the establishment that is destined to receive him.
The following information was included on the boy’s form:
“Since last asset forwarded to YJB [at time of original sentence]
concerns re vulnerability have continued. The boy has some
history of self-harm in custody. Whilst in most recent custodial
phase of DTO at Red Bank Secure, he made superficial cuts to
his arm on one occasion when he was upset over a family visit.
The boy also had two incidents whereby he was physically
restrained by staff after hitting out at them when he was upset.
“The boy uses alcohol and he has recently been drinking daily to
excess and also possibly using amphetamines both of which have
a detrimental effect on his well being, thinking and coping skills.
The boy has a mental health worker from local St Helens CAMHS
[Child and Adolescent Mental Health Service] who can quickly link
in with any custodial mental health services for support. He also
has a substance misuse worker who can quickly liaise with
custodial facility staff. A request is being made for recall, and it is
the Youth Offending Service assessment that the boy’s needs can
be adequately met in a Young Offender Institution as long as staff
consult asset docs post custody report and any vulnerability alert
forms which will follow.”
107. Below the box on the form in which the above information was recorded, there
is a list of other questions that must be answered. Those questions, together
with the associated answers, are repeated in the following table:
Question Answer
First time in custody? No
Potential self-harmer/suicide? Yes
History of abuse/trauma? Yes
Risk to others? Yes
Gang member No
Substance misuse Yes
Other health issues No
Requires detox? No
Mental health concerns? Yes
On medication? No
Is young person a parent? No
The question and answer list is written in the same font as the rest of the text
and does not stand out as having any more importance than the neighbouring
text.
108. The Placement Alert form has a “Suggested most appropriate placement”
section. The Head of Placement and Casework explained that a YOT worker
39
will usually have worked with a young person prior to custody, and should be
in a position to recommend a suitable placement to meet the young person’s
needs. The second YOT worker suggested that the boy would be most
suitably placed in a YOI and identified Lancaster Farms as the “preferred
unit”.
109. The YOT worker must then describe the reasons for the suggested placement
on the alert form. The second YOT worker wrote as follows:
“Previously requested Red Bank when the boy had not
experienced custody. However this would be the boy’s third time
in custody and Youth Offending Service (YOS) staff can liaise
appropriately with casework staff at Lancaster Farms which is
near enough to enable family visits to take place, and also any
relevant partnership staff can regularly visit to undertake ongoing
interventions and planning meetings.”
110. Underneath the suggested placement section of the placement alert form,
there is a table which guides a YOT worker to identify the appropriate
placement for a young person, according to his or her age and gender. For
14 to 16 year old males who have received a custodial sentence, the following
two suggestions are made:
“If assessed as having significant risk factors: Secure Children’s
Home (SCH) or Secure Training Centre (STC);
If not assessed as having significant risk factors: Young Offender
Institute (YOI).”
Vulnerability alert
111. The second YOT worker identified the boy as having risk factors, but
recommended that he should be placed in a YOI. The Head of Placements
and Casework explained that the YJB Placements team has an automated
vulnerability alert system. If any risk factors are identified on the alert form by
the Placements Officer, they are entered onto a database which triggers an
automatic vulnerability alert. The placement confirmation form faxed through
to the receiving establishment in advance of a young person’s arrival has a
red box with details of the young person’s risk factors. In large red capitals,
the vulnerability alert on the boy’s placement confirmation form read:
“Self-harm/suicide risk
Previous self-harm attempt
Potential Self-harmer (threats).”
112. During interview, the second YOT worker explained her recommendation for
the boy’s placement at Lancaster Farms. She said she did not consider that
the Secure Children’s Home met his needs. She was concerned about the
boy’s behaviour since his release from Red Bank because he had been
drinking heavily and staying away from home overnight. Despite the fact that
The second YOT worker reminded the boy of the consequences of missing
40
his appointments – including a return to custody – he had continued to do so.
The boy told the second YOT worker he did not care.
113. The second YOT worker told my investigators that she was primarily
concerned to help the boy to stop re-offending. She said:
“This would be his third time in custody and being 15, nearly 16,
he was going to a juvenile wing of a YOI rather than the Young
Offenders Department which I felt would be suitable for him. I
think because he had been to Red Bank twice and in a way it
hadn’t had a big effect on him I think that was what I was thinking.
You know a fresh somewhere different may have had a positive
effect on him.”
114. When asked whether she had considered the need to keep the boy as close
to home as possible, the second YOT worker said:
“We class Lancaster Farms as our local prison. I know there is
one closer but it’s an open facility which is Thorn Cross. The
reason I didn’t put Thorn Cross down was because he’d been
absconding from home and I felt there might have been a risk that
he could have done there.”
115. The second YOT worker explained that she did not consider recommending
Hindley YOI as the establishment “is the other side of Wigan”. She said she
consulted two senior practitioners about which YOI would be the best for the
boy. The second YOT worker thought Lancaster Farms was close enough to
enable family visits to take place and that staff involved in the boy’s case
would still be able to see him regularly. (At consultation stage, the St Helens
Youth Offending Service pointed out that the Youth Justice Board and Prison
Service agree the catchment areas for Youth Courts across the country and
that Lancaster Farms was the designated YOI for Merseyside courts at the
time. Hindley YOI was the designated YOI for youths from Manchester. As a
result of the rivalries between these two areas, young people were not mixed
at the time. Therefore, Hindley would not have been an option.)
116. My investigators asked the second YOT worker if she had considered how the
boy would be able to cope with the assertive environment of a prison and
whether he would be susceptible to bullying. She replied:
“As a case worker you have to consider that for all young people. I didn’t
think it was an issue for the boy when I was making the decision about which
custodial setting to recommend.”
117. The second YOT worker told my investigators that she was aware that in
court the boy had said he would stop eating and drinking if he were given a
custodial penalty. She said she had been told this by his aunt. The second
YOT worker asked the court worker to discuss this with the boy when the time
came to interview him in the court cells for the purpose of the post court report
(see paragraphs 131-133 below). The second YOT worker remembered
41
speaking to the boy about the fact that she had recommended placing him at
Lancaster Farms and that he did not mention any such threat to her.
42
Asset form
118. The following historical information was included in an Asset form made out
by the second YOT worker earlier in 2007:
“The boy had been bullied in the past,
his daily functioning was significantly affected by emotions or thoughts
resulting from past events,
he was affected by emotional or psychological difficulties [e.g. phobias,
eating or sleeping disorders, suicidal feelings],
he had previously harmed himself,
he had previously attempted suicide.”
119. At section 9 of the form, under the heading, Emotional and Mental Health, the
second YOT worker wrote:
“The boy presents as an extremely vulnerable young person. He
continues to have involvement with CAMHS and continues to
drink excessively. There has been a history of self-harm and
suicide attempts. Whilst there have not been any recent attempts
of suicide, he has most recently self-harmed while in police
custody on 9 June 07. The boy received a 4 month DTO on 11
June and as such his vulnerability has escalated. Concerns
regarding the impact of this sentence on his emotional and mental
health.”
120. Under the heading ‘Vulnerability’ at section 15, the second YOT worker wrote:
“Pre-sentence report 22 August 07:
THE BOY’S VULNERABILITY NEEDS ASSESSING IF RIC
[Received into custody]. HE HAS SELF-HARMED IN POLICE
CUSTODY RECENTLY – CUTS TO ARMS – AND AT LAST
RIC A REQUEST WAS MADE FOR THE BOY TO BE SENT TO
A SCURE REMAND RATHER THAN YOI. SAME ISSUES
PRESENT FOR PRE SENTENCE REPORT – SO COURT
STAFF WILL NOTIFY ANY CONCERNS VIA POST COURT
REPORT IF RIC.
“Pre sentence report Asset:
“The boy has never been in custody and I think he would find it
difficult to cope and this will impact on his mental health. I
would assess the boy’s vulnerability as being low to medium.
Although the boy stated at his ISSP interview there had been a
recent incident of self-harm (within the last 3-4 weeks), I have
no evidence of this. The boy will receive ongoing support from
CAMHS and a range of other professional agencies.”
43
121. However, the second YOT worker updated the boy’s Asset form on 24 October,
by which time the boy had spent a period at Red Bank and been released.
Although the above information had not been deleted from the form, the
indications were that many of the concerns raised prior to the boy’s admission
to Red Bank had not materialised.
122. By November, the second YOT worker believed the boy could benefit from the
more disciplined regime at Lancaster Farms. She said that Red Bank, “did
not seem to have worked for him” and that was the reason for her decision to
recommend placement in a YOI. The second YOT worker told my
investigation team that she had found it difficult to recommend that the boy’s
licence be revoked and she was reluctant to recommend a return to custody.
However, she believed that his failure to engage with her, coupled with his
chaotic behaviour following his release from Red Bank on 22 October, left her
with little choice but to recommend a custodial placement in a YOI. The
second YOT worker told my investigators, “St Helens has a pattern of
identifying Lancaster Farms, it’s our local custodial facility.” Thus, once she
had decided on a recommendation for placement in a YOI, it was in line with
normal practice for her to recommend Lancaster Farms. On 7 November,
following discussion with her manager at the Youth Offending Team, the
second YOT worker completed the Placements Alert form.
Court hearing
123. The boy appeared at St Helens Youth Court at about 11.30am on 8
November. The second YOT worker said that she did not always attend a
court appearance for every young person she supervised. However, the
second YOT worker did go to see the boy. She explained during interview:
“I specifically went there because there had been some
incidences where he was refusing to see me. I wanted to talk to
him on the day just to confirm how he was, his state of mind,
you know, his coping skills on the day. I wanted to be there to
support the family because I had worked quite closely with
particularly his auntie and because he was an intensive case.
You do more of those things with the type of case that the boy
was as opposed to a lower level referral order.”
124. An employee normally employed as a Bail Support Officer for the St Helens
Youth Offending Team, was also the designated court worker at St Helens
YOT. The court worker was thus responsible for looking after young people
from St Helens during any court appearances. The court worker was
responsible for reading to the court the report prepared by the second YOT
worker, whose concluding remarks were, “It is with regret that a
recommendation is made for a recall to custody.”
125. In interview, the court worker remembered the court appearance. She told my
investigation team that the boy was expecting to go to prison that day. She
said:
44
“… She [the second YOT worker] told him exactly what she was
putting in the report and what she was asking the court to do
which was to return him to custody. So far as I was aware, the
boy appeared in court under the impression he was going back to
custody.”
126. The court worker said that she was an experienced youth court worker and it
was rare for a judge to disagree with a YOT worker’s recommendation for
custody. The judge agreed with the second YOT worker’s recommendation
and decided the boy should spend the remaining 44 days of his sentence in
custody. (During the consultation stage of the draft report, the boy’s family
told my investigator that the hearing and resultant decision to recall the boy,
was particularly brief. Whilst investigation decisions made in court is beyond
my remit I would like to draw this matter to the attention of the Lord Chancellor
and for that purpose, forward this report to him). The court worker said the
boy did not seem visibly affected by the recall to custody, and made his way
to the court cell after a brief chat with his aunt who then told the court worker
that the boy had said he would “refuse food and drink whilst in custody”. The
court worker recorded this information in the boy’s post court report. The
court worker would have had a reasonable expectation that the post court
report would be studied upon the boy’s arrival at Lancaster Farms. However,
as will be shown later, there is confusion as to whether the report was
available to staff in reception.
127. After the boy left the court room, the court worker contacted the YJB
Placements team to confirm that the boy had been recalled to custody. She
said that she mentioned the boy’s threat of food refusal to the Placements
Officer who took the call. The Placements Officer did not remember the court
worker mentioning threats to refuse food. He said the boy’s vulnerability risk
factors were well documented in his records, which were all emailed to
Lancaster Farms after the court worker’s telephone call. After speaking with
the YJB Placements team, the court worker went to speak with the boy in his
court cell. She said he was very down and she was worried about him.
However, despite his low mood and threats to refuse food, she did not
consider changing the boy’s placement recommendation. The court worker
said that it was not her role to question the suitability of a placement of a
young person, and she would always rely on the judgement of the YOT
worker who made the placement recommendation. The court worker spoke to
the court staff and explained that she was concerned about the boy. She told
them that he had a history of self-harm. At interview, the court worker said to
my investigators, “When anyone goes into custody we have a yellow envelope
and inside that envelope goes a copy of the post court report, a copy of their
Asset, any risk of serious harm Asset if it’s applicable and a pre-sentence
report if they’ve been sentenced.” She confirmed that this procedure was
followed for the boy.
Placement confirmed by Youth Justice Board
128. At 1.30pm on 8 November, a placement confirmation form was generated by
the Placements Officer confirming the boy’s placement to Lancaster Farms.
45
One copy was sent to St Helens YOT and the other was sent to Lancaster
Farms. The form carried a clear and highly visible notation of the fact that the
boy had previously self-harmed and that he was therefore considered to be a
potential self-harmer in the future. The original version highlighted this
information in bold text, coloured red. The version received at Lancaster
Farms would have been a copy and therefore not in red.
129. The boy was collected from St Helens Youth Court at 4.40pm that day.
Global Solutions Limited (GSL – a private security company), took over his
custody from court staff and he was escorted to Lancaster Farms. (At
consultation stage, the St Helens Youth Offending Service drew my attention
to the court worker’s recollection that she verbally advised the escorting staff
of the boy’s statement that he would refuse food and that he should be
monitored.)
Lancaster Farms: 8 - 29 November
130. Before his arrival at Lancaster Farms on 8 November, the boy’s Asset,
Placement Alert and Placement Confirmation forms were faxed through to the
prison. Officers use these documents to create a core prison record.
131. The boy arrived at about 7.00pm along with five other young people who had
also appeared in court that day. It is mandatory for a form known as the
Prisoner Escort Record (PER) to be completed by whoever is given the task
of escorting prisoners between court and prison. The form is used to relay
important information about any risk factors the prisoner may present and
about any events that occur during the journey. The boy’s PER carried no
notations of any risk factors, including self-harm. During the journey, the boy
was checked about every 30 minutes. The journey passed without incident.
132. Prison Service Order (PSO) 4950 sets out a requirement that every young
person must be interviewed within one hour of his arrival in prison so that his
health needs, his vulnerabilities and his ability either to cope on his own in a
cell without self-harming or to share a cell without harming his cell mate, can
all be assessed.
Initial custodial reception assessment
133. During the reception procedures, those under 18 years of age are kept apart
from those over 18. The boy was placed in a holding room in the reception
building. When my investigators visited this building they noted that the décor
was characterless, unlike that which they had seen at Red Bank. They
believed that few newcomers to Lancaster Farms would gain an impression of
warmth or welcome.
134. At the time of the investigation, young people were routinely strip searched as
a normal feature of the initial reception procedures.
135. When the boy was called forward by the reception senior officer, he said he
had no particular concerns. The boy might have had a copy of his post court
46
report with him but the investigation found no firm evidence to clarify whether
this was the case.
136. The casework officer for the evening shift went over to the reception area to
collect the boy and the other young people who had arrived at the same time.
In interview the casework officer explained that, depending on the time of
night they arrived, he usually took new young people to the induction unit to
complete the initial custodial reception assessment there rather than in
reception. The form T1:V helps staff undertaking the reception interview to re-
assess the young person’s vulnerability, and any risk he might pose to others,
and to make plans to minimise the risk of the young person harming himself
or other people whilst in custody.
137. However, the casework officer told my investigators that, although he signed
the form, he did not conduct the whole of the assessment. He said this had
been done by someone else but could not recall who it was. He explained:
“I would have had general information about the boy through his
DTO placement order so I would have filled out the initial part of
that form. I think I did sign the bottom of that form, implying that,
in anticipation of me doing the interview … that interview was
subsequently then done by a member of the first night care team
on Buttermere.”
138. The casework officer told my investigator that whoever was responsible for
completing the reception assessment would normally see any available Asset
forms and vulnerability alerts. It was noted on form T1:V that the Asset
document indicated the boy was a risk to himself because he had self-harmed
seven months earlier.
139. One of the other members of staff interviewed was a unit officer. During his
interview, the unit officer said he worked on Buttermere Unit. He said the
responsibility for completing the T1:V form rested with the induction team.
The unit officer thought that it was the casework officer who completed the
boy’s form. Later, during a telephone conversation with my investigator, the
unit officer recalled that he only completed the boy’s history sheet and
confirmed that he did not play any part in filling in the T1:V. He said that the
form normally had to be completed within one hour of the young person’s
reception. According to the unit officer, this target was difficult to achieve in
cases where the young person arrived late in the evening. He said that, in
these circumstances, it was not unusual for another member of staff to
complete the task the following day. He thought this might have happened in
the boy’s case. However, my investigators were unable to identify who
actually completed the T1:V form.
140. The boy told his assessor he had no physical or mental health problems. He
answered the questions clearly, with good eye contact, and was “polite”
throughout the assessment. He said that he knew other young people at
Lancaster Farms from his home area and was not worried about any tensions
47
arising. The assessor indicated that the boy should be “monitored over the
initial period” but did not record any specific areas of concern.
First reception health screen
141. The Practice Nurse completed the boy’s reception health. The Practice Nurse
told my investigators she was regularly detailed to work in the reception area
of the prison, especially during her evening shifts when most young people
arrived from court. She said health screens took place in a private room, with
just the young person and the nurse present. The Practice Nurse said she
would talk to the individual and ask him questions about his medical history
and mental state, and whether he had any substance misuse needs. She
said a screen could take up to half an hour, depending on individual needs.
The Practice Nurse explained that the young person’s details would be
entered onto a computer programme during the interview. She said she felt
confident in her use of the computerised information system.
142. At interview, the Practice Nurse explained that the health screen took the form
of an interview. No physical examinations were involved. She said she could
not recall the boy’s health screen clearly but was able to recall some details
when prompted by the record.
Alcohol misuse
143. The boy told the Practice Nurse he drank around 50 units of alcohol a week.
The Practice Nurse considered this excessive but not unusual, adding that the
assessment of a young person’s use of alcohol was “usually approximate”.
She said she tried to encourage young people to think about whether they
had been accurate in their recollection by asking them where they normally
drank and the type of drinks they liked. The Practice Nurse told my
investigator that, as she knew that the boy was likely to be referred, if
necessary, to the substance misuse team during his secondary health screen,
she did not refer him herself. The Practice Nurse’s expectation was that the
secondary health screen would be completed about 24 - 48 hours later, and
this would form part of the boy’s induction programme.
Drug misuse
144. The boy told the Practice Nurse he had a “cocaine type drug dependence”. In
interview, the Practice Nurse said she believed this to be possible. However,
as she did not think the boy was withdrawing from drugs, she did not consider
it necessary to refer him to the substance misuse team or to CARATs
(Counselling, Assessment, Referral, Advice and Throughcare Service) at that
stage. The Practice Nurse said that, as with alcohol misuse, this matter would
have been picked up during the boy’s secondary health screen at a later
stage. She did not take a urine sample from the boy. Neither did she refer
him to a doctor in relation to his history of substance misuse.
Self-harm history
48
145. The Practice Nurse asked the boy about his history of self-harming. The
vulnerability alert and the post court report both clearly showed he had a
history of self-harming. The post court report indicated that the self-harm took
place while the boy was in custody. However, as indicated above, there is
some doubt as to whether any of the reception staff had sight of it. In section
9 of the Asset (entitled Emotional and Mental Health), the boy was recorded
as having previously self-harmed and attempted suicide. This information
was not prominently displayed on the form, but could be found at the end of a
checklist of questions with nothing to draw attention to it. The boy’s history of
self-harm and vulnerability was well chronicled in the “evidence” part of that
section. When asked during interview whether she would routinely read the
Asset form before or during a first reception health screen, the Practice Nurse
replied:
“That varies on the night, how many young people are coming
through, as you’ve got time constraints really. I do try and look
through and it’s a big document and we pick out those relevant to
us like the physical, the mental and the social side of things.”
146. When later asked how much time was available to her to complete each
reception health screen, the Practice Nurse said:
“I mean, as nurse I myself would take as long as I needed. Again,
it all depends on the timing you know, the officers finish at half
past eight and they need to be clear and there are sometimes
pressures on us if we get a late bus and there’s six of them on,
then obviously you know you have got that pressure but you take
as long as you need to, there are no – you’ve got to be over in ten
minutes.”
147. The Practice Nurse could not specifically remember whether she read the
boy’s Asset form. She said she “very rarely” saw post court reports or pre-
sentence reports and preferred to base her assessment of a young person’s
vulnerability on how he presented during the interview rather than on his
recorded history. She said she asked all young people whether they had any
thoughts of self-harm or suicide. She explained that she did not simply accept
the answer they gave but assessed the non-verbal cues when considering
their level of risk. The Practice Nurse said she had not been trained
specifically in mental health, but relied on her experience as a nurse and her
non-professional experience with teenagers. She said she had been trained
in ACCT procedures and regularly opened ACCT forms as a result of her
assessments during first reception health screens. She said:
“I’m assessing them from the minute they walk through the door,
their body language, their eye contact, how they react in
conversation to me to the answers to the question, whether
they’re laughing, whether they’re confident about it, whether
they’re blasé about it.”
49
148. The Practice Nurse did not open an ACCT document for the boy but did refer
him for a mental health assessment. She told my investigators:
“Because I felt he was happy at the time you know, his body
language and his eye contact was good, his answers that were
given me told me that [self-harm] was mostly done when he had
been drinking. So that I knew that he wasn’t going to be drinking,
you know, so there were those issues but because he had self-
harmed in the past, I wasn’t happy just to say that’s it, I wanted
him further assessed and that’s why I referred him to the in-reach
team.”
149. The Practice Nurse made the following entry in the boy’s medical record after
she had completed his health screen:
50
History No thoughts of deliberate self-harm
Examination Alcohol consumption the week before custody, 50
units this week.
Social Alcohol consumption, 50 units/week
Moderate smoker, 10 to 19 cigarettes per day
Charged with crime affray/recall
Additional Cocaine type drug dependence
Comment Discussed self-harm issues and says mostly done
when drinking. However, has self-harmed in the
past in YO institution. Maintaining good eye
contact and appears good in mood. Discussed
referral to in-reach team and happy for this to be
done. REFERRED.
Additional I do smoke
21 mg of Niquitin CQ
Ido not want NRT [Nicotine Replacement
Therapy]
Psychiatrist involved self-harmer
History of deliberate self-harm within prison 7
months ago. Cut self
Healthcare services information leaflet given
Planned action – no immediate action required
Fit for normal location, work and any cell
occupancy
Patient registered GMS1
Convicted - sentenced 4 months
First reception health screen done
Juvenile
150. The following comment was made by a caseworker, in the boy’s core record
on the day of his arrival:
i. “Previous self-harm
ii. Potential self-harmer (threats)
iii. Mental health concerns
iv. Substance misuse.”
151. The caseworker also passed this information to Buttermere Unit (where it was
written into the staff observation book), the healthcare centre, chaplaincy, the
resettlement department and the safeguards department.
Cell sharing risk assessment
152. The Casework Officer and the Practice Nurse also carried out the boy’s cell
sharing risk assessment. The Casework Officer completed section two of the
form. The following table details the questions he was asked and the answers
from the boy that were recorded (the comments in italics are mine):
Questions Answers
Does the prisoner have any previous No
convictions for the following and is the
current offence any of the following:
murder, sex offence, kidnapping,
manslaughter, false imprisonment,
GBH, ABH, stalking, arson,
51
aggravated burglary, possession of a
firearm with intent to endanger life or
resisting arrest?
Has the prisoner been convicted of a No (In fact, the boy’s Asset form showed that he
racist or homophobic crime? had been convicted of an offence of racially insulting
behaviour committed on 8 June 2007.)
Has the prisoner ever abused alcohol No (In fact, the boy had been a prolific user of
or drugs? alcohol and had often taken drugs.)
Is the prisoner currently dependent on No (In fact, his Asset form, which the Casework
alcohol or drugs? Officer said was available when the cell share risk
assessment was completed, indicated that the boy
considered substance misuse, including alcohol, to
be an essential factor in his lifestyle.)
Does the prisoner have an open No
ACCT?
Is there any evidence of the prisoner No (In fact the boy had been subject to ACCT
having a previous ACCT? procedures at Thorn Cross but no details of that
were available to Lancaster Farms.)
Does the prisoner have any concerns Yes. Would prefer single cell.
about sharing a cell?
Does the prisoner describe himself as Yes
aperson that gets angry/frustrated
quickly?
Based on your knowledge of the High (In other words, there is a clear indication of a
prisoner from the information high level of risk that the prisoner might assault his
available, please rate the risk of harm cell mate.)
to others:
High
medium
low
153. At interview, the Casework Officer did not clarify why he recorded that the boy
presented a high risk of harming others despite the other answers shown
above.
154. The Practice Nurse completed the healthcare information at section three of
the form. The following table records the details:
Questions Answers
During reception screening have you Insufficient evidence to give opinion
obtained any evidence that this
prisoner may be at risk of harming
others (due to various factors listed on
the form)?
Is there any evidence on the PER No response recorded to any of these questions
form or any accompanying
documentation that this prisoner may
be at risk of harming others because
of :
current acute psychosis
extremely disturbed behaviour
agitation or aggression
previous behaviour
Based on your knowledge of the Medium (In other words, no immediate risk but
prisoner from the information situation will need to be reviewed regularly.)
available, please rate the risk of harm
to others:
52
high
medium
low
Following the self-harm assessment, No
have any concerns been raised?
155. The Casework Officer told my investigators that on Buttermere Unit – the
induction wing for young people – there was shared accommodation in cells
one to five (where there were bunk beds) and cells 25 to 30, each of which
was the equivalent of two cells. The Casework Officer explained that these
cells were normally allocated to young people who were orderlies. All other
cells in Buttermere Unit were single cells. When asked if the cell sharing risk
assessment process was therefore academic, the Casework Officer said:
“Yes, I mean because what happens is there will be certain
elements down to population pressures as well of course, I mean
we don’t like to double juveniles up obviously with the event of the
Mubarek enquiry and things like that. Obviously these things are
looked into deeper now and that’s one of the reasons why we
don’t double these lads up straight away until they’ve been
properly assessed and we can check them over a period of time
before they do get doubled up. “
(The inquiry to which the Casework Officer referred was the public inquiry that
followed the racially motivated murder of Mr Zahid Mubarek by his cellmate at
HMYOI Feltham in March 2000. This led to the introduction of the cell sharing
risk assessment process that is now a mandatory element of the reception
procedures in every closed Prison Service establishment. Under PSO 2750 –
Violence Reduction Strategy – all closed prisons must ensure that a cell.
Sharing risk assessment is carried out for all prisoners. This provides a risk
assessment for accommodation and occasions where space may be shared,
such as in the healthcare centre or when with a peer supporter. For prisons
without shared accommodation, the cell sharing risk assessment allows
informed decision making about the management of potentially violent, racist or
homophobic behaviour.)
156. The Practice Nurse described the cell sharing risk assessment as a formality.
She said, “... from a first reception point of view, [the cell sharing risk
assessment] is a bit of a yeah sign here, you know, because they are going to
a single cell.”
157. The boy’s risk assessment concluded that he should be allocated to a single
cell.
First night needs assessment and Induction
158. The unit officer conducted the boy’s first night needs assessment. Included in
the documents presented to my investigation team was an extract from the
boy’s core record that carried the notation, ‘Cell Sharing Risk Assessments’.
Underneath this notation, the following further information was shown:
53
“1st Night Alert
“Previous self-harm/suicide attempts
History of trauma/abuse
Mental health concerns
Substance misuse
[Details withheld]
Father died.”
159. As the entry was not signed it is not clear who made it or whether it was linked
to the first night needs assessment documents.
160. My investigators formally interviewed the unit officer and, shortly afterwards,
talked to him informally. During the latter discussion, the unit officer said he
thought about opening an ACCT document but concluded it was not
necessary. He added that if he had opened one it was likely that the
document would have been closed the next day as “that was often the case”.
The unit officer felt that this practice was due in part to the high number of
ACCT documents being opened such that staff could not manage the volume.
161. The unit officer ensured that all elements of the first night needs
assessment form were completed. The boy was told who his
personal officer was. The boy was given two reception letters and, at
about 10.00pm, he took advantage of a free two minute telephone
call. The rules of the unit were explained and the boy signed Pin-
phone, in-cell television and behaviour compacts. He was given an
advanced canteen pack containing sweets. Although the boy
smoked, he was not allowed a smoker’s pack because of his age.
The boy was placed on his own in cell 47.
162. The unit officer made the following entry in the boy’s core prison record that
evening:
“Received onto Buttermere 2. Is on licence recall and is 15 years
old. Has been on Local Authority Care previously. He currently
lives with his aunty in St Helens. He does use drugs on the out
and drinks alcohol. Very polite during interview.”
163. The next day (9 November), the Senior Officer completed the First Night
Needs Assessment Managers checklist. At interview, the Senior Officer
confirmed that vulnerability issues had been raised and support was identified
as necessary. The Senior Officer told my investigator he had seen the cell
sharing risk assessment concerning the boy’s self-harm history and had made
a point of speaking to the boy personally. He said that, after he had done so,
he felt there was no need to place the boy on ACCT monitoring. The earlier
assessment that the boy was to remain in a single cell was confirmed.
Information to next of kin
54
164. Governors are also required to make arrangements to provide each young
person’s next of kin or other appropriate person with information about
visiting, personal property, pastoral care, and the sentence planning, review
and resettlement arrangements, within 48 hours of their arrival. The family
contact log presented to my investigation team records that an initial attempt
to contact the boy’s aunt was made on 15 November in order to discuss the
possibility of putting the boy in touch with his mother. However, on that day
nobody answered the telephone. A successful attempt was made four days
later.
165. On 9 November, the boy visited the gymnasium and underwent a PE
assessment. During the initial interview with the PE Officer, the boy
expressed an interest in kayaking. A physical activity readiness questionnaire
was also completed. This comprised a simple yes/no response to ten general
questions. There were no further comments made on the assessment form.
The boy toured the gym and then returned to Buttermere Unit. The boy did
not visit the gym to participate in any activity on any other occasion.
166. A member of the family links team also met the boy on 9 November as part of
the induction process and opened a file on him. A note was made in the file
to the effect that the boy’s YOT worker, was to be contacted. However, the
investigation found no evidence to confirm that such contact was made.
Food rejection
167. An entry made on the boy’s history sheet by a Prison Officer on 10 November
records that the boy declined food all that day and during the previous
evening. The boy told the Prison Officer he was not hungry and often went
without food at home. However, he said he was taking water. The Prison
Officer recorded that he was due to be on duty the following day and would
monitor him then. When the Prison Officer returned to duty the next day, he
noted in the boy’s record that he had taken his breakfast.
Secondary healthcare assessment
168. A Healthcare Assistant carried out a routine secondary healthcare
assessment on the boy on 11 November. The Healthcare Assistant entered
the following details of her assessment in the boy’s medical record:
History History of deliberate self-harm cut up six months ago. OK at moment
Examination On examination: height 177.8cm
On examination: weight 62kg
Body mass index: 19.61
Social Had a discussion with patient, discussed/given information regarding
health
Additional Referral to vaccination clinic
Parental support – expects family support and visits
Patient understands how to access healthcare here at Lancaster
Farms
Well man monitor, check done
Able to read
Able to write
55
Juvenile
First contact with Substance Misuse Team
169. On 12 November a member of the Substance Misuse Team met the boy to
conduct an initial assessment of his substance misuse. After the boy’s death,
the member of the Substance Misuse Team submitted a statement to the
police in which he said he did not think the boy was vulnerable when he first
met him. He said that, if he had thought otherwise, he would have returned
the boy to healthcare for further assessment. Following his initial interview
with the boy, the member of the Substance Misuse Team was formally
allocated to him as his substance misuse caseworker. He set a target date of
22 November to complete a full assessment.
Psychological needs assessment
170. The boy’s psychological needs were assessed on 13 November as part of his
induction programme. The report of that assessment, conducted by a
member of staff in the prison’s psychology department, was not signed. The
following table shows the principal findings and recommendations:
Subject Comments
Emotional behaviour score (EBS) This assessment is used to assess adolescent and
emotional coping strategies. The boy had scored
high on malevolent aggression suggesting he may
have poor behavioural conduct.
The boy has scored low on social self-esteem
suggesting he may experience emotional difficulties
and may need extra support from staff. This may
be reflected in not adjusting well in custody.
Hopelessness levels This assessment is related to suicide ideation. It
provides an indication as to feelings regarding self,
the future and the world. The boy’s score suggests
that he is feeling moderately hopeless at this time.
Custodial adjustment This assessment measures the degree of
adjustment to the custodial environment. The boy’s
scores suggest he is adjusting to the environment in
the way we would expect at this time.
Recommendations Due to the score the boy obtained on the Beck’s
Hopelessness Scale (BHS), staff should be aware
that he might need extra support. He is currently
experiencing some negative feeling towards
himself, the future and the world.
Due to the score the boy obtained on the social
esteem measure, staff should be aware that he may
have a low opinion of himself, especially in social
situations, for example, during association.
Due to the score the boy obtained on malevolent
aggression, it is recommended that he should be
referred for the anger management course.
171. The Beck’s Hopelessness Scale is a means by which a young person’s
feeling about himself, the world, and the future can be measured. A note
issued by the Psychology Department about the use of the scale contains the
following instructions:
56
“Please note that you must make an entry into the young person’s
wing file and the wing observation book about the findings. You
must also contact Safeguards and Healthcare in person and tell
them of any concerns you have regarding the young person.”
(Emphasis in original.)
(The term “Safeguards” refers to the Safeguarding Department. The term
“Safeguarding” is defined as the process of protecting the safety and welfare
of young people.)
172. My investigators were told that those young people whose score on the
subject of hopelessness is high (i.e. over 14) are considered to be vulnerable
to suicidal ideation. Their scores are therefore re-checked immediately, with
the young person present. If the score is confirmed, appropriate action must
be taken, including consideration of opening an ACCT form. A copy of the
assessment report must be passed in person to the caseworking office, the
education department, the healthcare centre, and the unit in which the young
person is resident.
173. The boy’s hopelessness score was less than 14 and was therefore
considered to be moderate. My investigators were told that, in the case of
anyone with a score of 14 or below, a copy of the assessment report must be
passed through the internal mail system to the same departments as for a
high score. The investigation found no evidence to clarify which of those
departments received a copy of the boy’s assessment report.
174. The boy’s psychological needs assessment clashed with an appointment
made earlier for a representative from the mental health in-reach team to see
him. Consequently, the mental health assessment was re-scheduled for the
following day.
Mental health assessment
175. On 14 November, a third year social work student on a six month placement
from Lancaster University and a member of the mental health in-reach team
at Lancaster Farms, carried out an assessment of the boy’s mental health.
This was in response to the referral made by the Practice Nurse during the
boy’s health screen on 8 November. At interview, the social work student told
my investigators she was unqualified and confirmed that this was the first time
she had worked in a prison. However, she explained that she had worked
with young people in other settings and therefore did not feel disadvantaged
in her work at Lancaster Farms. The social work student was supervised by
the in-reach team manager and was only one month from completion of her
placement.
176. The social work student told my investigators that the boy said he felt alright
and had no thoughts of self-harm. She said:
57
“I had read his family background and the Asset form when I
initially went to see him. [The Asset form was in the boy’s
medical record, the only file available to her.] When he came out
[for the interview] he did quite surprise me because he was happy
and bubbly. I was expecting him to be a lot different. I expected
it to be a harder session than it was. He did talk freely about
things. I asked him how he was feeling about being inside, about
being in custody and he said he felt fine. He talked about other
previous custody and how he was feeling here. He said he didn’t
have any worries about people in here. He talked about his self-
harm and he told me he felt it was more around when he was
stressed. We talked about how he feels stressed and when he
doesn’t feel stressed.”
177. When asked whether she thought the boy was putting on an act of bravado,
the social work student said, “No, I didn’t feel he was because he was
laughing and joking and obviously I do realise that people change”.
178. The social work student confirmed that she did not think the boy was “that
much at risk of self-harm at that point”. The boy told her he was not
interested in taking part in education classes, using the gym, or mixing with
other young people during association periods in his unit. He said he had
been visited by a representative of the Child and Adolescent Mental Health
Service in St Helens during the previous two years but did not know why. He
told the social work student he had been in Red Bank, Newton Aycliffe Secure
Children’s Home and in HMYOI Thorn Cross. The boy said he did not know
where his mother was and had lived with his uncle and aunt for the previous
seven years. He told the social work student he used to go to school but was
frequently sent home. He said his friendship group consisted of young boys
who, like him, had been in custody. He also said he had few interests beyond
getting drunk. When the social work student put to him that it was possible to
have fun whilst sober, he replied, “If you’re not pissed, everything is crap.” In
interview, she said the boy was open about the extent of his drinking habits.
He said he was used to drinking “Taboo” and vodka at weekends using
money given him by his uncle and aunt. He also admitted using ecstasy,
cannabis and, occasionally, cocaine. The boy added that he had been in
hospital on a number of occasions after taking drugs and alcohol. He said
that, on one occasion, he was admitted to hospital after cutting his arms.
179. The social work student concluded that the boy appeared clean, happy,
relaxed and able to communicate, albeit with some prompting. She thought
the boy had a “fine” perception and good orientation. She made a note of the
fact that the boy had self-harmed a month earlier but added that this was not
in the context of wanting to kill himself. Rather, she said, it was “just about
stress”. The social work student also recorded that the boy was not currently
subject to self-harm monitoring procedures. She told my investigators that
she had no reason to invoke ACCT procedures herself.
180. The boy tried to explain to the social work student why he did not want to take
part in association or activities such as PE and education. He said,
58
“Sometimes I like being on my own and if I want to come out then I will come
out.” The social work student said she “extended offers to the boy to go the
gym and things like that”. She said she asked the boy whether he was
frightened of other people. He told her he was not. She wrote on the
assessment form that her plan was to see the boy again the following week
and to keep the case open so that she could “approach self-harm”. At
interview, she explained that in fact she wanted to see the boy again on 27
November and so she entered this date in her diary. However, she told my
investigators she could not meet that appointment because an earlier
appointment with another client had taken longer than planned. The social
work student said she could not see the boy the next day because it was a
staff training day, a consequence of which was that all young people had to
remain in their cells. The social work student therefore planned to see the
boy on 29 November.
Contact with the boy’s aunt
181. The Lancashire Police provided my investigation team with transcripts of
telephone calls the boy made to his aunt on 11 and 15 November 2007. The
transcripts were compiled by a member of staff in the security department at
Lancaster Farms. Although the calls were recorded, they were not
simultaneously monitored by staff as there was no security or other reasons
for doing so. The police also provided seven original undated letters written
by the boy and sent to his aunt and uncle when he was at Lancaster Farms.
They were obtained from the boy’s family during the course of the police
investigation into his death.
182. In the first of his two telephone calls, the boy told his aunt that he hated being
at Lancaster Farms and wanted a transfer. He said he was not being bullied,
explaining that he could not be bullied because he was locked in his cell all
day. He told his aunt he had been asked if he wanted “to go in a room with
someone” and he had said he did not. During the call the boy also spoke to
his aunt’s daughter. He told her he had not eaten anything since his arrival at
Lancaster Farms but had eaten his breakfast that morning. He said the meal
was “disgusting”. Although the transcriber had difficulty hearing every word of
the boy’s conversation, it seems that at one stage he told his aunt or his sister
that he had sent a letter to them and that he had cried as he wrote it. His
aunt - whom he called “mum” - told him it would not be long before he was
home.
183. In the second call, the boy asked his aunt when she was intending to visit
him. She told him she had not yet received a visiting order (VO). (A visiting
order is a means by which potential visitors are identified / authenticated and
the visit booked.) The boy told his aunt his DTO meeting was due on 5
December. His aunt said she thought it was due on 4 December but the boy
said he had been told that day that it was on 5 December. The boy asked his
aunt to ring his YOT worker about the question of arranging a transfer. He
talked about the length of time he spent in his cell and about his views
regarding the standard of food. He specifically mentioned that he did not like
eating in front of so many other young people and told his aunt it “did his head
59
in”. When the boy’s aunt asked him if he was sleeping alright, he told her he
woke up every night at about 4.00am and switched his television on. He also
spoke about how cold his cell was and how hard his bed was. The boy told
his aunt he would rather be at Red Bank.
184. The undated letters given to my investigators also provide an insight into how
badly the boy felt about being at Lancaster Farms. The contents would not
have been known to staff as they were not required to read his mail. In each
letter he repeated what he had said on the telephone. He explained that he
only ate in his cell because he did not like eating in the company of a large
number of people. He also spoke of his fear of being arrested immediately
upon his release for an outstanding charge. The boy expressed his desire to
be transferred. In one letter he wrote:
“We keep our [unreadable word] in our pad [cell]. I just keep
looking at it and thinking should I do it but I don’t know why. I
think I am just scared of being in here. I will probably end up
doing it if I’m in here any longer and don’t get a transfer. It’s
doing my head in. When are you coming to see me? Please
make it soon.”
185. In two of his letters, the boy wrote that he was going to be tested for ADHD
(Attention Deficit Hyperactivity Disorder). However, there is no evidence in
his medical record to verify this. In another he wrote that he “needed beer
really badly” and thought he was “an alky”. In yet another, he wrote:
“To mum and dad, what are you up to? It’s proper s**t being
inside again. Can’t wait to get out. Counting down the days. Not
been eating. I hate it in here mum. Will you ask the second YOT
worker to give me a transfer please. It’s doing my head in being
in here. I can’t hack it. Didn’t think it would be like this. The
room is horrible. It’s freezing and am in it nearly all day. I just
keep thinking of doing something stupid but just don’t see the
point. I need a cig really bad. When I got up on that first morning
being here and I had to got to breakfast I got it and then you just
don’t know where to sit. There are so many people on my wing.
Just wish I had a way out of here.”
186. On 15 November, a member of the family links team at Lancaster Farms rang
the boy’s aunt because she wanted to discuss the boy’s contact with his
mother. Unfortunately, there was no reply. On 19 November, she tried again,
this time successfully. She made the following record in the boy’s family
contact log:
“Rang auntie. She tells me she has no details of mum or sister
at all. She has tried ringing mum but there has been no answer.
Uncle has gone to the address but there is no sign of mum living
there. Mum was supposed to be in crown court for the boy in
August but she never turned up and has since not been in
contact with auntie. She tells me she’d love to visit with uncle
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but hasn’t yet received a visiting order. She also told me she is
due for an operation on 27th but would still visit by then.”
187. The next day, the member of the Family Links Team made the following
further note in the boy’s file:
“Spoke to the boy to clarify exactly how/what contact he had in
Red Bank with mum and sister. Whilst in Red Bank, the boy
wrote to mum but never had her address as he sent it through the
social services. He did ring mum but the number is no longer
working and he hasn’t got a new number. The boy had one visit
from mum whilst in Red Bank and visited her once in the
community. The boy has never written to his sister whilst being in
Red Bank. He rang her once but has lost her number since. She
came to visit him with mum in the secure unit. The boy told me
that she and mum lived together whilst he was in Red Bank. The
boy said that he was going to send out a visiting order to auntie
and uncle and did not mention anything about auntie’s operation.
The boy was very talkative and in a good mood.”
188. At interview, the member of the Family Links Team told my investigator:
“As far as I was aware, the boy was convinced his auntie and
uncle wouldn’t visit and this is why I found it a bit strange because
they were very supportive from what I read in the case notes and
also from what I know from the phone conversation. So when I
went back I made a point of telling him, ‘Your auntie would love to
come and visit as well as your uncle.’ He was quite surprised. I
asked him why. He said he just didn’t think they would come. He
said he would send out a visiting order.”
189. The boy’s record of letters and visits show that the only visiting order he sent
out was to his aunt and uncle on 23 November. The visiting order was valid for
28 days from that date.
190. The boy’s record indicates that he received no family visits whilst he was at
Lancaster Farms.
191. The member of the Family Links Team told my investigator that she saw the
boy three or four times. She added that the boy never seemed stressed or
emotional about his lack of contact with his mother. The member of the Family
Links Team said he did not talk to her about transferring from Lancaster Farms.
When my investigator put it to her that the boy had written a letter in which he
described his hatred of the establishment, she said he did not mention this to
her. The member of the Family Links Team said the boy always smiled when
she saw him, even on the Monday before his death.
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192. The boy’s file records no other contact between the family links office and his
aunt or uncle.
Detention and Training Order (DTO) Plan
193. YJB National Standards require Governors and the Youth Offending Team
(YOT) Manager to ensure that a sentence plan - or DTO plan - is drawn up
within at most ten working days (that is two full weeks) of the date of
reception. Specific, measurable, achievable, realistic and time bounded and
agreed objectives must be set for each individual. Governors, in partnership
with the YOT Manager, must ensure that procedures are in place for the
young person’s progress to be monitored and regularly reviewed with due
account being taken of the young person’s learning style. The DTO planning
meeting should also set out firm arrangements to enable a seamless
transition into the community.
194. The boy’s DTO meeting should have been scheduled to take place on or
before 22 November. On 9 November, a second casework officer had been
detailed to work in the casework office. He had just returned to work following
an operation and was not allowed direct contact with prisoners. At interview,
the second casework officer described his role in the casework office as
“administrative work, involving the input of information about prisoners into the
database and booking DTO planning meetings”. He recalled speaking to the
boy’s YOT worker. He said he initiated contact with her in order to schedule
the DTO planning meeting within the target date. He thought that the second
YOT worker’s pregnancy would prevent her from attending a meeting in a
unit. This meant that the visit had to take place in the legal visits area of the
prison. The second casework officer therefore scheduled the meeting for 4
December, the next available date for a legal visit, but eight working days
after the target date. (At consultation stage, the St Helens Youth Offending
Service pointed out that in fact it was the second YOT worker who initiated the
contact rather than the second casework officer. The YOS also said that
when the second YOT worker was told of the proposed date, she told the
second casework officer that the date fell outside the National Standard.) The
second casework officer did not meet or speak to the boy or his family. This
was the second casework officer’s only involvement in his sentence plan. The
second YOT worker recalled that she was told by the prison that this was the
earliest available date for a DTO initial planning meeting. She said that, if she
had been made aware that her pregnancy had delayed the meeting, she
would have sent a colleague to attend in her place.
195. A second prison officer regularly worked in the casework office. During
interview, she recalled that she was on holiday at the end of October and the
beginning of November. She told my investigators that, “there was a pile of
files to do when I came back and it was just a case of grab one, do it”. On 15
November, the second prison officer found the boy’s casework file and
noticed that his T1:A form - the initial sentence plan - had not been
completed. This assessment and planning form is to be completed by the
staff member from the custodial unit responsible for the co-ordination of the
young person’s training plan, in consultation with the YOT representative and
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prior to the initial planning meeting. The second prison officer went through
the boy’s Asset page by page and copied the Asset score into a sentence
planning tool. She summarised the comments onto a table entitled, “What
factors do you consider should be addressed in the young person’s training
plan?” The second prison officer explained to my investigation team that the
table should be a summary of the Asset and how it relates to the sentence
planning needs of the young person. She identified the boy’s lifestyle,
substance misuse, and thinking and behaviour as requiring the most input.
The last section of the table - “Indicators of vulnerability” - was scored fairly
low, but the second prison officer noted that the boy had previously self-
harmed. The second prison officer did not meet with the boy.
196. Following the assessment of the boy’s needs through Asset, the second
prison officer completed form T:2. This document is used to set out a young
person’s training plan objectives. It was intended to be the starting point for
the boy’s sentence plan, and would have informed discussion at his DTO
initial planning meeting. After she had prepared the table and provisional
training plan, the second prison officer went to see the boy. She told my
investigators:
“ … then I’ll go and see the boy or anybody else and I’ll talk to him
about his actual, how long he’s going to be here for, which is what
I’ve done here, he’s actually said that he’s not going to be on
licence when he gets out and when he’s due for release … And
then we talk about the targets I’ve set him … And I’ve set him the
targets of good behaviour, which is on the [Incentives and Earned
Privilege scheme] positive attitude which is not getting himself into
trouble or in front of the governor for adjudications; substance
misuse which is the four score.”
197. The second prison officer explained that all these targets were generic and
set for every young person, regardless of the T:1A assessment. She said
that, if a young person was not going to be at Lancaster Farms for long, there
were limited courses available to them. She explained that the Young
People’s Enhanced Thinking Skills and Living Skills course was available at
Lancaster Farms. However, as the course lasted nine weeks, the boy would
not have had time to complete it.
198. The boy had no further contact with the casework team. His DTO Initial
Training Planning meeting, scheduled for 4 December, did not of course take
place.
Completion of induction and start of education
199. Induction at Lancaster Farms is designed as a “rolling programme” to be
completed within a week of arrival. The boy started his programme on 9
November. It should therefore have been completed by 15 November. By
then, the boy had only completed about half the modules. The following table
shows which modules were completed, together with dates where available:
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Session Tick Comments
First night assessment Ticked Aware
Chaplain visit 9/11 Seen
Domestic training Ticked Done
Safeguards Blank Blank
Independent Monitoring 13/11 Did not appear
Board
National Youth Advocacy 13/11 Did not appear
Service
Psychology 13/11 Done
Family links Ticked Done
Chaplaincy group visit 9/11 Done
Young People’s governor 14/11 Did not appear
talk
Violence reduction/anti- 21/11 Done
bullying
Race relations 21/11 Done
Use of force Ticked Done
Young People’s Ticked Seen
Substance Misuse Service
(YPSMS)
Thorn Cross information Ticked Done
Healthcare talk Blank Blank
Gym induction 9/11 Done
Induction completion Blank Blank
interview
200. My investigators were told that when young people have completed their
induction programme, they are automatically listed on the Local Inmate
Database System (LIDS) as being unemployed. If they have never been in
custody before, they are expected to attend an ‘introduction to work’ course
that usually runs from Monday to Friday. However, any young people who
have been in custody on a previous occasion could be fast tracked as their
needs assessment would normally have been completed and their
educational needs identified. As the boy had been in custody at Red Bank
and at Thorn Cross, he was fast tracked. My investigators were told that, on
completion of the induction programme, young people could commence the
fast track process on any day of the week by undertaking a test to determine
their learning skills. Classes were then allocated according to their needs.
Their education programme was normally initiated within the next 48 hours.
201. The boy was introduced to the education department on Friday 23 November
– two days after he had undertaken the last of the induction modules he
attended and two weeks after his arrival at Lancaster Farms. On that day, he
was interviewed by his education keyworker who took him through the
enrolment form, the purpose of which was to help her gain an understanding
of the boy’s self perception rather than to create a profile of his needs. The
boy told the education keyworker that he had emotional and behavioural
difficulties. She therefore referred him to a special needs coordinator. As she
was due to finish work early that day, the education keyworker was unable to
complete the boy’s learning plan. Her colleague therefore assumed that
responsibility.
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202. The education keyworker later liaised with a special needs coordinator at
Thorn Cross, who gave her the boy’s educational needs assessment results
over the telephone. However, the boy asked the education keyworker if he
could re-sit his numeracy and literacy tests again as he felt he had not applied
himself properly at Thorn Cross. He told the education keyworker he wanted
to achieve a better assessment score so that he could apply himself anew to
his education. The education keyworker told my investigator she would also
have checked with the boy’s school whether he needed any special needs
support.
203. In interview, the education keyworker described the boy as being very polite
during the interview. She said she was left with no cause for concern for him.
The only other time he attended the education centre was on Tuesday 27
November. On that day, he was interviewed by a Connexions Personal
Advisor. The day after the boy died, the Personal Advisor submitted a
memorandum to the Governor about that interview.
204. I repeat relevant extracts from her memorandum below:
“As a Connexions Personal Advisor working specifically with the Merseyside
juveniles, I saw the boy in juvenile education on 27 November 2007 for
approximately 20 - 30 minutes. As the boy was fast tracked into education, I
had not seen him during the induction period. I therefore explained my role
and how I would anticipate helping support his educational needs through his
sentence and in preparing him for his return to the community in December.
“Although the database is for factual information and we would not normally
record value judgements on young people’s moods or temperament,
anecdotally it is my personal feeling that the boy was fully engaged in our
conversation. I feel it is important to convey that the boy was friendly, happy
and smiley, so much so that I commented to him about his ‘catching smile’.
We concluded the interview by agreeing that I would contact his YOT worker
and be back to see him after his initial DTO meeting to discuss education
further.”
205. The Personal Advisor told my investigators this was the only time she met the
boy. She knew the boy had been inducted in the department but had not
been in a classroom before. The Personal Advisor remembered that the only
concern she had about the boy during her interview with him was that he did
not once mention his family. Otherwise, the boy gave her no cause for
concern. He did not mention anything about bullying or about having any
difficulty sleeping or eating. The Personal Advisor said he was looking
forward to going home, although not to education. He was especially looking
forward to being at home for Christmas.
Contact with Personal Officer
206. The boy was allocated his Personal Officer on his first night at Lancaster
Farms. However, the Personal Officer was on leave at the time and was due to
complete a period of night duty when he returned.
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207. The boy’s record shows that the first entry about him by the Personal Officer
was made three weeks later on Sunday 25 November, his first day in the unit
after his period of leave and night duty. The Personal Officer told my
investigators he looked at the roll board in the office in Buttermere Unit and saw
that he had been allocated to the boy as his Personal Officer. He therefore
went to see him. He confirmed that there was no cover scheme whereby
somebody else could stand in for him during any absences. However, he
pointed out that all officers were there to support the young people in their
charge. The Personal Officer remembered that the boy talked about his time at
Thorn Cross, but that he did not mention any problems he had there.
208. The Personal Officer said he was told by another member of staff that the boy
was not eating much. When he asked the boy about it, he explained that his
loss of appetite was due to the substance misuse treatment he had
undergone in the community. The Personal Officer said the boy did not raise
any concerns about mealtimes and interacting with other young people. The
Personal Officer said that various documents about the young people, such
as the record of their first night interview, security information, ACCT forms
and Asset forms, were kept in or near the unit office. The Personal Officer
stressed that young persons’ casework files were stored in the casework
office in a separate part of the building. He said he did not see any of the
boy’s documents when he saw him on 25 November, and neither did he have
any prior knowledge of the boy’s experience of HMYOI Thorn Cross or Red
Bank.
209. My investigators asked the Personal Officer if he was aware of the anxieties
the boy had expressed in his letters and telephone calls to his aunt. He said
he was not. The Personal Officer said that, if he had known that the boy was
scared of eating with others, he would have tried to find other young people
from the same area to support him. He said:
“When I spoke to the boy about why he preferred to stay in his
own cell and not eat out, he said it was because he didn’t like to
mix with young people because he didn’t want to start trouble. He
wanted to do his time here quietly without getting into trouble. I
was quite happy with the explanation because of the short time he
was going to be in custody - the length of the recall. I believe he
could pass his time easily.”
210. The boy’s aunt and uncle told one of my investigators that the boy made it clear
during some of his telephone conversations that he stayed in his cell all day
watching television and that he did not sleep well. When asked about this, the
Personal Officer indicated that there were times when there were gaps between
the induction and education programmes that were not always filled with any
activities. It was also put to the Personal Officer that, in his letters, the boy
repeatedly asked to be transferred out of Lancaster Farms. The Personal
Officer said he had no knowledge of this. According to the Personal Officer, the
boy was happy to stay where he was. The boy’s aunt and uncle also brought to
the attention of my investigators that the boy walked with a feminine gait which
66
might have made him a natural target for bullying. My investigator asked the
Personal Officer if he had ever noticed the boy’s walking and he said he had
not.
211. The Personal Officer told my investigator that when he entered the boy’s cell to
talk to him he was careful to appear relaxed. The Personal Officer thought the
boy engaged well with him and seemed to enjoy having someone to talk to.
The Personal Officer said:
“Even though it was five minutes, he welcomed the chance to
speak to somebody even though he was putting on a brave face,
engage with someone who wasn’t a person in custody.”
Second contact with Substance Misuse Team
212. On 26 November, a member of the Substance Misuse Team met the boy, as
planned, in order to agree a substance misuse care plan. The member of the
Substance Misuse Team told my investigators he took the boy into his own
department away from Buttermere Unit for the interview, during which the boy
spoke about his background. The member of the Substance Misuse Team
considered that the boy needed help to address his abuse of alcohol and
established a care plan to help him control his alcohol and drug misuse, and
to improve his family links. The boy made no reference to feeling depressed
during the interview.
213. In his record of the assessment, the member of the Substance Misuse Team
wrote that the boy had no objections to his aunt and uncle being contacted
about his care plan, the details of which can be seen in the following table:
Issues Desired Interventions Who was Review dates
outcomes responsible
Alcohol Reduce One to work Substance 15 December 2007
and links harm Ato Z DVD misuse worker
to re- Supply info and the boy
offending
Poly use Reduce Ditto Ditto Ditto
harm
Family Improve Family links Substance 28 November 2007
links family misuse worker Completed
relations
214. At interview, the member of the Substance Misuse Team said that he did not
have sight of the boy’s custodial record for the period he was in Red Bank
before seeing him on 11 and 26 November. Thus, he was unaware whether a
sentence plan had been drawn up for the period of the DTO.
Interview with Connexions personal advisor
215. On 27 November, only two days before the boy died, he was interviewed by
the Personal Advisor in the education department. At interview, the Personal
Advisor described her role as follows:
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“I work in a specific role with young people returning to the
Greater Merseyside area. My main role is looking at education
training and employment for when they return back to their home
area. We also cover every single other issue that may come up
and will liaise with other agencies and signpost young people to
different agencies and advocate on their behalf to YOT workers,
social workers, basically anything. If there’s a barrier to them
engaging in employment, education or training, we will work with
them.”
216. The Personal Advisor confirmed that she interviewed the boy because he was
from the Merseyside area. She told my investigators:
“I only met the boy once for about 25 minutes. It was just an
initial interview to get to know him a little bit – build a sort of
rapport and see what he actually wanted to do when he was
going home. He was very positive and happy. I even actually
commented to him, ‘you smile a lot, it’s catching’. He was very
jokey. We didn’t talk about family issues in a lot of detail. I just
knew he was living with auntie and uncle and he was happy to go
back there. He was actually looking forward to going home
although not to go into education. He didn’t do that.”
217. The Personal Advisor said the boy told her he wanted to continue doing what
he had been doing before he went into custody. She said the boy had
mentioned that he wanted to sell drugs. She recalled noticing that the boy did
not mention his mother or father during the interview, but in all other respects
the boy gave her no cause for concern. He was looking forward to being
released in time to be home for Christmas. The Personal Advisor recounted
how the boy had talked about his plans for the future. As far as she knew, he
was not having any difficulty sleeping or eating and he did not seem to have
been bullied.
Transfer to Windermere Unit
218. As the boy’s induction period was deemed to have been completed, his time
in Buttermere 2 Unit had come to an end. Arrangements were therefore
made to transfer him to Windermere Unit on 28 November.
219. During the previous day, the boy had spoken to another young person who
later gave a statement to the police in which he said that the boy had told him
he would refuse to move from the unit. The young person said the boy
generally stayed in his cell for dining and association but came out to shower
and use the telephone. When he had asked the boy why he stayed in his cell,
the boy replied that it was because he was scared of being bullied. He never
saw the boy speaking to other young people and he said the boy felt scared
and intimidated. They had discussed being in Red Bank and agreed that
moving to Lancaster Farms would have been a major culture shock for the
boy. The young person concerned said that he nevertheless did not think the
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boy had actually been bullied. He also said he did not think the boy had ever
spoken to staff about his fears. There is no evidence that the young person
concerned told staff what the boy had said.
220. The boy moved to Windermere 2 Unit at about 3.00pm on 28 November. As
this was a staff training day, all young people throughout the entire
establishment were required to remain in their cells until the evening period
when association could resume. However, a third prison officer was available
to look after the boy when he moved into Windermere Unit. At interview, the
third prison officer explained the circumstances of the boy’s transfer. He said:
“There was a lock down, it was a Wednesday. I had heard that
we may get one or two people on. We only had two empty cells
so I checked them out and one had previously been smashed
which was cell 44 but had been repaired. But I noticed that it
smelt a little of urine so I opened the windows and left the door
open for a couple of hours. Then, just after half past three, an
officer from Buttermere arrived with two trainees I wasn’t
expecting – I thought they were coming on Thursday. Their cells
had been allocated to them by other staff who were in the unit.
“They arrived. I came over from Windermere 1 and the staff said,
‘brought two’ and I said, ‘I thought they were to come tomorrow’. I
went out to see them and the officer from Buttermere. I said, ‘Well
I have got one good cell and one that is a bit smelly. I am not too
pleased that you have brought them over.’ He said, ‘Well it’s up
to you. You know I can take them back or stay.’ I spoke to a
young man I found later on to be called the boy, and I explained
the situation to him that the cell had earlier been smashed but
repaired but there was still a little bit of a smell of urine in there.
So I said he could either go back to Buttermere or maybe come
over the following day or they could come and have a look at the
cell with me. So the boy agreed to come into the cell with the
officer from Bettermere and he said it wasn’t too bad and he
agreed to stay.
“He was a nice young man. He was very polite. He went into the
cell, said it wasn’t too bad. I said I will change the mattress. I got
him a brand new mattress. I said you can brush and mop it out
which he did. He then asked me if he could have a change of
clothing because he only had one set of clothes with him that he
was wearing.
“I shouted down to our laundry orderly and I said, ‘Can you take
this lad and sort him out with some clothes?’ So he went down
and came back with some clothes a short while later.”
221. The boy’s cell was at the end of a row of cells on the first floor. It was a single
cell and contained sanitary facilities. It was fitted with a wooden cupboard, a
bed and a chair. As with all other cells, the security of the cell window was
69
reinforced by bars. The third prison officer told my investigator he did not lock
the boy into his cell. When asked if there was anything about the boy’s
demeanour that caused him to be concerned, the third prison officer said, “Not
at all. He was very polite. He had good eye contact.” The third prison officer
was not sure if the boy had any toiletries with him at the time.
222. At about 4.00pm, the boy was given a television set for use in his cell. At
about 4.30pm, a fourth prison officer gave the boy some cleaning materials.
At 4.44pm a fifth prison officer unlocked the boy’s cell door so that he could
collect his tea meal. In interview, the third prison officer remembered seeing
the boy at the hotplate. He said the boy seemed fine as he collected his
meal. The third prison officer did not see other young people talking to the
boy at the time. He said it was normal for officers to listen to what was being
said by or to new arrivals in the unit. The third prison officer confirmed that
the boy returned to his cell to eat his meal. This, he said, was usual on days
when there was a lock down (i.e. a period when all young people have to be
kept locked in their cells) for staff training. Otherwise, most young people ate
their meals in association with each other.
223. The investigation found that the association period scheduled for that evening
did not take place because officers from Windermere Unit had to be re-
deployed to Buttermere to allow association in that unit.
224. Shortly before 8.00pm, the third prison officer issued hot water and biscuits to
each young person in the unit. At interview, the third prison officer explained
what happened when he reached the boy’s cell. He said:
“I got to cell 44. I offered the boy hot water which I think he
declined. I think I gave him an extra biscuit because we had a
few extra biscuits left. And I spoke to him. I asked him how the
cell was because an officer had given him an air freshener. She
had asked me previously if he could borrow this. He shouldn’t
have had it but I said it won’t hurt. I asked him how the cell was
and he said, ‘It’s a lot better, it’s not too bad.’ He said, ‘I just
spray it occasionally.’ The last thing I actually said to him was
that I was on at half seven in the morning and, if it hadn’t
improved, then I would look into getting him another cell or move
him to another unit.”
225. The third prison officer thought the boy was otherwise alright. He told my
investigator that earlier that evening, at about 7.20pm, he heard some shouting
coming from the upstairs landing (the same landing as the boy). He said he
therefore went upstairs and spoke to three young people who were shouting at
one particular young person – not the boy – who they were instructing to smash
his cell. The victim of this taunting was three cells away from that occupied by
the boy. The third prison officer confirmed that he heard nobody shouting at
the boy. He went off duty just before 9.00pm.
226. The third prison officer said that shouting through the cell windows had been a
problem at Lancaster Farms. However, he thought that matters had improved
70
because staff were now authorised to block the windows in the cells occupied
by the perpetrators. He explained that windows could be blocked by placing
wooden blocks between the windows and the bars so that the windows could
not be opened. This, he said, had the effect of sound-proofing the cell. The
third prison officer also explained that staff were authorised to confront
perpetrators and, where necessary, impose penalties (such as the temporary
removal of television sets) upon the individuals concerned. (I have not
investigated the question of such penalties further, and for that reason have
made no formal recommendation. I understand their purpose. However,
informal ‘punishments’ are not permitted under the Prison Rules and the
Governor and Area Manager will wish to review the practice to ensure that it is
properly authorised.)
227. My investigators also interviewed the Principal Officer, the manager of
Windermere Unit. They wanted to hear her views about the boy’s transfer into
Windermere as well as the wider regime and cultural issues in relation to the
unit.
228. The Principal Officer confirmed that she was aware that the boy’s cell had
been damaged by another occupant but that it had been repaired. She said
the smell was not of urine but of an adhesive that had been used to repair the
linoleum and the toilet. As to the boy’s morale at the time he arrived in the
unit, the Principal Officer said she personally did not see the boy or speak to
him. However, she described the third prison officer as one of the most
experienced and caring officers in the establishment, who, if necessary, would
voluntarily remain on duty beyond his shift until his responsibilities towards his
charges had been fully met. (I should say that the third prison officer’s
concern for young people shines through in the extracts from his interview
with my investigator that I have cited above.) The Principal Officer also had
this to say about the boy’s transfer into the wing:
“It was a lock down day right across the prison. There was
several of the Windermere staff loaned out to Buttermere for the
evening. It was quite clear that there was going to be no
association on Windermere 2 that evening, so it meant that the
young boy came onto the wing while it was a lock down training
day. So he would have had no interaction with other lads, apart
from the serving of the tea and I don’t really know why he had to
be moved on to the unit that day. Coming on to the unit with no
association that evening would have been maybe another
worrying factor to him, I don’t know.”
229. When my investigator put to the Principal Officer the suggestion that, had the
boy remained on Buttermere Unit that day, he would not have had association
there either because it was a staff training day, the Principal Officer said,
“That is not correct because there were three staff loaned out to Buttermere
staff for the evening association period.” The Principal Officer emphasised
that the fact that 28 November was a staff training day was not the cause of
the loss of the evening association period in Windermere Unit. It was, she
71
said, solely because three of her staff were re-deployed to Buttermere in order
to allow association to take place there.
230. The Principal Officer told my investigator:
“I didn’t know him [the boy] at all. However, he would not have
known when he came on the wing that there was no association
that evening because that could have changed. For example, if
certain staff had returned from sick leave that afternoon that could
have changed the whole thing. That’s why the lads would not
have been told.
“On the day the boy came onto the unit, had there been
association and had the boy not come out of his cell, I can
guarantee that the third prison officer would have been in that
room, sitting on the boy’s bed and talking to him. The third prison
officer has a son of his own and he has so much time for these
young lads, it is unbelievable. There’s a lot of good quality staff
on this wing and they go that extra mile with the young lads, and
in return they are rewarded with respect.”
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Events during the night of 28/29 November
231. On duty on Windermere Unit during the night of 28-29 November was a sixth
prison officer and an Operational Support Grade (OSG). Both arrived on the
wing to start their shift at around 8.30pm. They told my investigators they
received a verbal handover from the staff who had worked the evening shift.
The sixth prison officer said he was told that “everything was okay, nothing
untoward had happened”. He also checked the wing observation book, and
saw an entry that there was a new 15 year old on the wing.
232. At around 8.40pm, the sixth prison officer and the OSG carried out the last roll
check (the counting of young people) of the day. It was the sixth prison officer
who went to the boy’s cell. He asked the boy if he was alright. The boy said
he was “fine” and so the sixth prison officer moved to the next cell. Despite
the fact that the local security strategy instructs staff to complete a further roll
check between 10.30pm and midnight, one was not carried out.
233. The sixth prison officer remarked at interview that Windermere Unit was
slightly noisier than normal that night. He thought this was because of the
lock down that day. He said the young people were more likely to shout to
each other more when they had not seen each other during the day.
234. The night staff were required to deal with two specific incidents on
Windermere in the first hours of their shift. At around 11.00pm, they attended
cell 23 as the occupant was being noisy. The OSG recalled that the individual
concerned was shouting abuse at staff and also at another young person in
cell 58, with whom he had had an argument the previous evening. At the
time, both a Senior Officer (SO) and an assistant night Orderly Officer were
on the wing as part of their rounds. As Orderly Officer, the SO was in charge
of the prison overnight. The young person in cell 58 settled down after the
Orderly Officer spoke to him. About an hour later, after the Orderly Officer
and the assistant Orderly Officer left the wing, the OSG answered a call bell
from cell 58. The young person swore at the OSG who placed him on a
disciplinary report for an offence under the Prison Rules. The night staff said
they did not recall hearing any other shouting or loud noises coming from
other young people on the unit during the night. However, overwhelming, but
unproven, evidence provided to the police and to my investigators after the
boy’s death leads me to believe that shouting did take place.
235. The next day, the first roll check was conducted by the OSG at about 5.30am.
At interview, the OSG recalled that he saw the boy lying in bed and that he
appeared to be asleep. The OSG did not think anything was untoward.
236. Evidence seen by my investigators shows that the night staff carried out
‘pegging’ on three occasions during the night. (‘Pegging’ is the term used
throughout the Prison Service to describe the process of recording the periods
during which night staff patrol their units. This does not involve the checking
of individual cells.)
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The boy found hanging
237. The table below shows the timing of events recorded on closed circuit
television cameras. The investigation found that these timings are about four
minutes ahead of those recorded on the control room log.
Time Event
7.10.40am A seventh Officer arrives at the boy’s cell and looks through
observation panel.
7.10.47am The seventh Officer runs off to raise alarm.
7.11.15am Landing lights come on.
7.11.20am The seventh Officer returns to the boy’s cell and enters on her
own.
7.11.24am The sixth Prison Officer arrives at cell and enters.
7.11.28am The assistant Orderly Officer arrives at cell and enters.
7.11.30am The OSG arrives at cell and enters.
7.11.47am The OSG leaves cell and disappears from view.
7.11.52am An eighth Officer arrives.
7.11.58am The OSG returns to view, radio in hand (presumably having called
for assistance). Does not enter cell.
7.12.15am A ninth Officer arrives at cell and enters followed by an tenth
Officer who does not enter cell.
7.12.20am An eleventh PO on arrives at cell but does not enter.
7.12.33am The Orderly Officer arrives at cell with the twelth Officer. The
Orderly Officer and the tenth prison officer enter cell. The
assistant Orderly Officer and the eight prison officer leave cell.
7.12.41am The Orderly Officer stands outside cell at doorway.
7.12.52am The ninth and tenth prison officers leave cell.
7.13.18am A thirteenth prison officer arrives at cell.
7.12.22am The sixth prison officer leaves cell.
7.13.27am The seventh prison officer leaves cell.
7.13.32am Cell door pulled to (not locked) by the thirteen prison officer.
7.14.11am The tenth prison officer opens door for a few seconds. He and the
assistant Orderly Officer look into cell.
7.14.26am The tenth prison officer enters cell.
7.14.37am The Orderly Officer enters cell, having appeared to take a piece of
equipment (? mouthpiece) from the assistant Orderly Officer.
7.14.47am The Orderly Officer leaves cell briefly then returns. The assistant
Orderly Officer, the sixth and eighth prison officers seen standing
outside cell.
7.15.19am A Healthcare Nurse and a HCA arrive at cell and enter
immediately.
7.15.46am The Healthcare Nurse appears at entrance to cell and asks for
something.
7.22.38am The seventh prison officer returns to view. Looks in cell but does
not enter.
7.22.58am The seventh prison officer leaves area.
7.23.23am The assistant Orderly Officer opens fire exit next to cell (?to
facilitate access by ambulance crew).
7.25.26am The tenth prison officer leaves cell.
7.25.42am The tenth prison officer re-enters cell.
7.26.35am The tenth prison officer leaves cell again.
7.26.59am The tenth prison officer re-enters cell.
7.27.25am The tenth prison officer leaves cell.
7.27.58am Paramedics arrive and enter cell.
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238. At about 7.00am, the seventh prison officer arrived on Windermere 2, the first
officer from the day shift to arrive. Her first task was to do her own roll check
to ensure that the figures given by the night staff tallied with the numbers she
found. The seventh prison officer was required to attract a verbal or physical
response from each cell occupant. At 7.10am, the seventh prison officer
reached the boy’s cell (number 44). At interview, she said that she could not
see him at first as he was not on his bed. However, she thought she saw the
boy on the floor. Her first impression was that he might have fallen out of bed.
But she then thought she could see the boy’s face looking towards her. The
seventh prison officer said that, although she could see nothing else at that
point, she “instinctively knew something was wrong”.
239. The seventh prison officer ran to the alarm button adjacent to cell 55 in order
to raise the alarm. Although another alarm bell was situated outside the boy’s
cell, the seventh prison officer said she thought that she would struggle to find
it without the lights on. The alarm button outside cell 55 was also visible to
the staff office on the floor beneath. The seventh prison officer told my
investigator:
“I went deliberately to that one [alarm button nearest cell 55]
because apart from the cell bell at 44 is right round the corner, it
was in the dark and I would have struggled to find that bell
anyway without the lights on but I knew that I needed to let the
staff know where I was as raising the alarm. I needed to let them
to come straight upstairs, not look around the wing to see where I
was.”
240. The seventh prison officer said she pressed the alarm button at the same time
as she sent a request for help over the radio. She could not recall exactly what
she said. However, she admitted that she did not ask for medical assistance at
that stage because she did not know what was wrong. Having just come on
duty, she still had her coat on. As she was hot she decided to take her coat off.
As she did so, her radio fell away from her belt. At this point, the seventh
prison officer saw that some colleagues were looking towards her from the wing
office. She returned to the boy’s cell door and opened the observation flap “to
observe what was going on”.
241. The seventh prison officer unlocked the door and entered the boy’s cell,
followed within a few seconds by the sixth prison officer and assistant Orderly
Officer. The OSG also followed them but remained outside the cell. They
found the boy hanging from a ligature made from a bedsheet. He had pushed
the sheet through his open window, and then closed the window so that it was
held firmly. The sixth prison officer supported the boy’s body whilst the
assistant Orderly Officer cut the ligature. They then laid the boy on the floor
of the cell and, between them; the assistant Orderly Officer and the seventh
prison officer removed the ligature from the boy’s neck. Around 17 seconds
after he arrived at the cell, the OSG used his radio to call for urgent medical
assistance.
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242. At interview, both the assistant Orderly Officer and the seventh prison officer
said that they considered administering CPR but, as they were not first aid
trained, they thought they would do more harm than good.
243. At consultation stage, the seventh prison officer expressed her view that the
report should reflect the point, made in her interview with my investigator, that
she was prepared to administer CPR. I repeat here the following extract from
the transcript of that interview:
“I asked the staff to help me lower him [the boy] flat on the
floor because I knew that CPR would have to take place …
And as we laid him down, I sort of positioned my hand on his
chest because going through my mind was I’m going to have
to start CPR once we get him to lay on the flat on the floor, in
the correct position, we are going to have to start CPR …
And I was trying to feel for a heart beat and I couldn’t feel
anything at all.”
244. When asked whether she did commence CPR, the seventh prison officer
replied as follows:
“No, because by that point, the tenth prison officer was in the cell, there
were other people by the door and sort of in the background I could
hear that someone was calling for medical assistance or somebody
was talking about medical assistance. I’m not first aid trained; thoughts
that were going through my mind were I don’t want to hurt him any
more than I have to. I don’t want to break his ribs; I might do more
harm than good. The fact that I knew medical staff were on the way, I
thought its better that they do it and do it properly than I do something
and cause him an injury which might be more detrimental. But I was
poised to do CPR but I do recall looking up at the tenth prison officer
and just saying, he’s gone. And maybe that was instinct, that’s what I
believed at the time and he said just put him in the recovery position
then, which I did. I did place him in the recovery position.”
245. When asked to estimate the time lapse between cutting the boy down and
putting him in the recovery position, the seventh prison officer replied that it
was “a couple of minutes”.
246. While the OSG was making his call for urgent medical assistance, the eighth
prison officer arrived and went inside the cell. He was followed about 20
seconds later by the ninth prison officer. Within another 20 seconds both the
tenth prison officer and Orderly Officer arrived, together with the twelfth prison
officer.
247. When the tenth prison officer went into the boy’s cell, the seventh prison
officer told him that the boy had died. The tenth prison officer asked that the
boy be put in the recovery position, and he checked his pulse for signs of life.
At interview, he recalled that the boy was very warm but had no pulse. At
around this time, the ninth prison officer asked if anyone was competent in
76
cardio-pulmonary resuscitation (CPR), but received no response. She put this
down to the staff being “shell shocked”.
248. At 7.13am, just over a minute after he arrived at the cell, the tenth prison
officer asked all the staff to leave and the cell door was closed. At interview,
the tenth prison officer told my investigators that, as some people were
peering into the cell, he closed the door because of a need to preserve
evidence. The tenth and the thirteenth prison officer, who had arrived about
15 seconds before the door was closed, then had a short conversation. They
agreed that the thirteen prison officer would deal with matters such as alerting
other people to the events. At interview, the thirteen prison officer said he
then went to the wing office and asked for an ambulance to be called.
249. The Orderly Officer told the tenth prison officer that they had a responsibility
to try to resuscitate the boy. Therefore, at 7.14am, about a minute after the
cell door was closed, the tenth prison officer and the Orderly Officer re-
entered the boy’s cell and began cardio-pulmonary resuscitation (CPR). The
Orderly Officer gave mouth to mouth resuscitation while the tenth prison
officer applied chest compressions. At interview, the Orderly Officer said he
had been trained in emergency first aid as did the ninth prison officer. The
tenth prison officer said that, although he used to be first aider, he had not
received refresher training for a number of years.
250. At 7.15am, the Healthcare Nurse and Healthcare Assistant (HCA) arrived at
the boy’s cell in response to the call for medical assistance made by the OSG.
Between them they took over the application of CPR. The Healthcare Nurse
also checked that an ambulance had been called. In between breaths he
checked for signs of life, but could find no pulse and noticed that the boy was
not breathing.
251. At interview, the Healthcare Nurse told my investigator that the first indication
he received that there was a problem in the establishment was at about
7.07am when the general alarm sounded. (The CCTV footage shows that the
alarm was raised a few seconds before 7.11am.) The Healthcare Nurse said
that, whenever this alarm was sounded, the radio net was placed on “talk
through” (which enables all call signs to hear every transmission). The
Healthcare Nurse said that “after a minute or two” he heard a further message
on the radio in which a request was made for medical assistance in
Windermere Unit. He knew at that point that something serious had
happened, although he did not know that the boy had been found hanging.
The Healthcare Nurse therefore ran to the clinic in the healthcare centre
where the emergency first aid bag was kept and took it with him to the unit.
He asked the HCA to accompany him. As he arrived at the boy’s cell he saw
“one or two officers hovering outside the door”. He said he could see the
Orderly Officer and the tenth prison officer administering cardio-pulmonary
resuscitation to the boy on the floor of his cell. The Healthcare Nurse told my
investigator:
“I could find no pulse, there was no breathing and his skin was
very sort of pale and like an ashen grey colour. His pupils were
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quite wide and fixed. There was no sign of life. I took over the
ventilations and then shortly after that the HCA took over
compressions to give the tenth prison officer a break. We
continued doing that until the paramedics arrived which was
around 7.27am.”
252. The Healthcare Nurse explained that the emergency bag he took with him
from the healthcare centre included oxygen, an ambu-bag (a device that
enables oxygen to be passed into a patient’s lungs via the throat), gloves,
bandages, sterile strips, and other items that are needed to deal with every
day eventualities in which first aid is required. The Healthcare Nurse
explained that, although a defibrillator was available, he did not use it as he
felt he was not adequately trained in its use.
253. As soon as the paramedics arrived, they and the healthcare staff shared the
administration of emergency first aid. At 7.45am, the paramedics took the
decision that they had done all that they could for the boy, and his death was
pronounced. No note was found in the boy’s cell indicating his intention to
take his own life.
254. The Governor at the time of Lancaster Farms was told over the telephone at
7.15am that the boy had been found hanging and that the matter was being
treated as a death in custody. (In fact, at that stage, the boy had not been
pronounced dead.) At this time, the former Governor was at the conference
of the Prison Service North West Area that I was attending myself. At about
7.45am, after briefing his Area Manager, the former Governor left for his
establishment. During a telephone conversation with his deputy governor on
the way to Lancaster Farms, the former Governor discussed the tasks to be
carried out, including the confirmation of next of kin details. The former
Governor was concerned to be ready to make a decision upon his arrival at
the establishment as to how the next of kin should be informed. He also left a
message on the chaplain’s telephone, alerting him to the probability that he
and the chaplain would break the news of the boy’s death to his family. The
former Governor arrived at Lancaster Farms at about 8.30am. By that stage,
a notice to staff announcing the boy’s death had been posted at the gate by
the deputy governor.
255. After receiving a full briefing on events, the former Governor went to the
prison chapel to speak to the staff who had discovered the boy hanging and
who had attempted to revive him. He then went on to Windermere Unit to see
the staff on duty there. At 9.00am, a notice to young people was issued
telling them of the boy’s death.
Informing the next of kin
256. At 10.00am, the chaplain arrived at the establishment and reported to the
Governor for a briefing. At 10.30am, the former Governor and the chaplain
left Lancaster Farms to break the news of the boy’s death in person to his
aunt and uncle. In keeping with arrangements made by the Governor, he and
the chaplain were to be joined by a representative from the St Helens Youth
78
Offending Team. It was therefore agreed that they would initially meet at the
representative’s office.
257. The Governor and chaplain met the representative as planned at about
11.30am. They then left together for the boy’s family home. When they
arrived, the door was answered by one his cousins. After explaining who he
was, the former Governor asked if he and his colleagues could go into the
house. The former Governor decided that, in the circumstances, it was
appropriate to break the news of the boy’s death to the cousin. She wanted to
call her father straightaway but was advised by the former Governor that she
should consider first seeking support from a close friend. The advice was
taken and the chaplain left briefly to bring a chosen friend to her. The friend
then rang the boy’s uncle and asked him to come home quickly as she
needed him. At this stage no details of the boy’s death was given to his
uncle. However, he called his daughter to ask her why he was needed. His
daughter told him that staff from the prison had arrived. At this point, the
former Governor took the telephone and broke the news of the boy’s death to
his uncle. The former Governor agreed to remain where he was until the
boy’s uncle arrived. The former Governor suggested that he and his
colleagues could wait elsewhere while they were waiting for the boy’s uncle to
arrive but they were told they were welcome to stay. When the boy’s uncle
arrived, the former Governor told him as much as he could about the
circumstances of the boy’s death and tried to answer the family’s questions.
The former Governor and his colleagues then left.
Support for young people and staff
258. Notices were issued to young people and staff informing them of the boy’s
death and offering additional support to anyone – young people and staff alike
– who felt in need of it. The Deputy Governor chaired a ‘hot’ debrief of those
staff involved in the discovery of the boy’s hanging and in the attempts to save
his life. The Governor also spoke to them separately and visited the staff in
Windermere 2 Unit. He also addressed key managers before departing to
break the news of the boy’s death to his family.
259. Arrangements were made to review the case of all those young people who,
at the time, were subject to ACCT procedures.
260. Later, the Governor arranged for two members of the Lancashire County
Council Critical Incident Support Team to visit Lancaster Farms on Friday 7
December in order to provide support for young people and staff who might
have been affected by the boy’s death.
Ongoing contact with the boy’s family
261. As a result of legal complications that arose after the boy’s death, his funeral
did not take place until Monday 16 June 2008. My investigators were told that
the establishment Family Liaison Officer (FLO) maintained contact with the
boy’s family at times during that difficult period, as did the family links
coordinator. The FLO also arranged for the boy’s family to visit Lancaster
79
Farms in order to meet the Governor, the chaplain, representatives of the
Youth Offending Team and the staff who found the boy. The family visited the
boy’s cell and laid flowers.
262. The Governor offered to meet the full costs of the boy’s funeral. He also
wrote to the boy’s aunt and uncle with regard to additional costs incurred at
the boy’s wake. The Acting Governor and a chaplain from the chaplaincy
represented NOMS at the funeral.
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ISSUES
263. I have serious concerns about a number of issues arising from this
investigation. They relate to aspects of the boy’s management from the time
he was first considered for placement at Lancaster Farms to the day he died.
(Whilst I make no judgements about his management at Red Bank Secure
Children’s Home and at HMYOI Thorn Cross, I do comment on aspects of the
interface between those establishments and HMYOI Lancaster Farms.) The
issues I explore are listed below:
(cid:1) Whether the decision to recommend placing the boy at Lancaster Farms
was appropriate.
(cid:1) Whether, once the decision to place the boy at Lancaster Farms was
confirmed by the YJB, adequate information about his self-harm history
and related vulnerabilities was made available to the establishment prior to
his arrival there on 8 November 2007.
(cid:1) Whether the boy’s healthcare needs and risk of self-harm were properly
assessed when he arrived at Lancaster Farms, and whether they were
followed up and acted upon thereafter.
(cid:1) Whether adequate provision was made for the boy’s induction, sentence
planning and access to education and other regime activities.
(cid:1) Whether there was an effective Personal Officer scheme in place.
(cid:1) Whether the boy was in any way bullied or taunted while he was at
Lancaster Farms and, if so, whether any measures were made to
safeguard him. I also consider whether his death could have been linked
to bullying.
(cid:1) Whether the response to the discovery of the boy hanging on 29
November was prompt and appropriate.
(cid:1) Whether the news of the boy’s death was promptly communicated to his
next of kin and whether appropriate courtesies and support were offered to
his family in the aftermath of his death.
At the end of each section of this chapter I list my findings and
recommendations. The latter are summarised at the end of my report.
The decision to place the boy at Lancaster Farms
264. The boy’s YOT worker explained to my investigation team that she worked
with the boy closely and knew him and his family well. She had supported the
boy through his sentence at Red Bank from August to October 2007, and was
responsible for supervising him when he was released on licence. Although
the boy breached the conditions of his licence on the evening of his release
from Red Bank, the YOT worker said that she would have been prepared to
81
recommend a continuation of the boy’s licence if he had made an effort to
comply with its conditions. (It should be noted that although the YOT worker
can make recommendation for recall or for continuation of the licence period,
it is the court that makes the final decision.) The YOT worker wrote in the
boy’s pre-sentence report:
“Unfortunately, since this breach was listed, the boy’s situation
has deteriorated. He is now refusing to engage with any Youth
Offending Service interventions and apart from his first day back
at school, he has since refused to attend any further education.
In addition there have been several further incidents of failure to
comply with his curfew, including two nights when he was absent
for the whole curfew period and was reported to police as a
missing young person. The boy has refused to engage with any
sessions to address these concerns.”
265. The YOT worker told my investigation team that she waited until the day
before the boy’s court appearance on 8 November before writing the report,
because she considered custody as an absolute last resort. She consulted
her colleague who had supervised the boy on his previous custodial sentence,
as well as her line manager, about the recommendation for recall. She also
spoke to the boy’s aunt and uncle on a number of occasions between his
release on 22 October and his court appearance. At interview, she explained
that she felt she had no choice but to recommend the boy’s recall because of
the “escalation in the boy’s risk of re-offending and his vulnerability”.
266. The success of community sentences is dependent upon the engagement,
cooperation and motivation of the person being supervised. The boy refused
to answer telephone calls from his YOT worker or to attend his appointments.
In addition, his behaviour became more and more erratic as time passed. I
therefore understand the YOT worker’s belief that she had no choice but to
recommend a recall to custody, and that the erratic behaviour the boy had
sometimes shown at Red Bank suggested that he had outgrown the positive
influence that the Secure Children’s Home could have on him.
267. However, as I have said elsewhere in this report, my investigation team were
struck by the immense difference between Lancaster Farms and Red Bank.
The mid-way option between a Secure Children’s Home and a Young
Offender Institution is a Secure Training Centre, an establishment designed to
look after young people between the ages of 12 and 17. They are
significantly smaller than YOIs and young people live in small residential units.
However, there are only four in the country and none in the North West.
Young people from the St Helens area who are recommended for a Secure
Training Centre are sent to Hassockfield Secure Training Centre in County
Durham, 150 miles away. St Helens has made referrals to Secure Training
Centres, but the YOT worker did not consider this for the boy. The relative
proximity of Lancaster Farms meant that regular visits were possible and the
boy might have had more opportunity to see his family.
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268. I agree with the YOT worker and the Head of the YJB Placements Team that
the boy was no longer suitable for placement at Red Bank. His disruptive
behaviour at the children’s home aside, it is difficult to overlook the
increasingly risky behaviour that the boy engaged in when he was released
from Red Bank on licence in October. The YOT worker described her
repeated attempts to engage with him and his reckless behaviour in response.
(At consultation stage the solicitor representing the boy’s family, commented
that the YOT worker’s conclusion that the boy was no longer suitable for
placement at Red Bank appeared to have been reached without input from
anyone at the Children’s Home. The solicitor also commented that the YOT
worker’s opinion was at odds with the findings of the author of the St Helen’s
review - i.e. the
independent Serious Case Review conducted by the St Helens Local
Safeguarding Children’s Board - who recorded that the boy had benefited
from Red Bank. It is not for me to comment on the findings of that review.
However, I remain satisfied that the conclusions reached by the YOT worker
and the Head of Placements from the YJB were reasonable given the boy’s
deteriorating behaviour both at Red Bank and afterwards in the community.)
269. By 7 November, the placement options for the boy were therefore very limited.
Although Red Bank was appropriate given the boy’s vulnerability and its
proximity to his family, the escalation in his offending behaviour showed that
he was unlikely to achieve anything by returning. There were no Secure
Training Centres in the vicinity of his home. (I have not considered the matter
in any detail, but on the face of it the absence of an STC in the North West is
very surprising. The YJB will obviously wish to satisfy itself that the
geographical spread of STC provision is optimal.) It seemed to the boy’s YOT
worker that the only option was to recommend the boy’s placement at
Lancaster Farms, one of the Prison Service’s 16 YOIs.
270. At the time of the investigation, there were 2,730 places for young men in
Young Offender Institutions in England and Wales. There were only 536 non-
YOI places, which were then, as now, also used for young women. The Head
of the YJB Placements Team explained that in reaching its decisions the team
has to balance the competing needs of young people for non-YOI places
because there are far fewer of them. He said that if a YOI has been
recommended with reasonable justification, the Placements Team would
rarely need to consult the young person’s document that accompanies the
placement alert form. As the boy’s YOT worker recommended that he be
placed at Lancaster Farms and went on to justify her recommendation, the
Head of Placements thought it was unlikely that the placement officer at the
YJB dealing with the alert form would have consulted the boy’s documents.
271. The boy had been placed in Thorn Cross YOI in June 2007, where he stayed
for ten days before being moved to Red Bank to serve the rest of his
sentence. At the time of the boy’s placement, Thorn Cross was the only YOI
with open conditions. (The YJB has since ceased purchasing the 60 places
that were available for juveniles at Thorn Cross and it now only
accommodates 18-21 year olds.) The Head of Placements explained that, at
that time, Thorn Cross operated a small unit with closed conditions, known as
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the Direct from Court Unit which was intended to assess a young person’s
ability to cope with the different demands of open conditions. The closed unit
had a higher ratio of staff than the open unit and the emphasis was on the
assessment of young people’s vulnerabilities and needs and whether they
could be effectively met by the more relaxed open conditions. In the boy’s
case, the YOI alerted the YJB Placements Team and the boy’s YOT worker
that it was their opinion that the boy was too vulnerable to cope with the
conditions at Thorn Cross and any YOI. (The police had also advised Thorn
Cross that, in their view, the boy was not suitable for open conditions because
he was facing a further trial.)
272. The boy’s Asset form detailed his history of self-harm in some detail under
section 15, “Vulnerability”. Serious concern was raised at the beginning of the
boy’s sentence, on 22 August, about his vulnerability if he were remanded to
custody. While the boy was at Red Bank on this sentence, the following entry
was made in his file:
“Start DTO – 18.9.07 – appropriate measures/steps were taken
by YOS [Youth Offending Service] to ensure vulnerability issues
were addressed. The boy is now at Red Bank and to my
knowledge there have been no concerns about self harm.
Anxiety levels need to be monitored.”
273. After the boy was released on licence, the following entry was raised about
his vulnerability:
“DTO licence 24.10.07 following on from info below, staff have
responded to incident of self harm … Child and Adolescent
Mental Health Services [CAMHS]] have been seeing the boy on
weekly basis, and support package for the boy and family is in
place from YOS and CAMHS.”
274. These are the last two entries before the boy was recalled to custody. His
vulnerability appeared to have been reduced by interventions from the
Community Mental Health Service and the intervention of the YOT worker.
During her interview with my investigators, she was asked about her view on
the boy’s vulnerability, especially in the environment of a YOI. She explained:
“I think, you know, as a case worker, you’ve got to consider that
for all young people. I didn’t think it was an issue for the boy
when I was making the decision about which custodial setting to
recommend.”
275. The YOT worker was aware of the boy’s unsuccessful period at Thorn Cross.
She understood his mental health issues and how they were being treated in
the community. She also knew about, and recorded the details of, his history
of self-harm in the Asset document. With all these factors in mind, the YOT
worker did not think that vulnerability “was an issue” for the boy when she
recommended him for placement at Lancaster Farms. Indeed, she wrote on
the placement alert form she submitted to the YJB on 7 November:
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“Previously requested Red Bank when the boy had not
experienced custody. However, this would be his third time in
custody and YOS staff can liaise appropriately with casework staff
at Lancaster Farms. Lancaster Farms is near enough to enable
family visits to take place and also any relevant partnership staff
can regularly also visit to undertake ongoing interventions and
planning meetings.”
276. The YJB website refers to the key factors Youth Offending Teams must take
into consideration when considering placement options. Examples quoted
are:
- risk of self-harm
- having been bullied
- separation, loss or care episodes
- risk taking
- substance misuse
- other health related needs
- the ability to cope in a YOI or other custodial establishment.
277. Most of these factors applied in the boy’s case. The YOT worker did not think
the boy would find it hard to adjust to a prison environment, saying “He mixed
really well with young people.” It is difficult to argue that anyone could be
better placed to make this judgment than the YOT worker, who had worked so
closely with the boy over the previous months. However, nothing could have
been further from the truth. The boy did find it hard to adjust at Lancaster
Farms. Such was his fear and perception of the prison environment that he
hardly left his cell. He certainly did not mix well with other young people.
278. In his interview, the Head of Placements said he thought the YOT worker’s
recommendation and the reason for it seemed appropriate. He said that,
unless a placements officer had to prioritise a non-YOI secure placement or
there was no clear recommendation for placement on the alert form, his
Placements Team did not need to refer to the documentation accompanying
the alert form, for example the young person’s latest Asset. He said that the
accompanying documentation was for the receiving establishment to look
through to plan how to care for each young person they received. The Head
of Placements did not think the Placements Team had any reason to question
the YOT worker’s judgement. He said the boy was therefore placed at
Lancaster Farms directly as a result of her recommendation.
279. In all the circumstances, I do not consider that it was unreasonable for the
YOT worker to recommend the boy’s placement in a YOI. Nevertheless, as
the YJB are ultimately responsible for making placement decisions, I do not
think they should rely solely on the recommendations of the YOT worker. In
para 38 above, I reproduced a table showing the criteria for placement options
as explained on the YJB website. For vulnerable males between 15 and 16, it
recommends a Secure Children’s Home or STC.
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280. I interpret the table as clearly indicating that, given the serious concerns about
the boy’s vulnerabilities, he should have been placed in a Secure Children’s
Home or a Secure Training Centre. (At consultation stage the family’s
solicitor, commented as follows:
“…There is a disparity between policy and practice. The YJB have no
choice but to place children younger than 15 – whether or not vulnerable –
in either Secure Training Centres or Secure Children’s homes. The YJB
policy on 15 and 16 year old boys is that if they are vulnerable they will be
placed in non Prison Service establishments. The YJB practice though is
that large numbers of vulnerable 15 and 16 year olds are placed in Prison
Service YOIs.”)
281. I am also concerned that the decision to place the boy at Lancaster Farms
was not informed by any assessment of the physical and cultural environment
to which he was to be sent. However, if - as I believe to be the case - not all
senior managers at Lancaster Farms knew of the extent of the mental bullying
that took place in Windermere Unit by night, the YOT worker cannot be
blamed for not knowing this either. Nevertheless, such an assessment should
become a standard element of the placement process in order to minimise the
risk of a further tragedy occurring. (At consultation stage, the St Helens Youth
Offending Service questioned how field workers could assess the physical
and cultural environment of a YOI and expressed the view that they – the field
workers – had a reasonable expectation that establishments should provide
proper care and safety for young people. I have some sympathy with his
view. However, I maintain that it is not unreasonable to expect YOS staff to
have a knowledge of those aspects of their establishments.)
282. As I have said, it is surprising that there is no Secure Training Centre in the
North West. Had one been available, I assume the YOT worker would have
recommended it for the boy.
Summary of findings
283. As the YJB are ultimately responsible for making placement decisions, they
should not rely solely on the recommendations of the YOT worker.
284. The decision to place the boy at Lancaster Farms was not informed by any
assessment of the physical and cultural environment to which he was to be
sent.
285. The table on the YJB website explaining the criteria for the placement of
young people within the secure children’s estate shows that, given the boy’s
vulnerabilities, he should have been placed in a Secure Training Centre or
Secure Children’s Home.
286. There is no Secure Training Centre in the North West.
Recommendation
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Urgent steps should be taken by the YJB to ensure that placement
decisions are made in accordance with the criteria explained on its
website. Placement recommendations and decisions should be
informed by an assessment of young people’s ability to cope with the
physical and cultural environment of the establishments under
consideration. Placement recommendations and decisions should also
take account of all available information about the young people under
consideration, including home circumstances, Asset details,
vulnerabilities and risks, as well as any relevant suggestions made by
staff in the establishments in which young people have previously been
held.
The information made available to Lancaster Farms about the boy’s risks and
vulnerabilities prior to his arrival
287. Paragraph 5.4 of Prison Service Order 4950, sets out the following guidance
with regard to the assessment of young people’s needs on reception:
“Governors must ensure that the prescribed systems are in place
for recording receipt of key documents – for example, Asset, Pre-
sentence report, post court report, YJB vulnerability alert and
suicide/self harm warning form; for informing YJB of missing
documentation; and for ensuring that outstanding information is
received as soon as possible.
288. The casework officer, who conducted the boy’s general reception interview,
told my investigators that the boy’s Asset document was available to him. But
there was some confusion as to what happened to his pre-sentence report
and post court report. The court worker said that the post court report was
placed in a yellow envelope and given to the staff who escorted the boy to
Lancaster Farms. The YJB monitor confirmed that she saw this report in the
boy’s file after his death. The casework officer confirmed that, although the
Prisoner Escort Record contained no mention of any risk of self-harm, the
boy’s Asset form carried a notation that he was at risk because he had
harmed himself seven months earlier. At interview, the Practice Nurse, who
conducted the boy’s initial reception health screen, said Asset forms were not
always received on the day of a young person’s reception.
Summary of findings
289. The investigation found no evidence to show that any effort was made by
anyone at Lancaster Farms to clarify which forms had been received or to ask
the YJB to obtain those that were missing.
290. A little over a fortnight elapsed between the boy’s release from Red Bank and
his admission to Lancaster Farms. Despite the fact that important information
about his time at Red Bank was contained in this file it was not passed to
Lancaster Farms until requested by the Governor after the boy’s death. The
documents also included vital information about the boy’s experience at Thorn
Cross. My investigation found that no clear system was in place for the
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transfer of information between Secure Children’s Homes and Young
Offender Institutions.
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Recommendations
A protocol should be agreed between the YJB and the Prison Service for
the prompt and efficient transfer of young people’s custodial records
when they move between Secure Children’s Homes, Secure Training
Centres and Prison Service establishments. The protocol should make
it clear that YOT workers are responsible for arranging the transfer of
such documents.
The Governor should take urgent steps to ensure that, in keeping with
paragraph 5.4 of PSO 4950, systems are in place to record accurate
details of which forms have been received in reception and that missing
documents are requested through the YJB.
The assessment and management of the boy’s healthcare needs and risk of
self-harm and other vulnerabilities
291. Paragraph 5.5 of Prison Service Order 4950 sets out the following guidance
for the assessment of young people’s immediate needs:
“Every young person must be screened on the day of arrival to
ensure their safety and to identify all immediate healthcare needs.
An assessment must be made of their likelihood of their harming
themselves and of the need for further in depth assessment of
physical, mental health and substance misuse history.
“Every young person must be interviewed within one hour of their
arrival to assess their needs and vulnerability and complete the
form T1:V.”
Initial healthcare screen
292. The boy’s reception health screen was conducted by the Practice Nurse
whose experience of managing children and young people had been gained
during the year she had spent at Lancaster Farms.
Risk of suicide or self-harm
293. The Practice Nurse regularly undertook the evening duty in the reception area
of Lancaster Farms and felt experienced in the first reception health screen
process. She had received ACCT training. Although she did not have formal
mental health training, she had worked with patients with mental health
problems in the community and felt sufficiently knowledgeable in this area.
Her non-professional experience with teenagers also helped her to make
judgments during the screening process.
294. The Practice Nurse considered that the boy was not at risk of suicide. She
assessed the way he answered her questions, his body language and his
good eye contact. In interview, The Practice Nurse said she saw the boy’s
Asset form but as it was such a large document it was difficult to read in the
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time available. The Practice Nurse said the Placement Confirmation form or
“first night alert” was also available to her and she would have questioned the
boy about its contents. The Asset form is central to the care of young people.
It guides staff in their assessment of risk and factors associated with their
offending behaviour. It also provides an opportunity to record any concerns
about young people’s welfare.
295. Although I am disappointed that the Practice Nurse did not look at all the
relevant evidence available to her before drawing her conclusion that the boy
was not at risk of self-harm, I consider that her decision not to open an ACCT
form was understandable given his presentation during the health screen.
296. The Asset form is designed with the intention of identifying the reasons a
young person offends. Its primary purpose is not to highlight a young
person’s vulnerability. However, I think much could be done to make the
design of Asset more user-friendly in a custodial environment. Information
such as an attempt at suicide is critical and should not simply be another item
on a checklist. When my investigators put this to the Head of Placements at
the YJB, he agreed that the tool was not designed with custodial staff in mind.
However, he said that a project was underway for the use of ‘eAsset’, an
electronic assessment tool. One of the objectives of that project is to ensure it
was compatible with use in a custodial environment. (I have seen eAsset in
operation at HMYOI Castington and I strongly support it.)
297. During the course of the investigation, my investigators were told that many
staff would not place individuals on ACCT documents as they were often
closed the following day. My investigators discovered that over 80 ACCT
documents were opened during the last quarter of 2007. More than 20 per
cent were closed on the same day or the day after they were opened. (This
seems a surprisingly high proportion.) If a member of staff opens an ACCT
document they may well be reluctant to open further documents if they see
them closed the next day. In my opinion, it is highly unlikely that the
underlying issues behind opening an ACCT form on a young person will have
been removed overnight. Although I make no formal recommendation on this
point, it may be that the NOMS Safer Custody and Offender Policy Group will
consider commissioning comparative research into the proportion of ACCT
forms opened and closed within 24 hours. There may be some important
learning to be gained.
Cell sharing risk assessment
298. The cell sharing risk assessment conducted by the casework officer and the
Practice Nurse was informed only by the responses the boy gave to the
questions listed on the assessment form. Despite the fact that the Asset form
was available at the time (on the casework officer’s own account), there is no
evidence that its contents were taken into account during the assessment
interview. Hence, a number of important aspects of the boy’s history were
ignored, as can be seen from my investigators’ comments in the table shown
in para 159 above and repeated here for convenience:
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Questions Answers
Has the prisoner been convicted of No. (In fact, the boy’s Asset form shows that he had
aracist or homophobic crime? been convicted of an offence of racially insulting
behaviour committed on 8 June 2007.)
Has the prisoner ever abused No. (In fact, the boy had been a prolific user of
alcohol or drugs? alcohol and often taken drugs.)
Is the prisoner currently dependent No. (In fact his Asset form, which the casework
on alcohol or drugs? officer said was available when the cell share risk
assessment was completed, indicated that the boy
considered substance misuse, including alcohol, to
be an essential factor in his life style.)
Is there any evidence of the No. (In fact, the boy had been subject to ACCT
prisoner having a previous ACCT? procedures at Thorn Cross, but no details of that
were available to Lancaster Farms.)
299. My experience of other investigations has shown that it is not uncommon for
reception staff to record only the responses given by prisoners during cell
sharing risk assessments. I am also conscious that, in the boy’s case, no
matter what his responses his placement in a single cell was almost inevitable
as there were no shared cells available for him. However, I do not approve a
practice that relies solely on those current responses rather than taking into
account relevant historical information. As with the need for the ACCT
process to take historical information into account when considering risk, so
must the cell sharing risk assessment. The details in the Asset form available
to staff at the time of the boy’s assessment should have been studied and
taken into account irrespective of the lack of shared cells available. The
historical factors ignored in the boy’s case might have changed the course of
his general management in the establishment had they been considered.
Substance misuse
300. The Practice Nurse did not refer the boy to the substance misuse team,
despite his “excessive” use of alcohol and probable “cocaine type drug
dependence”. She thought the boy’s substance misuse was not unusual and
knew that it would be followed up at the secondary health screen. Although
the investigation found that all young people are interviewed by a member of
the establishment’s Young Person’s Substance Misuse Service (YPSMS) as
a matter of routine, I consider that the boy’s history of significant recent
substance misuse was such that the Practice Nurse should have referred him
immediately to the YPSMS and to a doctor. In the absence of any physical
examination of the boy – no urine test was conducted – the Practice Nurse
could not have known whether the boy was in need of detoxification from
drugs or alcohol. The clinical review panel have commented, at paragraph
7.4 of their report, that “although his experience of alcohol and drug misuse
was identified, the boy was not referred directly to the YPSMS as it was
standard practice for that to occur as part of the routine induction protocol …
As part of a national roll out programme, PCTs are now required to
commission Integrated Drug Treatment Services (ITDS) for their population,
including prison services ...”
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301. A member of the Substance Misuse Service, confirmed that his team
automatically sees every young person who comes into Lancaster Farms
irrespective of whether they have any substance misuse problems. The
member conducted an initial assessment of the boy’s needs three days after
he arrived and then completed a full assessment on 26 November.
302. The investigation found no evidence that the boy was offered any medical
support for his alcohol dependency whilst he was at Lancaster Farms.
Secondary healthcare assessment
303. A secondary health screen was conducted on 11 November by a Healthcare
Assistant. She recorded that, although the boy had self-harmed six months
earlier, he was “ok at the moment”.
Mental health assessment
304. On 14 November, six days after arriving at Lancaster Farms, the boy was
assessed by a social work student, a member of the mental health in-reach
team, in response to the referral made during his reception health screen.
The social work student noted that the boy was not currently subject to ACCT
procedures and had told her he had no thoughts of self-harm. During his
interview, the boy said he did not want to take part in education, gymnasium
or association. He explained this by saying that sometimes he liked to be on
his own but would come out of his cell if he wanted to. He told the social work
student he was not afraid of other people. The effect of the boy’s reluctance
to engage in any activities, especially association, was likely to make him feel
isolated. But the social work student emphasised that the boy was “quite
happy and bubbly” when she interviewed him. She said she did not expect
him to be so open about how he felt. He told her he did not have any worries
about other people at Lancaster Farms and said he was only likely to self-
harm at times when he became stressed. The social work student did not
believe the boy was putting on an act of bravado. She said she considered
whether, in view of the boy’s history of self-harm, she should open an ACCT
form. However, she decided it was not necessary to do so given the boy’s
presentation during her assessment of him.
305. The investigation later found evidence, principally from letters written by the
boy and his telephone calls, that he was frightened to leave his cell.
However, it seems that he told no members of staff how he really felt.
Although, with the benefit of hindsight, it seems the social work student was
mistaken in her perceptions of the boy’s morale, his demeanour at the time
was positive. The social work student planned to assess the boy again two
weeks later. However, she was unable to do so as that day was designated a
staff training day. As the boy died the next day, the social work student did
not see him again.
Summary of findings
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306. Here I add my own findings to those included in the clinical review appended
to this report.
307. The nurse who conducted the first reception health screen should have taken
a urine sample from the boy in order to measure what, if any, immediate
substance misuse interventions were necessary.
308. Given the boy’s significant history of alcohol abuse, the nurse should have
made an immediate referral to a doctor and to the Young Person’s Substance
Misuse Service. The investigation found no evidence that the boy was offered
any medical support for his alcohol dependency whilst he was at Lancaster
Farms.
309. I am concerned that the first reception health screen seemed not to take
account of the concerns about the boy’s self-harm history recorded in his
Asset form. In my view, the decision whether self-harm monitoring
procedures should be invoked should not ignore available historical
information about the person being assessed.
310. Just as the ACCT process takes into account historical information about a
young person when considering risk, so the cell sharing risk assessment
should do the same.
311. At consultation stage the family solicitor, questioned whether the Practice
Nurse and the social work student were sufficiently qualified and experienced
to assess the boy’s needs. The solicitor commented that the Practice Nurse
had no formal mental health training and no specific training to work with
young men.
The solicitor also pointed out that the social work student was a 3rd year
student social work student with no formal psychiatric or psychological
qualifications. He said:
“We would suggest that suggest that issues around the boy’s vulnerability
may have been missed by the Practice Nurse and the social work student
which may have been picked up by more qualified mental health
professionals …”
The solicitor asked for a recommendation to be made that staff should receive
proper training specific to issues faced by vulnerable young people. I have
some sympathy with the solicitor’s views. However, the view of the panel who
conducted the clinical review of the management of the boy’s health needs is
different. At paragraph 7.2 of the clinical review, the comment is made that
the assessment carried out at first reception health screen provided clear
information and the actions of the practice nurse in initiating the referral to the
Mental Health In-Reach Team were reasonable and proportionate. At
paragraph 7.4 the further comment is made that the nurses on the Primary
Care Team undertaking the screening have access to RMN (Registered
Mental Nurse) qualified nurses on the ward if they have any concerns and
require immediate assistance.
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Where the social work student is concerned the clinical review states at
paragraph that the panel considered her level of training was appropriate for
mental health assessments provided that adequate supervision was available.
However, the panel were concerned that the supervision procedures in place
for the social work student appeared not to have been followed completely.
I am not in a position to question the professional views expressed by the
clinical review panel and I therefore make no formal recommendation.
However, the Coroner may wish to consider the matter further at the boy’s
inquest.
Recommendations
Those staff responsible for completing healthcare screens should pay
full attention to the information contained in Asset forms, especially
where the assessment of self-harm or suicide risk is concerned.
Urine samples should be taken during first reception health screens in
order to inform decisions about young people’s needs for detoxification
or other appropriate substance misuse interventions.
Healthcare staff conducting first reception health screens should, where
necessary, make an immediate referral of young people with a recent
history of significant substance misuse to a doctor and to the Young
People’s Substance Misuse Service so that decisions about
detoxification and other interventions can be made without delay.
Consideration should be given to the remodelling of the Asset form for
easier use in a custodial environment so that critical information such
as self-harm risk is clearly visible.
The Governor should satisfy himself that there is no impediment to
opening an ACCT form such as the perception by staff that forms will be
closed at such a speed as to render their use pointless. ACCT
documents should remain open until staff are satisfied that all issues
have been identified and effectively managed through appropriate case
reviews. Relevant training should be offered to staff in this regard.
The Governor, in conjunction with the PCT, should ensure that those
staff who carry out cell sharing risk assessments take into account
relevant historical information about a young person, such as that which
may be contained in Asset forms.
Induction, sentence planning, access to education and other regime activities.
312. During the reception procedures, those under 18 years of age are kept apart
from those over 18. The boy was placed in a holding room in the reception
building. When my investigators visited this building they judged that the
décor was bland, lacking in imagination, and offering neither warmth nor
welcome. They contrasted this with what they had seen at Red Bank. There
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are clear lessons here both for Lancaster Farms and for all Prison Service
establishments holding juveniles.
First night procedures and induction
313. Prison Service Order 4950 requires Governors to ensure the following
outcome for the induction of young people:
“To introduce every young person to the culture, rules,
opportunities and standards of behaviour of the establishment
during a formal, structured induction programme of at least one
week and to identify, assess and record the needs, abilities and
aptitudes of every individual and to draw up a plan to address
them.”
314. This outcome is embraced by the provisions of paragraph 5.19 of the PSO
which is as follows:
“Each young person must have an induction period of at least
one week that must include an introduction to the establishment
and its routines. The induction programme should ensure that
young people are fully and purposefully occupied in their first
few days in custody.”
315. During his first night interview with the unit officer, the boy was told who his
Personal Officer was to be. The boy was given two reception letters and, at
about 10.00pm, he used a free two minute telephone call (although it is not
clear who he called). The boy signed his Pin-phone, in-cell television and
behaviour compacts. He was given an advanced canteen pack containing
sweets. Although he smoked, he was not allowed a smoker’s pack because
of his age. The details of the first night procedures and outcomes were
appropriately recorded. The formality and structure attaching to these
procedures were, of course, very different from those the boy would have
experienced at Red Bank.
316. One of my investigators observed the first night interview process on
Buttermere Unit during a normal midweek evening, and was surprised to see
an officer conducting an interview with a young person seated at a dining
table outside a cell within earshot of other young people. Another officer was
conducting an interview in the normal interview room. There was little
confidentiality attached to the process.
317. Paragraph 5.12 of Prison Service Order 4950 requires Governors to make
arrangements to provide each young person’s next of kin or family or other
appropriate person with information about visiting, personal property, pastoral
care and the sentence planning, review and resettlement arrangements. This
should be done within 48 hours of their arrival. This target was not met. The
boy’s family were frustrated at the lack of official contact with them. They told
95
my Senior Family Liaison Officer that they received a letter bearing the boy’s
name and prison number but did not know how to contact him. The boy’s
aunt therefore rang Lancaster Farms and was given a number to try for a
member of the Family Links Team. When she tried this extension, the boy’s
aunt discovered it was the wrong number. Later, she tried again and was
given the correct extension. The boy’s aunt told my Senior Family Liaison
Officer she felt that information about how to contact the boy was given to her
piecemeal. She said the only helpful source of information was the Youth
Offending Team. The boy’s aunt emphasised that she wanted to help staff at
Lancaster Farms to look after the boy. She believed that, if she and her
husband had been involved in his management, they could have explained
how frightened he was.
318. I consider that the lack of engagement with the boy’s family was a significant
failure. I cannot overstate the importance I attach to the need for staff to
engage with the families of young people in their charge.
319. The first night element of the induction process requires the provision of a
great deal of information to young people in the early stages of custody. In
addition, forms have to be completed and general guidance provided.
Induction staff at Lancaster Farms said that the time available to them was
limited and the number of new receptions was often high. It was not
uncommon for some young people to arrive at the establishment quite late in
the day. Thus, the priority seemed to be to get young people settled into their
cell for the first night. Staff told my investigator they believed their priority
during the remainder of the induction process was to make sure that they set
the appropriate basic standards relating to discipline and control for young
people. They explained, for example, that on Buttermere Unit, bed packs had
to be made up each morning (that is sheets, blankets and pillows had to be
neatly folded and packed together). The unit officer said this was necessary
for hygiene reasons. However, the Head of Young People at Lancaster
Farms confirmed that this practice was about to cease as he had ordered
duvets for every cell in the Juvenile units. I welcome this change.
320. Although induction staff had ample forms and checklists to complete, there
was little evidence that the process included arrangements for finding out how
well a young person was settling in and helping them adapt to the Lancaster
Farms regime. The Head of Young People said he would have expected his
staff to have explained the establishment’s regime and routine to the boy in
order to take away his fear and let him know what he faced during the 44 days
he was required to spend in custody. The Head of Young People said the boy
ought to have had an understanding of what time he had to get up, when he
could go to the gym, what time he would go to school, and when he could
contact his family. He also confirmed that in normal circumstances, a young
person’s induction should take no longer than five working days. According to
the provisions of PSO 4950, there is no maximum limit on the time the
induction process should last.
321. The Head of Young People also told my investigators he believed that the
induction process had been hampered by the influx of a high number of
96
receptions in the aftermath of the disturbance that had taken place in the
young people’s units on 29 August 2007, when prison officers took industrial
action. During the disturbance, a great deal of damage was done to the
buildings and the accommodation had to be temporarily taken out of
commission. The Head of Young People explained that the units re-opened
about a month later.
322. The Head of Young People told my investigators:
“We were under immense pressure to get the spaces filled up as
quickly as possible, so I spoke to the YJB and agreed that we
would only take a certain amount each week. If they were going
to send us overcrowding drafts, say ten from Stoke Heath on
Monday, and then eight from Castington and our normal courts, it
would affect the induction process because we wouldn’t be able
to put all the lads through in that space of time.”
323. The Head of Young People said that in the four week period prior to the boy’s
arrival, 91 young people were received at Lancaster Farms. He pointed out
that he had telephoned the YJB on a number of occasions about how many
people the establishment could reasonably take. He said:
“The YJB have been under pressure and they were contacting
me, saying you’re going to have to take more. I went on leave
and came back at the beginning of November and we’d had an
influx of overcrowding drafts, so what that meant was we were
getting maybe four or five on a Monday and three or four on a
Wednesday. Monday turned up and we had 12 lads arrive and
then three days later we had another ten lads arrive. So to try to
get all those lads through induction, it just wasn’t feasible to get
everybody on.”
324. The data on the number of receptions at the material time given to my
investigators by the YJB did not match those presented by managers at the
establishment. The operational pressures on Lancaster Farms and other
parts of the Prison Service estate during the second half of 2007 were very
substantial. However, from the figures I have been given, the YJB made
every effort to minimise the impact on Lancaster Farms by reducing the
weekly intake of young people to a realistic level.
325. At consultation stage the family solicitor, commented as follows:
“It appears to us from the evidence of staff at Lancaster Farms that there
was significant pressure on the reception facilities leading up to and at the
time of the boy’s arrival at Lancaster Farms. It does not appear to have
been simply a problem of the volume of new arrivals each week but that
they often arrived late in the evening making it difficult for staff to induct
them properly…The arrival of large numbers of young people late in the
evening seems to have been a significant concern to staff in terms of their
ability to follow reception procedures.”
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I have briefly alluded to this problem at paragraph 326 above. However,
although I have some sympathy with the solicitor’s views, the investigation
found no evidence to show that there were any significant pressures on staff
at the time of the boy’s reception.
Summary of findings
326. At the time of the investigation, the décor in the reception building was bland
and lacking in imagination.
327. The investigation found no evidence that the disturbance in August 2007 had
unduly hardened staff attitudes towards young people. The management of
challenging behaviour of so many young people in custody demands a
healthy and sensible mixture of firmness and fairness by staff. However, the
induction process appeared to be mechanistic in its style and was not tailored
to the personality or to the history of each individual. The culture shock the
boy experienced upon his arrival at Lancaster Farms must have been
substantial. Induction staff at Lancaster Farms did not seem to have much
understanding of the adjustment the boy would have had to make.
328. During the boy’s induction programme, he was interviewed and assessed by a
range of specialists. However, he did not complete the induction process
within the programme timeframes. Several sessions were missed or not
delivered, including “Safeguards” (the protection and maintenance of child
welfare) which might have been of particular benefit to him. Although the boy
signed to say he had completed his induction on 22 November, this clearly
was not the case. The delay in completing the programme meant that the boy
had very little to occupy him. There were no obvious incentives for young
people to complete induction nor was there any apparent drive by staff for
them to do so. In fact, my investigators formed the impression that the
greatest driving factor was the pressure to create cell spaces for new
receptions. There was some evidence that the boy did not want to move from
Buttermere. Thus, he may have believed the delay was to his advantage.
Nevertheless, the induction process should be completed to the prescribed
timescales and tailored to the needs of the individual. The boy’s induction
process did not culminate in any plan to address his particular needs.
329. It is crucial that induction and other interviews are conducted in appropriate
surroundings, even during busy periods. It is unlikely that a young person will
discuss issues openly if he feels other young people may be able to overhear
his discussion with an interviewer.
330. The investigation found that official contact with the boy’s uncle and aunt was
not attempted until 15 November, one week after the boy’s arrival. Bearing in
mind that we are talking about a vulnerable 15 year old child, I think this was
simply unacceptable.
Recommendations
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The Governor should take steps to improve the décor and image of the
reception building in order to create an atmosphere of warmth and
welcome.
The Governor should ensure that all first night interviews take place in
conditions of privacy and sensitivity.
The Governor should ensure that official contact with young people’s
next of kin is made within the 48 hour timescale laid down in PSO 4950
unless there are exceptional reasons for not doing so.
The Governor should require his induction staff to familiarise
themselves with the culture and ethos of Secure Children’s Homes and
Secure Training Centres so as to improve the quality and style of the
induction of young people at Lancaster Farms.
The Governor should consider the introduction of a peer support
system through which newly arrived young people can be helped to
settle during their early days.
The Governor should ensure that all elements of the induction
programme for young people are delivered within appropriate
timescales.
Education
331. The boy was assessed by the education department on 23 November, and
allocated to classes to commence the next working day - Monday 26
November. The prison policy does not allow education assessments to be
carried out until the induction programme has been fully completed. The
delay in completing the induction programme meant that the boy had little
formal contact with education staff for almost two weeks. Had the induction
programme run to the timetable and all sessions been delivered, the boy
might have had more contact with staff and have been on education classes
for over a week before he was moved from Buttermere to Windermere Unit.
At the time of the investigation, the education assessment was carried out
after the induction had been completed. I believe that the assessment should
be completed as an integral part of the induction programme. This would help
to reduce the risk of a gap between the completion of induction and the start
of education, and the likelihood of young people being left in their cells with
little to occupy themselves. It would also mean that skills needs would be
more promptly identified.
332. Some of the assessments by staff during the boy’s induction period included
key information that does not appear to have been acted on. The first night
needs assessment manager’s check list completed by the SO identified
support as being necessary from the safeguards team. I could find no
documentary evidence that this support was provided. I am surprised that
staff working with the boy on the unit on a daily basis did not appear to have
any of the information available to them. The boy’s wing history sheet
99
contains very little information and the only entries of note were made by the
Prison Officer. This related to the boy’s failure to eat for a short period.
Summary of findings
333. Completion of the education assessment as part of the induction programme
would allow an individual’s skills needs to be identified more promptly and
would enable him to commence classes earlier. This would also help to
reduce the risk of young people being left in their cells with little to occupy
themselves. It would also mean that skills needs would be more promptly
identified.
334. Had information gathered by all staff from a variety of disciplines been entered
on the boy’s history sheet, a better overall impression of his progress might
have been possible.
Recommendations
The Governor should ensure that the education assessment is
completed as part of the induction programme.
The Governor should ensure that a brief summary of all interviews and
assessments carried out during the induction process is entered on
young people’s history sheets.
Sentence planning (DTO) meeting
335. Paragraph 5.26 of Prison Service Order 4950 sets out the following guidance
for young people’s sentence management:
“Governors and the Youth Offending Team manager must ensure
that the sentence plan and individual learning plan is drawn up
within at most ten working days of reception and that specific,
measurable, achievable, realistic time-bounded and agreed
objectives are set for each individual. The plan must also identify
the individual needs of the young person in relation to community
resettlement and take account of any needs arising from
vulnerability. The young person’s daily programme must be
based upon the plan.”
336. The YJB’s Strategy for the Secure Estate for Children and Young People,
published in 2007, sets out the following guidance on sentence planning:
“The YJB believes that all institutions within the secure estate for
children and young people should be characterised by end-to-end
sentence planning arrangements focused from the outset on the
resettlement of young people in the community.”
337. The YJB underlines the importance of sentence planning in a young person’s
experience of custody. In the boy’s case, the sentence began at Red Bank.
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He was released from there but recalled to custody to complete the
remainder. The information about his sentence plan and time at Red Bank
was not transferred to Lancaster Farms. Neither was the fact that the boy
was placed on an ACCT at Thorn Cross communicated to Lancaster Farms.
Nor was the comment made at Thorn Cross that the boy should not be placed
in any YOI.
338. My investigation team examined YJB National Standards, the NOMS/YJB
Service Level Agreement and PSO 4950 to determine who was responsible
for the transfer of sentence planning information from one establishment to
another. There is no such requirement. I am surprised that, with such an
emphasis on “end-to-end sentence planning”, a young person who is recalled
to a different establishment has to begin his sentence plan as if it had never
been started.
339. The boy arrived at Lancaster Farms on 8 November. The DTO planning
meeting should therefore have been scheduled to take place by 22 November.
340. The second prison officer regularly worked in the casework office but was on
leave when the boy arrived and only came across his file on 15 November.
She noticed that his sentence plan had not been completed. She therefore
went through the boy’s Asset page by page and copied the Asset score into a
sentence planning tool. The last section – headed ‘Indicators of vulnerability’
was scored fairly low, but the second prison officer noted the boy’s history of
self-harm.
341. The second prison officer then completed a provisional training plan for the
boy and went to see him to discuss the targets she had set him. The second
prison officer told my investigators the targets were generic to all the young
people at Lancaster Farms. She said that, as the boy was not going to be at
Lancaster Farms very long, the number of courses available to him was
limited. For example, the Juvenile Enhanced Thinking Skills course was a
nine week course and he would be unable to complete it. The boy had no
further contact with the casework team.
342. The reason for the failure to organise the sentence planning meeting on time
is difficult to determine from the evidence. The Head of Young People at
Lancaster Farms showed my investigation team the casework diary to
illustrate that the planning meeting could have taken place within the required
ten days. The Buttermere Unit casework team thought that the YOT worker’s
pregnancy would prevent her from attending a meeting in a unit at that stage.
It was said that she therefore organised a time for the meeting to take place in
legal visits and communicated with the casework team that the meeting was
due to take place on 4 December. However, during her interview, the YOT
worker made it clear that she was prepared to go to Buttermere Unit to attend
the meeting. She said that if she had not been able to attend the meeting
because of her pregnancy, she would have arranged for a colleague to attend
on her part. She said she was advised that 4 December was the earliest
available date for the DTO Initial Planning meeting to take place.
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343. The DTO Initial Planning meeting was not just an opportunity for the boy to
plan how he could address his offending behaviour. It was an opportunity for
him to see his family, who would have been brought to the YOI by the YOT
worker. In the absence of a Personal Officer, the boy did not seem to
establish a relationship with any particular member of prison staff. He did not
have an opportunity to confide his feelings to anyone other than his family.
Although they wrote to the boy, they could not easily visit him.
344. I am concerned that, on the day the boy was transferred to Windermere Unit,
there was no association for the young people in that unit. This was because
staff were being trained and because three officers were loaned to Buttermere
Unit to guarantee association there. Although I am reluctant to comment
upon the availability and deployment of staff in the establishment, and
therefore make no formal recommendation on the matter, I wish to emphasise
the importance I attach to the avoidance of interruptions to the regime for
young people. I believe this to be especially important in light of the
disturbance that occurred at Lancaster Farms in August 2007.
Summary of findings
345. No information about the boy’s sentence plan and time at Red Bank was
transferred to Lancaster Farms. Neither was the fact that he was placed on
an ACCT at Thorn Cross. Nor was the comment made at Thorn Cross that
the boy should not be placed in any YOI.
346. Neither the YJB National Standards nor the NOMS/YJB Service Level
Agreement nor PSO 4950 determine who is responsible for the transfer of
sentence planning information from one establishment to another following a
recall resulting in a placement to a different establishment.
347. The boy’s DTO planning meeting was not scheduled to take place until 4
December, 19 working days after he arrived at Lancaster Farms. It should
have taken place on or before 22 November.
348. The fact that the boy did not complete all the modules in his induction
programme, lack of contact with his Personal Officer until 25 November, and
the failure to organise a sentence planning meeting on time, suggests that
Lancaster Farms and St Helens YOT failed in their combined duty to help him
make the best use of his short time in custody.
349. Interruptions to the regime for young people should be avoided.
Recommendations
A protocol should be agreed between the YJB and NOMS for the prompt
and efficient transfer of young people’s custodial records when they
move between Secure Children’s Homes, Secure Training Centres and
NOMS establishments. The protocol should make it clear that YOT
workers are responsible for arranging the transfer of such documents.
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The Governor should examine the DTO Initial Planning procedures in
order to ensure that, other than in exceptional circumstances, the
requirement to hold a DTO meeting within ten working days is met.
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The Personal Officer scheme
350. The following guidance for the Personal Officer scheme for young people is
set out at paragraph 5.36 of Prison Service Order 4950:
“Every young person must have assigned to them a personal
officer/caseworker during the induction programme. They must
know who the assigned officer is and the personal officer or
caseworker system must be fully and clearly explained to them.
Arrangements must be made so that the young person knows
who he can contact when the personal officer is absent.”
351. My investigation of the previous death of a young person at Lancaster Farms
examined, in some detail, the Personal Officer Scheme at Lancaster Farms. I
made the following recommendation about the Personal Officer Scheme:
“The Governor should oversee a further review of the Personal
Officer Scheme. This review should clearly state the role of the
Personal Officer. It should also identify a system to ensure that
YOT supervisors and families of young people are appropriately
informed about incidents and events that occur whilst the young
person is in custody in line with YJB National Standards and PSO
4950. The new scheme should promote general dialogue
between the prison and the family of young person so that their
particular circumstances and culture can be better understood.”
352. The Prison Service accepted my recommendation. This investigation into the
boy’s death found that most of the specific objectives included in my
recommendation had been achieved. However, I am disappointed by what we
have discovered about the Personal Officer scheme as it affected the boy. He
was allocated a named Personal Officer on his first night at Lancaster Farms,
but the officer was on leave to be followed by a period of night duty. Thus, the
officer was not due to return to duty for another 17 days. The investigation
found no evidence that an alternative Personal Officer was appointed. This is
unacceptable.
353. My investigators were told that the responsibility for supporting young people
fell to all officers, not just the Personal Officer. I am sure that is right, but that
response misses the point that each young person must have a specific
member of staff to whom he can turn. In effect, the boy had no such person to
turn to until 25 November, three days before he moved to Windermere Unit and
four days before he took his own life. This represents a failure by the
establishment to provide for the boy the level of support he clearly should have
been given. The officer who conducted the boy’s initial reception assessment
recorded that he needed to be “monitored over the initial period”. If ever there
was a role for a Personal Officer, this was it. Although entries were made in the
boy’s wing history showing that staff did interact with the boy, no Personal
Officer was available to him during this crucial time.
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354. The boy’s designated Personal Officer explained that he did not usually consult
a young person’s Asset or casework file unless he had a serious concern about
him. He said that he would do so if a young person’s offending history was
such that he might put others at risk. The Personal Officer said that the
Casework team used the information in the casework file and officers did not
usually access this information. By contrast, the second prison officer said that
officers accessed this information all the time in order to inform the care of a
young person on the wing. However, she explained that the Personal Officer
rarely had an input into the sentence planning procedures. She said:
“ … the Personal Officer should be writing in the wing file and
then we have the wing file with us [at the DTO initial planning
meeting] and we do actually go through the wing file in the
meetings as well, say how he’s been behaving, if there’s poor
behaviour, if there’s good behaviour, it’s all in there. And that’s
the input from the Personal Officer.”
Summary of findings
355. The fact that the boy had not been eating in the early days at Lancaster
Farms, was apparently not associating with other young people, and did not
participate in any activities in the gym, should have been observed and noted
by his Personal Officer or other unit staff. If all these facts had been clearly
documented in his history file, I would have expected a Personal Officer to
follow up this unusual behaviour by talking to the boy and trying to establish
whether he was worried about being bullied.
356. There should be no confusion about the responsibility of unit staff to study
historical information about the young people in their charge, especially that
contained in Asset forms.
357. I think it is unreasonable that the boy was allocated a Personal Officer who was
on leave followed by night duty when appointed, and who was unable to
engage with him until 17 days after the boy’s arrival at Lancaster Farms. It is
unacceptable that no alternative Personal Officer was appointed.
358. Personal officers should take responsibility for ensuring that periods during
which young people are left in their cells with little to do are reduced to an
absolute minimum.
359. At consultation stage the family solicitor offered the following views:
“We submit consideration should be given to making a strong
recommendation that the Personal Officer should have early significant
contact – preferably face to face meeting but at the very least telephone
calls – with the YOT worker and family. This would help the Personal
Officer to understand how the young person deals with things, to pick up
signs of vulnerability, to assess the suitability of placement, if necessary to
make a transfer request and to ensure that appropriate measures are in
place to safeguard the child.”
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Whilst I sympathise with the solicitor’s views, it is clear to me that a
mechanism is already in place to ensure that contact is made at an early
stage of a child’s period in custody between the various agencies and
individuals responsible for his care. This mechanism is the DTO meeting
which, in the boy’s case, did not materialise. Had it occurred, the objectives
listed by the solicitor would in my view have had a good chance of being met.
Recommendations
The Governor should ensure that staff designated to be a Personal Officer
are available when appointed and that arrangements are in place for
temporary cover by an alternative Personal Officer at times when the
original Officer is absent from duty.
The Governor should ensure that Personal Officers familiarise
themselves with the contents of Asset forms relating to each young
person in their charge. Particular attention should be paid by Personal
Officers to information relating to young people’s risks and
vulnerabilities.
The Governor should ensure that the Personal Officer Scheme makes
clear the responsibility carried by officers designated that role for
reducing to an absolute minimum the time young people spend in their
cells with little to occupy them.
Bullying and taunting
360. On the day of the boy’s death, another young person who knew him and who
became upset when he learned of his death, was interviewed by staff. The
young person said:
“The boy was a normal happy person. I spoke to him the other
day at the doctor’s and he was happy. We discussed when he
was getting out and he said he couldn’t wait to get out. I asked
the boy why he stayed in his cell on Buttermere 2 Unit. He said
he was scared of being bullied. I reassured him that no one
would bully him and that I would look after him.
“I last spoke to the boy on Tuesday 27 November 2007 on
association on Buttermere 2 Unit, and he mentioned that he
refused to move units last time and that he didn’t want to move
this time.
“I never saw the boy speaking to anyone else on Buttermere 2
Unit and he would generally stay in his cell for dining and
association. The boy generally came out to use the phone and
the showers. The boy felt scared/intimidated but appeared
generally happy. We had a discussion about being in Red Bank
106
and knew it would be a major culture shock moving from Red
Bank to Lancaster Farms YOI.
“I wasn’t his best mate but I used to talk to him on association. I
don’t think the boy was being bullied. I don’t think the boy spoke
to staff about his problems.
(It is not clear what the boy meant if, as reported, he said he had earlier
refused to move from the unit. The investigation found no evidence that he
had previously been in Lancaster Farms nor that he had refused to move from
Buttermere 2 Unit on a previous occasion during his current sentence.)
361. Another young person who arrived at Lancaster Farms the same day as the
boy said in his police statement that they had met in reception. He added
that, whilst on Buttermere Unit, the boy did not mix with others and stayed in
his cell during meal times and association. He saw the boy when he moved
to Windermere 2 Unit during the afternoon of 28 November but they did not
speak to each other. He recalled gaining an impression that, when he had
met the boy on the first day in reception, he was frightened to be there. None
of the staff who had contact with the boy in the days before he moved to
Windermere Unit said the boy mentioned being scared or afraid. Most said
they had no concerns for the boy.
362. Later on 29 November, after the boy had died, numerous security information
reports were submitted by a range of staff, each alluding to claims from third
parties that the boy had been taunted during the previous night. Some
examples of those claims are shown below.
(cid:1) The boy had received threats from other young people in nearby
cells over a sustained period from about 8.00pm.
(cid:1) One named individual had allegedly told the boy he was going to
“bang him out” (in other words fight with him) the next day.
(cid:1) Unnamed young people had told the boy to “string himself up”
and said they were going to “kick the s**t out of him” the next day
if he didn’t.
(cid:1) The boy had been made to sing and say a nursery rhyme in order
to make him feel “stupid”.
(cid:1) Unnamed young people shouted to the boy words to the effect,
“you victim” and “suck your mum”.
363. Some of the reports contained third party claims that the boy made threats of
his own that he would kill his aggressors when he and they were released.
364. Each of the security information reports was referred to the Lancashire Police
who conducted an investigation into the claims. The police interviewed the
individuals named in the reports. No criminal charges have been brought.
365. My investigation team visited Windermere 2 Unit by night in order to acquaint
themselves with its atmosphere and culture during the dark hours. At about
10.00pm, they witnessed a prolonged period of concerted banging of doors
107
followed by an exchange of insults of a disgusting nature between a number
of young people, most of which seemed to be directed at one particular
individual. My investigators described this experience to the Principal Officer
and asked her if it was common practice. She replied:
“I’m led to believe it is. I’ve never ever done nights in this
establishment and when I’ve come on duty in the morning there’s
either something in the observation book or indeed told to me at the
gate coming in verbally. Yes, it is a regular occurrence.
“I think it’s a gang thing. If there’s somebody new comes on and
they are shouting out of the windows, well it’s not always out the
windows, it can be door to door in the middle you know. They ask
where you come from and I believe it starts then.”
366. The fact that young people often shouted at each other through their cell
windows had been known to the Governor for some time. On 31 July 2007, he
had issued the following notice to staff:
“Shouting out of windows
“Please note that all staff must respond to instances of witnessing a
young person shouting out of a cell window. If the shouting is not
abusive, the residential unit must be informed and a P mark issued
or the young person placed on a minor report. [The letter ‘P’ stands
for poor conduct – staff are authorised to award P marks to young
people for minor infringements of rules. If a young person is given
seven P marks, a manager can then impose a minor punishment
such as the removal of a young person’ s television set from his
cell. Again, I have not studied this system in detail, but my
comments at para 233 refer.]
“If the shouting is abusive, as a minimum, the young person should
be placed on a minor report. If not, the young person must be
placed on adjudication, thus reflecting the seriousness of the
abuse.
“Please note that numbers have now been placed outside cell
windows to help staff identify young people who are shouting out of
the windows and, while it is not always possible to identify the
young person who is shouting, on the occasions when it is, all staff
must action as above to tackle this ongoing unacceptable situation.”
367. This following notice was issued the same day to young people:
“Incidents of racism and homophobia
“Violence in any form is unacceptable. This includes verbal, racist
and homophobic abuse shouted out of windows. You are reminded
that staff at Lancaster Farms will not tolerate any such behaviour.
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“Everyone has a right to be treated with dignity and respect. Whilst
here, you will be expected to behave in a manner which promotes
tolerance and understanding of any other person’s beliefs, skin
colour, gender or sexual orientation.
“If you shout racist or homophobic abuse out of windows, write
insulting words in letters, write graffiti, threaten anyone using words
or actions or indeed assault another person because of their
beliefs, skin colour, gender or sexual orientation, you will be dealt
with accordingly. This will involve a governor’s adjudication, IEP
marking which will affect your incentive level, loss of privileges and
may involve removal from unit. You could also be placed on
Tackling Anti-Social Behaviour procedures.
“Matters of this nature are treated very seriously and any
information could be passed to the police and criminal proceedings
may follow.”
368. In her interview, the seventh prison officer expressed her views about the
bullying problem. She said:
“The gang culture that you’ve got outside is becoming more
prevalent inside prison and because of the overcrowding, the
way boys are moved from prison to prison, we find that if we
get a large group of say the Liverpool lads and the Manchester
lads or the black lads, that comes into play. We have
problems because of that. The culture that’s outside regards
discipline is also followed through in prison. It’s very hard to
deal with in a group basis. There is bullying that goes on. We
are trying our best at the moment to combat the bullying
issues but it’s always a major problem in prisons. And
because of staffing levels it is hard to keep on top of that all
the time.”
369. When asked whether the practice of shouting out of the windows had been a
problem, the seventh prison officer said:
“That has been a problem. We changed what we call the IEP
(Incentives and Earned Privileges) scheme whereby we couldn’t
actually discipline the boys immediately, so if we found a boy
shouting out of the windows we could actually do something at
that point - either pop him away in his room for five minutes to
cool down or we could remove any privileges he may have had
for a short term. It was up to us as individuals on the unit to
deal with it.”
Once more, while I understand the need to respond quickly to acts of
intimidation, my comments at para 233 are relevant.
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370. Other staff to whom my investigators spoke reported that the Governor’s
notices did help to reduce the amount of shouting by day. (And I should make
clear that I welcome the Governor taking the action he did.) Indeed, as my
investigators walked through the establishment during daylight hours, they
noticed very few instances of abusive shouting. However, their experience of
the extremely abusive and threatening behaviour in Windermere 2 Unit showed
that the situation was very different at night. Indeed, during the night of 28/29
November, the staff on duty in Windermere Unit had to deal with two instances
of shouting, as a result of which one young person was placed on a disciplinary
report.
371. My investigators were told that Duty Governors were required to visit the
establishment by night only once a month. I wonder if this is sufficiently
frequent or carries the risk of creating a ‘knowledge vacuum’ within the
managerial team as to the nature and extent of the prison’s nocturnal culture.
If, as may well have been the case, the boy was subjected to abuse during his
first and only night in Windermere 2 Unit, it is very likely that he would have
been frightened.
372. During the course of the investigation, the investigation team leader spent a
brief period at Hindley (another Young Offender Institution that holds juveniles),
primarily to ascertain whether that establishment experienced similar problems
where shouting through windows is concerned. He discovered that the
windows in place at Hindley are designed differently from those at Lancaster
Farms such that they form a sound barrier, limiting the ability of young people
to shout to each other. Staff at Hindley told my investigator the establishment
did experience episodes of bullying as they too had to contend with a gang
culture. They imagined that it was not such a severe problem as at Lancaster
Farms, primarily because of the relative inability of young people to shout
through the windows.
373. At the time of the investigation, Lancaster Farms was operating an anti-bullying
policy known as “TAB” – Tackling Anti-Social Behaviour. A copy of the policy
document was presented to my investigation team. Amongst the examples of
such behaviour listed in the document are intimidation, insults/name calling and
making fun of someone. The document also lists a number of objectives.
These include “the creation of a safe environment for all” and the intention “to
identify and confront all forms of anti-social behaviour”. The following three
further objectives are set out in the document:
(cid:1) The TAB process will be proactive, focussing on targets of anti-social
behaviour in addition to those suspected of anti-social behaviour.
(cid:1) To provide structured support and encouragement for those who are targets
of anti-social behaviour.
(cid:1) To ensure that the whole prison is involved, acting proactively to stamp out
anti-social behaviour at HMYOI Lancaster Farms.
374. As has been said above, my investigation team witnessed first hand through a
night visit many of the forms of anti-social behaviour listed in the TAB policy
document which seemed to be unchallenged. I do not conclude that this is the
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complete picture, but the random night visit to the very unit where the boy died
suggests to me that such behaviour may be common at night. I am not
convinced that the TAB process was as proactive as the authors of the policy
document expected it to be. Neither am I convinced that, in relation to the
nocturnal culture, the level of structured support for those who were targets of
anti-social behaviour was as envisaged by the TAB policy. Although the
Governor had clearly taken steps to reduce shouting through windows during
daylight hours, there was no evidence that the “whole prison” was involved in
efforts “proactively to stamp out anti-social behaviour” at Lancaster Farms by
night.
375. At consultation stage the family solicitor expressed his view
that it was difficult to see how two staff on duty in a young person’s unit could
hope to stop bullying/taunting between 120 children. The solicitor said staff felt
overburdened and were unable to do what was required of them. I disagree.
In my view, it was open to night duty staff to issue at least a verbal warning to
any young person who could be heard shouting and threatening others and to
follow up the warning with appropriate action the following day.
Summary of findings
376. Although nothing has been proven, I am persuaded from the evidence made
available to my investigation team that the boy probably was taunted during the
night of 28/29 November and that this may have contributed to his decision to
hang himself.
377. Notwithstanding the efforts made to reduce the level of day time shouting, it is
alarming that taunting and abuse at night by some young people upon others
has continued. If boys as young as the boy are to be sent to any young
people’s establishment, the nocturnal culture of bullying and intimidation found
at Lancaster Farms must be stopped. This will be no easy task, given the
problems of controlling ‘gang’ oriented behaviour and the ‘macho’ attitudes that
accompany it. Night duty staff should be especially vigilant about safeguarding
of young people new to the unit. If the aspirations expressed in the TAB
document are to be realised, the establishment must make greater effort to
confront and eradicate the problem.
Recommendations
Consideration should be given to the installation of new cell windows
where necessary in any juvenile unit that experiences the level of
shouting discovered at Lancaster Farms in order to reduce the ability of
the occupants to taunt each other. The windows at Hindley are reported
to be effective in this respect.
The Governor should increase the frequency of night visits by senior
managers in order that they can measure any threats to the safety and
security of young people and, in support of unit staff, respond to
examples of anti-social behaviour.
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NOMS should ensure that Governors of establishments holding
juveniles give clear guidelines to staff regarding the need for vigilance
and effective intervention in dealing with taunting, especially by night.
The discovery of the boy hanging
378. For ease of reference, I repeat here the table shown in para 244.
Time Event
7.10.40am A seventh Officer arrives at the boy’s cell and looks through
observation panel.
7.10.47am The seventh Officer runs off to raise alarm.
7.11.15am Landing lights come on.
7.11.20am The seventh Officer returns to the boy’s cell and enters on her
own.
7.11.24am The sixth Prison Officer arrives at cell and enters.
7.11.28am The assistant Orderly Officer arrives at cell and enters.
7.11.30am The OSG arrives at cell and enters.
7.11.47am The OSG leaves cell and disappears from view.
7.11.52am An eighth Officer arrives.
7.11.58am The OSG returns to view, radio in hand (presumably having called
for assistance). Does not enter cell.
7.12.15am A ninth Officer arrives at cell and enters followed by an tenth
Officer who does not enter cell.
7.12.20am An eleventh PO on arrives at cell but does not enter.
7.12.33am The Orderly Officer arrives at cell with the twelth Officer. The
Orderly Officer and the tenth prison officer enter cell. The
assistant Orderly Officer and the eight prison officer leave cell.
7.12.41am The Orderly Officer stands outside cell at doorway.
7.12.52am The ninth and tenth prison officers leave cell.
7.13.18am A thirteenth prison officer arrives at cell.
7.12.22am The sixth prison officer leaves cell.
7.13.27am The seventh prison officer leaves cell.
7.13.32am Cell door pulled to (not locked) by the thirteen prison officer.
7.14.11am The tenth prison officer opens door for a few seconds. He and the
assistant Orderly Officer look into cell.
7.14.26am The tenth prison officer enters cell.
7.14.37am The Orderly Officer enters cell, having appeared to take a piece of
equipment (? mouthpiece) from the assistant Orderly Officer.
7.14.47am The Orderly Officer leaves cell briefly then returns. The assistant
Orderly Officer, the sixth and eighth prison officers seen standing
outside cell.
7.15.19am A Healthcare Nurse and a HCA arrive at cell and enter
immediately.
7.15.46am The Healthcare Nurse appears at entrance to cell and asks for
something.
7.22.38am The seventh prison officer returns to view. Looks in cell but does
not enter.
7.22.58am The seventh prison officer leaves area.
7.23.23am The assistant Orderly Officer opens fire exit next to cell (?to
facilitate access by ambulance crew).
7.25.26am The tenth prison officer leaves cell.
7.25.42am The tenth prison officer re-enters cell.
7.26.35am The tenth prison officer leaves cell again.
7.26.59am The tenth prison officer re-enters cell.
7.27.25am The tenth prison officer leaves cell.
7.27.58am Paramedics arrive and enter cell.
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379. Although the times shown are different from those recorded in the control
room log which are reportedly four minutes ahead, they represent the delays
described below with pinpoint accuracy.
Delay in applying emergency first aid
380. After discovering the boy during her morning count, the seventh prison officer
promptly requested assistance and went into the boy’s cell. The ligature was
quickly cut and removed from the boy’s neck, and he was placed in the
recovery position. However, at this point none of the staff present began
CPR. The ninth prison officer thought this might have been because they
were “shell shocked”. At interview the sixth prison officer, assistant Orderly
Officer and the seventh prison officer all said that they thought the boy was
dead. Both the assistant Orderly Officer and the seventh prison officer said
that they considered administering CPR but, as they were not first aid trained,
they thought they would do more harm than good. The seventh prison officer
pointed out that she positioned the boy on the floor and placed her hand on
his chest because she knew that CPR would have to take place. When asked
if she did administer CPR she said she did not, “because by that point, the
tenth prison officer was in the cell, there were other people by the door and in
the background I could hear that somebody was calling for medical
assistance.” She added that she was concerned that she might hurt or injure
the boy.
381. The table above shows that there was a delay of over three minutes between
the time the seventh prison officer first entered the boy’s cell (7:11:20am) and
the time the tenth prison officer re-entered the cell after realising that staff had
a duty to attempt resuscitation. When the boy was checked for signs of life,
he was not breathing and had no pulse. However, his body was still warm.
382. I accept that the staff concerned were likely to have been in shock and may
not have been properly trained in the administration of CPR. However, I
consider they were wrong in assuming that the boy was already dead and,
even without training, they should have made attempts to revive the boy
without delay.
383. The following guidance to staff who discover a life threatening situation is set
out at Annex 13A of Prison Service Order 2700 issued in October 2007:
“If the prisoner is not breathing and/or no pulse is present, clear
the airway and attempt resuscitation using a face mask with a
non-return valve, unless rigor mortis of the limbs has clearly set
in.”
384. Local contingency plans to be followed by staff who discover self-harm by
strangulation also give a clear instruction that resuscitation should be
attempted in order to save life.
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385. There is no evidence that rigor mortis had set in when the boy was discovered
hanging. I believe, therefore, that there is no question but that attempts to
resuscitate the boy should have been made straightaway. This is
notwithstanding the seventh prison officer’s concern that she was not trained
in emergency first aid, and her fear that she might have done more harm than
good by applying CPR. The seventh prison officer’s concerns may well have
been shared by the other staff who were present, and I do not underestimate
the sense of shock they would all have felt. However, in many of my
investigations I commend prison staff for the speed with which they
commence CPR in situations which are no less shocking. I make no formal
recommendation about what happened on this occasion, but leave it to the
Governor at Lancaster Farms to decide whether, at this late stage, those who
failed to attempt to resuscitate the boy as soon as he was found should be
subject to a disciplinary investigation. At the inquest into the boy’s death, the
Coroner may wish to seek answers from witnesses better qualified than I to
judge whether the boy’s life could have been saved. (At consultation stage,
NOMS confirmed that a formal investigation would be conducted and that it
would be a led by a manager external to Lancaster Farms.)
Delay in calling an ambulance
386. A protocol was established in August 2004 between Lancaster Farms and the
Lancashire Ambulance Service NHS Trust. The protocol sets out that:
“The critical factor in survival rates is the time it takes a trained
paramedic to reach the patient … it is not necessary for the prison
healthcare team to be present at the scene before emergency
services are called.”
387. It appears that an ambulance was not called until the thirteenth prison officer
requested one from the Windermere 2 office, after the boy’s cell door was
shut. According to the CCTV footage, the call for an ambulance would
therefore have been made shortly after 7.14am, three minutes after the
seventh prison officer first entered the boy’s cell. This time accords with that
shown on the Lancashire Ambulance Service Patient Record, which shows
that they received a call at 7:14:36am. In my view, an ambulance should
have been called as soon as the seventh prison officer entered the boy’s cell
and found him hanging.
388. The local contingency plan for managing life threatening situations does not
contain any instructions to staff about calling an ambulance. This is
unsatisfactory.
Confusion over who was in charge when the boy was discovered
389. A SO was the orderly officer during the night of 28/29 November and was in
charge of the establishment. In this role he was given the radio call-sign
Oscar 1 (nights). The tenth prison officer was the permanent orderly officer
during the daytime. His call-sign was Oscar 1 (days). The tenth prison
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officer’s shift officially started at 7.30am, although he told my investigator he
usually comes on duty earlier so that he can avoid traffic congestion.
390. An additional Principal Officer started duty at 6.30am to supervise court
discharges, taking the role of Oscar 1 (days) until handing over to the tenth
prison officer at about 7.30am. On 29 November, the thirteenth prison officer
was Oscar 1 (days) from 6.30am.
391. At interview, the thirteen prison officer said he did not realise the tenth prison
officer was in the prison on 29 November until he saw him at the boy’s cell.
However, the thirteenth prison officer was clear that he was the orderly officer
at that time and that he was in possession of the correct radio.
392. The tenth prison officer confirmed he was not the orderly officer at that time.
However, he said nobody was in charge at the scene “until there was no more
we could do for the boy,” and he then assumed control. When the thirteen
prison officer arrived at the cell, they had a discussion, and divided the
responsibilities. In any emergency, normal procedures tend to fray. However,
there should be no doubt about who is in charge in such circumstances. The
determination of who is in charge should not pivot around the limits of what
can be done to save a young person’s life.
393. The Orderly Officer said that he was still identified on the radio net as Oscar 1
(nights) when the thirteen prison officer arrived to manage the court
discharges. He told my investigator, “At that point I don’t know whether he is
in charge of the prison or I’m in charge of the prison.”
Roll checks
394. Section 2.76 of the security strategy in place at Lancaster Farms at the time of
the investigation instructed that night staff should carry out a roll check
between 10.30pm and midnight and a further check between 5.45am and
6.15am.
395. The investigation found that, contrary to the security strategy, no roll check
was conducted between 10.30pm and midnight on 28/29 November.
Pegging
396. The security strategy in place at Lancaster Farms at the time of the
investigation required night staff “to carry out pegging as directed by the night
orderly officer”. But there was no guidance as to how regular or often the task
was to be completed. The investigation found that during the night of 28/29
November, Windermere 2 Unit was pegged at 10.00pm, 4.30am and 5.30am.
At interview, the OSG said that pegging was to be carried out twice in each
hour at random intervals. However, this does not accord with what actually
occurred.
Summary of findings
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397. During the night of 28/29 November, roll checks were not carried out in
accordance with local instructions.
398. The instructions contained in the local security strategy at the time of the
investigation for pegging by night staff did not clarify how frequently the task
should be completed.
399. Of those staff present at the boy’s cell, only the Orderly Officer and the ninth
prison officer had been trained in emergency first aid and had up to date
qualifications. The tenth prison officer said he used to be a first aider but had
not had any refresher training for a number of years.
400. As I have pointed out in many of my reports following deaths in custody,
speedy intervention by properly trained and qualified staff can make the
difference between life and death. In the boy’s case, I am unable to say
whether earlier administration of CPR would have saved his life. However, I
believe that the staff were wrong to assume that he was already dead. I also
believe it is essential that officers have the knowledge and confidence to carry
out CPR effectively. Such skills can only be maintained by regular training.
401. The following comments are made on this matter at paragraph 7.12 of the
clinical review:
“The CCTV footage shows there was a delay of between 3 and 4
minutes before CPR was commenced. The professional advice
available to the panel stated clearly that in such circumstances CPR
should be commenced immediately and that is consistent with prison
policy. On the basis of the evidence available, the panel were unable to
conclude whether immediate resuscitation may have produced a
different outcome.”
In addition to those comments, I make the stronger point that PSO 2700 is
perfectly clear on this issue: it says that, when dealing with a life-threatening
situation, staff should always attempt resuscitation unless rigor mortis has set
in.
402. The three minute delay in calling an ambulance was also unacceptable. An
ambulance should have been called as soon as staff entered the boy’s cell
and found him hanging. (I note that at paragraph 8.10 of the clinical review,
the panel concur.) The local contingency plans for managing a life
threatening situation contain no instructions to staff about calling an
ambulance.
403. When the boy was discovered hanging, there were two different orderly
officers on duty with the same call-sign. There should be no doubt about who
is in charge. Nor should the determination of who is in charge pivot around
the limits of what can be done to save a young person’s life. Although this did
not adversely affect the manner in which the emergency was managed, it did
cause confusion between the individuals concerned. This situation should be
avoided at all costs in the future.
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Recommendations
The Governor should remind night duty staff that roll checks must be
carried out at the times set out in his local security strategy.
The Governor should review his local security strategy to ensure that it
clearly instructs staff about the frequency of pegging.
The Governor should ensure that his contingency plans for the
management of a life threatening emergency reinforce the point, clearly
set out in PSO 2700, that an attempt at resuscitation should always be
made unless rigor mortis has set in.
The Governor should ensure that his contingency plans contain clear
guidance about the importance of calling for an ambulance promptly
and about the method of doing so.
The Governor should ensure that appropriate staff who are in contact
with prisoners receive proper initial and refresher training in the
administration of emergency first aid.
The Governor should issue a notice clarifying to staff who takes the role
of Orderly Officer between 6.30am and 7.30am.
The communication of the boy’s death to his aunt and uncle and the contact
with them thereafter.
404. I applaud the Governor’s decision to take personal charge of the responsibility
for informing the boy’s family, and for the manner in which he demonstrated
leadership by being visible to his staff after the boy had died. Although four
hours elapsed before the news of the boy’s death was communicated to the
family, I believe that the Governor’s decision not to leave the establishment
for the family home until he had gathered the necessary information about the
boy, and until the chaplain and the representative from the St Helens YOT
could accompany him, was justified in the circumstances. The boy’s uncle
and aunt have expressed their concern that they were initially told that the boy
was in intensive care and was okay. My investigator checked this point with
the Governor. He categorically denied saying anything of the sort himself,
and was of the view that it was highly unlikely that any of his staff would have
said so.
405. However, the boy’s uncle and aunt have said that their distress at viewing the
boy’s body was exacerbated by the fact that no one from the prison was there
to support them after allegedly promising to do so. Both the Governor and the
establishment’s Family Liaison Officer expressed the view that there had been
a misunderstanding within the Coroner’s office about who was to attend.
Nevertheless, the prison FLO has quite properly expressed his regret at any
distress this confusion may have caused.
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406. Notwithstanding the above points, I am pleased to be able to record that when
the boy’s family met my Senior Family Liaison Officer and investigation team
leader, they confirmed that they thought the staff at Lancaster Farms had
done all they could in the aftermath of the boy’s death, describing them as
“fantastic and 100 per cent helpful”.
407. Sadly, the boy’s funeral could not take place until 16 June 2008, some seven
months after he died. Throughout the intervening period, contact was
maintained between Lancaster Farms and the boy’s family. The Governor
offered to meet the full costs of the boy’s funeral and sent representatives to
the service.
Summary of findings
408. Although it was four hours before the news of the boy’s death was shared with
his family, I believe that the Governor’s decision not to leave the
establishment for the family home until he had gathered the necessary
information about the boy, and until the chaplain and the representative from
the St Helens YOT could accompany him, was justified in the circumstances.
409. When the boy’s family met my Senior Family Liaison Officer and investigation
team leader, they said they thought staff at Lancaster Farms had done all they
could in the aftermath of the boy’s death.
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FAMILY CONCERNS NOT COVERED IN MAIN BODY OF REPORT
Why was the first visiting order sent to the family left blank?
410. My investigators were unfortunately unable to clarify what led to this reported
error. Included amongst the documents presented to my investigation was a
copy of the boy’s record of letters and visits. They show that the boy applied
for only one visit while he was at Lancaster Farms. The visiting order was
sent to his aunt and uncle on 23 November so that they could visit him at any
time in the following 28 days. The records show that no visit took place
thereafter.
Why was the family told that the boy had self-harmed and was “okay in
intensive care”?
411. My investigators failed to ascertain who may have imparted this information.
In a telephone conversation with the then Governor, he said he could clearly
recall what he said to the family and was adamant that he did not say that the
boy was “okay in intensive care” or any other words that could have been
similarly construed.
Was the boy strip searched everywhere he went at Lancaster Farms?
412. At the time of the investigation, young people were routinely strip searched as
a normal feature of the initial reception procedures. They were only strip
searched on other occasions if they were suspected of presenting a risk to
security. In such circumstances, they could only be strip searched on the
express and written authority of the Orderly Officer or Duty Governor of the
day. Details of the search had to be recorded in the young person’s record.
No such detail was found in the boy’s history sheet.
Was the boy subjected to cold showers?
413. As far as being subjected to cold showers is concerned, my lead investigator
was told that young people at Lancaster Farms normally take their showers in
the dedicated shower room in each unit. They do so behind a privacy screen
and are monitored from a distance by an officer. If the showers were cold at
any time the boy was at Lancaster Farms, it is likely that the supervising
officer would have known or that the boy would have made a complaint. The
boy’s files contain no record of any complaints by him on any matter. The
word, “subjected” carries with it the notion that the boy was forced to have
cold showers. I can report that the investigation found no evidence of this.
Whilst it is, of course, possible that such behaviour can go undetected, I have
no reason to believe that anyone in authority at Lancaster Farms would have
treated the boy in this way.
Did an officer sit with the boy during phone calls?
414. With regard to the suggestion that an officer sat in with the boy when he made
a telephone call, I can report that the investigation found no evidence of this.
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When making personal telephone calls, young people at Lancaster Farms are
expected to use the telephones provided for them in the units. When the boy
was at Lancaster Farms there was one such telephone on each of the
landings in Buttermere and Windermere Units. Although the telephone is
inside a booth, it is highly unlikely that a young person’s conversation will be
overheard given the normal noise level in the unit. Prison officers do not
station themselves near the telephones. However, if the boy was at any stage
allowed to use an official telephone, then a member of staff would have been
with him when he made the call.
The boy claimed that an unnamed young person swore at him and threatened
him. The boy also claimed that prison officers threatened him. Are these
claims true?
415. In the absence of any further details it has not been possible to investigate
these reports
Was the boy frightened that he would be subject to a gate arrest on the day of
his release?
416. My investigators were told by the police after the boy’s death that he knew he
faced a further charge and that he could have been arrested upon or after his
release. However, there was no evidence that the boy told staff that he was
afraid.
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SUMMARY OF FINDINGS AND CONCLUSIONS
417. The investigation has highlighted some critical systemic failures relating to the
manner in which the boy’s placement at Lancaster Farms was decided upon,
and to aspects of his management in the establishment before he died. Most
shocking of all my findings is that relating to the response to the discovery of
the boy hanging, when there was a significant delay in administering
emergency first aid by some staff and a delay in calling an ambulance.
418. The decision to place the boy at Lancaster Farms was not informed by any
assessment of his ability to cope with the establishment’s subculture which,
especially by night, was characterised by cruel taunting of some young people
by their peers.
419. Detailed information about the boy’s experiences at Red Bank was not
passed to Lancaster Farms in time to be taken into account by reception and
induction staff. During the reception process, little attention was paid to the
information that was available about the boy, principally in his Asset form. His
risk of self-harm or suicide took no account of any such historical evidence.
420. The induction process seemed mechanistic and more suited to the needs of
the establishment than to those of individual young people. The boy’s first
night interview was conducted in an open area within earshot of other young
people, thereby putting at risk the confidentiality that such an important
interview should attract. This is not the approach to the care of a young
person that I would expect.
421. The officer appointed as the boy’s Personal Officer was on leave followed by
night duty when appointed. Nobody was asked to cover the officer‘s absence.
Thus, for most of his time at Lancaster Farms, the boy had no identifiable
reference point amongst the staff to whom he could turn for help and with
whom he could build a relationship. I criticised the Personal Officer scheme
at Lancaster Farms in the context of a previous self-inflicted death of a young
person there. I should not have found it necessary to do so again. During his
time in the induction unit, the boy hardly left his cell. Little effort was made to
discover why. Had a Personal Officer been available to him, the boy’s fears
of being bullied might have become known and managed.
422. Despite the fact that the boy did not complete all the induction modules, he
was deemed ready to transfer out of the induction unit on 28 November, a day
when all young people had to be locked in their cells to enable staff to attend
a training programme. The investigation found that one particular officer went
out of his way to help the boy settle into his new unit. However, the boy was
unable to mix with anyone else because of the lockdown during the day and
because of the absence of any association during the evening.
423. The sentence planning, or DTO, meeting that should have taken place within
ten working days of his arrival at Lancaster Farms, was not scheduled until 4
December 2007. It never happened because the boy had died six days
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earlier. The opportunity was lost to plan how to use his time in the
establishment and to prepare for his release.
424. Some of the staff who found the boy hanging early in the morning of 29
November were untrained in the administration of emergency first aid. There
was delay of over three minutes before emergency first aid was applied.
There was a similar delay in calling for an ambulance. I am shocked by these
findings. I leave it to the Governor to decide whether, at this late stage, the
staff involved should be subject to a disciplinary investigation.
425. I have commended the Governor for taking personal charge of the
responsibility for breaking the news of the boy’s death to the family, and for
the manner in which he demonstrated leadership by being visible to his staff
after the boy had died. Although four hours elapsed before the family were
told, I believe that the Governor’s decision not to leave the establishment
immediately for the family home was justified in the particular circumstances.
426. I have reported that the boy’s family have told my Senior Family Liaison
Officer and investigation team leader that staff at Lancaster Farms did all they
could in the aftermath of the boy’s death.
427. The investigation found direct evidence of taunting by some young people
through cell windows at night. I believe this may have contributed to the boy’s
death. This is a culture that must be rigorously challenged, not only at
Lancaster Farms but at any other NOMS establishment that holds young
people.
428. When considered individually, each of the above findings and conclusions is
significant. When considered together, they demonstrate a lamentable
standard of care for a vulnerable 15 year old boy in the charge of the state.
429. In light of the seriousness of the matters raised in this investigation, I believe
that a copy of this report should be considered at the highest level. I am
recommending therefore that copies be sent to the Secretary of State for
Justice and the chair of the Justice Select Committee.
Recommendation
Copies of this report should be sent to the Secretary of State for Justice
and the chair of the Justice Select Committee for their consideration.
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RECOMMENDATIONS
Recommendations made jointly to the Youth Justice Board and NOMS
1. A protocol should be agreed for the prompt and efficient transfer of young
people’s custodial records when they move between Secure Children’s
Homes, Secure Training Centres and Prison Service establishments. The
protocol should make it clear that YOT workers are responsible for arranging
the transfer of such documents.
2. Consideration should be given to the implementation of a system for the
effective transfer of information when a young person serves his sentence in
more than one location, whether that be a Secure Children’s Home, a Secure
Training Centre or a YOI.
At consultation stage, in response to these two recommendations, the YJB
commented as follows:
“The YJB has developed an electronic sentence management system
(e.Asset) for all children and young people within the secure estate that
enables all sentence management information to be shared electronically by
secure estate staff between secure establishments. The responsibility for this
process rests with the secure estate staff and not with YOT worker, as secure
estate staff have responsibility for managing eAsset and also because it is the
secure estate, with the authorisation of the YJB Placement and Casework
Service, that undertake transfers within the secure estate. All transfers are
managed through the transfer protocol which has been developed by the YJB
Placement and Casework Service. Service Level Agreements and contracts
between the YJB and secure estate providers also outline the process for
transferring children and young people between establishments. To further
reinforce this process, revised National Standards (anticipated to come into
effect on 30 November 2009) now include a requirement for the secure estate
to use eAsset to send sentence management information from the transferring
establishment to the receiving establishment in advance of the transfer, where
possible, or at the latest within one hour of the transfer taking place. This
covers young people on remand, on DTOs and on long term sentences.”
3. Copies of this report should be sent to the Secretary of State for Justice and
the chair of the Justice Select Committee for their consideration.
Recommendations to the Youth Justice Board
1. Urgent steps should be taken to ensure that placement decisions are made in
accordance with the criteria explained on the YJB website. Placement
recommendations and decisions must be informed by an assessment of
young people’s ability to cope with the physical and cultural environment of
the establishments under consideration. Placement recommendations and
decisions should also take account of all available information about the
young people under consideration including home circumstances, Asset
details, vulnerabilities and risks, as well as any relevant suggestions made by
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staff in the establishments in which young people may already have been
held.
At consultation stage, the YJB provided the following response:
“The YJB is confident that placement decisions are made in accordance with
the stated criteria. Factors in placement choice also include competing
demand for non YOI places. The YJB is satisfied that during the placement of
the boy at Lancaster Farms, sufficient attention was given to this decision in
the light of the boy’s individual needs and risks to himself and others. YOI’s
have been established to provide a safe and secure regime for young people
of the boy’s age and maturity. There are robust procedures in place to allow
either a YOT or staff at a YOI to discuss the placement following admission if
there are concerns as to the young person’s safety. This placement was as a
result of a breach of the community part of the DTO and as such the YOT
were fully aware of he circumstances surrounding this and clearly advised the
court that a return to custody was the most suitable option in relation to the
breach. The fact that the boy had served previously in a Secure Children’s
Home (SCH) does not mean that a Secure Training Centre (STC) place was
the most suitable as it would have meant a placement further from home,
something the YOT felt would not be helpful.
“The YJB had a conversation with the YOT on the day of sentence to discuss
whether a place at an STC or SCH would be preferable. The YOT re-stated
their view that Lancaster Farms would be the most suitable placement for the
boy.”
2. Consideration should be given to the remodelling of the Asset form for easier
use in a custodial environment so that critical information such as self-harm
risk is clearly visible.
At consultation stage, in response to this recommendation, the YJB commented as
follows:
“The YJB recognises that assessment processes need to assist practitioners
in identifying young people who may be at risk of committing self-harm or of
attempting suicide. The YJB is currently reviewing the assessment tools used
by youth justice practitioners and developing an assessment strategy which
will set out plans for future improvements in assessment processes and
practice. One of the aims of the strategy will be to ensure that there is a
closer integration of the assessment and planning processes used in the
community with those used in the secure estate. There will also be a number
of changes to the design and content of assessment tools like Asset and this
will include ensuring that significant risks and concerns, such as those
relating to self-harm, are recorded in a clear and more visible way.”
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Recommendations to the North Lancashire Primary Care Trust
1. Those staff responsible for completing healthcare screens should pay full
attention to the information contained in Asset forms, especially where the
assessment of self-harm or suicide risk is concerned.
2. Urine samples should be taken during first reception health screens in order
to inform decisions about young people’s needs for detoxification or other
appropriate substance misuse interventions.
3. Healthcare staff conducting first reception health screens should, where
necessary, make an immediate referral of young people with a recent history
of substance misuse to a doctor and to the Young People’s Substance Misuse
Service so that decisions about detoxification and other interventions can be
made without delay.
Recommendations to NOMS
1. Consideration should be given to the installation of new cell windows in any
juvenile unit that experiences the level of shouting discovered at Lancaster
Farms in order to reduce the ability of the occupants to taunt each other. The
windows at HMYOI Hindley are reported to be effective in this respect.
2. Governors of establishments holding juveniles should give clear guidelines to
staff with regard to the need for vigilance and effective intervention in dealing
with taunting, especially by night.
Recommendations to the Governor of Lancaster Farms
1. The Governor should take urgent steps to ensure that, in keeping with
paragraph 5.4 of PSO 4950, systems are in place to record accurate details of
which forms have been received in reception and that missing documents are
requested through the YJB.
2. The Governor should satisfy himself that there is no impediment to opening
ACCT forms, such as the perception by staff that forms will be closed at such
a speed as to render their use pointless. ACCT forms should remain open
until staff are satisfied that all issues have been identified and effectively
managed through appropriate case reviews. Relevant training should be
offered to staff in this regard.
3. The Governor, in conjunction with the PCT, should ensure that those staff
who carry out cell sharing risk assessments take into account relevant
historical information about a young person, such as that which may be
contained in Asset forms.
4. The Governor should take steps to improve the décor and image of the
reception building in order to create an atmosphere of warmth and welcome.
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5. The Governor should ensure that all first night interviews take place in
conditions of privacy and sensitivity.
6. The Governor should ensure that official contact with young people’s next of
kin is made within the 48 hour timescale laid down in PSO 4950 unless there
are exceptional reasons for not doing so.
7. The Governor should require his induction staff to familiarise themselves with
the culture and ethos of Secure Children’s Homes and Secure Training
Centres so as to improve the quality and style of the induction of young
people at Lancaster Farms.
8. The Governor should consider the introduction of a peer support system
through which newly arrived young people can be helped to settle during their
early days.
9. The Governor should ensure that all elements of the induction programme for
young people are delivered within appropriate timescales.
10. The Governor should ensure that the education assessment is completed as
part of the induction programme.
11. The Governor should ensure that a brief summary of all interviews and
assessments carried out during the induction process is entered on young
people’s history sheets.
12. The Governor should examine the DTO Initial Planning procedures in order to
ensure that, other than in exceptional circumstances, the requirement to hold
a DTO meeting within ten days is met.
13. The Governor should ensure that staff designated to be a Personal Officer are
available when appointed and that arrangements are in place for temporary
cover by an alternative Personal Officer at times when the original Officer is
absent from duty.
14. The Governor should ensure that Personal Officers familiarise themselves with
the contents of Asset forms relating to each young person in their charge.
Particular attention should be paid by Personal Officers to information relating
to young people’s risks and vulnerabilities.
15. The Governor should ensure that the Personal Officer Scheme makes clear the
responsibility carried by officers designated that role for reducing to an absolute
minimum the amount of time young people spend in their cells with little to
occupy them.
16. The Governor should increase the frequency of night visits by senior managers
in order that they can measure any threats to the safety and security of young
people and, in support of unit staff, respond to examples of anti-social
behaviour..
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17. The Governor should remind night duty staff that roll checks must be carried
out at the times set out in his local security strategy.
18. The Governor should review his local security strategy to ensure that it clearly
instructs staff about the frequency of pegging.
19. The Governor should ensure that his contingency plans for the management
of a life threatening emergency reinforce the point, clearly set out in PSO
2700, that an attempt at resuscitation should always be made unless rigor
mortis has set in.
20. The Governor should ensure that his contingency plans contain clear
guidance about the importance of calling for an ambulance promptly and
about the method of doing so.
21. The Governor should ensure that appropriate members of staff who are in
contact with prisoners receive proper initial and refresher training in the
administration of emergency first aid.
22. The Governor should issue a notice clarifying to staff who should take the role
of Orderly Officer between 6.30am and 7.30am.
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