The inquest into the death of an 18-year-old care leaver in custody has been slammed as a “pointless exercise” by his family after the jury reached an open verdict without seeing key evidence.
Daniel Nelson was found hanging in his cell at Doncaster Young Offender Institution in September 2005. Following the eight-day inquest in Doncaster that concluded last week, his family said they were “devastated” that the coroner did not give the jury an investigation report by the prisons and probation ombudsman. This found there should have been “more robust measures” to prevent his death.
Daniel’s sister Lisa Clarke told Community Care: “Daniel went into custody alive and three weeks later he was dead. The open verdict means there are still no answers as to why this happened. The jury could not decide and were given limited information.”
Daniel was placed in the care of his aunt aged 10. He left his aunt’s home at 16 and went to live on his own. “His life just spiralled and everything got on top of him,” Clarke said.
Daniel was remanded at Doncaster YOI on 25 August 2005 for alleged possession and supply of class A drugs. There his behaviour became erratic, despite his having no history of mental health problems.
Ruth Bundey, the solicitor for Daniel’s family, said his personal adviser at Leeds social services did not discover he was in custody until 31 August. The adviser made an appointment to see Daniel on 25 September but Bundey said he did not pass on information from social services.
Daniel was taken to Doncaster YOI’s healthcare unit after he expressed paranoid thoughts “that staff were going to hang him”. What happened afterwards was a “catalogue of disasters,” according to Bundey.
She claimed “no proper effort” was made to contact Daniel’s family, and said he should have been put under constant observation. A psychiatrist visited Daniel but could not see or hear him properly through the perspex sheet fitted on the cell door.
“The jury was in a muddle and failed to decide whether Daniel had a wish to die or whether his actions were a cry for help that went wrong,” Bundey said. “After two years of investigation we still don’t know and this is dreadful for the family.”
The family is exploring legal routes to take the case forward. “I just want someone to take responsibility for what happened to Daniel,” Clarke said.
A Leeds Council spokesperson said the council will look at any inquest recommendations.
A report by charity Inquest due next month is expected to recommend that coroners should refer bereaved families to support services including social workers and counsellors. It will also call for better training for social workers and other professionals in understanding the inquest system. More rights for bereaved families have been proposed as part of a future coroner reform bill.
Inquest begins to care leaver who died in custody
Inquest statement on Daniel Nelson case