Agencies including youth offending teams, prison and psychiatrists collectively failed to prevent the death of 16-year-old Gareth Price, an inquest ruled today.
Individuals and managers missed numerous opportunities to intervene in Gareth’s life before he was found hanging in his cell at Lancaster Farms young offender institution in January 2005, the jury found.
Youth offending team services failed to arrange meetings for Gareth, documentation was incomplete and there was “haphazard communication” between services.
The boy’s family solicitor “did nothing” with a psychiatrist’s report that warned of the risk Gareth posed to himself around the time of his sentencing, the narrative verdict said.
Post-traumatic stress disorder
Gareth had received counselling for symptoms of post-traumatic stress disorder when he was 14 after a series of bereavements, the inquest was told. But warnings in two expert reports that Gareth would attempt suicide around his sentencing date were ignored.
The jury found the psychiatrist who had concluded Gareth was at risk “assumed incorrectly” that her report would be shared with relevant agencies. Another report by a prison psychologist highlighting the boy’s risk of self-harm was lost in the internal mail.
Gareth was on remand awaiting sentence for rape at the time of his death. During his five months in prison, self-harm and suicide warning forms were opened for Gareth four times, but his parents were never told.
Suicide prevention training for prison officers was “inadequate” and health staff failed to monitor Gareth’s mental health after self-harm episodes, the jury concluded.
Coroner Dr James Adley is to write to the authorities concerned with recommendations to prevent similar deaths.
Dr Adley said: “What appals me about this death is the number of organisations and individuals who missed opportunities to intervene in Gareth Price’s life.
“This wasn’t a single missed opportunity but covered prison and community youth offending teams who failed both on a managerial and individual basis, to psychiatrists, psychologists, solicitor and the prison.”
After today’s verdict, Gareth’s family said: “We will never understand why every agency involved in Gareth’s care knew he was self-harming and suicidal, yet nobody told us. If everyone involved with Gareth had done their job properly he might not have died.”
Call for inquiry
Campaign group Inquest called for a full public inquiry into the youth justice system following today’s verdict.
In response, a Ministry of Justice spokesperson said: “Every death in custody is a tragedy, and our sympathies are with Gareth’s family. Every death in prison affects families, staff and other prisoners deeply. Ministers, the Ministry of Justice and the Prison Service are completely committed to reducing the number of such tragic incidents. Learning from deaths in custody is a key strand of the prisoner suicide prevention strategy, and we will be carefully considering the verdict to see what lessons can be learnt from Gareth’s death.”
Gareth is among 30 children to die in custody since 1990, including Liam McManus at Lancaster Farms YOI in November last year.
15-year-old found dead at Lancaster Farms