Agencies including youth offending teams, a prison and psychiatrists collectively failed to prevent the death of 16-year-old Gareth Price, an inquest ruled last week.
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.
Youth offending team services failed to arrange meetings, documentation was incomplete and there was “haphazard communication” between services, the jury found.
The boy’s family solicitor “did nothing” with a psychiatrist’s report that warned of the risk Gareth posed to himself, though the psychiatrist should have ensured the information was shared with other agencies, the verdict said.
In the time leading up to Gareth’s death, staff at County Durham youth engagement service had a high workload and efforts to alleviate this were “ineffective”.
Lancashire Council youth offending team employed untrained temporary staff, while systems used by Lancaster YOT were “not coherent”, the jury found.
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.
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.
Gareth was on remand awaiting sentence for rape at the time of his death. After the 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.”
The coroner is to write to authorities with recommendations to prevent similar deaths.
The Ministry of Justice, and Lancashire and Durham councils all said they would consider the recommendations.
Campaign group Inquest called for a full public inquiry into the youth justice system following the verdict.
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