The coroner in the inquest of 16-year-old Gareth Price has written to authorities highlighting their respective failures to prevent his death.
Dr James Adeley has made a series of recommendations under Rule 43 of the Coroner’s Rules 1984, which gives coroners the power to recommend action to prevent similar fatalities following an inquest.
An inquest jury last month found 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.
In a letter to County Durham youth engagement service, Adeley pointed to “wide ranging and extensive failings” including a lack of management action to address staff workloads during 2003-5. A worker who visited Gareth in prison in October 2004 “did not feel it necessary” to ask him questions regarding his emotional wellbeing or mental health. As a result, Gareth’s self-harm attempts were missed, Adeley said.
“In the view of evidence that I have heard the actions of County Durham youth engagement service amount to little more than going through the motions whilst contributing nothing of substance either to the welfare of Gareth Price, his family or the criminal justice system as a whole,” Adeley’s letter said. The coroner asked for confirmation of what action had been taken to address the issues.
In a letter to Gill Rigg, director of children’s integrated services at Lancashire Council, Adeley also raised concerns over management failings by Lancashire Council and Lancashire youth offending team.
The coroner also wrote to the Youth Justice Board with concerns about documentation. He said YJB documents on remand services and the role of YOTs were “arcane and unintelligable” to people who were not familiar with the workings of the system.
The Ministry of Justice and Lancashire and Durham councils have all said they will consider the coroner’s recommendations.
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