Catalogue of failures led to Liam McManus’ death

The Youth Justice Board and St Helens Council’s social services have been slammed by jurors at an inquest into the death of 15-year-old Liam McManus, who hanged himself at Lancaster Farms young offender institution in November 2007.

McManus (pictured) died with just 23 days left to serve of a sentence for breaching the terms of his licence. Jurors at the inquest today found “systemic failings” in both the prison and the community had contributed to the teenager’s death.

The Youth Justice Board was criticised by jurors for adopting a “target driven and top-down” approach, rather than a caring culture that addressed the individual needs of vulnerable children.

St Helens social services also came under fire for a decision to introduce McManus – who had spent time in care as a young child and lived with his aunt and uncle – to his birth mother. She lived a “chaotic lifestyle” but, despite this, McManus’ file was closed shortly afterwards due to staff shortages.

Call for public inquiry

Following the verdict, Mark Scott of Bhatt Murphy Solicitors, who represented McManus’ aunt and uncle at the inquest, called for a public enquiry into state treatment of vulnerable children who offend.

McManus, who had a history of self-harm and vulnerability, was known to both social services and the youth offending service (YOS).

The coroner reported “serious inadequacies” in St Helens social services’ handling of McManus’ case. Significant documents were lost and his file closed just before he went into custody, under the assumption that McManus would be safeguarded by the prison.

But the jury heard he received no visits from social services or the YOS over his 22 days in prison, due to “illness, sickness, absence and confusion” among staff and despite letters to friends and family in which the teenager asked when his youth offending team would visit.

The jury’s written verdict stated: “None of these links or positive factors were maintained and this contributed to the actions of Liam McManus that led to his death.”

Necessary safeguards absent

Deborah Coles, co-director of charity Inquest, said: “Liam McManus was an extremely vulnerable child placed in an environment that did not have the necessary safeguards in place to keep him safe, despite his known vulnerability, by all the professionals involved with him.

“Yet again an inquest jury have found systemic failings resulting in a child’s death and yet despite the deaths of 30 children since 1990 lessons are not learned. The ongoing systemic failings exposed by these child deaths in custody should be looked at as part of a public inquiry into the treatment of children in conflict with the law.”

This is the second inquest in less than two years into the death of a child at Lancaster Farms.

Failings by the prison service which the jury found also contributed to McManus’ death included:

· A failure by prison staff to recognise Liam’s risk level and needs.

· An inadequate induction process.

· An ineffective interpretation of the Personal Officer policy which should have meant that Liam was given the continuing support of one officer.

· Incomplete and inconsistent training of officers.

· A failure by all agencies to have the same assessment criteria for vulnerability and therefore communicate effectively.

· A failure to hold a DTO (Detention and Training Order) planning meeting despite guidance that this should take place within 10 days. This would have given those working with Liam an opportunity to share their knowledge of him and assist prison staff in supporting him appropriately.

· Transferring Liam to a new wing on a night when there was reduced staff levels, meaning that other prisoners had no association during the day and were restless. This lead to heightened shouting and bullying through the windows on the night of his death, including calls for him to “string up” which the jury recognised would have been frightening and intimidating.

The coroner will write to the Youth Justice Board to ensure that the YOS sends important information about young people to young offender institutions in a “readily accessible” format.

Procedures reviewed

A Prison Service spokesperson said: “Every death in custody is a tragedy, and our sympathies are with Liam’s family. Ministers, the Ministry of Justice and the National Offender Management 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 of collaborative work across custodial sectors. Lessons have already been learned from the Prison Probation Ombudsman’s recommendations, and we will be carefully considering the inquest verdict and findings, and any Coroner’s Rule 43 letter, to see what further lessons can be learned from Liam’s death.”

A spokesperson for St Helens Council said: “First and foremost our deepest sympathy go to Liam’s family over this tragic incident. St.Helens takes its Safeguarding responsibilities extremely seriously.

“Following Liam’s death in 2007 we carried out a Serious Case Review led by an independent, external consultant. We also commissioned an independent consultant to review practice in respect of Custody cases.

“We have enhanced procedures and practice in respect of both the placing of young people in Custodial settings and the on-going support they receive. We have recently had very good inspections of both youth and children’s services.”

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