Failings in care of three children who died in custody, finds ombudsman

Campaigners warn lessons have clearly not been learnt from previous child deaths in custody

Youth offending teams and prison staff failed to appropriately safeguard and support three vulnerable boys who took their own lives in custody, the prisons ombudsman has found.

In a report, published today to share learning from the tragedies, ombudsman Nigel Newcomen examined the custodial care given to the three young people who died in 2011-12 – the first such child deaths since 2007.

The report found different professionals working with the three young prisoners, before and during their imprisonment, had failed to manage and communicate their vulnerability on a number of occasions.

Following the court decision to send each child to prison, professionals did not spend enough time considering which custodial placement would best manage their vulnerability.

Placements that didn’t meet needs

In two of the cases, youth offending workers had recommended the children be placed in a secure training centre, rather than a young offender institution (YOI), on account of their vulnerability, yet neither recommendation was acted upon. Only one of the recommendations was heard by the court and only one youth offending team explained why the boy was vulnerable.

In both cases, a placement at the Keppel Unit – a specialist facility for the most vulnerable boys – was discounted, despite being a good alternative to the harsher regime of a YOI.

In two of the cases the boys’ vulnerability was clear, with both self-harming and withdrawing from contact. Although there were specialist wings within the prison, which staff considered moving the young people to, neither boy was moved. Both had been resistant to the move, but staff should have taken more “active measures to promote the benefits”, the ombudsman found.

In the third case, the boy’s needs were less apparent, but he was a looked-after child and it was his first time in custody. The prison did not take sufficient consideration of these risk factors when the boy was suddenly moved from the induction wing, nor was it considered that his challenging behaviour could have been masking acute stress.

Independent holistic inquiry needed urgently

Mistakes were also made in the way risk was assessed and information shared. Due to the different approaches of agencies working with the boys, poor recording and confusion about what information was relevant, risk was recorded inconsistently.

Ombudsman Nigel Newcomen said the report suggests the early learning that might help avoid such tragedies in the future, and ensure children in custody are better safeguarded, adding he hopes “these lessons are learned”.

Deborah Coles, co-director of Inquest, said the failings were a “depressingly familiar” feature of previous deaths. “There is an urgent need to learn from the failings that cost all these children their lives. An independent, holistic inquiry, where these issues are examined in the context of the entire system of detention for children, is long overdue,” she said.

Frances Crook, chief executive of the Howard League for Penal Reform, agreed, saying the report shows that history is repeating itself and it is time for a change. “The deaths of these three boys in just one year might have been avoided if they had received a sentence outside the prison walls that focused on their needs. It is clear that lessons have not been learnt.”

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