A review board has found that despite communication failings by various agencies these shortfalls did not contribute to the death of a teenager who hanged himself in custody.
Jake Hardy, 17, of Stonegravels, Chesterfield, hanged himself while serving a sentence for affray and assault at Hindley Youth Offenders’ Institution in Wigan.
However, a Derbyshire Safeguarding Children Board’s Serious Case Review revealed today, Thursday, November 13, that communication errors made by the agencies involved in Jake’s care prior to custody had not contributed to his death.
DSCB chairman Christine Cassell said: “Our deepest sympathies are with this young man’s family, loved ones and friends. While the report notes many of the agencies involved in this young man’s care worked extremely hard to support him, it found they sometimes failed to communicate effectively with each other. However, the report concludes this did not directly contribute to his death which could not have been predicted or prevented.”
An inquest jury in April into ADHD sufferer Jake’s death in January, 2012, found multiple failings by YOI staff had contributed to his death. These included a failure to protect him, investigate bullying, support him, record his suicidal thoughts and reports of verbal abuse and a failure to review the risk of self-harm and to move him.
The DSCB review, which focussed on events prior to custody, has now identified a need for a multi-agency approach to ADHD youngsters because agencies had sometimes failed to communicate effectively with each other and there had been no multi-agency meeting with Jake and his family.
A Prison and Probation Ombudsman’s Review and a Clinical Health Review by Wigan Primary Care Trust also identified serious concerns about the care of Jake by some HMP Hindley YOI officers. These included failing to protect him from bullying, failing to implement the prison’s suicide prevention process and to provide an holistic care approach.
The prison’s mental health team was also criticised for a lack of effort in obtaining information from the Child and Adolescent Mental Health Services, and the Youth Offending Service was criticised for failing to provide a post-court report. But despite the inquest findings, the DSCB stated these reviews did not conclude that these errors directly contributed to Jake’s death.
The DSCB added that the agencies concerned have already begun implementing changes.
The Youth Justice Board has made changes to the documentation required before custodial sentences. The Youth Offending Service has undertaken a review of youngsters in custody and a review of practice in court with guidance about the transfer of documents to the Youth Justice Board and the Secure Estate.
Chesterfield Royal Hospital NHS Foundation has recognised improvements are necessary for ADHD sufferers. And Derbyshire Community Health Services has made improvements in record keeping focusing on family and early intervention with safeguarding training for health visitors. A review is also planned for its school nursing service.
Following the DSCB review, the board stated it will monitor the implementation of recommendations and seek assurances that detained youngsters are protected. It aims to monitor arrangements to provide multi-agency support for ADHD youngsters and aims to highlight the importance of professionals making contact with each other and the importance of seeing youngsters.
Christine Cassell added: “The board will continue to seek assurances that other Derbyshire young people are safe while in custody and seek those same assurances from young offender institutions.
“We’ve already shared the learning findings of this serious case review and will continue to monitor how the recommendations are put in place to make sure they make a difference to professional practice to safeguard and protect young people.”
The DSCB’s panel included Derbyshire Constabulary, Derbyshire Children and Younger Adults Social Care, Derbyshire Young Offending Service, Chesterfield College, Chesterfield Royal Hospital, NHS Derbyshire County PCT, the Youth Justice Board and others.