Furious mum slams reviews’ findings over teen’s death

Elizabeth Hardy whose son Jake Hardy hanged himself in custody.
Elizabeth Hardy whose son Jake Hardy hanged himself in custody.

The furious mother of a teenager who hanged himself in custody has slated three reviews which claim agency failings did not contribute directly to the death of her son.

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.

And A Prison and Probation Ombudsman’s Review and a Clinical Health Review - which identified serious errors in the care of Jake by some HMP Hindley YOI officers - were judged by DSCB as to have also not to have directly contributed to the youngster’s death.

Jake’s mum Liz Hardy said: “If they had kept him out of custody or moved him from Hindley to a safer location he would still be alive today so I can’t understand how they can say there was no link.”

Despite the review’s conclusions, 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 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.

Liz added: “The inquest explained there was a complete communication breakdown. It would have taken the Youth Offending Team five minutes to send a letter and Jake had been seen and he said he was being bullied and they did half a job because they could have sent a letter to the Youth Justice Board and they would have moved Jake to Wetherby with a specialist unit where he would have been looked after under 24 hour suicide watch. But they failed in their job.

“There were only two people who helped Jake - a Youth Offending Team worker who picked up on him being suicidal and she sent a form to Hindley but they said they never received it, and a teacher who reported he was being bullied at Hindley.

“If someone had picked up on the paperwork and followed everything through Jake would have been moved and would still be alive today.

“The reason and clinical reviews totally contradict the inquest which had found failings linked to Jake’s death. I feel let down. I feel as though my son was let down and if it was not for people not doing their job my son would be here today.

“He may have gone to custody but he could have been looked after better. They failed him. Officers did not recognise his illness. The safeguarding board has let us down with these review findings, but the inquest told the truth.”

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.

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.

“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.

Ms Hardy is considering civil action involving HMP Hindley.