Jake Hardy

Date of report	30 Jun 2014
Reference	2014-0305
Deceased	Jake Hardy
Coroner	Alison Hewitt
Coroner area	Manchester (West)
Category	State Custody related deaths
Source	judiciary.uk record · original PDF
Responses published	none published
The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
Re : JAKE REGINALD HARDY DECEASED
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

. The Secretary of State for Justice

The Youth Justice Board

. The National Offenders Management Service
HM YOI Hindley

AeNo

CORONER

| am Alison Hewitt, Assistant Coroner for the coroner area of Manchester

(West).

CORONER’S LEGAL POWERS
| make this report under paragraph 7 of Schedule 5 to the Coroners and

Justice Act 2009 and regulations 28 and 29 of the Coroners
(Investigations) Regulations 2013.

INVESTIGATION and INQUEST

On the 31* January 2012 an investigation was commenced into the death
of Jake Reginald Hardy, aged 17 years.

The inquest was heard between the 24'" February and the 4" April 2014.

The inquest jury concluded that :

1. On the 20" January 2012 Jake Hardy was found partially suspended in
his cell at HM Young Offender Institute Hindley. The medical cause of his
death was | a Hypoxic / Ischaemic Brain Injury, due to | b Cardiac Arrest,

due to | c Hanging.

2. He died as a result of his own deliberate act but the evidence did not
establish, beyond reasonable doubt, whether he intended that act to
cause his death.

3. His death was caused or more than minimally contributed to by failures
by the State to protect his life, namely :

(i) a failure to provide him with adequate personal officer support and
monitoring;

(ii) a failure adequately to record and consider reports of previous self-
harm and thoughts of self-harm and suicide;

(iii) a failure adequately to refer to the Safeguarding Department
observed and reported verbal abuse;

(iv) a failure to record on C-Nomis and in the wing observation book
observed and reported verbal abuse;

(v) a failure from the 29" December 2011 onwards to investigate reports
that he was being verbally abused by other young persons and to take
action to address such abuse;

(vi) a failure on the 18" January 2012 onwards to provide, update and
utilise under the ACCT process an adequate care map in respect of his
risk of self-harm;

(vii) a failure from the 18" January 2012 onwards to move him from cell
F 1/24 to a different location;

(viii) a failure on the evening of the 20" January 2012 to permit him to
use the telephone;

(ix) a failure on the evening of the 20" January 2012 to supervise
association properly and to protect him from the negative behaviour of
other young persons towards him;

(x) a failure on the evening of the 20" January 2012 to review the level of
his risk of self-harm;

(xi) a failure on the evening of the 20" January 2012 to review the
regularity with which he was checked; and

(xii) a failure on the evening of the 20" January 2012 to review the
suitability of his location for his safety overnight.

At the conclusion of the inquest the Interested Persons requested time to
make, and respond to, written submissions concerning my duty to make a
report to prevent future deaths. | granted the request because of the
complexity of the facts and issues considered during the inquest and the
quantity of documentary material relating to changes which have been
made since Jake Hardy’s death. | have received written submissions from

all the Interested Persons, the last being received on the 22" May 2014. |
have since taken time to review the evidence and to consider all the
submissions and all the documentary material before me.

CIRCUMSTANCES OF THE DEATH

Jake Hardy was a 17 year-old young man from Chesterfield, Derbyshire
who was sentenced to a detention and training order and sent to HM YOI
Hindley, Wigan in December 2011. He was a young person with a
number of vulnerabilities. He had been diagnosed as having learning and
behavioural difficulties, had been issued with a Statement of Special
Educational Needs and had attended a “special needs school”. He had a
low reading age and was emotionally immature. He also had a history of
being bullied by his peers at school and some history of self-harming
behaviour and suicidal ideation. He relied heavily on his family, especially
his mother, for emotional support.

As the jury's findings show, several of the policies and procedures then in
place within the HM YOI Hindley designed to identify, monitor and protect
vulnerable detainees and those at risk of self-harm were not utilised
either as fully as they should have been or at all in relation to Jake.
Further, there were failures by prison and clinical staff both to consider
and to record relevant information in Jake’s records.

|
Over the seven weeks that Jake was in HM YOI Hindley he told staff on a
number of occasions that he was being verbally bullied by other
detainees but no referral was made to the Safeguarding Department until
shortly before his death. Further, a written report made in late December
2011 by Jake’s Youth Offending Service worker, linking the verbal abuse
to Jake’s risk of self-harm and suicide, did not result in effective protective
steps being taken.

After evening lock-up on the 17" January 2012, Jake smashed the
television in his cell and used the broken glass to self-harm. He was
placed on an “Assessment Care in Custody and Teamwork” (“ACCT”) |
process but the jury found that, when it was reviewed, there was a failure
to create an adequate “care map” in respect of his risk of further self-
harm.

When questioned about the incident, Jake stated that he was being
verbally bullied and that detainees in other cells were shouting out
obscenities about his family. Subsequently, perpetrators of the verbal
abuse were identified but no action was taken to re-locate either them or
Jake, in part because Jake resisted this. Jake’s mood and presentation
between the 17" and 20" January was variable but concern for his

mental health and his safety were raised when he was disciplined for

breaking his television.

On the 20" January 2012 Jake appeared to be calm and cheerful during
the day but he became angry and upset when the prison staff supervising
evening association forgot to unlock his cell as he had wanted to
telephone his mother, to whom he had not spoken for several days,
before the other detainees were released from their cells. He was told by
the staff that he could use the telephone later, although this was not in
fact permitted because of his subsequent behaviour.

During the association period Jake remained in his cell and a number of
detainees congregated outside his door. The evidence revealed that
some of those detainees behaved in a harassing manner towards Jake,
opening and closing his observation flap, hitting his door and calling and
gesturing to him. Supervising staff did not take any or sufficient steps to
prevent or stop this. Jake was again angry and upset and he repeatedly
tried to cover his observation panel with paper and he was kicking his
door for over an hour. Further, shortly after evening association was
finished, Jake was found to have broken the furniture in his cell.

Despite Jake’s presentation and behaviour, the prison staff failed prior to
final lock-up to review under the ACCT procedure the level of Jake's risk |
of self-harm, the regularity with which he was to be checked overnight

and the suitability of his location for his safety overnight. Jake was found
by night staff less than an hour later, on a routine check, to be partially
suspended by a ligature tied to a window bar.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed a large number of
matters giving rise to concern. However, | heard evidence and have been
provided with documentary material showing the changes which have
taken place within the Youth Justice Board, the Youth Offending Service
and HM YOI Hindley since Jake’s death and | am satisfied that action has
already been taken to address many of the matters giving rise to concern.
For example, the Youth Justice Board has improved its documentation
used for the placement of young offenders and has introduced “Asset
Plus” for information recording and risk assessment. There have also
been wide-ranging and significant changes to the policies and procedures
in place at HM YOI Hindley. These include the introduction of a new
“Managing Vulnerability Policy’, routine risk assessment 10 days after a
detainee’s arrival, an improved safeguarding referral process, improved
risk assessment tools and more individualised intervention plans. Matters
of concern have also been addressed by the Greater Manchester West
Mental Health NHS Foundation Trust and Bridgewater Community
Healthcare NHS Trust.

Despite the changes which have taken place, some matters giving rise to
concern continue and these are set out below. In my opinion there is a
risk that future deaths will occur unless action is taken in relation to these
continuing matters. In the circumstances it is my statutory duty to report
to you.

The MATTERS OF CONCERN are as follows —

A. To (i) the Secretary of State for Justice
(ii) the Youth Justice Board

1. It was apparent from the evidence | heard that a significant proportion
of the children and young persons placed in HM YOI Hindley are
vulnerable and have complex needs. This may well be true of the children
and young persons placed in other Youth Offender Institutions also.

Clearly, the nature and extent of Jake Hardy's vulnerabilities were not
unusual amongst this population, with many detainees having some form
of learning difficulty. | was told that other detainees are vulnerable for
different reasons, for example because they have been abused or
neglected or their upbringing has been adversely affected by a parent's
misuse of aicohol or drugs. Many are “looked after children”. | was also
told that these detainees’ “complexities affect their reaction to authority
and boundaries and are probably the reason they ended up in custody in
the first place’.

It was also apparent that vulnerable detainees are likely to lack the
emotional and intellectual maturity and resilience they may need to cope
with the pressures of life in custody (such as separation from family and
bullying) and that the risk of self-harm and suicide can increase in
consequence. | was told that safeguarding these detainees is made more
difficult by the prevalence of their volatile and unpredictable behaviour.

Overall, the evidence suggested that the placement of vulnerable children
and young persons with complex needs in the environment of a Youth
Offender Institute (particularly if some distance from home) does, in some
cases, result in an increased risk of self-harm and suicide which it is often
difficult for prison and clinical staff to manage effectively, even with the
benefit of the various policies and procedures which are in place.

2. As stated above, significant changes of policy and procedure have
| been introduced at HM YOI Hindley in order to address concerns raised |

| about the identification, monitoring and protection of vulnerable children
and young persons and those at risk of self-harm and suicide. It may well
be that some or all of those changes would provide better protection to
detainees in other Young Offender Institutes but | am not aware that
consideration has been given to the adoption of these changes elsewhere
in the estate.

B. To (i) the Secretary of State for Justice
(ii) the Youth Justice Board
(iii) the National Offenders Management Service
(iv) HM YO! Hindley

1. A number of the prison staff from HM YOI Hindley who gave evidence
at the inquest clearly lacked (a) any or sufficient aptitude or
temperamental suitability for the demands of working with vulnerable
young persons with complex needs and/or (b) any or sufficient
understanding of those needs and their causes (such as the nature and
effect of specific learning difficulties and the effect of abuse or neglect in
childhood).

| have been told that these matters are now addressed to some extent by
the Youth Justice Board and HM YOI Hindley but that further changes are
being considered to the way in which prison staff working in Young
Offender Institutes are recruited, screened for aptitude and trained. |
report this concern so that any outstanding further steps can be
considered.

2. The evidence revealed an almost complete failure to provide Jake
Hardy with the benefit and protection of a Personal Officer, despite a
comprehensive scheme being in piace. Currently the scheme is of pivotal
importance for the identification and monitoring of vulnerability and risk.

There remains a concern about whether all officers at HM YOI Hindley
have a sufficient understanding of this role and its importance and about
the absence of any system to alert managers to any failure by a Personal
Officer to meet his obligations under this scheme or to audit his
performance. This concern may be of relevance to other Young Offender
Institutes also.

3. Cells containing ligature points (such as window bars) are still in use at
HM YOI Hindley for detainees who have been assessed to be at risk of
self-harm or suicide. This concern may be of relevance to other Young
Offender Institutes also.

—_t |

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4. Verbal bullying by means of detainees “shouting out” at night is a
common problem in HM YO! Hindley and can increase the risk of self-
harm and suicide by those targeted, especially overnight. The fabric, lay-
out and design of the cells in HM YOI Hindley does not remedy this
problem. Further, it is difficult for the night orderly officer on duty ona
wing, who is there alone, to tackle the problem effectively. There is no
effective system in place to ensure that the problem is routinely monitored
and tackled effectively, wnether by means of additional staff or otherwise.
This concern may be of relevance to other Young Offender Institutes
also.

5. The children and young persons detained at HM YOI Hindley are
provided with a weekly credit which they may use to telephone family or
other approved numbers. Calls are made from a communal telephone
located in the association area of a wing. Prison staff have a discretion to
permit further calls to be made from an office telephone for good reason.

| was told that in-cell telephony has been introduced in newly built parts of
the children and young persons’ estate but it is not available in HM YO!
Hindley and other Young Offender Institutes. Currently, therefore, these
detainees are not able to speak privately on the telephone and there is no
sufficient system in place to ensure that a child or young person in crisis
or in need of emotional support (whether by reason of being bullied or
experiencing feelings of self-harm or suicide) can speak to a family
member without significant delay.

6. The shift patterns of Senior Officers working on the wings within HM
YO! Hindley are such that they do not always overlap and handover is
often by means of written entries in a “handover book”. The handover
book | saw contained short notes addressing random matters and there
was apparently no routine recording of a more comprehensive review of
the shift. There is no system in place to ensure that important information
and outstanding tasks are sufficiently recorded by one Senior Officer at
the end of his shift and then read by the next Senior Officer at the start of
his shift.

It was clear from the evidence that it is the Senior Officer’s responsibility
to have an overview of what is happening on the wing and matters of
relevance to the safeguarding of detainees housed there. Therefore, the
passing of key information and outstanding tasks between Senior Officers
on a wing is of real importance to the safety of detainees. This concern
may be of relevance to other Young Offender Institutes also.

[1

-

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths by
addressing the concerns set out above and | believe you or your
organisation has the power to take such action in respect of those
concerns identified as relating to you.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date
of this report, namely by the 26" August 2014.

|, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be

taken, setting out the timetable for action. Otherwise you must explain
why no action is proposed.

a

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following
Interested Persons and to the other organisations listed below which may
find it useful or of interest :

Derbyshire Youth Offending Service

The Greater Manchester West Mental Health NHS Foundation
Trust

Bridgewater Community Healthcare NHS Trust

Derbyshire Local Safeguarding Children Board

Wigan Local Safeguarding Children Board

HM Inspectorate of Prisons

Independent Advisory Panel on Deaths in Custody

Prisons and Probation Ombudsman

| am also under a duty to send to the Chief Coroner a copy of your
_| response.

The Chief Coroner may publish either or both in a complete or
redacted or summary form. He may send a copy of this report to any
person who he believes may find it useful or of interest. You may
make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the
Chief Coroner.

9 | 30" June 2014 Alison Hewitt
The report

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