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JURY RULES CATALOGUE OF SHOCKING FAILURES LED TO PREVENTABLE DEATH OF 17 YEAR OLD JAKE HARDY AT HINDLEY PRISON
Friday 4 April 2014
A jury has concluded that a series of 12 individual failures more than minimally contributed to the death of a 17 year old child in prison. After three days of deliberation, the jury unanimously concluded that Jake Hardy’s death could have been prevented.
17 year old Jake Hardy hanged himself in his cell at HMYOI Hindley on 20 January 2012 and died in hospital four days later. A vulnerable boy with a history of self-harm, Jake had repeatedly told officers he was being bullied, yet insufficient steps were taken to protect him.
Prior to entering Hindley on 6 December 2011 Jake had been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and Conduct Disorder, had been given a statement of special educational needs, and was under the care of the local mental health team. Hindley was informed of all of this information, together with the fact that he had been bullied at school.
Jake’s mother Elizabeth Hardy said:
“While we finally have some answers, as a family we have been shocked by the attitude of some of the officers who clearly just didn't care that my son was being bullied. Other officers took such small steps and never followed it through to the end. If they had done their job properly they could have prevented Jake's death.
“I feel distraught that Jake could have been moved to a safer cell the night he hung himself. Every day we have to wake up to this nightmare that Jake died and some officers could have helped him. Jake was too vulnerable and should never have gone to a place like Hindley to start with. I kept my son safe for 17 years yet Hindley couldn’t keep him safe for two months.”
Deborah Coles, co-director of INQUEST said:
“Jake Hardy was utterly failed by prison officers and a prison system supposed to protect him. Every warning sign about his vulnerability was starkly evident but systematically ignored. The decision to ignore the heartbreaking pleas for help from a scared child, alone in his cell resulting in his desperate act should shame us all.
“How many more times do inquests have to report on children dying in prisons that are rife with bullying, physical restraint and self harm, and where there are failures to protect the lives of children in its care. The imprisonment of children is simply wrong.
“The preventable death of a child in the custody of the state should be a national scandal, prompting the government into decisive action. Instead we are met with a calculated institutional indifference, with a refusal to acknowledge what is being done to our most vulnerable children in our name. No doubt we will hear the repeated and empty words that lessons will be learned. As a starting point, the decision to exclude children from the review recently announced into prison deaths of young people must be reversed. And the scope of the review must include whether these children should ever have been in prison in the first place.”
Helen Stone, solicitor representing Jake’s family said:
“The jury have delivered a devastatingly critical verdict identifying a range of serious failings from the moment Jake entered Hindley until the time he hanged himself. He constantly asked staff to protect him from bullying, they failed to do so and this caused to him take his own life. As Jake said in the complaints form he wrote, all Jake wanted was for staff to do their job properly, they failed to do so, they failed him, and materially contributed to this child's death.”
The inquest heard evidence that:
- A report was sent to Hindley on 6 December flagging up that Jake had recently self-harmed but this was not noted in Jake’s records by staff at Hindley.
- As early as Jake’s first week in custody he reported that boys on the wing were trying to intimidate him. No action was taken in respect of this.
- There was almost a complete failure of supervision and support by Jake’s Personal Officer.
- In late December the prison was informed by Jake’s Youth Offending Team worker that Jake was “getting grief” off a named young person on his landing. Jake had stated he may harm himself and would be better off dead and that officers “took the piss out of him”. The prison did not investigate this.
- On 17 January 2012 Jake damaged furniture in his cell and cut his wrist; he told a senior officer that this was a direct result of other young people on his wing “constantly verbally abusing him over a prolonged period of time”.
- On 18 January Jake’s mother told a Senior Officer that the week before Jake had “thought of ending it”. This was not reported to the Safeguarding Department and Jake’s level of risk was not reviewed in light of this new information.
- The same day Jake’s Keyworker witnessed the named bully shouting at Jake through his cell door but did not report this behaviour.
- On 19 January Jake told a Governor that he was receiving verbal abuse and that staff were “taking the piss out of him”. The Governor expressed serious concerns about his state of mind and well-being. That day Jake named a second young person as verbally abusing him but no action was taken to challenge that young person.
- While Jake was in his cell during evening association on 20 January, young people were shouting at him and were hitting and kicking his door. Staff admitted failing properly to supervise this association period.
- Shortly afterwards Jake again damaged furniture in his cell and told a Senior Officer that he would continue to do this. There was evidence Jake said he had done this because of verbal abuse from young persons. The Senior Officer locked Jake back in his damaged cell, saying he was going home. There was no review of Jake’s risk of self-harm. Less than an hour later Jake was found hanging from a ligature made from a bed sheet.
- A note found in Jake’s cell dated 20 January stated “so mum if you are reading this I not alive cos I can not cope in prison people giveing [sic] me shit even staff.”
- A complaint form found in his cell stated that young people were threatening to beat him up and put him in hospital, that he told staff and they had done nothing. In the section asking what remedy he would like, Jake had written “To see the staff do their job properly.”
INQUEST has been working with Jake Hardy’s family since his death in January 2012. Jake’s family are represented by INQUEST Lawyers Group members Helen Stone of Hickman and Rose solicitors, and Dexter Dias QC and Richard Reynolds, both of Garden Court Chambers. A photograph is available of Jake, please contact INQUEST.
Notes to editors:
1. The jury concluded the following:
Jake Hardy’s death was caused or more than minimally contributed to by:
1. a failure to provide him with adequate personal officer support and monitoring,
2. a failure adequately to record and consider reports of previous self-harm and thoughts of self-harm and suicide,
3. a failure adequately to refer to the Safeguarding Department observed and reported verbal abuse,
4. a failure adequately to record on C-Nomis and in the wing observation book observed and reported verbal abuse,
5. a failure from the 29th December 2011 onwards to investigate reports that he was being verbally abused by other young persons and to take action to address such abuse,
6. a failure on the 18th January 2012 onwards to provide, update and utilise under the ACCT process an adequate care map in respect of his risk of self-harm,
7. a failure from the 18th January 2012 onwards to move him from cell F1/24 to a different location,
8. a failure on the evening of the 20th January 2012 to permit him to use the telephone,
9. a failure on the evening of the 20th January 2012 to supervise association properly and to protect him from the negative behaviour of other young persons towards him,
10. a failure on the evening of the 20th January 2012 to review the level of his risk of self-harm,
11. a failure on the evening of the 20th January 2012 to review the regularity with which he was checked, and
12. a failure on the evening of the 20th January 2012 to review the suitability of his location for his safety overnight.
They also concluded:
“Jake Hardy died as a result of his own deliberate act but the evidence does not establish, beyond reasonable doubt, whether he intended that act to cause his death.”
2. Jake’s case will be featured in an upcoming documentary ‘Dead Behind Bars’ being shown on BBC Three towards the end of April, as part of its Crime and Punishment Season
3. There have been 33 deaths of children in penal custody since 1990. Jake Hardy’s death occurred two days before the death of 15 year old Alex Kelly, and nine months after the death of 17 year old Ryan Clark.
4. INQUEST’s briefing on the need for an independent review of the deaths of both children and young people aged 18-24 is available here
5. The government’s announcement of a review excluding children is available here
‘We would like to thank INQUEST and our case worker for their help and support. INQUEST is a real lifeline for people who have lost loved ones and they have helped us practically and emotionally. They are worthy of much more funding than they receive to carry on their excellent work in increasing understanding in this area and in the way they support bereaved families.’
– Family of a man who died in custody