24 June 2021

Before HM Coroner Ivan Cartwright
Leicester City Hall
7-23 June 2021

Jaskiran Kainth, 18, was found unresponsive in a cell at Leicester Magistrates Court on 29 April, 2019. He had been detained awaiting a hearing. He was taken to hospital but died on 3 May 2019. An inquest has concluded that Jaskiran died by misadventure, meaning he did not intend to take his own life.

An inquest jury concluded that inadequate recording and sharing of information between agencies, and inadequate risk assessment by and training of GeoAmey staff contributed to Jaskiran’s death.

BACKGROUND

The family describe Jaskiran as a sensitive and unique person, who was good at sports and loved playing football. In his last year of school, he was given an outstanding achiever’s award for computer science. He had a history of mental ill health, including suicidal ideation, paranoia, and episodes of psychosis.

Jaskiran had been detained under the Mental Health Act in the Bradgate mental health unit in March 2019, just a few weeks prior to his death. He had self-harmed in police custody in early April 2019 but Leicestershire Police did not pass this information to court custody staff.

Two days before the incident in court, on 27 April 2019, Jaskiran attended A&E at Leicester Royal Infirmary presenting with chest pain and described low mood and anxiety. He told them that he tried to strangle himself at home. He had a mental health assessment at the hospital and was deemed fit to be discharged. On the morning of 28 April, Jaskiran attended Leicester Royal Infirmary again after reporting an overdose. He was again deemed fit to be sent home.  

Having just returned from hospital, Jaskiran damaged two family cars. The family were unable to stop him and called the police, who arrested Jaskiran and took him to Beaumont Leys Police Station. The family informed the police of Jaskiran’s vulnerability and asked that they look after him.

The following day, on 29 April, Jaskiran was transferred to the custody of GeoAmey, private contractors who run custody services at Leicester Magistrates court for a first hearing. The document which arrived with him, the Prisoner Escort Form, did not have key information about his attendances at hospital on 27 and 28 April of his self-harm in police custody in early April.

Court staff told the inquest that they did not know that Jaskiran had been to hospital in recent days and they were not treating him as a suicide or self-harm risk.  That information was known to two mental health nurses of the Criminal Justice Liaison and Diversion Service who failed to pass that information on to the police and to GeoAmey.

The inquest heard that, whilst in the court, staff reported Jaskiran was displaying odd behaviour. He was seen by a mental health nurse who reported no concerns about his mental health to the court custody officers.

At 12.30pm, court staff had found Jaskiran with an item of clothing. Staff removed the item as well as Jaskiran’s shoelaces. They left him with only one item of clothing. Jaskiran told an officer that he was cold. The incident was not treated as high risk, but staff were subsequently told to check on Jaskiran six times an hour.

Twelve minutes after the first incident, staff returned to the cell. They found Jaskiran had ligatured with his another item of clothing, causing asphyxiation. Staff and paramedics attempted to revive him before he was taken to hospital, where he died a few days later. The court also heard that key court staff had not received training on mental health and self-harm/suicide prevention for up to 20 years.

INQUEST CONCLUSIONS

After two weeks of evidence, the inquest jury concluded that Jaskiran’s death was by misadventure. In a narrative conclusion, they also found that the following contributed to Jaskiran’s death:

• Inadequate recording of information on his mental health;
• Inadequate sharing of information on his mental health;
• Inadequate assessment of self harm and suicide risk while in custody at Leicester Magistrates’ Court; and
• Lack of training and skills in frontline staff on assessing risks posed by detainees with mental health difficulties.

The coroner will consider whether to make a Prevention of Future Deaths report within seven days.

Charnjit Kainth, Jaskiran’s father, said: “Jaskiran was a sensitive person who was not only academically bright but also very talented at sport. My son had his whole life ahead and could have had a bright future but opportunities to help him were missed.

I am grateful to the jury for highlighting inadequate action by multiple authorities entrusted to look after Jaskiran.

That Jaskiran will never get to fulfil his potential his heartbreaking for our family. All I can hope for now is that lessons can be learned from his story. I miss him every day and always will.”

Selen Cavcav, Senior Caseworker at INQUEST, said: “It is clear that a litany of failures by multiple agencies resulted in the loss of life of an 18-year-old. The safety of court cells has been ignored for far too long, with private providers too often delivering poor standards of care to thousands of people, often at their most vulnerable. GeoAmey has a corporate responsibility to ensure what happened to Jaskiran never happens again. In light of this inquest, there must be radical improvements in managing mental ill health in courts nationally.”

Juliet Spender of Irwin Mitchell who represent the family said: “The jury’s conclusion mirrors what Charnjit has always believed – that this tragic death resulted from a cry for help and was preventable. Charnjit firmly believes warning signs as to his son’s mental state were clearly visible and more action should have been taken to prevent his death, and if GeoAmey had robust policy and training of its staff it would have been.

It is also a tragedy that such significant risk information was known to the health care professionals and police, but not shared. While nothing can make up for Charnjit’s loss we’re pleased to have helped secure him answers. We join him in urging for lessons to be learned so other families don’t have to suffer like Charnjit has.” 

ENDS

NOTES TO EDITORS
For further information please contact INQUEST communications team, Lucy McKay on 020 7263 1111 or [email protected] or the Irwin Mitchell press office on 0114 274 4666.

The family are represented by INQUEST Lawyers Group members Juliet Spender of Irwin Mitchell and Sam Jacobs at Doughty Street Chambers. The family are supported by INQUEST caseworker Selen Cavcav.

Other interested persons represented are GEOAmey (private contractors for custody services at Leicester Magistrates’ Court), Leicestershire Police, Leicester Partnership NHS Trust, Ministry of Justice, and a solicitor who saw Jaskiran in custody.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

Court cells

• Deaths in court cells are relatively rare, with only a handful taking place in the past decade.
• In December 2018, a few months before Jaskiran’s death, HM Inspectorate of Prisons inspected Leicester court facilities. They found that most staff had not received any training in identifying and supporting detainees experiencing mental ill health. They recommended that staff receive mental health training.
• More recent inspections around the UK show wider issues with mental health awareness in courts, including in other courts run by GEOAmey.