A serious case review into the death of Alex Kelly, who killed himself in his cell at Cookham Wood Young Offender Institution (YOI) in Kent last January, found that he had been sexually abused as a child and taken into care at the age of six.
The review said that the agencies in contact with Alex, referred to in the report as Child F, over the following nine years made a series of mistakes.
These agencies included children's social services, independent reviewing officers, the youth offending team and Cookham Wood YOI.
It found that the “most significant weakness” in Alex’s case was in the working relationship between the health service, the mental health service and prison officers in the YOI.
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