The SCR published by Leeds Local Safeguarding Children Board (LSCB) into the death of 17-year-old Ryan Clark at Wetherby young offender institution (YOI) in 2011 found he had been let down over a number of years while in care and in custody.
Although the SCR says professionals “could not reasonably have predicted Ryan’s death", it adds “they were insufficiently alert to the emotional turmoil that underlay his overt behaviour”.
A key failure by professionals was to react to his challenging behaviour rather than consider the underlying cause.
There was an absence of "regular and thorough" assessments and reassessments of Ryan’s situation, including his vulnerability and risk of harm, which was prevalent in the 12 months leading up to this death. While in the YOI this lack of assessment continued, the SCR found.
The SCR also noted that while social care and youth justice workers had “invested considerable time and money” in supporting Ryan, it was “insufficiently co-ordinated”.
Leeds City Council came in for particular criticism for failures in its duty as a corporate parent to Ryan.
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