The jury found that "systematic failings" in the prison and the community contributed to the death of Liam McManus, who hanged himself in custody at HMYOI Lancaster Farms in 2007.
It said that factors contributing to Liam's death included the Youth Justice Board's target driven and top-down approach instead of a caring culture that addressed the needs of individual children. It also blamed social services for deciding to introduce Liam to his birth mother who loved a chaotic lifestyle, but closing his file shortly afterwards due to staff shortages, and prison staff for failing to recognise Liam's needs. The coroner also reported serious inadequacies from social services who lost significant documents and closed Liam's file before he entered custody on the assumption he would be safeguarded by the prison.
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