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.
The SCR concluded that: “The collective corporate system let Ryan down despite the best efforts and good intentions of individual members of staff. There was no one person who assumed responsibility for Ryan as a looked-after child, ensuring that his overall wellbeing was promoted and safeguarded. The organisation legally charged with parental responsibility did not adequately discharge it.”
Leeds LSCB chair Jane Held said: “Ryan was undoubtedly a troubled young man who over the last year of his life could have had better support.”
She added though that improvements had been made since Ryan’s death. This includes the development of a supported housing service for vulnerable young people as placement breakdowns had been a common feature of Ryan’s time in care in the years leading up to this death.
Held added: “I am confident that changes have been put in place in the organisations responsible for safeguarding children and young people to try to prevent such tragedies in the future.”
She also noted improvements within Wetherby YOI, including the drafting in of three new social workers to better support young offenders.
Steve Walker, deputy director of children’s services at Leeds City Council said: “We accept the report’s findings and agree that some aspects of the care Ryan received should have been better, for this we apologise. However the report does also show that there were many positive relationships formed throughout Ryan’s life with people employed by Leeds City Council and that the staff working with Ryan never gave up on him.
“Since Ryan’s tragic death in 2011 many changes have taken place in the council’s children’s services department, including a major restructure which means services are now delivered locally, enabling much closer working between teams and partners. We have also made significant improvements to services for children leaving local authority care and have recruited more social care staff to reduce caseloads and ensure each looked after child has the stability of one case manager.”
The timing of the SCR publication had been delayed until after the inquest into Ryan’s death. In delivering a verdict of accidental death in January the inquest jury concluded that his actions had been a “cry for help” due to bullying within Wetherby rather than intentional suicide.
Inquest co-director, Deborah Coles said: “This is a damning indictment of the multi-agency failings which spanned the course of Ryan’s life. The 'collective corporate system' that was responsible for his welfare was unable to protect him from harm. Sadly Ryan’s story is not unfamiliar, but part of a pattern of systemic failure and neglect."