Prisons ombudsman highlights systemic failings in case of boy's suicide

A report by the Prisons and Probation Ombudsman into the death of 15-year-old Liam McManus, found hanging in his cell at Lancaster Farms YOI in November 2007, was completed in August last year but publication was delayed due to legal issues.

It identifies a series of "systemic failures", finding:

• The Youth Justice Board (YJB) should not have placed Liam in a YOI over a more staff-intensive environment
• The personal officer scheme at the YOI, a scheme designed to give children in custody a single point of reference for concerns or advice, failed
• Prescribed timescales for a sentence-planning meeting for Liam were not met
• Prison officers did not attempt to resuscitate Liam for more than three minutes after he was found despite his body still being warm
• Some officers at the YOI had not received resuscitation training

The report, which adds to concerns aired at an inquest held last year, revealed that Liam had a history of self-harm and drug and alcohol abuse.

He had spent time in custody earlier in the year at Thorn Cross YOI but was transferred to Red Bank secure children’s home.

The move was primarily because he was deemed unsuitable for the open unit due to an outstanding criminal charge, although his ability to cope in a prison environment was also questioned.

However, in spite of his known vulnerabilities and his known fear of being sent to prison, just a few months later Liam was placed at Lancaster Farms YOI by the YJB after breaching a community element of a detention and training order.

On completion of a 20-day induction period Liam was transferred to the main unit of the YOI on 28 November.

At 7.10am the following day, the boy was found hanging in his single cell. He had been due for release less than a month later, on 22 December.

"The investigation has highlighted some critical systemic failures relating to the manner in which the boy’s placement at Lancaster Farms was decided upon, and to aspects of his management in the establishment before he died," ombudsman Stephen Shaw said in the report.

Referring to a YJB table indicating that vulnerable males aged 15 to 16 should be sent to a secure children’s home or STC, he said: "I interpret the table as clearly indicating that, given the serious concerns about the boy’s vulnerabilities, he should have been placed in a secure children’s home or a secure training centre."

He also criticised procedures at the YOI including the personal officer scheme, with the staff member assigned to Liam initially being on leave and then on night duty until 25 November. No alternative personal officer was allocated in the meantime.

Shaw reserved his fiercest criticism for the fact no immediate attempt to revive Liam was made.

"Most shocking of all my findings is that relating to the response to the discovery of the boy hanging, when there was a significant delay in administering emergency first aid by some staff and a delay in calling an ambulance," he said.

A total of 32 recommendations to the key agencies involved in Liam’s management — Lancaster Farms YOI, the Youth Justice Board, the National Offender Management Service and the North Lancashire Primary Care Trust — were made.

"When considered individually, each of the findings and conclusions is significant," Shaw said.

"When considered together, they demonstrate a lamentable standard of care for a vulnerable 15-year-old boy in the charge of the state," he added.

The YJB responded to the ombudsman’s concerns over McManus’ placement, arguing that all placements are made in accordance with its stated criteria.

"Factors in placement choice also include competing demand for non-YOI places," the response said.

"The YJB is satisfied that during the placement of the boy at Lancaster Farms sufficient attention was given to this decision in the light of the boy’s individual needs and risks to himself and others."

"There are robust procedures in place to allow either a YOT [youth offending team] or staff at a YOI to discuss the placement following admission if there are concerns as to the young person’s safety.

"This placement was as a result of a breach of the community part of the DTO [detention and training order] and as such the YOT were fully aware of the circumstances surrounding this and clearly advised the court that a return to custody was the most suitable option in relation to the breach.

"The fact that the boy had served previously in a secure children’s home does not mean that a secure training centre place was the most suitable as it would have meant a placement further from home, something the YOT felt would not be helpful.

"The YJB had a conversation with the YOT on the day of sentence to discuss whether a place at an STC or SCH [secure children's home] would be preferable.

"The YOT re-stated their view that Lancaster Farms would be the most suitable placement for the boy."