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.
The Young Offenders Service also came under fire for failing to ensure that Liam received visits from his youth offending service worker and mental health worker during his time in custody.
The coroner said he would write to the Youth Justice Board to ensure recommendations, including that the Youth Offending Service should send YOIs important information about young people in a readily accessible format, would be implemented.
Deborah Coles, co-director of advice service Inquest, said: "Yet again an inquest jury has found systemic failings resulting in a child's death." She added: "The ongoing systemic failings exposed by these child deaths in custody should be looked at as part of a public inquiry into the treatment of children in conflict with the law."
Liam, who had a history of self-harm, was the thirtieth child to die in state custody since 1990 and his inquest was the second in less than two years into the death of a child at HMYOI Lancaster Farms.
A Prison Service spokesperson said: "Learning from deaths in custody is a key strand of the prisoner suicide prevention strategy, and of collaborative work across custodial sectors. Lessons have already been learnt from the Prison Probation Ombudsman's recommendations, and we will be carefully considering the inquest verdict and findings, and any Coroner's Rule 43 letter, to see what further lessons can be learnt from Liam's death."
