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Jury returns critical findings in the inquest into the death of 15 year old Alex Kelly at HMYOI Cookham Wood

Tuesday 16 December 2014

Alex was 15 years old when he was found hanging in his cell at HMYOI Cookham Wood on 24 January 2012.  He died in hospital the following day on 25 January 2012.  He was one of three children to die in Young Offenders Institutions from apparently self-inflicted deaths within a ten month period.

The jury concluded that a number of failures led to Alex Kelly’s death; that he took his own life but his intention at the time cannot be proven beyond reasonable doubt and that his emotional state had been significantly compromised on 24 January 2012.  Amongst other findings, the jury also concluded that a failure to allocate a named Social Worker to Alex hampered the continuity of care to a vulnerable looked after child.   

The inquest heard evidence that:

  • Alex was an extremely vulnerable and troubled child who had been sexually abused at a very early age by a member of his maternal family.
  • Alex was 5 years old when he was taken into care by the London Borough of Tower Hamlets who became his “corporate parent” although Alex’s father was later granted parental responsibility.
  • He had complex needs with identified special education needs and attachment issues in addition to the trauma suffered through the abuse.
  • Alex was placed into long term supportive foster care in Medway, Kent and retained contact with his father.
  • Over time Alex’s behaviour became more troubled and there were significant failings by the corporate parent in the support provided to Alex and his carers in the time leading up to his custodial sentence. This includes the failure to provide adequate therapeutic support to Alex who was recognised to be very disturbed as a result of the abuse he suffered as a young child.
  • In October 2011 Alex was sentenced to a 10 month Detention and Training Order (DTO).  The custodial sentence was passed without a forensic mental health assessment to fully understand his vulnerabilities and complex needs. The requirement for such an assessment had been identified by a multi agency meeting a month before his sentence but was not acted upon.
  • Although it had been recommended that Alex should be placed in a Secure Training Centre because of his vulnerabilities this recommendation was not put to the court resulting in Alex being sent to Cookham Wood YOI.  At the age of 15, Alex was one of the youngest children there.
  • A number of witnesses from multiple agencies repeatedly acknowledged that he was a particularly vulnerable 15 year old boy. 
  • Whilst in Cookham Wood YOI Alex began to withdraw from participation in the regime and from association from other boys.  His vulnerabilities and complex needs became more apparent and there was recognition that these could not be adequately managed on the wing.
  • He was put on report for breaching prison rules for self tattooing even though the case manager of the self harm prevention system had recommended that he should not be. 
  • Although still retaining legal responsibility for Alex as his ‘parent’ there was a failure of Tower Hamlets to address his care needs whilst in custody. Throughout his short life Alex had been assigned 8 different social workers through Tower Hamlets. At the time of his death he had not met his latest social worker.
  • Alex’s behaviour became increasingly disturbed and distressing in the days before his death, including acts of self harm, blocking his cell observation panel, drawing pictures of hangmen, practising making nooses with his shoelaces and attaching them to his locker and regular threats that he would ‘string up’. 
  • On the evening of 24 January 2012 Alex disclosed to a Prison Officer that he had been sexually abused as a young child and was observed to be in a low/distressed state.
  • His observations were increased but prison officers found Alex later that evening in his cell hanging by his shoelaces attached to his locker.
  • He was taken to hospital where he died on 25 January 2012.

As a result of the evidence heard the Coroner intends to make a Prevention of Further Deaths report.

The inquest was extremely complex and although legal representation for the Prison Service, the Youth Justice Board, the Medway Youth Offending Team and the London Borough of Tower Hamlets was funded by the public purse, Alex’s father was initially refused legal aid which was only granted after a leader column in a national newspaper. 

Nick Popat, Alex’s father said:

“No one should have to attend an inquest into their child’s death in prison. This has been a difficult and painful process for me. I would not have been able to have navigated this without expert legal advice and representation funded by legal aid and the support of the charity INQUEST.

“Alex was a looked after child. The evidence that emerged exposed serious failings in the care and support that Alex and his carers received from Tower Hamlets Social Services and by placing him in a prison that was never going to be able to cater for his many needs. I hope that lessons can be learnt from the tragedy of my child’s death so that another family does not have to go through what I have.”

Deborah Coles, co-director of INQUEST said:

“Alex was a very vulnerable child in need of therapeutic support and protection and yet he was lamentably failed by the very agencies that should have been there to protect him. What is so shameful is that these failings have been reported time and again in a pattern of previous child deaths and it appears we have learned nothing. It is unacceptable that he was ever imprisoned in the first place, the worst and most dangerous environment for children with such complex needs. The warning this case should send out is that imprisoning children is damaging dangerous and must end”

Mark Scott, solicitor representing Alex’s father said:

Alex was extremely vulnerable and a child in need of care but instead was treated as a child in need of custody”.

INQUEST has been working with Alex Kelly’s father since his death in January 2012. Alex’s family are represented by INQUEST Lawyers Group members Mark Scott of Bhatt Murphy solicitors, and Danny Friedman QC of Matrix Chambers.

Ends

Notes to editors:

1. The jury concluded that Alex Kelly died of
1a. Irreversible cerebral hypoxia
1b. Suspension
And
On 24 January 2012 between 21.17 and 21.37 hours Alex Kelly suspended himself by a ligature tied to his locker and made from his shoe laces in his cell at Cookham Wood Young Offenders Institution. He was transferred to Medway Maritime Hospital where he died on 25th January 2012.
Conclusion
Based on the evidence the following can be stated;
• Alex Kelly took his own life
• His intention cannot be proven beyond all reasonable doubt
• His emotional state was significantly compromised on 24 January 2012
And the following failures identified

1. After Alex was sentenced there a failure by Tower Hamlets Social Services to address the issue of Alex’s placement after his release from Cookham Wood Yes/no/Can’t say

2. After Alex was sentenced was there a failure by Tower Hamlets Social Services to address the issue of Alex wanting to see his grandmother
  Yes/no/Can’t say

3. Were the in-reach staff or the YOT caseworker hampered in their ability to effectively deal with safeguarding issues by being unable to get a response from Tower Hamlets Social Services in relation to Alex’s wish to see his grandmother and or the issue of placement 
  Yes/no/Can’t say

4. Did the Senior Officer on duty with responsibility for reviewing the safeguarding provisions for Alex before the handover on the evening of the 24th January 2012 have sufficient information before reviewing the safeguarding provisions Yes/no/Can’t say

5. If no, what further reasonable enquiries should have been made

6. Should the review of safeguarding provisions by the Senior Officer have included any of the following:
a. Requesting Alex to move to a supervision cell for the night and maintaining constant observations Yes/No
b. Mandating Alex to move to a supervision cell for the night and maintaining constant observations Yes/No
c. Removing his laces Yes/No
d. Removing other ligature opportunities Yes/No

7. The internal systematic failure within Tower Hamlets Social Services to allocate a named Social Worker hampered the following:
• Communication with other agencies
• Addressing the ongoing concerns around Alex Kelly’s mental health issues and
• Alex Kelly’s continuity of care

All of which led to an inadequate level of support for a vulnerable looked after child

8. At Cookham Wood Young Offenders Institution the effective sharing and evaluation of important information was hampered by

• The number of different types of systems used to record information concerning Alex Kelly
• Lack of Communication between staff and departments and
• The Lack of communication with external parties

All if which led to a reduced ability to safeguard Alex Kelly effectively

For further information, please contact: Anita Sharma on 020 7263 1111 or anita@inquest.org.uk

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