PRESS RELEASE

26 SEPTEMBER 2002

Jury Find Neglect Contributed To Death Of 16 Year Old In Feltham Young Offender Institution

Hammersmith and Fulham Coroners Court, 25 Bagley's Lane, London SW6.
Before HM Coroner for West London Alison Thompson

Today Thursday 26th September the jury returned a verdict of "suicide to which neglect contributed" at the inquest into the death of sixteen-year-old Kevin Jacobs who was found hanging from the bars in his single cell in HM Young Offenders' Institute Feltham in the early hours of 29th September 2001. The jury found that there were "gross deficiencies within the system:- lack of co-ordination of documents; failure to provide consistent and safe accommodation in prison (no ligature hooks); lack of inter-service co-ordination (placement on release)".

Deborah Coles, co-director of INQUEST said:

"The evidence heard at this inquest is a damning indictment of the statutory agencies responsible for Kevin's care. Kevin had been recognised by everyone involved as a deeply disturbed young boy at risk of suicide and yet he was placed in a cell at Feltham that everyone knew was unsafe. At no stage were any attempts made to transfer him out of the prison system to more appropriate accommodation.

This case raises fundamental questions about the increasing use of prison for children. If children like Kevin continue to be sent to prison they will continue to die; are we as a society prepared to take on that responsibility? How many times do the Prison Service have to be told that cells with easily accessible ligature points are unsafe for vulnerable prisoners?"

The inquest, which began on Monday 16th September, has heard that during Kevin's young life he suffered a horrendous history of institutional neglect. Kevin was the subject of a care order and the responsibility of Lambeth social services when he was arrested, charged and remanded to Feltham on 3 July 2001, and he remained at Feltham following a six-month detention training order imposed upon him on 19 July 2001.

Despite a wealth of information and evidence that was available to all concerned relating to his history of disturbed self-harming behaviour, Kevin was kept at Feltham instead of being removed to local authority secure accommodation or hospital. Prison staff, social workers and doctors have all described Kevin as an exceptionally vulnerable, disturbed and "at risk" young boy. During his three months at Feltham, Kevin had been a victim of bullying and self-harm on numerous occasions, including a particularly serious incident on 14 September 2001 - two weeks before his death - when he managed to hang himself to the point of unconsciousness in his cell on the induction wing of the prison. He made it clear that he wanted to die and knew how to achieve that outcome. But for the intervention of two prison officers who found him hanging, Kevin would have died there and then.

As his sentence progressed, Kevin became increasingly anxious about where he was going to be placed on release from Feltham, since he had been told that Lambeth social services would not pay for him to return to his former residential care home in Guilford and no other arrangements had been made, leaving him with the fear that he would end up isolated in bed and breakfast accommodation. The events in the last two days of his life speak for themselves:

• On 26 September 2001, Kevin smashed a light in his cell on the induction wing, he was seen to be playing with a plastic knife and ripped sheets together with a ligature hook were found under his bed. Staff were "extremely concerned about his safety", so he was moved to the Health Care Centre where he smashed up his cell and described experiencing flashbacks to sexual abuse that he had suffered in care. He was then placed in a safe, low stimulus cell overnight with15 minute checks;
• On 27 September he was returned directly from the non-stimulus cell to the induction wing at 10 a.m.. The safe cell on the wing was unavailable because it was being refurbished, so Kevin was placed in an unsafe, single cell with easily accessible ligature points and only hourly checks by a civilian night time jailer;
• On 28 September 2001, Kevin was visited by his social worker and it was confirmed to him that he would not be returning to his former residential care home in Guilford;
• In the early hours of 29 September 2001 Kevin was found hanging from a sheet tied to the cell bars of his cell on the induction wing.

The death of Kevin Jacobs raised a number of serious concerns:

• Kevin's allocation to HMYOI Feltham (as opposed to secure accommodation) despite his well documented and exceptional vulnerability was clearly inappropriate - staff from Lambeth social services and the Youth Justice Board described a real shortage of secure places for 16 year old boys;
• Despite the detailed knowledge of Kevin's past and recent self harm and attempted suicide together with the assessments made of this vulnerability, no attempt was made by Feltham, Lambeth social services or the Youth Justice Board to find an alternative placement for Kevin - staff at Feltham were unaware of their duty to report Kevin's serious suicide attempt to the Youth Justice Board;
• The nature and quality of the psychiatric assessments carried out on Kevin within Feltham were clearly inadequate - none of the doctors who saw him had any qualification in child and adolescent psychiatry, nor were they approved under the Mental Health Act; they were not in possession of all the relevant background information on Kevin, nor did they take any steps to inform themselves of that history; and at no time did Kevin have a full mental health assessment;
• Following Kevin's serious suicide attempt on the 14 September 2001 there was a failure to respond effectively to the deterioration in Kevin's state of mind and his increasing anxiety about his release plans - there was a lack of clear and concise information on Kevin's serious suicide attempt and this was not communicated promptly to outside agencies.