INQUEST Press Release

Tuesday 16 December 2014 – for immediate release
JURY RETURNS CRITICAL FINDINGS IN THE INQUEST INTO THE DEATH
OF 15 YEAR OLD ALEX KELLY AT HMYOI COOKHAM WOOD
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:
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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
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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;
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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
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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
[email protected]
INQUEST provides specialist advice and a complex casework service to people
bereaved by a death in custody/state detention or involving state agents and
works on other cases that also engage article 2 of the ECHR and/or raise wider
issues of state and corporate accountability. INQUEST's policy and parliamentary
work is informed by its casework and we work to ensure that the collective
experiences of bereaved people underpin that work. Its overall aim is to secure
an investigative process that treats bereaved families with dignity and respect;
ensures accountability and disseminates the lessons learned from the
investigation process in order to prevent further deaths.
Please refer to INQUEST the organisation in all capital letters in order to
distinguish it from the legal hearing.
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