AN INQUEST has concluded that failures in the care of a 17-year-old contributed to his death at HMP and Young Offenders' Institution in Hindley.
Jake Hardy had been sentenced to a detention and training order and had been in custody for less than two months when he was found hanging in his cell on January 20, 2012.
He died in hospital four days later.
The jury at the six-week inquest at Bolton Coroners' Court concluded unanimously today, Friday, that the state failed Jake in all 12 areas they had been asked to consider.
The inquest was told that Jake, from Chesterfield, Derbyshire, had a history of self-harm and had repeatedly told officers he was being bullied.
Jake’s mother Elizabeth Hardy said: “While we finally have some answers, as a family we have been shocked by the attitude of some of the officers who clearly just didn't care that my son was being bullied.
"Other officers took such small steps and never followed it through to the end. If they had done their job properly they could have prevented Jake's death.
“I feel distraught that Jake could have been moved to a safer cell the night he hung himself. Every day we have to wake up to this nightmare that Jake died and some officers could have helped him.
"Jake was too vulnerable and should never have gone to a place like Hindley to start with. I kept my son safe for 17 years yet Hindley couldn’t keep him safe for two months.”
The jury spent three days deliberating their verdict and concluded that Jake's death could have been prevented.
They concluded that "Jake Hardy died due to his own deliberate act but the evidence does not establish beyond reasonable doubt whether he intended that act to cause his death."
Assistant deputy coroner Alison Hewitt closed the inquest.
She said: "This process has been very important because I will now produce a report on action that needs to be taken and bring it to the attention of the state agencies involved to prevent future deaths in similar circumstances.
"I offer my sympathy to Jake's family for his death and particularly for the way that it happened and I hope the proceedings have helped to some extent."
The jury concluded that the following failures more than minimally contributed to Jake's death:
- A failure to provide him with adequate personal officer support and monitoring.
- A failure adequately to record and consider reports of previous self-harm and thoughts of self-harm and suicide.
- A failure adequately to refer to the Safeguarding Department observed and reported verbal abuse.
- A failure adequately to record on C-Nomis and in the wing observation book observed and reported verbal abuse.
- A failure from the December 29 2011 onwards to investigate reports that he was being verbally abused by other young persons and to take action to address such abuse.
- A failure on January 18 2012 onwards to provide, update and utilise under the ACCT process an adequate care map in respect of his risk of self-harm.
- A failure from January 18 2012 onwards to move him from cell F1/24 to a different location.
- A failure on the evening of January 20 2012 to permit him to use the telephone.
- A failure on the evening of January 20 2012 to supervise association properly and to protect him from the negative behaviour of other young persons towards him.
- A failure on the evening of the January 20 2012 to review the level of his risk of self-harm.
- A failure on the evening of January 20 2012 to review the regularity with which he was checked.
- A failure on the evening of January 20 2012 to review the suitability of his location for his safety overnight.