Inquest into the death of 14 year old Adam Rickwood in custody: a pre-sentencing report had said that he constituted "no risk of self-harm".

'No risk of self-harm': the official verdict on the youngest child to die in penal custody - The Independent

Extract:

"The youngest child to die in custody in Britain was not recognised as a suicide risk in reports by social workers, despite having been admitted to hospital nine times after harming himself.

An inquest into the death of Adam Rickwood was told yesterday that magistrates who sent the 14-year-old into custody were told in a pre-sentencing report that he constituted "no risk of self-harm".

The decision to send him to Hassockfield secure training centre near Consett, Co Durham, also drew on the results of a form completed by Lancashire County Council's youth offending team which indicated that Adam had had no contact with mental services, had received no kind of mental diagnosis and had never harmed himself.

In fact, the boy had been in hospital seven times after repeatedly overdosing on alcohol/drug mixes and cutting his wrists twice. Lancashire County Council's director of children's integrated services, Gill Rigg, said Adam's mental health record was the "key, relevant factor" in determining whether he should have been in custody at all. "I accept that was a very critical and essential piece of information that should have been on [the] form," she told the inquest at Chester-le-Street magistrates' court, Co Durham.

Adam's despair at being sent to a secure unit 150 miles from home was evident in his last letter to his mother and stepfather, Carol and John Pounder, which was read to the jury. "I need to be at home," he wrote. "If I could have the chance to be at home and with my family I will never get in trouble again in my life. I will do anything to be with you's [sic] but if people try to stop that I will flip."

The inquest heard that Adam, from Burnley, Lancashire, was a profoundly vulnerable child who had been known to social services from the age of three and had been referred to Lancashire's child and adolescent mental health unit.

He seemed to respond to those who found time for him, particularly his paternal grandfather, who was wheelchair-bound. "He used to lie in bed with granddad, watching TV [and] eating sweets [with him]. They shared everything," Mrs Pounder told the jury.

It was after his grandfather's death that Adam, then 11, entered a spiral of decline. He fell in with a group of older boys, took cannabis, was convicted of burglary and had been excluded from school."

You wonder how this unhappy young boy could possibly have been judged to be at "no risk of self-harm"...)o: