Jury blames serious failings in care for Liam McManus hanging

AN inquest jury examining what led a 15-year-old St Helens boy to hang himself in a young offenders institute has ruled that “systemic failings” in both the prison and the community contributed to his death.

Liam McManus was found hanging from a bed sheet tied to the window of his single cell at Lancaster Farms on November 29, 2007.

He was in custody after breaching the terms of his licence and had only 23 days left to serve when he took his own life, becoming the 30th child to die in state custody since 1990.

Throughout a seven-week inquest a jury heard evidence of a catalogue of failings by many agencies involved in Liam’s care.

Their damning narrative verdict stated that “an accurate picture of Liam was never established by the prison resulting in him never receiving the right level of support”.

Liam was said to be “a troubled child who had suffered significant loss and trauma in his short life”.

He was taken into care as a young child, lived with his aunt and uncle since he was seven, had a history of self-harm and had been involved with a mental health worker for more than two years.

His vulnerability was said to be well known to both social services and the young offenders’ service.

In their verdict, the jury recognised that a series of factors contributed to his death.

These include a failure by the young offenders service to ensure that “protective factors” of visits from Liam’s YOS worker, mental health worker and family would be in place during his sentence.

During the three weeks he was in the institute, he wrote seven letters to family and friends, repeatedly asking when his youth offending team worker would visit.

They found a subsequent failure by all to register when they did not take place.

The jury found there was a ‘target driven’ and ‘top-down’ approach by the Youth Justice Board rather than a ‘caring culture’ for vulnerable children.

Before Liam was in custody, a decision by St Helens Council’s Children and Young People’s Service assessed him as a “high risk” case.

But the jury stated he was still introduced to his birth mother – who lived a “problematic and chaotic lifestyle”.

And when his social worker was about to leave the service a staff shortage led to “no replacement” being introduced and his case was closed without “consideration for the consequences”.

A failure by prison staff to recognise Liam’s “risk level and needs” was also cited.

The jury noted that this included officers accepting Liam’s response to questions and not referring to important documentation which provided critical information about him.

Lancaster Farms was criticised for keeping these documents in a room which was separate to the wings, resulting in officers not having immediate access to the information.

Jurors highlighted an ineffective interpretation of the personal officer policy which should have meant that Liam was given the continuing support of one officer.

They added there was a failure by all agencies to have the same assessment criteria for ‘vulnerability’ and communicate effectively.

And there was a failure to hold a planning meeting about his care despite guidance that this should take place within ten days.

The jury said this would have given those working with Liam an opportunity to share their knowledge of him and assist prison staff in supporting him appropriately.

The jury was also told Liam was transferred to a new wing on a night when there was reduced staff levels, meaning other prisoners did not mix during the day and were restless.

This led to heightened shouting through the windows by other juvenile prisoners on the night of his death, including calls to ‘string up’ and “bag you out”.

Though the jury believes the vicious words were directed at a new boy in a different cell, the jury recognised the intimidating calls would have affected “Liam’s frame of mind” and contributed to his actions that tragic night.

The jury found: “Whilst some of the defects and factors identified may appear to have had a minimal impact, collectively they contributed to systemic failings in the care and support of Liam that contributed to the actions of Liam McManus that contributed to his death.”

The coroner reported significant inadequacies in the performance of social services, who lost significant documents and closed Liam’s file just before he was due to go into custody, apparently without review, on the assumption that he would be safeguarded in the institution.

Following the verdict, Liam’s aunt and uncle said via a statement: “It seems to us that Liam’s serious vulnerability was never picked up by anyone in HMYOI Lancaster Farms and we are happy that the jury have recognised this.

“We hope in future that prison officers will take that bit of time to read all the information that comes into prison so that vulnerable children are given the care and consideration that they need.

“We also hope that those dealing with vulnerable children take on board the evidence heard at this inquest, the jury findings and recommendations of the coroner so that deaths like Liam’s can be avoided in the future.

“The most important thing now is that no other family should have to go through what we have been through in the last two years.”

Mark Scott, of Bhatt Murphy solicitors – who represented Liam’s aunt and uncle, made the following statement: “This case raises fundamental questions about how the state treats vulnerable children who offend.

“It is time for there to be a public inquiry to ensure that lessons are learnt.”

In a written statement responding to the findings, St Helens Council said: “A Council spokesperson said: “First and foremost our deepest sympathy go to Liam’s family over this tragic incident.

“St Helens takes its safeguarding responsibilities extremely seriously.

“Following Liam’s death in 2007 we carried out a Serious Case Review led by an independent, external consultant.

“We also commissioned an independent consultant to review practice in respect of custody cases.

“We have enhanced procedures and practice in respect of both the placing of young people in Custodial settings and the on-going support they receive.

“We have recently had very good inspections of both youth and children’s services.”

A Prison Service spokesperson added: “Every death in custody is a tragedy, and our sympathies are with Liam’s family.

“Every death in prison affects families, staff and other prisoners deeply. Ministers, the Ministry of Justice and the National Offender Management Service are completely committed to reducing the number of such tragic incidents.

“Learning from deaths in custody is a key strand of the prisoner suicide prevention strategy, and of collaborative work across custodial sectors.

“Lessons have already been learnt from the Prison Probation Ombudsman’s recommendations, and we will be carefully considering the inquest verdict and findings, and any Coroner’s Rule 43 letter, to see what further lessons can be learnt from Liam’s death.”