Tom Stoate, instructed by Eva Whittall and Anna Crawford of Hickman and Rose Solicitors (and supported by INQUEST), represented the family of Ben Grimes, a vulnerable 18 year-old who was found hanging in his cell on the reception wing at HMPYOI Portland, Dorset, on the morning of 22 November 2009, having spent only four nights in the prison.
After three days of evidence, the inquest jury at County Hall, Dorchester, delivered a damning narrative verdict - criticising failures both HMYOI Portland and HMYOI Feltham (from where Ben was transferred) to recognise and deal with Ben's vulnerabilities, including severe special education needs and diagnoses of attachment disorder, possible attention deficit disorder and conduct disorder (which has a statistical link to suicide), at a crucial time of transition to young adulthood.
Under questioning, the inquest heard that the medical and prison staff who assessed Ben during reception and induction at Portland and found him to be of no concern would have acted differently had more information been provided on Ben's potential risk factors, and would have referred Ben to qualified mental health staff. It is unclear whether HMYOI Feltham provided HMYOI Portland with the relevant information at the time of Ben's transfer or whether HMYOI Portland failed to read the information provided to them.
In particular, the jury found that the following contributed to Ben's death:
- Insufficient verbal and written communication between the agencies responsible for Ben's welfare and wellbeing;
- A failure to provide key risk management documents to those with direct responsibility for Ben;
- A failure to understand Ben's individual needs and vulnerabilities during his transfer between HMYOIs Feltham and Portland;
- A failure to complete the proper transfer documentation to the acceptable standard; and
- Interruptions in the continuity of Ben's social care support in custody
The jury also heard evidence that the Support Grade prison staff who found Ben had had no specific training in dealing with an emergency situation where someone is found having seriously self-harmed. The Coroner is currently considering a Rule 43 report into this issue, as well as into issues of communication of information upon transfer of prisoners.
Lisa Courtney, Ben Grimes's mother, said:
"The jury's verdict is a damning indictment of institutional and systemic failures in the care of young people in custody. We agree with the jury that Ben was badly let down. We sincerely hope that lessons are learnt from Ben's tragic death."
The inquest was heard between Monday 8 - Thursday 11 April 2013, before HM Coroner for Dorset, Mr Sheriff Payne.