Jury delivers damning narrative verdict after the inquest into the death of Ben Grimes
15 Sep 2016
Monday 8 April – Thursday 11 April 2013
Before HM Coroner for Dorset, Mr Sheriff Payne
Sitting at County Hall, Dorchester, Dorset
A jury has delivered a damning narrative verdict after the inquest into the death of Ben Grimes at HMYOI Portland, criticising failures by two young offenders’ institutions to recognise and deal with a young man’s vulnerabilities.
On the morning of 22 November 2009 Ben Grimes was found hanging in his cell on the reception wing at HMPYOI Portland, having spent only four nights in the prison. He had turned 18 six weeks before his death. On 13 November 2009 he had been sentenced to five years’ imprisonment and was expecting to serve 26 months (taking in to account time served). He had been on remand at HMYOI Feltham, close to his family, since 15 October 2009, but on 19 November 2009 he had been transferred to HMYOI Portland.
Ben’s ASSET profile (a risk management assessment completed by the Youth Offending Team) and Pre-Sentence Report (PSR) had noted that Ben was a vulnerable young man, with severe special education needs and diagnoses of attachment disorder, possible attention deficit and hyperactivity disorder and conduct disorder – the latter of which has a statistical link to suicide, according to evidence from the Prison and Probation Ombudsman’s expert clinical reviewer heard at the inquest. The ASSET further noted that removing Ben’s support network and contact with his Safe Start mentor would increase his risk.
Ben had been given 24 hours notice of his transfer to Portland, and had initially refused to go – raising concerns in particular about the distance from home. On arrival at Portland Ben had been kept waiting in a prisoner transport van while a prison officers’ meeting was concluded.
The inquest heard that for reasons which remain unknown the medical and prison staff who assessed Ben during reception and induction at Portland never saw the ASSET and PSR reports. These staff would have acted differently had they known about Ben’s vulnerability, and would have referred him to qualified mental health staff.
After three days of evidence the jury found 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 the ASSET and PSR to those with direct responsibility for Ben;
- A failure to understand Ben’s individual needs and vulnerabilities during his transfer between 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 how to handle an emergency where someone has 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.’
Anna Crawford and Eva Whittall of Hickman and Rose solicitors and Tom Stoate of Garden Court Chambers represented Ben’s family (supported by INQUEST). Eva Whittall, said:
‘Ben’s death is a stark reminder of the danger of placing vulnerable young people into an institution which fails to recognise and respond to their individual needs and vulnerabilities. The fact that such vulnerabilities are sometimes difficult to spot makes correctly following procedures, and ensuring the right information and support is available to those with responsibility for prisoners’ welfare, all the more important – especially at such a crucial time of transition to young adulthood.’