In January last year, a 15-year-old boy was found unconscious in his cell at Cookham Wood, a young offender institution in Kent. He had hanged himself with his shoelaces. Staff tried to resuscitate him and paramedics attended before he was taken to hospital, but he was pronounced dead at 19:30 GMT.
His name was Alex Kelly. Here is his story, which is told in a case review  into his death by Tower Hamlets Safeguarding Children Board.
Alex was in the care of Tower Hamlets council and was serving a 10 month detention and training order for burglary and theft from a vehicle. He was taken into care at the age of 6 after being repeatedly raped by a family member over a substantial period of time. According to the report, “The abuse had a profound effect on his emotional health and behaviour throughout the rest of his childhood.”
He became preoccupied with finding out about his history, his identity and why he was not living with members of his family, which led to increasing difficulties with his behaviour. Tower Hamlets provided no allocated social worker from October 2011 until shortly before the time of his death. Prior to this, he had eight different social workers between 2002 and 2012.
After sentencing in the Magistrates’ Court, the local Youth Offending Team recommended that Alex should be sent to Cookham Wood – despite the fact that his vulnerability meant he would have been eligible for placement in a small unit offering higher levels of support, like a secure children’s home.
At the time of his death he was on an open ACCT (Assessment, Care in Custody and Teamwork) plan. This was because he had threatened to “string up” on a number of occasions, was cutting himself and blocking the observation panel in the cell door. He received formal disciplinary charges in response to these cries for help.
The Serious Case Review found that there were serious failings in the working relationship between the health service, the mental health service and prison officers in Cookham Wood. If mental health staff had taken account of the records of prison officers regarding his behaviour, his risk of suicide would have been assessed as much higher, which would have influenced the way he was managed. For example, they might have removed his trainers from his cell. He also managed to stop his medication without staff being aware.
The night he died was the first time at Cookham Wood that he mentioned the previous sexual abuse he had suffered in conversation with a prison officer. His observations were increased to five per hour. He hanged himself in between these observations.
Alex was the second young boy to die in a week by his own hand in a young offender institution, and one of three to die in 2011-2. There have been 34 deaths since 1990. The prisons ombudsman found  two may have suffered bullying in the young offender institutions, were extremely vulnerable and should have been moved to specialist units. Evidence from CCTV suggested that even when staff witnessed harassing behaviour from other young people it was not adequately challenged.
There was a familiar problem maintaining a balance between care and discipline - or in the report’s words:
Assessments of vulnerability and risk of self-harm did not adequately weigh static risk factors against presentation or fully take into account the complex ways children can show emotional distress.
I speak to Andrew Neilson, Director of Campaigns at the Howard League for Penal Reform, to try to make sense of this case. He tells me:
The case is extreme: he took his own life - but it’s typical of the young people we encounter who end up in custody. We see a lot of chaos, neglect and abuse. We see police and social services aware of these problems but not intervening.
Once these youths offend, then the weight of the state comes down on them - but it’s the criminal justice system, which only serves to compound the problem. The punishment comes first: the welfare is an afterthought. It’s a problem which is only set to get worse as prison budgets are cut.
Neilson tells me that Alex’s problems were exacerbated by the fact he wasn’t in prison for a serious crime:
The people who come in for more serious crimes will be subject to more intense interventions in a bid to stop them offending again.
The state in its entirety failed Alex Kelly. While the Serious Case Review makes a number of important recommendations for Cookham Wood and Tower Hamlets council, one institution that isn’t held to account is the judiciary: in this case the magistrate that sentenced him.
Magistrates make vital decisions every day,” says Neilson, “But they have very little accountability. To some degree it’s understandable: we want to maintain the judicial independence of judges - but in the end they’re lay people and so we believe they should have more contact with the outcomes of their decisions, as it may influence the decision-making process in the future.
Neilson suggests nothing has been learned from the recent reports into these deaths:
The Government’s Transforming Youth Custody Consultation  outlined all the welfare issues surrounding children who end up in prison, but then it just ignored them and went concentrated on education and secure colleges.
Calling for a root and branch reform of the way we treat the most vulnerable in our society is not some left-wing call for soft justice. It’s a basic call for humanity. More than that: it’s economically logical: every child like Alex Kelly costs tens of thousands every year to keep incarcerated. Basic things like sharing information better, improving access to mental health care and tackling bullying in child prisons are the most minor steps. That the Government would rather prioritise its latest ideological agenda is highly disappointing.