Pounder v HM Coroner for the North & South Districts of Durham & Darlington

JurisdictionEngland & Wales
Judgment Date22 January 2009
Neutral Citation[2009] EWHC 76 (Admin)
Docket NumberCase No: CO/7082/2007
CourtQueen's Bench Division (Administrative Court)
Date22 January 2009

[2009] EWHC 76 (Admin)




Before: The Hon. Mr Justice Blake

Case No: CO/7082/2007

R(On the Application of Carol Pounder)
HM Coroner for the North and South Districts of Durham and Darlington
Youth Justice Board
1st Interested Party
Serco Home Affairs Limited
2nd Interested Party
Lancashire County Council
3rd Interested Party

Richard Hermer (instructed by Bhatt Murphy Solicitors) for the Claimant

Richard Perks (instructed by Hewitts Solicitors) for the Defendant

Wendy Outhwaite (instructed by the Treasury Solicitors) for the 1 st Interested Party

Samantha Leek (instructed by Lupton Fawcett Solicitors) for the 2 nd Interested Party

Hearing dates: 18 th, 19 th December 2008

The Honourable Mr Justice Blake:



Adam Rickwood has the mournful distinction of being the youngest person to die in a British penal establishment, at least in modern times. On the 8 th August 2004, shortly before midnight, he was found in his bedroom cell at Hassockfield Secure Training Centre (STC) having strangled himself with the assistance of a shoe-lace. Resuscitation failed and in due course he was pronounced dead. He was 14 years at the time, having been born on 14 th November 1989. He was a troubled child with a history of offending, self-harm, substance abuse and absconding from care. In his cell were found two documents: a farewell letter to his family and a statement complaining of his treatment at Hassockfield STC some six hours earlier that day.


On the 29 th June 2004 Adam had appeared before the Burnley Pendle and Rossendale Magistrates' Court who ordered his secure remand on a charge of wounding with a knife and an offence of burglary. No secure beds were available. Adam absconded on three occasions from less secure local authority children's accommodation, and on the 10 th July 2004 he was placed at Hassockfield STC in response to the repeated decisions of the magistrates' court who had ordered secure remand. It was his first experience of custody. Hassockfield STC is a custodial centre run by a private company Serco Ltd (the second interested party in these proceedings), under powers given to the Secretary of State under s.7 of the Criminal Justice and Public Order Act 1994. At that time STCs were intended to house particularly challenging children aged between 12 and 15 who were sentenced by the criminal courts. Subsequently, the age range for admission to an STC was increased to 17 for those on remand or sentenced to a detention and training order. Other offenders over 15 and under-21 could be assigned to a Young Offenders institution run by the prison service directly.


There was a detailed contract made between the relevant government department (originally the Home Office and now the Ministry of Justice) setting out the powers and duties of the STC and its staff. The monitoring and enforcement of this contract as well as the duties of purchasing and allocation of placements in secure facilities for children who had been sentenced or remanded in custody was to be performed by the Youth Justice Board (YJB) who is the first interested party in these proceedings. The YJB is an executive non-departmental government body set up under the Crime and Disorder Act 1988.


As Adam had died in a penal institution, the Coroners Act 1988 s. 8(1) and (3) required the Coroner to conduct the inquest with a jury. By s.11 (5) of that Act the inquisition shall set out as far as the particulars have been proved who the deceased was and how, when and where the deceased came by his death. The proceeding before this court is an application for judicial review of that inquest made by the claimant, Adam's mother. The defendant in this matter is HM Coroner for the North and South Districts of Durham and Darlington. The first two interested parties have already been identified. The third interested party is Lancashire Country Council which was the local authority with statutory responsibilities for Adam. It participated in the inquest proceedings but has played no part in the proceedings before this court.


It should be stated at the outset of this judgment that it is clear from the three volumes of the transcript of the record of the inquest, the three volumes lodged in support of this application for judicial review, and the detailed grounds and skeleton arguments of the parties that the defendant Coroner conducted a very substantial inquiry into a number of questions that may have caused or materially contributed to Adam's self-inflicted death. Over a five week period from 30 th April 2007 the jury heard from at least 33 different witnesses into many and various aspects of the history whereby Adam came to be remanded to Hassockfield STC, his assessment of suicidal vulnerability on arrival there, and his subsequent inmate history there.


It is plain from the evidence gathered and the inquisition returned by the jury that Adam was unhappy at being remanded in custody at all and was unhappy at being detained at Hassockfield STC in County Durham some 100 miles and three hours away from his family in Burnley the other side of the Pennines. There are very real limits to the extent that an inquest is either required or is able to investigate questions of resources and juvenile penal policy that led to this remand. The decision-making process that led to this outcome was fully explored before the jury as was his request for a transfer.


Adam was assessed at high risk of self harm on arrival at Hassockfield STC and was placed on the register of those who were considered to be at high risk of self-harm (HRAT). Nevertheless, he seemed to make progress in addressing his situation and the reasons why he was there. He was regarded as a model trainee who had earned substantial privileges by reason of his good behaviour and at the end of July 2004 a decision was taken to remove him from the HRAT register. Again the reasons for doing this were explored at the inquest and no complaint is made of the way the jury examined these issues and the conclusion to which it came that this decision was an appropriate one.


Adam died late on a Sunday night. On the previous day he had lost privileges and had his television removed from his bedroom cell because he had been supplied with two contraband cigarettes by his mother during a visit. Adam was also under the mistaken impression that an application for bail was being made to a judge in chambers the following week and he believed he had good prospects of success in such an application. On the Sunday evening he twice spoke to his solicitor, and as a result of one of those conversations he learned that no such application was to be made. The jury concluded that his loss of privileges and the disappointing news as to the possibility of an imminent bail hearing contributed to his decision to take his life. No complaint is made of those conclusions.


Another factor that was a potential contributory cause of his self-inflicted death, was the treatment he received around 6.00pm on the Sunday 8 th August. This was the subject of an oral complaint made to staff, his statement found in his cell and the topic of at least one of the conversations he had with his solicitor that evening. It is the consideration given by the inquest to this factor that forms the basis of this application for judicial review.


In broad terms the evidence adduced at the inquest reveals the following picture. In the early evening in question, Adam and another inmate were in their free association period outside their bedroom cells. A third inmate who had been deprived of association and sent to his cell for disciplinary reasons passed a note under his cell door to Adam in which abusive remarks were made about the female training officer (Ms Murray) who was supervising the trainees. As a result of disobeying an order to hand over the note, Adam was himself ordered to go to his cell by way of sanction. He refused to go to his cell protesting that he had done nothing wrong. He sat down and resisted requests to move without offering any violence to himself, other inmates or staff or inciting other inmates to violence or disorder. Ms Murray called a more senior officer (Mr Gardiner), whose attempts to persuade Adam to go to his cell were also unsuccessful and who in turn called for emergency assistance from other members of staff by way of a call known as first response. The evidence before the inquest suggested that calling for first response tended to result in the use of physical restraint. Officers Hamilton, Lowerson, Clark and Hodgson attended the scene in response to the call. As Adam still refused to leave the association area voluntarily two male officers (Hamilton and Lowerson) physically took hold of each of his arms. He struggled in resistance to this and so a third officer (Hodgson) controlled his head with both hands. There was further resistance and a fourth training officer (Clark) came from behind Adam and took hold of both his legs. He was lifted off the ground and moved face downwards to his cell where he was placed face down on the floor before the officers left the cell. Officer Horseman attended to make a video recording of the restraint. During the manoeuvre, Mr Hodgson, the officer who held Adam's head feared that Adam was trying to bite the officer's fingers and so applied what is known as a nose distraction technique. This is a short sharp movement applying force by fingers under the nostril against the counter-force of the other hand holding the...

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