0:00:02 > 0:00:07This programme contains some strong language and scenes which some viewers may find upsetting.
0:00:07 > 0:00:10'..and within days was found hanging from a sheet tied...'
0:00:10 > 0:00:13'Adam Rickwood was just 14 years of age when he was found hanged.'
0:00:13 > 0:00:17In the last ten years, 80 young people aged 21 and under
0:00:17 > 0:00:19have killed themselves in prison.
0:00:19 > 0:00:21"This is the report of an investigation
0:00:21 > 0:00:25"into the circumstances surrounding the death of Ryan Clark.
0:00:25 > 0:00:27"When Ryan was found hanging in his cell,
0:00:27 > 0:00:29"he was 17 years old.
0:00:29 > 0:00:32"I would like to offer my sincere sympathy to Ryan's family."
0:00:32 > 0:00:35"CCTV footage showed that on the day of his death,
0:00:35 > 0:00:39"Jake was subjected to verbal abuse and banging on his cell door."
0:00:39 > 0:00:43"15 weeks before Adam's death, another young man
0:00:43 > 0:00:47"died at Brinsford, in the same cell and using the same method."
0:00:47 > 0:00:52This is the story of three young men who died behind bars...
0:00:52 > 0:00:54"So, Mum, if you're reading this, I'm not alive
0:00:54 > 0:00:57"cos I can't cope being in prison no more."
0:00:57 > 0:00:59..told by the people who knew them best.
0:00:59 > 0:01:01He knows what a grass is and he knows what happens to grasses
0:01:01 > 0:01:04and he knows what happens to people who go running to screws.
0:01:04 > 0:01:07He didn't have the mind of the 17-year-old he were.
0:01:07 > 0:01:10He had the mind of, like, a young teenager.
0:01:10 > 0:01:13It reveals how they died in the care of the state.
0:01:15 > 0:01:18They were bullied that much, I think he were tortured.
0:01:19 > 0:01:21His mind were tortured.
0:01:21 > 0:01:23And he lost his life at the end of it.
0:01:33 > 0:01:37'We have systems in place to ensure we learn lessons from deaths
0:01:37 > 0:01:41'in custody. That's what the Ministry of Justice has said.'
0:01:41 > 0:01:45'The compelling evidence is the fact that the deaths continue to occur.
0:01:45 > 0:01:46'More crucially, it is
0:01:46 > 0:01:49'the pattern of deaths with worryingly familiar themes.'
0:01:51 > 0:01:54Jake Hardy is one of the 80 young people who have
0:01:54 > 0:01:57taken their own lives in prison in the last decade.
0:01:57 > 0:02:00He died in Hindley Young Offenders Institution
0:02:00 > 0:02:01when he was just 17.
0:02:04 > 0:02:09Mummy's boy. That's my lad. Very handsome but still a mummy's boy.
0:02:09 > 0:02:13Any trouble, he'd come running home to Mummy.
0:02:13 > 0:02:18That one is a week before he went to prison.
0:02:18 > 0:02:20Jake were a follower, not a leader.
0:02:20 > 0:02:24If somebody said to him to do it, Jake probably would.
0:02:24 > 0:02:27He couldn't tell right from wrong, really.
0:02:27 > 0:02:29But that were his mental capacity.
0:02:29 > 0:02:31Six foot four and a half
0:02:31 > 0:02:34with a mental age of between 12 and 13 years old.
0:02:35 > 0:02:37That's Jake and his sister, Samantha.
0:02:37 > 0:02:40I think he were about 14 there.
0:02:40 > 0:02:42That's Jake with his hair gelled back.
0:02:42 > 0:02:46He were going to a Christmas party at church, I think.
0:02:46 > 0:02:49If he hadn't had his tablets, he couldn't hold a limb still.
0:02:49 > 0:02:54He were all giddy. We used to call it Jake doing the wall of death.
0:02:54 > 0:02:56As in motor bikes going round and round and round.
0:02:56 > 0:02:58That's how Jake were.
0:02:58 > 0:03:01And he'd say, "Mum, I just want to be normal, Mum."
0:03:01 > 0:03:03That's how he saw himself.
0:03:03 > 0:03:06He wanted to be like the other lads.
0:03:06 > 0:03:08And, of course, he weren't.
0:03:08 > 0:03:12And he just followed their lead and got himself into trouble.
0:03:12 > 0:03:13That's how it all started.
0:03:15 > 0:03:19They did know in primary school there was something the matter with him.
0:03:19 > 0:03:23I mean, I went to... I had to take him to a speech therapist twice
0:03:23 > 0:03:24cos he couldn't finish a word off.
0:03:24 > 0:03:27I had to take him to have his eyes tested
0:03:27 > 0:03:29cos they thought that might be a problem.
0:03:29 > 0:03:33It wasn't till he got expelled, at 12, from his senior school,
0:03:33 > 0:03:35that he were diagnosed.
0:03:35 > 0:03:40It were good to know that he'd got ADHD and something WERE wrong,
0:03:40 > 0:03:43not just he were a naughty boy who liked to destroy everything
0:03:43 > 0:03:45he put his hands on and set fire to things.
0:03:45 > 0:03:47- INTERVIEWER:- What did they diagnose him with?
0:03:47 > 0:03:53ADHD and conduct disorder, dyslexia and mildly autistic.
0:03:53 > 0:03:56Jake and my mum and my sister dancing in the kitchen.
0:03:56 > 0:03:57DANCE MUSIC
0:03:58 > 0:04:00They were always dancing, weren't they?
0:04:00 > 0:04:02That were a normal day, weren't it?
0:04:02 > 0:04:05- There were nobody like him. - Nobody.- No-one.
0:04:05 > 0:04:06If he weren't out making something,
0:04:06 > 0:04:09- he were taking something apart, weren't he?- Yeah.
0:04:09 > 0:04:10Or annoying me.
0:04:10 > 0:04:13Normally annoying me by taking my things and breaking them.
0:04:13 > 0:04:14Do you remember one time
0:04:14 > 0:04:17he came racing down the road in a wheelie bin?
0:04:17 > 0:04:19On top of a black bin just skidding down the road.
0:04:19 > 0:04:21He did a lot of things with black bins.
0:04:21 > 0:04:23He used it as a boat, didn't he, at the canal?
0:04:23 > 0:04:26Yeah, bobbing down the canal in the black bin.
0:04:26 > 0:04:29Abseiling out through his bedroom window.
0:04:29 > 0:04:32Which, what, is 20 foot off the floor?
0:04:32 > 0:04:36Jake got a four-inch piece of rope. Four-inch.
0:04:36 > 0:04:38I says, "What are you doing, duck?"
0:04:38 > 0:04:40He says, "Try abseiling down here, Mum."
0:04:40 > 0:04:43I says, "Oh, don't do that, duck."
0:04:43 > 0:04:45Not many understood him.
0:04:45 > 0:04:48Like, the people he were close, close to understood him
0:04:48 > 0:04:51but if you were to meet him on the street, you'd not...
0:04:52 > 0:04:53You'd not, like...
0:04:53 > 0:04:57He'd be one that you'd look at and you'd think, "Prick."
0:04:57 > 0:05:00I mean, if he'd got a great, big scar on his head
0:05:00 > 0:05:03they'd probably relate more to that
0:05:03 > 0:05:07but Jake's was in his brain. His mental difficulties.
0:05:07 > 0:05:11And people just looked at Jake and thought, "Normal kid.
0:05:11 > 0:05:13"He's a naughty normal kid."
0:05:18 > 0:05:20On the night of his 17th birthday,
0:05:20 > 0:05:23Jake and his friends were involved in a fight.
0:05:23 > 0:05:28Jake was charged with affray and bailed to appear in court.
0:05:28 > 0:05:30Just two months later, he was in trouble again.
0:05:32 > 0:05:34This girlfriend must have been special.
0:05:34 > 0:05:38She were older than him, though, and he adored her.
0:05:38 > 0:05:40Jake was only...
0:05:40 > 0:05:44He were only 17 and he were madly in love with her. Besotted by her.
0:05:44 > 0:05:48And she ended it and he went back up to see her.
0:05:48 > 0:05:52And he had a...
0:05:52 > 0:05:55a knife in his hand and he were going to stab himself
0:05:55 > 0:05:57if she wouldn't go back with him.
0:05:57 > 0:06:00And she pulled the knife out of his hand and they had a row
0:06:00 > 0:06:02and she phoned the police.
0:06:04 > 0:06:07He were worried about going to court and he started
0:06:07 > 0:06:12mutilating himself, cutting his face with anything he could get hold of.
0:06:12 > 0:06:14Clippers, nail clippers, scissors.
0:06:16 > 0:06:19And cos he were already on bail for the affray,
0:06:19 > 0:06:22that's why they sent him to prison.
0:06:22 > 0:06:28The judge just said, "I'm sentencing you to four months." And Jake just...
0:06:28 > 0:06:32His last words that day were, "Mum, Mum, help me, Mum.
0:06:32 > 0:06:33"Mum, help me."
0:06:35 > 0:06:38And he just walked away crying.
0:06:38 > 0:06:39He were a right mess.
0:06:40 > 0:06:44Yeah, right mess. Proper couldn't hold it in or anything.
0:06:44 > 0:06:46Proper upset.
0:06:46 > 0:06:52He did do wrong and he did need punishing, but he wasn't necessarily
0:06:52 > 0:06:59forced to be sent to a normal prison cos Jake weren't normal.
0:06:59 > 0:07:01He couldn't go to mainstream school.
0:07:01 > 0:07:03Why did they send him to a mainstream prison?
0:07:04 > 0:07:06He couldn't cope with it.
0:07:12 > 0:07:16Three years before Jake, Adam Rushton killed himself
0:07:16 > 0:07:19in Brinsford Young Offenders Institution.
0:07:19 > 0:07:20He was 20.
0:07:22 > 0:07:27Poppy. Good girl. That's a good girl.
0:07:27 > 0:07:30Three days before his seventh birthday,
0:07:30 > 0:07:32we picked Adam up and all his worldly goods,
0:07:32 > 0:07:35which wasn't very much, and brought him home.
0:07:35 > 0:07:38And so this is where he grew up.
0:07:38 > 0:07:41It's where he played, where we tried to show him
0:07:41 > 0:07:44there was a better way of being.
0:07:44 > 0:07:47He seemed happy quickly, to be here.
0:07:55 > 0:08:01We had adopted Chris about six years before and that had gone really well.
0:08:01 > 0:08:04We were a very happy threesome
0:08:04 > 0:08:07and adding to it just seemed like a really good idea.
0:08:07 > 0:08:11So we actually got in touch with our old social worker.
0:08:11 > 0:08:15She told us about a little boy.
0:08:15 > 0:08:19He and his twin brothers had been taken into care because his mum
0:08:19 > 0:08:22just couldn't cope with them and they were concerned for their welfare.
0:08:22 > 0:08:25- I didn't know you were there. - What are you doing?
0:08:25 > 0:08:29- He's taking a picture of you and Christopher.- Can I look through it?
0:08:29 > 0:08:33- Whatever you see is what gets filmed. - I want to look up in the sky.
0:08:33 > 0:08:35All right then. Oh, my goodness.
0:08:36 > 0:08:39- Bye, Dad.- Bye, Daddy.
0:08:42 > 0:08:43Can we do some more...?
0:08:45 > 0:08:49This is Adam with his twin brothers before he came to live with us.
0:08:51 > 0:08:56Adam, even at that very young age, we learnt, had to help
0:08:56 > 0:08:59look after his baby brothers. They would be hungry.
0:08:59 > 0:09:03There might be Weetabix in the house but there'd be no milk.
0:09:03 > 0:09:07He would go outside and wander up and down the street
0:09:07 > 0:09:11and look for somebody's milk on the doorstep.
0:09:11 > 0:09:15So, we soon came to realise that, from a very early age,
0:09:15 > 0:09:18the only way Adam could survive was by taking things.
0:09:18 > 0:09:23And he was very busy, very active, always on the go and mischievous.
0:09:23 > 0:09:26In school, he was very disruptive. He'd go to the toilet
0:09:26 > 0:09:29and flood the toilets or break something in the toilet.
0:09:29 > 0:09:33So he was very difficult. His behaviour was very challenging.
0:09:35 > 0:09:38He would have periods of bad behaviour
0:09:38 > 0:09:41most often when he'd had a particularly nice day.
0:09:41 > 0:09:45You'd go to the seaside or you'd go and do something with them
0:09:45 > 0:09:50and then you'd come home and his behaviour would deteriorate
0:09:50 > 0:09:55and the only way we could ever really understand it or explain it
0:09:55 > 0:09:59was that this child didn't think he deserved to have anything nice
0:09:59 > 0:10:01or to do anything nice.
0:10:01 > 0:10:04As if he believed, "I don't deserve this.
0:10:04 > 0:10:08"I'm bad." He couldn't believe that he was lovable.
0:10:10 > 0:10:15Like Jake, Adam was 12 years old when he was diagnosed with ADHD.
0:10:15 > 0:10:18He was given a place at a special boarding school.
0:10:18 > 0:10:22Tregynon Hall School was a private independent school.
0:10:22 > 0:10:27It was home from home. We could see hope, yeah, in abundance.
0:10:27 > 0:10:29For me, I'm not sure my husband would agree,
0:10:29 > 0:10:34but me being...my mug ever half full, I was hopeful.
0:10:34 > 0:10:39At 15, I was, "Yes, that's my boy.
0:10:39 > 0:10:43"Going to be OK." And that was suddenly taken away from us.
0:10:45 > 0:10:48He was suspended from school. We were asked to come and fetch him.
0:10:48 > 0:10:52His behaviour towards another child had been aggressive
0:10:52 > 0:10:54and they would never have him back.
0:10:54 > 0:10:57He just wasn't allowed back to school.
0:10:57 > 0:11:01He went back to feeling, "I'm just a lot of rubbish, aren't I?
0:11:01 > 0:11:06"What's the point? I might as well just do what I want to do."
0:11:08 > 0:11:10Soon after Adam was expelled from school,
0:11:10 > 0:11:16he left home and went to live in a hostel in nearby Newtown. He was 16.
0:11:16 > 0:11:20It wasn't long before he started to get into trouble with the police.
0:11:20 > 0:11:23He was good at stealing.
0:11:23 > 0:11:30He was good at it. And if he stole, he would be risen in the eyes
0:11:30 > 0:11:35of his new friends, who were not always very savoury.
0:11:35 > 0:11:38But these were people who would look up to him
0:11:38 > 0:11:40because he was good at something.
0:11:40 > 0:11:43Because he'd been learning it from a very young age -
0:11:43 > 0:11:45how to take things to survive.
0:11:45 > 0:11:46So that's what he did.
0:11:53 > 0:11:56Ryan Clark was just 17 when he killed himself
0:11:56 > 0:11:58in Wetherby Young Offenders Institution.
0:12:02 > 0:12:04Ryan was the quiet one.
0:12:04 > 0:12:06Happy-go-lucky, I called him.
0:12:06 > 0:12:10He didn't cry, he didn't whinge.
0:12:10 > 0:12:12Timid. Really timid.
0:12:14 > 0:12:18Very, very small as well for his age.
0:12:18 > 0:12:22Yeah, very small. We used to always call him little gnome.
0:12:22 > 0:12:23Just tiny.
0:12:26 > 0:12:28About here.
0:12:29 > 0:12:33Ryan, like Adam, was taken into care at an early age.
0:12:34 > 0:12:38This is what we call Ryan's table.
0:12:38 > 0:12:42We light these candles at Christmas time, don't we? Birthdays.
0:12:42 > 0:12:46This one's myself, Ryan, the smallest,
0:12:46 > 0:12:48Gino and Karl, his brothers.
0:12:48 > 0:12:51Got Ryan on there again.
0:12:51 > 0:12:56We sort of made a collage of bits and bobs.
0:12:56 > 0:12:58Before his ears were pinned back.
0:12:58 > 0:13:01I like to live surrounded by the pictures.
0:13:01 > 0:13:05Cos they weren't with me all the time, that were my safety net.
0:13:05 > 0:13:09They weren't here, but they were still around me.
0:13:09 > 0:13:12They were brought up in foster care cos I was unable to
0:13:12 > 0:13:15look after them myself through mental health problems.
0:13:15 > 0:13:20I suffer with bipolar type II.
0:13:21 > 0:13:22I'm actually now in remission.
0:13:24 > 0:13:28I think if I'd been diagnosed a lot of years ago,
0:13:28 > 0:13:29my children would all be here.
0:13:31 > 0:13:33Things would have been different.
0:13:36 > 0:13:38They all went to the same foster carer.
0:13:39 > 0:13:42Ryan was the main one that was stable
0:13:42 > 0:13:44for most of the time.
0:13:44 > 0:13:47Karl and Gino had both turned into little terrors
0:13:47 > 0:13:49going to high school.
0:13:49 > 0:13:53So they left that placement and I think that affected Ryan
0:13:53 > 0:13:56quite a lot because he'd grown up with his two siblings
0:13:56 > 0:14:01and then to suddenly be the only one, I think
0:14:01 > 0:14:04that would have had a big impact on Ryan,
0:14:04 > 0:14:08especially with Gino leaving, because he were close with Gino.
0:14:08 > 0:14:10Ryan started to get unsettled a bit,
0:14:10 > 0:14:13going and getting distraught in the house and getting a bit angry.
0:14:13 > 0:14:17He kind of come out of care around about 13, 14
0:14:17 > 0:14:20and just started living in hostels round Leeds, getting into crime.
0:14:20 > 0:14:22I think they were desperate to belong
0:14:22 > 0:14:25but I think because everybody was split up into...
0:14:25 > 0:14:28Cal was in one place, Gino, another,
0:14:28 > 0:14:30me another place.
0:14:30 > 0:14:33I think he was torn between all of us
0:14:33 > 0:14:35and then started tagging with Gino.
0:14:35 > 0:14:40I think he thought Gino was the only one who sort of cared about him.
0:14:40 > 0:14:42Who made this?
0:14:42 > 0:14:46My little brother, Gino, who's currently back in prison.
0:14:46 > 0:14:47- What's it made out of?- Matchsticks.
0:14:47 > 0:14:50If you can get a close-up through the window inside,
0:14:50 > 0:14:53you'll be able to see all inside as well - matchsticks.
0:14:53 > 0:14:57He made these on his three-and-a-half-year sentence.
0:14:57 > 0:15:00- Is he in prison at the moment? - He is, yeah.
0:15:00 > 0:15:03Currently serving a two- or three-year sentence.
0:15:03 > 0:15:05Did Ryan look up to Gino?
0:15:05 > 0:15:07Yeah, he wanted to follow Gino into his footsteps.
0:15:07 > 0:15:11- Do you maybe he had followed your footsteps?- Not really.
0:15:11 > 0:15:15I wish he had just followed his own footsteps and learnt his own way.
0:15:15 > 0:15:17I wasn't exactly a good boy myself.
0:15:20 > 0:15:23The 12 months before Ryan went to prison,
0:15:23 > 0:15:26Ryan lived in the hostel, not a very nice hostel.
0:15:27 > 0:15:31Starting to do street robberies with other people.
0:15:31 > 0:15:34He was addicted to amphetamines by then,
0:15:34 > 0:15:37cannabis, M-Cat.
0:15:37 > 0:15:39Wasn't nice seeing him like that.
0:15:39 > 0:15:41We should have seen it as well.
0:15:41 > 0:15:44It was like him turning out and saying,
0:15:44 > 0:15:46"I'm scared, I need help."
0:15:46 > 0:15:50The alleged offence that Ryan was remanded for was robbing a phone
0:15:50 > 0:15:51and money, I think.
0:15:51 > 0:15:55He said, "I'm going to prison. They are not going to let me come home.
0:15:55 > 0:15:58"They're going to remand me. They're going to remand me."
0:15:58 > 0:16:01You could just tell that he wasn't looking forward to prison.
0:16:01 > 0:16:03He even cried before he went to prison, saying,
0:16:03 > 0:16:04"I don't want to go to prison."
0:16:04 > 0:16:07"Really frightened they're going to look me up."
0:16:07 > 0:16:09Ryan was remanded into custody
0:16:09 > 0:16:12at Wetherby Young Offenders Institution,
0:16:12 > 0:16:16which houses over 350 inmates aged between 15 and 17.
0:16:16 > 0:16:19What did you think when you heard he was going to prison?
0:16:19 > 0:16:23He was going to get bullied. He was definitely going to get bullied.
0:16:23 > 0:16:27I knew he would get bullied because Ryan wasn't a fighter.
0:16:27 > 0:16:31He was little, very slim, nothing to him.
0:16:32 > 0:16:34I was quite worried about Ryan.
0:16:47 > 0:16:50Our role there, we were protecting him,
0:16:50 > 0:16:52seeing to his needs and such things.
0:16:52 > 0:16:56Would he cope? And what would he do if he couldn't cope?
0:16:56 > 0:17:02How would his emotions surface... knowing what my son was.
0:17:02 > 0:17:04When Jake was sentenced to four months
0:17:04 > 0:17:07at Hindley Young Offenders Institution,
0:17:07 > 0:17:10it was the first time he'd ever been away from his mum, Liz.
0:17:11 > 0:17:14The only present Jake ever had...
0:17:14 > 0:17:16what he never destroyed.
0:17:16 > 0:17:18They are like stilts.
0:17:18 > 0:17:22He could run up this street within seconds with these on.
0:17:22 > 0:17:25All you saw was a pair of legs going past your window.
0:17:25 > 0:17:27The only thing he never destroyed.
0:17:27 > 0:17:32He once said to me, "Mum, can I wash your car down?" "Yeah."
0:17:32 > 0:17:36I'd got no windscreen wipers on 'em because he was making them better.
0:17:36 > 0:17:38Just never thought it through to the end.
0:17:38 > 0:17:40I was the only mainstay in his life
0:17:40 > 0:17:43who could talk him out of what he was doing.
0:17:43 > 0:17:47If somebody had upset him upstairs, he'd go and smash
0:17:47 > 0:17:51his bedroom to smithereens and I mean smash everything.
0:17:51 > 0:17:55I would say, "Come on, son. Tell your mam what's gone on.
0:17:55 > 0:17:58"If you can't tell your mam, you can't tell anybody."
0:17:58 > 0:18:00"Oh, give over, Mam. Give over."
0:18:00 > 0:18:02"Now, come on."
0:18:02 > 0:18:05That's how he got round it.
0:18:05 > 0:18:07Cost me 300 quid, these.
0:18:07 > 0:18:11The best 300 quid I've ever spent in my life for that kid.
0:18:17 > 0:18:20I thought Jake would be safe, because they must cater for
0:18:20 > 0:18:25some sort of mental health issues but it was horrendous from day one.
0:18:29 > 0:18:33Jake had ADHD and learning disabilities, but despite his
0:18:33 > 0:18:37vulnerability, he wasn't put into one of Hindley's specialist units.
0:18:38 > 0:18:44They looked at Jake, assessed him as though he could handle himself.
0:18:44 > 0:18:48That is written down, "Looked as though he could handle himself,"
0:18:48 > 0:18:51and that's why they put him on the wing he was on...
0:18:53 > 0:18:55..with the sort of people that were on that wing.
0:18:58 > 0:18:59He wasn't coping at all.
0:18:59 > 0:19:02They were giving him medication at the wrong time.
0:19:02 > 0:19:04They were giving it to him at like 7.30.
0:19:04 > 0:19:07By doing so, he wouldn't go to sleep.
0:19:07 > 0:19:09So he was having no sleep and they were getting him up
0:19:09 > 0:19:11just as he was going to sleep.
0:19:11 > 0:19:14On the first visit, his tongue was swelled up.
0:19:14 > 0:19:17It was like green and pussy
0:19:17 > 0:19:20and that was a sign of him being run down.
0:19:20 > 0:19:22He wasn't coping.
0:19:24 > 0:19:28He was telling people, different people, how he was being bullied.
0:19:28 > 0:19:31Witnesses saw how he was being bullied.
0:19:31 > 0:19:33If he was on the phone to me,
0:19:33 > 0:19:36there would be somebody effing and blinding in the background,
0:19:36 > 0:19:38vile, nasty things
0:19:38 > 0:19:42and he'd say, "There's been a fight, Mum."
0:19:42 > 0:19:45I'd say, "Go back to your room. Put your head down. Get it down.
0:19:45 > 0:19:47"Don't cause any trouble or owt like that."
0:19:47 > 0:19:50Huh. Wrong advice.
0:20:03 > 0:20:06This was like a week before he got put in prison.
0:20:06 > 0:20:09He looks like a right tramp. He'd been smoking.
0:20:09 > 0:20:12He was sat there and couldn't stop laughing
0:20:12 > 0:20:15so thought I'd take a picture of it because I thought it was funny.
0:20:15 > 0:20:17Oh, that's him as a baby. That's cute.
0:20:17 > 0:20:21You see he's cute there. He doesn't look like a tramp.
0:20:22 > 0:20:24Ryan had never been locked up before.
0:20:24 > 0:20:27They had it down on file that he'd been to a secure placement
0:20:27 > 0:20:30but he hadn't.
0:20:30 > 0:20:32He'd never been to secure.
0:20:34 > 0:20:36When he arrived at Wetherby, Ryan's record stated
0:20:36 > 0:20:40he had been banging his head on the police cell wall.
0:20:40 > 0:20:42But the prison didn't issue a self-harm warning
0:20:42 > 0:20:45and he was put straight on the induction wing.
0:20:45 > 0:20:51It was written down on his file three times in the first two days,
0:20:51 > 0:20:56"Refer to CAMS," which is Child Mental Health Service.
0:20:56 > 0:21:01And he wasn't picked up. He wasn't referred. He didn't see nobody.
0:21:03 > 0:21:06They said, because he was quiet and because he said he was fine...
0:21:06 > 0:21:09that it was OK and he was handling it.
0:21:09 > 0:21:12I would be asking some more questions if somebody's quiet.
0:21:15 > 0:21:19But five days after Ryan arrived, his behaviour changed.
0:21:19 > 0:21:21He had an argument with a prison officer
0:21:21 > 0:21:23and threatened to snap her jaw.
0:21:24 > 0:21:27In fact, he was upset because it was Mother's Day.
0:21:27 > 0:21:32He hadn't been able to make contact with his own mum and he perceived
0:21:32 > 0:21:37that the officer he was talking to had slagged off his mother.
0:21:37 > 0:21:40So those two things combined in his head, to make him
0:21:40 > 0:21:45go over the top and behave in a very angry and unpleasant way.
0:21:46 > 0:21:51His punishment was severe. He was confined to his cell for seven days.
0:21:51 > 0:21:54Then he was moved straight onto a main wing.
0:21:54 > 0:21:57It wasn't long before he was being bullied by other inmates.
0:21:59 > 0:22:02Of course he was going to get bullied.
0:22:02 > 0:22:05He was 17 when he went and it's like... He didn't look 17.
0:22:05 > 0:22:08He looked 13, maybe 14.
0:22:08 > 0:22:12I always remember him being this small child with spots,
0:22:12 > 0:22:14and little acne face, in his tracksuit.
0:22:14 > 0:22:17A skinny little guy.
0:22:17 > 0:22:21When he was sentenced - remand! You know what I mean? Remand!
0:22:21 > 0:22:25You shouldn't put a remand with a convict. Prisons are just ruthless.
0:22:25 > 0:22:27In big man jail...
0:22:27 > 0:22:31A lot more relaxed, far more relaxed.
0:22:31 > 0:22:34Older men have got a wiser head
0:22:34 > 0:22:37and just want to get on with their sentence, do the sentence, get out.
0:22:37 > 0:22:39YOs - 15 to 18. That's...
0:22:39 > 0:22:4215 to 18's a pretty rowdy age, do you know what I mean?
0:22:42 > 0:22:44Constant fighting.
0:22:44 > 0:22:46You're sat down, eating your dinner, you look at him
0:22:46 > 0:22:48and go, "What are you looking at?"
0:22:48 > 0:22:50And it's like...
0:22:50 > 0:22:52If you put your head down like that,
0:22:52 > 0:22:55you have just more or less said, "Come batter me."
0:22:55 > 0:22:59Bullying is a big thing in jail. That's cos it's all young fellas
0:22:59 > 0:23:02thinking they are hard or trying to prove a point.
0:23:02 > 0:23:04He was a small, quiet kid.
0:23:04 > 0:23:07He knows what a grass is and he knows what happens to grasses
0:23:07 > 0:23:10and he knows what happens to people who go running to screws.
0:23:10 > 0:23:13He's thought, "How else can I deal with this?"
0:23:18 > 0:23:21Ryan had a relative who was also serving time at Wetherby.
0:23:21 > 0:23:23He was being bullied too
0:23:23 > 0:23:26and tried to hang himself in a desperate attempt to be moved
0:23:26 > 0:23:29to the Keppel unit, a wing for vulnerable prisoners.
0:23:29 > 0:23:33For Ryan though, the bullying wasn't over.
0:23:33 > 0:23:35On 17th April, it got worse.
0:23:37 > 0:23:40They'd been taunting him through the window that night,
0:23:40 > 0:23:44threatening to go in the next morning and stab him.
0:23:44 > 0:23:47And I think Ryan wanted to go to Keppel.
0:23:48 > 0:23:52That night, after lock-up, Ryan decided to copy his relative.
0:23:54 > 0:23:58That young relative, if you like, had the sense to ring the bell
0:23:58 > 0:24:02before doing what he did and somebody had come.
0:24:02 > 0:24:07He had been taken to hospital and he was moved to Keppel.
0:24:07 > 0:24:11But when Ryan did it, he apparently called out
0:24:11 > 0:24:14to those on cells either side of him,
0:24:14 > 0:24:17"Ring your bell. Let's string up."
0:24:17 > 0:24:21And he then, it appears... did "string up".
0:24:21 > 0:24:24And that boy didn't press his bell.
0:24:30 > 0:24:34The youngster told the prison, "I couldn't ring the bell because
0:24:34 > 0:24:39"I was in trouble for ringing the bell before unnecessarily
0:24:39 > 0:24:43"and I thought if I did it, I'd lose my television."
0:24:43 > 0:24:46So nobody rang any bell at all and...
0:24:48 > 0:24:52..the outcome for Ryan was that he died.
0:25:02 > 0:25:05Do you think Ryan may have done what he did out here?
0:25:05 > 0:25:08No. No. Not at all.
0:25:08 > 0:25:13He'd have done it a long time ago if he was going to.
0:25:13 > 0:25:15He's had threats before.
0:25:15 > 0:25:18He must have really, really desperately wanted
0:25:18 > 0:25:20to get off that wing
0:25:20 > 0:25:24and really thought that something was going to happen that next day.
0:25:39 > 0:25:42Love changes everything, doesn't it?
0:25:42 > 0:25:46I really believed that, right through until...
0:25:46 > 0:25:49Probably right up until the day he died.
0:25:49 > 0:25:52I always believed, part of me,
0:25:52 > 0:25:55either hoped or believed that Adam was going to come good.
0:25:58 > 0:26:03At 17, Adam was living on his own, away from his parents.
0:26:03 > 0:26:06We could go a few weeks without hearing from Adam.
0:26:06 > 0:26:08Unfortunately, sometimes that was,
0:26:08 > 0:26:10"Oh, Mum, I'm in this prison or that prison."
0:26:11 > 0:26:14He was at a hostel called Ty Welyn Newtown.
0:26:15 > 0:26:19The staff there knew more about Adam and what was happening to him
0:26:19 > 0:26:24than we did and they were his second family. I really believe that.
0:26:26 > 0:26:29That's Ty Welyn.
0:26:31 > 0:26:33We all felt a lot for Adam.
0:26:33 > 0:26:38We all tried very hard to help him get what he wanted out of life.
0:26:38 > 0:26:43Unfortunately, we didn't sort of find the answer for Adam.
0:26:43 > 0:26:46Adam was always in trouble of some sort.
0:26:46 > 0:26:51Very petty crimes, generally, things like shoplifting.
0:26:51 > 0:26:53Over the next few years,
0:26:53 > 0:26:57Adam served over ten short prison sentences, all for minor crimes.
0:26:57 > 0:27:00He would come and knock on the door and we'd have a cup of tea,
0:27:00 > 0:27:02a chat and then he'd be gone for weeks
0:27:02 > 0:27:06and then he'd come back again. I'd say, "Where have you been?"
0:27:06 > 0:27:10He'd say, "I've been to prison." "Oh! Again!" Yeah.
0:27:10 > 0:27:12So, we never knew what was going on
0:27:12 > 0:27:14but I've known him since primary school.
0:27:16 > 0:27:20Leading up to his final term in prison,
0:27:20 > 0:27:22he kind of got in a funny way.
0:27:23 > 0:27:26He had ten pills, which he was trying to sell.
0:27:26 > 0:27:29He was trying to get rid of them. He couldn't get rid of them.
0:27:31 > 0:27:34So he crushed them all up into a powder and was just dabbing.
0:27:36 > 0:27:39His life became extremely chaotic,
0:27:39 > 0:27:42worse than I've ever seen in the past.
0:27:42 > 0:27:45His eyes were sunken in over the few days
0:27:45 > 0:27:48because he wasn't getting sleep
0:27:48 > 0:27:51and I don't imagine he was eating either.
0:27:51 > 0:27:53It wasn't the Adam I recognised
0:27:53 > 0:27:56because the Adam I knew, I could speak to.
0:27:56 > 0:28:00This guy... was almost sitting there blank.
0:28:00 > 0:28:03He stole a few phones as well, mobile phones.
0:28:03 > 0:28:05He had like three at once.
0:28:05 > 0:28:09And then he went out and stole another one and got caught.
0:28:11 > 0:28:16The sergeant who knew Adam very well knew that he was not right
0:28:16 > 0:28:18when they got him in custody.
0:28:18 > 0:28:22His behaviour in the holding cell at court
0:28:22 > 0:28:26was very worrying for the solicitor.
0:28:26 > 0:28:30He smeared faeces all over the cell wall.
0:28:30 > 0:28:32The solicitor asked for him
0:28:32 > 0:28:36to be assessed by the community psychiatric nurse.
0:28:36 > 0:28:38The community psychiatric nurse saw him
0:28:38 > 0:28:41and although Adam maintained he was perfectly all right, had no plans
0:28:41 > 0:28:46to commit suicide, the psychiatric nurse felt otherwise
0:28:46 > 0:28:50and actually made that recommendation on his report -
0:28:50 > 0:28:53if the magistrate sent him back to prison,
0:28:53 > 0:28:56he was at risk of taking his own life.
0:28:56 > 0:28:59But they still sent him back to prison.
0:29:00 > 0:29:05That psychiatric report didn't go with him.
0:29:05 > 0:29:09And when it was faxed to the prison the following day,
0:29:09 > 0:29:11our information is that it was filed.
0:29:11 > 0:29:14But nobody even read it.
0:29:14 > 0:29:16Nobody joined anything up.
0:29:17 > 0:29:20No-one raised any concerns about Adam's state of mind
0:29:20 > 0:29:24when he arrived at Brinsford Young Offenders Institution.
0:29:24 > 0:29:26He was fast-tracked through induction,
0:29:26 > 0:29:28and on the second day of his sentence,
0:29:28 > 0:29:31he was moved to a single cell containing bunk beds.
0:29:31 > 0:29:36That evening, Adam hanged himself from the top bunk.
0:29:45 > 0:29:48I'm not sure I would have predicted that,
0:29:48 > 0:29:50looking at the video of him as a little boy.
0:29:52 > 0:29:54Um...
0:30:00 > 0:30:01Yeah.
0:30:11 > 0:30:13This is Jake's perfect role.
0:30:13 > 0:30:15What the fuck are you on about?
0:30:15 > 0:30:17Bless him.
0:30:20 > 0:30:22That luminous jumper.
0:30:26 > 0:30:28Nice chips.
0:30:30 > 0:30:33- That was Jake. That was our Jake, wasn't it?- Yeah.
0:30:33 > 0:30:35That was Jake on a typical day.
0:30:35 > 0:30:40Being a... It's nice to watch, just because he was happy then, really.
0:30:40 > 0:30:43"Hi, Samantha. I'm sorry I didn't write to you.
0:30:43 > 0:30:45"You're the best sister in the world.
0:30:45 > 0:30:48"I didn't mean to call you a fat bastard.
0:30:48 > 0:30:52"So, Samantha, I love you so, so much. See you when I get out.
0:30:52 > 0:30:54"PS, love you, Lily, Samantha and Cole."
0:30:54 > 0:30:56He shouldn't have been there.
0:30:56 > 0:30:59He didn't deserve to be there and get bullied.
0:30:59 > 0:31:02- Was he an easy target, do you think?- Yes.
0:31:02 > 0:31:04He always got bullied, didn't he? Always.
0:31:04 > 0:31:06Because he was vulnerable
0:31:06 > 0:31:11because people knew that Jake was an emotional person.
0:31:11 > 0:31:13But a lot of people thought, "He's a big, tough lad,
0:31:13 > 0:31:17"e can take it," you know what I mean? But he couldn't.
0:31:19 > 0:31:21After four weeks in prison,
0:31:21 > 0:31:26Jake was back in court to answer his second charge for affray.
0:31:26 > 0:31:28He was sentenced to another six months.
0:31:28 > 0:31:31His youth offending officer reported that he was being
0:31:31 > 0:31:33bullied at Hindley.
0:31:33 > 0:31:37She requested a transfer, but Jake was sent straight back there.
0:31:37 > 0:31:42My last words to him, because he was sat behind a glass panel,
0:31:42 > 0:31:44were, "Don't cry, son, don't cry."
0:31:46 > 0:31:48And they sent him back to Hindley.
0:31:52 > 0:31:56On the Tuesday, he smashed his telly to smithereens
0:31:56 > 0:31:58because of the bullying.
0:31:58 > 0:32:01And he scratched all down his arm.
0:32:02 > 0:32:06Jake was given more support, but despite self-harming,
0:32:06 > 0:32:09he wasn't moved to Hindley's specialist unit.
0:32:09 > 0:32:12Why didn't they put him on the Willow unit,
0:32:12 > 0:32:15which caters for mental health, for people who are threatening
0:32:15 > 0:32:17and tried to commit suicide?
0:32:17 > 0:32:2124-hour care. Suicide watch.
0:32:21 > 0:32:24But it wasn't deemed necessary.
0:32:25 > 0:32:28Over the next couple of days, Jake's mood worsened.
0:32:29 > 0:32:34He segregated himself off in his cell and didn't come out for food,
0:32:34 > 0:32:38didn't come out for association, just sat in his cell all the time.
0:32:41 > 0:32:46Summat kicked off on Friday and they are all crowded round his cell.
0:32:46 > 0:32:51Kicking his door, calling him meth boy, throwing piss at him,
0:32:51 > 0:32:54telling him he's got to go and fucking shag this young kid,
0:32:54 > 0:32:57telling them they're going to fuck my mum,
0:32:57 > 0:32:59they're going to fuck his girlfriend.
0:33:02 > 0:33:05CCTV recorded inmates kicking
0:33:05 > 0:33:08and hitting Jake's cell door with table tennis bats.
0:33:08 > 0:33:11The prison officer was just sat letting it all happen,
0:33:11 > 0:33:13never said, "Don't do it."
0:33:14 > 0:33:18He was bullied that much, I think he was tortured.
0:33:18 > 0:33:20His mind was tortured.
0:33:21 > 0:33:25Nobody helped him. Nobody helped him at all.
0:33:25 > 0:33:27Yet he was crying out for help.
0:33:28 > 0:33:33Later that night, a prison officer saw Jake writing at his desk.
0:33:33 > 0:33:35The cell light was on.
0:33:35 > 0:33:39The officer returned 30 minutes later to find the cell in darkness.
0:33:40 > 0:33:45He shone his torch into the cell and saw Jake hanging from the window.
0:33:46 > 0:33:49Prison officers cut him down and began to resuscitate him.
0:33:51 > 0:33:54"They keep giving me shit, I told the staff
0:33:54 > 0:33:56"and they didn't do anything about it.
0:33:56 > 0:33:58"So, Mum, if you're reading this, I'm not alive,
0:33:58 > 0:34:00"cos I can't cope with it in prison no more.
0:34:00 > 0:34:04"People giving me shit, even staff.
0:34:04 > 0:34:07"I'm sorry cos Lily isn't even going to know her Uncle Jake.
0:34:07 > 0:34:10"So, Lily, I'll always be looking over you.
0:34:10 > 0:34:13"You are my baby I could never have."
0:34:16 > 0:34:18It's horrible.
0:34:18 > 0:34:21To think my brother had fought with something so drastic
0:34:21 > 0:34:24- to try and get out and... - Nobody listened to him,
0:34:24 > 0:34:28he didn't have anyone to help him and say, "Jake, it's all right."
0:34:28 > 0:34:31- Cos no-one gave a fuck, did they? - No.
0:34:34 > 0:34:39I found out at 10.45 on Friday, 20th January.
0:34:39 > 0:34:42We were just going upstairs, I'd just gone in my bedroom
0:34:42 > 0:34:46and was just getting undressed, putting my pyjamas on and there was a bang on the door.
0:34:46 > 0:34:49Our Samantha flew downstairs to answer the door.
0:34:49 > 0:34:53She said, "Mum, the police are here." I went, "They've come to the wrong house.
0:34:53 > 0:34:56I put my trousers on and went downstairs and...
0:34:58 > 0:35:00"Is your son in Hindley?" I went, "Yeah."
0:35:00 > 0:35:03He said, "He's dead, he's just hung himself."
0:35:03 > 0:35:06I said, "I beg your pardon. I think you'd better come in."
0:35:06 > 0:35:09It was horrible, they were like, "Your son's tried hanging himself,
0:35:09 > 0:35:12"he's done it, at the minute he is breathing."
0:35:12 > 0:35:15I thought my legs were going to go from underneath me.
0:35:15 > 0:35:18I couldn't believe it, to start with.
0:35:20 > 0:35:22Horrible. Really horrible.
0:35:22 > 0:35:26I had to scramble to my dad's and get my dad and then drove up there.
0:35:26 > 0:35:30This nurse said, "Go into the family room." And I said to Gary,
0:35:30 > 0:35:33"When you go in the family room, it's bad."
0:35:33 > 0:35:36And then a consultant came out and told us...
0:35:37 > 0:35:40..he was on a life-support machine.
0:35:40 > 0:35:44There were just two prison officers sat at the end of my brother's bed,
0:35:44 > 0:35:47like he was going to get up and fucking run away or something.
0:35:47 > 0:35:50I just sat there watching him.
0:35:50 > 0:35:53Later on that morning, they took him down for a scan
0:35:53 > 0:35:55and he came back and he says,
0:35:55 > 0:35:58"I thought I was going to tell you he was going to die,
0:35:58 > 0:36:02"but I can see a little bit of hope, just a little bit."
0:36:02 > 0:36:05That was Saturday morning.
0:36:06 > 0:36:08And, er...
0:36:11 > 0:36:14Sunday they should have took him...
0:36:14 > 0:36:16for another scan.
0:36:17 > 0:36:19But there was no hope then.
0:36:21 > 0:36:25Distraught. Mum was in a bad, bad way.
0:36:26 > 0:36:29And I sat and held his hand, I was on one side...
0:36:30 > 0:36:32..and Gary was on the other side.
0:36:34 > 0:36:38And she just turned his machine off.
0:36:41 > 0:36:42He died.
0:37:14 > 0:37:18"This report considers the circumstances surrounding the death
0:37:18 > 0:37:23"of Mr Adam Rushton at Her Majesty's Young Offenders Institute Brinsford
0:37:23 > 0:37:26"on 22nd October 2009.
0:37:26 > 0:37:31"Adam was found hanging in his cell shortly after 6pm.
0:37:31 > 0:37:33"He was 20 years old."
0:37:33 > 0:37:38The mortuary experience was a bit surreal.
0:37:39 > 0:37:43I wasn't sure what to expect - after all, Adam had hung himself
0:37:43 > 0:37:45and I don't think that would be very nice.
0:37:45 > 0:37:49And they said, "Well, he'll probably just seem like he's just asleep."
0:37:51 > 0:37:54And he was. He was just there.
0:37:54 > 0:37:56I couldn't see his neck.
0:37:58 > 0:38:02And I felt quite cross with him for being such a silly boy.
0:38:04 > 0:38:06And he was cold.
0:38:07 > 0:38:11And that's where we said goodbye to our son.
0:38:16 > 0:38:18And then we went to the prison.
0:38:21 > 0:38:24They asked if we'd like to see where he died.
0:38:24 > 0:38:28And I said, "No, thank you, I don't want to see where he hung himself."
0:38:30 > 0:38:32And the governor said,
0:38:32 > 0:38:35"Oh, you'll be very pleased to know."
0:38:35 > 0:38:38"I'm going to be pleased to know what?"
0:38:38 > 0:38:42"Well, Adam had hung himself from the top of a set of bunk beds
0:38:42 > 0:38:48"and you'll be really pleased to know that we've now moved the bunk beds out of there...
0:38:49 > 0:38:52"..as a result of Adam's death.
0:38:52 > 0:38:55"We wouldn't want it to happen again," or something like that.
0:38:57 > 0:39:01And then, as time went by, the run-up to the inquest,
0:39:01 > 0:39:05it became apparent that another young man
0:39:05 > 0:39:07had died in the same cell...
0:39:07 > 0:39:09in the same way...
0:39:09 > 0:39:11from the same bunk bed.
0:39:12 > 0:39:14I couldn't believe it.
0:39:14 > 0:39:21And not only that, it became apparent that cells used for single occupancy
0:39:21 > 0:39:23should not have bunk beds in them.
0:39:23 > 0:39:26And on the Monday before my son killed himself,
0:39:26 > 0:39:30e-mails were going between the prison governor and the estates manager,
0:39:30 > 0:39:35saying, "How much time will it take to have the bunk bed removed
0:39:35 > 0:39:37"and how much will it cost?
0:39:38 > 0:39:41"Should we have to do it?"
0:39:43 > 0:39:47Well, it cost my son his life.
0:39:50 > 0:39:55If the bunk beds had been moved, maybe he wouldn't be dead now.
0:39:57 > 0:39:58It feels...
0:39:59 > 0:40:03..like nobody really gives a damn, to be honest, nobody really cares.
0:40:12 > 0:40:14# So young, so how were you to know?
0:40:14 > 0:40:17# Know, know
0:40:18 > 0:40:20# You're a carrier, a carrier
0:40:20 > 0:40:23# Of the life inside of you... #
0:40:23 > 0:40:25Well, a guy came down and took pictures of everybody
0:40:25 > 0:40:28and graffitied him. That's Samantha.
0:40:28 > 0:40:31That's Jake, you can see his face better.
0:40:33 > 0:40:36- Do you spend a lot of time down here?- All the time.
0:40:36 > 0:40:39When he died, that's where they put messages for him all down here,
0:40:39 > 0:40:42- and left flowers and notes. - Yeah, all around the back of there.
0:40:42 > 0:40:44- How is your mum coping with it? - Rubbish.
0:40:44 > 0:40:47- She puts on a brave face most of the time.- She does.- Rubbish.
0:40:47 > 0:40:51She just feels like she's existing and not living.
0:40:51 > 0:40:54Cos she lived for you, but because of Jake's problems,
0:40:54 > 0:40:56she lived for Jake, didn't she?
0:40:56 > 0:40:59And her life was looking after Jake and making sure Jake was all right
0:40:59 > 0:41:02- cos you could sort yourself out, couldn't you?- Exactly.
0:41:02 > 0:41:03She needed him and he needed her.
0:41:03 > 0:41:05They both kept each other going,
0:41:05 > 0:41:08whereas now all she does is sits inside all the time.
0:41:08 > 0:41:11It's hard to see my mum go downhill like that.
0:41:13 > 0:41:16After every death in prison, an inquest is held.
0:41:16 > 0:41:19Jake's is expected to last for six weeks.
0:41:19 > 0:41:24There's loads and loads and loads of paperwork, mountains of the stuff.
0:41:24 > 0:41:26When did it arrive?
0:41:26 > 0:41:30Monday, we went out and fetched it from the post office on Monday.
0:41:30 > 0:41:32There's bits and bobs coming through every day
0:41:32 > 0:41:35now it's coming up closer to the inquest.
0:41:35 > 0:41:38There's paperwork from the Coroner, paperwork from the solicitor,
0:41:38 > 0:41:41there's paperwork from Safeguarding Children.
0:41:41 > 0:41:45There's paperwork from everywhere. It's very overwhelming.
0:41:45 > 0:41:49His autopsy report - how many scratches he's got on his body,
0:41:49 > 0:41:51what was in his bowel.
0:41:51 > 0:41:55They had to take his brain out of his body to do some tests on it.
0:41:57 > 0:42:02How they undid his skull and his brain popped through it.
0:42:02 > 0:42:05It's horrendous having to read things like that.
0:42:06 > 0:42:11I'm stressing out about the inquest. It's frightening me.
0:42:11 > 0:42:17It's overwhelming me. I don't want to be sat there...all this crying.
0:42:17 > 0:42:21I want to be strong for him, but I know I won't be able to be.
0:42:21 > 0:42:23I am strong.
0:42:23 > 0:42:25But it's through the day.
0:42:25 > 0:42:27It's at night-time,
0:42:27 > 0:42:30I can't sleep at night,
0:42:30 > 0:42:33and I dream about him every night.
0:42:40 > 0:42:45Once it's all over and done with, I might be able to get some peace.
0:42:50 > 0:42:51SIREN WAILS
0:42:55 > 0:43:00The inquest into Ryan's death has been under way for several weeks.
0:43:00 > 0:43:03No, can't be playing with the ball now. Go on, into bed.
0:43:03 > 0:43:05The first day was the hardest day.
0:43:05 > 0:43:07It was really hard being on that stand.
0:43:09 > 0:43:13I was made to go through all Ryan's letters and listen to phone calls.
0:43:15 > 0:43:17You feel like...
0:43:17 > 0:43:20you're there giving evidence, but you're doing...
0:43:20 > 0:43:25well, it feels like you're on trial - very, very hard.
0:43:25 > 0:43:29'I thought, over two and a half years, I'd built myself up.
0:43:29 > 0:43:33'I'd been knocked down with the death. You start to pick yourself up.
0:43:33 > 0:43:37'I actually said, "I'm prepared, I'm not going to let it get me down."
0:43:37 > 0:43:39"I know what to expect, I've read all the paperwork,
0:43:39 > 0:43:41"I've read all the statements."
0:43:41 > 0:43:45And then, I think three weeks in, boomf!
0:43:46 > 0:43:48That's when it hit me.
0:43:48 > 0:43:52And I had to start having days off, because I couldn't cope.
0:43:54 > 0:43:57We'll have this little bit of evidence that's left
0:43:57 > 0:44:00and then the coroner will start her summing up
0:44:00 > 0:44:03- and will probably go on for two days.- Yeah?
0:44:03 > 0:44:06Yes, because there's an awful lot for her to say.
0:44:06 > 0:44:09What's likely to happen is that the jury will come back
0:44:09 > 0:44:12and give what they call a short form verdict -
0:44:12 > 0:44:17suicide, accident or misadventure - and I'll explain those,
0:44:17 > 0:44:18or an open verdict.
0:44:18 > 0:44:20I just don't want it to come back suicide,
0:44:20 > 0:44:24cos I don't believe it was suicide.
0:44:24 > 0:44:25- Not full suicide.- No.- No.
0:44:25 > 0:44:30As long as that don't come back, I'll be all right. Yeah.
0:44:34 > 0:44:36I don't think the verdict should be suicide
0:44:36 > 0:44:39and I know Sonya would hate it if it was.
0:44:39 > 0:44:46I mean, it would be dreadful for her to feel that Ryan was so depressed
0:44:46 > 0:44:50and so lacking in hope for the rest of his life
0:44:50 > 0:44:52that he wanted to end it.
0:44:52 > 0:44:57I think it's terribly important for Sonya not to be faced
0:44:57 > 0:44:58with that kind of a conclusion.
0:45:02 > 0:45:06The grief is really hard...to explain,
0:45:06 > 0:45:09with me, more so, because we ended on a bad note.
0:45:10 > 0:45:13I must have received about seven letters
0:45:13 > 0:45:17within the space of a week and half, begging me to go and see him.
0:45:19 > 0:45:21I don't visit my children in prison.
0:45:21 > 0:45:25To me, if they've done wrong, they were in there for punishment.
0:45:25 > 0:45:28I didn't answer a lot of his calls,
0:45:28 > 0:45:32but when I did answer them, I was harsh, very.
0:45:34 > 0:45:38I heard it back at the inquest, the phone call and it hurt me more
0:45:38 > 0:45:41cos I felt I sounded nasty.
0:45:43 > 0:45:47Just no emotion there. It was just, "Why have you done this?
0:45:47 > 0:45:51"I'm not going to lie for you." Things like that.
0:45:52 > 0:45:57And that's how it ended, with me and Ryan on that bad note.
0:45:58 > 0:46:02That's made it worse for me because I wasn't able to tell him how I felt.
0:46:02 > 0:46:07I was just angry with him and I can't change that now.
0:46:17 > 0:46:22Jake's inquest started today and I'm in a hotel room,
0:46:22 > 0:46:26waiting for tomorrow for me to be the first witness.
0:46:26 > 0:46:31I'm happy in some ways because I want to tell the jury my son wasn't
0:46:31 > 0:46:36a bad lad, he wasn't a naughty boy, he wasn't a bad lad, he was ill.
0:46:36 > 0:46:38What are you not looking forward to?
0:46:38 > 0:46:42They'll be all posh and they're all solicitors, they're barristers,
0:46:42 > 0:46:47and I just come from a council estate in Chesterfield.
0:46:47 > 0:46:51They don't know how we live, they don't know how anybody lives.
0:46:51 > 0:46:53It's not something you do every day.
0:46:53 > 0:46:57I should be sat at home now watching Coronation Street...
0:46:57 > 0:46:58or something like that.
0:47:04 > 0:47:07When my son died, I had to take his socks off...
0:47:09 > 0:47:12..and these socks have been everywhere with me.
0:47:16 > 0:47:17I know it sounds silly.
0:47:20 > 0:47:23Pff! They still smell of him.
0:47:23 > 0:47:28I take his socks everywhere with me. Wherever I go, these socks go.
0:47:40 > 0:47:42'How do you think it will be like
0:47:42 > 0:47:45- 'over the next four to six weeks? - Horrendous.
0:47:48 > 0:47:51'People talking about Jake, people talking about what
0:47:51 > 0:47:53'sort of background he came from,
0:47:53 > 0:47:56'cos they'll try to blacken our names as well,
0:47:56 > 0:47:58'even though we've done nothing wrong.
0:47:59 > 0:48:03'He didn't die in the care of me. He died in the care of the state.'
0:48:18 > 0:48:23The jury in Ryan's inquest has been sent out to consider its verdict.
0:48:26 > 0:48:30Waiting now, a week today, for the verdict to come in.
0:48:32 > 0:48:34Wasn't too bad last week -
0:48:34 > 0:48:37I think towards the end of the week it's got worse.
0:48:37 > 0:48:40I thought they'd be back by Friday, they weren't back by Friday.
0:48:40 > 0:48:45I spent most of the weekend crying.
0:48:45 > 0:48:48Tired, really tired.
0:48:48 > 0:48:51How will you feel if it comes back suicide?
0:48:51 > 0:48:53I don't think I could handle that.
0:48:53 > 0:48:57That'd take longer to get over because I won't accept that.
0:48:57 > 0:48:59I will not accept that it was suicide.
0:49:09 > 0:49:13You don't take note, really, of suicides that go on in prison.
0:49:15 > 0:49:18The public's reaction, "It's his own fault.
0:49:19 > 0:49:22"Shouldn't have been in prison in the first place."
0:49:25 > 0:49:29I've heard it. I've probably thought it myself before, if I'm honest.
0:49:32 > 0:49:36They just look at, "Oh, it's a thug, another thug,"
0:49:36 > 0:49:40but that thug, as they call it, is still a child...
0:49:41 > 0:49:44..some of them have made mistakes - we all make mistakes.
0:49:44 > 0:49:48Some have made more than others. They're still children.
0:49:52 > 0:49:54TEXT MESSAGE ALERT
0:49:54 > 0:49:57Right, it's Ruth.
0:49:57 > 0:49:59"They have a verdict, but don't panic,
0:49:59 > 0:50:02"they have gone for lunch whilst everything is being typed."
0:50:02 > 0:50:04Hiya, they've got a verdict.
0:50:04 > 0:50:07- Got a verdict.- You have?
0:50:09 > 0:50:12- Shaking.- You're making me nervous, I'm not even going.
0:50:29 > 0:50:32I'm shaking inside. I've got butterflies.
0:50:33 > 0:50:36It's like you can't wait for it to come and then when it's here,
0:50:36 > 0:50:38you want it to be a bit longer.
0:50:48 > 0:50:50SIREN WAILS
0:50:57 > 0:50:59SIREN WAILS
0:51:00 > 0:51:02Oh!
0:51:03 > 0:51:05- What's the verdict?- Accidental...
0:51:07 > 0:51:08..due to the bullying.
0:51:09 > 0:51:13I think, I mean, I'm looking at it and just absorbing it
0:51:13 > 0:51:17just as you are, but there's some really, really positive things here.
0:51:17 > 0:51:23Um, missed opportunities to see how vulnerable Ryan was and then
0:51:23 > 0:51:26the fact that the jury recognised this was a cry for help.
0:51:26 > 0:51:31He'd never want to leave any of you or anything like that.
0:51:34 > 0:51:37I knew he didn't mean to do it. I knew he didn't mean to do it.
0:51:39 > 0:51:42I think... That's what I needed, somebody to agree.
0:51:44 > 0:51:47Ryan was one of 11 young people who killed themselves
0:51:47 > 0:51:50in young offender institutions in 2011.
0:51:50 > 0:51:54One of the recommendations made to Wetherby, to prevent future deaths,
0:51:54 > 0:51:57was to improve mental health assessments,
0:51:57 > 0:52:01another was to challenge bullying more effectively.
0:52:01 > 0:52:05When I was told its recommendations, I was quite angry,
0:52:05 > 0:52:09because I was told that even if they do just one recommendation
0:52:09 > 0:52:12out of six, they've made a change...
0:52:13 > 0:52:16..but how many inquests has there been now
0:52:16 > 0:52:20for deaths in children's prisons, all recommendations,
0:52:20 > 0:52:22it's still happening.
0:52:24 > 0:52:26It's still happening.
0:52:41 > 0:52:44It took us a long time to choose the right spot.
0:52:49 > 0:52:52That's all that's left of my poor lad.
0:53:03 > 0:53:08You get all these inquests, reports and it's supposed to explain
0:53:08 > 0:53:15what happened, but I'm not sure it does, really. Maybe nothing can.
0:53:15 > 0:53:16SHE SNIFFS
0:53:16 > 0:53:18It shouldn't have happened.
0:53:18 > 0:53:21He should still be here, causing havoc and mayhem...
0:53:25 > 0:53:26..but he isn't, so...
0:53:31 > 0:53:36When I used to visit prison, I would look around the room
0:53:36 > 0:53:42and I would see 30 or 40 Adams, all with the same look in their eyes,
0:53:42 > 0:53:46all with the same expressions on their faces
0:53:46 > 0:53:49and, yeah, they deserve to be punished, but...
0:53:51 > 0:53:55..there should be something a bit more for them.
0:53:59 > 0:54:01The inquest into Jake Hardy's death
0:54:01 > 0:54:04in Hindley Young Offenders Institution
0:54:04 > 0:54:06has just finished after six weeks.
0:54:09 > 0:54:10SHE SIGHS
0:54:10 > 0:54:12"On 20th January, 2012,
0:54:12 > 0:54:17"at 21.11 hours in cell F1, Jake Hardy
0:54:17 > 0:54:20"died as a result of his own deliberate act,
0:54:20 > 0:54:25"but the evidence does not establish beyond reasonable doubt
0:54:25 > 0:54:31"whether he intended that act to cause his death."
0:54:31 > 0:54:35At the inquest, we found out that on the 20th, that night,
0:54:35 > 0:54:40- he should have been moved to a safer cell.- And why wasn't he moved?
0:54:41 > 0:54:43I've no idea.
0:54:43 > 0:54:4512 failings.
0:54:46 > 0:54:5112 times they could've saved his life, but nobody did.
0:54:54 > 0:54:56"A failure to provide him
0:54:56 > 0:55:00"with adequate personal officer support and monitoring,
0:55:00 > 0:55:03"a failure adequately to record
0:55:03 > 0:55:07"and consider reports of previous self-harm
0:55:07 > 0:55:10"and thoughts of self-harm and suicide,
0:55:10 > 0:55:15"a failure to review the level of his risk of self-harm,
0:55:15 > 0:55:21"a failure to investigate reports that he was being verbally abused,
0:55:21 > 0:55:25"a failure to protect him from the negative behaviour
0:55:25 > 0:55:31"of others young persons towards him, a failure to investigate..."
0:55:33 > 0:55:36Two months ago, the government announced a review into
0:55:36 > 0:55:41the self-inflicted deaths in prison of young people aged 18 to 24.
0:55:41 > 0:55:44The findings will be published in a year's time.
0:55:47 > 0:55:53You expect a state... er, to look after your children,
0:55:53 > 0:55:56not to pamper them, not to love them,
0:55:56 > 0:56:02just to keep them warm, fed and safe so they come home.
0:56:04 > 0:56:06Why didn't they just look after him?
0:56:08 > 0:56:12They only had him 46 days, 46 days.
0:56:12 > 0:56:15I had him 17 years and kept him safe...
0:56:16 > 0:56:19..but they couldn't look after a child.
0:56:23 > 0:56:24Really makes me angry.