30 Jun 2014 Jake Reginald Hardy · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 12 Failure to provide detainees with the benefit and protection of a Personal Officer View source Insufficient staff understanding of vulnerable young persons’ complex needs and their causes View source Lack of a system for timely telephone contact with family during crisis or emotional need View source Night-time verbal bullying increasing self-harm and suicide risk among targeted detainees View source Unavailability of private telephone communication for detained children and young persons View source Increased risk of self-harm and suicide among vulnerable detainees with complex needs placed in Youth Offender Institutions View source Use of cells containing ligature points for detainees at risk of self-harm or suicide View source Lack of consideration of adopting safeguarding policy and procedure changes across Youth Offender Institutions View source Lack of understanding and performance oversight of Personal Officer obligations View source Insufficient staff aptitude or temperamential suitability for working with vulnerable young persons with complex needs View source Lack of a reliable system for recording and reading important wing information and outstanding tasks during Senior Officer handover View source Lack of an effective system to routinely monitor and tackle night-time verbal bullying View source See 9 more concerns
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Jake Reginald Hardy · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jake Reginald Hardy, a 17-year-old detained at HM YOI Hindley, died on 20 January 2012 after being found partially suspended by a ligature in his cell. The report describes failures to identify, record and respond to his vulnerabilities, self-harm risk and reports of verbal bullying, including failures in safeguarding, ACCT care planning, supervision and overnight risk assessment. Concerns also included ligature points in cells, inadequate personal officer support, staff training and communication systems, and limited access to family telephone support.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hindley Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide detainees with the benefit and protection of a Personal Officer
Wider context from the report “2. The evidence revealed an almost complete failure to provide Jake Hardy with the benefit and protection of a Personal Officer , despite a comprehensive scheme being in place. Currently the scheme is of pivotal importance for the identification and monitoring of vulnerability and risk .
There remains a concern about whether all officers at HM YOI Hindley have a sufficient understanding of this role and its importance and about the absence of any system to alert managers to any failure by a Personal Officer to meet his obligations under this scheme or to audit his performance. This concern may be of relevance to other Young Offender Institutes also.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hindley Prison; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff understanding of vulnerable young persons’ complex needs and their causes
Wider context from the report “1. A number of the prison staff from HM YOI Hindley who gave evidence at the inquest clearly lacked (a) any or sufficient aptitude or temperamential suitability for the demands of working with vulnerable young persons with complex needs and/or (b) any or sufficient understanding of those needs and their causes (such as the nature and effect of specific learning difficulties and the effect of abuse or neglect in childhood).
I have been told that these matters are now addressed to some extent by the Youth Justice Board and HM YOI Hindley but that further changes are being considered to the way in which prison staff working in Young Offender Institutes are recruited, screened for aptitude and trained . I report this concern so that any outstanding further steps can be considered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hindley Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for timely telephone contact with family during crisis or emotional need
Wider context from the report “5. The children and young persons detained at HM YOI Hindley are provided with a weekly credit which they may use to telephone family or other approved numbers. Calls are made from a communal telephone located in the association area of a wing. Prison staff have a discretion to permit further calls to be made from an office telephone for good reason.
I was told that in-cell telephony has been introduced in newly built parts of the children and young persons’ estate but it is not available in HM YOI Hindley and other Young Offender Institutes. Currently, therefore, these detainees are not able to speak privately on the telephone and there is no sufficient system in place to ensure that a child or young person in crisis or in need of emotional support (whether by reason of being bullied or experiencing feelings of self-harm or suicide) can speak to a family member without significant delay.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hindley Prison; that does not assign responsibility.
PFD Monitor interpretation Night-time verbal bullying increasing self-harm and suicide risk among targeted detainees
Wider context from the report “4. Verbal bullying by means of detainees “shouting out” at night is a common problem in HM YOI Hindley and can increase the risk of self-harm and suicide by those targeted , especially overnight. The fabric, lay-out and design of the cells in HM YOI Hindley does not remedy this problem. Further, it is difficult for the night orderly officer on duty on a wing, who is there alone, to tackle the problem effectively. There is no effective system in place to ensure that the problem is routinely monitored and tackled effectively, whether by means of additional staff or otherwise. This concern may be of relevance to other Young Offender Institutes also.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hindley Prison; that does not assign responsibility.
PFD Monitor interpretation Unavailability of private telephone communication for detained children and young persons
Wider context from the report “5. The children and young persons detained at HM YOI Hindley are provided with a weekly credit which they may use to telephone family or other approved numbers. Calls are made from a communal telephone located in the association area of a wing. Prison staff have a discretion to permit further calls to be made from an office telephone for good reason.
I was told that in-cell telephony has been introduced in newly built parts of the children and young persons’ estate but it is not available in HM YOI Hindley and other Young Offender Institutes. Currently, therefore, these detainees are not able to speak privately on the telephone and there is no sufficient system in place to ensure that a child or young person in crisis or in need of emotional support (whether by reason of being bullied or experiencing feelings of self-harm or suicide) can speak to a family member without significant delay.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hindley Prison; that does not assign responsibility.
PFD Monitor interpretation Increased risk of self-harm and suicide among vulnerable detainees with complex needs placed in Youth Offender Institutions
Wider context from the report “1. It was apparent from the evidence I heard that a significant proportion of the children and young persons placed in HM YOI Hindley are vulnerable and have complex needs. This may well be true of the children and young persons placed in other Youth Offender Institutions also.
Clearly, the nature and extent of Jake Hardy’s vulnerabilities were not unusual amongst this population, with many detainees having some form of learning difficulty. I was told that other detainees are vulnerable for different reasons, for example because they have been abused or neglected or their upbringing has been adversely affected by a parent’s misuse of alcohol or drugs. Many are “looked after children”. I was also told that these detainees “complexities affect their reaction to authority and boundaries and are probably the reason they ended up in custody in the first place”.
It was also apparent that vulnerable detainees are likely to lack the emotional and intellectual maturity and resilience they may need to cope with the pressures of life in custody (such as separation from family and bullying) and that the risk of self-harm and suicide can increase in consequence. I was told that safeguarding these detainees is made more difficult by the prevalence of their volatile and unpredictable behaviour.
Overall, the evidence suggested that the placement of vulnerable children and young persons with complex needs in the environment of a Youth Offender Institute (particularly if some distance from home) does, in some cases, result in an increased risk of self-harm and suicide which it is often difficult for prison and clinical staff to manage effectively , even with the benefit of the various policies and procedures which are in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hindley Prison; that does not assign responsibility.
PFD Monitor interpretation Use of cells containing ligature points for detainees at risk of self-harm or suicide
Wider context from the report “3. Cells containing ligature points (such as window bars) are still in use at HM YOI Hindley for detainees who have been assessed to be at risk of self-harm or suicide . This concern may be of relevance to other Young Offender Institutes also.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hindley Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of consideration of adopting safeguarding policy and procedure changes across Youth Offender Institutions
Wider context from the report “2. As stated above, significant changes of policy and procedure have been introduced at HM YOI Hindley in order to address concerns raised about the identification, monitoring and protection of vulnerable children and young persons and those at risk of self-harm and suicide. It may well be that some or all of those changes would provide better protection to detainees in other Young Offender Institutes but I am not aware that consideration has been given to the adoption of these changes elsewhere in the estate .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hindley Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding and performance oversight of Personal Officer obligations
Wider context from the report “2. The evidence revealed an almost complete failure to provide Jake Hardy with the benefit and protection of a Personal Officer, despite a comprehensive scheme being in place. Currently the scheme is of pivotal importance for the identification and monitoring of vulnerability and risk.
There remains a concern about whether all officers at HM YOI Hindley have a sufficient understanding of this role and its importance and about the absence of any system to alert managers to any failure by a Personal Officer to meet his obligations under this scheme or to audit his performance . This concern may be of relevance to other Young Offender Institutes also.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hindley Prison; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff aptitude or temperamential suitability for working with vulnerable young persons with complex needs
Wider context from the report “1. A number of the prison staff from HM YOI Hindley who gave evidence at the inquest clearly lacked (a) any or sufficient aptitude or temperamential suitability for the demands of working with vulnerable young persons with complex needs and/or (b) any or sufficient understanding of those needs and their causes (such as the nature and effect of specific learning difficulties and the effect of abuse or neglect in childhood).
I have been told that these matters are now addressed to some extent by the Youth Justice Board and HM YOI Hindley but that further changes are being considered to the way in which prison staff working in Young Offender Institutes are recruited, screened for aptitude and trained. I report this concern so that any outstanding further steps can be considered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hindley Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of a reliable system for recording and reading important wing information and outstanding tasks during Senior Officer handover
Wider context from the report “6. The shift patterns of Senior Officers working on the wings within HM YOI Hindley are such that they do not always overlap and handover is often by means of written entries in a “handover book”. The handover book I saw contained short notes addressing random matters and there was apparently no routine recording of a more comprehensive review of the shift. There is no system in place to ensure that important information and outstanding tasks are sufficiently recorded by one Senior Officer at the end of his shift and then read by the next Senior Officer at the start of his shift .
It was clear from the evidence that it is the Senior Officer’s responsibility to have an overview of what is happening on the wing and matters of relevance to the safeguarding of detainees housed there. Therefore, the passing of key information and outstanding tasks between Senior Officers on a wing is of real importance to the safety of detainees. This concern may be of relevance to other Young Offender Institutes also.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hindley Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective system to routinely monitor and tackle night-time verbal bullying
Wider context from the report “4. Verbal bullying by means of detainees “shouting out” at night is a common problem in HM YOI Hindley and can increase the risk of self-harm and suicide by those targeted, especially overnight. The fabric, lay-out and design of the cells in HM YOI Hindley does not remedy this problem. Further, it is difficult for the night orderly officer on duty on a wing, who is there alone, to tackle the problem effectively. There is no effective system in place to ensure that the problem is routinely monitored and tackled effectively , whether by means of additional staff or otherwise. This concern may be of relevance to other Young Offender Institutes also.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations