I am grateful for this opportunity to debate the very tragic death of Gareth Myatt, to ensure that the lessons that should be learned are learned, and that Gareth's mother, Pam, knows that other children and young people will have more safeguards.
Gareth's death was a terrible event in which a 15-year-old boy, 4 ft 10 in tall, weighing 6½ stone, was restrained by three members of staff and died. The details of what happened are harrowing. He went into Rainsbrook secure training centre in Northamptonshire on
As you know, Mr. Deputy Speaker, I have been unable to raise questions in Parliament about Gareth's death because of the sub judice rule. There was only the briefest of official Home Office statements, and for three and a half years there has been no calling to account of the Executive over what happened to Gareth. Despite all the anxieties about the risks of the regime that led to his death, that regime has now been relaxed to lower the threshold for the use of restraint, which is why there is such anger about statutory instrument No. 1709.
I want to go through some of what happened to Gareth, so that the full horror is on the record. The summing up by Judge Richard Pollard, who presided at the inquest, set out the sequence of events. Gareth was the last person to use the unit's sandwich toaster on the Sunday evening and took exception when he was asked to clean it up. "You clear it up," he told staff. He was asked to go to his room, and the CCTV footage shows him calmly waiting to go to his room, where he was locked in. Shortly afterwards, he was visited by two members of staff—a man and a woman—to discuss his behaviour. He told them to get out of the room because they had no right to be there. He was then told that, because he was not calming down, the staff needed to take some stuff out of his room, and they began doing just that. They took out a magazine, then some papers and pencils. The staff said, "You're not doing what we asked you, so I don't see why should have these." They then took another piece of paper that had Gareth's mother's new mobile phone number on it, and he shouted at them—I am sure that you will stop me if this is unparliamentary, Mr. Deputy Speaker—"You're not fucking taking that," and then "Don't take my mum's phone number."
Order. The hon. Lady should realise that words are no more acceptable because they are given in a quote. Mr. Speaker has ruled on that. She allowed herself to use that word, without my being able to stop her.
Order. I could not have made myself clearer: such words are unacceptable even if they are being used in a quote from someone else.
That was when the struggle started, and it was said that Gareth—a 6½ stone boy—clenched his fist and swung it at the man. The officers and Gareth ended up lying on his bed, with one member of staff holding his legs and another holding his upper body. A third officer, also a man, came into the room, and Gareth was placed in an approved hold: a seated double embrace, with two members of staff holding his upper body, his torso pushed forward and one officer holding his head.
Gareth then said that he could not breathe, so the officer told him, "If you're shouting, you can breathe." He then said that he was going to defecate, and was told, "You will have to then," and he actually did so. Those were his last words. Finally, while still restrained, Gareth was sick. When he was released, he was unconscious and all attempts at resuscitation failed. One member of staff concluded, "I should never have PCC'ed; he was half my size. It was rather like having run over a cat and then thinking...if I hadn't gone down that street, it wouldn't have happened."
The jury found that the officer who restrained Gareth caused the death accidentally—something that, although the correct decision, the family understandably finds hard to accept. However, this was an accident waiting to happen—a completely preventable disaster—because the jury also found that a string of failings in the system had caused Gareth's death. That is what I want to turn to in some detail.
As my right hon. Friend the Minister will know, there have been a series of criticisms of restraint in secure training centres over the years leading up to, and since, Gareth's death. Those include concerns about the holds used, the frequency with which they have been used, and the injuries suffered by trainees and staff; concerns that the deliberate infliction of pain is being used as a means of control to get compliance; and concerns about the training of staff, the recording and reporting of incidents of restraint, the role of the Youth Justice Board and the lack of transparency. Virtually all those things were found by the jury at Gareth's inquest to be failings that contributed to his death.
The findings of the jury in relation to the YJB were damning. They found that there had been an inadequate assessment of the safety of physical control in care and, in particular, an inadequate assessment of the seated double embrace before it was introduced, and that that inadequate assessment caused or contributed to Gareth's death. I know that my right hon. Friend the Minister will say that that particular hold has been banned, but the jury finding related to the whole system of PCC. The inquest heard that as early as 1998 it was known that there needed to be a review, and by the end of the 1990s it was accepted that restraint could cause death. The judge commented in his summing up:
"somewhere in the grey corridors of whitehall the obligation was overlooked, eventually the quest for uniformity in the whole juvenile estate and the commission of the NCB review taking the civil service eye off the ball...Even an apparent assurance by a minister Mr Paul Boateng on 8.6.2000 did not ensure that a review took place".
I know that, again, the Department wants to have a review of the whole juvenile estate, so I warn it to heed the judge's words.
The inquest heard about failings in the training, including the lack of manuals for staff and the fact that they did not know about the risks of positional asphyxia. One member of staff said:
"I did not know that someone who could speak could be dying of asphyxia."
The jury found that an inadequacy in the response by the YJB to the National Children's Bureau report, on the urgent need for a medical review of PCC, caused or contributed to Gareth's death. The same applies to the YJB's response to the letters of David Tuck, the YJB monitor at Rainsbrook in 2002 and 2003, in which it was noted that children were complaining that they could not breathe while being restrained and that some were vomiting. The YJB's regional manager sent the letters up through the system so that they could get to the heart of the YJB, but nothing happened: the letters disappeared in the system.
The jury found that the lack of effective monitoring of the use of PCC at Rainsbrook by the YJB caused or contributed to Gareth's death. The judge said that everybody at Rainsbrook understood that PCC should not be used to gain compliance, as one of my right hon. Friend's ministerial predecessors, my hon. Friend Fiona Mactaggart, pointed out to me in a previous debate. The use of restraint was restricted to the narrow circumstances set out in secure training centre rule 38. The judge pointed to reports of a young person who was restrained until the blood vessels in his eye burst. He also pointed to the fact that the Home Office monitor, in a working sense, lived close to the director of Rainsbrook and found it hard to challenge him over what had happened at the centre.
Despite the generally good reports that the Commission for Social Care Inspection gave to Rainsbrook, the jury also found that inadequacy in the monitoring of the use of PCC at Rainsbrook by Rebound management caused or contributed to Gareth's death. That calls into serious question the adequacy of the inspection regime at the secure training centre. The jury did not point the finger of blame at the staff. Instead, they pointed it firmly at the system—at the people in grey suits. They gave a damning indictment of a system that is faulty in design, flawed in implementation and so weak in monitoring that it resulted in this tragic death. It is inconceivable that this flawed and failing system can be left untouched. Simply to remove one hold is not adequate.
As my hon. Friend knows, Gareth Myatt was my constituent. I wish to make two brief points. First, I pay tribute to my hon. Friend for the extraordinary way in which she has pursued this case. Co-operation between Members of Parliament on cases such as this, which fall in between various constituency responsibilities, is often difficult and sometimes impossible. In the 24 years that I have been in the House, I have never experienced such willing and tenacious co-operation from a colleague. She has pursued this case, often in the face of blank resistance from the system, as she describes it, with extraordinary tenacity, zeal and intelligence, and has shown great generosity in involving me at all points.
I knew Gareth Myatt; he often came to my advice surgery. He was an extremely difficult child, but he was tiny. My hon. Friend has given some statistics, but he was a shrimp of a young man. He was so small that he hardly existed, and he was frenetic. He was like an eel—
Order. Even in an Adjournment debate, there is a distinction between a speech and an intervention. The hon. Gentleman's intervention is turning into a speech in the middle of a speech, and that is out of order. Perhaps he has made his point. He might make another intervention later, but Ms Keeble should be allowed to complete her speech.
I ask four things of my right hon. Friend the Minister. First, there should be a public inquiry into the use of restraint in secure training centres. I say "public" because there was a review in 2004, at the time of Gareth's death. A 113-page report was produced, which I have with me. It was rewritten several times and was finally reduced to a one-page summary, which was posted on the Youth Justice Board website. That is completely inadequate. Internal reviews have not dealt with the issues, which only emerged into the public domain as a result of Gareth's death and inquest. They would not have emerged if it had not been for the work done by an organisation called Inquest.
I should like to point out the difficulty of raising issues about young people in the House. For example, a question tabled in the Commons about the case of Mohammed Hussain was replied to by letter. That letter contains information about the fact that oxygen had to be used to revive a young man in Rainsbrook only about 15 months after Gareth's death. I have a copy of it with me, but there is no time to read it into the record. Any review must be public. Young people who have been restrained and bereaved families must be able to participate fully, so that people can be assured that they have access to all the information, can see how the decisions are made and can ensure that changes are implemented.
There are other instances in which the public need to be sure of information. Information that was supposed to be put in the Library, following a request from the Joint Committee on Human Rights, was not placed there until yesterday, when I phoned up and agitated for it—and it was just a couple of tables. I have raised that point with my right hon. Friend.
Secondly, in order for the review to take place, the Government must withdraw statutory instrument No. 1709, the Secure Training Centre (Amendment) Rules 2007. Judge Richard Pollard's summary clearly sets out the basis on which physical control in care can be used. I cannot spend a lot of time going through that summary now, but I urge my right hon. Friend to look at it closely. The judge says, and everyone else who has been involved in the debate believes, that the statutory instrument makes a substantial change to the use of PCC in secure training centres—it lowers the threshold for its use. My right hon. Friend will say that we are talking about difficult young people, and so we are, but restraint was used 3,000 times in secure training centres last year. That makes it not a last resort, but routine.
Thirdly, given the failures of the inspection regime for secure training centres, I ask that the inspection function be given to Her Majesty's inspectorate of prisons, which has the expertise and experience required for the task. It is clear that inspectorates that have great expertise in child care and education may not be best placed to assess the different regime in secure establishments. I also ask my right hon. Friend to place in the Library the inspection reports for the Oakill secure training centre, where it was necessary to remove and replace the director because of failings there.
Fourthly and most importantly, I ask for a major overhaul of the operations of the Youth Justice Board. It has manifestly failed to establish and operate routine administrative and reporting systems that would have mitigated the chances of a disaster such as Gareth's death. Despite clear warnings being sounded, it failed to ensure that meetings of its advisory panels were held to deal with the concerns. It failed to ensure that action was taken following warnings of risk to trainees. By all accounts, the warnings got lost in the system. It seems that some of the relationships between the YJB and its contractor, Rebound, were too close. The YJB failed to ensure proper training of staff and failed to monitor services in a high-risk environment. Those were all routine administrative functions that should have been well within the scope of such an organisation, and it is an indictment of the organisation that it failed to fulfil those tasks, with catastrophic results for Gareth.
It is easy to say that lessons must be learned—it is almost trite. When I first set out to look into the matter, I thought that it might have been individual wrongdoing by a member of staff that led to Gareth's death, but it was much worse than that. It was a complete systematic collective failure, which so far has not been put right. On a personal note, what particularly appals me is the complete lack of any sense of horror on the part of officialdom at what happened. As the jury found, the gruesome death of a boy was caused by profound failures in a system for which, ultimately, Ministers are responsible to the House.
In a letter that my right hon. Friend sent to my hon. Friend Mr. Dismore, he wrote:
"A secure facility cannot be run safely if aggressive and dangerous behaviour is allowed to go unchecked, or if good order is compromised to the extent that staff lose effective control. The behaviour of young people in custody is frequently challenging and sometimes dangerous."
In this case, the boy, who weighed 6½ stone and was 4 ft 10 ins tall, was locked in his room for refusing to clean a sandwich toaster. When people went in, that began the sequence of events that led to his death.
The letter goes on to say:
"Physical restraint must be available—in the last resort—so that everyone in the secure facility can be kept as safe as possible."
I wonder who was being kept safe on
I thank my hon. Friend Ms Keeble for the way in which she has put the case. Gareth Myatt's death raises issues of severe concern. I welcome the fact that Mr. Garnier, Mr. Boswell, my hon. Friends the Members for Stoke-on-Trent, Central (Mark Fisher) and for Stourbridge (Lynda Waltho) and my right hon. Friend Mr. McAvoy have also attended the debate. It is important to show that there is widespread interest in the matter.
As my hon. Friend the Member for Northampton, North knows, I took over responsibility for the Youth Justice Board when my right hon. Friend the Prime Minister appointed me, on his appointment as Prime Minister some two weeks ago. I am examining the issues in great detail. With the statutory instrument before the House in another place, it is opportune for the debate to take place today.
May I say at the outset that Gareth's death is a tragedy and I wish it had not happened. We must make sure that we learn the lessons from his death, because lessons are there to be learned. My thoughts go to his mother, Pamela, who has my deepest sympathy. Gareth, as my hon. Friend mentioned, was born in Stoke-on-Trent on
There were many other factors that may have contributed to Gareth's behaviour. Although he was described as "academically very able", the education system struggled to engage with him throughout his life, and by the end of 2003, sadly, he was not receiving any education at all. The pattern of Gareth's life is not unusual. Our youth justice system sees too many children whose lives have followed a similar pattern. They are children who are greatly in need of care. Between 2000 and 2003, Gareth experienced, as many young people do, five episodes of being looked after by Stoke-on-Trent social services, and a further spell in private foster care.
For such children, in many cases their offending behaviour eventually leads to the courts, and the courts eventually decide that other options have been exhausted and custody is the only one left. I take the view that these children, like all our children, should have a role in the country's future. We must find positive ways to make them feel part of society. This is not just a youth justice issue; it is a fundamental social issue.
As my hon. Friend said, Gareth died on
The system of physical restraint approved for use in secure training centres was devised in the late 1990s and assessed at that time by a panel of experts, including medical experts. It was specifically designed to avoid causing pain and to minimise the risk of broken bones—something that had occurred previously in the secure children's home environment in the 1990s. However, the jury on the inquest into Gareth's death found that the risk of positional asphyxia had not been specifically addressed when the system was originally designed. I have to say openly and honestly to my hon. Friend that the jury was critical of the fact that the system was not reviewed in a timely fashion after implementation. In their evidence to the jury, the former and current chief executives of the Youth Justice Board expressed their regret that such a review had not happened.
A key lesson—perhaps the key lesson—from Gareth's death is that greater attention should have been paid to reviewing the safety of restraint techniques.
I welcome my right hon. Friend to his position and I am grateful to him for his concern about this case. When he considers the lessons to be learned, will he be minded to consider the use of restraint generally? As my hon. Friend Ms Keeble said, 3,000 occurrences in a year is not acceptable. My right hon. Friend will know, even two weeks into the job, that 10 young people have committed suicide in young offenders institutions over the past two years. Something is going wrong with the way that young people are being looked after in many such institutions. Gareth's death—a most extreme and horrific example—highlights the failures in the system. Surely 10 suicides is an unacceptable state of affairs.
I am grateful to my hon. Friend for his intervention. I was going to refer to that matter later, but as he has raised it I will take it on. There are wider issues relating to restraint not only in the secure training centre estate but in young offenders institutions and secure children's homes. We need to look honestly at the policy and practice across the board. I have had discussions not only in the Ministry of Justice but with the Minister for Children, Young People and Families, my right hon. Friend Beverley Hughes, and we agreed that we wish to set up a joint review of restraint issues. We will announce in short order—in the next week—further details of the content of the review and a range of issues that I know my hon. Friend will be interested in following up. I give that assurance to him and to my hon. Friend the Member for Northampton, North.
As I said, a key lesson from Gareth's death is that we need to review physical control and care. The Youth Justice Board has brought together a panel of experts to review the approved techniques. As my hon. Friend the Member for Northampton, North said, use of the double-seated embrace, the hold with which Gareth had been restrained, and which had been suspended on police advice shortly after his death, is now permanently discontinued.
Those changes were vital, but the Youth Justice Board has also recognised the need to improve the management of challenging behaviour in all under-18 custodial establishments, not only secure training centres. In February 2006, it published a code of practice on behaviour management—an important document, not least section 10, which spells out the very limited circumstances in which physical restraint may be used. Paragraph 6 requires that restrictive physical interventions must be used only as a last resort when there is no alternative available and all other options have been exhausted. That wording is worth noting because it echoes the requirement in the secure training centre rules that physical restraint may be used only where no alternative method is available.
Again, I say to my hon. Friend that there is a debate on the statutory instrument in another place. I am not in a position to withdraw it, but there will be a debate on it next week, and I hope that my noble Friend, Lord Hunt of Kings Heath, the junior Minister at the Ministry of Justice, will be able to give assurances on the use of restraint.
Those are not matters for me. Lord Carlile has prayed against the order in another place, and that debate will take place. I have not prevented a debate here, but the matter has not yet been brought forward. My hon. Friend knows that there will be a debate, and I say to her that the statutory instrument before the other place, which was considered by this House, clarifies the rules of restraint and is based on an inquest on Adam Rickwood that took place several weeks ago. We were advised by the coroner at that inquest to examine the rules—not to change the legislation—so that individuals could operate the system in a legal way. Those rules came into effect on
I am conscious that time is running out. We must examine the fact that the code of practice put in place by the Youth Justice Board requires all custodial establishments for those aged under 18 to assess their compliance with the paragraphs in the published code. The board conducted an audit of those assessments. Establishments need to do more, and the board is setting a follow-up assessment to gauge how much progress has been made. The jury's findings in this case point to a lack of strategic co-ordination in the management of physical control and care, and we shall consider addressing that, with the Youth Justice Board and other stakeholders, by setting up a new management board that oversees work on all issues connected with the safety of PCC. That will do a great deal to assure Ministers, Parliament, my hon. Friend and people in general that such attitudes are vital, and that they are considered thoroughly and consistently addressed.
The Youth Justice Board takes its responsibilities for monitoring performance seriously. My hon. Friend referred to the Oakhill training centre. Today I issued a written ministerial statement about steps the board is taking, following our discussions, to improve performance at Oakhill, which is the newest secure training centre. The safeguarding and protection of young people in custody is at the very centre of the board's work. My hon. Friend asked whether we will publish that report. I will reflect strongly on her comments on that, and I expect it to be published in due course. However, I cannot yet give her a date when that will happen.
Ultimately, I hope that the debate has been valuable for my hon. Friend. The Government need to review the use of restraint. We shall do so very shortly, and I hope that that will be of benefit to my hon. Friend, who has raised this matter in the House. I appreciate her input into the debate, and that of other hon. Members, because they have brought the issue to the attention of the House, and focused my mind on it during the two weeks I have held a position involving responsibility for the Youth Justice Board. I hope that in due course I will be able to help and to comment on the issues that she raised over and above what I have undertaken today.
Question put and agreed to.
Adjourned accordingly at twenty-seven minutes to Seven o'clock.