Gareth Myatt

Part of the debate – in the House of Commons at 6:04 pm on 12 July 2007.

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Photo of Sally Keeble Sally Keeble Labour, Northampton North 6:04, 12 July 2007

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.