5 December 2022
This is a media release by Bhatt Murphy solicitors, reshared by INQUEST
Before Acting Senior Coroner Lydia Brown
West London Coroner’s Court
21 November 2022 – 5 December 2022
On 15 August 2016 Lance Scott Walker was killed by Idris Hassan, another young person living in the same unregulated accommodation in Hayes, West London.
An inquest jury has returned a damning narrative. It concluded that serious failings on the part of London Borough of Islington, London Borough of Ealing and the West London NHS Trust caused or contributed to Lance’s death.
The coroner also indicated that she would be exercising her power to make a report to prevent future deaths to the Secretaries of State for Education, and Health and Social Care, London Borough of Ealing, London Borough of Islington, the West London Alliance and OFSTED raising her concerns about unregulated accommodation for 18 – 21 year old care leavers.
Lance was an 18 year old vulnerable care leaver who had been placed by Islington Council in accommodation at 23 Gledwood Gardens. This was entirely unregulated accommodation run by a private company named Urban Youth Flex. On 4 August 2016, Idris Hassan, another vulnerable 18 year old care leaver, was placed in the same accommodation by Ealing Council.
The inquest heard evidence of the commissioning process undertaken by both Islington and Ealing councils to contract Urban Youth Flex to provide accommodation to their care leavers. It was established that neither local authority had a formal contract with Urban Youth Flex, and both failed to establish whether when the placements were commissioned that the staff working there had DBS checks or appropriate training and experience.
Urban Youth Flex was being run by staff most of whom did not have DBS checks or relevant training or experience. Some were even described as ‘volunteers’. Earlier in 2016, Brent Council had terminated its contract with Urban Youth Flex due to concerns about the service it provided. Neither Ealing nor Islington were aware of this.
Idris Hassan had a diagnosis of psychosis and had a history of carrying knives. He had been sectioned in November 2015 but on release in April 2016 he had disengaged with mental health services and had been non-compliant with his antipsychotic medication. Despite indications from various sources that he was relapsing into psychosis, Idris did not have any face-to-face consultations with the Early Intervention in Psychosis team at West London NHS Trust from the point of his transfer to adult services on 29 June 2016 until Lance’s death. In July 2016 he was arrested for a series of offences and bailed to a hostel, but on 3 August 2016 he was evicted for behaviours relating to his mental health diagnosis.
On 4 August 2016 Idris was placed by Ealing Council at 23 Gledwood Gardens, where Lance was already living. During the inquest it was admitted that although some information about his mental health condition was contained in the Ealing Council referral form to Urban Youth Flex, Ealing did not state that he was non-compliant with his medication, that he had a history of carrying knifes and violent crime or that he had a propensity to be bullied.
Between Idris’ placement on 4 August 2016 and the death on 15 August 2016 a conflict grew between Lance and Idris as Idris’s mental health was deteriorating. Police were called on 11 August 2016 to deal with a fight between young people throwing bottles. On 12 August 2016 an ambulance was called on and Idris Hassan later attended A&E on 13 August 2016 reporting an injury to his jaw and that he had been punched.
On 15 August 2016 Idris Hassan stabbed Lance Scott Walker to death.
After hearing seven days of evidence the jury has concluded that the following errors, omissions and failures caused or contributed to Lance’s death:
- West London NHS Trust
- Failed to adequately plan for Idris Hassan’s transition from CAMHS to adult services and thereafter inadequately managed his care;
- Failed to assess him under the Mental Health Act 1983;
- Failed to assess the risks posed by Idris Hassan to others;
- Failed to communicate with the London Borough of Ealing and Urban Youth Flex in respect of Idris Hassan’s mental health and risks
- London Borough of Islington
- Failed to properly exercise financial due diligence or ensure that there was a contract with Urban Youth Flex setting out the expectations of what kind of support it was supposed to provide to Lance, and that accordingly the commissioning of Urban Youth Flex was “unsatisfactory”
- Failed to suitably manage Lance Scott Walker whilst he was living at 23 Gledwood Gardens
- London Borough of Ealing
- Failed to properly exercise financial due diligence or ensure that there was a contract with Urban Youth Flex setting out the expectations of what kind of support it was supposed to provide to Idris, and that accordingly the commissioning of Urban Youth Flex was “unsatisfactory”;
- Inappropriately placed Idris Hassan in unregulated accommodation;
- Failed to share information with Urban Youth Flex when Idris was placed at 23 Gledwood Gardens, including details of his forensic history, risk of offending, harm to others, medication, or propensity to be bullied;
- Failed to share information with the Trust or Urban Youth Flex after Idris was placed at 23 Gledwood Gardens on 4 August 2016
- Failed to ensure that information from the police was properly shared with Idris’ duty social worker.
The jury also found that failures in Urban Youth Flex’s staffing, management and information sharing also “possibly” contributed to Lance’s death.
Lance’s aunt Patricia O’Neill said: “The jury’s findings today have vindicated our six-year battle for justice for Lance. We have always known that Lance’s death was not a ‘tragic accident’ but it has taken us until now to hear the full extent of the shocking failures that caused his death. Lance’s death was preventable. Idris was acutely ill and should have never been placed in the Urban Youth Flex accommodation which was incapable of supporting someone with his needs. Lance and Idris – two vulnerable young men – were both catastrophically let down by professionals who were meant to keep them safe and Lance paid for those failures with his life. Lance was loved unconditionally by his family and was adored by his girlfriend, and we do not want his death to be in vain”.
Sophie Naftalin, solicitor for the family said: “The damning conclusion of this jury and the coroner’s report to prevent future deaths should send a clear message to the government that the current regime of using unregulated accommodation requires urgent reform. Whilst local authorities continue to have an obligation to care leavers like Lance beyond their 18th birthday, there is no form of regulated accommodation for that age group.
Without change, inadequate care providers like Urban Youth Flex will continue to go unchecked, leading to other preventable deaths. The government has committed to ensuring that 16 and 17 year olds are no longer placed in unregulated accommodation. This family call on the government to change the law so that 18 to 21 year olds – like children in care – are also properly safeguarded and protected.
NOTES TO EDITORS
For further information or request for comment please contact Sophie Naftalin at Bhatt Murphy on 020 7729 1115 or [email protected]
In December 2021, the Department for Education announced that it would ban the use of unregulated accommodation for 16 and 17 year olds to be implemented fully by 2024. Going forward, supported accommodation for 16 and 17 year olds will have to adhere to mandatory national standards, and the regime will be overseen by OFSTED. The government consultation is here. There is no equivalent requirement for accommodation for care leavers aged 18 – 21.
Patricia O’Neill is represented by Sophie Naftalin and Christina Bodenes of Bhatt Murphy and Jamie Burton KC of Doughty Street Chambers.