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Gareth Myatt

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Gareth Myatt

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19 Apr 2004
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A teenager who died days after starting a sentence at a detention centre was being restrained by staff when he lost consciousness, it has been revealed.

Gareth Myatt, 15, of Stoke-on-Trent, Staffordshire, died in hospital on Monday after collapsing at Rainsbrook Secure Training Centre in Northants.

Police investigating the death said on Friday the incident was being treated as "very serious".

A post-mortem examination into Gareth's death proved inconclusive.

Gareth had been just four days into his 12-month sentence for assault and theft when he collapsed.

An ambulance was called, but he was pronounced dead at Walsgrave Hospital in Coventry.

On Friday, officers investigating the death revealed Gareth was being restrained by three members of staff - two men and a woman - when he lost consciousness.

Det Ch Insp Charles Moffat, from Northamptonshire Police's homicide and major crime team said the purpose of his investigation was to determine whether criminal charges should be brought at an individual or corporate level.

"This is an extremely serious incident which will be investigated most thoroughly with the full cooperation of the other agencies involved," he said.

"Our findings will be passed to both the coroner and the Crown Prosecution Service.

Wait for tests

"We are keeping in close contact with Gareth's family and supporting them fully at this tragic and difficult time."

He added: "The incident occurred at about 2115 BST and it was necessary for staff to exercise their normal techniques of physical control and care in dealing with Gareth.

"While that procedure was being undertaken he lost consciousness."

Following Gareth's death, a post-mortem examination was carried out at Leicester Royal Infirmary, but this was inconclusive and further tests were being carried out.

Police said results from the tests could take some weeks.

Reform call

A forensic examination has also been carried out of the scene where Gareth died and witness statements have been taken from staff and residents at the centre.

Prison reformers have called for an independent inquiry into his death.

Director of the Howard League for Penal Reform, Frances Crook, said the use of solitary confinement and physical restraint are potentially dangerous to children and needed investigating.

Rainsbrook opened in July 1999 and has room for 67 trainees.

It is operated by Rebound, a subsidiary of Group 4, on behalf of the Youth Justice Board.

"Boy Died After Being Restrained." BBC News, 23 Apr. 2004.

*****

No prosecution in restraint related death of 15 year old Gareth Myatt at Rainsbrook Secure Training Centre

Today the CPS announced that there will be no prosecution in the case of 15 year old Gareth Myatt who died on April 19th 2004 at Rainsbrook secure training centre near Northampton, whilst being restrained by staff.

Speaking after the decision the solicitor for Gareth's mother Pamela Wilton, Mark Scott from Bhatt Murphy, said:

"Some 19 months after 15 year old Gareth Myatt died in custody my client remains largely in the dark about how he came by his death. The little information that has been disclosed has been to raise serious concerns about the techniques of restraint with which we allow our children to be controlled. The decision of the CPS on the basis of evidence that is not yet available will itself be the subject of scrutiny."

Helen Shaw, co-director of INQUEST said;

"The shocking death of Gareth Myatt begs questions about how it was that potentially lethal methods of restraint were being used against children. There must now be a thorough and far reaching inquest to ensure that the full facts surrounding his death are subject to proper public scrutiny. This must happen quickly to allow his mother the opportunity to discover the full circumstances surrounding her son's death."

Notes to editors:

On 16 April 2004 Gareth Myatt was made the subject of a twelve month Detention and Training Order and sent to Rainsbrook Secure Training Centre. Rainsbrook opened in July 1999 as one of three privately owned children's jails in England. It is operated by Rebound EDC, a subsidiary of the security company Group 4.

On the evening of April 19, just three days into his sentence, three members of Rainsbrook staff physically restrained him. Gareth was subjected to a 'seated double embrace' restraint technique (which has subsequently been suspended) during which he lost consciousness. A Duty Nurse failed in attempts to resuscitate him and an ambulance was called and he was taken to Walsgrave hospital in Coventry where he was pronounced dead at 10.25pm.

INQUEST is the only non-governmental organisation in England and Wales that works directly with the families of those who die in custody. It provides an independent free legal and advice service to bereaved people on inquest procedures and their rights in the coroner's courts. INQUEST has long standing concerns about restraint related deaths in custody and in particular the deaths of black people following its use.

"No Prosecution in Restraint Related Death of 15 Year Old Gareth Myatt at Rainsbrook Secure Training Centre." Inquest, 19 Dec. 2005.

*****

The failure to look at the potential dangers of a restraint method was one of the factors in the death of a boy at a detention centre, an inquest found.

A jury ruled the death of 15-year-old Gareth Myatt, of Stoke-on-Trent, at the Rainsbrook Secure Training Centre in Northamptonshire, was accidental.

But jurors criticised civil servants at the Youth Justice Board (YJB).

They said the YJB's failure to review the medical safety of the system of restraints was a factor in the death.
Gareth was the first child to die while being restrained in custody.

Restraint banned

He was held down by two male officers and a female colleague using the Home Office-approved seated double embrace restraint.

Gareth died in April 2004 from "positional asphyxia" after choking on his own vomit as he was held down.

The hold used to restrain him has since been banned by the Home Office.

Gareth had served just three days of a 12-month sentence at the centre near Daventry when he died.

The system of restraints was introduced in 1998 with a promise that its use would be constantly reviewed.

Despite numerous warnings about its safety, a medical review into the use of restraints was not ordered until after his death.

David Tuck, the Youth Justice Board's monitor - said to be the "eyes and ears of the Home Office" - wrote of his concerns about health effects of the techniques used by guards at the privately-run prisons, and at Rainsbrook in particular.

'Difficult to breathe'

In a letter written to managers in June 2002, Mr Tuck warned of the dangers of youngsters vomiting while being restrained.

One girl at the centre, known by the initial "C", complained she struggled to breathe while being held down.

More than a year later he wrote again, saying children were complaining their heads were being pushed down into their groins, doubling them up and cutting off air supplies.

In his first letter - which was sent to social services, Rainsbrook's director John Parker and head of care Barbara Davies, as well as the Youth Justice Board - Mr Tuck wrote: "C says she is accustomed to physical restraints from her other placements but none has been as uncomfortable as those applied to her at Rainsbrook.

"She says that the approved technique of bending her forward, placing her head between her knees, makes it difficult for her to breathe."

Nothing was done in the light of the letter, the inquest heard.

Criminal prosecution

Speaking after the inquest, Gareth's mother Pamela Wilton Myatt's was critical of everyone involved in the detention of her son.

"It has been hard enough to accept what happened to Gaz," said Miss Wilton.

"But hearing everything that's come out... how long the injuries were going on, years of injury and vomiting and kids complaining.

"I hope to see change to ensure that it doesn't happen again, that kids are hurt."

She added that she was considering pushing for a criminal prosecution in relation to the death.

Deborah Coles, co-director of justice group Inquest, said: "The jury's verdict is a shameful indictment of a catalogue of failure by the Youth Justice Board.

"The jury accept that these failures directly caused Gareth's death. He died a most horrific and violent death while being restrained by custody officers.

"His death was entirely preventable and was a disaster waiting to happen."

"Criticism Over Youth Jail Death." BBC News, 28 June 2007.

*****

Fifteen years old and less than five feet tall, Gareth Myatt died in custody while being restrained by three adults. Three years on, his mother has finally found out what happened in his last moments. She talks to Laura Smith

Gareth Myatt was just three days into a six-month sentence at Rainsbrook Secure Training Centre in Northamptonshire when he was restrained by three members of staff after refusing to clean the sandwich toaster. He tried to tell them he couldn't breathe, but they did not release him. As they held him down, Gareth choked on his own vomit and died. He was 15.

The five-week inquest into Gareth's case, which ended last Thursday, found that his death was an accident. But the jury also found that he might still be alive if the Youth Justice Board (YJB), which oversees privately run centres like Rainsbrook, had carried out adequate safety checks into the types of restraints staff were being trained to use on the children in their care.

Gareth's mother Pam Wilton is on a rare day home from attending the inquest when we meet at her house on a post-war council estate in Stoke-on-Trent, Staffordshire. In the front room, framed colour photographs of her three children adorn the wall. Gareth, the eldest boy, appears aged six months, wearing little shorts, braces and a cardigan. "He was gorgeous," says Wilton. "He had the biggest, loveliest smile, big brown eyes, a cheeky grin."

Gareth was mixed race. Wilton, who is white, did not tell his father, who is black, that she was pregnant before they split up, and Gareth grew up without him. As a little boy, he was confident, and Wilton shrugged off comments from neighbours about her brown baby. But when he started school aged five, things began to change. "He used to come home upset and he never said why," says Wilton, who has the weary blink of somebody who has seen enough for one lifetime. She says people regularly came outside the house to call him "black bastard".

Gareth began to struggle with his identity. Although he had plenty of friends, the absence of contact with his black relatives made his adolescence confusing. "I used to ruffle his hair and play with his curls," says his mother. "He had lovely hair and gorgeous skin. He would say, 'No I haven't - I hate it.' He never said he wanted to be white in so many words but if you mentioned anything about the other side, he just didn't want to know."

Wilton says she can't remember the first time Gareth came to the police's attention, but that in the years leading up to his one and only conviction, whenever anything went wrong locally, officers would turn up at the door wanting to talk to him. "I thought they were picking on him because of his colour," she says. Wilton admits her son was "no angel", but believes his confusion over his identity may have made him more vulnerable to influence. "He wasn't a bad lad. I think he followed the others to fit in because all his mates were white and they accepted him, but others didn't."

Whether the police attention was a result of his race, his actions or a combination of the two, a stint in custody seems to have been almost inevitable. Even so, it came as a shock to his family when he was convicted of stealing a bottle of beer and assaulting a residential social worker at a children's unit. He was sentenced to a 12-month detention and training order, including six months in Rainsbrook. "It was obvious we were all upset," says Wilton, lighting the latest in a long line of cigarettes. "I said to him, 'I'll come and see you. It won't be long, it will soon go'."

On the evening of April 19 2004, Gareth refused to clean the sandwich toaster in the dining area. Two members of staff followed him to his room and began removing things. When one of them tried to take away a piece of paper from the shelf, Gareth became upset and staff say he lunged at one of them. It later emerged that the paper contained his mother's new mobile phone number, thrust into his hands by his solicitor as he left court three days earlier.

In the ensuing struggle, the two members of staff, Diana Smith, a training assistant and David Beadnall, a training supervisor - joined by David Bailey, a training assistant who had by now entered the room - began to restrain Gareth, who was 4ft 10in and weighed under seven stone. They used a technique called the seated double embrace, which involves two members of staff forcing a person into a sitting position and leaning them forward, while a third takes care of the head.

The next few moments were related in appalling detail by Smith at the inquest. "Gareth was doing a lot of shouting and swearing. He did say at one stage that he couldn't breathe. Somebody said, 'Well, if you are shouting, you can breathe.' Gareth said he was going to shit himself. Somebody said, 'Well, you are going to have to shit yourself, because we can't let you go while you are like this,' Bailey looked back and said he had actually shat himself. The struggling seemed to go on for a while and then he seemed to settle down. After a few minutes we realised something was wrong. I looked at his face and he had something coming down his nose and he looked as if his eyes were bulging. I can't remember much more. I've tried to get it out of my mind."

Gareth Myatt's death prompted three separate inquiries, and in June 2004, the seated double embrace - which had been approved for use on children by the Home Office and the YJB as part of a series of techniques known as Physical Control in Care - was withdrawn from use within juvenile custody. It has not been used since.

At his inquest it emerged that before Gareth died, at least four other children had complained of being unable to breathe while being held in the seated double embrace. One boy was taken to hospital with breathing problems and haemorrhaging that left blood in his eyes, and a girl was left wearing a neck brace for five days. After Gareth's death, an investigation into the use of restraints at the centre found that the methods used in two-thirds of the cases examined were "potentially lethal".

Yet those in charge do not appear to have appreciated the dangers. David Tuck, the YJB's monitor at Rainsbrook, said that although he expressed concern about the technique, he did not recommend that its safety be examined because it did not occur to him that somebody could die. Mark Perfect, YJB chief executive at the time, has admitted that on his watch the only review into restraint techniques used on young people in custody was carried out by the National Children's Bureau and failed to investigate the safety of the procedures in place - though it has since emerged that it would have cost only an extra £1,500 to do so.

Deborah Coles, co-director of the campaigning group Inquest, which has worked with Gareth's family for the past three years, says it is a scandal that such serious failings came to light only through Pam Wilton's tenacity. "Gareth died a terrifying death that was entirely preventable," she says. "The shameful failings of the Youth Justice Board resulted in dangerous techniques being routinely used - behaviour which in any other setting would be seen as child abuse."

Ellie Roy, chief executive of the YJB, was not available for an interview but said in a statement: "It is clear that everyone working with young people in custody needs to learn lessons from this tragic case. The Youth Justice Board is clear - restraint must be used as a last resort." Yet the YJB backs new rules, put in motion by the Ministry of Justice and due to come into force this Friday, that would allow staff in secure training centres to make even wider use of restraint, including inflicting pain on children who refuse to go to bed or be quiet. This is a significant extension of the existing rules at the institutions, which state that restraint can only be applied where there is a genuine risk to people or property, or the chance of escape.

The first Wilton knew that anything was wrong was when police knocked on her door at around 5am the next day to tell her Gareth was dead. "I waited until 9am and rang up Rainsbrook," she says. "They got back to me at about midday. All they said is, 'It happened while he was being restrained.' And right up until the inquest they didn't tell me anything else, so I didn't know anything." She says she received no phone call or letter expressing regret, no offer of help or support, and her attempts to get information were blocked at every turn. She says the first apology she received from anyone was from Mark Perfect outside the inquest.

Wilton does not like to think about Gareth's last moments. Pausing to think about how her life will be now that the inquest is over, she closes her eyes and is silent for some time. "There are so many things I wanted to say to Gaz if I had known," she says finally. "I speak to him now and it helps. He gives me strength. We were close and I believe that if he can, he won't be far away. I get through it by thinking he is in a better place; nobody can hurt him now. He is safe".

Smith, Laura. "'Nobody Can Hurt Him Now.'" The Guardian, 4 July 2007.

*****

One spring day nine years ago, 15 year old Gareth Myatt, on his third day at Rainsbrook Secure Training Centre near Rugby, refused to clean the sandwich toaster. He was sent to his room. He complied.

A note on Gareth's file said that if he became aggressive, which didn't happen often, the best thing was for staff to leave him alone to calm down. They didn't do that.

Instead, six foot, sixteen stone David Beadnall and a fellow guard followed Gareth (4 ft 10" and 6½ stone) to his room. They told him off. They later claimed that Gareth, who was of mixed race, responded defiantly, asking them to leave.

The guards chose not to leave. Instead they began the punishment procedure known as 'single separation' in a stripped down room. All Gareth's personal possessions would be removed from his room.

Gareth had few personal possessions. One was a scrap of paper. His mother's new mobile phone number was written on it.

They took it. He objected.

What happened next?

Here is an account, drawn from court transcripts, by the charity INQUEST.

"The officers alleged that Gareth said 'You're not fucking taking that' and 'Don't take my mum's phone number'. Gareth is then said to have clenched his fist and swung it at David Beadnall who stood at over 6 ft tall and weighed over 16 stone.

[Beadnall] claimed that this behaviour amounted to a threatening situation and as such warranted using a restraint technique on Gareth. The staff members and Gareth ended up lying on his bed, with one staff member holding his legs and the other holding his upper body."

A third officer then came into the room and Gareth was placed in a hold called the Seated Double Embrace. Two staff members held his upper body and pushed his torso forward towards his knees while one officer held his head.

Gareth complained: 'I can't breathe'.

Beadnall responded: 'if you can talk then you can breathe'.

Gareth said he was going to defecate.

He was told: 'you are going to have to shit yourself' and the restraint continued.

Gareth did defecate. The restraint continued. Gareth vomited. The restraint continued. Gareth slumped forward. The restraint carried on for several minutes. When the restraint stopped it was too late.

Attempts to resuscitate him failed. The cause of death was recorded as asphyxia resulting from inhalation of gastric content and his body position during the period of physical restraint.

Gareth had an older sister, aged 16, and a younger brother who was 9 at the time of his death. He had lived with his mother in Stoke-on-Trent.

The inquest, held in 2007, heard that one year before Gareth died, David Beadnall had been investigated for using pain-inducing 'distraction techniques' too often. Beadnall told the inquest he had no recollection of that.

G4S training documents listed guards' nicknames. They included "Clubber", "Crusher" and "Mauler".

Last week, after repeated requests, G4S reluctantly confirmed that Dave Beadnall is now Safety, Health and Environmental Manager at G4S Children's Services.

Company spokesperson Nicola Savage added: "His current role does not involve any direct contact with young people."

Beadnall's name has popped into the public domain again because he sent a statement to Aylesbury Vale District Council in support of a planning application to turn a house into a children's home. The application itself omitted the company's name, in an apparent attempt to evade local opposition. (There is an article about that here).

G4S Children's Services runs children's homes and secure training centres. According to the G4S website, staff work with local schools, sit on Local Safeguarding Children's Boards and train child protection officers.

Beadnall is "responsible for monitoring and managing the Safety, Health and Environmental aspects and impacts of G4S Children's Services", according to his LinkedIn Profile.

Savage was reluctant to confirm the current job titles of two other senior executives at G4S Children's Services, Paul Cook and John Parker.

Paul Cook is Managing Director of G4S Children's Services.

John Parker is Director of Children's Services at G4S Children's Services.

In February 2006, Paul Cook, described as director for children's services at Rainsbrook Secure Training Centre, told the magazine, Community Care: "It was a shock to find that a restraint hold considered to be safe turned out to be unsafe. This was as much a tragedy for the staff as for Gareth's family."

John Parker, the director of Rainsbrook at the time of Gareth's death, told the inquest that he had not read the Physical Control in Care manual; he was not aware of the risks involved.

The Crown Prosecution Service said in January 2006 that there was 'insufficient evidence' to bring prosecutions over the death of Gareth Myatt. The Coroner recorded a verdict of Accidental Death in June 2007.

After the Inquest, the Coroner, Judge Pollard wrote personally to then justice secretary Jack Straw to ensure that no other child should be harmed by improper restraint methods, and to highlight the remarkable failure of G4S's management to act on reports of abuses. (He refers to Rebound, the division of G4S responsible for Rainsbrook).

"Inadequacy in the monitoring of the use of Physical Control in Care at Rainsbrook by Rebound management caused or contributed to Gareth's death," wrote the Coroner. "We also wish to record that there was a problem with the lack of response by Rebound to the information from Rainsbrook."

G4S continued to use dangerous restraint techniques, as evidenced by the death of Jimmy Mubenga in the company's care six years after the death of Gareth Myatt. This time G4S guards, in evidence to an inquest jury, claimed that their detainee forced his own head down between his knees. The jury did not believe them. They returned a verdict of unlawful killing.

Sambrook, Clare. "G4S Guard Fatally Restrains 15 Year Old - Gets Promoted." Open Democracy, 22 July 2013.
A teenager who died days after starting a sentence at a detention centre was being restrained by staff when he lost consciousness, it has been revealed.

Gareth Myatt, 15, of Stoke-on-Trent, Staffordshire, died in hospital on Monday after collapsing at Rainsbrook Secure Training Centre in Northants.

Police investigating the death said on Friday the incident was being treated as "very serious".

A post-mortem examination into Gareth's death proved inconclusive.

Gareth had been just four days into his 12-month sentence for assault and theft when he collapsed.

An ambulance was called, but he was pronounced dead at Walsgrave Hospital in Coventry.

On Friday, officers investigating the death revealed Gareth was being restrained by three members of staff - two men and a woman - when he lost consciousness.

Det Ch Insp Charles Moffat, from Northamptonshire Police's homicide and major crime team said the purpose of his investigation was to determine whether criminal charges should be brought at an individual or corporate level.

"This is an extremely serious incident which will be investigated most thoroughly with the full cooperation of the other agencies involved," he said.

"Our findings will be passed to both the coroner and the Crown Prosecution Service.

Wait for tests

"We are keeping in close contact with Gareth's family and supporting them fully at this tragic and difficult time."

He added: "The incident occurred at about 2115 BST and it was necessary for staff to exercise their normal techniques of physical control and care in dealing with Gareth.

"While that procedure was being undertaken he lost consciousness."

Following Gareth's death, a post-mortem examination was carried out at Leicester Royal Infirmary, but this was inconclusive and further tests were being carried out.

Police said results from the tests could take some weeks.

Reform call

A forensic examination has also been carried out of the scene where Gareth died and witness statements have been taken from staff and residents at the centre.

Prison reformers have called for an independent inquiry into his death.

Director of the Howard League for Penal Reform, Frances Crook, said the use of solitary confinement and physical restraint are potentially dangerous to children and needed investigating.

Rainsbrook opened in July 1999 and has room for 67 trainees.

It is operated by Rebound, a subsidiary of Group 4, on behalf of the Youth Justice Board.

"Boy Died After Being Restrained." BBC News, 23 Apr. 2004.

*****

No prosecution in restraint related death of 15 year old Gareth Myatt at Rainsbrook Secure Training Centre

Today the CPS announced that there will be no prosecution in the case of 15 year old Gareth Myatt who died on April 19th 2004 at Rainsbrook secure training centre near Northampton, whilst being restrained by staff.

Speaking after the decision the solicitor for Gareth's mother Pamela Wilton, Mark Scott from Bhatt Murphy, said:

"Some 19 months after 15 year old Gareth Myatt died in custody my client remains largely in the dark about how he came by his death. The little information that has been disclosed has been to raise serious concerns about the techniques of restraint with which we allow our children to be controlled. The decision of the CPS on the basis of evidence that is not yet available will itself be the subject of scrutiny."

Helen Shaw, co-director of INQUEST said;

"The shocking death of Gareth Myatt begs questions about how it was that potentially lethal methods of restraint were being used against children. There must now be a thorough and far reaching inquest to ensure that the full facts surrounding his death are subject to proper public scrutiny. This must happen quickly to allow his mother the opportunity to discover the full circumstances surrounding her son's death."

Notes to editors:

On 16 April 2004 Gareth Myatt was made the subject of a twelve month Detention and Training Order and sent to Rainsbrook Secure Training Centre. Rainsbrook opened in July 1999 as one of three privately owned children's jails in England. It is operated by Rebound EDC, a subsidiary of the security company Group 4.

On the evening of April 19, just three days into his sentence, three members of Rainsbrook staff physically restrained him. Gareth was subjected to a 'seated double embrace' restraint technique (which has subsequently been suspended) during which he lost consciousness. A Duty Nurse failed in attempts to resuscitate him and an ambulance was called and he was taken to Walsgrave hospital in Coventry where he was pronounced dead at 10.25pm.

INQUEST is the only non-governmental organisation in England and Wales that works directly with the families of those who die in custody. It provides an independent free legal and advice service to bereaved people on inquest procedures and their rights in the coroner's courts. INQUEST has long standing concerns about restraint related deaths in custody and in particular the deaths of black people following its use.

"No Prosecution in Restraint Related Death of 15 Year Old Gareth Myatt at Rainsbrook Secure Training Centre." Inquest, 19 Dec. 2005.

*****

The failure to look at the potential dangers of a restraint method was one of the factors in the death of a boy at a detention centre, an inquest found.

A jury ruled the death of 15-year-old Gareth Myatt, of Stoke-on-Trent, at the Rainsbrook Secure Training Centre in Northamptonshire, was accidental.

But jurors criticised civil servants at the Youth Justice Board (YJB).

They said the YJB's failure to review the medical safety of the system of restraints was a factor in the death.
Gareth was the first child to die while being restrained in custody.

Restraint banned

He was held down by two male officers and a female colleague using the Home Office-approved seated double embrace restraint.

Gareth died in April 2004 from "positional asphyxia" after choking on his own vomit as he was held down.

The hold used to restrain him has since been banned by the Home Office.

Gareth had served just three days of a 12-month sentence at the centre near Daventry when he died.

The system of restraints was introduced in 1998 with a promise that its use would be constantly reviewed.

Despite numerous warnings about its safety, a medical review into the use of restraints was not ordered until after his death.

David Tuck, the Youth Justice Board's monitor - said to be the "eyes and ears of the Home Office" - wrote of his concerns about health effects of the techniques used by guards at the privately-run prisons, and at Rainsbrook in particular.

'Difficult to breathe'

In a letter written to managers in June 2002, Mr Tuck warned of the dangers of youngsters vomiting while being restrained.

One girl at the centre, known by the initial "C", complained she struggled to breathe while being held down.

More than a year later he wrote again, saying children were complaining their heads were being pushed down into their groins, doubling them up and cutting off air supplies.

In his first letter - which was sent to social services, Rainsbrook's director John Parker and head of care Barbara Davies, as well as the Youth Justice Board - Mr Tuck wrote: "C says she is accustomed to physical restraints from her other placements but none has been as uncomfortable as those applied to her at Rainsbrook.

"She says that the approved technique of bending her forward, placing her head between her knees, makes it difficult for her to breathe."

Nothing was done in the light of the letter, the inquest heard.

Criminal prosecution

Speaking after the inquest, Gareth's mother Pamela Wilton Myatt's was critical of everyone involved in the detention of her son.

"It has been hard enough to accept what happened to Gaz," said Miss Wilton.

"But hearing everything that's come out... how long the injuries were going on, years of injury and vomiting and kids complaining.

"I hope to see change to ensure that it doesn't happen again, that kids are hurt."

She added that she was considering pushing for a criminal prosecution in relation to the death.

Deborah Coles, co-director of justice group Inquest, said: "The jury's verdict is a shameful indictment of a catalogue of failure by the Youth Justice Board.

"The jury accept that these failures directly caused Gareth's death. He died a most horrific and violent death while being restrained by custody officers.

"His death was entirely preventable and was a disaster waiting to happen."

"Criticism Over Youth Jail Death." BBC News, 28 June 2007.

*****

Fifteen years old and less than five feet tall, Gareth Myatt died in custody while being restrained by three adults. Three years on, his mother has finally found out what happened in his last moments. She talks to Laura Smith

Gareth Myatt was just three days into a six-month sentence at Rainsbrook Secure Training Centre in Northamptonshire when he was restrained by three members of staff after refusing to clean the sandwich toaster. He tried to tell them he couldn't breathe, but they did not release him. As they held him down, Gareth choked on his own vomit and died. He was 15.

The five-week inquest into Gareth's case, which ended last Thursday, found that his death was an accident. But the jury also found that he might still be alive if the Youth Justice Board (YJB), which oversees privately run centres like Rainsbrook, had carried out adequate safety checks into the types of restraints staff were being trained to use on the children in their care.

Gareth's mother Pam Wilton is on a rare day home from attending the inquest when we meet at her house on a post-war council estate in Stoke-on-Trent, Staffordshire. In the front room, framed colour photographs of her three children adorn the wall. Gareth, the eldest boy, appears aged six months, wearing little shorts, braces and a cardigan. "He was gorgeous," says Wilton. "He had the biggest, loveliest smile, big brown eyes, a cheeky grin."

Gareth was mixed race. Wilton, who is white, did not tell his father, who is black, that she was pregnant before they split up, and Gareth grew up without him. As a little boy, he was confident, and Wilton shrugged off comments from neighbours about her brown baby. But when he started school aged five, things began to change. "He used to come home upset and he never said why," says Wilton, who has the weary blink of somebody who has seen enough for one lifetime. She says people regularly came outside the house to call him "black bastard".

Gareth began to struggle with his identity. Although he had plenty of friends, the absence of contact with his black relatives made his adolescence confusing. "I used to ruffle his hair and play with his curls," says his mother. "He had lovely hair and gorgeous skin. He would say, 'No I haven't - I hate it.' He never said he wanted to be white in so many words but if you mentioned anything about the other side, he just didn't want to know."

Wilton says she can't remember the first time Gareth came to the police's attention, but that in the years leading up to his one and only conviction, whenever anything went wrong locally, officers would turn up at the door wanting to talk to him. "I thought they were picking on him because of his colour," she says. Wilton admits her son was "no angel", but believes his confusion over his identity may have made him more vulnerable to influence. "He wasn't a bad lad. I think he followed the others to fit in because all his mates were white and they accepted him, but others didn't."

Whether the police attention was a result of his race, his actions or a combination of the two, a stint in custody seems to have been almost inevitable. Even so, it came as a shock to his family when he was convicted of stealing a bottle of beer and assaulting a residential social worker at a children's unit. He was sentenced to a 12-month detention and training order, including six months in Rainsbrook. "It was obvious we were all upset," says Wilton, lighting the latest in a long line of cigarettes. "I said to him, 'I'll come and see you. It won't be long, it will soon go'."

On the evening of April 19 2004, Gareth refused to clean the sandwich toaster in the dining area. Two members of staff followed him to his room and began removing things. When one of them tried to take away a piece of paper from the shelf, Gareth became upset and staff say he lunged at one of them. It later emerged that the paper contained his mother's new mobile phone number, thrust into his hands by his solicitor as he left court three days earlier.

In the ensuing struggle, the two members of staff, Diana Smith, a training assistant and David Beadnall, a training supervisor - joined by David Bailey, a training assistant who had by now entered the room - began to restrain Gareth, who was 4ft 10in and weighed under seven stone. They used a technique called the seated double embrace, which involves two members of staff forcing a person into a sitting position and leaning them forward, while a third takes care of the head.

The next few moments were related in appalling detail by Smith at the inquest. "Gareth was doing a lot of shouting and swearing. He did say at one stage that he couldn't breathe. Somebody said, 'Well, if you are shouting, you can breathe.' Gareth said he was going to shit himself. Somebody said, 'Well, you are going to have to shit yourself, because we can't let you go while you are like this,' Bailey looked back and said he had actually shat himself. The struggling seemed to go on for a while and then he seemed to settle down. After a few minutes we realised something was wrong. I looked at his face and he had something coming down his nose and he looked as if his eyes were bulging. I can't remember much more. I've tried to get it out of my mind."

Gareth Myatt's death prompted three separate inquiries, and in June 2004, the seated double embrace - which had been approved for use on children by the Home Office and the YJB as part of a series of techniques known as Physical Control in Care - was withdrawn from use within juvenile custody. It has not been used since.

At his inquest it emerged that before Gareth died, at least four other children had complained of being unable to breathe while being held in the seated double embrace. One boy was taken to hospital with breathing problems and haemorrhaging that left blood in his eyes, and a girl was left wearing a neck brace for five days. After Gareth's death, an investigation into the use of restraints at the centre found that the methods used in two-thirds of the cases examined were "potentially lethal".

Yet those in charge do not appear to have appreciated the dangers. David Tuck, the YJB's monitor at Rainsbrook, said that although he expressed concern about the technique, he did not recommend that its safety be examined because it did not occur to him that somebody could die. Mark Perfect, YJB chief executive at the time, has admitted that on his watch the only review into restraint techniques used on young people in custody was carried out by the National Children's Bureau and failed to investigate the safety of the procedures in place - though it has since emerged that it would have cost only an extra £1,500 to do so.

Deborah Coles, co-director of the campaigning group Inquest, which has worked with Gareth's family for the past three years, says it is a scandal that such serious failings came to light only through Pam Wilton's tenacity. "Gareth died a terrifying death that was entirely preventable," she says. "The shameful failings of the Youth Justice Board resulted in dangerous techniques being routinely used - behaviour which in any other setting would be seen as child abuse."

Ellie Roy, chief executive of the YJB, was not available for an interview but said in a statement: "It is clear that everyone working with young people in custody needs to learn lessons from this tragic case. The Youth Justice Board is clear - restraint must be used as a last resort." Yet the YJB backs new rules, put in motion by the Ministry of Justice and due to come into force this Friday, that would allow staff in secure training centres to make even wider use of restraint, including inflicting pain on children who refuse to go to bed or be quiet. This is a significant extension of the existing rules at the institutions, which state that restraint can only be applied where there is a genuine risk to people or property, or the chance of escape.

The first Wilton knew that anything was wrong was when police knocked on her door at around 5am the next day to tell her Gareth was dead. "I waited until 9am and rang up Rainsbrook," she says. "They got back to me at about midday. All they said is, 'It happened while he was being restrained.' And right up until the inquest they didn't tell me anything else, so I didn't know anything." She says she received no phone call or letter expressing regret, no offer of help or support, and her attempts to get information were blocked at every turn. She says the first apology she received from anyone was from Mark Perfect outside the inquest.

Wilton does not like to think about Gareth's last moments. Pausing to think about how her life will be now that the inquest is over, she closes her eyes and is silent for some time. "There are so many things I wanted to say to Gaz if I had known," she says finally. "I speak to him now and it helps. He gives me strength. We were close and I believe that if he can, he won't be far away. I get through it by thinking he is in a better place; nobody can hurt him now. He is safe".

Smith, Laura. "'Nobody Can Hurt Him Now.'" The Guardian, 4 July 2007.

*****

One spring day nine years ago, 15 year old Gareth Myatt, on his third day at Rainsbrook Secure Training Centre near Rugby, refused to clean the sandwich toaster. He was sent to his room. He complied.

A note on Gareth's file said that if he became aggressive, which didn't happen often, the best thing was for staff to leave him alone to calm down. They didn't do that.

Instead, six foot, sixteen stone David Beadnall and a fellow guard followed Gareth (4 ft 10" and 6½ stone) to his room. They told him off. They later claimed that Gareth, who was of mixed race, responded defiantly, asking them to leave.

The guards chose not to leave. Instead they began the punishment procedure known as 'single separation' in a stripped down room. All Gareth's personal possessions would be removed from his room.

Gareth had few personal possessions. One was a scrap of paper. His mother's new mobile phone number was written on it.

They took it. He objected.

What happened next?

Here is an account, drawn from court transcripts, by the charity INQUEST.

"The officers alleged that Gareth said 'You're not fucking taking that' and 'Don't take my mum's phone number'. Gareth is then said to have clenched his fist and swung it at David Beadnall who stood at over 6 ft tall and weighed over 16 stone.

[Beadnall] claimed that this behaviour amounted to a threatening situation and as such warranted using a restraint technique on Gareth. The staff members and Gareth ended up lying on his bed, with one staff member holding his legs and the other holding his upper body."

A third officer then came into the room and Gareth was placed in a hold called the Seated Double Embrace. Two staff members held his upper body and pushed his torso forward towards his knees while one officer held his head.

Gareth complained: 'I can't breathe'.

Beadnall responded: 'if you can talk then you can breathe'.

Gareth said he was going to defecate.

He was told: 'you are going to have to shit yourself' and the restraint continued.

Gareth did defecate. The restraint continued. Gareth vomited. The restraint continued. Gareth slumped forward. The restraint carried on for several minutes. When the restraint stopped it was too late.

Attempts to resuscitate him failed. The cause of death was recorded as asphyxia resulting from inhalation of gastric content and his body position during the period of physical restraint.

Gareth had an older sister, aged 16, and a younger brother who was 9 at the time of his death. He had lived with his mother in Stoke-on-Trent.

The inquest, held in 2007, heard that one year before Gareth died, David Beadnall had been investigated for using pain-inducing 'distraction techniques' too often. Beadnall told the inquest he had no recollection of that.

G4S training documents listed guards' nicknames. They included "Clubber", "Crusher" and "Mauler".

Last week, after repeated requests, G4S reluctantly confirmed that Dave Beadnall is now Safety, Health and Environmental Manager at G4S Children's Services.

Company spokesperson Nicola Savage added: "His current role does not involve any direct contact with young people."

Beadnall's name has popped into the public domain again because he sent a statement to Aylesbury Vale District Council in support of a planning application to turn a house into a children's home. The application itself omitted the company's name, in an apparent attempt to evade local opposition. (There is an article about that here).

G4S Children's Services runs children's homes and secure training centres. According to the G4S website, staff work with local schools, sit on Local Safeguarding Children's Boards and train child protection officers.

Beadnall is "responsible for monitoring and managing the Safety, Health and Environmental aspects and impacts of G4S Children's Services", according to his LinkedIn Profile.

Savage was reluctant to confirm the current job titles of two other senior executives at G4S Children's Services, Paul Cook and John Parker.

Paul Cook is Managing Director of G4S Children's Services.

John Parker is Director of Children's Services at G4S Children's Services.

In February 2006, Paul Cook, described as director for children's services at Rainsbrook Secure Training Centre, told the magazine, Community Care: "It was a shock to find that a restraint hold considered to be safe turned out to be unsafe. This was as much a tragedy for the staff as for Gareth's family."

John Parker, the director of Rainsbrook at the time of Gareth's death, told the inquest that he had not read the Physical Control in Care manual; he was not aware of the risks involved.

The Crown Prosecution Service said in January 2006 that there was 'insufficient evidence' to bring prosecutions over the death of Gareth Myatt. The Coroner recorded a verdict of Accidental Death in June 2007.

After the Inquest, the Coroner, Judge Pollard wrote personally to then justice secretary Jack Straw to ensure that no other child should be harmed by improper restraint methods, and to highlight the remarkable failure of G4S's management to act on reports of abuses. (He refers to Rebound, the division of G4S responsible for Rainsbrook).

"Inadequacy in the monitoring of the use of Physical Control in Care at Rainsbrook by Rebound management caused or contributed to Gareth's death," wrote the Coroner. "We also wish to record that there was a problem with the lack of response by Rebound to the information from Rainsbrook."

G4S continued to use dangerous restraint techniques, as evidenced by the death of Jimmy Mubenga in the company's care six years after the death of Gareth Myatt. This time G4S guards, in evidence to an inquest jury, claimed that their detainee forced his own head down between his knees. The jury did not believe them. They returned a verdict of unlawful killing.

Sambrook, Clare. "G4S Guard Fatally Restrains 15 Year Old - Gets Promoted." Open Democracy, 22 July 2013.

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