An unlawful use of force contributed to the decision by the youngest person to die in custody in recent times to take his own life, an inquest jury concluded today.
Adam Rickwood, of Burnley, Lancashire, was just 14 when he was found hanging at Hassockfield Secure Training Centre, near Medomsley, County Durham, in 2004.
The teenager was an "extremely troubled and vulnerable young man" with a history of cannabis abuse when he was sent 150 miles from his home town on remand after he was charged with wounding another youth, the inquest in Easington, County Durham, was told.
On the day he died, Adam had rowed with a female member of staff in the association area and was lifted by four care officers and placed face-down in his room.
On the way, care officer Steve Hodgson used the controversial nose distraction technique - a sharp painful blow - to stop the boy trying to bite him, the inquest heard.
Adam's nose bled afterwards and he was left alone in his room to calm down.
The teenager spoke to members of staff and he did not seem too despondent afterwards, but six hours later he was found dead in his room.
The jury concluded there had been a serious system failure at the centre which led to an unlawful regime.
The panel also criticised training.
Summing up, assistant deputy coroner Jeremy Freedman said the jury should consider whether the restraint technique and the blow to his nose might have led to Adam's death.
He said: "Adam was a deeply troubled and disturbed 14-year-old boy who had a history of drug abuse, self-harm, suicidal thinking and feelings of hopelessness.
"You know this was his first time in custody, his first time in a secure establishment where he was locked in at night.
"You also know he was very attached to his home and his family."
He directed the panel to consider 16 questions relating to Adam's death.
They focused on the events in the run-up to Adam's death, staff training, the involvement of the Youth Justice Board, the Hassockfield regime and the factors that might have contributed "more than minimally" to his death.
Consultant forensic psychiatrist Dr Hilary Grant told the inquest yesterday that she considered the restraint technique and the use of nose distraction on Adam had more than minimally contributed to his death.
The jury of four men and five women agreed unanimously that before and at the time of Adam's death, there was "a serious system failure in relation to the use of physical control in care at Hassockfield, giving rise to an unlawful regime".
They found that Adam was unlawfully restrained and hurt in a way that contributed to his taking his own life.
They said more care should have been taken of the troubled and vulnerable teenager after his admission to the secure training centre near Medomsley, County Durham, in 2004.
Rajiv Menom, for the teenager's mother Carol Pounder, said the verdict condemned the Youth Justice Board and the entire prison system.
Assistant deputy coroner Jeremy Freedman had asked the jury panel to consider a series of issues and to decide whether they had contributed to the teenager's death.
These focused on the events in the run-up to Adam's death, staff training, the involvement of the Youth Justice Board, the Hassockfield regime and other factors the jury decided had contributed "more than minimally" to his death.
Adam's mother, Carol Pounder, wept as the jury announced its finding.
She said she wanted the guards who restrained Adam to be prosecuted and would be seeking legal advice in the near future.
Speaking outside the court, she said: "I feel that at last I have got some sort of justice for Adam.
"I have had six and a half years of waiting for this today and I feel like at last I have got some answers.
"What I have not had is for Serco or the Youth Justice Board to put their hands up and say 'Sorry, we got it wrong'.
"They have not just killed Adam, they have killed thousands and thousands of other children locked up in prisons across the country.
"I'm hoping to have the staff charged with assaulting Adam.
"They should be facing court proceedings for assaulting a little boy, because that's what Adam was, a little boy.
"If you or I had done that to Adam or another child we would be locked up.
"But because they work for the Government it was swept under the carpet."
Deborah Coles, co director of INQUEST, a charity which supports the families of people who have died in custody, said: "As a society we owe Carol a great debt. She has pursued this because she believed what happened to Adam was wrong.
"Adam, a 14-year-old boy, knew what had happened to him was wrong, but it has taken six years for the public acknowledgement of that to be made.
"It is astounding to think that a prison that holds some of society's most vulnerable children could fail so dramatically at every level.
"The very state apparatus that are supposed to inspect and regulate these institutions failed to take any action at all.
"This is an issue that needs to be looked at at the very highest level of government."
Mr Freedman told Mrs Pounder he hoped the inquest finding would bring finality, if not closure to her torment.
He said: "She has had a very, very long wait for this outcome. It would have been an unbelievably difficult time. None of us could imagine or appreciate it.
"It is a cliche to say that somehow you will find closure but at least there is some finality here.
"I know how much the outcome of this inquest means to you. You have sat through it patiently and courteously throughout and I know how terribly difficult and painful it has been at times."
The jury found that staff at Hassockfield were not properly trained in High Risk Assessment Team (HRAT) procedures designed to safeguard trainees who might self-harm, nor in suicide awareness skills or behaviour management.
Nor had they been adequately trained by the Prison Service in the use of Physical Control in Care (PCC) techniques.
The inquest found that, before and at the time of Adam's death, the Youth Justice Board should have been aware that PCC was being used unlawfully and in breach of Hassockfield's contract with the Home Office.
This amounted to a "serious system failure" at the STC.
It found that Adam should have been assigned a replacement key worker when his own went off sick.
It also found that Hassockfield had failed to effectively implement an HRAT programme to safeguard the teenager upon his arrival at the STC, and had made a mistake in "closing the book" with regard to HRAT care in July that year.
It found that neither Hassockfield not the Lancashire Youth Offending Team had dealt appropriately with the teenager's request to be moved to an STC closer to his family home.
Care officers should have been made aware of an entry in the HRAT book which detailed Adam's self-harm when angry.
The HRAT book should have been reopened after Adam was restrained on the night of his death, and the teenager should have been checked by staff every 15 minutes once he was put on lock- down that night.
They found that being in an STC which was more than 150 miles away from his home, the news that he would be denied a bail hearing, the unlawful use of PCC and the nose distraction technique on him on August 8, and his intrinsic vulnerability had all "more than minimally contributed to his death".
The jury concluded that the guards had genuinely believed they were acting lawfully at the time.
Serco expressed its condolences to Adam's family.
A spokesman for the YJB also expressed his condolences and said measures had been taken since Adam's death to ensure that what happened could not happen again.
A spokesman for Hassockfield STC said major changes in the way young offenders were dealt with had been made since Adam's death.
The spokesman said: "Adam's death was a tragedy. Our thoughts are with his family and all those affected by his death, including those who helped, taught and cared for him.
"We have fully supported all investigations into what happened and we accept the verdict.
"As the inquest heard, since Adam's death in 2004 major changes have been made nationally to the way in which troubled and challenging young people in the criminal justice system are cared for in secure training centres.
"We have made significant improvements to suicide and self-harm awareness training.
"In addition to the full induction programme (which is now a BTEC qualification), we are providing a course to all staff leading to a nationally recognised safeguarding qualification - two-thirds of staff are already accredited.
"We remain absolutely committed to preventing all the young people in our care from coming to any sort of harm.
"The jury found that, in 2004, care officers genuinely believed it was lawful for them to use PCC in order to gain compliance with an instruction.
"Since 2006, all our staff have been trained in non-physical techniques to de-escalate difficult or violent situations.
"We recognise that the use of PCC to maintain good order and discipline was found to be unlawful by the Court of Appeal.
"The practice was immediately stopped across all of the YJB's STCs.
"We also recognise that the nose distraction technique is unlawful.
"Hassockfield stopped using it five years ago, and a year before it was stopped nationally."
The Youth Justice Board (YJB) expressed its deep regret for Adam's death, and said it unequivocally accepted the jury's verdict.
It welcomed the coroner's acknowledgement that the YJB systems in place today were "incomparably better than they were".
YJB chief executive John Drew said: "Keeping young people in custody safe is our highest priority.
"We have made huge progress in this area since 2004.
"As a result there have been dramatic reductions in the use of restraint and in the risk of injuries to young people in custody.
"There is always more that can be done to improve things and we will study the verdict carefully with this in mind."
Maggie Atkinson, Children's Commissioner for England, welcomed the judgment.
She said: "We recognise that members of staff in the secure estate can work with some of the country's most troubled children.
"But physical force should only ever be used as a measure of last resort.
"We need to remember that children in custody are some of our most vulnerable; many suffer from mental health problems, learning disabilities and many have suffered abuse and violence in their lives.
"We welcome this verdict and hope that the tragic death of Adam Rickwood and this ruling pave the way for the abolition of the unacceptable deliberate use of pain to control children in secure juvenile settings."
Penelope Gibbs, director of the Out Of Trouble programme for the Prison Reform Trust, said Adam's death was an "avoidable tragedy".
She said: "When a child dies in the care of the State it shames us all.
"His treatment in a secure training centre contributed to this 14-year-old's suicide and much should be learnt from this inquest about how children in custody should be treated.
"However we should also ask questions about our culture of imprisoning children.
"Why was a very vulnerable child in custody when he had not even been convicted of an offence?
"Teenagers pleading innocent should only be imprisoned when absolutely necessary and, if they are, it should always be remembered that these are troubled children who may or may not be convicted of crimes."