Life seemed to hold rich promise for Micah Richards and Daniel Nelson. Their love of football outstripped that of all the other boys who played on the rough streets of Chapeltown, Leeds, eight years ago. Both teenagers played for the revered local junior team, Sao Paolo, and had Brazilian-style football skills to show for it. They liked exchanging music, and racing full-pelt into one of their neighbour's swimming pools. They used to talk deep into the night about the dream they both shared: making it big in football, and finding a way out of the deprivation around them.
"It was every boy's dream to be a professional," Richards recalls. "Things were no different for Danny and me at that time."
Tragically, only one of the pair was to make it. Richards signed for Manchester City, where his extraordinary footballing talents have this season seen him cement a place in the England team. Nelson fell in with the wrong crowd, turned to drugs and wound up at the Doncaster Young Offenders Institution (YOI) in South Yorkshire. There, after 27 days in custody, he was discovered hanging from bedsheets he had rigged to his cell door. He had just turned 18.
Nelson is one of 27 people under the age of 21 to have taken their lives in custody in the last six years, according to data gathered by campaign group Inquest. Last week, an inquest into Nelson's death recorded an open verdict. But the jurors considering the case did not know that an ombudsman's report into the tragedy, published in February and seen by The Independent, expressed "concern" over the prison staff's failure to manage Nelson's "propensity for self-harm."
The teenager had not been placed on a round-the-clock suicide watch, despite cutting his wrists with a plastic knife and being twice found attached, unharmed, to a ligature in the seven days before he died.
Richards has been both devastated and astonished by his friend's death. "In an area like the one we were brought up in there were obviously distractions, but Danny was not distracted," he says. "He had such energy, and he was always so chilled. This was so utterly out of character."
Yet those who have monitored the experience of troubled teenagers in custody were not so surprised. They say the aspiring young footballer's death is a product of Britain's desire to lock up difficult teenagers, instead of finding ways of putting them back on track. They also say that Daniel Nelson, and young men and women like him, need greater mental-health provision, and more establishments that understand their particular vulnerability and susceptibility to self-harm. A coroner examining a similar case of a 16-year-old who took his life called for a public inquiry into these issues three years ago, but the Government has refused. A further 21 young people, including five under 17, have since died in the penal system.
Prison had seemed to the last place Daniel Nelson would wind up when he and Richards were growing up together. They were introduced by Nelson's cousin, Mark Harding, a friend of Richards' since their early primary-school days. Their mutual understanding was cemented when they played together in the same year intake for the Sao Paolo team. "Danny played up front or on the wing, and I played pretty much wherever I could: right back, midfield, up front," Richards recalls. "There were great battles."
When the games were finished, they and a few others from the team would descend on the house of Bridget Harding, Nelson's aunt, for Sunday dinner and long nights playing music. In the summer, the Hardings' swimming pool – a real novelty in Chapeltown – provided great entertainment. "I'd put sheets of plastic down and Daniel, Micah and the others would race up and slide in," says Mrs Harding. Richards remembers staying over. "I'd just kip down and we'd go straight to school from Bridget's on the Monday morning," he says.
There was one essential difference in the two boys' lives. Parental stability. While Richards' father, Lincoln, was around (he still coaches at the Brazilian soccer school in Leeds) Daniel's father, Melbourne Nelson, was a peripheral figure in his life, who visited only occasionally before heading back to Jamaica in 1999.
Daniel Nelson was close to his stepsister Lisa Clarke (now a student nurse) and his younger brother Jordan. But Nelson's life degenerated into chaos in 1997, when, aged 11, his mother became hooked on alcohol and prescription drugs. She also dabbled with crack cocaine and made a number of attempts on her own life. Such was the tumult in the family home that Nelson and his brother were taken into care, though, for a time, they were placed in the home of their aunt Bridget.
Nelson lived in a number of children's homes – but contentedly so. He loved dance, and once toured Canada with Reggae, Jazz and Contemporary, a black contemporary dance company well known in Leeds for its highly physical shows. He did not display quite the same footballing flair as Richards, who was signed by Oldham Athletic at the age of 12, but the two friends still saw each at weekends. Nelson eventually enrolled on a course at the Thomas Danby College in Leeds, and secured a soccer scholarship to the US, which he intended to take up in 2005.
Then the surrogate support of his care-home place came to end. Aged 16, Nelson started to struggle. While his old friend focused hard on the Oldham Athletic traineeship and was signed by Manchester City, Nelson drifted around various hostels, lost contact with his social services officer and got involved with drugs. In the summer of 2005, he was remanded in custody after being arrested on suspicion of possessing a class-A narcotics. His crime was exacerbated when he ran away from the police and failed to answer bail.
Nelson's sister refused for several weeks to visit him in prison. "I decided he needed to think about his behaviour and what had brought him into custody," she says. Then a letter from Nelson arrived, addressed to his younger brother, Jordan. In his West Indian patois, he expressed sadness at his perceived failure as a role model.
"I failed you lil nigga, don't worry cos I'll make it up to you wen I get out," he wrote. "I hustled in da first place to give u a better life, but I went greedy it took over me. I no dat life hasn't been da best for you." Nelson drew images of his tears on the A4 sheet, which was torn out of a pad.
Nelson's family was astonished by his apology. As his sister says, it was as though they had got their "old Daniel back" and made plans to visit him. But it was too late. Within a few days Lisa Clarke discovered "on the community grapevine" that her brother had taken his life. That evening she answered the door to West Yorkshire police, who arrived to confirm the news.
Her brother's mental decline had been a rapid one. Though Nelson seemed, at first, to accept imprisonment, and was not initially considered to be in need of psychiatric examination, his behaviour suddenly became erratic. He had been warned about his conduct, and accused of assaulting another inmate. He had also begun displaying signs of paranoia. Having asked to move cells because he feared that his cellmate was about to attack him, he then told one nurse that the whole prison wing believed that he was HIV positive (he was not.) On 11 September 2005, he told a prison nurse that "hanging ropes" had been found under his bed and that he believed prison staff would hang him. He told a nurse, in her words, that "before they do that he will do it himself".
A prison doctor who examined Nelson on 12 September found him "...very paranoid. Agitated." Another nurse described him as resembling "a rabbit in the headlights".
At 5.30pm on 13 December, he was found with a ligature made out of bedding around his neck and attached to heating pipes in his cell, number 2.27. He was moved to next-door cell – 2.28 – where the sink and heating pipes were boarded up.
He had been there less than 30 minutes when he was found to have made a ligature and wedged it between the cell door and its frame. A nurse reported: "States he is feeling guilty because he neglected his younger brother who, he feels, he should be taking care of. States his mother's voice is telling him to kill himself as he is not worth it."
Prescribed an anti-psychotic drug usually used to reduce aggression, Nelson tried to cut his arm with a plastic knife at 3pm on 14 September and cried through the night for sister and mother. When Dr Patrick Quinn, a psychiatrist, arrived to see him, he had to conduct his assessment interview through an opaque, darkened Perspex door, rather than in a separate interview room, because Nelson was adjudged too dangerous. At 5am on 20 September, a prison officer looking in on Nelson at 15-minute intervals found him dead, hanging from bedding forced between the cell door and its frame.
The author of the subsequent ombudsman's report, Ian Truffet, questioned the decision not to position a prison officer outside his room on constant suicide watch. He also concluded that the opaque door inhibited monitoring of Nelson and "must also have had a debilitating effect on him".
The report's eight recommendations included a review of the criteria used to judge whether a prisoner is a suicide risk, and replacement of the opaque door. Truffet also criticised the way the prison chronicled Nelson's deteriorating condition in a way that resembled "a diary, rather than any systematic review and reappraisal". He also said Nelson's care plan was "limited in its approach", and that the inquest jury may "wish to consider" his recommendations.
To the surprise of the family's solicitor, Ruth Bundey, the Doncaster coroner, Stanley Cooper, ruled that the jury should not see the report because it might prejudice their deliberations. Bundey is now examining whether this decision may be challenged in law. The jury did hear testimony which hinted at the vast gulf between a penal establishment and a care facility versed in how to deal with distressed young people. James Parrott, one of the warders who had the unenviable task of dealing with Nelson as he screamed and lashed out in his cell, was asked whether he had attempted to establish verbal contact with the teenager to get a sense of his state of mind.
"We contact medical staff for that because we are not qualified," he told the coroner. The same warder had, of his own volition, started a diary chronicling Nelson's behaviour, which detailed the red marks around his neck after one of the earlier ligature incidents. The cell where Nelson died was "a reduced-risk cell, not an anti-suicide cell", he said.
Inquest juries have heard many such stories over the past three years. The case that asked the most searching questions of penal establishments' ability to deal with vulnerable children was that of Joseph Scholes, who was found hanging from the bars of his prison cell five weeks after his 16th birthday, and nine days after arriving at a YOI in Staffordshire.
Despite his youth and extreme vulnerability – his childhood was destroyed by alleged sexual abuse, depression and repeated self-harm – and although he was only a look-out in a series of mobile-phone thefts, Scholes received an automatic prison sentence during a purge on street crime instigated by both the courts and politicians.
The Mid and North Shropshire coroner who examined the case, John Ellery, was frustrated that the remit of his inquiry could not include issues such as the severity of Joseph's sentence, the arrangements for dealing with him, and the shortage of facilities for dealing with vulnerable offending juveniles who had a history of self-harm and suicide attempts. He demanded a public inquiry. But the Government has refused, a decision which since been upheld at judicial review and is currently being challenged in Europe by Inquest.
In the meantime, the death toll of teenagers has mounted. Gareth Myatt was 15 and weighed less than seven stones when he choked to death while being restrained in at Rainsbrook secure training centre in Northamptonshire in April 2004. He was three days into a six-month sentence when staff followed him to his room after he refused to clean a sandwich toaster.
Four months later, 14-year-old Adam Rickwood became the youngest boy to die in a penal establishment. The inquest into his death heard how he, like Joseph Scholes, had a long history of self-harm but was not recognised as a suicide risk in social services reports that accompanied him into custody, despite having been admitted to hospital nine times after harming himself.
His mother told the Hassockfield Secure Training Centre in County Durham, that, in letters home before his death, he had threatened to kill himself. He took his life after being restrained by four staff using a controversial nose-twisting technique designed to cause brief but sharp pain and which was their way of forcing him to go to his room.
In the aftermath of these deaths, and others, there has been no lack of scrutiny of how challenging young people should be dealt with. A report by the Liberal Democrat peer Lord Carlile, commissioned after Gareth Myatt's death, expressed shock last year at the way hundreds of children in YOIs were being held in solitary confinement, often for weeks at a time.
The Parliamentary Joint Committee on Human Rights has said in its own report that local authority secure accommodation should be used "wherever possible" for children, with the use of prison service custody reduced to "an absolute minimum". The call for a public inquiry on the issue has been backed by the General Synod of the Church of England, 111 MPs through an early day motion, and many peers as well as the committee.
In the case of Daniel Nelson, Serco, the for-profit company whose home affairs division runs the Doncaster YOI in which he died, said that it always reviews its systems after a death, but pointed out that the inquest jury had not made any specific criticisms.
"We always undertake a review if there is a death in custody in any of our prison," says its spokesman, Michael Clarke. "We will look at what lessons can be learned." As yet, Serco has been unable to provide any information as to what, if any, those might have been.
Ruth Bundey says that the failure to notify Nelson's family of his distress has haunted them. "The family remain heartbroken that they were never informed that Nelson had been exhibiting paranoia and bizarre behaviour, constantly calling for them, and scarcely sleeping," she said. "If Daniel's watch had been raised to constant observation, at least until the dangerous cell door could have been replaced; he would be alive to day."
Micah Richards only has music to remember his old friend by. Daniel Nelson introduced him to a track by the singer Carl Thomas called "Make it Alright", and he still carries it on his iPod.
"It will always be his track for me," says Richards. "In the area where we've grown up, bad things can happen, but you just don't expect that. It's hard to believe how things have turned out. I last saw Danny at Bridget's and he seemed fine. There was mentioned that he'd also got a place at a football academy in America. He just had so much to live for."