Failings contributed to Leicester teenager's court cell death

Jaskiran Kainth, 18, was found unresponsive in a cell at Leicester Magistrates' Court ahead of a hearing

Inadequate staff training contributed to the death of a man found unconscious in custody with his trousers around his neck, an inquest concluded.

Jaskiran Kainth died in hospital on 3 May 2019, four days after he was found in a Leicester Magistrates' Court cell.

An inquest jury found the 18-year-old's death was by misadventure, meaning he did not intend to kill himself.

His father Charnjit Kainth said opportunities to help his son were missed.

A jury at Leicester Coroner's Court delivered a narrative conclusion and highlighted a number of failings.

These included inadequate recording and sharing of information between agencies about Mr Kainth's mental health, inadequate assessment of self-harm and suicide risk while in custody, and a lack of training in front-line staff on assessing risks posed by detainees with mental health difficulties.

The coroner will consider whether to make a Prevention of Future Deaths report within seven days.

'I miss him every day'

Charnjit Kainth said his son "was not only academically bright but also very talented at sport".

He added: "My son had his whole life ahead and could have had a bright future but opportunities to help him were missed.

"That Jaskiran will never get to fulfil his potential is heartbreaking for our family. All I can hope for now is that lessons can be learned from his story. I miss him every day and always will."

The inquest heard the teenager was arrested on 28 April after damaging two family cars and taken to Beaumont Leys Police Station. His family asked officers to look after him.

The next day, he was transferred to the custody of GeoAmey, contractors in charge of custody services at Leicester Magistrates' Court, ahead of his hearing.

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Mr Kainth's family lawyers said court staff were unaware he had attended hospital on 27 April where he told healthcare professionals he had tried to strangle himself and on 28 April for reports of an overdose.

Court staff were also not told about his self-harm in police custody earlier that month, and did not treat him as a suicide or self-harm risk, they added.

While in the court, he was seen by a mental health nurse who reported no concerns.

But the inquest was told he was behaving oddly and at 12:30 BST staff removed Mr Kainth's jumper and shoelaces, and left him with only his trousers.

When Mr Kainth was checked on 12 minutes later, staff found he had tied his jogging bottoms around his neck and was unresponsive. He was taken to hospital after attempts to revive him.

'Radical improvements'

Juliet Spender, the lawyer representing the family, said: "The jury's conclusion mirrors what Charnjit has always believed - that this tragic death resulted from a cry for help and was preventable.

"Charnjit firmly believes warning signs as to his son's mental state were clearly visible and more action should have been taken to prevent his death, and if GeoAmey had robust policy and training of its staff it would have been.

"It is also a tragedy that such significant risk information was known to the healthcare professionals and police, but not shared."

Selen Cavcav, from the charity Inquest, said: "It is clear, in our view, that a litany of failures by multiple agencies resulted in the loss of life of an 18-year-old.

"In light of this inquest, there must be radical improvements in managing mental ill health in courts nationally."

A GEOAmey spokesperson said: "GEOAmey would like to extend our condolences to the family of Jaskiran Kainth for their loss.

"The safety of those in our custody is the highest priority for us as an organisation.

"In addition to the improvements implemented following our exhaustive post-incident investigations, we will be giving careful consideration to any recommendations that may be made by HM Coroner."