Nearly a year after Vanessa Wint, a teenage ward of the State, hanged herself inside an adult correctional facility, an oversight agency has concluded that the Government "failed in its duty to safeguard her life".
As a result, the Independent Commission of Investigations (INDECOM), which made the finding, has recommended that the solicitor general's office be asked to consider compensating Wint's estate for breach of her right to life and for negligence.
However, INDECOM said it would not make public any of its findings on the possible individual culpability of any Department of Correctional Services (DCS) employee, as the case was now with the Coroner's Court.
The oversight body sought to explain that its stance was to ensure that those proceedings were not prejudiced.
INDECOM gave the assurance that "the coroner will have the full benefit of the commission's investigation in that regard".
several suicide attempts
After several attempts, Wint - who was being held at the Horizon Adult Remand Centre in St Andrew on a court order that she was 'uncontrollable' - reportedly used a bed sheet to hang herself inside a cell on November 21 last year.
Lieutenant Colonel Sean Prendergast, who headed the DCS at the time, told The Gleaner then that there were several officers on duty who should have seen the teen before she killed herself.
However, in one of several scathing criticisms of the way the troubled teen was treated, INDECOM said it found that the decision to remand Wint was "irregular and possibly unlawful".
The commission said this was "... due to the fact that the committal order was not endorsed by the minister as required by the law."
In its criticism, the commission concluded that the State failed to take "all reasonable steps" to ensure that the teen was closely monitored in a manner that would facilitate swift response should she make another attempt to harm herself or take her own life.
"Liability on the part of the State for Vanessa's death is evident in case law (Reeves v Commissioner of Police for the Metropolis), which dictates that it is the custodian's duty to take reasonable care to guard against suicides, although suicide was a voluntary and deliberate act," INDECOM argued.
"This duty arises from the level of control the gaoler exercises over the prisoner and the additional special danger of people in custody taking their own lives," it continued.
Turning to the DCS, the oversight body said it observed, with great concern, "a failure of the department to promulgate standard operating procedures to prevent suicides and to train staff in preventing suicides".
The commission said: "This, we believe, is inexcusable because it is widely known that there is a greater risk of suicide when a person is incarcerated, and the State has a responsibility to preserve the life of these persons."
As a result, the oversight agency has recommended that the DCS issue standard operating procedures and develop training for an effective regime to detect and manage the risk of suicide by inmates and wards by December.