IT all started as a bit of horseplay. A rude note written about a care officer passed between two boys who refused to hand it over.

What followed was to lead to the tragic death of 14-year-old Adam Rickwood – the youngest person to die in the British penal system.

And over the course of nearly seven years it was to result in the eventual exposure of the routine and unlawful use of physical restraints within the country’s secure training units.

It was an abuse which led to “thousands upon thousands of children” being routinely assaulted in the course of restraints.

According to evidence at an inquest in Easington, an inexperienced female care officer at Hassockfield Secure Training Centre, near Med-omsley, County Durham, had ordered Adam and the other boy to their rooms when they refused to hand the note over.

When Adam refused, she radioed for “first response”, which invariably led to the use of restraint known as Physical Control in Care (PCC).

As Adam sat clinging on to a table leg, two officers took hold of his arms and bent him over, while a third took his head in a lock and a fourth took hold of his legs. As he was carried face down to his room, the officer holding Adam’s head – believing he was about to be bitten – applied a so-called nose distraction technique. This involved a short, sharp and paininducing burst to the base of the nose with two fingers.

Enraged, Adam covered his room in blood. And, though he calmed down, he was found hanged hours later.

Quashing the findings of the first inquest, a High Court judge was unambiguous: Adam’s removal from free association and the use of PCC in the circumstances was unlawful.

As for the nose distraction technique, it was illegal – full stop.

Over course of three weeks, a jury heard the use of PCC was clearly set out in secure centre training rules. It could only be used to prevent a trainee escaping, from causing harm to others or themselves, or damaging property.

This was further underpinned by Hassockfield’s own director’s rule, which stipulated PCC could not be used merely to obtain compliance to an order – and by the contract between the Home Office and Serco.

A prison office who instructed care officers at Hassockfield, who in turn taught PCC to other officers at Hassockfield, insisted these rules had been made “crystal clear”.

He added they had also been told the controversial nose distraction technique could only be used in extreme cases.

But Hassockfield director Trevor Wilson-Smith said he believed all these rules were overridden by Section 9 of the Police and Public Order Act which empowered the “use of reasonable force to maintain good order and discipline”.

He said PCC could also be used to obtain compliance.

Mr Wilson-Smith said the use of physical restraint was widely used in secure training centres at the time and had been sanctioned by the Youth Justice Board.

He added he had personally planned to ban nose restraint days before Adam’s death, because it “did not sit right”. But it remained in use at Hassockfield for 15 months after he was found hanged.

Between April 2003 and March 2004, PCC was used 912 times at Hassockfield – 20 per cent of these instances nose distraction was used.

But the jury agreed this was unlawful.

The Youth Justice Board had the responsibility of ensuring Serco complied with its Home Office contract and had monitors on the ground.

But, the jury found serious failings by the Youth Justice Board, which should have prevented the unlawful use of PCC.