Critically reviews the inquest into the death of a 19 year old male inmate at which a verdict of death by suicide was returned. Questions about this verdict were raised by abrasions consistent with attempts to remove the straps by which he hung; the coroner’s failure to mention lack of care as a possible verdict; the inmate having been assaulted 2 months previously; & the family learning of the funeral arrangements the day of the cremation. (RM)