This research was conducted by the Prison Reform Trust in the United Kingdom to examine whether changes were made to the country's prison system following the deaths of children and young people in custody. The research examined the deaths of children and young people in prison between 2003 and 2010 and found that 1) these children were some of the most disadvantaged in society and they had experienced problems with mental health, self-harm, and substance abuse; 2) had significant interaction with community agencies before entering prison; 3) had not been diverted out of the criminal justice system despite earl identification of their vulnerabilities; 4) were placed in prisons with unsafe environments and cells; 5) experienced poor medical care and limited access to therapeutic services; 6) were exposed to bullying, segregation, and use of restraints while in prison; and 7) were failed by the system set up to safeguard them from harm. The report also notes that despite these findings, the institutional response to these deaths has been inadequate. The day-to-day practices used for caring for these individuals has not become more responsive to their needs and inquests into the deaths of children and young people in prison continue to be delayed and carried out in an untimely fashion. The report recommends a critical review of the lessons learned from these deaths in order to apply the lessons to policy and practice. A set of recommendations for change aimed at preventing further deaths of vulnerable children is presented and discussed. Tables, appendixes, and references