Dear Mrs Brown; Re. Mr Greg Revell Further to your report dated 28 April 2015, in accordance with paragraph 7 , Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 offer the following response. We have investigated the matters of concern that have arisen during the course of the inquest of Mr Greg Revell Leicestershire Partnership NHS Trust takes these matters very seriously and hope that you and Mr Revell's family will be satisfied that we have taken the appropriate measures to prevent such an occurrence happening again: Carole Robson, Service Manager for Prison Healthcare, will be leading on our response. The system for capturing all available healthcare information was insufficiently robust: There was no clear monitoring of obtaining a GP summary promptly to ensure medications and previous medical history could be checked as soon as possible: We now have a robust system in regard how clinical information is sought and there is a flow chart (Attachment 1) identifying team member's responsibilities to ensure consistency and follow up if required. This flowchart details the responsibility of each discipline within the team to ensure that there is a robust mechanism in place t0 ensure that Prisoners Clinical Notes are requested and followed up. flow chart details that staff have a responsibility to escalate their concerns initially to a Clinical Nurse Manager who will then in turn Iiaise with the Healthcare Manager at the specific Prison. Should the matter go unresolved that the Healthcare Manager escalate his her concerns to the next level to the Prison Healthcare Service Manager. In addition the situation will have been reported on our risk reporting system which also ensures that this information is scrutinised at a senior level within the organisation: Chair; Professor David Chiddick CBE Chief Executive; Dr Peter Miller 2 City The willl Mout Ative 015a8149

An opportunity for restarting anti-depressant medication in this case was missed_ the Clinical Director for Prisoners has reviewed the patient's case notes and has also reflected on the investigation findings: Anti-depressant medication was considered but having reviewed the clinical notes it would appear that the prescribing of anti-depressant medication was not clinically indicated. It is felt therefore that on this occasion an opportunity for restarting anti-depressant medication in this case was not missed.

Dear Ms Brown Inquest into the death of Mr Revell on 11 June 2014 whilst in HMYOI Glen Parva Thank you for your regulation 28 report of 28 April 2015 addressed to the Governor of HMYOI Glen Parva and the Chief Executive of Leicestershire Partnership Trust concerning the recent inquestinto the death of Mr Revell; Your letter has been passed to Equality, Rights and Decency (ERD) Group, the National Offender Management Service (NOMS), are responsible for policy on suicide prevention and self-harm management and for sharing learning from deaths in custody: This response is provided behalf of the Governor of HMYOI Glen Parva. As you have requested; will respond to your first six concerns in turn understand that the Chief Executive of Leicestershire Partnership Trust will be responding separately to your seventh concern: (1) Greg_had been in Glen Parva_YOLearlier the_same_year_and on that_occasion presented with a florid and_ undistinquishable liqature mark on his neck from an attempt at self-harm shortly before his imprisonment Notwithstanding this he was not_placed on an ACCL It is accepted that Mr Revell should have been placed on an Assessment Care in Custody and Teamwork (ACCT) when he first came into HMYOI Glen Parva Local policies and procedures have since been reinforced to ensure that an ACCT is opened on reception whenever there is evidence of a recent self-harm attempt: A new Safer Prisons strategy was launched in October 2014. This includes a new procedure for recording decisions made in response to the risk information on the self-harm warning form. The new procedure has been disseminated through training and briefings with reception and health care staff, who have been informed that must refer to all relevant information about newly arrived prisoners, including the Person Escort Record, and make an entry on C-Nomis to record what they have observed and decided. Healthcare staff have also be reminded t0 record this information on SystmOne (the electronic medical records system):
2) There_was confusion_amongst_prison officers_who gave_evidence_reqarding when was appropriate t0 open an AccL accordance with PSI64/2011 Safer Custody, the local Safer Prisons strategy gives clear guidance to staff on when it is appropriate to open an ACCT, All existing staff have been briefed on the strategy, and new staff will receive 'Introduction to Safer Custody' training to ensure that they are confident about this process, A new Safer Custody team is now in place to City Greg they

provide ongoing help; advice and support to staff on these matters and to monitor adherence to the strategy:
3) There was suqgestion that there would be many ACCTS' and they would be_ineffective if allprisoners with risks were_placed onan ACCL All prisoners presenting with a risk of suicide or self-harm are placed on an ACCT, regardless of the number of ACCTs that are already open in the establishment: At times when there are particularly high numbers of ACCTs the Governor will ensure that resources are reallocated to ensure that they are managed appropriately: 4 & 5) There was over-reliance_upon what the prison officers were_told bY Greq_and insuffcient emphasison previous [ecorded risk factors in documentation available to All staff have been reminded of the local policy which states that an ACCT must be opened whenever information is received to indicate that prisoner is at risk, even if the prisoner himself does not present as being at risk: Case managers have also been reminded t0 take account of all the relevant information and to have regard to the dynamic and static risk factors for the individual when carrying out case reviews, and not simply to rely on their assessment of the prisoner's presentation: This ensures that the level of risk is assessed on the basis of comprehensive information.
6) There was a culture of_over-reliance on 'others' being responsible for enquiring further _into statements regarding depression and self-harm_made by_Greg rather_than ank_focus individual responsibilitk All staff have been reminded that safer custody is everyone's responsibility, and that whenever they identify a prisoner as being at risk of suicide or self-harm must open an ACCT. hope this provides assurance that the concerns that you have identified have been addressed.