Liam Lambert
PFD Report
Partially Responded
Ref: 2016-0335
1 of 2 responded · Over 2 years old
Response Status
Responses
1 of 2
56-Day Deadline
15 Nov 2016
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
1. The ACCT document was not completed fully, did not accompany Liam around the prison as it should have and not all appropriate individuals were invited to the reviews. Available documentary information was not read or used, and pressures of time were cited to explain these failings. Consideration should be given to formally confirming that all necessary documentation has been considered prior to the ACCT review, and to ensure the Officers and Healthcare staff are aware of their responsibilities.
2. This ACCT was only open for a short period. It did not serve Liam's needs properly and was closed before any review system picked up the inadequacies.
3. The Governor provided evidence that resourcing was affecting the ability of officers to carry out their duties regarding keeping prisoners safe from self harm. In this particularly vulnerable population of young men, their safety is paramount and this should be the first consideration. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.
2. This ACCT was only open for a short period. It did not serve Liam's needs properly and was closed before any review system picked up the inadequacies.
3. The Governor provided evidence that resourcing was affecting the ability of officers to carry out their duties regarding keeping prisoners safe from self harm. In this particularly vulnerable population of young men, their safety is paramount and this should be the first consideration. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.
Responses
Response received
View full response
Dear Mrs Brown Inquest into the death of Liam Adrian John Lambert Safer Custody and Public Protection Group Naiionai Offender Management Service 4th Fioor, Ciive House, 74 Petty France, London, SW1H 9HD Thank you for your Regulation 28 Report of 16 September 2016. Your report has been passed to Safer Custody and Pubiic Protection Group in the National Offender Management Service (NOMS), as we are responsible for policy on suicide prevention and for sharing learning from deaths in prison custody. i am responding on behalf of the Secretary of State for Justice, the Chief Executive of NQMS and the Governor of HMP & YOI Glen Parva. i will address each of the matters of concern that you have raised in turn. 1 The ACCT documenf was not completed fully, did not accompany Liam around fhe prison as if should have and not all appropriate individuals were invited to the reviews. Available documentary information was not read or used, and pressures of time were cited to explain these failings. Consideration should be given to formally confirming that all necessary documentation has been considered prior fo the ACCT review, and fo ensure the officers and Healthcare staff are aware of their responsibilities. You will be aware that Prison Service Instruction 64/2011 Safer Custody sets out the relevant policy, and that chapter 5 describes the processes associated, Assessment, Care in Custody and Teamwork (ACCT) document. A Safer Custody toolkit was introduced at Glena Parva in August 2016, providing.clear local instructions that are in accordance with the national policy, In September 2016 all staff were reminded at staff briefings of the need for all ACCT documents to be completed fully, and that they should record all relevant information in the ACCT document, and in the wing observation boak and on P-NOMIS where appropriate. Staff were also reminded that ACCT documents must accompany prisoners when they mave around the prison, Management checks are now regularly undertaken to ensure that staff are correctly completing the documents, and all ACCT documents are quality assured and monitored by the Head of Safer Custody. A notice has been issued to remind staff of their responsibilities when attending ACCT case reviews, and a local template for reviews was introduced In October 2016. This prompts case managers to check that all relevant documentation is available and requires them to confirm that they have read it before undertaking the review. Anew scheduling system was also introduced in October 2016, and this will ensure that sufficien# time is allocated to all future case review meetings. 2 The ACCT was only open for a short period, !f did not serve Liam's needs properly and was closed before any review system picked up the inadequacies.
The Safer Custody toolkit that was introduced in August 2016 provides clear instructions to staff regarding ACCT procedures, including the importance of ensuring that ail relevant risks and triggers are considered before the ACCT document is closed. In September 2016 ACCT case managers were reminded of the importance of a multi- discipiinary approach to ACCT reviews, particularly when making decisions to close the document. They were also reminded to check that the ACCT care map addresses the prisoner's needs and that all the actions must be completed satisfactorily before the ACCT document is closed. Management checks are now regularly undertaken to ensure that staff correctly follow these procedures, and all ACCT documents are.quality assured and monitored by the Head of Safer Custody. The Governor is confident that the new system of more consistent management checks, introduced in July 2016, has significantly improved the implementation of the ACCT process at the prison. The two matters of concern that you have raised about the operation of the ACCT process in this case are reflected in the outcome of a national review undertaken in 2015, which found that the policy and system are sound, but that work is needed on improving compliance with policy and the quality of delivery of care, The review made 2Q recommendations, including revisions to the policy and to the form, and these are currently being addressed. We aim to complete implementation by March 2017, and will continue to monitor the pertormance of the ACCT system to ensure that the anticipated improvements are delivered. 3 The Governor provided evidence That resourcing was affecting the ability of officers to carry out their duties regarding keeping prisoners safe from self-harm. In this particularly vulnerable population of young men, their safety is paramount and this should be the first consideration. Staffing levels in public sector prisons have been set through a benchmarking process, designed to provide sufficient staff for the prison to operate safely, decently and securely. .The Governor has raised concerns about the staffing level at Glen Parva, and recently submitted a business case to increase by 12 prison officers the benchmark operating level set for the prison. This is under consideration. Moreover, the prison has frequently been operating below this level, as there are currently a number of staff vacancies, most significantly at prison officer and operational support grade levels, and these are having an impact on the regime. Where there are insufficient staff available to deliver the new benchmarked regime, proportionate curtailments to the regime are made. Staff recruitment is happening at pace to ensure that these curtailments are temporary; and we will continue to safeguard the access to activities and facilities which are important to prisoners and their rehabilitation, NOMS is committed to delivering safe, decent and secure prisons, and to identifying and supporting those at risk of suicide and self-harm. Additional funding of £10m for prison safe#y was announced in May 2015, and Glen Parva was one of a number of establishments that received extra resources, which have been used on a number of initiatives including security measures to detect mobile phones and other contraband entering the prison and partnership working with organisations providing support to prisoners, for instance in managing issues of debt. In the light of the evidence of increased violence and higher levels of self-inflicted deaths in prisons, the Secretary of State for Justice recently announced that an additional 2,500 more prison officers will be employed across the prison estate by the end of 2018. This includes an immediate investment of £14m to bring over 400 additional prison officers into ten particularly challenging prisons by March 2017. This will allow every offender to have a dedicated prison officer offering regular, one-to-one support.
The Secretary of State also announced further moves to modernise the prison estate, including the intention to seek planning permission to redevelop the site at Glen Parva to construct a new, modern prison. The current establishment will close to facilitate this redevelopment. Thank you for bringing these matters of concern to our attention. We hope that the contents of this letter have been helpful in providing some national context and assurance that the concerns that you have raised are being addressed locally at Glen Parva.
The Safer Custody toolkit that was introduced in August 2016 provides clear instructions to staff regarding ACCT procedures, including the importance of ensuring that ail relevant risks and triggers are considered before the ACCT document is closed. In September 2016 ACCT case managers were reminded of the importance of a multi- discipiinary approach to ACCT reviews, particularly when making decisions to close the document. They were also reminded to check that the ACCT care map addresses the prisoner's needs and that all the actions must be completed satisfactorily before the ACCT document is closed. Management checks are now regularly undertaken to ensure that staff correctly follow these procedures, and all ACCT documents are.quality assured and monitored by the Head of Safer Custody. The Governor is confident that the new system of more consistent management checks, introduced in July 2016, has significantly improved the implementation of the ACCT process at the prison. The two matters of concern that you have raised about the operation of the ACCT process in this case are reflected in the outcome of a national review undertaken in 2015, which found that the policy and system are sound, but that work is needed on improving compliance with policy and the quality of delivery of care, The review made 2Q recommendations, including revisions to the policy and to the form, and these are currently being addressed. We aim to complete implementation by March 2017, and will continue to monitor the pertormance of the ACCT system to ensure that the anticipated improvements are delivered. 3 The Governor provided evidence That resourcing was affecting the ability of officers to carry out their duties regarding keeping prisoners safe from self-harm. In this particularly vulnerable population of young men, their safety is paramount and this should be the first consideration. Staffing levels in public sector prisons have been set through a benchmarking process, designed to provide sufficient staff for the prison to operate safely, decently and securely. .The Governor has raised concerns about the staffing level at Glen Parva, and recently submitted a business case to increase by 12 prison officers the benchmark operating level set for the prison. This is under consideration. Moreover, the prison has frequently been operating below this level, as there are currently a number of staff vacancies, most significantly at prison officer and operational support grade levels, and these are having an impact on the regime. Where there are insufficient staff available to deliver the new benchmarked regime, proportionate curtailments to the regime are made. Staff recruitment is happening at pace to ensure that these curtailments are temporary; and we will continue to safeguard the access to activities and facilities which are important to prisoners and their rehabilitation, NOMS is committed to delivering safe, decent and secure prisons, and to identifying and supporting those at risk of suicide and self-harm. Additional funding of £10m for prison safe#y was announced in May 2015, and Glen Parva was one of a number of establishments that received extra resources, which have been used on a number of initiatives including security measures to detect mobile phones and other contraband entering the prison and partnership working with organisations providing support to prisoners, for instance in managing issues of debt. In the light of the evidence of increased violence and higher levels of self-inflicted deaths in prisons, the Secretary of State for Justice recently announced that an additional 2,500 more prison officers will be employed across the prison estate by the end of 2018. This includes an immediate investment of £14m to bring over 400 additional prison officers into ten particularly challenging prisons by March 2017. This will allow every offender to have a dedicated prison officer offering regular, one-to-one support.
The Secretary of State also announced further moves to modernise the prison estate, including the intention to seek planning permission to redevelop the site at Glen Parva to construct a new, modern prison. The current establishment will close to facilitate this redevelopment. Thank you for bringing these matters of concern to our attention. We hope that the contents of this letter have been helpful in providing some national context and assurance that the concerns that you have raised are being addressed locally at Glen Parva.
Report Sections
Investigation and Inquest
On 25~h March 2015 I commenced an investigation into the death of Liam Adrian John Lambert. The Inquest concluded on 7t" September 2016.The Jury's conclusion was: Suicide-Narrative Conclusion.(Questions and Answers).
1. Were the alleged incidents of bullying adequately recorded in all required documentation on each occasion? Answer. No. Were all appropriate persons notified to afford a proper opportunity to avoid future occurrences, such as the Acorn workshop staff? Answer. No.
2. ACCT Document. Was this fully completed with all relevant information? Answer. No. Did it accompany Liam on each occasion when he left the unit? Answer. No. Did it identify the relevant issues, needs and risks and adequately plan actions to resolve or reduce these? Answer. No. Were all appropriate individuals or organisations invited to the ACCT reviews on each occasion? Answer. No. Was it appropriate to close the ACCT on 19th March 2015? Answer. No.
3. Are there any other factors or circumstances outside the prison you feel to be relevant? Answer. Lack of family contact, bad relationship with his father in England, Liam's trouble with a restraining order with his girlfriend and the lack of contact with his family in Australia.
4. Was there a delay in identifying the discovery of Liam on evening of 19th March 2015 as requiring a code blue (emergency medical) response? Answer. Yes. If so, did that delay possibly contribute to the outcome? Answer. Yes. Was there a delay by prison staff in assisting paramedics to reach Liam's cell on that night? Answer. Yes. If so, did the delay possibly contribute to the outcome? Answer. Yes.
Cause of death: 1a Hypoxic brain injury 1 b Asphyxia 1c Hanging
1. Were the alleged incidents of bullying adequately recorded in all required documentation on each occasion? Answer. No. Were all appropriate persons notified to afford a proper opportunity to avoid future occurrences, such as the Acorn workshop staff? Answer. No.
2. ACCT Document. Was this fully completed with all relevant information? Answer. No. Did it accompany Liam on each occasion when he left the unit? Answer. No. Did it identify the relevant issues, needs and risks and adequately plan actions to resolve or reduce these? Answer. No. Were all appropriate individuals or organisations invited to the ACCT reviews on each occasion? Answer. No. Was it appropriate to close the ACCT on 19th March 2015? Answer. No.
3. Are there any other factors or circumstances outside the prison you feel to be relevant? Answer. Lack of family contact, bad relationship with his father in England, Liam's trouble with a restraining order with his girlfriend and the lack of contact with his family in Australia.
4. Was there a delay in identifying the discovery of Liam on evening of 19th March 2015 as requiring a code blue (emergency medical) response? Answer. Yes. If so, did that delay possibly contribute to the outcome? Answer. Yes. Was there a delay by prison staff in assisting paramedics to reach Liam's cell on that night? Answer. Yes. If so, did the delay possibly contribute to the outcome? Answer. Yes.
Cause of death: 1a Hypoxic brain injury 1 b Asphyxia 1c Hanging
Circumstances of the Death
Liam arrived in Glen Parva Young Offenders Institution at the beginning of February 2015. His anticipated release date was 1St April 2015. On 12~h March he caused minor deliberate self harm and an ACCT document was opened, noting that the reason for his self-harm was due to bullying on the wing. He was identified as being socially isolated as his family were living in Australia. He had no visits and made no telephone calls: an official visitor was planned but did not see him before he died. Liam was assaulted on 2 separate occasions by different individuals, despite being moved from the wing where the bullying had taken place, as these individuals were encountered in general areas of the prison estate. Proper consideration of the risks, the available intelligence and Liam's activities would have avoided these assaults. The ACCT was not fully or properly completed or utilised and was closed inappropriately. On the day Liam ligatured himself, the ACCT was closed, he later that afternoon asked for and was granted a move to a single cell. He was discovered hanging later in the evening. The emergency response of the prison officers was not according to policy, and there was a delay in assisting the ambulance crew to attend scene.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.