UK Inquiry Tracker

Gary Leyland

PFD Report Partially Responded Ref: 2019-0395

Date of Report 20 November 2019

Coroner Joanne Kearsley

Coroner Area Manchester (North)

Response Deadline est. 22 February 2020

Alcohol, drug and medication related deaths Suicide (from 2015)

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

The probation service failed to refer mental health concerns to medical practitioners. Supported accommodation exhibited poor documentation, unclear welfare check protocols for security staff, and inadequate risk assessment updates, without policy for GP contact.

View full coroner's concerns

National Probation Service Due to the fact Mr Leyland was residing in supported accommodation the Probation Officer reported her concerns to the Spring Street_ However no attempt was made to contact any medical practitioner ie GP or mental health services. It was unclear at the conclusion of the Inquest whether there is policy within the Probation for staff indicating to whom concerns should be raised for example if Mr Leyland had been residing in his own home and where the risk is not believed to be imminent although clearly present: Jigsaw Home Group Documentation_and_Recording_of_Information during the course of the Inquest_the Court was provided with and taken to various documents and records relating to Mr Leyland. The Court found the recording and documentation to be of a poor quality and standard. The chronology document was not complete , information as to when Mr Leyland had been seen was missing The observational iog was completed in some instances with the use of an X as opposed to the staff members initials so it was not clear jf he had been seen and if so by whom: Only the handover sheets for the 7"h and 8" November were updated to advise staff to "keep an on Mr Leyland. NO updates were on the handover sheets for the 9-12th November despite the evidence being welfare checks would still have been expected on these dates It is therefore unclear how security staff working the and 11th November (weekend) would have been aware of the expectation to check on Mr Leyland: The fact that the expectation was security staff would be expected to conduct welfare checks at a weekend was heard for the first time in evidence. There was no evidence as to how they are trained; what information is provided to them about self -harm and the risk of suicide. This practice was of grave concern to the Court Ghe Court heard there was no updated risk assessment conducted as was envisaged following the email from the Probation Service Welfare Responsibility and Suicide Prevention
5. The Court heard evidence that Oldham Council who commissioned the supported accommodation through Jigsaw Homes Group_ The Court heard evidence part of the contract provision for the service includes the fact that Threshold the branch of Jigsaw Homes which provided the Spring Street accommodation must comply with certain policies which included risk assessment and risk and Safeguarding Adults_ However no evidence was provided to the Court as to any seanaaem entsaicddeapogagraallabllts staovreleing @ Couetey shouid deal with such issues-which may arise. In this case Spring Street clearly took responsibility by virtue of their plan (welfare checks; update risk assessment etc) for Mr Leylands welfare once they were put on notice of the Probation Service concerns_ No attempt was made to re-direct the Probation Service to another agency ie Mr Leylands GP nor was any attempt made by Spring Street to contact Mr Leylands GP_

Responses

HM Prison and Probation Service Central Government

17 Jan 2020

Action Planned
The National Probation Service (NPS) launched its Health & Social Care Strategy 2019-22, along with a Suicide Prevention Strategy Action Plan, to support collaborative and multi-agency working. (AI summary)

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Dear Senior Coroner, INQUEST INTO THE DEATH OF MR GARY LEYLAND Thank you for your Regulation 28 Report dated 20 November, addressed to the Chief Executive Officer. Her Majesty's Prison & Probation Service is grateful for the observations in your report: You raised a concern relating to suicide prevention and policy on notification of concerns by probation staff to providers of health and social care_ know that a significant number of offenders leaving custody on licence will find it difficult to meet the challenge of returning to the community. National Probation Service (NPS) is committed to doing everything it can to try to safeguard vulnerable individuals. Recognising that there was scope to enhance the arrangements we had in place, in June last year the NPS launched its Health & Social Care Strategy 2019-22_ Together with the accompanying Suicide Prevention Strategy Action Plan, we believe this will directly contribute to Government's commitment to reduce the number of self-inflicted deaths. The Strategy supports the need for collaborative and multi-agency working to deliver holistic care and support through partnership working across the health and criminal justice systems at national, regional and iocal levels hope this provides the assurance you were seeking of the NPS's commitment to addressing the needs of vulnerable offenders.

Sent To

HM Prison and Probation Service
Jigsaw Homes Group

Response Status

Linked responses 1 of 2

56-Day Deadline 22 Feb 2020

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On the 18th November 2019 concluded the Inquest into the death of Mr Leyland who died on the 13th November 2018 at The medical cause of death was recorded as 1a) Morphine toxicity The conclusion was Mr Leyland died as a result of suicide_

Circumstances of the Death

The accommodation Mr Leyland was residing in was supported accommodation (herein referred to as "Spring Street"): He had been placed in this accommodation following his release from Prison in April 2018. Whilst not directly relevant to the Inquest; Mr Leyland had a number of physical health issues which meant he used mobility scooter to mobilise_ In addition to his physical health issues the Court also heard evidence Mr Leyland had longstanding history of depression and had on occasions made comments referring to there being no 'going on passing From April 2018 until the time of his death the Court heard Mr Leyland had Probation Officer and subject to supervision. was On the zh November 2018 Mr Leyland was visited at Spring Street by his Probation Officer: She noted he was low in mood and during the meeting he disclosed that he was having thoughts of suicide He also indicated that the next few months would be difficult for him. Mr Leyland had suffered number of bereavements the most recent being that of his wife It was approaching the anniversary of her diagnosis of cancer , Mr Leyland told his Probation Officer there were times when he could; "just take all of his tablets. Whilst the Probation Officer gave evidence to the Court that she did not believe there was an imminent risk to his life the Court found that she clearly had concerns_ Her subsequent actions indicated there was a concern as to the risk he posed to himself. When leaving Mr Levland his Probation Officer spoke to staff at Spring Street to advise them of Mr Leylands presentation: In addition she emailed his allocated worker later the same day: In her email she advised the Spring Street staff of the fact Mr Leyland was Of low mood and that he was "thinking of taking a handful & tablets_ She concludes the email by advising she will try and get in touch with GP and asks if can "keep an eye on him" The Court heard from Mr Leylands GP that no contact was made with him by any agency: Following the email the Probation Officer Manager at Spring Street increased the checks on Mr Leyland to one_per shift ie am, pm_and evening: The_Court_heard_evidence_that the expectation was that Gary point his they from these checks would be welfare checks and would therefore Iinvolve meaningful interaction with Mr Leyland. The Court heard evidence that over the weekend (the 10th and 11th November) any checks would be corducted by the Security staff who were contracted to conduct security checks on the building Whist there was evidence before the Court that Mr Leyland was seen on a number of occasions between the 8" and the 12" November 2018 the Court found the majority were not meaningful welfare checks_ On the 12"h November the checks were stepped down to once in hours which was the normal observational level. Mr Leyland was found deceased in his room on the 13"h November having taken an excess of his prescribed medication: There was evidence Mr Leyland had intended to end his life_

Action Should Be Taken

In opinion action should be taken to prevent future deaths and believe each of you respectively my have the power to take such action eye" 10th