“HMYOI Glen Parva 1”
Dated 28 Apr 2015, from the coroner for Leicester City and South Leicestershire. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 23 Jun 2015. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated28 Apr 2015
- Deadline23 Jun 2015
- Published on judiciary.uk28 Apr 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| HM YOI Glen Parva | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Leicestershire Partnership NHS TrustNamed in the report as “Leicestershire Partnership Trust” | Response publishedPublished on judiciary.uk in April 2015. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— HMYOI Glen Parva 1. Greg had been in Glen Parva YO! earlier the same year, and on that occasion presented with a florid and undisguisable ligature mark on his neck from an attempt at self harm shortly before his imprisonment. Notwithstanding this, he was not placed on an ACCT. 2. There was confusion amongst Prison Officers who gave evidence regarding when it was appropriate to open an ACCT. 3. There was suggestion that there would be “too many ACCTS” and they would be ineffective if all prisoners with risks were placed on an ACCT. 4. There was over reliance upon what the Prison Officers were told by Greg, and 5. _ insufficient emphasis on previous recorded risk factors in documentation available to them. 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 any focus on individual responsibility. Leicester Partnership Trust 7. 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. An opportunity for restarting anti-depressant medication in this case was missed.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2015-0165
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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