Concerns raised 6 Premature closure of ACCTs before identified inadequacies are detected and needs are properly served View source Failure of the ACCT document to accompany prisoners around the prison View source Failure to read and use available documentary information in ACCT reviews View source Insufficient resourcing for officers’ duties to keep prisoners safe from self-harm View source Failure to complete ACCT documentation fully View source Failure to invite all appropriate individuals to ACCT reviews View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Liam Adrian John Lambert · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Liam Adrian John Lambert was a young offender at Glen Parva Young Offenders Institution who died after ligaturing himself in a single cell on the evening of 19 March 2015. The report identified concerns about bullying and assaults, inadequate completion and use of the ACCT self-harm documentation, its inappropriate closure, prison resourcing, and delays in the emergency response and access for paramedics.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glen Parva Young Offender Institution; that does not assign responsibility.
PFD Monitor interpretation Premature closure of ACCTs before identified inadequacies are detected and needs are properly served
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glen Parva Young Offender Institution; that does not assign responsibility.
PFD Monitor interpretation Failure of the ACCT document to accompany prisoners around the prison
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glen Parva Young Offender Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to read and use available documentary information in ACCT reviews
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glen Parva Young Offender Institution; that does not assign responsibility.
PFD Monitor interpretation Insufficient resourcing for officers’ duties to keep prisoners safe from self-harm
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glen Parva Young Offender Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to complete ACCT documentation fully
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glen Parva Young Offender Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to invite all appropriate individuals to ACCT reviews
Wider context from the report “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.
” Open source report
Concerns raised 4 Insufficiently robust and timely capture of available healthcare information View source Over-reliance on prisoners’ accounts instead of previous recorded risk factors View source Over-reliance on others to make further enquiries about statements of depression and self-harm View source Failure to consistently open ACCTs for prisoners presenting with self-harm or other risks View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Greg Revell · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Greg Revell was found hanging in his cell at HM YOI Glen Parva, and resuscitation was unsuccessful. The concerns included that a previous ligature self-harm attempt did not lead to an ACCT, uncertainty among prison officers about when to open an ACCT, insufficient consideration of recorded risk factors, and weaknesses in capturing healthcare information and obtaining a GP summary.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glen Parva Young Offender Institution; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust and timely capture of available healthcare information
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glen Parva Young Offender Institution; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on prisoners’ accounts instead of previous recorded risk factors
Wider context from the report “4. There was over reliance upon what the Prison Officers were told by Greg, and insufficient emphasis on previous recorded risk factors in documentation available to them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glen Parva Young Offender Institution; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on others to make further enquiries about statements of depression and self-harm
Wider context from the report “5. 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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glen Parva Young Offender Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently open ACCTs for prisoners presenting with self-harm or other risks
Wider context from the report “1. Greg had been a prisoner at Glen Parva YOI earlier the same year, and on that occasion presented with a florid and undiagnosable 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.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Brief existing staff and provide new staff with Safer Custody training on when to open an ACCT.
Verbatim wording from the response “In 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” Source location 2015-0165-Response-by-NOMS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Place every prisoner presenting a suicide or self-harm risk on an ACCT, regardless of the number already open.
Verbatim wording from the response “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.” Source location 2015-0165-Response-by-NOMS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Safer Prisons recording procedure and train reception and healthcare staff to document risk information and decisions in O-Nomis and SystmOne.
Verbatim wording from the response “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 they must refer to all relevant information about newly arrived prisoners, including the Person Escort Record, and make an entry on O-Nomis to record what they have observed and decided. Healthcare staff have also been reminded to record this information on SystmOne (the electronic medical records system).” Source location 2015-0165-Response-by-NOMS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reallocate resources when ACCT numbers are particularly high to ensure they are managed appropriately.
Verbatim wording from the response “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.” Source location 2015-0165-Response-by-NOMS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff to open an ACCT whenever information indicates suicide or self-harm risk, even when the prisoner does not appear at risk.
Verbatim wording from the response “All staff have been reminded of the local policy which states that an ACCT must be opened whenever information is received to indicate that a prisoner is at risk, even if the prisoner himself does not present as being at risk. Case managers have also been reminded to 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.” Source location 2015-0165-Response-by-NOMS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind case managers to consider comprehensive dynamic and static risk information during individual case reviews.
Verbatim wording from the response “All staff have been reminded of the local policy which states that an ACCT must be opened whenever information is received to indicate that a prisoner is at risk, even if the prisoner himself does not present as being at risk. Case managers have also been reminded to 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.” Source location 2015-0165-Response-by-NOMS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce reception procedures requiring an ACCT to open when a recent self-harm attempt is identified.
Verbatim wording from the response “(1) Greg had been in Glen Parva YOI earlier the same year, and on that occasion presented with a florid and distinguishable ligature mark on his neck from an attempt at self-harm shortly before his imprisonment. Notwithstanding this, he was not placed on an ACCT.
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.” Source location 2015-0165-Response-by-NOMS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a Safer Custody team to advise and support staff and monitor adherence to the Safer Prisons strategy.
Verbatim wording from the response “In 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” Source location 2015-0165-Response-by-NOMS
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations