20 Nov 2019 Mr Gary Leyland · Prevention of Future Deaths report Manchester North
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Concerns raised 8 Failure to redirect concerns or contact the person's GP View source Failure to update handover information about expected welfare checks View source Failure to maintain complete and reliable welfare-check records View source Lack of a staff policy for responding to self-harm or suicide issues View source Lack of a policy directing staff where to raise clearly present non-imminent concerns View source Failure to contact relevant medical or mental health services about identified concerns View source Lack of training and information for security staff on self-harm and suicide risk View source Failure to conduct updated risk assessments View source See 5 more concerns
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AI-generated summary
Mr Gary Leyland · 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
Mr Gary Leyland was found deceased in his supported accommodation on 13 November 2019 after taking excessive prescribed medication, with the inquest conclusion recording suicide and morphine toxicity. Concerns included failures to contact medical or mental health services after suicidal thoughts were disclosed, poor documentation and handover information, the use of security staff for welfare checks without clear evidence of training, and the absence of an updated risk assessment.
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 Jigsaw Homes Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to redirect concerns or contact the person's GP
Wider context from the report “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 brand of Jigsaw Homes which provided the Spring Street accommodation ) must comply with certain policies which included risk assessment and risk management and Safeguarding Adults. However no evidence was provided to the Court as to any self-harm or suicide policy available to staff relating to how they should 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.
” 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 Jigsaw Homes Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to update handover information about expected welfare checks
Wider context from the report “2. Only the handover sheets for the 7th and 8th November were updated to advise staff to “keep an eye” 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 10th and 11th November (weekend) would have been able to expect to check on Mr Leyland.
” 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 Jigsaw Homes Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain complete and reliable welfare-check records
Wider context from the report “1. 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 log was completed in some instances with the use of an X as opposed to the staff members initials so it was not clear if he had been seen and if so by whom.
” 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 Jigsaw Homes Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a staff policy for responding to self-harm or suicide issues
Wider context from the report “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 brand of Jigsaw Homes which provided the Spring Street accommodation ) must comply with certain policies which included risk assessment and risk management and Safeguarding Adults. However no evidence was provided to the Court as to any self-harm or suicide policy available to staff relating to how they should 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.
” 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 Jigsaw Homes Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy directing staff where to raise clearly present non-imminent concerns
Wider context from the report “1. 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 a policy within the Probation for staff vindicating 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.
” 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 Jigsaw Homes Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to contact relevant medical or mental health services about identified concerns
Wider context from the report “1. 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 a policy within the Probation for staff vindicating 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.
” 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 Jigsaw Homes Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of training and information for security staff on self-harm and suicide risk
Wider context from the report “3. 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.
” 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 Jigsaw Homes Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct updated risk assessments
Wider context from the report “4. The Court heard there was no updated risk assessment conducted as was envisaged following the email from the Probation Service.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations