Liam Adrian John Lambert · Prevention of Future Deaths report

On 25th March 2015 I commenced an investigation into the death of Liam Adrian John Lambert.
The Inquest concluded on 7th 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.

Liam arrived in Glen Parva Young Offenders Institution at the beginning of February 2015. His anticipated release date was 1st April 2015. On 12th 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.

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.