PFD report

Greg Revell · Prevention of Future Deaths report

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Issued 28 Apr 2015•Leicester City and South Leicestershire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
9

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Insufficiently robust and timely capture of available healthcare information
    Part of recurring concern: Unreliable access to relevant clinical records for safe care
  2. Over-reliance on prisoners’ accounts instead of previous recorded risk factors
    Part of recurring concern: Failure to investigate concerning presentations beyond initial appearance and self-reportPart of recurring concern: Unreliable safety risk assessments for prisoners
  3. Over-reliance on others to make further enquiries about statements of depression and self-harm
    Part of recurring concern: Failure to investigate concerning presentations beyond initial appearance and self-reportPart of recurring concern: Ineffective prison suicide and self-harm prevention systems
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.9

  1. Action

    Implement a robust clinical-information process with documented responsibilities, follow-up, escalation and senior risk-system scrutiny for obtaining prisoners’ clinical notes.

    Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 April 2015.
  2. Action

    Brief existing staff and provide new staff with Safer Custody training on when to open an ACCT.

    Stated by Glen Parva Young Offender InstitutionStated plannedThe respondent said that this action was planned when they made their response on 28 April 2015.
  3. Action

    Place every prisoner presenting a suicide or self-harm risk on an ACCT, regardless of the number already open.

    Stated by Glen Parva Young Offender InstitutionStated completedThe respondent said that this action was complete when they made their response on 28 April 2015.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unreliable access to relevant clinical records for safe care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to investigate concerning presentations beyond initial appearance and self-report; Unreliable safety risk assessments for prisoners.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to investigate concerning presentations beyond initial appearance and self-report; Ineffective prison suicide and self-harm prevention systems.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Ineffective prison suicide and self-harm prevention systems.

Open source report

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 a robust clinical-information process with documented responsibilities, follow-up, escalation and senior risk-system scrutiny for obtaining prisoners’ clinical notes.

Verbatim wording from the response

“We now have a robust system in regard how clinical information is sought and there is a flow chart (Attachment 1) identifying team member's responsibilities to ensure consistency and follow up if required. This flowchart details the responsibility of each discipline within the team to ensure that there is a robust mechanism in place to ensure that Prisoners Clinical Notes are requested and followed up.”

Source location

2015-0165-Response-by-Leicestershire-Partnership-NHS-Trust
Page 1 · response
Published 28 April 2015

Open published response

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
Page 1 · response
Published 28 April 2015

Open published response

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
Page 2 · response
Published 28 April 2015

Open published response

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
Page 1 · response
Published 28 April 2015

Open published response

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
Page 2 · response
Published 28 April 2015

Open published response

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
Page 2 · response
Published 28 April 2015

Open published response

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
Page 2 · response
Published 28 April 2015

Open published response

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
Page 1 · response
Published 28 April 2015

Open published response

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
Page 1 · response
Published 28 April 2015

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The opportunity to restart antidepressant medication was not missed because prescribing was not clinically indicated.

    Stated by Leicestershire Partnership NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The opportunity to restart antidepressant medication was not missed because prescribing was not clinically indicated.

Verbatim wording from the response

“An opportunity for restarting anti-depressant medication in this case was missed.”

Source location

2015-0165-Response-by-Leicestershire-Partnership-NHS-Trust
Page 2 · response
Published 28 April 2015

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026