Glen Parva criticised over Greg Revell death
A coroner has criticised a young offenders' institution for failing to identify the risk to an 18-year-old remand prisoner who hanged himself.
Greg Revell from Long Eaton, Derbyshire, died on 11 June at HMP Glen Parva in Leicestershire.
An inquest jury at Leicester Town Hall heard he was depressed and had tried to take his own life three months earlier.
The prison service said it would look at the findings to see what further lessons could be learned.
The inquest concluded Mr Revell, who had a history of self-harm, committed suicide.
The jury found his needs were not properly assessed and prison staff failed to implement a procedure called an Assessment Care in Custody Teamwork (ACCT).
The assistant coroner for Leicester and South Leicestershire, Lydia Brown, said injuries on Mr Revell's neck should have alerted staff.
The coroner also expressed concerns about a reliance on postal services to deliver Mr Revell's notes from his GP.
Speaking after the inquest, Greg's mother Karin said: "We are absolutely devastated by the lack of care and treatment for Greg.
"He was a vulnerable young man, but not one member of staff took the time to assess his vulnerabilities fully."
The inquest also heard another young man had killed himself at the prison in recent weeks.
Glen Parva was labelled unsafe by HM Inspectorate of Prisons in August 2014 following an inspection in April. Concerns were raised about bullying, linked to self-harm and suicides.
The prison has applied for funding in order to provide additional "safe cells" for vulnerable people. It currently has two.
Staff have also been given further training about when to open the ACCT process, logging details and sharing information.
The coroner is writing to Glen Parva and HM Inspectorate of Prisons to express her concerns relating to Mr Revell's care at the prison.
A prison service spokeswoman said: "Every death in custody is a tragedy which is why reducing the number of self-inflicted deaths is a priority.
"We will carefully consider the findings of the inquest to see what further lessons can be learned in addition to the Prisons and Probation Ombudsman's investigation."