Glen Parva suicidal detainee 'not kept safe'
A man with mental health problems killed himself at a young offenders institute after he was wrongly judged "low risk" and was inadequately monitored, an inquest jury has decided
Steven Davison died in YOI Glen Parva, Leicestershire, where he was detained after threatening to stab himself.
A jury at Leicester Coroner's Court concluded he killed himself while the balance of his mind was disturbed.
The institute was branded "unsafe" in August by prison inspectors.
The jury made its conclusions in a narrative verdict on the death of the 21-year-old father-of-one.
His mother, Lynda Davison, said her son had warned officials when he was sent to Glen Parva in July 2013 he would kill himself.
Staff at the institute, south of Leicester, assessed him as low risk days before he killed himself, despite several warnings and "trigger" events including the death of his grandfather and the break up of his relationship.
The four-day hearing in Leicester was told there was no mental health assessor at a meeting to review his risk of self-harm and only his case manager was present.
Staff and mental health experts also failed to share information and three days before his death his risk was recorded as low, the court heard.
A jury of six men and four women concluded that this judgement "was not justified".
They said the frequency and recording of prison staff's observations of Mr Davison to check he was safe were "inadequate".
It added: "On September 28 [the day before he died], transferring Steven to a safe cell would have protected Steven and kept him safe."
Speaking after the hearing, his father Jeffrey Davison, 63, said: "The jury made the right decision. The staff at the prison didn't do their jobs and neither did the mental health team.
"Glen Parva has to make changes because they can't keep putting families through this."
Mr Davison had originally been arrested for possession of an offensive weapon after threatening to kill himself.
His mother said: "When he was sentenced, he said in court he would kill himself.
"The judge said he would have to go [to Glen Parva] because there were no mental health beds so he would have to go on suicide watch."
Glen Parva governor Alison Clarke gave evidence to the coroner - which he will use to make recommendations to the Ministry of Justice - while the jury was considering its conclusions
Speaking about the continuity of care in Glen Parva she said changes had been made in the way staff work, but she added: "What happened was not acceptable."
Earlier this year, HM Inspectorate of Prisons concluded there were high levels of self harm and bullying and an "unacceptable attitude among some staff" at the institute.
Mr Davison was one of two men at Glen Parva to kill themselves in 2013. There have been 26 suicides at the unit since 1988.