Glen Parva has 'lessons to learn' after prisoner Steven Davison's death

Steven Davison Steven Davison, from Loughborough, initially went to Glen Parva on remand on 13 June 2013

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A young offender institution has "lessons to learn" after a man with a history of mental health problems killed himself, a report has said.

An inquest jury found on Thursday that Steven Davison, 21, took his life at YOI Glen Parva, Leicestershire, while the balance of his mind was disturbed.

The Prisons and Probation Ombudsman recommended staff are better trained to manage inmates at risk of suicide.

The prison has put in place some of the report's recommendations, it said.

'Troubled young man'

Ombudsman Nigel Newcomen criticised staff for relying on Davison's assurances that he would not kill himself, despite several incidents which, he said, should have triggered a review of his level of risk.

"The man was evidently a very troubled young man and, while he had access to mental health services at Glen Parva, the investigation found that the identification and management of his risks were poor," he wrote.

Davison, who had attempted suicide many times, including an overdose just a week before his arrest, was arrested on 13 June 2013 for possession of a knife after threatening to cut his throat.

Mr Newcomen said it was "difficult to see" how reception staff and a nurse who carried out his initial health assessment failed to identify him as being at risk of suicide or self-harm.

Glen Parva Steven Davison had not been in custody before his time at Glen Parva

Suicide prevention procedures were not started until 25 September when he deliberately burned himself.

The same day, after a telephone conversation in which his girlfriend ended their relationship and told him his grandfather had died, his level of risk was not reviewed.

Three days later an officer noticed he had made cuts to his legs but there was still no review.

The next day he was found hanging in his cell.

The jury at his inquest concluded that transferring him to a safe cell the day before he died "would have protected Steven and kept him safe."

Mr Newcomen said he should have been checked at least every 30 minutes but his monitoring document showed he was left for nearly an hour before his body was discovered.

"There are clearly lessons for Glen Parva to learn from this tragic case about the management of risk when receiving new prisoners and adhering to the requirements of the suicide and self-harm prevention procedures," Mr Newcomen said.

The report said the prison, which last month was branded "unsafe" by inspectors, has taken on the ombudsman's recommendations including producing clear guidance about procedures for identifying at-risk prisoners and supporting them on arrival.

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