7th September 2016

Before HMAC Mrs Lydia Brown
At Leicester Coroner’s Court, Town Hall, Leicester.

The inquest into the death of Liam Lambert concluded today finding that there was a succession of serious and inadequate responses by prison staff which contributed to his death.

Liam grew up in Australia where he lived with his mother, step father and brother.  Aged 18 he moved to the UK to form a relationship with his estranged father.  That relationship broke down. Liam became homeless and misused drugs and alcohol.  He was sentenced to 16 weeks in prison arriving in HMYOI Glen Parva on 4 February 2015.  He was found hanging in his cell on 19 March and was transferred to hospital. Liam died on 24 March 2015.  He was 20 years old.

Over the course of the week the jury heard evidence that Liam was a kind and genuine person unaccustomed to the prison setting. Liam had no immediate support network as his family were in Australia. He was completely dependant on the prison staff to protect him.

Liam had reported being bullied on a number of occasions which continued despite a wing move.  He self harmed resulting in the opening of an ACCT (a prison self harm and suicide prevention scheme). However, the ACCT was closed on review by one prison officer rather than a multi agency review in line with official guidance. 

A paramedic gave evidence that there was an “unnatural delay” and lack of urgency in escorting them to Liam in his cell.  He completed an incident report following hand over to the hospital to raise his concerns.

When questioned about the adequacy of staffing levels, HMYOI Glen Parva Governor, Alison Clarke, admitted that a lack of resources from the Ministry of Justice prevented staff from being able to adequately protect prisoners at risk of suicide and self harm.

Concluding the inquest the jury recorded that:

  • There were inadequate steps to protect Liam from on going bullying.
    • Liam was socially isolated and his needs as a foreign national, whilst identified, were not met.
    • Risk assessments were inadequate and the ACCT should not have been closed on 19 March 2015. 
    • The delay in calling for an emergency response on discovering Liam and the delay in assisting paramedics to reach Liam contributed to the outcome.

The Coroner will be issuing a prevention of future deaths report noting the Governor’s comments regarding a lack of resources and that whilst efforts have been made to improve record keeping this is insufficient if they are not read and acted upon.

Terri and David, Liam’s mother and step father said:  

Liam had no history of self-harm or significant drug use in Australia, and we have been stunned to hear of the path his life took on moving to the UK.Prison staff are in incredibly important positions of responsibility for the vulnerable young men in their care. From the evidence that we have heard in this inquest we believe some of those staff were plainly unfit for those positions.

We had hoped that the same mistakes in Liam’s case would not be repeated however we are seriously concerned to hear that there have been two further deaths since Liam passed away. We hope that further steps are taken to hold those involved accountable, as had mistakes not occurred, Liam may still be with us today. He was much loved and will be forever missed.”

Deborah Coles, Director of INQUEST said:

Sending a vulnerable homeless young man to prison for 16 weeks cost him his life.  Liam is one of 11 self-inflicted deaths at the prison since 2010. These all too familiar failings are repeated time and again. It is clear that recommendations from previous deaths and Inspectorate reports have gathered dust and young people continue to die as a result.”

Gemma Vine, Solicitor for the family said:

“This is a deeply tragic case involving the death of a highly vulnerable young man whilst a prisoner at HMP/YOI Glen Parva which could have and should have been avoided. Liam’s death echoes the repeated failings highlighted in previous inquests involving deaths within this establishment and identifies serious flaws in the management of prisoners who are at risk of suicide, self harm and bullying. The systems that are currently in place are failing to protect the young men in their care and these deaths will keep occurring until the appropriate action is taken by the prison to make necessary changes.

INQUEST has been working with the family of Liam Lambert since his death in 2015. His family are represented by INQUEST Lawyers Group members Gemma Vine and Charles Myers from Lester Morrill solicitors and barrister Jude Bunting of Doughty Street Chambers.


Notes to editors:

  1. Jake Foxall died 8 months after Liam Lambert at HMYOI Glen Parva.  The inquest is due to start on Thursday 8 September. See here


  1. Jamie Robert died at Glen Parva on 12 August 2016.  The inquest has been opened and adjourned for further investigations. 


  1. Table of self inflicted deaths in Glen Parva since 2010

First Name

Last Name

Date of Death














































Source: INQUEST Casework and monitoring

  1. The number of self inflicted prison deaths (England and Wales) has continued to rise over the past five years: 58 in 2011, 61 in 2012, 76 in 2013, 88 in 2014, 88 in 2015 and 73 already in 2016.
    See INQUEST statistics here.


  1. In February 2014 the Government announced an independent review chaired by Lord Harris into the self inflicted deaths of 18 to 24 years.  The report was published in July 2015 with 108 recommendations, see here
    INQUEST submission to the Review can be found here.

The Government’s response to the report can be found here.


  1. The latest HM Inspectorate of Prison’s reports can be foundhere:  
    HMYOI Glen Parva inspection report can be viewed here.