11th September 2014

Leicester Coroner’s Court, Leicester
Before Assistant Coroner Martin Gotheridge

A jury has concluded that Steven Davison died on 29th September 2013 whilst the balance of his mind was disturbed.

The jury recorded that Steven’s individual needs, risks and vulnerabilities were not properly assessed, understood or recorded between 25 and 29th September in line with the ACCT process. The jury was also critical of the lack of continuity in Steven’s care, that information was not passed on to the appropriate individuals, that the frequency and recording of observations was inadequate and that there was a failure to allocate Steven to a safer cell (a cell with no ligature points) which would have protected him and kept him safe.

Steven Davison was 21 years old when he was remanded to HMP YOI Glen Parva on 13 June 2013, for possession of an offensive weapon which he threatened to use cut his own throat. This was his first time in prison.

Steven had a long history of mental health issues, self harm and suicide attempts.  He entered the prison system with a self harm and suicide warning form highlighting his risks. The initial assessing nurse did not consider Steven to be at risk of self harm or suicide despite this information.  It emerged during the inquest that the nurse had not been trained in the Assessment, Care in Custody and Teamwork (ACCT) procedures (a system used for prisoners at risk of self harm) at the time and that she had only received the training in August 2014 by which time she had worked at the prison for 2 years.

The following day staff realised Steven’s vulnerabilities and began the ACCT process which remained in place until 6th August 2013. Steven always spoke openly of his suicidal ideations and self harm.  He regularly spoke of the support he received from his girlfriend. Staff accepted Steven’s assurances that he would not take his own life in prison  and placed an over reliance on his presentation despite the known risk factors.

On 25th September 2013 Steven self harmed by burning his arm with a cigarette lighter. An ACCT was opened. On the same day Steven’s girlfriend ended their relationship and he was also informed that his grandfather had died. Despite both these serious occurrences coming immediately after the incident of self harm; an ACCT case review was not carried out.

On 28th September there was a further occurrence of self harm and Steven was treated for cuts to his legs. His low mood was noted and he became increasingly withdrawn. An ACCT review was still not carried out. No change was made to the level or frequency of observations. 

On 29th September Steven made a short telephone call to his mother and then returned to his cell.  He should have been checked at least every 30 minutes but this did not happen. Steven was discovered by staff hanging in his cell some 45 minutes after he had been locked in his cell.

The recent HM Inspectorate of Prisons report on HMP YOI Glen Parva has been highly critical deeming the prison unsafe and unfit for purpose. It notes that there are still weaknesses in the ACCT monitoring arrangements and that some young men are not getting the support they needed.

Assistant Coroner Mr Gutheridge confirmed that he intends to make a Regulation 28 report which will be addressed not only to the prison but also to the National Offenders Management Service.

Lynda Davison, Steven’s mother said:

“Steven was let down by mental health services before he even arrived at Glen Parva. He was let down again in Glen Parva. I just wanted Glen Parva to look after him. I was pleased that Governor Clarke admitted in evidence that there were ‘clear failings and clear missed opportunities’, but it is too late for Steven.”

Deborah Coles of INQUEST said:

“Steven should never have been sent to Glen Parva when he was in fact in need of professional support for his mental health issues. He was a demonstrably vulnerable young man whose complex mental health needs could not be met by the prison system. 

“The fact of another death of an 18 year old shortly after Steven’s death in Glen Parva reinforces concerns of the way the prison manages the care and needs of vulnerable young people. It is clear that the prison has failed to act on recommendations following previous deaths.  

“The Inspectorate of Prisons’ latest report found Glen Parva to be unsafe and unfit for purpose.

“Ministers must be held to account for their collective failure to act in response to previous deaths and the fact that young people continue to die”.

Fiona Borrill, solicitor representing Steven’s family said:

“This is a highly critical conclusion to another inquest into the death of a mentally ill young man in prison which could and should have been avoided. Shocking evidence has been given as to the poor and inadequate implementation of the ACCT process which must be urgently addressed locally at Glen Parva but nationally too as tragically Steven’s death is not an isolated case.”

INQUEST has been working with the family of Steven Davison since 7 May 2014. The family is represented by INQUEST Lawyers Group members Fiona Borrill of Lester Morrill Solicitors and barrister Jude Bunting of Doughty Street Chambers.


Notes to editors:

  1. Steven’s case will be considered as part of the independent review the government has recently announced into the deaths of 18-24 year olds in prison http://www.justice.gov.uk/about/deaths-in-custody-independent-review.

  2. The Chief Inspector of Prisons report can be found at:  http://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2014/08/Glen-Parva-Web-amended-2014.pdf