Glen Parva is a prison in Leicestershire which has been designated as a Young Offenders Institution and Remand Centre. It is a place where young men are held, either on remand or as sentenced prisoners.
In 2014, an inspection condemned the prison as being “unsafe” and described conditions as “unacceptable”.
The team of inspectors, led by the Chief Inspector of Prisons, Nick Hardwick (right), found high levels of violence, drugs and self-harm. They also saw evidence of rackets, where prisoners were charging “rent” for cells and threatening violence if this wasn’t paid.
In his summary, Mr Hardwick said that: “There was a direct link between the high levels of bullying and levels of self-harm,” and concluded that “Glen Parva is a concerning institution.”
Since 2010, 11 young men between the ages of 19 and 24 have taken their lives while at Glen Parva. During the past month, inquests have been held for two of them.
20-year-old Liam Lambert (left), an Australian citizen who had found himself homeless in England, was serving a 16-week prison sentence for theft. He was transferred to Glen Parva on February 4th 2015, and had been due to be released on April 1st. However, on March 19th he was found hanged in his cell. Five days later, Liam died in hospital without ever regaining consciousness.
At his inquest at Leicester Town Hall earlier this month, the jury was told by a former cellmate that Liam had built up a debt of about £50, probably due to a substance misuse habit. This was regarded as a serious debt and could lead to the debtor being beaten up or even attacked with a blade.
Dr Samuel Adcock (right), the prison GP, said he saw Liam on three occasions and prescribed him with antidepressants. Although Liam was understandably anxious and fearful, there is no mention that he was ever diagnosed with clinical depression. This would mean that the prescription of antidepressants breached NICE Guidelines, and was particularly risky if Liam had been taking other mind-altering drugs.
When questioned about staffing levels at the prison, the governor of Glen Parva, Alison Clarke (left), told the jury that a lack of resources from the Ministry of Justice prevented her staff from being able to adequately protect prisoners at risk of suicide and self-harm.
In their narrative verdict, the jury concluded that: “Liam was a victim of both physical and verbal bullying. Steps were taken to protect him, but were inadequate. Liam was socially isolated and had no visits or telephone calls with friends or family. His needs as a foreign national were identified, but not met. Liam was in debt to other prisoners that he could not afford to pay, which put him under pressure. The risk assessments that were conducted were inadequate due to insufficient use of the information available.”
Gemma Vine (right), solicitor for Liam’s family, said: “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.”
The PPO Report on Liam, published after the inquest, named the prescribed antidepressant as Citalopram, and confirmed that, at an assessment six days before his death, Liam “was talkative and the officer did not think he seemed depressed.”
This week, the inquest of 19-year-old Jake Foxall (left) took place. Jake, who was from Oxfordshire, was on remand at Glen Parva, having been charged by the police with robbery. He was not serving a prison sentence, but was detained until the trial was to be held.
Jake had been in HMP Bullingdon, Oxfordshire, for three months before being transferred to Glen Parva, more than 100km further away from home, on October 16, 2015.
His next court appearance was to be on November 9th, in Oxford. However, two days before this could happen, he was found hanged in his cell, and died in hospital on November 12th.
At his inquest, an inmate told the jury that Jake was in fear of bullies, who intended to punish him for a prison debt racked up by his cousin.
He said: “He was quite upset. Someone else told me he owed some money to someone. It was a smoking debt. The person who owed the debt was his cousin. It was worth about £15. But he was leaving to move to another prison, meaning the debt passed on to Jake. It’s not supposed to happen, but it does. And if you don’t pay it then you can be beaten up.”
In a statement read out to the jury, another Glen Parva inmate said: “I was aware that Jake was having problems with other prisoners. They were orderlies who had access to the cell area. I remember one person sprayed air freshener all over him. They used to go around switching the lights on an off from outside the cells. There was nothing you could do about it.”
Mental health nurse Deborah Davies told the court that, the day after Jake arrived at Glen Parva, she carried out an assessment on Jake and noted his suicide risk as “low”. The next day, after a self-harm incident, an “Assessment, Care in Custody and Teamwork (ACCT) Review” was opened because it was felt he was at risk.
Following an assessment of him on October 31, Nurse Davies recorded “moderate depression” and referred him to a doctor for medication. As a result, Jake was prescribed Citalopram by a prison doctor on November 4, three days before he hanged himself. The extent to which Jake was monitored in what proved to be the final week of his life was not reported at the inquest.
The jury’s summary stated that Jake was isolated during his time in Glen Parva, that the ACCT was not properly reviewed, and that the prison failed to respond appropriately to Jake’s concerns about bullying and also failed to contact his family for additional support. They concluded that Jake’s death was accidental.
After Jake’s inquest, his mother Maryann (right) said: “Jake was a lovely son and brother. His death has left a huge hole in our hearts. Bullingdon Prison called me when they had concerns about Jake. Glen Parva never did. Had they called, I believe Jake would be alive today. The prison must learn from these deaths and keep young vulnerable prisoners safe.”
Deborah Coles (left), director of INQUEST, added: “The situation at Glen Parva is a national disgrace and exemplifies a prison service in crisis. This month, INQUEST has supported two families through inquests into the deaths of their young sons, who died within eight months of each other at HMP/YOI Glen Parva. Both inquests have concluded that systemic failures to address bullying, ensure family contact and prevent self harming by these first time prisoners played a significant role in their deaths.”
It would be a mistake, however, to think that Glen Parva is unique in its failure to protect and care for its inmates.
In April, analysis of prison data by The Independent found that incidents of suicide and self-harm have risen sharply in prisons since 2010. Hanging attempts have risen from 580 recorded in 2010 to 2023 in 2015. Prison reform campaigners have raised concerns that staff and budget cuts are pushing prisons past breaking point and creating an environment of chaos and violence.
To prescribe antidepressants to prisoners is a course of action that is fraught with risks, particularly in an environment where it is becoming ever more difficult to carry out the close monitoring that is required when the prescription is initiated, changed or withdrawn.
So far this year, I have found 18 other media reports on inquests, either opened or completed, where a self-inflicted death in an English prison has been linked to the prescription of medication for depression:
Ahmedreza Fathi, 28 (Gartree). MfD. Overdose of drugs
Brian Hull, 52 (Walton). MfD. Hanged
Callum Brown, 25 (Highpoint). ADs. Hanged
Darren Hackett, 32 (Humber). Venlafaxine. Hanged
David Smith, 38 (Highpoint). ADs. Hanged
Derrick Rose-Fowler, 44 (Stoke Heath). MfD changed. Hanged
Ian Brown, 44 (Woodhill). Venlafaxine. Hanged
John Betteridge, 43 (Durham). MfD stopped. Hanged
Josh Collinson, 18 (Swinfen Hall YOI). Sertraline. Hanged
Kevin Dermott, 60 (Risley). MfD. Hanged
Levi Cronin, 26 (Highpoint). MfD. Hanged
Richard Walsh, 43 (Belmarsh). MfD. Hanged
Rodney Blair, 40 (Pentonville). Citalopram stopped. Hanged
Sarah Reed, 31 (Holloway). MfD. Strangled herself
Scott Bevan, 21 (Swansea). ADs. Hanged
Sheldon Woodford, 24 (Winchester). MfD. Hanged
Simon Hall, 36 (Wayland). Citalopram. Hanged
Steven May, 28 (Ranby). MfD. Hanged
Steven Trudgill, 23 (Highpoint). MfD. Hanged
Given that self-inflicted deaths of prisoners are rarely reported in detail, and that coroners are not keen on details of medication being revealed, it is certain that those named above form only a small proportion of the actual number of those who have taken their lives while in prison after being subjected to the inappropriate prescribing, changing or withdrawing of antidepressants.