David Glass

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Independent investigation into
the death of Mr David Glass,
a prisoner at HMP Altcourse,
on 20 February 2024
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2026
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr David Glass was found hanging in his cell at HMP Altcourse on 20 February 2024. He
was taken to hospital but was pronounced dead on arrival. He was 48 years old. I offer my
condolences to Mr Glass’ family and friends.
Mr Glass was the seventh prisoner to take his own life at Altcourse in three years. Up to
the end of July 2024, there has been one further self-inflicted death at the prison.
Mr Glass was being held in the segregation unit when he was found hanging. He was
refusing to move back to a standard wing because he said he was under threat from other
prisoners. We are satisfied that Mr Glass gave no indication to staff that he was at
imminent risk of suicide. However, we consider that staff could have done more to explore
Mr Glass’ concerns about being under threat. I have asked the Director to review
Altcourse’s violence strategy so that more guidance is available to staff on dealing with
alleged threats of violence.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman November 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
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Summary
Events
1. On 29 November 2023, Mr David Glass was sentenced to one year in prison for
assault. He was sent to HMP Altcourse. It was not his first time in prison.
2. Mr Glass had a history of substance misuse and had anxiety and depression. When
he arrived at Altcourse, Mr Glass told staff he had attempted suicide by taking an
overdose in the past but had no current thoughts of suicide or self-harm.
3. Mr Glass was reviewed by a mental health nurse and a substance misuse worker.
Neither had any concerns.
4. On 12 December, Mr Glass told a prison custody officer (PCO) that he was affiliated
with a gang and had problems because of selling drugs and being in debt.
5. On 9 February 2024, prison staff found Mr Glass with an improvised weapon. Staff
put Mr Glass on report (a disciplinary charge), and confined him to a cell on his
own, while he waited for an adjudication (a prison’s version of a court hearing.)
6. The next day, Mr Glass told the adjudicator that the weapon was for self-defence.
He said someone had come to his cell and threatened him. The adjudicator found
Mr Glass guilty of breaking prison rules and gave him seven days’ cellular
confinement as punishment. Staff moved Mr Glass to the segregation unit.
7. On 16 February, Mr Glass refused to go back to his previous unit and was placed
on report again for refusing a lawful order. The next day, at his adjudication, Mr
Glass told the adjudicator that other prisoners had accused him of being a sex
offender and he was going to be assaulted. (Mr Glass did not have a conviction for
a sexual offence.)
8. Mr Glass said he was willing to move to the vulnerable prisoners’ unit (VPU) but
would not move to any other unit. The adjudicator rejected Mr Glass’ request to
move to the VPU and found Mr Glass guilty. As punishment Mr Glass was given a
further seven days’ cellular confinement and remained in the segregation unit.
9. At 8.23am on 20 February, two PCOs, a nurse and a chaplain went to Mr Glass’ cell
to conduct a welfare check and deliver breakfast. Staff found Mr Glass with a
ligature around his neck, which he had tied to the TV stand on his wall. Staff
immediately entered the cell. The PCOs cut the ligature, radioed a medical
emergency code and started CPR.
10. At 8.37am, paramedics arrived and continued CPR. They found faint signs of life
and took Mr Glass to hospital. However, Mr Glass was pronounced dead on arrival
at 9.38am.
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Findings
11. We are satisfied that Mr Glass gave no indication to staff at Altcourse that he was at
risk of suicide or self-harm and that they could not have foreseen his actions.
12. We consider that staff did not do enough to explore Mr Glass’ concerns about being
under threat. Although Altcourse has a Violence Strategy, it provides very little
guidance to staff on how to support and manage victims of bullying, intimidation, or
violence.
13. Mr Glass was held in segregation for 11 days but did not have an Initial Segregation
Review Board throughout that time. The prison told us that as Mr Glass was held
under cellular confinement, he did not require one. Segregation policy was updated
two years ago to say that staff should hold an Initial Segregation Review Board for
any prisoner held in segregation for more than 72 hours regardless of the Prison
Rule under which they are held.
Recommendations
• The Director should review the prison’s Violence Strategy so that it provides clear
guidance to staff on how to identify and support prisoners at risk of bullying,
intimidation, or violence.
• The Director should ensure that:
• staff hold an Initial Segregation Review Board within the first 72 hours of
segregation irrespective of which Prison Rule a prisoner is segregated under;
and
• all relevant segregation paperwork is updated to reflect the changes outlined in
the June 2022 Security Briefing Note on Segregation.
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The Investigation Process
14. HMPPS notified us of Mr Glass’ death on 20 February 2024.
15. The investigator issued notices to staff and prisoners at HMP Altcourse informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
16. The investigator visited Altcourse on 7 March. He obtained copies of relevant
extracts from Mr Glass’ prison and medical records. He also obtained CCTV and
Ambulance Service records. He obtained further information from the Deputy Head
of Safety and the Head of Reducing Reoffending.
17. The investigator interviewed four members of staff at Altcourse on 7 March and 23
May. In May, June and July, he interviewed a further two staff and one prisoner
over telephone and video call.
18. NHS England commissioned an independent clinical reviewer to review Mr Glass’
clinical care at the prison. The clinical reviewer and investigator conducted joint
interviews with two members of healthcare staff in July by video call.
19. We informed HM Senior Coroner for Liverpool of the investigation. We have sent
the Coroner a copy of this report.
20. The Ombudsman’s office contacted Mr Glass’ mother to explain the investigation
and to ask if she had any matters she wanted us to consider. Mr Glass’ mother
raised no issues and asked for a copy of this report.
21. We shared our initial report with HMPPS. They pointed out factual inaccuracies,
which has been amended in this report.
22. We sent a copy of our initial report to Mr Glass’ family and their solicitor. The
family’s solicitor pointed out some factual inaccuracies, which have been amended
in the report. The family’s solicitor raised some other concerns, which have been
addressed in a separate letter.
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Background Information
HMP Altcourse
23. HMP Altcourse is a local prison in Liverpool, which receives sentenced and
remanded adult male prisoners and young offenders from the Cheshire and
Merseyside courts. About half the population are on remand or serving very short
sentences. Sodexo took over management of the prison from G4S in June 2023.
24. Practice Plus Group provides primary healthcare services at Altcourse. Mersey
Care provides mental health services. Phoenix Futures provides non-clinical
substance misuse services.
HM Inspectorate of Prisons
25. The most recent inspection of HMP Altcourse was in November 2021. At the time of
inspection Altcourse was run by G4S.
26. Inspectors noted that prisoners’ safety was not sufficiently good and had
deteriorated since the last inspection in 2017. Eight prisoners had taken their own
lives; four in the previous 12 months. Levels of self-harm remained high and Early
Learning Reviews had not been transferred into longer term safety plans. Staffing
numbers had a detrimental impact on the development of primary and mental health
care.
27. Staff-prisoner relationships remained a real strength. Inspectors observed
supportive and caring interactions between staff and prisoners across all units. Key
work took place more frequently than in similar prisons and was of a better
standard.
Independent Monitoring Board
28. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to July 2023, the IMB reported that
staff shortages had impacted on the prison. Incidents of self-harm had risen.
Previous deaths at HMP Altcourse
29. Mr Glass was the twentieth prisoner to die at Altcourse since February 2021. Of the
previous deaths, six were self-inflicted, 11 were from natural causes and two were
drug related. Up to the end of July 2024, there has been one further self-inflicted
death and two from natural causes.
30. Following a self-inflicted death at Altcourse in April 2021 (under G4S management),
we recommended that the Director should ensure that staff identified and managed
prisoners at risk of bullying, intimidation, or violence in line with the prison’s violence
reduction policy.
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31. We were told that the prison planned to deliver Challenge, Support, and
Intervention Plan (CSIP) training and awareness sessions for all operational staff in
April 2022. The training would address the key principles of CSIP, the referral
process and the requirements of staff when managing at risk prisoners. It would
also ensure staff were aware that the CSIP process must be considered as a tool to
support all apparent victims of violence, bullying and intimidation.
Key worker scheme
32. The key worker scheme is a key part of HMPPS’s response to self-inflicted deaths,
self-harm, and violence in prisons. It is intended to improve safety by engaging with
people, building better relationships between staff and prisoners, and helping
people settle into life in prison. Details of how the scheme should work are set out in
HMPPS’s Manage the Custodial Sentence Policy Framework. This says:
• All prisoners in the male closed estate must be allocated a key worker whose
responsibility is to engage, motivate and support them through the custodial
period.
• Key workers must have completed the required training.
• Governors in the male closed estate must ensure that time is made available for
an average of 45 minutes per prisoner per week for delivery of the key worker
role, which includes individual time with each prisoner.
33. Within this allocated time, key workers can vary individual sessions to provide a
responsive service, reflecting individual need and stage in the sentence. A key
worker session can consist of a structured interview or a range of activities such as
attending an ACCT review, meeting family during a visit or engaging in conversation
during an activity to build relationships.
34. In 2023/24, due to exceptional staffing and capacity pressures in parts of the estate,
some prisons are delivering adapted versions of the key work scheme while they
work towards full implementation. Any adaptations, and steps being taken to
increase delivery, should be set out in the prison’s overarching Regime Progression
Plan which is agreed locally by Prison Group Directors and Executive Directors and
updated in line with resource availability.
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Key Events
35. On 29 November 2023, Mr David Glass was sentenced to one year in prison for
assault. He was sent to HMP Altcourse. It was not his first time in prison.
36. When he arrived at Altcourse, Mr Glass told the reception nurse that he had anxiety
and depression. He said that he had never self-harmed but had attempted suicide
18 months earlier by taking an overdose (five months earlier, according to his pre-
sentence mental health assessment and years earlier according to medical
records). Mr Glass told staff he had no current thoughts of suicide or self-harm. A
GP continued his prescription for mirtazapine (an antidepressant).
37. Mr Glass told the reception nurse that he had a history of substance misuse and
tested positive for several illicit substances including cocaine and methadone (a
medicine used to treat heroin addiction). The nurse referred him to the prison’s
substance misuse service (SMS). A GP continued the methadone prescription.
38. Staff allocated Mr Glass to a cell on Furlong Red, an induction and detoxification
unit. Healthcare staff monitored him for withdrawal symptoms and assessed that he
was showing no significant symptoms.
39. On 1 December, a nurse carried out a mental health assessment with Mr Glass. He
said he had no mental health concerns and no thoughts of suicide or self-harm. She
noted his diagnoses of anxiety and depression and had no concerns. She told him
how to contact the mental health team if he required support.
40. On 4 December, a member of the SMS team reviewed Mr Glass. He said that he
had taken an overdose previously but had no current thoughts of suicide or self-
harm. The SMS worker gave him harm minimisation advice and booked another
review in 13 weeks.
41. On 10 December, a prison custody officer (PCO) saw Mr Glass for a key worker
session. He noted that Mr Glass told him he was fine and had no problems. Mr
Glass said he wanted to be drug free and move to Furlong Green, the substance
misuse recovery unit.
42. On 12 December, the gang liaison officer visited Mr Glass. Mr Glass told her that he
had issues due to dealing drugs and debts in the community. She told us that when
she tried to explore further, Mr Glass was evasive and would not give her a straight
answer. (Information suggested Mr Glass had issues with a local gang and there
was a “remote chance” he was under threat.)
43. On 14 December, Mr Glass was moved to Reynoldstown Blue unit (a standard
residential unit).
2024
44. On 8 February 2024, at 10.28am, Mr Glass phoned home and spoke to his brother.
The investigator listened to the call. Mr Glass told his brother he had bought vapes
for £10 from other prisoners. To pay for the vapes, Mr Glass asked his brother to
transfer £10 into someone’s bank account. Mr Glass’ brother agreed to transfer the
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money. (Mr Glass’ family noted that the actual amount Mr Glass requested they
send to a prisoner’s partner’s bank account was £10.01.)
45. At 6.26pm, Mr Glass phoned home and spoke to his mother. The investigator
listened to the call. He asked her to transfer the money for the vapes he had
bought. Mr Glass’ mother said she was not able to transfer the money until the
following morning. Mr Glass also spoke with his brother and told him he had
received a court fine of £1200 and needed to pay a lump sum of £150 within 56
days of his release.
46. On 9 February, CCTV footage shows Mr Glass had his cell door closed throughout
the morning. Prison staff then found Mr Glass with an improvised weapon. Staff put
Mr Glass on report (issued him with a disciplinary charge for breaking prison rules)
and moved him to a cell on Canal Green unit, while he waited for an adjudication (a
prison’s version of a court hearing).
47. The next morning, at his adjudication, Mr Glass told the adjudicator, an operational
middle manager (OMM), that he had the weapon for self-defence. He said someone
had come to his cell and threatened him. The OMM found Mr Glass guilty of
breaking prison rules. As punishment, she gave Mr Glass seven days cellular
confinement. Prison staff then moved Mr Glass to the Care and Separation Unit
(CSU - the segregation unit) to serve his period of cellular confinement.
48. A nurse completed an initial segregation health screen (segregation algorithm) and
assessed that there were no health reasons why Mr Glass could not be held in
segregation. A nurse or GP saw him daily and had no concerns.
49. On the morning of 16 February, Mr Glass had completed his cellular confinement,
but refused to go back to Canal Green. Prison staff put Mr Glass on report for
refusing a lawful order. Later that morning, Mr Glass phoned home, but no one
answered.
50. The next morning, at his adjudication, Mr Glass submitted a written statement, in
which he said other prisoners had accused him of being a sex offender and
prisoners would stab, slash, or throw hot water at him. (Mr Glass did not have a
conviction for a sexual offence.) He said there was a price on his head and that he
could not go to any of the units in the prison other than Melling, the vulnerable
prisoners’ unit (VPU), and even if he went to the VPU, he would have to make a
‘shiv’ (an improvised weapon) to protect himself.
51. The adjudicator, the Head of Residence, rejected Mr Glass’ request to move to the
VPU as he did not meet the vulnerable prisoner criteria. (Vulnerable prisoners are
those who would be at risk due to their offence (sexual offences) or due to being a
former police or prison officer.) He found Mr Glass guilty of refusing a lawful order to
move back to a standard unit. As punishment he gave Mr Glass a further seven
days in the CSU.
52. A nurse partially completed a segregation algorithm and indicated that there were
no health reasons why Mr Glass could not continue to be held in segregation. A
nurse or GP saw Mr Glass daily and had no concerns.
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53. On 19 February, Mr Glass called home five times. There was no answer for four of
the calls but, at 2.38pm, someone answered and spoke with Mr Glass for 15
seconds. (The investigator was unable to listen to this call due to the changing of
the telephone system at Altcourse and the loss of the recording.) At 3.40pm,
someone transferred £30 into Mr Glass’ prison account.
54. CCTV footage shows that at around 6.50pm, staff unlocked Mr Glass and took him
to collect his medication. Staff then returned Mr Glass to his cell.
55. CCTV footage shows that throughout the night and into the early morning of 20
February, prison staff checked Mr Glass hourly. There were no concerns.
Events of 20 February
56. At 6.58am on 20 February, a PCO carried out a routine check of all prisoners on the
CSU. He told us in interview that he saw Mr Glass lying on his bed under his
blanket, with his knees up.
57. Later that morning two PCOs, a prison chaplain and a nurse were doing welfare
checks and handing out breakfast in the CSU. CCTV footage shows that they
arrived at Mr Glass’ cell at 8.23am.
58. A PCO looked through Mr Glass’ observation panel and saw Mr Glass with a
ligature around his neck. Mr Glass had made the ligature from a bed sheet and had
attached it to a TV stand above the sink in his cell. The PCO said Mr Glass’ feet
were touching the floor.
59. The PCOs immediately entered the cell, followed by the nurse. Both PCOs cut the
ligature. A PCO radioed a code blue medical emergency (used when a prisoner is
unconscious which tells the control room to call an ambulance immediately).
60. The nurse told us she shook Mr Glass by the shoulder and called his name. She
said Mr Glass did not respond and she could not find a pulse. She said she and the
PCOs put Mr Glass on his back, and they started CPR.
61. At 8.24am, control room staff called an ambulance.
62. The nurse told us that after two rounds of CPR Mr Glass still had no pulse or signs
of life. She then took over chest compressions. More prison and healthcare staff
arrived, and CPR continued.
63. A PCO fetched the defibrillator, which healthcare staff attached to Mr Glass.
Another nurse noted that the defibrillator advised no shock, so staff continued CPR.
64. At 8.37am, paramedics arrived at the cell and took over CPR. Shortly after, a
second ambulance crew arrived. Paramedics detected faint signs of life and took Mr
Glass to Aintree Hospital. However, a hospital doctor pronounced him dead on
arrival at 9.38am.
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Contact with Mr Glass’ family
65. On 20 February, at 9.45am, the prison appointed a family liaison officer (FLO). At
10.50am, the FLO and the Prison Director attended Mr Glass’ mother’s address and
informed her of Mr Glass’ death.
66. The FLO maintained contact with Mr Glass’ family over the following days, offering
support and advice. On 28 March, the FLO, as a prison chaplain, led Mr Glass’
funeral service.
67. The prison contributed to the costs of Mr Glass’ funeral in line with national policy.
Support for prisoners and staff
68. After Mr Glass’ death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
69. The prison posted notices informing other prisoners of Mr Glass’ death and offering
support. Staff reviewed all prisoners assessed as being at risk of suicide or self-
harm in case they had been adversely affected by Mr Glass’ death, and prison
carers were deployed in the CSU to support prisoners if needed.
Post-mortem report
70. We have not yet received the post-mortem report from the Coroner.
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Findings
Assessment of Mr Glass’ risk
71. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), sets out the procedures (known
as ACCT) that should be followed when a prisoner is identified as being at risk of
suicide and self-harm. It sets out the risk factors and triggers that could indicate
increased risk.
72. Mr Glass had previously attempted suicide by taking an overdose. However, we are
satisfied that Mr Glass gave no indication that he was at risk of suicide or self-harm
while he was at Altcourse. This included while he was in the CSU when he was
seen daily by either a GP or nurse. No concerns were ever raised. We are satisfied
that staff could not have foreseen Mr Glass’ actions.
Violence reduction
73. Mr Glass told staff that he was under threat from other prisoners, and he refused to
leave the CSU to go back to a standard residential unit because he was scared that
he would be attacked. He asked to go to the Vulnerable Prisoners Unit, but staff
refused this request.
74. We have previously noted the links between bullying and self-inflicted deaths of
prisoners of all ages. In our PPO thematic report into self-inflicted deaths in 2013-
2014, we found that reports or suspicions that a prisoner is being threatened or
bullied need to be recorded, investigated, and responded to robustly.
75. Altcourse’s Vulnerable Prisoner (VP) Policy dated March 2023, says, “In the event
that a prisoner claims to be under threat, he will be interviewed by the FLM and the
details surrounding the threat / issue explored. Consideration will be given to a
possible change of cell or unit location. The prisoner will not be offered VP status
unless he fits the criteria for VP due to his offence.”
76. Mr Glass’ offence did not meet the criteria for VP status, so we consider it
reasonable that his request was refused. However, staff did very little to explore the
nature of the alleged threat against Mr Glass.
77. Altcourse has a Violence Strategy dated January 2024, which sets out the process
for raising and investigating any identified or suspected acts of aggression, bullying,
intimidation or violence, using the Challenge, Support, and Intervention Plan (CSIP)
model. However, the focus of Altcourse’s strategy is on the perpetrators of bullying,
intimidation, or violence, with little to no guidance on how to support and manage
victims. All it says is, “Particular attention will always be paid to the victims of
violence or bullying. They will require support and may have concerns regarding
their personal / mental wellbeing or the safety of their families and will require help
to restore confidence and feel secure.” We consider that this does not provide
sufficient guidance to staff.
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78. We recommend:
The Director should review the prison’s Violence Strategy so that it provides
clear guidance to staff on how to identify and support prisoners at risk of
bullying, intimidation, or violence.
Segregation review board
79. Mr Glass was segregated for a total of 11 days between 9 and 20 February. Staff
did not hold an Initial Segregation Review Board for Mr Glass throughout that time.
80. Prison Service Order (PSO) 1700 on segregation recognises that a prisoner’s
mental health is likely to decline when they are kept in segregation. One of the
purposes of the Initial Segregation Review Board is to discuss any concerns about
how the prisoner is coping with segregation and to consider whether segregation
continues to be appropriate or whether additional steps are needed to safeguard
the prisoner’s mental health.
81. PSO 1700 used to say that only prisoners held under Rule 45 (a specific Prison
Rule which does not cover prisoners segregated for cellular confinement after an
adjudication) would receive an Initial Segregation Review Board after 72 hours.
However, following a previous PPO investigation, we recommended that an Initial
Segregation Review Board should be held for all prisoners held in segregation
beyond 72 hours, irrespective of the Rule under which they were held. HMPPS
accepted this and in June 2022, issued a Security Briefing Note to this effect to all
prisons.
82. Mr Glass was not held under Rule 45 so prior to June 2022, would not have
required an Initial Segregation Review Board. However, he did require one under
the updated segregation policy. If an Initial Segregation Review Board had taken
place in Mr Glass’ case, it would have given an extra opportunity to identify any
decline in his mental health and to offer additional planning and support. We
recommend:
The Director should ensure that:
• staff hold an Initial Segregation review within the first 72 hours of
segregation irrespective of which Prison Rule a prisoner is segregated
under; and
• all relevant segregation paperwork is updated to reflect the changes
outlined in the June 2022 Security Briefing Note on Segregation.
Clinical care
83. The clinical reviewer concluded that the care Mr Glass received at Altcourse was
not of a satisfactory standard and was not equivalent to that which he could have
expected to receive in the community. He identified that Mr Glass’ secondary health
screening was completed outside the seven-day timescale and the medicines
reconciliation was completed outside the 72-hour timescale. Also, the second
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segregation algorithm was not fully completed, and some of the reviews conducted
by healthcare staff were not recorded in Mr Glass’ medical records.
84. The Head of Healthcare said that staffing shortages had affected the timeliness of
the secondary health screen and medicines reconciliation. She said that steps had
been taken to address the issues with the segregation algorithm, including training
for healthcare staff and liaison with the Head of Safety with a view to improving joint
working between prison and healthcare staff for segregated prisoners.
85. The clinical reviewer made several recommendations not directly related to Mr
Glass’ death, which the Head of Healthcare will wish to address.
Key work
86. All prisoners in the male closed estate are supposed to receive weekly key worker
sessions. However, since arriving at Altcourse, Mr Glass only received one key
worker session in December 2023, while he was on Furlong Red, an induction and
detoxification unit.
87. The Head of Reducing Reoffending accepted that it was not reasonable for Mr
Glass to have received only one key worker session while at Altcourse.
88. The Head of Reducing Reoffending said Altcourse had faced post COVID-19
challenges, which included staffing issues. He said not all prisoners received key
work. To address key work delivery at Altcourse, he said work was being done on
staff recruitment and retention; assigning residential unit staff specifically for key
work duties; monitoring delivery and improving the quality of sessions.
89. The Head of Reducing Reoffending said that currently they were targeting key work
delivery towards more vulnerable prisoners, and the number of key work sessions
delivered had improved.
90. It is difficult to say whether Mr Glass would have shared any risk related information
with a key worker. Mr Glass gave no indication to staff that he was a risk of suicide.
It is possible therefore that key worker sessions would have made no difference to
the outcome for Mr Glass. Nevertheless, key worker sessions are important in
establishing good relationships between prisoners and staff and should be fully
resumed as soon as staffing levels allow.
Inquest
91. At the inquest, held from 14 to 23 September 2026, the jury reached a narrative
conclusion:
David John Glass had experienced a history of mental health difficulties including
anxiety and depression, suicide attempts and ideation and an increasing fear of
perceived threats. These circumstances contributed to his decision in taking his
own life. David subsequently died as a result of injuries sustained in his suicide
attempt.
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