Richard Glenn

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Independent investigation into
the death of Mr Richard Glenn,
a prisoner at HMP Lincoln,
on 12 September 2022
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 HMPPS in ensuring the standard of care received by those
within service remit is appropriate then our recommendations should be focused,
evidenced and viable. This is especially the case if there is evidence of systemic failure.
Mr Richard Glenn died of a self-inflicted incised wound to the neck on 12 September 2022,
while a prisoner at HMP Lincoln. He was 53 years old. I offer my condolences to Mr
Glenn’s family and friends. Mr Glenn was the tenth prisoner to die at Lincoln in three
years.
Mr Glenn harmed himself on 2 August and staff rightly started suicide and self-harm
prevention procedures (known as ACCT) to manage the risks. The ACCT procedures were
generally well-managed, but when they were stopped on 9 September, healthcare staff did
not consider a psychiatry assessment completed earlier the same day which raised
concerns about Mr Glenn’s presentation. While we cannot measure the impact on Mr
Glenn, it is important that staff consider all relevant information when assessing suicide
and self-harm risks.
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 May 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 12
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Summary
Events
1. On 8 June 2022, Mr Richard Glenn was released from prison on licence. He was
recalled to HMP Lincoln shortly afterwards, arriving at the prison on 13 June.
2. Mr Glenn had attempted suicide on several occasions, most recently in October
2018. Staff at Lincoln started Prison Service suicide and self-harm prevention
procedures (ACCT) on 2 August 2022, after he harmed himself and shared suicidal
thoughts.
3. On 9 September, staff stopped monitoring Mr Glenn because they were satisfied
that he no longer posed an immediate risk to himself. However, notes from a
psychiatric appointment earlier that day were not shared with staff for their
consideration. The psychiatrist recorded concerns about Mr Glenn, who had
presented as run down and low in mood.
4. At 5.13am on 12 September, an officer checked Mr Glenn through his cell
observation panel and saw him lying on the floor in a considerable amount of blood.
She immediately radioed a medical emergency code, indicating a serious injury and
triggering a call for an ambulance.
5. Around one minute later, other officers and healthcare staff responded to the code
and opened the door immediately. They could not find a pulse and noted that rigor
mortis was present. When the nurse examined Mr Glenn, she noted a deep
laceration to the right side of his neck. She decided not to start cardiopulmonary
resuscitation (CPR). Paramedics later confirmed that Mr Glenn had died.
Findings
Management of risk of suicide and self-harm
6. Prison staff appropriately started ACCT procedures when Mr Glenn reported
thoughts of harming himself. The ACCT procedures were generally managed well,
including use of constant supervision at times of crisis, consistent contribution from
the mental health team, and the use of ad hoc case reviews to review risk when
necessary.
7. The decision to stop ACCT monitoring was reasonable based on the progress Mr
Glenn appeared to have made, including his plans for his impending release.
However, staff did not have access to the outcome of a psychiatrist’s assessment,
which took place earlier the same day, and which identified concerns about Mr
Glenn. The psychiatrist’s record should have been considered as part of the suicide
and self-harm risk assessment process.
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Recommendations
• The Head of Healthcare should ensure that healthcare staff check clinical records in
preparation for ACCT review discussions, to ensure all available risk information is
considered.
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The Investigation Process
8. We were notified of Mr Glenn’s death on 12 September 2022.
9. The investigator issued notices to staff and prisoners at HMP Lincoln informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
10. The investigator visited HMP Lincoln on 1 November 2022. He obtained copies of
relevant extracts from Mr Glenn’s prison and medical records.
11. The investigator interviewed 11 members of staff at HMP Lincoln during November
2022.
12. NHS England commissioned a clinical reviewer to review Mr Glenn’s clinical care at
the prison. She conducted all staff interviews jointly with the investigator.
13. We informed HM Coroner for Lincolnshire of the investigation. The Coroner gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
14. The Ombudsman’s family liaison officer contacted Mr Glenn’s mother to explain the
investigation and to ask if she had any matters she wanted us to consider. Mr
Glenn’s family asked about the level of mental healthcare received by Mr Glenn at
Lincoln. They were also concerned that Mr Glenn had been released without his
medication on 8 June 2022, before being recalled to prison shortly afterwards.
15. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out one factual inaccuracy and this report has been amended
accordingly.
16. Mr Glenn’s family received a copy of the initial report. They raised a number of
issues that do not impact on the factual accuracy of this report and have been
addressed through separate correspondence.
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Background Information
HMP Lincoln
17. HMP Lincoln is a Category B prison, which predominantly serves the courts of
Lincolnshire. It holds up to 600 remanded and convicted adult/young adult male
prisoners. Nottingham Healthcare NHS Foundation Trust provides health services
and there is 24-hour nursing cover.
HM Inspectorate of Prisons
18. The most recent inspection of HMP Lincoln was in December 2019 to January
2020. Inspectors reported that Lincoln was a much safer prison since their last
inspection in 2017, though there had been two self-inflicted deaths since then.
Inspectors said that the prison’s approach to prisoners in crisis was good, and they
had implemented previous PPO recommendations. The inspectors found that
prisoners and staff had a good relationship, which was a real strength.
Independent Monitoring Board
19. 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 31 January 2022, the IMB
reported that a range of safety measures were in place, including behaviour
management, frequent reviews of and responses to incidents of violence and self-
harm, and sharing of information among all relevant departments within the prison.
The report stated that there had been a reduction in self-harm and that
staff/prisoner relationships continued to be generally positive and supportive.
Previous deaths at HMP Lincoln
20. Mr Glenn was the tenth prisoner to die at Lincoln since September 2019. Of the
previous deaths, four were self-inflicted and five were from natural causes. There
are no notable similarities in our findings across recent investigations.
Assessment, Care in Custody and Teamwork
21. Assessment, Care in Custody and Teamwork (ACCT) is the Prison Service care-
planning system used to support prisoners at risk of suicide or self-harm. The
purpose of ACCT is to try to determine the level of risk, how to reduce the risk and
how best to monitor and supervise the prisoner. After an initial assessment of the
prisoner’s main concerns, levels of supervision and interactions are set according to
the perceived risk of harm. Checks should be carried out at irregular intervals to
prevent the prisoner anticipating when they will occur. Regular multidisciplinary
review meetings involving the prisoner should be held.
22. As part of the process, support actions are put in place. The ACCT plan should not
be closed until all the support actions have been completed. All decisions made as
part of the ACCT process and any relevant observations about the prisoner should
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be written in the ACCT booklet, which accompanies the prisoner as they move
around the prison. Guidance on ACCT procedures is set out in Prison Service
Instruction (PSI) 64/2011, Management of prisons at risk of harm to self, to others
and from others (Safer Custody).
23. Following the closure of an ACCT, ‘post-closure’ monitoring must take place for a
minimum period of seven days, to ensure closure is appropriate and risks can be
managed without additional monitoring.
24. As soon as possible following this seven-day monitoring period, the ACCT Case
Coordinator must chair a post-closure review, reviewing the progress made since
the ACCT was closed. During the post-closure review, consideration should be
given to the current feelings of the prisoner, access to support (both formal and
informal), and progress since closure. At the end of the review, the Case
Coordinator and any other members of the case review team present will decide
whether there needs to be any further post-closure reviews (and, if so, their
frequency), or whether the ACCT needs to be re-opened.
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Key Events
Background
25. On 28 February 2022, Mr Richard Glenn was released on licence from HMP
Lincoln. On 2 March, he was recalled to Lincoln after being charged with assaulting
an emergency worker on the day of his release.
26. Mr Glenn had been to prison several times. He had been diagnosed with
depression, anxiety, and mixed personality disorder, for which he was prescribed
medication. Mr Glenn had a long history of self-harm. He attempted suicide on
several occasions, most recently in October 2018.
27. On 4 March, Mr Glenn asked officers for a razor to cut his wrist. Staff started ACCT
procedures, which they closed the following day when they were satisfied that Mr
Glenn was no longer a risk to himself.
28. On 8 May, staff started ACCT procedures again, when Mr Glenn threatened to kill
himself with a razor blade. Staff closed the ACCT on 20 May.
29. On 8 June, Mr Glenn received a 20-week sentence of imprisonment. He had served
more than half of the sentence already, on remand, and so was released straight
from court into the community. (Offenders sentenced to sentences of less than two
years in prison serve half of their sentence in prison and half in the community on
licence.) Mr Glenn was required to report to his local probation office on the day of
his release, but he failed to attend, and probation made a decision to recall him to
custody. The next day, Mr Glenn was arrested by police as part of the recall. He
assaulted a police officer during the arrest which resulted in further charges.
Recall to HMP Lincoln
30. On 13 June, Mr Glenn arrived at Lincoln and the reception nurse assessed his
mental and physical health. Mr Glenn said that he had not taken any medication
since his release from prison on 8 June, and that he had drunk a lot of cider. Based
on Mr Glenn’s medical history, the nurse referred him to the mental health team for
further assessment. He remained under the care of the mental health team until his
death.
31. Mr Glenn applied for vulnerable prisoner (VP) status (for prisoners who would be at
risk of attack if kept in the mainstream prison population), which was granted. He
applied for VP status because he had previous convictions for sexual offences. He
was allocated a single occupancy cell.
32. On 14 June, a GP prescribed Mr Glenn venlafaxine (an antidepressant) and
olanzapine (an antipsychotic).
33. On 15 June, a mental health nurse assessed Mr Glenn to ascertain his mental
health needs. Mr Glenn told her that he had been through “a rough time” after being
granted immediate release from court without any medication or a discharge grant.
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34. On 20 July, after refusing to work and littering, staff placed Mr Glenn on the ‘basic’
level of privileges, meaning that he would only have basic entitlements such as
telephone calls, visits, access to books and education. Mr Glenn remained on the
basic privileges level until 16 August, when staff were satisfied that his behaviour
had improved.
35. On 28 July, Mr Glenn was sentenced to 26 weeks in prison for assaulting an
emergency services worker during his recall arrest.
36. On 2 August, in the early hours of the morning, staff started ACCT procedures after
Mr Glenn told the night patrol officer that he was going to harm himself. He showed
the officer some razor blades he was holding in his cell and said he was struggling
with his mental health. Staff initially decided to monitor Mr Glenn through hourly
observations.
37. The ACCT case co-ordinator chaired an ACCT case review later that day, which
included a representative of the mental health team and Mr Glenn’s prison offender
manager (POM). Mr Glenn said that he felt low and had thought about harming
himself but chose to seek the help of the night officer rather than “suffering in
silence”. The case co-ordinator recorded a support action for Mr Glenn to work with
the mental health team. He set ACCT observations at three during the day and four
during the night, after Mr Glenn cited protective factors and said he had no current
thoughts of suicide or self-harm. (From this point onwards, Mr Glenn was only
allowed a razor blade for the period in which he wanted to shave. He would
immediately hand it back to staff when finished.)
38. On 6 August, the mental health team added Mr Glenn to the Red RAG (‘Red Amber
Green’) rating of intervention and input from the team, due to the deterioration of his
mental health which was leading to thoughts of self-harm. (The RAG rating is a tool
used to assess the risk levels for patients. Individuals rated red receive at least
weekly intervention from the mental health team.)
39. At around 6.20am on 8 August, Mr Glenn made small cuts to his arm with a razor
obtained illicitly from a prisoner on the wing. He told staff that his mental health was
deteriorating. A Supervising Officer (SO) led an ad hoc ACCT case review
afterwards, and recorded that Mr Glenn gave no reason for harming himself other
than that it was “quiet”. He arranged a full ACCT case review for the following day.
40. On 9 August, the ACCT case co-ordinator chaired the ACCT case review, which
included a mental health nurse and the POM. Mr Glenn said that his “head was full”
and requested that the mental health team arrange hospital admission. The nurse
explained that Mr Glenn would be able to speak to a psychiatrist about this.
41. On 11 August, Mr Glenn self-harmed by cutting his left wrist with another razor
blade he had obtained illicitly. Again, he said he was struggling with his mental
health. The ACCT case co-ordinator chaired an ad hoc ACCT review, recording that
Mr Glenn said that his mental health concerned him and that at the time he felt like
he wanted to kill himself. A mental health nurse present recorded that she would try
to arrange for his appointment with the psychiatrist (which was set for 26 August) to
be brought forward. The co-ordinator added this as a support action and increased
the level of observations to a minimum of two per hour.
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42. On 16 August, Mr Glenn cut his neck and arm with an illicitly obtained razor and told
staff he was depressed. Due to the severity of Mr Glenn’s injuries, he was admitted
to hospital for an operation. While in hospital, Mr Glenn told escorting staff that he
would cut himself again at the first opportunity when he got hold of a razor. As a
result, when Mr Glenn was released from hospital on 20 August, staff decided to
place him under constant supervision, with a review booked for 22 August.
43. On 22 August, Mr Glenn’s ACCT review took place. As constant supervision was in
place, a Custodial Manager (CM) chaired the review and was now the case
coordinator. Other attendees included the ACCT case co-ordinator, the POM and a
nurse from the mental health team. Mr Glenn told staff that he felt he had recovered
physically after his operation but not mentally. He said he felt his olanzapine
medication was not helping him, and that this was the main cause of his mental
deterioration. The CM noted that Mr Glenn had an appointment with the psychiatrist
later that day, where his medication would be reviewed. Mr Glenn did not want to
return to the cell that he had occupied up until 16 August, so staff relocated him to a
cell in a different part of the VP Wing. Mr Glenn did not object to his new location
but said he would like to return to a section of the VP Wing where he had resided
while previously in custody, as he had felt settled there. Staff agreed to facilitate this
for him once a cell became available. The case review team chose to keep constant
supervision in place.
44. After the ACCT review, a SO met Mr Glenn in her capacity as his key worker. (She
was a prison officer at the time that she worked with Mr Glenn. She has since been
promoted to SO.) Mr Glenn told her that he had been struggling recently and had
self-harmed. Mr Glenn told her that part of the reason for his self-harm was his
olanzapine medication not working for him. He told her that he was going to request
a change in his medication from olanzapine to quetiapine (an alternative
antipsychotic).
45. Later the same day, Mr Glenn met with a psychiatrist, who reduced his daily
olanzapine medication in preparation for stopping all together and switching to
quetiapine. The psychiatrist booked a follow-up appointment for 9 September, with
a view to increasing the dose of quetiapine should Mr Glenn be tolerating it well.
46. On 23 August, the next ACCT constant watch review for Mr Glenn took place,
chaired by a CM and attended by a nurse, the POM, and a wing SO. The nurse told
the group that the psychiatrist would not support a move to a secure mental hospital
because Mr Glenn did not meet the criteria. Mr Glenn appeared shocked and
disappointed by this news, but was pleased that he had another review with the
psychiatrist booked in. The nurse recommended that Mr Glenn should be kept
under constant supervision because his risk of further self-harm was high, which the
group agreed was the correct approach.
47. On 26 August, the next ACCT constant supervision review took place, chaired by a
CM and attended by a nurse, the POM and others. Mr Glenn told the group that he
was “a bit better” than at the last review but still recovering. He said that he had
been sleeping better since his medication had been changed to quetiapine and he
felt good about it. Mr Glenn presented well and said his thoughts of self-harm were
still there but less intrusive than before. The group agreed that Mr Glenn should no
longer be under constant supervision, but that his ACCT should remain open with
three observations per hour and three conversations per day.
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48. On 29 August, a CM chaired the next ACCT case review, with a SO and a member
of the mental health team also present. Mr Glenn talked a lot about how his new
medication had improved his mood and sleep. He said he was looking forward to
his appointments with the mental health team and psychiatrist. Staff reported that
Mr Glenn was still waiting for a space in his preferred section of the VP Wing.
49. On 31 August, the mental health team completed the Colombia Suicide Severity
Rating Scale (C-SSRC - a suicide risk assessment tool designed to assess the
severity and immediacy of that risk and the level of support a person needs) for Mr
Glenn. They assessed him as at high risk and he remained on the red RAG rating.
September 2022
50. On 2 September, a SO chaired an ACCT review, with a nurse, and a CM. Mr Glenn
told the group that he felt okay and looked forward to his upcoming appointment
with the psychiatrist. He said that he sometimes thought about self-harming but
used television and books to distract himself. Mr Glenn told the group that he had
ordered a razor from the canteen, which they flagged as a concern and removed
from his delivery. Staff agreed that Mr Glenn should be monitored and supervised
while shaving, which he understood. In interview, the nurse told us that Mr Glenn
appeared fixated on his canteen delivery for the week, which he said was because
he wanted to repay vapes to two other prisoners. She had concerns about Mr
Glenn’s fixation on his canteen delivery and felt his level of observations should
remain the same. However, the CM and the SO felt that Mr Glenn was going in the
right direction and chose to lower the observations to once every two hours, with
three conversations a day.
51. The next ACCT review took place on 6 September, chaired by the ACCT case co-
ordinator and attended by the POM and a nurse. Mr Glenn told the group that he
was looking forward to his release on 26 October, and that he kept himself busy by
watching television, reading, and occasionally meditating. The co-ordinator and
POM considered this to be a positive sign and agreed to reduce Mr Glenn’s level of
observations to three per day (plus three conversations) and four observations
overnight.
52. At around 9.20am on 9 September, Mr Glenn attended a review with the
psychiatrist. Mr Glenn told him that did not feel brilliant but felt better than he did
when taking olanzapine. They agreed to increase his quetiapine dose gradually.
The psychiatrist recorded on Mr Glenn’s medical record that he still struggled with
low mood and was “very run down”. Mr Glenn told her that he had struggled with
thoughts of self-harm in the past few weeks but did not currently experience such
thoughts. He also expressed some concerns about his lack of accommodation on
release from prison.
53. At around 10.30am, the ACCT case co-ordinator chaired the next ACCT case
review, attended by a nurse and a CM from the Safer Custody Team. Mr Glenn told
the group that he was looking forward to his release from prison (on 26 October)
and wanted a period of stability after this. To assist Mr Glenn with his
accommodation concerns, the co-ordinator contacted the Lincolnshire Action Trust
(LAST) to see if they could assist. Although a transfer to his preferred section of the
VP Wing was still not possible, Mr Glenn was told that this may change in the
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coming days. He said that since his change in medication, he had only fleeting
thoughts of self-harm and no plans or intention to harm himself. The information
from Mr Glenn’s psychiatric appointment that morning was not shared with the
ACCT review group. Staff agreed to close the ACCT and put it into ‘post-closure’
state (during which time it could be reopened if additional concerns arose). They
scheduled a post-closure interview, where final closure of the ACCT would be
discussed, for 16 September.
54. At 4.45pm on 11 September, Mr Glenn left his cell to collect his dinner. He returned
to his cell and closed the door at 4.48pm. CCTV footage shows that staff completed
visual checks on Mr Glenn through his cell observation panel at 4.50pm, 5.01pm
and 5.38pm. They raised no concerns. At 8.23pm, an Operational Support Grade
(OSG) observed Mr Glenn through his cell observation panel as part of her evening
routine check. She raised no concerns. Mr Glenn was not subject to any other
checks during the night.
Events of 12 September
55. At 5.13am, the OSG checked Mr Glenn through his cell observation panel as part of
the early morning routine check. She saw him lying on the floor of his cell in a lot of
blood and immediately radioed a medical emergency ‘code red’, indicating a serious
injury and triggering a call for an ambulance. She attempted to open the door with
her key but inadvertently failed to unlock the bolt at the bottom of the door, so was
unable to open it.
56. Around one minute later, prison and healthcare staff arrived at the cell and opened
the door immediately. A nurse could not find a pulse and noted that rigor mortis was
present. She noted a deep laceration to the right side of Mr Glenn’s neck. Due to
the rigor mortis and laceration, she decided not to start cardiopulmonary
resuscitation (CPR).
57. Paramedics did not attend the prison immediately as it was clear that Mr Glenn
showed no signs of life. At 7.20am, they attended and confirmed Mr Glenn’s death.
58. After Mr Glenn’s death, an officer told us that two prisoners said that Mr Glenn had
asked them for a razor the previous night, but both had not given him one. Police
found a blade on the floor of Mr Glenn’s cell which they believe he used to make the
laceration. However, investigations have not established where or from whom he
obtained it.
Contact with Mr Glenn’s family
59. At around 11.00am on 12 September, the prison family liaison officer and a prison
chaplain arrived at the home of Mr Glenn’s next of kin, his mother, to inform her of
the death.
60. Lincoln contributed to the costs of Mr Glenn’s funeral, in line with Prison Service
policy.
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Support for prisoners and staff
61. After Mr Glenn’s death, an operational 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.
62. The prison posted notices informing other prisoners of Mr Glenn’s death and
offering support.
63. On 24 September, the Head of Residence and Services held a ‘cold de-brief’ with
staff, to discuss the emergency response and what could have been done
differently. No specific learning was identified.
Post-mortem report
64. A post-mortem examination concluded that Mr Glenn died due to an incised wound
to the neck. The toxicology examination showed no evidence to suggest drugs or
alcohol caused or contributed to Mr Glenn’s death.
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Findings
Management of suicide and self-harm risk
65. Prison Service Instruction (PSI) 64/2011, Safer Custody, contains requirements for
the management of suicide and self-harm prevention procedures. It requires all staff
who have contact with prisoners to be aware of the risk factors and triggers that
might increase the risk of suicide and self-harm and take appropriate action. Any
prisoner identified as at risk of suicide or self-harm must be managed under ACCT
procedures.
66. Prison staff appropriately started ACCT procedures on 2 August. The case reviews
were multidisciplinary, including consistent input from the mental health team, and
case management was broadly consistent. Constant supervision was used
appropriately when Mr Glenn’s risk was judged to be very high, and ad hoc case
reviews were held when he harmed himself. The ACCT procedures were closed on
9 September, three days before he died. We have considered whether monitoring
was ended prematurely.
67. Much of Mr Glenn’s risk revolved around his mental health and his thoughts of
harming himself were seemingly linked to deteriorations in mental health. He
worked with the mental health team and psychiatrist and, over time, said that he
was feeling the positive effects of his new medication, was sleeping better and that
his thoughts of harming himself had reduced. Mr Glenn also spoke positively about
the future, including his upcoming release, and staff agreed that his outward
presentation had improved.
68. Mr Glenn had an appointment with a psychiatrist on the morning of 9 September.
The psychiatrist recorded that Mr Glenn presented as run down and low in mood. A
nurse attended Mr Glenn’s next ACCT review, but did not check his records, so was
unaware of the psychiatrist’s notes. She told us that there was a lot of “future focus”
in Mr Glenn’s final ACCT review, and that she “did not see any immediate concerns
with his safety”.
69. We consider that the decision to close Mr Glenn’s ACCT was, on the surface,
reasonable, based on staff’s assessment of his progress and forward thinking.
However, healthcare staff should have checked Mr Glenn’s medical notes before
the review, to ensure all relevant and up to date information was shared with the
ACCT review. The psychiatrist’s assessment record might have impacted the
decisions made. We make the following recommendation:
The Head of Healthcare should ensure that healthcare staff check clinical
records in preparation for ACCT review discussions, to ensure all available
risk information is considered.
Clinical care
70. The clinical reviewer concluded that the clinical care provided to Mr Glenn was
equivalent to that which he could have expected to receive in the community. The
mental healthcare provided to Mr Glenn was of a good standard and he received
regular input from the mental health team, including the psychiatrist.
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Head of Healthcare to note
Release on 8 June 2022 prior to recall
71. In addressing concerns raised by Mr Glenn’s family, we found that Mr Glenn was
released from prison following a court appearance on 8 June without his prescribed
medication, which appears to have impacted on his mental health. We found that
healthcare staff did not receive any prior notice of Mr Glenn’s release from prison,
so when he was released directly from court after his hearing, there had not been
an opportunity to provide him with take home medications.
72. Although this matter did not impact directly on Mr Glenn’s death, it is important that
prisoners are released with essential medication to ensure continuity of treatment
while awaiting access to community services.
Inquest
73. The inquest into Mr Glenn’s death concluded on 23 March 2026, and recorded that
Mr Glenn intended to take his own life. The jury concluded that insufficient sharing
of risk information between healthcare and prison staff possibly contributed to his
actions.
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