04 Dec Inquest concludes that Sodexo’s system failures and Neglect contributed to the death of Ricky Crosher at Lowdham Grange

Before HM Area Coroner Laurinda Bower
Nottingham City and Nottinghamshire Coroner’s Court

11 to 28 November 2025

CONTENT WARNING: This article contains themes of self-harm and self-inflicted death.

A jury has found that there was a sustained failure by Sodexo to address the operational safety concerns at HMP Lowdham Grange, from the commencement of their contract to run the prison to Ricky’s death on 11 October 2023.

Sodexo were awarded the contract to manage the prison by the Ministry of Justice. Sodexo took control of the prison on 16 February 2023, following the first private provider to private provider transfer.  Within 37 days 3 men were dead. Anthony Binfield died on 6 March 2023, David Richards on 13 March and Rolandas Karbauskas on 25 March. All died by ligature. Early learning from these men’s deaths highlighted a catalogue of systemic failings at the prison. Sodexo failed to learn lessons and to implement basic safety measures. The same problems were persisting during the time Ricky was at the prison, over 6 months later.

The jury found that at the time of Ricky’s death Sodexo: 

• Failed to have in place a sufficient number of staff to run a safe, secure and decent regime;
• Failed to assure themselves as to the capabilities of the staffing body and to remedy any deficiencies by supplying staff with training;
• Failed to run a safe and decent regime, including purposeful activity, that would promote prisoner wellbeing;
• Failed to provide a Safer Custody function, including safer custody voicemail and prisoner advice line, that was fit for purpose;
• Failed to embed learning from previous deaths in custody, meaning past failings were repeated in Ricky’s care; and
• Failed to establish a robust system of management functions including quality assurance, governance and supervision of staff. 

These system failures all probably more than minimally contributed to Ricky’s death.

When Ricky arrived at HMP Lowdham Grange in July 2023, he disclosed mental health problems; a history of self-harm coping mechanisms including previous attempts to end his life; and substance use that had led him into debt in the past. Ricky should have been supported by a Key Worker, but he was not.

The inquest heard that the prison was consistently running on a diminished amber or red regime. Everyone spent huge amounts of time in their cells alone, with no purposeful activity or meaningful interactions. This led to a growing sense of frustration and increased violence at the prison.

A month after arriving at the prison, in August 2023, Ricky was seen with multiple injuries to his face and told staff he had been “jumped” and was under threat. A nurse submitted an intelligence report about Ricky’s suspicious injuries, but no welfare check or other follow up action was taken by prison staff as a result. That month, prison staff also noted Ricky appeared to be under the influence, but policy was not followed as Ricky was left unobserved and no follow up action was taken.

In September 2023, Ricky pleaded with the prison for a job and explained his lack of employment was making him depressed. No-one went to see Ricky to discuss his mental state as a result of his application. Ricky was also treated for new facial injuries, but no intelligence reports were submitted by staff in relation to these visible injuries.

In the days before his death, Ricky’s behaviour became increasingly desperate.

• On 7 October 2023, Ricky pressed his cell bell at 04:12am to inform staff he had feelings of self-harm. He explained to prison staff that he was under threat on the wing and intended to self-isolate until he was moved. Contrary to policy, Ricky was left alone and there was a missed opportunity to prevent his serious self-harm that morning. A Code Red was called due to a significant loss of blood, but the ambulance was stood down.
• Ricky was placed on an ACCT (national prison policy to manage and care plan for those at risk of self-harm and suicide), but the paperwork was so poorly completed he did not receive the benefit of the support that should have been given to him. Despite his family being noted as a protective factor, Ricky was not informed they could be part of the ACCT process. Furthermore, Ricky’s request to move cells was not escalated.
• The following night, on 8 October 2023, at 02:03am Ricky pressed his cell bell after setting fire to his pillow. There was a serious delay in deploying a demister and gaining entry to his cell. Ricky again told prison staff that he was under threat and that he set fire to his cell so he would be moved. Due to smoke damage, Ricky was moved to a new cell on B wing, which is adjacent to A wing and on the same houseblock. Ricky told prison staff that he still felt unsafe and he wanted to move to segregation or another jail.
• The escalation in Ricky’s risk and vulnerability was not properly recorded or acted upon by prison staff. The jury found that there was a “consistent failure to record risk pertinent information and record keeping where completed lacked rigor, with inconsistencies and poor detail. There was a lack of access to systems for all staff to record risk pertinent information and prison staff lacked knowledge of how to contact healthcare via email.”

On both nights when these serious incidents occurred, the Duty Manager in charge of the prison had been newly promoted under Sodexo’s streamlined staffing model. She had received no training before stepping up from being a prison officer, a role she had been in for less than 2 years.

Ricky was advised to press his cell bell, speak to staff or call the Safer Custody Line if he felt like he needed help.

As guided by staff, Ricky left multiple messages to Safer Custody which were not recorded by the Safer Custody Team and did not receive a response. Ricky made a final call to the Prisoner Advice Line at 13:03 on 10 October 2023 and left a voice message stating, “I need to speak to someone urgently. Can you come and see me or call me”. This message was not listened to and acted on prior to his death.

The Safety Intervention Meeting on 10 October 2023 was poorly attended, and no actions were generated in respect of Ricky.

Over the night of 10 October into 11 October 2023, there were further significant failures by prison staff. Staff carrying out observations on Ricky included an Operational Support Officer who had been newly promoted to night duties without adequate training. She did not even know what an ACCT document was or fully understand the purpose of the checks she was carrying out.

• The jury found discrepancies between the recording of ACCT observations in the documentation and the observations actually undertaken by night staff (as shown on CCTV). The ACCT observations were not completed correctly or in accordance with policy and were insufficient in duration to adequately observe Ricky’s welfare.
• After Ricky pressed his cell bell at 02:30am requesting to see a nurse, there was a “gross failure to escalate Ricky’s ACCT case”. The jury found “an increase in ACCT checks and an improved quality of these checks probably would have made a real difference to the outcome. Had adequate care been given, it probably would have saved or prolonged life”.
• At a welfare observation at 07.02am, Ricky’s cell observation panel was found covered and he was unresponsive. In breach of policy, officers did not enter the cell immediately instead they delayed by seeking to use the inundation bung to view the cell (the bung should only be used to deploy a demister in the case of a fire). This was a repeat of the circumstances and failure to provide an immediate emergency response to Anthony Binfield, which contributed to his death on 6 March 2023.
• When officers finally entered Ricky’s cell, he was found ligated, CPR was administered but sadly Ricky was pronounced dead at 07:48.
• The jury found Neglect contributed to Ricky’s death.

Amalia King, solicitor for Ricky’s family, comments: 

“Sodexo’s sustained failures to have in place basic systems to ensure safety contributed to Ricky’s death. It is shocking that Sodexo did not embed learning from the 3 men’s deaths in March 2023 and the same failings were repeated. The vital Safer Custody Team was non-functioning. Demands were placed on inexperienced staff to carry out roles they had not been trained to do. There was an absence of leadership, supervision or quality assurance. Community, the Prison Officers’ union, repeatedly raised serious concerns with senior managers at the prison but felt unheard. The overwhelming evidence is that safety at the prison for all those living and working there got worse and worse during Sodexo’s 9 months in charge. Many witnesses reflected that it was the worst time of their careers. The complete breakdown of safety systems tragically led to Ricky becoming the 4th of 5 men to die while Sodexo were being paid to run the prison. The jury have rightly found that Ricky’s death was contributed to by Neglect.”

 The jury also found multiple failures to have provided Ricky with support for his mental wellbeing, with a view to seeking to reduce his risk of harm to self, prior to his death. Failures to provide Ricky with support that probably contributed more than minimally to his death, included:

• a failure by prison staff to have properly investigated the injuries observed to Ricky’s face, to have assessed whether he was under threat of harm from other prisoners and to have taken appropriate supportive actions;
• failure by prison staff to have prevented Ricky from accessing drugs while in prison, and by prison and/or healthcare staff to have properly supported him when he was suspected of being under the influence of substances;
• a failure by Prison and/or Healthcare staff, contrary to National Policy (PSI 64/2011 and the July 2021 Annex), to identify and share all relevant suicide and self-harm Risk Pertinent Information about Ricky; and
• a failure by prison and/or healthcare staff to comply with National Policy in relation to the ACCT open between 7 and 11 October 2023.

Ricky’s Family have bravely fought to shine a light on Ricky’s treatment to bring change for others. Ricky’s mum (Sue Beck), dad (Steve Crosher) and sister (Faye Crosher) attended the hearings and made the following statement after the conclusions:

“Prison isn’t meant to be an enjoyable experience, but it should at least be humane. It should cost people their liberty, not their lives.

 In Lowdham Grange my son was isolated in a tiny space for days on end, with virtually no human contact, no exercise, no meaningful or productive activity. He feared for his safety from further assaults, but his many pleas to be moved or go into segregation fell on deaf ears. His mental and physical health needs were neither understood nor tended to. If you treated a dog that way you would likely (quite rightly) find yourself accused of neglect and cruelty.

 During this inquest, we have heard evidence that working at Lowdham Grange was causing officers stress, anxiety and exhaustion due to continual understaffing, last minute cross deployment and expansion of staff roles without adequate training or support. The communication of critical policies and operating procedures took the form of nothing more effective than emails to staff who were already struggling to stay on top of day-to-day basic duties. High sickness, absence levels and staff attrition all added to the problems. It’s easy to imagine how working there was nightmare. Senior management seemed not to heed the many warnings from staff that the situation in the prison was impossibly chaotic and dangerous. They chose to keep increasing the number of prisoners instead of seeking urgent help to save lives.

 How HMPPS (who had oversight staff on site at Lowdham Grange during Sodexo’s time) failed to see how dire the situation was for so long, we don’t know. 5 men were allowed to die in the months before they finally stepped in.

 It seems to us that Sodexo senior management and HMPPS could and should have recognised much sooner the serious risks to prisoners that the many failings represented. If they had acted sooner the resulting catastrophe may have been avoided and Ricky may still be with us. For us, this is unforgivable!

 We would like to express our heartfelt thanks to the Coroner, who left no stone unturned during the inquest. She exceeded our expectations in her thoroughness and determination to get to the truth. Also, to our legal team who as well as doing an amazing job of pulling all the evidence together and standing up in court, have been so supportive and understanding of our grief and anger throughout the time since Ricky died. We are relieved and delighted that the jury’s conclusions picked up on so many of the obvious failures.

 Although we will never get Ricky back, we are hopeful that his death has served to improve safety for other people in prison. Our sympathies and best wishes go out to the families and loved ones of the men who died in Lowdham Grange after Ricky, who have the ordeal of inquest to face in the coming months.”

 Selen Cavcav, Senior Caseworker at INQUEST says:

“The responsibility for Ricky’s death rests squarely not only with private providers like Sodexo, who put profit before people, but also with the government itself, which continues to hand out these contracts without proper scrutiny. Ricky did everything he possibly could to access the support he desperately needed, yet all the systems that are supposed to protect vulnerable prisoners fell by the wayside. The jury’s findings in this inquest are nothing short of damning. They demand immediate and decisive action to tackle deep-rooted failures that are still putting lives at risk today.”

ENDS

Ricky’s family are represented by INQUEST Lawyers Group members Amalia King and Rachel Tribble of Deighton Pierce Glynn, and Taimour Lay of Garden Court Chambers. Ricky’s family are also supported by INQUEST caseworker Selen Cavcav.

Other Interested Persons represented include Sodexo, the Ministry of Justice and Nottinghamshire NHS Trust.

After the jury’s conclusions, the Area Coroner Laurinda Bower stated that a Prevention of Future Deaths Report will be issued in respect of ongoing concerns about the Safer Custody phoneline at the prison.

For further details see BBC coverage of the hearings:

Cell fire ‘a cry for help’ before prisoner’s death

Prison workers suspended over checks on inmate

‘Vicious circle’ in prison before inmate’s death

If you are feeling low, Samaritans are here – day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch. 

 Notes for media: Please refer to the Samaritans guide on reporting inquests: https://www.samaritans.org/about-samaritans/media-guidelines/guidance-reporting-inquests/

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