07 Feb Inquest into the deaths of three men at Lowdham Grange concludes with findings that multiple individual and system failures contributed to the deaths and the need for “radical change”

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

4 November 2024 to 7 February 2025

HMP Lowdham Grange was the first of several prisons to reach the end of its Private Finance Initiative (“PFI”) contract in 2023. Against the backdrop of a troubled prison Serco lost the contract to Sodexo but within 37 days 3 men were dead at their own hand. Anthony Binfield died on 6 March 2023, David Richards on 13 March and Rolandas Karbauskas on 25 March. All died by ligature.

Returning their conclusions today, 7 February 2025, the jury found multiple individual and system failures had contributed to the deaths including shortcomings in culture and processes, with senior directors “out of touch with issues being faced on the shop floor”. They described the “late recruiting of staff [which] impacted the safer custody team being unmanned and disbanded.”

The jury singled out failings in the mobilisation and transfer process including “poor leadership” and “poor staffing levels forcing cross deployment of staff with no regard for safer custody”.

The jury heard evidence that the transfer was chaotic and under-resourced. Most significantly as the deadline for the handover approached, 15 February 2023, the prison experienced what the Ministry of Justice described as a “haemorrhaging” of staff. Those left behind described feeling “overwhelmed”, “understaffed” and “burnt out” with morale at an “all-time low”.

In an exceptionally hard-hitting Preventing Future Death Report HM Area Coroner has sought formal responses from the Prison Minister, Lord Timpson, Sodexo and HMPSS addressing:

• A complete breakdown in the system of risk identification and information sharing at the prison.
• Her concern that continued understaffing of prison and healthcare teams will undoubtedly contribute to future deaths in custody.
• The need for “a radical change in culture, and reflective learning from deaths” as many of the contributory factors in the deaths had been raised in the investigations into other deaths at the prison.
• The “widespread evidence of failures to do the basics” with “staff fai[ling] to ensure the welfare of prisoners at roll count, fail[ing] to challenge flagrant breaches of prison rules such as passing items under cell doors, and did not know how to properly deal with obscured cell observation hatches” which calls into question “the adequacy of their basic training, and the system for supervision and mentoring”.
• Compelling evidence from prison and healthcare staff that “they were overwhelmed, over- burdened and under-supported in their work at HMP Lowdham Grange”.
• A focus from Sodexo and HMPPS on “the number of staff, rather than the skills set or experience of the staffing body as a whole’ with one stating that “he was considered the most senior on shift in the houseblock with less than 2 years’ experience of working as a prison officer”.
• The system for transfer of prisoners between establishments is disorganised and unsafe with insufficient “scrutiny of the safety of the prison before, during and after the contract exit/transfer process”.
• Evidence that the HMPPS Controllers at HMP Lowdham Grange “did not have a sufficient grasp of the longstanding cultural issues pertaining to safety” which put in e question of the efficacy of the Controller role and “exactly how Controllers assure themselves that the provider is learning from deaths”.
• HMPPS have “no effective system for gathering, retaining, reviewing and disclosing potentially relevant material so that the issues relevant to death can be identified and learning put in place”.
• “It is most concerning that there is a marked discrepancy between the failings that were admitted in oral evidence by the vast majority of witnesses when faced with irrefutable evidence, against the written statements submitted to the coronial investigations which contained very little, if any, reflection and candour. Even after the evidence had been called, the prison organisations did not respond to my request to advance admissions in order to relieve the jury of the burden of making findings on each and every

Rather than prioritise the safety of vulnerable individuals the jury heard evidence that the safer custody function was “disbanded”. Violent incidents in the prison escalated and the jury heard evidence from prison and healthcare employees that they did not feel safe on the wings and nor did the people who lived there. Staff also described significant issues with IT post-transfer which hindered their ability to access critical systems and to make important entries relating to the 3 men that ought to have been made and would have protected them.

Within 5 days of the handover, on 21 February 2023 a senior prison manager who held responsibility for the Safer Custody function raised concerns to prison leadership stating that “things are going to start to get missed” and that he did not want the prison to “come a cropper”.

The inquest was adjourned twice due to the Ministry of Justice not complying with directions for disclosure. During the course of the inquest the Court fined the Ministry of Justice for non-compliance with court directions, a highly unusual development which can now be reported. [1]

Anthony Binfield

Anthony was 30 years old when he died. He had arrived at HMP Lowdham Grange in August 2021 and within matter of months started making applications for transfer to another prison. One such application in late 2022 stated “I have been in danger here for over  a year I have tried to get a transfer many times to no avail!! This is a paper trail to prove I’m under threat”.

• On the weekend before he died, Anthony asked to see mental health staff as he was “feeling very low”. An email from prison to mental health staff about this was never received, because it was sent to new Sodexo email addresses created for healthcare staff without their knowledge.
• Anthony was found under the influence of “spice”[2] in his cell in the days before his death. Anthony was known to be a prolific self-harmer and the jury heard evidence that Anthony’s spice use was a form of self-harm.
• On the evening he died, healthcare staff mandated half-hourly observations due to further spice consumption. CCTV showed that checks were recorded on prison logs that were in fact never completed. One entry on the relevant observation log had been scribbled out. The officer who did this accepted that he had scratched out the entry with such force that the pen had made holes in the paper.
• Following damage to an electricity socket in Anthony’s cell, power to the cell was isolated to prevent injury. Prison staff explained that this would have left the lighting and call bell functional, but no electricity available to the cell. However, Body Worn Video showed that, at some point during the evening, the lighting in Anthony’s cell appears to have stopped working.
• At 9.23pm a prison officer found Anthony’s cell observation panel obscured with paper. There was no response from the cell. Paper had also been hung from inside the cell to obscure the view through the inundation point.[3] There was an 11 minute delay in entering the cell, during which officers used two pens like “chopsticks” to try to move the paper aside. The Coroner’s expert considered that if Anthony’s cell had been entered promptly he would probably have survived.

 

The Area Coroner took what she described as the “exceptional step” of issuing a formal Prevention of Future Deaths report prior to the conclusion of Anthony’s inquest, which can now be reported. This was due to her concerns about a “dangerous culture” around staff responses to obscured observation panels at HMP Lowdham Grange.[4]

Amalia King, of Deighton Pierce Glynn, who represents Anthony’s family said:

“The chaotic handover led to a cruel and inhumane prison, imperilled the lives of the most vulnerable and as the jury have found, contributed to Anthony’s death and those of David and Rolandas in just 37 days”.

“The warning signs were clear, yet too little was done. Frontline staff were left without the training, resources or supervision needed to maintain safety. Even the most basic systems for sharing risk-relevant information were absent. Drugs, bullying and violence took hold. Senior managers remained disconnected from the cruel reality faced by the most vulnerable in their care. Instead of addressing the obvious risks, plans were made to run the prison without adequately staffing the specialist Safer Custody team, removing a critical safeguard. Lowdham Grange is a stark example of how leadership failures create unsafe conditions for all those living and working in a prison. Without urgent change, further serious incidents and loss of life are inevitable.

Anthony’s pleas for help were ignored while he was at Lowdham Grange. His words were heard at the inquest and best tell the impact of living in a prison where the most basic safety systems are broken. Anthony wrote: “These fucking backwards places have finally got the better of me. Taking years of my life was not enough! I always told myself I would not be a statistic and die in prison… The system would have trapped me forever always dictating my life. I have been failed continuously by every part of the prison system and finally I have no hope left, no happiness…”.

David Richards

 

David died on 13 March 2023. He had arrived at HMP Lowdham Grange on the 24 February 2023 just days after Sodexo took charge. .

 

• On arrival at HMP Lowdham Grange, David expressed concerns about his safety at HMP Lowdham Grange. He had been placed on the Vulnerable Prisoner Unit at his previous prison for his own protection. Lowdham Grange didn’t have a VPU. One staff member described him as like a “rabbit in headlights”. David was moved onto the induction wing initially. The same staff member considered that he would be “eaten alive” on one of the main wings. David later told a mental health professional he was “petrified” in prison.

 

• David was told before lunchtime on 13 March that he would need to move off the induction wing that afternoon. Around this time, efforts were being made to clear space in cells on the induction wing to accommodate a forthcoming increase in prisoner numbers at HMP Lowdham Grange.

 

• David’s cell door was locked at 11.10am. At 1.16pm a fellow prisoner, who had described David as “very nervous” about the move, went to David’s cell to check on him. This prisoner found David ligated in his cell.

 

David had expressed feelings of suicidal ideation in his previous prison and had attempted suicide in the community. He was prescribed antidepressant and antipsychotic medication. At his previous prison, he had to take this under supervision. At HMP Lowdham Grange, healthcare staff working for Nottinghamshire NHS Trust risk assessed him as suitable to have this medication in his possession. During the inquest, Trust accepted that in light of his medical history this decision was not appropriate. Toxicology evidence indicated that David had not taken his medication for at least 5-6 days at the point he died.

Jo Eggleton, of Deighton Pierce Glynn, who represents David’s family said: “Some of the evidence heard was truly shocking. Anthony, David and Rolandas may have died almost 2 years ago but be under no illusion that this is all in the past. Five more men have died while these inquests have been underway. This suggests the prison is as unsafe now as it was then. Urgent decisive steps to prioritise safety need to be taken now. It is not encouraging to hear that the prison is about to get it’s sixth new Governor/Director in 4 years”.

David Richards’ family said: “David was just 42 years when died. He was a much-loved son, brother,nephew and cousin. He was a force of nature who lived life and although it was cut short, he lived it to the full. To people who really knew him, David was a sensitive soul, he had a kind and caring nature and would not have hesitated in giving you his last pound should you have needed it.”

 

Rolandas Karbauskas

Rolandas died five days after his arrival in the prison. He was a Lithuanian national and spoke extremely limited English.

• When Rolandas arrived at the prison, problems with the telephone interpretation service meant that a fellow person in prison had to translate. Rolandas told the reception nurse that he had depression and wished to start medication. The nurse made an urgent mental health referral, noting that he spoke no English at all and would require a translator.

 

• On 22 March Rolandas had a meeting with prison staff in which it was clear that he had not been eating, had previous problems with alcohol, remained unmedicated, spoke virtually no English and had no family support. At no stage was a plan put in plan to address his risk of isolation. Records show that Rolandas had a nut allergy, something about which no witnesses to the inquest were aware.

 

• On 23 March Rolandas was seen by a mental health nurse, who did not book an interpreter. The nurse gave evidence that, in order to assess Rolandas’ risk to of suicide, the nurse asked “Do you want to die?” and made a gesture drawing his hand across his neck.

 

• On 24 March a fellow person in prison observed that Rolandas was not eating and was giving food away. That same person directly raised concerns with an officer but no specific action was taken. Rolandas was locked in his cell at 4.59pm hours on 24 March. At 9.47am his door was unlocked but, contrary to policy, no welfare check was conducted. At 10.29am a fellow person in prison found him ligated.

 

Events since these deaths

In December 2023, the Ministry of Justice took back control of the prison from Sodexo. Since these three deaths, there have been six further deaths in HMP Lowdham Grange, the causes of which have yet to be determined. In a press release accompanying their most recent inspection report in February 2024, the Chief Inspector of Prisons observed: “It’s unprecedented for the prison service to use their power to ‘step in’ and take back control of a privately run prison, so we knew Lowdham was struggling, but even so we were shocked by quite how bad things had got at the jail.”

Selen Cavav of INQUEST says:

“This damning inquest conclusion exposes once again that greed and putting profit before people, kills. The abhorrent failures which led to the deaths of Anthony, David and Rolandas are horribly familiar when it comes to the track record of the private providers that run our prisons, immigration removal centres and secure training centres.

 But we cannot just lay the blame solely at their door steps. Ultimately it is MoJ who hands out these contracts without due diligence and care. We know that nine other people have died at Lowdham Grange since March 2023, with two having died within the last four weeks. 

Our prison service, whether it is private or state run, is not fit for purpose. We cannot continue locking people up to die. Instead of investing in more prisons and punishment, the government must address the root causes of harm and invest in community services.”

 

ENDS
The family are supported by INQUEST caseworker Selen Cavcav.

The Families of Anthony Binfield and David Richards are represented by INQUEST Lawyers Group members Jo Eggleton, Amalia King and Rachel Tribble of Deighton Pierce Glynn, and Fiona Murphy KC and Stephanie Davin of Doughty Street Chambers.

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

 

[1] A fine was issued pursuant to Schedule 6 of the Coroners and Justice Act 2009 following several notices made under Schedule 5 of the same Act.

[2] New Psychoactive Substances (“NPS”)

[3] This is a hole in the cell designed only for use to quell fires, not to view individuals in their cell.

[4] This ‘Prevention of Future Deaths report, issued pursuant to paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013