31 Aug Inquest jury finds neglect by staff contributed to prisoner’s murder
The inquest into the death of 43-year-old Brett Lowe concluded on Monday 22 August 2022, with the jury finding that Brett’s death was preventable and there was gross failure to take basic steps to safeguard Brett, with prison staff consistently failing to execute their responsibilities. They concluded that Brett’s murder at the hands of his cellmate was contributed to by neglect. The jury found that Brett took every opportunity available to him to alert staff to the risk to his own life and that staff failed to intervene at any time in the chain of events. The jury also highlighted systemic issues contributing to Brett’s death, including issues with leadership, culture and training.
On 16 July 2018 two men arriving at Nottingham Prison were allocated the shared cell D206 on the prison’s induction unit, D wing. One of these men was Ferencz-Rudolf Pusok, who would go on to murder Brett only two days later in the same cell. The jury heard that D wing was in a state of pandemonium at that time. The Governor at the time, Phil Novas told the inquest that Nottingham was the worst prison he had worked in in his 32-year career.
Overnight the prisoner sharing with Pusok felt seriously threatened by Pusok’s behaviour. He came to fear that Pusok was going to “hot water” him, after he repeatedly boiled the kettle during the night. The man kept himself awake all night so he could fend off any attack. The following morning, on 17 July 2018, he told the officer who unlocked him what had happened and requested a cell move. His concerns were not documented or acted upon at all and he was placed back into the cell with Pusok. He was moved off the wing later for unrelated reasons.
Brett arrived at the prison later that evening. He was a remand prisoner and was awaiting his trial date. He was put into cell D206 with Pusok. Brett awoke in the middle of the night to find Pusok attempting to strangle him. He activated his cell bell at 03:41 and reported that his cell mate had attempted to throttle him. The responding officer described that Brett had “fear in his eyes” and told the jury that Pusok made no attempt to deny what he had done, simply sitting “with an evil look in his eyes.” The only action taken was to report this verbally to a Senior Officer. No action was taken to separate them. No record was made of the incident. No reference was made to the incident in the morning handover.
As soon as he was unlocked on 18 July Brett reported what had occurred to a Senior Officer who agreed to a cell move, but rather than action that move he told Brett to go to the wing office to facilitate a move by himself. At the office Brett again alerted staff to the incident and requested a cell move but he wasn’t moved, no further investigation of the incident took place, and nothing was recorded to indicate the severity and heightened risk.
Brett was locked back in the cell with his cell mate at about 9am. Sometime between 09:00 and 10:20, while locked in the cell, Brett sustained serious injuries as result of a horrific assault by Pusok. He was discovered at 10:21 lying unresponsive on the cell floor. He died that day as a result of ligature and strangulation injuries inflicted by Pusok, who would go on to plead guilty to Brett’s murder. No motive was ever provided for the vicious murder.
The jury found that Brett’s death was preventable had reasonable actions been taken but opportunities were missed due to failures of communication; lack of staff accountability and a failure to provide a safe environment for Brett. They found that systemic issues regarding staffing, leadership, document reporting, training, communication, culture & risk assessments all contributed to Brett’s death.
The current Governor of Nottingham, Paul Yates told the Coroner that the OSG on duty overnight on 17-18 July has been dismissed for gross misconduct and that disciplinary proceedings will be reviewed regarding others following the conclusion of the inquest.
Brett’s family said: “Our lives have been on hold for so long now waiting for answers about how this was allowed to happen. I expected the witnesses to focus on my brother but all I heard was people trying to avoid accountability and save their own skins, including some of them lying on oath. I am angry that Brett was so viciously and pointlessly murdered and I’m angry that Bret was let down by so many people in the prison. It was their job to keep him safe and they didn’t, even when he told them what was happening and asked for help. How could they just ignore him? If just one of them had done something he would be here now.”