“Failure to have in place an appropriately staffed and resourced Safer Custody function 2”
Dated 20 May 2026, from the coroner for Nottingham City and Nottinghamshire. Sent to 4 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Report put online after its 56 daysOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
judiciary.uk put this report online on 28 Jul 2026, after the 56 days for replies had ended (15 Jul 2026). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated20 May 2026
- Deadline15 Jul 2026
- Published on judiciary.uk28 Jul 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| HMP Lowdham Grange | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Nottingham and the Head of Healthcare | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| HMP Lowdham Grange | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Northamptonshire Healthcare NHS Foundation Trust | Response publishedPublished on judiciary.uk in July 2026. |
The coroner’s concerns
1. Failure to have in place an appropriately staffed and resourced Safer Custody function 2. Failure to have in place a robust system for managing the safer custody telephone line 3. Failure to provide a safe Care and Separation Unit which adhered to expected policy and minimum standards of decency 4. Persistent failure to have in place a robust system for learning from deaths 5. Failure to retain evidence pertinent to the death 6. Failure to ensure a safe and productive working relationship between prison and healthcare staff 11. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles] Ricky’s Family Matthew’s Family HMPPS Sodexo Northamptonshire NHS Foundation Trust (the new healthcare provider) I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12. SIGNATURE Miss Laurinda Bower HM Area Coroner Nottingham City and Nottinghamshire
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2026-0277
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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