“(brief summary of matters of concern) The accounts detailing Christopher’s decline over…”

The coroner’s concerns

(brief summary of matters of concern) The accounts detailing Christopher’s decline over the course of a week; from a young, fit, engaging and polite gentleman, to a man who could not speak, eat, or properly stand, were harrowing for all to hear, not least his family. These accounts were supported by CCTV footage demonstrating Christopher’s extreme vulnerability on account of his acute ill health. I remain unable to comprehend how, in the face of Christopher’s clear need for urgent medical assistance, this was not facilitated for him by those charged with the responsibility for his care, at a time when Christopher was unable through illness to ask for help. This was a clear case of the most serious neglect contributing to Christopher’ tragic death. 1. An inability to provide prisoners at HMP Lowdham Grange with safe clinical care I heard evidence, and the jury reached findings, that there was an unsafe practice of staff conducting important healthcare and wellbeing observations via the cell door observation hatch. Observing an unwell prisoner through a hatch slightly larger than a letterbox undermines the safety of the clinical assessment. Healthcare staff did not utilise the NEWS2 system of monitoring the condition of an acutely unwell prisoner, despite the Trust having adopted this recognised healthcare tool many years prior. The Forensic Directorate has continued to lag behind other areas of the Trust where NEWS2 is fully embedded and this has previously been identified as an issue linked to other deaths. There was a lack of robust GP visits, despite such being mandated by the Prison Rules. When visits did take place, they were often via the cell door observation hatch and conducted as “fleeting glances” rather than robust clinical assessments. Again, this is unsafe. There was a lack of effective leadership of the healthcare department to ensure that staff had created a safe plan of care for Christopher. Senior personnel were not aware of Christopher’s week-long deterioration in the segregation unit until very late in the chronology of events, nor were they aware of a dispute between the mental health and physical health teams as to the differential diagnoses that might be causing his concerning symptoms and deterioration. Despite daily lunch time meetings, there was a stark lack of professional curiosity from senior staff as to the plan of care for Christopher and what safety netting, if any, was in place. 2. An inability to record, retain and supply HM Coroner with material relevant to the inquest The progress of this inquest, taking places years after Christopher’s death, was halted many times due to the late disclosure of material relevant to the inquest. Policies and procedures said to exist at the time were produced mid-hearing. Despite the Trust having conducted their own review of the case, being provided with ample notice of the inquest hearing, and having attended multiple pre-inquest review hearings, there was an inability to identify key material and to supply that to the court in good time. The ability to reflect on the care provided in advance of a prisoner’s death is dependant on the Trust’s ability to isolate the relevant evidence, and to analyse it. Without the appropriate professional curiosity to understand exactly what happened, the Trust will repeatedly miss opportunities to learn from deaths and to take action to seek to prevent future deaths. Regulation 28 – After Inquest Document Template Updated 30/07/2021 An example of this, is the issue of a lack of safe system for NEWS2 monitoring of acutely unwell patients. This issue has repeatedly been raised at inquests involving the Trust’s forensic division. 3. A complete lack of candour, openness and honesty when engaging in post death investigations. Without exception, each witness from the healthcare trust accepted some level of failing in the care they provided to Christopher. Yet none of the witness statements submitted in advance of the inquest contained any such reflection of what went wrong or what should have happened. Despite a Direction from the court that the Head of Healthcare was to submit a statement “nailing colours to the mast” as to what the genuine issues of care were i.e. what policies were in place at the material time and whether care had departed from those policies, a candid statement satisfying this Direction was not forthcoming. This left the Coroner and the other Interested Persons, especially Christopher’s family, at a distinct disadvantage in identifying the actual issues, because of an overwhelming unwillingness to act in an open and honest manner, contrary to the expectations of a state agency when engaging in an inquest. If staff are either unwilling, or are not given the opportunity, to reflect on what went wrong in an open and honest manner, then the Trust cannot seek to learn from events at the earliest opportunity, and these issues of concern will persist, leading to further deaths.

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, 2023-0420

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8 Oct 2026

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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