“Matters of Operational Concern While the evidence called at inquest relates to HMP…”

The coroner’s concerns

– Matters of Operational Concern While the evidence called at inquest relates to HMP Lowdham Grange, these issues are likely to be relevant across the prison estate, and for that reason I highlight my concerns to both the Minister for Prisons and NHS England as commissioners for prison healthcare. 1. Recruitment, retention and training of prison and healthcare staff (response required by the Minister for Prisons and NHSE) Staffing levels I heard compelling evidence from prison and healthcare staff who told me they were overwhelmed, overburdened and under-supported in their work at HMP Lowdham Grange. I understand from both prison providers (Serco and Sodexo) and the Healthcare Trust (Nottinghamshire Healthcare NHS Foundation Trust), that recruitment and retention of staff was a persistent challenge, meaning more often than not the staff on shift were required to cover more than their fair workload. This led to low staff morale, higher levels of sickness absence, and an inevitable deterioration in prisoner safety. The inadequate prison and healthcare staffing levels led to a restricted regime and healthcare provision. The prison was unable to offer keywork to all men, and the mental health team could no longer offer a named nurse service. Both of these aspects of care are fundamental to supporting the most vulnerable prisoners. For months prior to the deaths, the Trust failed to fulfil its commissioned obligations to provide a nurse during night state. Prison staff have only basic first aid training and lacked the expertise of a medical professional when attempting to provide CPR to Anthony. Skill mix and experience I am concerned by the failure to retain experienced prison officers and healthcare staff. The private prison operator and the Authority were focused on the number of staff, rather than the skills set or experience of the staffing body as a whole. One PCO told me 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 healthcare team had worked for a protracted period with no permanent Head of Service in post. Without a sufficient number of experienced staff, the prison had lost organisational memory, allowing poor custom and practice to become the norm amongst inexperienced and overwhelmed staff. Training All of the prison staff had completed the ITC programme, and yet there was widespread evidence of failures to do the basics. Staff failed to ensure the welfare of prisoners at roll count, failed 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. This calls into question the adequacy of their basic training, and the system for supervision and mentoring during the early years of practice. Healthcare staff were often not included in the same training as prison staff, and where agency staff were used to fill vacancies, they were not part of Trust training. Again, this led to poor custom and practice such as failing to read medical records before reviewing the mental health and wellbeing of the prisoners. Accepting there is a complex interplay between staffing numbers, experience and quality of training, I highlight to you my concern that continued understaffing of prison and healthcare teams will undoubtedly contribute to future deaths in custody. 2. A complete failure to identify and share risk pertinent information between prison and healthcare staff, and within those teams (response required from the Minister for Prisons, NHSE, Serco, Sodexo and Nottinghamshire Healthcare NHS Foundation Trust) The staff remaining at the prison in March 2023 were, by their own admission, firefighting what was in front of them, rather than working in a collaborative and holistic way to better serve prisoner safety. There was a complete breakdown in the system of risk identification and information sharing. Prison and healthcare staff did not routinely consider information captured within the electronic systems, nor did they update the systems with risk pertinent information gathered during interactions with the prisoners. The prison records (the core file and P-NOMIS) and healthcare records (systemone) are a valuable source of risk pertinent information, that will enable prison and healthcare staff to comply with the mandatory requirement of PSI 64/2011 “All staff who have contact with prisoners must be aware of the triggers that may increase the risk of suicide, self-harm or violence, and take appropriate action.” Many prison and healthcare witnesses believed there was no working system in place at HMP Lowdham Grange to allow them to identify and share risk pertinent information. As a result, operational decisions were made in silo, and interactions with Anthony, David and Rolandas, were conducted without due consideration of their risk pertinent information. This causes concern from both a training and policy perspective. It would be impossible for prison and healthcare staff to remember the triggers for each and every prisoner in their care. Therefore, the system in place needs to make it as easy as possible for staff to quickly and readily understand the risk that exits for the prisoner and what might trigger that risk to materialise in any given circumstance. In this case, as in previous deaths, there was excessive focus on the prisoner’s current presentation (i.e. the absence of saying they were going to harm themselves) without any understanding of their previous self-harm and suicidality. Specific missed opportunities included:  a failure by prison and healthcare staff to read the incoming prisoner’s core file. This hard copy file contains valuable information such as previous ACCT documents and SASH warning forms, yet instead of reviewing this material and pulling out key triggers for past self-harm and suicidality and recording the same on P-NOMIS and/or systemone, the

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, 2025-0079

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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