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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”

HMP Lowdham Grange was the first of several prisons to reach the end of its Private Finance Initiative (“PFI”) contract in 2023. In February 2023 it was handed over from Serco to Sodexo – the first ever transfer of a prison from one private provider to another. The following month three men called Anthony, David and Rolandas died in the prison. All died by ligature. 

The Area Coroner joined the inquests into their deaths, which were heard in Nottinghamshire Coroner’s Court from 4 November 2024 and concluded on 7 February 2025. 

The jury found that 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”. The jury singled out failings in the mobilisation and transfer process including poor leadership and poor staffing levels. This followed evidence that the transfer was chaotic and under-resourced.

HM Area Coroner issued a Prevention of Future Deaths report in which she described a “complete breakdown in the system of risk identification and information sharing” at the prison and “widespread evidence of failures to do the basics”. 

The report contains stark criticism of Sodexo, Serco and the Ministry of Justice for failing to approach the inquests with candour. The Area Coroner stated that she is troubled that, without a “radical change in culture” more men will die in the prison. 

This follows two highly unusual procedural developments in these inquests which have been subject to reporting restrictions to date: 

  • First, 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. 
     
  • Second, the Coroner issued a fine to the Ministry of Justice (under Schedule 6 of the Coroners and Justice Act 2009) for repeated failures to comply with directions for disclosure. 

Fiona Murphy KC and Stephanie Davin acted for the families of Anthony Binfield and David Richards. The jury heard evidence that both were in fear at HMP Lowdham Grange: 

  • Anthony, a prolific self-harmer, was found under the influence of spice in the days before he died and he 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. On the evening Anthony died, mandatory checks were recorded on logs but not completed. There was an 11 minute delay in entering his cell which the jury found probably contributed to his death. 
     
  • David was described as like a “rabbit in headlights” upon arrival to the prison a few days after the transfer to Sodexo. One staff member considered that he would be “eaten alive” on one of the main wings. On the day he died, David was told before lunchtime 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 was found by another prisoner ligated in his cell that afternoon.   

Rolandas Karbauskas died five days after his arrival in the prison. He was a Lithuanian national and spoke extremely limited English. Staff at HMP Lowdham Grange were aware that Rolandas was not eating, had previous problems with alcohol, remained unmedicated for mental health problems, spoke virtually no English and had no family support. At no stage was a plan put in plan to address his risk of isolation and an urgent mental health assessment was carried out without an interpreter. Rolandas, like David, ligated and was found by a fellow prisoner. 

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.” 

The inquests attracted national media attention. Selected press includes:  

Fiona and Stephanie were instructed by Jo Eggleton, Amalia King and Rachel Tribble of Deighton Pierce Glynn. The families are supported by INQUEST caseworker Selen Cavcav.

You can contact the Samaritans for free on 116 123 or from prison on 0845 450 7797.