Source · Prevention of Future Deaths

Colin Lovett

Ref: 2025-0265 Date: 30 May 2025 Coroner: Rachael Griffin Area: Dorset Responses identified: 2 / 2 View PDF

Prison staff lack essential diabetes training and understanding of critical attacks. Non-24/7 healthcare and poor awareness among staff risk delayed care and future deaths for insulin-dependent prisoners.

Date 30 May 2025

56-day deadline 25 Jul 2025 est.

Responses identified 2 of 2

Alcohol, drug and medication related deaths State Custody related deaths

Coroner's concerns

AI summary

View full coroner's concerns

(1) Evidence was provided by the Prison Service staff during the Inquest that they have never received training about diabetes and there is a lack of understanding, and national guidance for Prison Service staff relating to the symptoms of a hypo glycaemic or hyper glycaemic attack, which can be fatal.

(2) The healthcare department at HMP The Verne is only operated between 7.30am and 6pm daily and is not therefore available 24 hours a day. Outside of these operational times, access to healthcare would be via 111 or 999 which could cause delay in action being taken to resolve a hypo glycaemic or hyper glycaemic attack. This will be the position in other prisons nationally.

(3) Whilst insulin dependent diabetics are likely to be experts in their own care, some prisoners may have poorly managed diabetes and require support which could be at any time.

(4) It is acknowledged that there is a balance to be stuck with training non-medical individuals in diagnosing medical symptoms, which could lead to miss diagnosis, and ensuring care is provided without delay, however the Head of Healthcare at HMP the Verne stated that there would be benefit in providing an awareness to Prison Service staff of the impact on prisoners of long term conditions such as diabetes.

(5) Several members of Prison Service staff gave evidence at the Inquest and only one, who had personal experience through a family member, had an understanding of diabetes and the impact it can have upon an individual, including the symptoms of a hypo glycaemic or hyper glycaemic attack.

(6) Prisoners are dependent upon support provided by Prison Staff. I am concerned that the lack of awareness of the needs of prisoners with insulin dependent diabetes amongst Prison Service staff who provide care to prisoners at times when healthcare staff are not on site, could lead to future deaths. .

(7) Although the evidence was based on the position at HMP The Verne, I am concerned this could be apply to other prisons nationally.

“6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.

Responses

2 respondents

HM Prison and Probation Service Central Government

4 Aug 2025 PDF

Disputed

HMPPS does not believe it's necessary or appropriate to require all operational prison staff to undertake specific diabetes awareness training. However, following discussion with the Governor, the healthcare provider at The Verne has provided a diabetes awareness and guidance document which has been disseminated to all staff. (AI summary)

View full response

Dear Ms Griffin

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

Thank you for your Regulation 28 report of 30 May 2025 following the inquest into the death of Colin Lovett at HMP The Verne, which was sent to the Secretary of State for Health and Social Care and His Majesty’s Prison and Probation Service (HMPPS). I am responding on behalf of HMPPS as Director General of Operations.

I know that you will share a copy of this response with Mr Lovett’s family, and I would firstly like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.

Following evidence heard at the inquest, you have raised concerns regarding diabetes awareness training among prison staff and emphasised the importance of this in the light of the restricted operating hours of the healthcare provider at HMP The Verne. My response will address the point about staff awareness training, and I understand that NHS England will send a separate response addressing the issue of healthcare operating hours, as they have responsibility for the commissioning of healthcare services within prisons.

Whilst HMPPS is committed to working closely with healthcare partners to support the wellbeing of individuals in custody it is important that prisoners’ health concerns are managed effectively by trained healthcare professionals. The role of prison staff, who are not medically trained, is to ensure that the healthcare provider is made aware of any concerns about prisoners’ wellbeing, and to carry out appropriate non-clinical actions to support healthcare colleagues.

I understand your concern to ensure that prisoners with diabetes receive high quality care. However, I do not believe that it is necessary or appropriate to require all operational prison staff to undertake specific training or awareness sessions relating to diabetes. Training time is limited and there are many other topics that are of higher priority and/or have more general application. Instead, where a healthcare provider identifies a need for prison officers to have increased awareness of diabetes (or any other particular medical condition) locally, they are able to raise this with the Governor and consideration can then be given to developing local awareness sessions, which can be delivered by healthcare staff as deemed necessary.

This is precisely what has now happened at The Verne where following discussion with the Governor, the healthcare provider has provided a diabetes awareness and guidance document which has been disseminated to all staff.

Thank you for bringing your concern to my attention. I trust that this response provides assurance that local action has been taken to address it.

Department of Health and Social Care Central Government

22 Aug 2025 PDF

Action Planned

NHS England will share the details of this case and concerns raised with all regional health and justice commissioning teams, along with links to NICE guidance and the National Diabetes Audit. (AI summary)

View full response

Dear Ms Griffin,

Thank you for your Regulation 28 report of 30 May 2025 sent to the Secretary of State about the death of Colin David Lovett.

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Lovett’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. Thank you for the additional time provided to the Department to provide this response to the concerns raised in your report.

Your report raises concerns over a lack of training and guidance for prison staff regarding diabetes and its effects, the restricted hours of availability of healthcare services at HMP The Verne and how that could impact on prisoners with diabetes, support for prisoners with poorly managed diabetes and a general lack of awareness among prison staff at The Verne and perhaps more widely within the prison sector about the management of long term conditions like diabetes.

In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns related to healthcare services at the prison. Your other concerns regarding issues related to training, guidance and raising awareness of diabetes for prison staff are for the Director General Chief Executive of His Majesty’s Prison and Probation Service to address in their response to you.

I understand your concerns about the healthcare services at HMP The Verne not being available 24 hours a day, which could mean delays in action being taken to resolve a hypo glycaemic or hyper glycaemic attack outside of its operational hours. However, this is a Category C prison, and under the Health and Social Care Act 2022, NHS England is required to ensure the provision of healthcare to Category C prisons is within core hours. This is equivalent with community provision.

The core hours of healthcare provision are agreed between health and justice commissioners based on local population needs, identified through a comprehensive health needs assessment. The Act states that urgent and out of hours care is the responsibility of integrated care boards for all prisons. Healthcare providers, supported by NHS England regional health and justice commissioning teams should work with local out of hours and urgent care services to agree effective pathways for any urgent care needs outside of routine healthcare hours.

As your report has highlighted, some prisoners may have poorly managed diabetes and may require support at any time. NHS England service specifications for prison healthcare require all healthcare providers to comply with National Institute for Health and Care Excellence (NICE) guidance on Type 1 diabetes in adults: diagnosis and management which is available at: https://www.nice.org.uk/guidance/ng17 and guidance on Type 2 diabetes in adults: management which is available at: https://www.nice.org.uk/guidance/ng28

Both of these include recommendations for healthcare staff to ensure individualised care and education, which would include arrangements for out of hours care and deteriorating health. Any high-risk patients should be alerted to prison staff, with an outline of emergency escalations.

As a result of your report, NHS England has agreed to share the details of this case and the concerns raised by you with all regional health and justice commissioning teams, along with links to the relevant NICE guidance and the National Diabetes Audit - a comprehensive, England and Wales-based audit that measures the effectiveness of diabetes care against NICE guidance (and now includes prison healthcare data). This is to ensure that learning from this case is spread nationally.

As signatories to the National Partnership Agreement for Health and Social Care for England, the Department of Health and Social Care and NHS England are committed to working with partners to reduce health inequalities for people in prison and improving services to ensure that people have access to timely and effective healthcare whilst in prison. I would like to inform you that the Chief Medical Officer for England’s report on health in prisons is due to be published this year and will provide recommendations for further action.

I hope this response is helpful. Thank you for bringing these concerns to my attention. All good wishes,

PARLIAMENTARY UNDER-SECRETARY OF STATE FOR PATIENT SAFETY, WOMEN’S HEALTH AND MENTAL HEALTH.

Report sections

Investigation and inquest

On 4th November 2022, I commenced an investigation into the death of Colin David Lovett, born on the 26th February 1969 who was aged 53 years at the time of his death. The investigation concluded at the end of the Inquest before a jury on the 28th May 2025. The medical cause of death was:

Ia Insulin overdosage

II Hypertensive and Ischaemic Heart Disease

The conclusion of the Inquest was:

Suicide –

We The Jury believes that there were contributory factors related to Colin's suicide as follows:

1. The decision of the monitoring of the telephone calls Colin made following the review on the 11th October 2022 and the lack of the monitoring of Colin's telephone calls after the 11th October 2022 probably contributed more than minimally to his death.
2. Colin's access to medication in his cell possibly contributed more than minimally to his death.
3. The inadequacy of Colin's risk management and support at HMP The Verne possibly contributed more than minimally to his death.

Circumstances of the death

On the 29th October 2022 Colin, who was diagnosed with Type 1 Diabetes in 1989 for which he was insulin dependent, was found in a collapsed and unresponsive condition in his room, Room 5 on Wing B1 at HMP the Verne, Portland Dorset.

Copies sent to

HMP the VerneMinistry of JusticePractice Plus Group (PPG)Oxleas NHS Foundation TrustDorset County Hospital NHS Foundation Trust

Inquest conclusion

1. The decision of the monitoring of the telephone calls Colin made following the review on the 11th October 2022 and the lack of the monitoring of Colin's telephone calls after the 11th October 2022 probably contributed more than minimally to his death.
2. Colin's access to medication in his cell possibly contributed more than minimally to his death.
3. The inadequacy of Colin's risk management and support at HMP The Verne possibly contributed more than minimally to his death.

Similar PFD reports

Shared signals

Report details

Reference: 2025-0265
Date of report: 30 May 2025
Coroner: Rachael Griffin
Coroner area: Dorset

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 25 Jul 2025 (estimated).

Sent to

Department of Health and Social Care

HMPPS

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.