Source · Prevention of Future Deaths

Anthony Binfield

Ref: 2025-0080 Date: 17 Dec 2025 Coroner: Laurinda Bower Area: Nottingham City and Nottinghamshire Responses identified: 1 / 1 View PDF

A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm risk, persists despite repeated policy reminders and staff unawareness.

Date 17 Dec 2025

56-day deadline 11 Feb 2026 est.

Responses identified 1 of 1

State Custody related deaths Suicide (from 2015)

Coroner's concerns

AI summary

A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm risk, persists despite repeated policy reminders and staff unawareness.

View full coroner's concerns

(1) Prison staff failing to manage the covering of cell observation panels in a safe way that is compliant with the policy and guidance issued by the prison over many years. I am taking the exceptional step of writing to you formally before the conclusion of the inquest as I am so concerned by the evidence called to date regarding the custom and practice of officers when discovering obscured cell observation panels at night. There is a dangerous culture of staff assuming the prisoner has obscured the observation panel for privacy purposes or as a form of protest against the regime. This neglects the obvious and very real risk that the prisoner is seeking to harm themselves, without detection. The HMPPS Safety Nudge, issued in February 2018, made clear that cell observation panels are a vital tool in keeping prisoners safe and must be kept clear at all times in order to preserve life. The custom and practice of seeking to visualise the prisoner via the inundation unit hole (and other means, such as the side of the door) has developed over time and is now an embedded culture accepted by many officers as a response to this occurrence. This practice leads to delay in entering the cell, risks lives and is contrary to policy. This is not a new issue for the prison and hence my concern that the prison has failed to tackle this issue over many years. In August 2020, a prisoner died at HMP Lowdham Grange as a result of drug use. When officers conducted a welfare check they found his cell observation panel to be obscured. Contrary to policy and guidance, Prison staff delayed entering the cell while they fetched the inundation unit key to attempt to observe inside the cell. The Prison and Probation Ombudsman made a recommendation to the Prison Director that they should ensure that observation panels are kept clear, and that staff actively challenge prisoners who cover them. In response, the Prison Director issued a notice to staff in January 2021 reminding staff of the need to treat any prisoner as unresponsive if they fail to acknowledge the officer, and to call a code blue. A similar notice was issued in April 2021, reminding staff of the need to perform a dynamic risk assessment and enter the cell in a quick and safe manner when there is no response to asking the prisoner to remove the offending item. The notice was re-issued in November 2021, and after the inquest in approximately April 2023. Despite these multiple notices, a number of witnesses who remain members of staff at the prison (now under HMPPS employ) reported being unaware of the expected procedure when faced with an obscured cell observation panel until attending Anthony’s inquest in December 2024. It is clear that the issuing of staff notices has not addressed the problem of prisoners covering their cell hatches, nor the unsafe custom and practice of staff leaving the cell and thereby delaying safe entry.

Responses

1 respondent

HM Prison and Probation Service Central Government

PDF

Action Taken

HMPPS has reinforced the importance of clear observation panels at HMP Lowdham Grange through staff briefings, Governor's orders, and video messages to prisoners. Prisoners blocking panels may face sanctions and a new local PFD meeting has been established. (AI summary)

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Dear Miss Bower,

Thank you for your Regulation 28 report of 17 December 2024 addressed to the Governor of HMP Lowdham Grange following evidence heard at the inquest into the death of Mr Anthony Binfield who died at the prison on 6 March 2023 when the prison was managed by Sodexo. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations.

I know that you will share a copy of this response with Mr Binfield’s family, and I would 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 a concern about blocked observation panels and how staff manage this challenge, and I share your concern. The covering of observation panels represents a threat to the safety of prisoners, the safety of staff and the security of the prison.

It is crucial that staff carry out regular safety checks on prisoners when they are locked in their cells. Every time staff approach a prisoner’s cell they must ensure that the observation panel is clear of obstruction in case of an emergency situation. The obscuring of observation panels is a constant challenge across the prison estate as prisoners continue to cover and block observation panels for a variety of reasons, including for privacy and decency. However, HMPPS has a clear stance on the issue and all prisons must set out to staff what action should be taken if an observation panel is found to be covered or blocked.

I have received assurances from the Governing Governor of HMP Lowdham Grange that since the prison formally became a public sector prison in August 2024, action has been taken to increase staff confidence, skills and understanding of relevant policies and procedures. The prison recognises the inherent risks of blocked observation panels and has taken a number of proactive steps to ensure that staff and prisoners understand the importance of the panels remaining uncovered at all times. There is now a specific

reference made to the blocking of observation panels within the Incentives Policy Framework. This means that prisoners who continue to block observation panels may receive warnings, loss of privileges; or other formal sanctions awarded by a governor grade during a formal adjudication process.

It has been made clear to staff and prisoners that the covering of observation panels is unacceptable. This message is regularly communicated to staff through face-to-face briefings where staff have been reminded of the action that must be taken in circumstances where a response cannot be elicited from a prisoner and where visual observations of the inside of the cell cannot be made. This issue was the subject of notices to staff and a Governor’s order on a number of occasions last year, and the most recent reminder was published in January 2025. In addition to regular reminders, all new staff and Operational Support Grades (OSGs) at the prison now receive a briefing on observation panels during their induction period.

It is vital that prisoners also recognise the importance of observation panels remaining clear and the consequences they could face if they choose to block them. This message has been conveyed to the prisoner population through video messages over the last 12 months, with the most recent video message published in January 2025.

In recognition of the fact that blocked observation panels have featured in previous deaths in custody at the prison, a new local prevention of future deaths (PFD) meeting has been established to ensure that matters of concern are kept under review and the enforcement of messages and action from continued learning are discussed regularly.

Thank you again for bringing your concerns to my attention. I trust that my response underscores a commitment to reducing the prevalence of this behaviour and provides assurance that action is being taken by the Governing Governor to address this matter at the prison.

Report sections

Investigation and inquest

On 7 March 2023, I commenced an investigation into the death of Anthony Binfield. The inquest has not yet completed.

Circumstances of the death

Anthony Binfield died as a result of ligature asphyxiation inside his cell on H wing, Houseblock 2, at HMP Lowdham Grange, Nottinghamshire, at 22.19 hours on Monday 6 March 2023. At 21.23 hours, while undertaking an NPS log check, a prison officer found that Anthony had covered his cell observation panel from the inside. Contrary to the expected policy and guidance in place at the time, the officer left the cell after gaining no response to knocking and returned to the office to collect the inundation unit key. He returned to Anthony’s cell and attempted to remove the inundation unit from the door but was unable to do so. He returned to the office again and arranged for a member of the security team to assist him with removing the inundation unit. Eventually, after 11 minutes, the obstruction was moved by officers via the inundation hole, whereupon they discovered Anthony was hanging from a ligature. He could not be resuscitated. There was an 11-minute delay between prison staff learning Anthony was unresponsive to knocking and banging, and subsequently entering his cell. This delay is unacceptable and contrary to local policy and guidance. It will be for the jury to determine whether this delay probably more than minimally contributed to his death.

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Report details

Reference: 2025-0080
Date of report: 17 December 2025
Coroner: Laurinda Bower
Coroner area: Nottingham City and Nottinghamshire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 11 Feb 2026 (estimated).

Sent to

HMP Lowdham Grange

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.