Source · Prevention of Future Deaths

Anthony Binfield, David Richards and Rolandas Karbauskas

Ref: 2025-0079 Date: 7 Feb 2025 Coroner: Laurinda Bower Area: Nottingham City and Nottinghamshire Responses identified: 5 / 5 View PDF

Inadequate recruitment, retention, and training of prison and healthcare staff led to severe understaffing, restricted services, and fundamental failures in prisoner welfare, supervision, and basic safety protocols.

Date 7 Feb 2025

56-day deadline 4 Apr 2025

Responses identified 5 of 5

State Custody related deaths Suicide (from 2015)

Coroner's concerns

AI summary

View full 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, over-burdened 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 files were sent straight to storage. This is despite the fact that a background history of deliberate self-harm is an evidence-based risk factor for suicide as set out in PSI 64/2011  Healthcare staff concluding on Friday 3 March 2023 that Anthony’s inability to attend a candle lighting service might be a trigger for self-harm, but such was not communicated to prison staff or safer custody or recorded on any prison systems  David’s PNOMIS file clearly indicated his fear of joining the general prison population led to him requiring VP status in his previous establishment. However, the officers who sought to move him from the induction wing had not read his notes nor were they aware of the content of his previous ACCTs. HMPPS, prison and healthcare providers need to carefully scrutinise the system for identifying risk pertinent information to ensure that the staff on the ground know how and when to access that information to support timely risk assessment when engaging with prisoners. This is especially important in the early days in custody setting, but not exclusively so. I am also concerned by the use of email to convey risk pertinent information. In this case, prison staff communicated their concerns about Anthony’s mental health to individual nursing Sodexo email inboxes, which the nurses were not expected to regularly access. The use of email means that such concerns are not accessible to other members of staff as they would be if they were recorded in PNOMIS or Systemone.

Again, this needs to be addressed in policy and re-enforced in training. Staff told me that while the PSI mandates they should be aware of risks and triggers, there was no clearly documented system setting out how and when this should occur.
3. The system for transfer of prisoners between establishments is disorganised and unsafe (Minister for Prisons) I heard evidence in the course of exploring David’s death, that he was transferred from the vulnerable prisoner unit (‘VPU’) at HMP Chelmsford to HMP Lowdham Grange, a prison which did not offer a VPU. David had been afforded VP status as a result of publicity about his business affairs and the nature of the offence that had resulted in his incarceration. He was scared that he might be targeted for violence and/or extorsion by fellow prisoners on account of this. David had been on 4 open ACCTs at HMP Chelmsford and had told his ACCT case co-ordinator that he was fearful of losing his VP status on transfer. While the Prison Director said he would have expected both HMP Chelmsford and HMP Lowdham Grange to have spoken about this risk in advance of the transfer, there is no evidence that any individual fully explored this potential trigger, and David was not informed that his VP status was being rescinded on leaving HMP Chelmsford. Between 20 October 2021 and 10 January 2022, Anthony made 17 applications to transfer to another prison because he did not feel safe at HMP Lowdham Grange. There were numerous intelligence reports to substantiate that Anthony was at risk of harm from others, and that, on occasion, he had been assaulted. Anthony’s applications were dealt with in a haphazard manner. He did not receive a formal answer to his transfer request and had to chase many times for updates. This left Anthony feeling frustrated. I heard evidence that there is no formal policy framework or system for managing the progress of prison-to-prison transfers, including a lack of expected response times or formal escalation plan if a prison fails to provide any response. Notwithstanding the pressures on prison population management, it was agreed that the system for administering such applications should be co-ordinated and predictable, regardless of the success or otherwise of the application, rather than leading to prisoner frustration in waiting for answers that never come.
4. Failure to reduce isolation of Foreign National Prisoners (Minister for Prisons) Prison can be an isolating experience for any prisoner, but especially so for one who does not speak English. I heard evidence that the Big Word translation service did not work on multiple occasions across multiple sites within the prison. Staff gave evidence that even when the system did connect, they could be waiting in a queue for up to an hour to access an appropriate interpreter. There was no plan to seek to reduce Rolandas’ obvious isolation, and seemingly no provision for expediting his induction so that he could be housed with fellow Lithuanian speakers. I have seen no evidence of a national or local plan to support Foreign National Prisoners. There is a clear risk of future self-inflicted deaths if language barriers and isolation are not adequately addressed.
5. Drugs (Minister for Prisons) HMP Lowdham Grange, like many establishments, continues to face challenges related to novel psychoactive substance misuse. There is no requirement for prisons to have an NPS specific drug policy and I am concerned that generic drug reduction strategies are ineffective against this particular threat. NPS is highly dangerous and carries a risk of death. I am concerned that more young men will die in custody as a result of NPS use. Matters relating to the transfer of the prison contract

6. The process of transferring the prison from one private provider to another, lacked sufficient scrutiny of the safety of the prison before, during and after the contract exit/transfer process (Minister for Prisons) Safety was not front and centre of the Mobilisation and Transfer project. I heard evidence from the HMPPS witnesses that there was a willingness to ensure that nothing like this ever happens again. However, I invite a formal response detailing exactly what action has been taken or is proposed, as it is likely that further transfers shall occur across departments when PFIs expire, or contracts change provider. Matters relating to learning from deaths in custody
7. Persistent Failure to learn from deaths over many years (Serco Justice Director, Minister for Prisons) Embedding learning from deaths I heard evidence that many of the contributory factors leading to the deaths of Anthony, David and Rolandas, had been raised as issues in the investigations following previous deaths in custody at HMP Lowdham Grange. While Serco no longer manage HMP Lowdham Grange, they continue to manage prisons, and there is a risk of future deaths if the organisation is unable to create a robust culture of seeking to identify issues early, adopt learning, and continually monitor culture to ensure any action taken is embedded to reduce the risk of future deaths. From a HMPPS perspective, while private prison providers assume the operational risks of running the establishment, the HMPPS Controllers remain responsible for assuring a safe, decent and secure prison. I am concerned that the Controllers at HMP Lowdham Grange did not have a sufficient grasp of the longstanding cultural issues pertaining to safety. This raises the question of the efficacy of the Controller role and exactly how Controllers assure themselves that the provider is learning from deaths.
8. A failure to act with candour when engaging in post-death investigations (Minister for Prisons, Serco, Sodexo) Full, frank and timely disclosure of potentially relevant material to those investigating deaths The quality of any post-death investigation is predicated by the openness, honesty and transparency of the agencies involved. This inquest was beset with disclosure failures by HMPPS. A significant volume of disclosure, running to thousands of pages, was provided to the court towards the end of the hearing despite many months of active case management. HMPPS conduct their business primarily through emails, rather than any case management system, and it took a long time to review and supply this material to the court. HMPPS have no effective system for gathering, retaining, reviewing and disclosing potentially relevant material so that the issues relevant to death can be identified and learning put in place. If the process of learning from deaths is obfuscated by failures in the disclosure process, there is a risk that deaths will occur in the future from matters which could and should have been rectified. Candour The Healthcare Trust are subject to a statutory duty of candour. HMPPS, Serco and Sodexo failed to embrace the same ethos during these investigations. Consequently, there was minimal acceptance of the risk factors set out above, all of which may cause or contribute to deaths in the prison in the future. I have shared my concerns previously with those at HMP Lowdham Grange (PFD report relating to Christopher Howard Smith, dated 7 July 2023). I am troubled that unless there is a radical change in culture, and reflective learning from deaths is prioritised, prisoners will continue to die in custody.

It is most concerning that there is a marked discrepancy between the failings that were admitted in oral evidence by the vast majority of witnesses when faced with irrefutable evidence, against the written statements submitted to the coronial investigations which contained very little, if any, reflection and candour. Even after the evidence had been called, the prison organisations did not respond to my request to advance admissions in order to relieve the jury of the burden of making findings on each and every issue. I would like to understand any action proposed by the Minister, Serco and Sodexo to address the issue of candour.

Responses

5 respondents

NHS England NHS / Health Body

7 Feb 2025 PDF

Action Taken

NHS England highlights the 'We Are Prison Nurses' campaign and nursing preceptorship to address workforce demands and notes several platforms locally to enable effective sharing of information. Findings will be tabled at a future NHS England Health and Justice Delivery Oversight Group. All Health and Justice related Reports to Prevent Future Deaths are shared and discussed at the HJDOG, and assurance is sought from regions where learning and action is identified. (AI summary)

View full response

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Anthony Binfield, David William Richards and Rolandas Karbauskas who died at HMP Lowdham Grange between the dates of 6 and 25 March 2023

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 7 February 2025 concerning the deaths of Anthony Binfield, David William Richards and Rolandas Karbauskas on 6, 13 and 25 March 2023 respectively. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to the families and loved ones of Anthony, David and Rolandas. NHS England are keen to assure the families and the Coroner that the concerns raised about their care have been listened to and reflected upon.

I have responded to the concerns raised that sit within NHS England’s remit below.

1. Recruitment, retention and training of prison and healthcare staff

Providers of adult healthcare within the prison estate in England experience the same types of recruitment and retention workforce issues that are experienced by acute and community services.

However, vacancy rates within the prison estate are significantly higher, which can be due to the perceived risk and stigma attached to prison environments, and these unfilled vacancies can increase pressures on existing healthcare and prison staff, leading to elevated levels of stress, high turnover and increased absenteeism.

To help address workforce demands within prisons, nursing within the criminal justice system (CJS) needs to be widely promoted as a career option and NHS England is supporting this promotion with the ‘We Are Prison Nurses” campaign and nursing preceptorship (a period of structured transition where newly qualified nurses are supported by an experienced practitioner).

The ‘We Are the NHS” recruitment campaign has been in operation since 2018 and was developed with the aim of increasing positive perceptions of, and pride in, working for the NHS across a diverse range of roles. It aims to motivate target audiences to undertake a career in the NHS including nursing, the Allied Health Professions and as Healthcare Support Workers (HCSWs). National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

3 April 2025

To target support on recruitment into prison healthcare and retention of healthcare staff, NHS England’s National Health and Justice Team undertook a programme of work alongside the ‘We Are the NHS’ campaign, specifically relating to prison healthcare which forms the basis of the ‘We Are Prison Nurses” campaign. This campaign started in December 2023 and targets student nurses to encourage them to consider a career in prisons, by increasing awareness of, and exposure to, prison nursing roles. The campaign toolkit contains a wide range of resources designed to support providers and employers with the recruitment of nurses into prison healthcare services: We are Prison Nurses | We Are The NHS | Campaign Resource Centre.

In February 2024, NHS England also published the ‘Nursing preceptorship in adult prison healthcare – best practice guidance’. Preceptorship is a period where all newly qualified practitioners are given guidance and support in their transition from student to autonomous practitioner.

A good preceptorship programme undertakes the following:
• Effectively supports newly qualified nurses to become competent and confident practitioners
• Ensures nurses and nursing associates feel valued by their organisation and have a positive experience during their first 12 months.
• Enhances patient care and experience.
• Supports organisations to recruit and retain registered nursing staff.

The best practice guidance is designed to support staff and organisations in the design and delivery of effective preceptorship programmes within adult prison healthcare services. It is also for registered nurses who are new to prison healthcare. The guidance ensures these professionals understand how an evidence-based preceptorship programme can support, develop, and value them in their first year of clinical practice.

To support the quality performance assurance and oversight of prison healthcare providers, there are quality measures in place. The measures identified and included are aligned to standard NHS contract quality measures, to ensure consistency in approach, while avoiding increasing the burden of any reporting.

Recent data from quality schedules indicates a noticeable increase in compliance with mandatory training at HMP Lowdham Grange. This is monitored closely through contract review meetings (CRM) with clinical quality oversight.

CRMs take place for each site every quarter and review the performance and quality (covering safety, effectiveness, and experience) of healthcare services commissioned within prison settings, based on key indicators. There will be agreement of remedial actions where required.

Quality and performance (Q&P) meetings also cover the clinical quality of the contract monitored under the NHS England Direct Commissioning Assurance Framework. Review meetings and/or clinical quality site visits are determined by the level of surveillance required. By exception, clinical quality representatives from both

organisations may be invited to attend the Q&P meeting to discuss any quality related matters arising that require in depth review.

There is also a monthly Rapid Improvement Group (RIG) meeting. The RIG is an improvement methodology where an intense improvement activity occurs over a short period. It is hoped that this approach will bring about a significant improvement in performance that can encompass a small number of different work teams or processes without a high degree of complexity. This relies on the fact that the participants, who do the job every day, are the people best placed to identify process improvements. The methodology identifies the change required, offers solutions, and allows participants to plan the actions required for implementation. NHS England provides oversight from both commissioning and quality perspectives, with additional support for the Trust from NHS England’s improvement teams.

Healthcare services are commissioned based on patient need and there should be equivalence to services available in the community. Healthcare services outside of the core working day are commissioned by Nottingham & Nottinghamshire Integrated Care System (ICS). In January 2018, 24-hour healthcare was implemented when there was an escalation in the use of psychoactive substances at HMP Lowdham Grange and this was continued as a response to the Covid-19 pandemic, to reduce the healthcare impact on the wider health community.

In September 2022, a Health Needs Assessment focused on the provision of 24-hour healthcare across the prison estate in the East Midlands was undertaken. The findings for HMP Lowdham Grange did not support continuation of this service, with funding invested to support a longer core day to enable patients to access healthcare services prior to the prison entering night state.

2. A complete failure to identify and share risk pertinent information between prison and healthcare staff, and within those teams

I recognise that effective information sharing is essential to support the ongoing care provided to patients across the whole of the CJS and information sharing is most important when an individual is managed by both healthcare and secure estate staff.

All staff have a common interest in the wellbeing of patients, reducing risk, keeping them safe and treating them appropriately, which requires routine information sharing.

In 2023, NHS England’s national quality function for health and justice developed the Information Sharing Position Statement (ISPS). This supports a common understanding between NHS England and partners across the CJS about patient confidentiality and the sharing of health information (UK GDPR) which is considered more sensitive and therefore amounts to ‘special category’ data.

The ISPS sets out NHS England’s position on information sharing and consent and supports healthcare staff to make decisions about sharing information.

The ISPS only relates to the general and routine sharing of health information for purposes connected with the care of individuals in the CJS and is not intended to cover the sharing of health information in situations where there is an urgent need to share

information for the purposes of providing care, or where there is a safety risk to either an individual or others. In all cases where there is a safety risk, local safeguarding processes should be followed.

Additionally, there are several platforms locally to enable effective sharing of information. These are morning briefings, through CRMs as mentioned above and local delivery boards (LDB). Oversight from the clinical quality team at CRMs will inform quality visits to ensure information sharing is embedded in practice.

The findings, information and any learning from this Report will be tabled at a future NHS England Health and Justice Delivery Oversight Group (HJDOG). The HJDOG is the senior leadership forum, which holds responsibility for the oversight of delivery and continuous improvement in Health and Justice commissioned services, through both national and regional teams. All Health and Justice related Reports to Prevent Future Deaths are shared and discussed at the HJDOG, and assurance is sought from regions where learning and action is identified.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad deaths of Anthony, David and Rolandas, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Serco Private Sector

3 Apr 2025 PDF

Action Planned

Serco has committed to undertaking a 'lessons learned' exercise with the MOJ and Sodexo, facilitated by the Cabinet Office, to identify aspects of the prison transition that went wrong and produce a Transitions Playbook for future use. (AI summary)

View full response

Dear Ms Bower, Thank you for your Prevention of Future Death Report ('PFDR') dated February 2025 following the conclusion ofthe inquests into the deaths of Mr Binfield, Mr Richards and Mr Karbauskas who all sadly died in March 2023 at HMP Lowdham Grange_ am responding on behalf of Serco to matters of concern that you have raised in the PFDR, in so far as relate to Serco. am aware that you will share a copy of this response with the families of Mr Binfield, Mr Richards and Mr Karbauskas and would like to express my sincere condolences for their loss_ death in custody is a tragedy, and the safety ofthose detained in our prisons is our absolute priority: am grateful to you for bringing the matters of concern to my attention and have responded to the issues below: Eailure _to identify and share risk pertinent information between prison and healthcare staff Over the many years that we have been operating prisons on behalf of the MOJ, Serco established and maintained excellent working relationships with the various Healthcare providers commissioned by NHS England to provide Healthcare provision within the prisons we manage_ In the prisons that we manage on behalf of the Ministry of Justice, the Heads of Healthcare meet regularly with the relevant prison Director and the HMPPS Controller, and they attend our daily Senior Management Team (SMT) morning meetings, so are able to engage with the SMT and raise any issues of concern on behalf of their own management team and staff. For those prisoners who have been identified as at risk of self-harm and suicide members of the relevant Healthcare team are invited to ACCT Case Review and give invaluable input to assist us in keeping the men in our care safe. Our staff are also aware of the need to liaise with Healthcare staff and make appropriate referrals to Healthcare or signpost prisoners to do so. However, as you will be aware, due to medical confidentiality requirements, custodial staff are not permitted to access the healthcare IT system, System One: As a result; we rely on healthcare staff communicating any risk pertinent information to custodial staff or our Safer Custody Departments if and when feel that medical information, or information disclosed by prisoners which may be relevant to their risks come to their attention: As you will appreciate many prisoners have multi-facetted issues including substantive histories of suicide attempts and self-harm, physical and mental health issues, substance misuse issues, and debt: Assisting them in managing such issues can be very challenging, particularly when, for whatever reason a prisoner feels unable to disclose their concerns to either healthcare or custodial staff: As you will no doubt appreciate, when used correctly, PNOMIS is an invaluable tool for recording and checking risk pertinent information for the prisoners in our care, particularly as it contains information previous establishments. Previous ACCTs can also be very valuable: However, in many cases the PNOMIS account is very lengthy and if a prisoner has been on numerous ACCTs in a previous prison, the old ACCTs (if closed) not be received with the prisoner, and even if are are often too voluminous for staff to review meaningfully: This is particularly the case in local remand prisons, given the high number of new prisoners arriving daily, many of whom have a substantial history of self-harm and/or suicidal ideation. In addition, often the risks detailed in old ACCTs are not still relevant at the time Serco Justice & Immigration Impact Serco House, 16 Bartley Wood Business Park; Bartley better Hook; Hampshire; RG27 QUY United Kingdom T:+44 (0)1256 745 900

future Serco Limited, cOmpany registered England arc Wales Na: 2048608 Registared Otice: Scrco House; Bartley Wood Business Park; Bartley Way; Hook; Hampshire RG27 QUY, United Kingdom they Every has they being they they from they may they Way;

serco prisoner is transferred as individuals' risks can change with their circumstances. Unfortunately, due to resource constraints, it is not always possible for staffto review PNOMIS or ACCTs, although the expectation would be that staff prioritise these tasks for prisoners who have only recently been on an ACCT or are on an ACCT at the time oftheir arrival. Of course, any risk pertinent information should be communicated to the Safer Custody team on a prisoner's arrival, so that necessary steps can be in place to keep that prisoner safe. Serco staff are always encouraged to record all risk pertinent information and to share this information with each other (via handovers and wing observations books), with Safer Custody and with Healthcare, where applicable, by telephone or email: concern regarding email being used to communicate with specific members of the healthcare team is also noted, and have requested a review of the practice used across the Serco estate to ensure that staff are notjust communicating with specific email addresses, in case the individual to whom the emails are addressed are not on shift Eailureto deaths over many years By way of background, can confirm that Inquests relating to deaths of prisoners in Serco's custody are managed by our in-house Inquest Solicitor. She works closely with the staff and management of the prisons Serco manage_ and particularly with the Heads of Safer Custody. Her role includes reporting to me; the Serco Justice and Immigration Director; Prison Directors and Prison Heads of Safer Custody throughout the Inquest process, starting upon notification of a death right through to the inquest conclusion and beyond. She liaises with the Prison Directors and Heads of Safer Custody to ensure that swift and comprehensive action is taken to remedy any issues identified following a death in custody, not only in the prison where the death occurred, but across our custodial estate_ Our Inquest Solicitor reports to and attends quarterly Safety Forum meetings, along with the Heads of Safer Custody and members ofthe Serco Psychology Team for each prison: These pan custodial meetings are chaired by the Head of Prisons and Immigration Removal Centres and Serco Prison Director: Inquest Solicitor reports on issues arising from investigations, PPO reports and Inquests, so that a full and frank discussion can take place to ensure that learnings are cascaded, and relevant changes/improvements put in place and are rolled out across the estate am aware ofyour concern that following previous deaths in custody, learnings do not appear to have been fully embedded operationally by staff 'on the ground'; this is also a concern for me, particularly when learned these Inquests ofthe 'cultural issues' at Lowdham Grange prior to and after the handover ofthe prison to Sodexo_ As you will no doubt be aware, some ofthe issues identified during these Inquests are issues that are repeated in other Inquests involving deaths in custody across the prison estate, not just in Serco-run prisons. Sadly, some of the issues relate to the most basic requirements upon PCOs such as ensuring that proper checks are completed to ensure that prisoners are safe at roll counts and welfare checks, the covering of observation hatches is challenged, and that risk pertinent information is properly recorded in PNOMIS_ am aware that the jury made findings that IT issues, poor staffing levels, and several cultural legacy issues contributed to the deaths of all three prisoners and that many ofthe issues have been raised in previous cases at Lowdham Grange: note and share your concern that lessons have not been fully learned previous deaths in custody: However, itis my understanding that the vast majority ofthe staff confirmed in evidence that were aware ofthe correct processes, and had received training on the issues, but could either not specifically recall the detail of such training or re-training, or simply failed to follow the correct processes, despite aware ofthem_ It is my understanding that several middle managers at the prison also accepted their evidence that it was not only their responsibility to ensure that PCOs were following the correct processes, but that failed to do so. Serco is grateful to you for alerting us to this issue, and we are taking steps to ensure that staff in middle management positions are tasked with ensuring that more junior staff are not only aware of the numerous prison processes, are regularly reminded of them, and that managers ensure that the processes are consistently followed and enhanced quality control checks are put in place: As you will be aware, staff receive training in the initial training course and are regularly reminded of issues identified as requiring updates: Traditionally notices to staff and Toolbox Talks have been utilised to remind staff of the requirements but share concern that the message is not fully 'landing with staff' and unacceptable fully old put Your Jearn from Our during from they being during they fully your

serco practices persist: In light ofthe concerns that the issues identified, and remedial actions are not fully embedded across our estate we have recently created a new role of Pan Custodial Safety Lead and appointed an Assistant Director with extensive operational experience. She is responsible for driving the and well-being of individuals across all custodial sites by leading initiatives that improve outcomes related to self-harm, suicide violence, and debt: She will assist in chairing the Safety Forum meetings and will liaise with the Inquest solicitor, to ensure that lessons are learned and that improvements are fully embedded operationally following review of investigations, PPO reports, Inquests and PFDRs issued in the future: Serco sees her appointment as bridging the gap between the legal team and the operational issues, and it is certainly intended that her appointment will assist in ensuring that lessons can be fully embedded following all future deaths and Inquests. As you may also be aware Serco has introduced initiatives across our prison estate, above and beyond the measures required by HMPPS, as a direct result of learnings previous deaths; which we believe assist staff in keeping the men in our care safe_ Examples of this are 'Under the Influence' processes trialled in some of our prisons and ensuring regular welfare checks are embedded in the prison regimes We are also in the process of establishing joint operational forum with other private providers to identify common operational issues and share good practice and lessons learned to assist in keeping the men in our care safe can assure you that Serco will continue to learn lessons from deaths of prisoners across our estate, and we are continuing to strive to ensure that all remedial actions are embedded operationally, which will continue to be monitored by our Pan Custodial Lead. failure to act with candour when engaging in post-death investigations_ As Serco no longer operated the prison at the time ofthe deaths of Mr Binfield, Mr Richards or Mr Karbauskas, we did not receive any official notification of their deaths and initially the only information known to Serco was that published in the press_ We were not made aware that there were issues with the transfer ofthe prison which could potentially have impacted on the deaths ofthe three prisoners until your office notified us. As we no longer mana ged the prison when the deaths occurred, we were not entitled to see any documentation relevant to the three prisoners nor were we entitled to contact any staff involved in the deaths, as by that time they were Sodexo employees: It was therefore not possible for Serco to carry out investigations into the deaths to ascertain whether there were any issues which we could assist you with: Once Serco had been granted IP status, our Inquest solicitor attempted to collate relevant information and documentation to assist you in your investigations. As understand was made clear during the Inquests, there were some technical issues during the transition to Sodexo, which resulted in difficulties in various documents being located, for which | apologise. In relation to the issue of candour, understand that several issues, including certain points of culture, only came to light during the oral evidence of the various witnesses through questioning from You, and were not detailed in the written statements disclosed before the Inquest commenced. In addition, the facts that all three men died after the transfer ofthe prison to Sodexo, that two ofthe men arrived at the prison after the transfer and our lack of visibility of issues prevailing in the prison after the transfer; led to inevitable difficulties in Serco being in a position to make admissions, to assist the jury by limiting the issues they were required to consider. However, understand that the senior Serco leaders who gave evidence did make appropriate concessions during their evidence. can however provide an assurance that in similar cases in other jurisdictions the issue of candour is fully considered and, where appropriate, admissions are considered and made. In addition to the issues you have raised in you PFDR, given some of the issues aired during the cluster Inquests we have made a commitment to undertake a 'lessons learned' exercise with the MOJ and Sodexo, facilitated by the Cabinet office to identify aspects of the transition that went wrong, with a view to production of a Transitions Playbook for future use safety any safety from any fully

serco Thank you again for bringing your concerns to my attention. can assure you that Serco is fully committed to keeping the often-vulnerable men on our care safe and well and hope you are reassured by this response to the issues raised If l can be of any further assistance, please do not hesitate to contact me_

Nottingham NHS

4 Apr 2025 PDF

Action Taken

Nottinghamshire Healthcare NHS Foundation Trust has enhanced Executive led oversight and assurance reviews for Offender Health, mandated daily checks of electronic patient records, and requires attendance at ACCT case reviews. They have also improved handover processes and email communication. (AI summary)

View full response

Dear HMC Bower

Further to the Joinder Inquest into the death of Anthony Binfield, David William Richards and Rolandas Karbauskas, I write on behalf of Nottinghamshire Healthcare NHS Foundation Trust in response to the Prevention of Future Deaths Report issued on 7 February 2025. . All three men died as a result of self-inflicted injuries in March 2023 while in state detention at HMP Lowdham Grange, within a 19-day period of one another.

We accept the inquest conclusion and would like to assure you that we take the findings very seriously. Please see the following, in which we detail the actions we have taken to improve patient care and experience subsequently to the inquest. The Inquest conclusion identified that there was a complete failure to identify and share risk pertinent information between prison and healthcare staff, and within those teams: More specifically, there was a concern in relation to 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 Trust is committed to being compliant with 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.”

Improvement oversight for Offender Health and HMP Lowdham Grange - The Trust has established enhanced Executive led oversight and assurance reviews for Offender Health. This comprises a weekly meeting where progress against the Transformation Plan is reviewed with individuals held to account. The update against the required actions for this PFD will be reviewed as part of this process. Reception screening: A new national template for prison reception screening for the male prison estate was launched on the 1 April 2025. Staff are in the process of receiving the Nationally delivered

Highbury Hospital, Highbury Road, Nottingham, NG6 9DR

training for this and the benefits include a standardised and simplified model of screening which enable the understanding and recording of previously documented clinical risk which needs to be further considered as part of the reception and induction process. Part of the reception screening is the ability to access a digital Person Escort Record (PER). This is a prison document which follows the prisoner journey through their custodial sentence and contains risk pertinent information. There is no ability to audit this access however, the supervision proforma for the clinical staff in reception will be amended to ensure it forms part of the supervision record. The Head of Safer Custody has introduced a new Early Days in Custody (EDIC) booklet along with colleagues from Reception and the Induction wing. This booklet has now been in place for one month and contains a section for healthcare staff to complete, identifying any immediate risks that the individual may present with and including any historical information. Ideally the document is completed in reception and follows the patient to the induction unit. The Officer in charge of the induction unit will meet with the Head of Healthcare to audit the use of the EDIC forms on a monthly basis to enable ongoing quality improvement as required. Safety Interventions Meeting (SIM): We have worked with Prison colleagues to ensure that SIMs are attended on a weekly basis by a member of the Mental Health Team. This meeting is to discuss any patients of concern and highlight any specific issues relating to that individual. A Prison safeguarding referral form (Annex Q) is now in use and concerns can also be raised online via the DPS system. A random spot check of attendance and the quality of information shared will be randomly reviewed by the Head of Healthcare at HMP Lowdham Grange. CSIP: Patients can also be referred to CSIP (Challenge, Support and Intervention Plan). This is a prison risk management system and process that will enable information sharing on risk in the prison estate and also support the development of cross professional relationships. Healthcare staff are currently accessing the training for this, and full compliance is aimed to have been achieved by June
2025. Training - Healthcare staff have arranged to attend the Prison staff induction programme so that they can deliver health training to the Prison Officers. Initially this will be focused on emergency response but will later include Mental Health awareness training. This was agreed at the Local Delivery Board and the first session was provided on 23 January 2025. Feedback from staff was very positive. Healthcare staff will continue to receive clinical risk, self-harm and suicide training, which is an inhouse training programme. Compliance will be achieved by July 2025. Discussions have taken place with the Head of Residential Services to discuss how appropriate risk pertinent information can be shared on the wings as part of effective information sharing with prison colleagues. Systems such as identifying clinical risk by adding a coloured dot to their name on the wing prisoner list are being scoped. Healthcare staff have been informed that they must document in the wing observation book any relevant risk pertinent information to alert staff to any potential issues. Again, this will be audited and reviewed for quality by the Head of Healthcare and Safer Custody Officer. ACCT: Assessment, Care in Custody and Teamwork processes are being managed through a booking process with advance notification. All first ACCT reviews are attended by a registered nurse in line with the ACCT process. Subsequent follow up reviews are attended where possible or prioritised based on clinical risk and need. Phone and email contributions are also supported if required. The process of our ACCT attendance and contribution will be reviewed as part of the safer custody process to ensure the quality is as desired and required. As part of the ACCT process

Highbury Hospital, Highbury Road, Nottingham, NG6 9DR

safety plans should be shared with the Patient and with prison colleagues with escalation routes identified. This will be reviewed and audited by the Head of Healthcare as part of local quality assurance processes. Healthcare daily handover: Daily attendance at the prison morning meeting handover should provide any risk information at the start of the day that may have occurred overnight. This information is then cascaded for action to the Healthcare Team as required. The healthcare team have a daily lunch time handover which is designed to capture any matters of concern, risk or escalation. Where appropriate, this should be recorded in the S1 record. A brief note of the risk should be recorded in the meeting record along with person responsible for management. Email: Healthcare has generic email inboxes which are monitored daily by administrative staff which have been provided to the wings as a first point of contact for non-urgent issues. This includes a mailbox for each clinical pathway. A reminder has also been sent to Prison staff via the Governors secretary, to the wings, of the mailbox addresses and call signs on the radio for contacting healthcare. No personal emails should be used for patient related queries. I hope this information provides assurance that we have and continue to consider the points identified very seriously, and that we are actively seeking to improve the services we provide by implementing the actions outlined

Sodexo Private Sector

4 Apr 2025 PDF

Action Taken

Sodexo highlights its compliance with Early Days In Custody PSI, use of SASH forms, ACCT training, and CMS for information sharing. Post-inquests, Sodexo ringfenced key safety tasks and safer custody staff to address resourcing pressures. (AI summary)

View full response

Dear Miss Bower

Cluster Inquests into the deaths of Anthony Binfield, David Richards and Rolandas Karbauskas

Thank you for your Regulation 28 Report, issued following the inquest into the deaths of Anthony Binfield, David Richards and Rolandas Karbauskas at HMP Lowdham Grange. As you know Sodexo Limited took over the operational management of HMP Lowdham Grange on 16 February 2023, with these deaths occurring on day 18, day 25 and day 37 of the contract commencement.

Your Regulation 28 report raises 8 numbered concerns, and we have adopted your numbering to respond to the two specific concerns directed to Sodexo and others:

2 A complete failure to identity and share risk pertinent information between prison and healthcare staff, and within those teams (response required from Minister for Prisons, NHSE, Serco, Sodexo and Nottinghamshire Healthcare NHS Foundation Trust). Sodexo recognises the importance of prison staff capturing and recording risk pertinent information. Whilst Sodexo no longer operates HMP Lowdham Grange, it does operate five prisons in England and is able to respond to your concerns on that basis. Sodexo complies fully with Early Days In Custody – Reception In, First Night In Custody, And Induction To Custody (PSI 07/2015 PI 06/2015, Re-issue date 4 November 2024). As part of this compliance, Sodexo routinely operates the following information sharing systems across its prisons:
- Suicide/Self Harm Warning (SASH) forms are shared with the Reception Nurse

- ACCT training is made available to all Healthcare staff, jointly with prison staff, including training on triggers and scenarios indicating when an ACCT should be opened

- Healthcare staff are invited to attend the following meetings alongside prison staff, where cases of concern are discussed. These meetings include

o Senior Staff morning meeting, including the Prison Director and Head of Healthcare. Within this meeting, prison staff present information about prisoners of concern following incidents or receiving of intelligence reports. o Weekly Safety Intervention Meeting (SIM). Attendance includes physical healthcare, mental health staff and psychology o Monthly Safer Custody Meeting o Complex case meetings, ad hoc, focusing on prisoners of concern o ACCT reviews o Briefings on each prison wing at each shift change. Staff concerns (prison or healthcare staff) are recorded in Wing Observation Book. Staff at all Sodexo prisons have been reminded of the importance of recording concerns in NOMIS and the wing observation book.

- Sodexo ensure that NOMIS is available to healthcare staff, including installing NOMIS- compatible PCs in healthcare offices, so healthcare can access risk information before assessing or treating prisoner/patient.

- The Safer Custody Team in each prison share risk information for all new prisoners with wing staff and key workers, in different forums depending on the urgency of the risk (verbally briefing, email, morning meetings, weekly SIM meeting) as well as within the Monthly Safer Custody Meeting.

- Sodexo have recently introduced a digital Reception Screening Risk Assessment (RSRA) tool across its prisons, implemented on CMS following 2 years of development and trialling led by Sodexo in partnership with Unilink

- The RSRA is completed by operational staff in reception when interviewing the prisoner on arrival and guides staff to consider obligatory key pieces of information that might indicate risk of harm, either to self or others upon arrival into custody, such as previous history of self- harm, information taken from Suicide / Self-Harm Warning Form (SASH) and/or Person Escort Record (PER), which all contribute to staff making appropriate risk decisions in the first few hours and days of custody.

- Where the prisoner’s responses indicate a potential risk of harm the system will automatically generate a digital Early Risk Indicator alert (ERI) and enables consideration of appropriate intervention and support to be provided at an early stage to help manage and reduce risks identified. Where an increased risk is identified the ERI warning flag will appear on the prisoner’s CMS record alerting the induction unit staff and directing them to review the risk identified.

- Staff will not be able to locate the prisoner into a cell until the staff member has acknowledged they have read the risks flagged. It will also flag where the RSRA is incomplete, perhaps due to the prisoner’s volatility, or physical/mental ability to participate in the interview.

- The availability of this information is immediately accessible to prison staff on CMS enabling prompt sharing of information.
8. A failure to act with candour when engaging in post-death investigations (Minister for Prisons, Serco, Sodexo)

Sodexo’s investigation process following deaths in custody, which has been shared as part of the substantive inquest proceedings, is to prioritise and identify risk at the earliest opportunity and to implement changes as required by any learning.

In these inquests, in candour, Sodexo took the decision at an early opportunity to share its death in custody investigation reports with the Coroner. The disclosure of the reports was notably before any direction for disclosure. The disclosure of the Sodexo investigation was in advance of the Prison and Probation Ombudsman’s investigation reports, and indeed the Sodexo reports noted more failures than the PPO reports.

Whilst Sodexo always considers early admissions and agreed facts, the unique circumstances of these cases, with the number of overlapping organisations involved and individual officers with separate IP status, as well as ongoing and late disclosure of relevant material by the Ministry of Justice, meant that admissions by Sodexo, without trespassing on factual evidence due to be heard at the inquest involving other IPs, was more difficult and complex than would usually be the case. There are three further inquests involving Sodexo concerning deaths at HMP Lowdham Grange, and Sodexo will give careful consideration to admissions and agreement of facts in relation to each.

We know that you will share a copy of this response with the families, and we would like to again express our sincere condolences for their loss. Following the inquests Sodexo have ringfenced key safety tasks and safer custody staff in the event of changes in resourcing pressures. The implementation of learning from these sad deaths is a priority.

HM Prison and Probation Service Central Government

10 Jun 2025 PDF

Action Taken

HMPPS took over management of HMP Lowdham Grange on 1 August 2024. Since then, HMPPS has increased safer custody staffing levels, established a senior management team with relevant experience, and reviewed the ACCT process. Additionally, HMPPS has disseminated existing guidance regarding document retention and will review its approach to making formal admissions at inquests. (AI summary)

View full response

Dear Miss Bower,

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS – ANTHONY BINFIED, DAVID WILLIAM RICHARDS, ROLANDAS KARBAUSKAS.

Thank you for your Regulation 28 report of 7 February 2025 following the inquests into the deaths of Anthony Binfield, David William Richards and Rolandas Karbauskas at HMP Lowdham Grange, which was sent to the Ministry of Justice. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations.

Thank you for agreeing an extension to the usual deadline for this response. As you know your report raised a wide range of matters of concern and I am grateful for your understanding that it has taken longer than usual to bring together a full response.

I know that you will share a copy of this response with the bereaved families, 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.

As you are aware, at the time of the deaths HMP Lowdham Grange had recently transferred from management by Serco to Sodexo, with HMPPS providing contract management. In December 2023 HMPPS, concerned re standards, stepped in and on 1 August 2024 brought the prison under HMPPS management and leadership.

As heard at the inquest, the transition detailed above significantly impacted on a challenging recruitment picture and the low staffing levels along with a reduction in staff with a significant length of service and experience. As you are aware, healthcare staffing is a matter for the healthcare provider, who have responded separately.

Since taking over the management of Lowdham Grange HMPPS has taken a number of steps to improve recruitment and retention, including the provision of additional support to the prison to undertake recruitment activity.

The site has been in receipt of support from other establishments in the form of National Detached Duty of prison officers. They are also supported by bonus schemes that incentivise staff to commit to overtime hours in return for a bonus paid out at the end of a qualifying period.

Recent recruitment marketing campaigns have included a high-profile national campaign with additional support provided to the Long Term High Security Estate (LTHSE), which includes Lowdham Grange. This included TV and local and national radio advertising, and a range of digital advertising.

As a result of this activity the site currently has a pipeline of 275 applicants at various stages of the recruitment process and are predicted to be close to full staffing by the end of September
2025.

Key to creating a stable, effective prison with a positive culture is a strong Senior Management Team (SMT), and I am pleased to say that this this is now in place, led by an experienced HMPPS Governor and Deputy Governor who are committed to driving improvements. The SMT are overseeing a drive to create a skilled and committed workforce, and with support from national resources have introduced a number of initiatives aimed at ensuring staff are able to meet the expectations of their role and understand the importance of doing so.

Following the introduction of New Colleague Mentors, made up of experienced staff to support newly arrived prison officers, an ‘Induction Passport’ has been created. This document provides comprehensive information and guidance on the key duties of staff, as well as detail on how to seek support. Alongside the Induction Passport a ‘buddy’ system is in place, providing new recruits with a link to a more experienced member of staff to provide support and guidance. Packages have also been delivered to line managers to help them steer new and less experienced staff confidently and effectively.

At a national level, as we know that sufficient and skilled frontline staffing is fundamental to delivering safe, secure, and rehabilitative prison regimes, the department operates a centralised recruitment model, providing targeted support to prisons with acute local recruitment problems - we continuously review our recruitment process to ensure officers are best suited to their role. In addition to this, HMPPS have a retention oversight process in place
- all establishments are required to regularly review their attrition and determine local action supported by a retention toolkit to tackle their main drivers of attrition. We have invested in several new initiatives to improve the experience of our new joiners and increase retention of our employees.

The identification and management of risk is a vital element of core prison officer duties. A range of measures are being introduced by the SMT at Lowdham Grange to ensure risks are

identified and appropriately shared across all disciplines and agencies. Work is ongoing to develop a triggers database, to ensure shift handovers are effective in communicating issues, and to improve first night and induction processes.

Work is also ongoing to create a positive and collaborative relationship between the prison and the healthcare provider, to build better working relationships and ensure all are aware of their responsibilities in sharing information with colleagues. It will be reinforced to staff in all areas that information should be shared using the relevant systems, such as NOMIS, SystmOne, and observation books, rather than through emails.

The Safety Intervention Meeting (SIM) is being refreshed so that it provides a more effective mechanism for all those involved in the care of prisoners and to discuss those at risk, share information and ensure a strategic overview that pulls in all relevant information and agencies to ensure support is tailored to the individual. The Governor is committed to learning from deaths that have occurred and has introduced a meeting to focus on work to address issues raised in Reports to Prevent Future Deaths.

At national level our policy is clear, both in Prison Service Instruction (PSI) 7/2015, Early Days in Custody – reception in, first night in custody, and induction to custody, which places a requirement on prisons to make use of all the information available for the purposes of risk assessment on reception, and in the Prison Safety Policy Framework, which requires that Governors put in place an effective process to identify and record a prisoner’s relevant risk information, keep this up to date as the prisoner progresses through their time in custody and make it accessible to all staff involved in their care.

We know that achieving full compliance with these policies can be challenging and we continue to work with healthcare partners and others to support Governors in implementing them, including through the HMPPS/NHSE Information Sharing Advisory Group which meets regularly to tackle issues in this area. For example, we are currently working with NHSE to devise revised guidance on information sharing in prison reception areas, focused particularly on healthcare staff access to the digital Person Escort Records (dPER).

We are also revising the training provided to prison staff deployed in reception areas to provide increased focus on their role in identifying risk, including where to look for risk information, details of cohorts that are known to be at higher risk and a clear warning against relying solely on the prisoner’s presentation when making decisions about risk levels.

The decision on how men move through the prison system is determined by the National Allocation Protocol and the National Offender Flows, and in line with the Security Categorisation Policy Framework and indeterminate prisoners with the Progressive Transfers for Indeterminate Sentence Prisoners.

Since Mr Richards’ transfer from HMP Chelmsford to HMP Lowdham Grange the way that prisoners are allocated from reception prisons to appropriate category B prisons has developed significantly. Now, prisoners with 27 years left to serve would generally be allocated to a dispersal prison, particularly if it is their first time in custody and little is known about them and their risk to themselves and others. Where possible prisoners will be allocated to prisons close to their home area.

Decisions to move prisoners between establishments must take into account a range of factors including the needs of the prisoner to support their progression, wider population management and the stability of prisons. To support this, Category B prisons can arrange transfers between establishments, and in the LTHSE this is done by the LTHSE population management team. Factors such as vulnerable prisoner (VP) status will be considered. The issues surrounding VP status are complex and prisoners are not managed solely based on this status. Some prisoners who hold VP status in one prison are able to reside safely on normal location in other prisons as the demographics of the population vary significantly and the risk is abated.

While appropriate considerations will be made regarding individuals’ wishes regarding their location, in order to effectively manage the prison population and stability, it is not always possible or appropriate to move prisoners to a prison of their request. Wherever possible there should be discussion with prisoners and where requests are denied reasons should be given (unless there are security or other valid consideration that prevent this). Prisoners may appeal through the prison’s internal appeal process, and if requests are still denied, or were not considered within 30 days, they have recourse to complain through the independent Prisons and Probation Ombudsman (PPO).

You raise concerns about services for Foreign National Offenders (FNO) and the risk that these individuals may become isolated. HMPPS has several national policies which consider the needs of FNOs, including the PSIs on Early Days in Custody and Prisoner Communications. These policies set out the support that is available to FNOs to maintain contact with their family members.

During the inquest you heard evidence concerning access to The Big Word translation service. The Ministry of Justice is committed to ensuring that the justice system is supported by high- quality language services that meet the needs of all users. In 2016, Thebigword Group Ltd was appointed as the supplier of language services, specifically spoken face-to-face, telephone, and video interpretation services, as well as foreign language-related translation and transcription services. The department’s contracts provide a robust governance structure and performance regime, including the monitoring of telephone interpretation to ensure compliance with the contracted standards. Thebigword has confirmed that their data shows no evidence presently of waiting times over an hour to service any calls at Lowdham Grange.

However, we are committed to working with both suppliers and venues to investigate any connectivity issues or unreasonable waiting times when raised, and establish the root cause

of the issue, as it may be that there is another issue contributing to this experience (for example, equipment connectivity).

Locally, Lowdham Grange is recruiting for an FNO manager who will ensure FNOs are effectively managed and supported, as well as developing an assurance process to determine the use of Big Word.

Your report identifies the significant risk posed by psychoactive substances (PS). HMPPS recognises the risks relating to drug and alcohol use including most significantly the risk to life and actively works to reduce these. Evidence obtained through drug testing and intelligence identifies that, from a national perspective, the most prominent drugs used in prisons are synthetic cannabinoids (also referred to as SCRAs/PS).

HMPPS has a prison drug strategy that adopts a whole system approach to restricting supply and reducing the demand for drugs and to building recovery. PS is often used in conjunction with other drugs, and as a result our strategy sets out a set of principles and actions that are sufficiently flexible to apply across the estate, rather than a drug-specific approach. As the risk and impact of drug and alcohol use is variable between prisons it is the responsibility of each prison to understand local risk and develop local strategies to ensure the risks are identified, understood, and effectively managed.

However, to ensure staff understand the risks specific to PS use, an eLearning package is available for all staff to access. This course has been designed to increase awareness of the types of synthetic cannabinoids: understanding their effects, how to deal with them and where to signpost for support to assist staff in reducing the demand for these substances, managing the associated risks and promoting recovery from dependency.

In addition to this the HMPPS Drug and Alcohol Operational Framework (an internal guidance document published in January 2025) has been designed to support frontline staff in their day- to-day work. It emphasises the importance of taking a person-centred approach when working with people who use drugs and alcohol to support individuals to access the treatment and recovery support they need.

At Lowdham Grange the drug strategy is overseen at a monthly meeting attended by senior leaders and operational managers, and there are two dedicated drug strategy officers in place. Supply restriction measures include work to prevent drone drops, body scans for prisoners, and a network of security liaison officers are on each houseblock to ensure that information on those organising and using illicit items is passed on. Future plans include the installation of windows that will prevent the entry of parcels and a publicity programme to raise awareness in the community of the drone problem and to encourage the reporting of suspicious behaviour. The local drug strategy also includes various measures to reduce demand, enable recovery and reduce harm. These include a video on the dangers of synthetic opioids that was created

in house and is played on the in cell TV system and the availability of naloxone, with staff trained in its use.

As stated at the inquest, we are committed to learning from the experience of the transfer of Lowdham Grange from one provider to another to inform subsequent competitions for contracts and their mobilisation, and a number of changes have already been made in response.

Future competition documentation has been amended to add requirements to develop a culture plan to ensure there is a clear focus from operators on assessing and building on the existing culture at a prison. Additionally, future competitions will see increased weighting in the evaluation for the response on safety, and all bidders are now required to submit a safety response which outlines how the supplier intends to understand, identify, monitor and review safety risks and achieve their intended outcomes.

To assist bidders with a better understanding of the prison at the point of competition, the project now provides a Current Regime and Services document as part of the Prison Specific Competition Data Room. This amalgamates previous disparate pieces of information and provides more detailed data, so bidders have a clear overview of all aspects of the prison. The project has also introduced an improved process for operating procedures from HMP Altcourse mobilisation onwards, which assists incoming Operators in identifying current processes in place and provides them with clear templates and guidance to streamline the process.

Improvements have also been made to the mobilisation process as a result of the findings of this inquest. Timelines for submission of key mobilisation documents such as local operating procedures have been revised to enable a new operator to stagger activity and keep focused on operations and critical systems in the lead up to handover and a staff communications toolkit has been developed to ensure alignment of messaging between all parties.

The Mobilisation Blueprint was updated to provide further information about the expectations of what activity should take place in each phase to ensure bidders understand what the priority is for each phase and include realistic timelines for their activity in their plans.

Visits to expiring private prisons have been agreed with the HMPPS National Safety Group during the mobilisation stage, focusing on the early days processes including reception, first night and induction, with a follow up visit during the transition period. The Safety Group share their findings via a report to the site to ensure all parties are aware of what areas need focus.

We have also agreed with the Performance, Assurance, Risk (PAR) Group to conduct Safety Audits at these sites, closer to the mobilisation period. The Safety Audits are usually unannounced, however, given the challenging nature of transferring a site from one Operator to another, we have agreed that these safety audits are carried out 6 – 9 months prior to expiry for these sites (the incumbent operator still won’t be notified prior to them going in). Final

Reports and recommendations for the incumbent will be shared with the Private Prison Expiry Team and Controller Team to help inform key areas of focus and provide recommendations.

Your report references the role of Controllers within the contracted estate, particularly in the context of learning from deaths in custody.

The role of the Controller within contracted prisons is vital and is responsible for ensuring the establishment operates in line with the contract and to HMPPS standards, and for overseeing the processes related to learning from deaths within the private prison estate. This includes ensuring that all action plans created following a death are reviewed systematically and thoroughly and that the implementation of recommendations is overseen by physically testing processes in the prison and reporting on compliance against prison service policy frameworks. Controllers work closely with the providers and local Safety teams to ensure that changes are made to prevent future deaths and improve care quality and are responsible for applying necessary contractual action as required to drive continuous improvement.

To assure themselves that the provider is learning from deaths, Controllers conduct regular compliance and assurance testing of the prison’s safety strategy and processes to ensure compliance with national guidelines and internal policies. These checks help verify that lessons learned are being effectively integrated into practice. Controllers have established governance structures where findings from assurance are discussed, promoting a culture of continuous learning and improvement. Controllers are also responsible for monitoring the impact of implemented changes through ongoing evaluation. They track the provider’s performance and outcomes to assess the effectiveness of actions taken and make further offers of support and/or required challenge to the providers where adjustments are needed.

By fulfilling these responsibilities, Controllers play a crucial role in ensuring that our provider is not only learning from deaths but also continuously improving the quality of care provided to prisoners.

More generally HMPPS is committed to learning from all deaths and to taking action to address any issues that are identified as a result. The Follow-up to Deaths in Custody policy framework describes the early learning review process for all apparently non-natural deaths, through which cases are reviewed by the group safety lead and the resulting report considered by the Governor, the Prison Group Director and the National Safety Group. It also explains our commitment to supporting the various independent investigation processes that follow a death and particularly to meeting our duty of candour, including by disclosing all relevant documents.

The National Safety Group uses PFD reports alongside other sources of learning to identify themes to inform improved guidance, regular learning bulletins and the development of our approach to prison safety more generally. These themes are also discussed at regular meetings of group safety leads who share the learning with the prisons in their groups.

I am sorry that there were delays in the disclosure of material during these inquests. We have reviewed the handling of the inquests with Government Legal Department (GLD) and we believe that this was the result of the unusual circumstances of this case, which had a broad scope that reached into areas that are not commonly subject to such investigation. The Follow- up to Deaths in Custody policy framework sets out very clearly the requirement to retain documents relevant to the death and specifically notes that there may be a considerable delay between the death and the inquest, and that the coroner may ask for documentation not requested by either the police or the PPO, pointing out that it is therefore crucial that prisons retain all documentation available. In the vast majority of cases prisons are complying with this guidance and it is proving sufficient to meet the needs of coroners.

I am committed to a culture of transparency and openness throughout the organisation’s work and this extends to our participation in all investigations into deaths in custody. It is vital that individual staff and the organisation is able to reflect on their actions and admit where failures have occurred. At an inquest, this approach is reflected in ensuring staff at all grades and in all circumstances are aware of our duty of candour and give their evidence honestly.

To date we have considered this approach to meet our duty of candour and have not routinely sought to make formal admissions in the way that you have advocated. Rather it has seemed appropriate to us to allow the jury to make their findings based on the evidence, as elicited by the Coroner and the representatives of the interested parties. Not making formal admissions in the context of the inquest does not imply any reluctance on our part to acknowledge failures or any lack of will to learn from them.

Following this inquest and the concerns that you have expressed about this approach we will review and consider this position with GLD and Counsel. If you have further thoughts on this issue that you believe would be useful for us to consider during this process we would be very glad to hear them.

Thank you again for bringing your concerns to my attention. I trust that this response provides assurance regarding ongoing work at HMP Lowdham Grange.

Report sections

Investigation and inquest

On 5 April 2023, I commenced an investigation into the death of Anthony Binfield, David William Richards and Rolandas Karbauskas. The investigation concluded at the end of an inquest, heard before a jury, calling evidence on dates between 4 November 2024 and 7 February 2025. The conclusion of the inquest was that Anthony, David and Rolandas had all died as a result of self-inflicted ligature asphyxiation, while in state detention at HMP Lowdham Grange, within a 19-day period of one another. The jury found multiple failings and missed opportunities in their care had probably more than minimally contributed to their deaths.

Circumstances of the death

Serco had operated HMP Lowdham Grange, Nottinghamshire, for 25 years under the provisions of a Private Finance Initiative (‘PFI’). When the PFI expired on 15 February 2023, the Ministry of Justice awarded the prison operator contract to Sodexo. This was the first private provider to private provider prison transfer to take place in England and Wales. To facilitate the contract exit and transfer, Serco, Sodexo and HMPPS each established their own mobilisation and transfer team to oversee the project between August 2022 and February 2023. Sodexo assumed operational control of the prison on 16 February 2023. On 6 March 2023, Anthony Binfield was declared deceased inside his cell, having died as a result of using a ligature. His death was the result of suicide. On 13 March 2023, David William Richards was declared deceased outside his cell, having died as a result of using a ligature. His death was accidental. On 25 March 2023, Rolandas Karbauskas was declared deceased outside his cell, having died as a result of using a ligature. His death was the result of suicide.

All three men had vulnerabilities and had been in contact with prison and healthcare staff concerning these vulnerabilities in the period shortly before their deaths. There were multiple missed opportunities to have considered the risk pertinent information held within various systems and records when engaging with all three men. The jury found that there were shortcomings in the culture and systems with regards to prison and healthcare services, which contributed to the three self-inflicted deaths. Further, the jury found that the way in which the mobilisation and transfer of the prison contract had been conducted, probably more than minimally contributed to the deaths.

Action should be taken

In my opinion action should be taken to prevent future deaths and I believe you have the power to take action in relation to the above matters. (1) Minister for Prisons and NHSE (2) Minister for Prisons, NHSE, Serco, Sodexo and Nottinghamshire Healthcare NHS Foundation Trust (3) Minister for Prisons (4) Minister for Prisons (5) Minister for Prisons (6) Minister for Prisons (7) Serco Justice Director and Minister for Prisons (8) Minister for Prison, Serco and Sodexo

Copies sent to

In addition to the organisations identified above

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2025-0079
Date of report: 7 February 2025
Coroner: Laurinda Bower
Coroner area: Nottingham City and Nottinghamshire

Responses identified

Responses identified 5 of 5

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Apr 2025.

Sent to

HMPPS

NHS England

Nottinghamshire Healthcare NHS Foundation Trust

Serco

Sodexo

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.