Luke Ashcroft

Coroner's concerns

AI summary

Corded telephones in CSU cells pose a clear self-harm risk when suspended, and unreliable provision of telephone access prevents prisoners in crisis from reaching support services.

View full coroner's concerns

I received evidence in relation to the availability of telephone access for inmates at HMP Lincoln. I was told that, in the main, the prison had in-cell telephony, permitting prisoners access to telephones 24 hours a day, subject to them having sufficient phone credit and subject also to necessary security restrictions upon the numbers to be called. The position was said to be different in CSU. I was told that in-cell telephones were precluded by virtue of the construction of the unit, but that each cell was allocated a corded phone, which remained outside the cell until requested by the inmate. At that point it would be passed inside for use (as long as the unit was not then on "patrol state" during which time additional staff would be required to attend to permit the cell door to be opened). Once provided, the phone would remain in the cell for as long as the prisoner wished to retain it. Cell J 109 which housed Mr Ashcroft was said to be equipped with an anti-ligature door fitting. I was told that as a consequence, it was only possible for the phone to be passed over the top of the door, where it would dangle on its cord. That position, described from June 2020 was said to continue. I was told that cell J 109 was equipped with variable glass panels to the door, permitting improved observation of the inmate. It was selected for Luke Ashcroft in part as a consequence of him being subject to the ACCT procedures and subject to regular observations. It was recognised that he should be provided with telephone access. My concerns are twofold. Firstly, whilst not directly relevant to the death of Luke Ashcroft, I am concerned about the clear and obvious risks of self harm posed by the provision of a corded telephone, secured at one end, suspended at head height in a cell commonly occupied by prisoners, who may seek to self harm. I was told that the cell J109 had no ligature points and that the door was fitted with anti ligature fittings. As a consequence, that was the only method of securing telephone access. That same issue may extend to other cells in the CSU. Whether at head height or otherwise, the provision of a corded phone may well be an issue in potential cases of self harm and appears incongruous in comparison with other steps taken to ensure safety within that cell. The risks of an inmate utilising that cord in an act of self harm are self evident. Secondly, the mechanism of provision of telephone access on CSU appears to require a prisoner requesting such provision before the cells are locked down. Thereafter, whilst a request can be made by a prisoner, telephone provision may depend upon the availability of additional officers to attend whilst the cell is unlocked and the telephone provided. That is not certain to take place. Given the proper availability to prisoners in crisis of freephone access to Samaritans and similar services, the possible absence of a handset to access such services is a matter of concern.

Responses

2 respondents

HM Prison and Probation Service Central Government

21 May 2026 PDF

Action Planned

HMP Lincoln is developing a business case for long-term structural changes to in-cell telephony in the CSU. Interim measures being implemented include modifying cell doors for secure cable routing, fixing telephones to internal walls, installing non-weight bearing handset cradles, and enhancing governance of risk assessments for in-cell phone retention. (AI summary)

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Dear Mr Smith, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR LUKE ASHCROFT Thank you for your Regulation 28 report of 20 March 2026 following the inquest into the death of Luke Ashcroft at HMP Lincoln on 1 July 2020. I am providing the response on behalf of His Majesty’s Prison and Probation Service (HMPPS). I know that you will share a copy of this response with Mr Ashcroft’s family, and I would first 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. You have raised concerns regarding the provision of telephones in the Care and Separation Unit (CSU) at HMP Lincoln, including location of the cord during use and access to telephones which in the CSU is on request. The establishment has undertaken a review of the current telephony arrangements within the CSU. While the relocation of telephone sockets within cells has been considered, this would require significant structural alteration and capital investment. The Governor of HMP Lincoln is therefore developing a formal business case to assess the feasibility, proportionality, and associated operational and security risks of implementing such a longer-term solution. In the interim, a number of risk reduction measures are being implemented including work to modify the CSU cell doors to enable telephone cables to be routed securely beneath the door. This adjustment will remove the requirement for cables to pass over the top of cell doors, thereby reducing the identified ligature risk.

[Page 2] In addition, telephones will have the ability to be fixed to the internal wall to minimise excess slack and restrict the potential for inappropriate use. A fixed, non-weight bearing handset cradle will also be installed within cells using appropriate attachments, ensuring that the handset can be safely stored without the need for prisoners to maintain tension on the cable during use. To support access to telephony for prisoners who may be in crisis, and where it is assessed as appropriate, telephones may be retained within cells in an adapted cradle designed to mitigate risk. Such arrangements will be subject to an individual, case-by-case risk assessment, taking full account of the prisoner’s presentation, including any risks identified through Assessment, Care in Custody and Teamwork (ACCT) processes, and will be kept under regular review. In parallel with these physical adjustments, the establishment is strengthening governance and oversight within the CSU. There will be enhanced scrutiny of defensible decision-making documentation to ensure that all decisions relating to regime, risk management, and access to telephony are clearly recorded, justified, and proportionate. This will be supported through oversight by senior managers. The implementation and effectiveness of these measures will be monitored through the establishment’s safety and assurance frameworks. The controls introduced will be subject to ongoing review to ensure that they remain effective, proportionate, and responsive to any emerging risks or learning. Thank you for bringing these matters to my attention. I trust that this response provides assurance that appropriate and proportionate action is being taken to address the concerns identified.

HM Prison and Probation Service Central Government

21 May 2026 PDF

Action Taken

• The establishment has undertaken a review of current telephony arrangements within the Care and Separation Unit (CSU). • Interim risk reduction measures are being implemented, including modifying CSU cell doors to route telephone cables securely. • Telephones will be fixed to internal walls to minimise slack, and non-weight bearing handset cradles will be installed. (AI summary)

View full response

Dear Mr Smith, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR LUKE ASHCROFT Thank you for your Regulation 28 report of 20 March 2026 following the inquest into the death of Luke Ashcroft at HMP Lincoln on 1 July 2020. I am providing the response on behalf of His Majesty’s Prison and Probation Service (HMPPS). I know that you will share a copy of this response with Mr Ashcroft’s family, and I would first 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. You have raised concerns regarding the provision of telephones in the Care and Separation Unit (CSU) at HMP Lincoln, including location of the cord during use and access to telephones which in the CSU is on request. The establishment has undertaken a review of the current telephony arrangements within the CSU. While the relocation of telephone sockets within cells has been considered, this would require significant structural alteration and capital investment. The Governor of HMP Lincoln is therefore developing a formal business case to assess the feasibility, proportionality, and associated operational and security risks of implementing such a longer-term solution. In the interim, a number of risk reduction measures are being implemented including work to modify the CSU cell doors to enable telephone cables to be routed securely beneath the door. This adjustment will remove the requirement for cables to pass over the top of cell doors, thereby reducing the identified ligature risk.

[Page 2] In addition, telephones will have the ability to be fixed to the internal wall to minimise excess slack and restrict the potential for inappropriate use. A fixed, non-weight bearing handset cradle will also be installed within cells using appropriate attachments, ensuring that the handset can be safely stored without the need for prisoners to maintain tension on the cable during use. To support access to telephony for prisoners who may be in crisis, and where it is assessed as appropriate, telephones may be retained within cells in an adapted cradle designed to mitigate risk. Such arrangements will be subject to an individual, case-by-case risk assessment, taking full account of the prisoner’s presentation, including any risks identified through Assessment, Care in Custody and Teamwork (ACCT) processes, and will be kept under regular review. In parallel with these physical adjustments, the establishment is strengthening governance and oversight within the CSU. There will be enhanced scrutiny of defensible decision-making documentation to ensure that all decisions relating to regime, risk management, and access to telephony are clearly recorded, justified, and proportionate. This will be supported through oversight by senior managers. The implementation and effectiveness of these measures will be monitored through the establishment’s safety and assurance frameworks. The controls introduced will be subject to ongoing review to ensure that they remain effective, proportionate, and responsive to any emerging risks or learning. Thank you for bringing these matters to my attention. I trust that this response provides assurance that appropriate and proportionate action is being taken to address the concerns identified.

Report sections

Investigation and inquest

On 06 July 2020 I commenced an investigation into the death of Luke Owen ASHCROFT aged 33. He died in Lincoln County Hospital on 1 July 2020. He had been admitted to hospital from his cell within the Care and Separation Unit at HMP Lincoln on 24 June 2020 . At the time he was discovered he was unconscious. The investigation concluded at the end of the inquest on 16 March 2026. The findings of the inquest jury were that: When: Between 06.36 and 06.54 on 24 June 2020. Where: In cell J 109 within the Care and Separation Unit at HMP Lincoln. We find that: An initial screen and subsequent triage by healthcare staff were missed opportunities to initiate an effective healthcare plan, including medication review and consideration of risk control measures such as an ACCT from an earlier date. Risk-pertinent information sharing between disciplines and systems was inadequate; procedures intended to prompt discussions, including an algorithm, were not followed correctly. This led to mitigations in place for Luke to be inadequate for his circumstances when in the CSU. When the ACCT procedure was implemented on 23 June 2020, the immediate actions and details of the plan were inadequate to effectively address the risks Luke's circumstances presented. Failures by a prison officer to carry out the basic requirements of the ACCT plan led to Luke being neglected at a time of crisis. The jury concluded that; On the balance of probability, considering all the evidence we have heard, we are satisfied that Luke Ashcroft did not intend to take his own life and therefore record a conclusion of death by misadventure

Circumstances of the death

1. The death of Mr Ashcroft was confirmed at Lincoln County Hospital at 08.10 am on 1 July 2020. A later post mortem examination would find that the cause of death was 1a Hypoxic Brain injury 1b consistent with ligature application. A toxicology screen identified a number of substances not prescribed to Mr Ashcroft together with evidence of “ a synthetic cannabinoid.
2. Mr Ashcroft had been admitted to Lincoln County Hospital on 24 June 2020 from HMP Lincoln where he was being detained.
3. Luke Ashcroft was 33 at the time of his death. As a child he had been diagnosed with ADHD and prescribed medication. His behaviour was on occasion challenging but was managed by his family.
4. As he grew older his mental health problems worsened. He became addicted to drugs and that addiction impacted upon his mental health. In 2017 he was formally diagnosed with schizophrenia and was prescribed medication for that condition.
5. On 21 May 2020 he was released from HMP Humber on licence. As a consequence of his failure to comply with the term of his release was recalled to prison on 23 May 2020 and sent to HMP Lincoln. On arrival he tested positive for opiates and cocaine. He was already on a methadone (heroin substitute) programme, which was continued at Lincoln.
6. Shortly after arriving at HMP Lincoln, on 27 May, he told healthcare staff that he had spiders living inside his body. He was prescribed antidepressant and antipsychotic medication but continued to report his belief that he was infested by spiders. As a consequence, on 14 June he was seen by Healthcare and referred for an urgent appointment with a psychiatrist. That was fixed for 23 June.
7. On 22 June, Mr Ashcroft became more distressed about the spiders and barricaded himself in his cell. He was subsequently moved to the segregation unit (known as the Care and Separation Unit (CSU)). A nurse assessed that he was medically fit to be segregated.
8. On 23 June, a psychiatrist assessed Mr Ashcroft and diagnosed him with a condition of delusional parasitosis (a fixed but false belief that the body is infested with insects). He found that Mr Ashcroft was having ‘an acute psychotic episode’. He ordered tests to exclude any physical cause but considered it likely that Mr Ashcroft would require further assessment and treatment in a secure psychiatric hospital. He was then moved to another cell within CSU after causing some damage to his cell.
9. Later that day, a nurse started suicide and self-harm procedures (known as an ACCT) after Mr Ashcroft told her that he had spiders in his body and was ready to kill himself. He remained in the CSU after a further assessment.
10. Mr Ashcroft was subject to five observation checks an hour. The officer responsible for the checks during the night of 23 June into 24 June failed to carry out numerous checks but falsified the ACCT log to say he had in fact done so. His last entry in the ACCT log was at 6.50am which described that Mr Ashcroft was pacing in his cell. That entry was false. CCTV showed that his last check was made at 6.36am.
11. At 6.54am upon commencing his shift, the day shift officer checked Mr Ashcroft. He saw him lying on the cell floor . The officer called for assistance. As soon as he heard colleagues arrive on the unit, he entered the cell and cut the ligature from Mr Ashcroft’s neck. Another member of staff called a medical emergency code and healthcare staff arrived quickly.
12. The emergency services attended and Mr Ashcroft was taken to hospital, where his death was confirmed on 1 July.

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