Source · IMB Annual Report

Lowdham Grange

Year: 2025 Published: 18 Jun 2025 Type: Prison · Cat B Population: 837 Recommendations: 7 Key concerns Positive findings

HMP Lowdham Grange has seen some safety improvements since HMPPS took over, but faces critical challenges including six deaths in custody, widespread drug availability with high positive test rates, and a significant increase in use of force. Healthcare provision remains a major concern due to chronic staffing shortages, lack of night cover, and long mental health transfer delays. Persistent under-resourcing in probation and psychology departments impacts prisoner progression and resettlement, while the regime continues to be hampered by staffing issues and reduced social visits.

Safety statistics

Incidents during reporting year
IndicatorThis yearPrevious
Deaths in custody6
Self-harm incidents821844
Prisoner assaults450462
Assaults on staff261209
Use of force762414
Drug finds410197

Positive findings

The Board welcomed progress in making the prison safer, particularly since HMPPS took control in August 2024, noting enhanced gate security, vigilance against drones, and effective intelligence-led searches. The reintroduction of the Listeners' scheme, improved staff-prisoner relationships, and generally good food quality were also positive. Healthcare saw improved working relationships and successful social care input, including a well-managed TB screening. Education provision was praised by attendees, and workshops provided meaningful employment leading to qualifications. The OMU improved internal processes and high-risk prisoner management, while a successful peer coach initiative aided behavioural programmes. The Board also noted positive feedback on regular family days and improvements to the visits environment.

Key concerns

70 items
Safety Repeated There have been six deaths in custody since our last report, bringing the total number of deaths at the prison to 20 in six years.
Substance Misuse Repeated Prisoners report that drugs are still readily available, mandatory drugs testing has shown positive results almost reaching 50%, and there is a marked increase in the number of 'code blue' calls for prisoners unresponsive under the influence of drugs.
Mental Health Self-harm incidents have fallen slightly, but the number of individuals who self-harm has increased.
Safety Prisoner-on-prisoner violence has fallen, but assaults on staff are still at a high level, and the use of force on prisoners has increased significantly.
Complaints/Property The prison complaints system has been improved, but the Board receives many applications about late and inadequate responses.
Healthcare Repeated The provision of healthcare to prisoners is still a major concern due to no head of department for sustained periods, staff shortages, no healthcare cover at night, the use of agency staff leading to lack of continuity in care, long delays in finding placements for severely mentally ill prisoners in secure hospitals, and long waits for dentist and optician appointments.
Regime/Time Out of Cell The number of key work sessions with prisoners is still below target.
Education/Purposeful Activity Delivery of behavioural courses has been hampered by staffing issues in the psychology department.
Resettlement/Release Prisoners with category C and D status are waiting many months for transfers to suitable prisons.
Resettlement/Release Prisoners are released without full support, due to staffing issues within probation services at the prison.
Other The prison has a duty to inform the IMB whenever there is an event classed as a ‘serious incident’, but this has not happened on numerous occasions during the year.
Estate/Conditions The reception area is often cluttered, poorly laid out and badly organised, and holding rooms are small and bare.
Other Prisoners frequently express their frustration at being unable to access their property, which is stored in reception, and property going missing during transfers.
Safety Repeated HM Coroner was heavily critical of the failure to learn from previous deaths in custody at Lowdham Grange and found failings in culture and systems contributed to three self-inflicted deaths.
Safety Concerns over the lack of staff training and guidance in the use of Hydramist to deal with cell fires.
Safety Prisoners subject to ACCTs generally received limited support; observations were often chaotic, and paperwork difficult to locate.
Safety The high number of prisoners on an ACCT on some wings, plus staff unfamiliar with the wing, led to poor-quality support for some vulnerable men.
Safety Repeated High levels of violence have continued at the prison throughout the reporting period.
Safety Demand for Challenge, Support and Intervention Plans (CSIPs) was greater than the supply of trained staff to support these plans.
Safety The Board is not aware of any measurement to identify if the CSIP plans had challenged the perpetrators of violence or supported them to change their behaviour.
Regime/Time Out of Cell Staff shortages and inexperienced officers on the wings frequently meant self-isolating prisoners were not identified and did not have access to showers, exercise, or food.
Safety It has not been possible to provide a full breakdown of planned versus spontaneous use of force incidents, as the records available to the Board are incomplete.
Safety Repeated Governance of Use of Force incidents was previously judged to be very poor by HMIP due to insufficient oversight and accountability.
Safety Board members were not advised of Pava incidents, making monitoring its use very challenging.
Safety Use of Force scrutiny meetings were either cancelled or moved to different days/times without warning, making attendance impossible for several periods.
Safety No evidence that operational managers are routinely checking on prisoners who have been subject to force in the 24 hours after the event.
Substance Misuse The Board has serious concerns about prisoner safety and staff wellbeing when the availability of illicit drugs is so great.
Estate/Conditions Observed poor standards of cleanliness on wings at times.
Regime/Time Out of Cell Complaints that some phones, especially in the Care and Separation Unit (CSU), are not working.
Food/Catering Complaints about small portion sizes, with Board members witnessing very small lunches being served.
Food/Catering Prisoners in the CSU have complained of feeling hungry and/or finding food inedible.
Estate/Conditions One wing reported three microwaves were broken and had not been replaced, despite several requests to the works department.
Estate/Conditions The fabric of the CSU remains tired and needs regular redecoration; cells are often out of action due to damage.
Staffing CSU staff have frequently told the Board that the unit is understaffed, impacting the regime offered on many occasions.
Regime/Time Out of Cell Prisoners have little purposeful activity in the CSU; in-cell activities were not observed, and exercise is limited to 30 minutes a day, often disrupted by staff shortages.
Healthcare The lack of attendance by a member of staff from the healthcare department at segregation reviews remains a concern.
Staffing Staff were frequently assigned to wings where they were not familiar with the prisoners accommodated there, impacting relationships and continuity.
Resettlement/Release Prisoners expressed frustrations that the lack of contact with offender management unit staff was affecting their sentence progression.
Equality/Diversity Equality issues failed to be monitored and managed during most of the reporting year due to no consistent person in place as the equality officer, resulting in no data.
Complaints/Property The Prisoner Information and Advice Committee (PIAC) and User Voice were disbanded, with prisoners feeling they weren't getting answers.
Equality/Diversity There has been no steering group for younger prisoners, few activities for older prisoners, and a lack of association time for retired prisoners.
Equality/Diversity Equality data is unavailable for this 12-month period, and Discrimination Incident Report Forms (DIRFs) were not getting a reply due to lack of resources.
Healthcare The planned change for Nottinghamshire Healthcare NHS Foundation Trust (NHCFT) to have a directly employed GP arrangement for the prison was not implemented successfully, leading to no GP provision for one week.
Healthcare Plans to store medicines in individual locked cupboards are still being delayed, and frequent changes in regime have hindered healthcare staff delivering medication rounds.
Safety A serious incident where a prisoner stabbed a prison officer at the hospital caused further anxiety about the risk involved in hospital attendances.
Mental Health The loss of a psychology service was a direct consequence of management changes from Serco to Sodexo, impacting beneficial changes for prisoners with severe mental health issues.
Mental Health Delays in implementing a wellbeing centre to deliver positive outcomes for mental health, which was planned and funded over two years ago.
Regime/Time Out of Cell The severe limitations posed by the regimes during the year have had a negative impact on prisoner health, evident in the number of ACCTs.
Healthcare The issue of providing healthcare services at night has been raised again by recent inquests into deaths, highlighting an urgent matter.
Education/Purposeful Activity The library opening times make it difficult for full-time workers to attend; it is not well resourced and has a limited budget for improvements.
Staffing Repeated The probation team in the Offender Management Unit (OMU) remains under-resourced, with only nine probation officers in role managing caseloads of over 90 prisoners, leading to the department being overloaded.
Staffing OMU staff attendance on wings was delayed for over a year due to unsafe prison conditions, impacting the quality of probation officer and prisoner engagement.
Estate/Conditions There are no longer allocated interview rooms in each house block for probation officers to use, forcing reliance on visits or wing interactions and lacking safe, private spaces.
Resettlement/Release Transferred-in prisoners to HMP Lowdham Grange have still been arriving with incomplete records.
Resettlement/Release Decisions made by OMU staff regarding public protection issues were a concern, with many applications relating to cuts in family ties generating negative outcomes for prisoners.
Resettlement/Release There is no restorative justice programme at HMP Lowdham Grange.
Resettlement/Release Prisoners find it difficult to enrol on courses for progression to category C status, complete sentence plans, or improve parole chances.
Education/Purposeful Activity Employment offered affords prisoners little opportunity to gain recognised qualifications or useful experience for future employment.
Education/Purposeful Activity Prisoners' studies are hampered by a lack of access to computers and the internet, and disruptions from prison transfers.
Resettlement/Release Those achieving category C status are frustrated by long waits for transfers to suitable prisons, with some even attaining Category D status while still at Lowdham Grange.
Resettlement/Release The OMU had limited flexibility in the programmes it was able to offer prisoners.
Resettlement/Release There is a waiting list of 80 for the Kaizen programme, with only 18 men currently going through it a year, indicating unsatisfactory throughput based on need.
Education/Purposeful Activity Course delivery has been impacted significantly by regime changes and staffing issues, leading to extended course durations.
Staffing A lack of qualified psychologists makes it difficult to introduce more non-accredited programmes for prisoners.
Regime/Time Out of Cell Social visit sessions have been limited to a maximum of 25 prisoners, reduced from 45 pre-Covid, and the number of days for family social visits was cut.
Regime/Time Out of Cell Prisoners have numerous concerns regarding reduced visiting hours and ongoing problems booking social visits, with many prime slots appearing 'block booked'.
Equality/Diversity 150 prisoners have not received social visits at all during the reporting year.
Regime/Time Out of Cell Families are being delayed unduly by entry gate searches, and escorts to and from wings regularly run late, cutting short friends and family time.
Equality/Diversity The outside play area for family days is targeted at only the youngest children, with plans to remedy this.
Resettlement/Release HMP Lowdham Grange is not resourced as a resettlement prison, and the probation team is completing the ‘resettlement role’ without adequate support or expertise.

Recommendations

7 items
#RecommendationAddresseeStatus
1 What is being done to improve rehabilitation and resettlement provisions to help bring down re-offending rates?
Response
It is deeply concerning that six individuals have died in custody since your previous report. I extend my heartfelt sympathies to their families and friends, and to the staff managing these tragic incidents. Each case will be subject to independent review. I note your comments around past failings that have contributed to previous deaths and hope these are now being addressed. I want to assure you that His Majesty’s Prison and Probation Service (HMPPS) takes every such incident extremely seriously and remains committed to learning lessons to improve safety and prevent future harm.
Ministry of Justice In progress
1 When will the Prison Service introduce effective safeguards for prisoners’ property during transfers between prisons or between cells within the prison? HMPPS
1 What is being done to ensure the mistakes and omissions highlighted in the recent Prevention of Future Deaths reports by the Coroner are not repeated? Governor / Director
2 What is the Government planning to do about prisoners still being held on imprisonment for public protection (IPP) sentences?
Response
Access to timely and appropriate mental health care remains a key priority. The healthcare provider in place at the time of your last report has now exited the contract and a new provider commenced services in July 2025 following a structured handover process. Psychology staffing has improved with full-time clinicians now on site and the range of services available includes cognitive behavioural therapy (CBT) and one-to-one counselling. During the transition, support was provided by regional teams and by staff from HMP Fosse Way to ensure continuity of care. NHS England also commissioned temporary additional staffing to bridge any shortfalls. At a national level, the Mental Health Bill introduces a new statutory time limit of 28 days for transfers from prison to hospital under the Mental Health Act. Implementation planning is underway and will be supported by the newly established Mental Health and Justice Strategic Advisory Group, which brings together operational partners to address barriers and improve oversight. Locally, HMP Lowdham Grange is maintaining joint governance arrangements and holding weekly operational meetings to monitor caseloads and waiting times to ensure timely escalation and coordination of care.
Ministry of Justice In progress
2 What is being done to bolster mental health services to offer adequate help to the high numbers of prisoners with mental health problems? HMPPS
3 What steps are being taken to give Governors greater autonomy to introduce local initiatives to benefit prisoners?
Response
We remain committed to ensuring that individuals are held in establishments that reflect their current risk and sentence progression needs. The Population Management Unit (PMU), supported by the LTHSE and the Offender Flows team, continues to prioritise the progressive transfer of prisoners who have been re-categorised as Category C or D. Despite pressures on capacity, there has been a sustained reduction in the number of lower-category prisoners held at HMP Lowdham Grange. The prison has recently received a significant allocation of Category C spaces, which has enabled further transfers to be carried out. We will continue to monitor progress and ensure that transfers take place in a timely and appropriate manner, wherever possible.
Ministry of Justice In progress
3 Is anything being done to expedite the moves of prisoners granted category C and D status to suitable establishments? HMPPS

Applications to the IMB

CategoryCurrentPrevious
Accommodation (including transfers) 45 38
Adjudications (including appeals) 20 19
Catering 42 35
Discrimination 6 2
Education and training 38 25
Healthcare 57 68
Legal 22 18
Official visits (including correspondence) 10 8
Other 48 36
Personal Finances (including pay) 15 12
Privileges (including incentives and earned release) 28 20
Property 35 28
Race relations 0 0
Security 18 15
Segregation (including time out of cell) 25 18
Staff conduct 12 10
Substance misuse 25 18
TOTAL 533 452
Visits (including domestic, child and family) 48 42
Work (including vocational training) 20 18

Related inspections & investigations

3 Mar 2025 HMIP · Unannounced
8 Jan 2024 HMIP · IRP
15 May 2023 HMIP · Unannounced Safety 2 · Respect 2 · Activity 1 · Release 2
PPO fatal incident Adam Diesa-Green · Other non-natural
PPO fatal incident Uziel Mendoza-Sillerico · Natural causes
PPO fatal incident Stephen Metcalfe · Other non-natural
PPO fatal incident Patrick Maughan · Other non-natural
25 Nov 2023 PPO fatal incident Matthew Osborne · Self-inflicted
17 Dec 2025 PFD Anthony Binfield · Suicide (from 2015) | State Custody related deaths
3 Aug 2022 PFD Nigel Saunders · State Custody related deaths

Other reports for Lowdham Grange

2024 Published 12 Jul 2024 Population 808 · Self-harm 844 · Concerns
2023 Published 31 May 2023 Population 860 · Self-harm 606 · Concerns
2022 Published 21 Jun 2022 Population 880 · Self-harm 528 · Concerns
2021 Published 17 Aug 2021 Population 885 · Self-harm 480 · Concerns
2020 Published 15 Jul 2020 Population 885 · Concerns

Report details

Establishment
Lowdham Grange
Type
Prison · Cat B
Report year
2025
Published
18 June 2025
Responsible body
HMP Lowdham Grange
Recommendations
7
MoJ rating (2024/25)
1 — Serious concern

Population

Population837
Operational capacity888

Service providers

Education
Novus
Healthcare
Nottinghamshire Healthcare NHS Foundation Trust

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