Adam Diesa-Green

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Independent investigation
into the death of
Mr Adam Diesa-Green, a
prisoner at HMP Lowdham
Grange, on 17 January 2025
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2026
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Adam Diesa-Green died on 17 January 2025, at HMP Lowdham Grange. He was 24
years old. He died because of a cardiac arrest caused by the use of synthetic
cannabinoids. I offer my condolences to Mr Diesa-Green’s family and friends.
Mr Diesa-Green was the fourth prisoner to die of drug toxicity within a year at Lowdham
Grange and in total there were six drug related deaths at the prison between March 2024
and April 2025.
Mr Diesa-Green had a history of using illicit substances in prison. Mr Diesa-Green
engaged with the substance use service at Lowdham Grange. Just two days before he
died, Mr Diesa-Green attended a substance use support group that specifically highlighted
the dangers of psychoactive substances (PS).
In December 2023, HMPPS took back interim control of Lowdham Grange and on 1
August 2024, the prison was formally taken back into public sector control. I commented at
that time the prison was in a period of transition and faced significant challenges. This
remains the case, and the recent drug related deaths are of particular concern. I
acknowledge the prison has developed an action plan to address these issues and is
receiving additional support from the national safety team. A new Governor has also
recently taken up post at Lowdham Grange with a view to tackling the current issues
facing the prison.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman December 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 12
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Summary
Events
1. On 16 December 2021, Mr Adam Diesa-Green was remanded in prison custody
charged with grievous bodily harm with intent and taken to HMP Manchester. On 9
May 2023, Mr Diesa-Green was sentenced to five years and ten months in prison.
On 23 June, he was transferred to HMP Lowdham Grange.
2. Mr Diesa-Green used illicit substances in the community, which continued while in
prison. Mr Diesa-Green had disclosed his dependency on alcohol and while at
Lowdham Grange he regularly brewed illicit alcohol, which he said he drank daily. In
November 2024, Mr Diesa-Green was taken to hospital after being found under the
influence of drugs, and he later told staff that he had used psychoactive substances
(PS).
3. In January 2025, Mr Diesa-Green attended a substance use group, which focused
on the risks associated with using PS.
4. At 5.52pm on 17 January, while locking prisoners in their cells for the evening, an
officer found Mr Diesa-Green unresponsive in his cell. Staff and paramedics
attempted to resuscitate Mr Diesa-Green but, at 6.47pm, paramedics pronounced
life extinct.
Findings
5. The clinical reviewer found the substance use and mental health care Mr Diesa-
Green received at Lowdham Grange was equivalent to that which he could have
expected to receive in the community. However, we identified the need for better
assessment and clinical management of prisoners with alcohol dependency, such
as Mr Diesa-Green.
6. Mr Diesa-Green was one of several drug-related deaths at Lowdham Grange within
a short period of time. The prison remains in transition following an unstable period
which resulted in HMPPS taking back control. Significant steps have been taken to
address the ingress of drugs, including a diagnostic visit from the HMPPS
Substance Misuse Group in September 2024, and managers have begun to
implement their recommendations and made additional changes to security
procedures. However, we consider that more can be done to ensure prisoners
understand the very real risks of psychoactive substances.
Recommendation
• The Head of Healthcare should ensure that CIWA scores are used in the
management of those prisoners who disclose a new or ongoing alcohol
dependency.
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The Investigation Process
7. HMPPS notified us of Mr Diesa-Green’s death on 20 January 2025.
8. The investigator issued notices to staff and prisoners at HMP Lowdham Grange
informing them of the investigation and asking anyone with relevant information to
contact her. Three prisoners responded.
9. The investigator visited Lowdham Grange on 23 January and obtained copies of
relevant extracts from Mr Diesa-Green’s prison and medical records.
10. NHS England commissioned a clinical reviewer to review Mr Diesa-Green’s clinical
care at the prison.
11. The investigator and the clinical reviewer conducted joint interviews with eight
prison and healthcare staff. In addition, the investigator spoke to three prisoners.
We have also made reference to interviews completed by different investigators
with the Head of Healthcare, Head of Security and Head of Drug Strategy as part of
other ongoing investigations.
12. We paused our investigation between March and July 2025, pending toxicology
results.
13. We informed HM Coroner for Nottingham City of the investigation. The Coroner
gave us the results of the toxicology. We have sent the Coroner a copy of this
report.
14. The Ombudsman’s office contacted Mr Diesa-Green’s mother and partner to
explain the investigation and to ask if they had any matters, they wanted us to
consider.
15. Mr Diesa-Green’s partner wanted to know how he died and if he had an epilepsy
diagnosis. Mr Diesa-Green’s mother asked the following questions which have been
answered in this and the clinical review report:
• What care did Mr Diesa-Green receive after he was discharged from hospital in
late 2024?
• Did he use his cell bell on the day he died?
16. Mr Diesa-Green’s family received a copy of the initial report. They did not identify
any factual inaccuracies.
17. The prison also received a copy of the report and did not identify any factual
inaccuracies. An action plan for the recommendation is annexed to the report.
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Background Information
HMP Lowdham Grange
18. HMP Lowdham Grange is a category B male adult prison located in Lowdham,
Nottinghamshire. Nottinghamshire Healthcare NHS Foundation Trust provides
healthcare services. Primary healthcare is provided from 7.00am to 7.15pm, seven
days a week. From 19 November, Northamptonshire Healthcare NHS Foundation
Trust will deliver healthcare provision.
19. Lowdham Grange opened in 1998 and was privately managed by Serco for 25
years. In February 2023, Sodexo took over running of the prison; the first time a
prison had transferred from one private contract manager to another. In December
2023, due to concerns about the running of the prison, HM Prison and Probation
Service (HMPPS) took over some aspects. In May 2024, HMPPS decided to take
full control and terminated the contract with Sodexo. On 1 August 2024, HMPPS
took over full public sector control of the prison.
HM Inspectorate of Prisons
20. During an inspection of HMP Lowdham Grange in May 2023, inspectors found that
despite a six-month preparation phase leading up to the handover from Serco to
Sodexo, progress had not always happened early or quickly enough.
21. Inspectors reported that stability in the prison was being undermined by the
availability of illicit drugs and the lack of experienced officers to enforce rules and
tackle antisocial behaviour. They found that large numbers of prisoners were
suspected of being under the influence of illicit substances. There was an integrated
clinical and psychosocial substance misuse service available, but staffing vacancies
affected the range of support provided.
22. Inspectors were told that staff corruption and smuggling through social visits were
the primary sources of these drugs. Despite ongoing concerns about corruption,
staff were not searched often enough, there was no enhanced gate security and
checks on staff and visitors entering the prison were inadequate.
23. Following the inspection, the Ministry of Justice and senior HMPPS leaders
considered that conditions at the prison had deteriorated so significantly that, on 18
December 2023, the government announced that HMPPS would activate the ‘step-
in’ procedure to stabilise the prison. The ‘step in’ process allows the Secretary of
State to intervene when there are serious concerns over the operation of a privately
run prison and the provider’s capacity to fulfil the obligations set out in the contract.
24. The step-in process enabled immediate actions to be taken, including the
deployment of an experienced HMPPS governor to take on operational command of
the prison, and additional HMPPS staff.
25. Inspectors returned to Lowdham Grange in January 2024 and conducted a review
of progress. They found that outcomes for prisoners had declined further, and the
prison was not safe enough. Outcomes were being undermined by violence, the
ready availability of illegal drugs and an inexperienced staff group who lacked the
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confidence to provide effective supervision and management. Illicit drug use had
increased.
26. The most recent inspection of Lowdham Grange was in March 2025. Inspectors
noted the prison was three months into a complex and difficult transition between
contractors. They concluded that outcomes for safety and respect were not
sufficiently good, and outcomes for purposeful activity were poor. Inspectors
reported that a new governor had recently arrived and had a clear sense of the
challenges and seriousness of the concerns identified.
27. The random drug testing positive rate was 41% for the previous 10 months and
56% of prisoners at Lowdham Grange said it was easy to get hold of drugs.
Inspectors found that staff-prisoner relationships were inadequate: prisoners could
not rely on staff, who were inexperienced and poorly supervised, and key work (one
to one sessions with a named officer) barely happened. Time out of cell was
inconsistently delivered and inspectors found 43% of prisoners locked in their cells
during the working day.
Independent Monitoring Board
28. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 31 January 2025, the IMB
concluded that progress had been made making the prison a safer place for
prisoners since HMPPS took control.
29. The Board noted that drugs were still readily available and nearly 50% of mandatory
drug tests (MDTs) were positive. The Board reflected that there had been a marked
increase in the number of medical emergencies for prisoners found unresponsive
under the influence of drugs. However, they noted that positive action had been
taken with enhanced gate security, greater vigilance on detecting drones and the
use of sniffer dogs and electrical scanning of incoming post and parcels.
30. The Board reported that healthcare was a major concern. There had been no
substantive Head of Healthcare and a high level of staff shortages due to vacancies
and sickness. The use of agency staff led to a lack of continuity in care.
HMPPS Substance Misuse Group
31. In September 2024, following a recommendation from the PPO in relation to the
death of a prisoner in 2023, the HMPPS Substance Misuse Group (SMG)
conducted a drug strategy support visit at the prison. The aim of the visit was to
understand the scale and nature of substance use problems at Lowdham Grange
and understand the scale of the prison’s vulnerability to the conveyance of illicit
drugs.
32. Their findings included:
• Drugs predominantly used were cannabis and Synthetic Cannabinoid Receptor
Antagonists (SCRA – otherwise referred to as psychoactive substances (PS)).
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• Security & analyst team colleagues had developed a strong understanding of
illicit substances within the prison via detailed intelligence reports, allowing them
to produce a detailed and thorough Local Tactical Assessment (LTA) which was
used as the basis for further action plans at departmental level. However, there
was further scope for this to be used as one of the primary drivers to allow Drug
Strategy & Safety to work collaboratively.
• There were knowledge gaps among staff around substance use.
• Several vulnerabilities were observed in the visit area, including staff not being
given a security briefing prior to visits, lack of zonal patrolling and a lack of
secure communication means between officers and CCTV operators.
• There were no staff trained to operate the baggage X-ray machine.
• Legal visits presented a risk of drug ingress, notably in the form of paper based
illicit substances. The team suggested the prison adopted a digital approach to
minimise the amount of paper entering.
• The prison highlighted drone incursions as one of its primary routes of ingress.
• Revised monthly drug strategy meetings had started and were proving
successful. However, residential staff had little knowledge of the strategy and
how their roles contributed to its effective delivery.
• Prisoners raised frustrations at the lack of activities to keep them occupied,
resulting in increased levels of boredom and frustration with some using
substances as a coping mechanism.
33. The SMG made six recommendations. These included that:
• Activity should be undertaken to raise awareness of substance use and drug
strategy among staff.
• Managers should drive a widespread understanding across the prison of its
under the influence (UTI) policy to ensure all staff are aware of the correct
actions to take.
• The Senior Management Team should ensure there is closer strategic
alignment between security, safety and drug strategy activity.
• The prison should conduct a full review of existing visits procedures.
• The prison would benefit from conducting a review of its parcel process.
• Photocopying of social mail.
Previous deaths at HMP Lowdham Grange
34. Mr Diesa-Green was the 11th prisoner to die at Lowdham Grange in the three years
from January 2022. Two of the previous deaths were due to natural causes, five
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were self-inflicted and three were due to illicit drug use. To the end of September
2025, there have been two further drug related deaths and two from natural causes.
35. Between March 2024 and April 2025, six prisoners, including Mr Diesa-Green, died
at Lowdham Grange due to apparent drugs toxicity. We conducted individual
investigations into each of these deaths, but have considered in this report the
range of issues and findings that these investigations identified.
Psychoactive substances (PS)
36. The term psychoactive substances is a broad term that refers to a drug or other
substance that affects mental process. Synthetic cannabinoids and synthetic
opioids (including nitazenes) are substances that mimic the effects of traditional
controlled drugs such as cannabis, cocaine, heroin and amphetamines. Synthetic
cannabinoids and synthetic opioids can be difficult to detect as the compounds
used in their manufacture can vary and use of these substances presents a serious
problem across the prison estate.
37. PS can affect people in a number of ways, including increasing heart rate, raising
blood pressure, reducing blood supply to the heart and vomiting. Prisoners under
the influence of these substances can present with marked levels of disinhibition,
heightened energy levels, a high tolerance of pain and a potential for violence.
Besides emerging evidence of such dangers to physical health, the use of PS is
associated with the deterioration of mental health, suicide and self-harm. Testing for
PS is in place in prisons as part of existing mandatory drug testing arrangements.
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Key Events
Background
38. On 16 December 2021, Mr Adam Diesa-Green was remanded in prison custody
charged with grievous bodily harm with intent and taken to HMP Forest Bank. He
had not been to prison before. On 9 May 2023, Mr Diesa-Green was sentenced to
five years and ten months in prison. On 23 June, he transferred to HMP Lowdham
Grange. On 25 August, Mr Diesa-Green was sentenced to one year in prison for
possession of a class A drug with intent to supply, to run consecutively to his earlier
sentence.
39. Mr Diesa-Green had a diagnosis of attention deficit hyperactivity disorder (ADHD)
and a history of anxiety and depression. Mr Diesa-Green was prescribed
medication for all his diagnosed conditions, which he took as prescribed.
40. Mr Diesa-Green had a long history of substance use in the community. He started
smoking cannabis aged 12 years and drinking alcohol the following year. Mr Diesa-
Green recognised by the age of 17 years he had an alcohol dependency. However,
when he first arrived in prison, he did not disclose any issues with either alcohol or
drugs and so he was not referred to substance use services. There was no record
of Mr Diesa-Green using or being under the influence of drugs or alcohol in prison
prior to his move to Lowdham Grange.
HMP Lowdham Grange
41. On 23 June 2023, when Mr Diesa-Green arrived at Lowdham Grange, he did not
disclose any concerns. The reception nurse recorded that Mr Diesa-Green said he
had no issues with alcohol or drugs.
42. Over the next year, Mr Diesa-Green often breached prison rules. Prison staff found
him in possession of homemade weapons, an illicit mobile phone, and on three
occasions found illicitly brewed alcohol (known as hooch) in his cell. On each
occasion staff charged Mr Diesa-Green with a prison disciplinary offence and he
lost privileges because of his behaviour.
43. On 16 September 2024, wing staff discovered Mr Diesa-Green had approximately
four litres of illicitly brewed alcohol in a bucket. Wing staff chose not to charge him
with an offence and instead referred him to the substance use team for support.
44. The next day, Mr A from the substance use team met Mr Diesa-Green, who told him
that he occasionally drank hooch in prison and that he had issues with alcohol in
the community. Mr A provided information on the risks of hooch and alcohol, as well
as overdose from PS, tolerance levels and not mixing drugs which Mr Diesa-Green
said he understood. Mr Diesa-Green requested ongoing substance use support and
agreed to complete a Comprehensive Substance Misuse Assessment (CSMA).
45. On 1 October, Mr A completed the CSMA. Mr Diesa-Green said that he had a
strong compulsion to drink and that he made his own alcohol. He also disclosed
that he had tried PS but did not like the effects. Mr A repeated information about
excessive alcohol consumption, the risks of hooch and distilled alcohol, as well as
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PS overdose, tolerance and not mixing substances which Mr Diesa-Green again
said he understood. Mr A gave Mr Diesa-Green a leaflet containing this information.
In addition, an alcohol screen (AUDIT-C) was completed. Mr A completed a
recovery support care plan and noted that Mr Diesa-Green would be reviewed
every six weeks and given one-to-one structured counselling support to promote
harm reduction, motivation and relapse prevention. (From 8 October, Mr Diesa-
Green was also required to collect his prescribed medications from the hatch, rather
than have in his possession, due to his illicit substance use.)
46. On 23 October, wing staff found Mr Diesa-Green under the influence of drugs. Mr B,
substance use team, saw him and Mr Diesa-Green said that it had been an
accident, because he took someone’s vape pen, which was laced with PS. Mr B
spoke to Mr Diesa-Green about harm minimisation and the associated risks of
overdose, tolerance levels and mixing drugs, which he again said he understood.
47. On 11 November, an officer held a key work session with Mr Diesa-Green, who said
he was settled and had no concerns. (This was the only completed key work
session that Mr Diesa-Green had at Lowdham Grange.)
48. On 12 November, wing staff found Mr Diesa-Green under the influence and
requested healthcare assistance. Officers placed Mr Diesa-Green in the recovery
position and observed that he had a seizure lasting around 30 seconds. Nurse A
responded and administered naloxone (a lifesaving medication that can reverse the
effects of opioid overdose). Mr Diesa-Green responded well clinically, but he
became verbally abusive and attempted to kick staff. Staff found a pocketknife on
the floor and took him to reception so he could be searched thoroughly.
49. While in the reception holding cell, healthcare staff continued to monitor Mr Diesa-
Green every two to five minutes. Nurse A observed that Mr Diesa-Green’s condition
began to deteriorate. He became distressed, confused, started vomiting, became
pale and clammy to touch. Nurse A radioed a code blue medical emergency (used
to indicate when someone is having breathing problems or unresponsive).
Paramedics took Mr Diesa-Green to hospital where doctors prescribed medication
to stop him vomiting. They referred him to the ‘first seizure clinic’ for a follow up
appointment.
50. The next day, Mr Diesa-Green returned to Lowdham Grange. Ms A, substance use
team, met Mr Diesa-Green who said that he had smoked PS and that he knew who
to buy it from and who sold ‘bad shit’. Mr Diesa-Green said he did not use PS daily,
only when he struggled to sleep. Ms A discussed good sleep hygiene and provided
Mr Diesa-Green with information around the significant risks of using PS due to the
uncertainty of what other drugs it may be mixed with. Ms A discussed the impact of
using PS on Mr Diesa-Green’s physical and mental health and the implications of
becoming in debt to those selling illegal drugs. Mr Diesa-Green said he understood
the advice given and accepted an information letter reiterating what had been
discussed. Mr Diesa-Green knew how to contact the substance use team and was
told that he would be allocated a key worker from that team to support him further.
51. On 18 November, Dr A, psychiatrist, met Mr Diesa-Green, who said it was the first
day he had felt his normal self. Mr Diesa-Green disclosed that he had used
cannabis but had not taken other drugs recently.
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52. On 20 November, staff found hooch in Mr Diesa-Green’s cell. Shortly after the find,
he became unwell. Nurse B responded and assessed Mr Diesa-Green, who said
that he suddenly felt unwell. Nurse B observed that Mr Diesa-Green was alert and
spoke in full sentences, had good colour, and no pain or dizziness. Nurse B did
observe a tremor to his hands, but noted that Mr Diesa-Green became calmer when
she reassured him. Clinical observations indicated that Mr Diesa-Green’s pulse and
blood pressure were elevated. Nurse B did not complete a CIWA score to establish
if these were alcohol withdrawal symptoms (Clinical Institute Withdrawal
Assessment, is a tool used to assess alcohol withdrawal symptoms). Nurse B asked
wing staff to monitor Mr Diesa-Green and to contact healthcare if they had any
other concerns.
53. On 22 November, Ms A met Mr Diesa-Green. He spoke about his alcohol
dependency in the community and said that since being in prison he had drunk
hooch daily. Ms A discussed the risks associated with illicit alcohol and the physical
dangers due to its uncertain alcohol content after brewing. Mr Diesa-Green said he
understood, and that he drank small amounts at a time to reduce potential harm.
54. On 4 December, Ms B, substance use recovery worker, met Mr Diesa-Green. She
introduced herself as his key worker and reviewed his substance use care plan. Mr
Diesa-Green engaged well in the conversation, said he enjoyed drinking hooch and
enjoyed making and selling it. Ms B explored his motivation for stopping and Mr
Diesa-Green agreed to list the pros and cons of drinking for his next review. Ms B
recorded that Mr Diesa-Green recognised the impact of his drinking on his mental
and physical health, as well as his relationships and that they discussed the
importance of maintaining a routine and engaging in meaningful daily activities. Mr
Diesa-Green said he had no debts, that his ADHD was under control and his family
was supportive. Ms B provided Mr Diesa-Green with harm reduction advice.
55. On 16 December, Officer A telephoned Mr Diesa-Green to undertake a key work
session. He did not answer the phone, and no further contact was made.
56. On 8 January 2025, Ms B met Mr Diesa-Green. He reported no change in his
drinking habits and that he had struggled to identify any pros to drinking, other than
the pleasant feeling of being disconnected from reality. He identified a con as the
trouble alcohol caused, reflecting why he was in prison. Ms B recorded that their
conversation covered motivation, self-discipline, the steps Mr Diesa-Green could
take to gain more control and ways to distract himself when feeling bored. She also
provided harm reduction advice. Mr Diesa-Green agreed to attend group work
about PS.
57. On 9 January and 15 January, Mr Diesa-Green attended group work sessions
facilitated by Mr B from the substance use team. The sessions focused on the
dangers of using PS, and to identify strategies to reduce harm. Mr B said Mr Diesa-
Green responded well in the sessions, sharing that he had issues with alcohol, but
said that he had never taken PS.
Events of 17 January 2025
58. The investigator watched Closed Circuit Television (CCTV) footage, body worn
video camera (BWVC) footage and listened to radio communications from 17
January. She also obtained staff statements and interviews, and information from
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East Midlands Ambulance Service. The following account has been taken from all
sources.
59. During the day, staff found another prisoner on Mr Diesa-Green’s wing
unconscious, seemingly under the influence of drugs.
60. In the afternoon, prisoners were unlocked to spend time with their peers. Mr Diesa-
Green socialised with many prisoners on the wing. He returned to his cell at
5.27pm. There is nothing of concern from the CCTV footage. He did not activate his
cell bell.
61. At around 5.45pm, staff began to lock prisoners in their cells for the night. At around
5.52pm, Officer B arrived at Mr Diesa-Green’s cell. His door was closed but not
locked and Officer Ms B knocked and opened the door. He found Mr Diesa-Green
lying face down on the floor and radioed a medical emergency code blue. Officer C
and Officer D, who were very close by, responded and started CPR.
62. Healthcare staff responded to the code blue and quickly arrived at Mr Diesa-
Green’s cell. They attached a defibrillator which advised Mr Diesa-Green had no
shockable heart rhythm. Nurses also administered naloxone and staff continued
CPR until paramedics arrived.
63. Paramedics arrived at Mr Diesa-Green’s cell at around 6.15pm. They assessed Mr
Diesa-Green and continued resuscitation attempts. At 6.47pm, they pronounced life
extinct.
64. After Mr Diesa-Green died, prison staff found 34 tampered vape capsules, a USB
stick, three weapons, 50-100ml of illicit alcohol and notes with phone numbers and
bank details (commonly known as a debt list) in his cell.
Contact with Mr Diesa-Green’s family
65. Lowdham Grange appointed Ms C, a programmes manager, as the prison’s family
liaison officer (FLO) and Supervising Officer (SO) A, as her deputy. That evening,
they travelled to the home of Mr Diesa-Green’s partner, who he had listed as his
next of kin, to break the news of his death. They then travelled to Mr Diesa-Green’s
mother’s address to break the news to her. Mr Diesa-Green’s funeral took place on
4 March 2025. The prison contributed to the funeral costs in line with national
policy.
Support for prisoners and staff
66. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case-by-case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans
to provide confidential peer-support) to identify prisoners most affected by the
death.
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67. Lowdham Grange initiated postvention care after Mr Diesa-Green’s death. Mr C, a
prison manager, debriefed the staff involved in the emergency response to ensure
they had the opportunity to discuss any issues arising, and to offer support. The
staff care team and TRiM (trauma management) also offered support.
68. The prison posted notices informing other prisoners of Mr Diesa-Green’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Diesa-Green’s death.
Samaritans and Listeners were quickly notified of the death and provided support to
prisoners. In addition, the Governor issued a notice warning prisoners of the
potentially fatal effects of using PS.
Post-mortem report
69. The post-mortem examination concluded that Mr Diesa-Green died from a cardiac
arrest due to synthetic cannabinoid use.
70. Toxicology investigation of Mr Diesa-Green’s blood and urine samples detected the
presence of synthetic cannabinoids and recent use of ketamine.
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Findings
Mr Diesa-Green’s substance use
71. Mr Diesa-Green had a long history of substance use in the community and incidents
of being under the influence of illicit substances while in prison. The clinical
reviewer found that the substance use team at Lowdham Grange followed national
guidelines. They completed a comprehensive assessment of Mr Diesa-Green’s
drug history and created a clinical management recovery plan, which they reviewed
every six weeks.
72. The clinical reviewer found that the substance use and mental health care Mr
Diesa-Green received at Lowdham Grange was satisfactory and equivalent to that
which he could have expected to receive in the community.
Psychoactive substances
73. Mr Diesa-Green’s cause of death was cardiac arrest caused by the use of synthetic
cannabinoids (PS). While he had reportedly used PS in 2024, in the weeks
immediately before he died there was no indication that Mr Diesa-Green continued
to use PS and no specific security intelligence linking him to drug use on the wing.
Mr Diesa-Green attended a group two days before he died which focused on the
risks associated with using PS. The clinical reviewer found that the substance use
team offered a targeted approach to Mr Diesa-Green’s needs, while respecting his
autonomy to make decisions around his level of engagement.
74. However, we identified that Mr B, the PS group facilitator, did not know Mr Diesa-
Green’s full history with substances and the clinical reviewer found that there was
no evidence of professional curiosity. Mr Diesa-Green said he had never used PS
but had Mr B looked at his prison and medical record, he would have identified that
Mr Diesa-Green had been found under the influence as recently as November
2024. Mr B said he took people at ‘face value’ and while he did check the history of
those on his caseload, this was not routine. Had Mr B known that Mr Diesa-Green
had used PS, it may have led to appropriate challenge during the group.
Alcohol management
75. Mr Diesa-Green was frequently found with illicit alcohol, which he disclosed he
made himself and drank most days. This meant that Mr Diesa-Green had an
uncontrolled drinking habit, and nobody knew what he had used to brew the hooch
or the level of alcohol it contained. As well as putting him at immediate risk of harm,
this also meant that Mr Diesa-Green might have experienced unrecognised alcohol
withdrawal symptoms.
76. The clinical reviewer identified that obtaining a more robust history and completing
a CIWA score to establish alcohol withdrawal symptoms might have proved
beneficial and would have better informed how Mr Diesa-Green was managed. At
times he presented with tremors, and elevated pulse and blood pressure, all signs
of alcohol withdrawal.
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77. The clinical reviewer found that there were no documented uses of CIWA scores in
the clinical management of Mr Diesa-Green, as outlined in NICE guidelines. The
primary healthcare team have not been trained in substance use, including alcohol,
and its management. We therefore make the following recommendation:
The Head of Healthcare should ensure that CIWA scores are used in the
management of those prisoners who disclose a new or ongoing alcohol
dependency.
Drug strategy at Lowdham Grange
78. Mr Diesa-Green was able to access illicit drugs with apparent ease. His was the
fourth drug related death at Lowdham Grange since March 2024. To the end of
September 2025, there have been two further drug related deaths.
79. There is significant evidence, including the number of drug related deaths, to
indicate that Lowdham Grange is experiencing substantial problems in dealing with
the supply and ingress of illicit drugs. Several factors have emerged from this and
other investigations including staff inexperience and common routes of ingress,
including via staff and vehicles entering the prison.
80. Lowdham Grange’s drug strategy, dated August 2024, noted significant increases in
finds of all illicit items (except for illegally brewed alcohol with reported finds down
by over 50%). There was a 24% increase in illicit drugs finds in 2023/2024
compared to 2022/2023. There had also been an increase in reported incidents
involving PS and health partners suggested there was significant under-reporting of
PS use, with the number of incidents potentially up to double those reported.
Random and mandatory drug testing fell short of the 15% target and there was little
evidence of supplementary suspicion, frequency or risk testing. At the time of this
investigation, the drug strategy was under review to reflect HMPPS taking
ownership of the prison.
81. In September 2024, the HMPPS Substance Misuse Group (SMG) conducted a drug
strategy support visit at the prison. The aim of the visit was to understand the scale
and nature of substance use problems and understand the scale of the prison’s
vulnerability to the conveyance of illicit drugs. They found PS and cannabis were
the most used drugs. They identified some knowledge gaps among staff around
substance use and physical vulnerabilities to drug incursion including visits and
searching. Positively, they found security and analyst teams had developed a
strong understanding of illicit substances within the prison via detailed intelligence
reports, allowing them to produce a detailed and thorough Local Tactical
Assessment (LTA) which was used as the basis for further action plans at
departmental level. Revised monthly drug strategy meetings had started and were
proving successful.
82. The SMG made six recommendations including that activity should be undertaken
to raise awareness of substance use and drug strategy across the prison, drive
understanding of the prison’s under the influence policy, closer strategic alignment
between security, safety and drug strategy activity, a review of existing visits
procedures, review of the parcel process and photocopying social mail.
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83. As part of the current PPO investigations taking place at Lowdham Grange, we
interviewed Mr D, Head of Drug Strategy and Ms D, Head of Security, in January
2025 (shortly after Mr Diesa-Green died). Mr D and Ms D said that at the time of
their interviews there was no mandatory or random drug testing taking place.
Suspicion testing was being re-embedded, although a lot of prisoners had refused
the tests. Of those tested, 75% tested positive for PS.
84. Mr D and Ms D told the investigator that the prison has been experiencing a sharp
increase in the number of medical emergency code blues due to prisoners
suspected of being under the influence of drugs, since around October 2024.
Cannabis and PS remained the predominant drugs used. However, prison
intelligence suggested that a variety of other substances, including fentanyl,
ketamine and opiates were also being used.
85. Drones were identified as a significant issue. Both the Head of Security and Head of
Drug Strategy said they worked closely with local police and felt they had a good
relationship with them. However, both said they felt the approach to managing
drones was reactive rather than proactive. There were examples of collaborative
work taking place, particularly around information sharing about vehicles which had
resulted in arrests. However, often there were times when it was difficult to be
proactive until a drone had entered and they had a starting point to build
intelligence. Searching and risk drug testing remained challenging due to lack of
resources.
86. Since Mr Diesa-Green’s death, random drug testing has been re-established and, in
July 2025, there were 40 random tests, of which 20% were positive. Anecdotally,
prison managers also said that they had seen a reduction in the number of
prisoners under the influence.
87. Ms D said that intelligence-led cell searching took place, as well as daily cell fabric
checks. Although staff were able to conduct suspicion searches, Mr D and Ms D
said that staff needed upskilling to develop the necessary skills to know what they
were looking for and to search effectively.
88. Following his death, staff found 34 tampered vape capsules in Mr Diesa-Green’s
cell. Prisoners tampering with vapes to allow them to smoke PS or other drugs is a
common theme throughout the prison estate. HMPPS is in the process of
transitioning to a safer, tamper-proof vape, which we hope will reduce deaths and
incidents of prisoners being under the influence of drugs.
89. In response to SMG recommendations, Lowdham Grange is reviewing their drug
strategy and have introduced measures to combat drug ingress including securing
funding for netting and window grill replacements and delivering corruption
prevention training with a focus recently on civilian staff. Ms E, group safety lead for
the Long-Term High Security Estate (LTHSE) told PPO investigators that the SMG
action plan had been developed, and further assurance visits were already planned
to review how Lowdham Grange were progressing with the recommendations from
their report.
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Actions taken by Lowdham Grange
90. The Head of Security said the gate area was a concern as the prison experiences a
high number of people and vehicles coming through. Enhanced gate security and
other measures have been introduced, including a limit on paper permitted into the
prison and the photocopying of mail. The prison is also exploring the development
of a dedicated wing for incentivised substance free living.
91. The SMG scheduled a review for April 2025. Before it could take place, the SMG
reconfigured to the Drug and Alcohol Group (DAG), with a new focus on capability
and training. Direct prison support, including visits, stopped. Regional drug and
alcohol leads have recently been appointed to undertake this role.
92. On 9 April, the regional safety group undertook a safety visit and agreed with the
DAG to look at some of SMG’s key recommendations from September 2024. They
found evidence of enhanced searching and additional training to support this.
Progress had been made to raise awareness of substance use and the prison’s
drug strategy. However, it was unclear how many staff had completed training
through an email link.
93. The SMG suggested that a tripartite meeting linking safety, security and drug
strategy may be beneficial. They also found there were no courses being delivered
to prisoners in relation to substance use. The prison is exploring alternatives which
may be delivered through the education provider. In May 2025, Lowdham Grange
accepted an offer from the Regional Safety Team and DAG to become a pilot site to
undertake a training needs analysis and develop bespoke staff training.
94. We fully recognise the significant challenges inherent in preventing drugs coming
into Lowdham Grange. The illicit drugs market in prison is controlled by organised
crime gangs and Lowdham Grange recognises that the scale of the problem needs
a co-ordinated approach which they have been implementing.
95. Lowdham Grange has experienced a turbulent two years and the demand for drugs
and ingress into the prison is one of many significant problems they need to
address. In March 2025, Ms F was appointed as the new Governor of Lowdham
Grange. Although some good work is being done at Lowdham Grange, including
limiting paper coming into the prison and enhanced gate security, the threat from
drugs is constantly evolving and more can always be done.
96. We welcome the work underway at Lowdham Grange to tackle the availability of
drugs and expect the Governor to maintain focus on all actions needed to reduce
the supply and demand for drugs. However, we also consider that work to educate
and warn prisoners about the dangers of using drugs, particularly synthetic
cannabinoids is vitally important. In September 2025, we recommended that the
Governor ensure there is a robust and auditable programme for educating and
communicating to prisoners the risks of drugs use, specifically of psychoactive
substances. The HMPPS response and action plan to this recommendation is
currently outstanding, so we do not repeat the recommendation here.
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Governor to Note
Key worker Scheme
97. Mr Diesa-Green only received one recorded key work contact during his 18 months
at Lowdham Grange (on 11 November 2024). Key work is a key part of HMPPS’
response to self-inflicted deaths, self-harm, and violence in prisons, and is intended
to improve safety by engaging with people, building better relationships between
staff and prisoners, and helping people settle into life in prison.
98. It is clear that this was not operating as it should at Lowdham Grange and was
another area that had been impacted by the changes that had taken place at the
prison and shortages in the staffing group. In August 2025, we were told that only
5.5% of prisoners received key work. The Governor will want to ensure that delivery
of the key work scheme is improved, and that staff are sufficiently trained and given
the time to deliver this crucial area of work.
Inquest
99. The inquest into Mr Diesa-Green’s death concluded on 28 May 2026. Mr Diesa-
Green’s death was due to misadventure, because of ingesting PS which had
unintended consequences while he was alone in his prison cell.
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