David Loch

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Independent investigation into
the death of Mr David Loch,
a prisoner at HMP Lowdham
Grange, on 6 April 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 David Loch died from the effects of synthetic cannabinoids on 6 April 2025 at HMP
Lowdham Grange. He was 35 years old. I offer my condolences to Mr Loch’s family and
friends.
Mr Loch was the sixth drug related death at Lowdham Grange since November 2024.
Mr Loch had been at Lowdham Grange for 10 days before he died. He had a history of
illicit drug use in the community and in prison and had been referred to the substance
misuse team for assessment. There were no reported concerns about Mr Loch using illicit
drugs in the days prior to his death.
The clinical reviewer concluded that the care Mr Loch received at Lowdham Grange was
good and at least equivalent to what he could have expected to receive in the community.
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 that 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 that the prison has developed an action plan to address these issues and is
receiving additional support from the national safety team. Following a recent investigation
into another of the five suspected drug-related deaths, I recommended the prison ensure
there is a programme to educate and communicate the risks of drug use to prisoners. 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 ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
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Summary
Events
1. On 20 June 2019, Mr David Loch was remanded to prison charged with grievous
bodily harm. On 12 February 2020, he was sentenced to 12 years in prison. On 27
March 2025, Mr Loch transferred to Lowdham Grange.
2. Mr Loch had been previously diagnosed with attention deficit hyperactivity disorder
(ADHD) and emotionally unstable personality disorder and was prescribed
medication for these conditions. He also had a history of substance use.
3. In November 2024, Mr Loch had been monitored under suicide and self-harm
monitoring (known as ACCT) after he made superficial cuts to his arm. There were
no further acts of self-harm and staff did not raise any concerns about his risk or
well-being.
4. While at previous prisons, Mr Loch’s behaviour had been problematic and he used
illicit drugs, the last time being on 6 and 25 December 2024 at HMP Full Sutton. On
1 April, following his transfer to Lowdham Grange, Mr Loch was placed on the
prison’s drug and alcohol team list for assessment.
5. At 9.00am on 6 April, staff unlocked Mr Loch’s cell and found him lying on his bed,
unresponsive. Staff immediately radioed a medical emergency code. On
examination, it was clear that Mr Loch was dead and cardiopulmonary resuscitation
(CPR) was not considered to be appropriate. At 9.21am, paramedics pronounced
Mr Loch’s life extinct.
6. The post-mortem examination established that Mr Loch died from the use of
synthetic cannabinoids.
Findings
7. Mr Loch was the sixth prisoner to die from the effects of drugs at Lowdham Grange
since November 2024. He was able to access illicit drugs (specifically synthetic
cannabinoids) with apparent ease, despite having only been at the prison for 10
days.
8. On 5 and 6 April, the officer on night duty failed to check on Mr Loch as part of the
mandatory roll checks at 6.45am, 5.25pm and 9.00pm. However, on both
occasions, the officer reported the correct number of prisoners, despite not counting
them all. The prison is conducting an internal investigation into the officer’s actions.
9. The clinical reviewer concluded that the clinical care Mr Loch received at Lowdham
Grange was of a good standard and at least equivalent to what he could have
expected to receive in the community.
10. In response to the drug related deaths at Lowdham Grange, the National Substance
Misuse Group (SMG) carried out a Drug Strategy Support visit on 11-12 September
2024. SMG made six recommendations including photocopying of incoming mail to
reduce the ingress of drugs imprinted on paper, reviewing the parcel process, a full
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review of visits procedures, ensuring staff better understand those prisoners found
under the influence of drugs and actions that should be taken and raising
awareness of the substance misuse and drug strategy across the prison. The safety
group for the Long Term, High Security Estate (LTHSE) have developed an action
plan to address the recommendations.
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The Investigation Process
11. HMPPS notified us of Mr Loch’s death on 6 April 2025.
12. 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 him. No one responded.
13. The investigator visited Lowdham Grange on 15 April. He obtained copies of
relevant extracts from Mr Loch’s prison and medical records and viewed CCTV and
body worn video camera (BWVC) footage relevant to the investigation.
14. The investigator interviewed four members of staff at Lowdham Grange on 13 June
2025.
15. NHS England commissioned a clinical reviewer to review Mr Loch’s clinical care at
the prison.
16. We informed HM Coroner for Nottingham City and Nottinghamshire of the
investigation. The Coroner gave us the results of the post-mortem examination. We
have sent the Coroner a copy of this report.
17. The Ombudsman’s office wrote to Mr Loch’s next of kin to explain the investigation
and to ask if they had any matters, they wanted us to consider. The family were
spoken to on 8 July and confirmed that they had no questions but would like to
receive a copy of our report.
18. The family of Mr Loch received a copy of our initial report but made no comments
on our findings.
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Background Information
HMP Lowdham Grange
19. HMP Lowdham Grange is a category B male adult prison located in Lowdham,
Nottinghamshire. The prison was operated by Serco for 25 years until 16 February
2023, when Sodexo Justice Services took over the running of the prison. This was
the first time a prison had transferred from one private contract manager to another.
20. In December 2023, HMPPS took back operational management of the prison for an
interim period, bringing in an experienced governor and additional HMPPS staff,
including officers on detached duty, to improve staffing levels. The interim period of
HMPPS control was initially extended from March to September 2024 but in May
2024, HMPPS decided to take back full control of the prison and terminate the
contract with Sodexo. On 1 August 2024, the prison was formally taken back into
public sector control.
21. Northamptonshire Healthcare NHS Foundation Trust provides healthcare services.
HM Inspectorate of Prisons
22. HM Inspectorate of Prisons inspected Lowdham Grange in March 2025. Inspectors
noted that since their last inspection in 2023 there had been 10 deaths in custody,
four of which were suspected of being attributed to drug misuse. A very high
number of medical emergencies were linked to drugs, yet health services were no
longer providing round-the-clock care, were not meeting the needs of patients, and
in some cases were unsafe.
Independent Monitoring Board
23. 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 January 2024, the IMB reported
that the prison was unsafe. They found that safety in the prison deteriorated
throughout the whole reporting period. They also noted that outcomes were being
strongly influenced by the availability of illegal drugs, along with the associated
violence, combined with inexperienced staff who lacked the skills and confidence to
successfully manage prisoners with challenging behaviour. There was an
increasing number, during the year, of prisoner-on-prisoner assaults and prisoner-
on-staff assaults, a rise in prisoner self-harm, the number of ‘in-cell fires’ set by
prisoners, and the significant number of weapons’ finds, culminating, in January
2024, in the largest number of weapons’ finds ever recorded in one lock down
search by HMPPS.
24. The Board noted that by May 2023, 35% of mandatory drug tests (MDTs) carried
out were positive. By the year end, this had gradually increased to over 50%
positive, and there were daily incidents of prisoners being under the influence of
psychoactive substances and/or alcohol. Consequently, the underlying economy of
drugs and other substance use increased the negative impact of gang cultures at
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the prison, putting more prisoners into debt and making prisoners feel less safe and
more likely to self-isolate.
Previous deaths at HMP Lowdham Grange
25. Mr Loch was the 16th prisoner to die at Lowdham Grange since January 2022. Of
the previous deaths, five were from natural causes, five were self-inflicted and five
were drug related. Up to the end August 2025, there have been no deaths at the
prison since Mr Loch’s death.
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Key Events
26. On 20 June 2019, Mr David Loch was remanded to prison, charged with grievous
bodily harm. On 12 February 2020, he was found guilty and sentenced to 12 years
in prison.
27. Over the following years, Mr Loch transferred between four different prisons. At
times, he was subject to suicide and self-harm monitoring (known as ACCT), the
most recent being in November 2024, after he made superficial cuts to his arm. The
ACCT was closed on 2 December. There were no further acts of self-harm and staff
did not raise any concerns about his risk or well-being.
28. Evidence from the previous prisons indicated that Mr Loch displayed problematic
behaviour, including illicit drug use. Mr Loch had also been under the care of the
mental health teams due to his diagnoses of attention deficit hyperactivity disorder
(ADHD) and emotionally unstable personality disorder. Mr Loch was prescribed
quetiapine (antipsychotic) and lisdexamfetamine (ADHD medication).
29. Mr Loch had a history of illicit drug use both in the community and in prison. On 6
and 25 December 2024, he was found under the influence of illicit drugs and was
downgraded to the basic incentives level (meaning certain privileges, including in-
cell television were removed). His behaviour deteriorated further and he smashed
the contents of his cell and threatened staff. As a result, he was relocated to the
segregation unit at Full Sutton on 28 December. He remained there for the duration
of his stay at Full Sutton.
30. On Thursday 27 March 2025, Mr Loch was transferred to HMP Lowdham Grange.
31. Nurse A completed an initial health screen with Mr Loch and he reported no
physical health issues. Nurse A referred him to the substance misuse team, mental
health team and the neurodevelopmental/neurodiversity occupational therapist due
to his ADHD diagnosis.
32. Mr Loch was located on the first night/induction residential unit. There is no
evidence that Mr Loch received a formal induction.
33. On 29 March, Nurse B completed a secondary health screen. It was noted that due
to Mr Loch’s substance use history he would not be allowed to keep his medication
with him in his cell, and this would be dispensed under supervision.
34. On 1 April, Nurse C from the substance misuse team, spoke to Mr Loch about his
support needs. It was noted that while at Full Sutton, Mr Loch had regular
psychosocial intervention for substance use. Nurse C placed Mr Loch on the waiting
list for a Comprehensive Substance Misuse Assessment (CSMA). The initial
assessment had been scheduled for 27 March but could not be completed due to
staff shortages.
35. On 1 April, Mr Loch moved from the induction wing to M wing, houseblock 4, cell
30, a standard residential wing. There are no entries on Mr Loch’s prison record
after 1 April, other than a statement which said he had completed the induction.
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36. On 3 April, Ms A, a Neurodiversity Occupational Therapist, saw Mr Loch to
complete a detailed assessment of need and social functioning. Mr Loch said he
had no thoughts of suicide or self-harm and she found no evidence of any active
psychotic symptoms. Ms A confirmed Mr Loch’s neurodiversity and indicated that
he had ADHD with some obsessive-compulsive disorder traits. Ms A also recorded
that Mr Loch had a history of substance use but that he had told her he had not
used illicit substances for around 18 months. Records show that this was not the
case as he had been found under the influence during his time at Full Sutton in
December 2024.
37. On 3 April, Dr A, a Consultant Psychiatrist, completed a desktop review of Mr
Loch’s notes and Ms A’s assessment, to ascertain the risk and the urgency for a
face-to-face assessment. Dr A noted that there appeared to be no immediate risk in
relation to Mr Loch’s well-being and he decided that Mr Loch would not be offered a
routine mental health assessment within the standard two-week period.
38. No concerns were raised about Mr Loch the following day.
Events of 5 and 6 April
39. The following account has been taken from documentary evidence provided by
Lowdham Grange, CCTV and Body Worn Video Camera (BWVC) footage, medical
records and transcripts of interviews with staff.
40. During the morning period from around 10.00am on 5 April, CCTV shows Mr Loch
around the entrance to his cell, playing and watching other prisoners playing pool.
He was interacting with other prisoners, two of whom staff believed were involved in
the illicit drug trade at Lowdham Grange. At approximately 11.57am, after collecting
his lunch, staff locked Mr Loch in his cell.
41. At 2.15pm, staff unlocked Mr Loch’s cell for social time. Between 2.15pm and
5.05pm, CCTV shows Mr Loch playing pool and going to cells occupied by the two
prisoners he had engaged with during the morning. Between 3.43pm and 3.47pm,
Mr Loch was in the cell of one of the other prisoners, before returning to his own
cell.
42. At 4.03pm, CCTV footage shows Mr Loch at the door of his cell and he appeared
unsteady on his feet. When interviewed, prison staff said that they had not been
aware of any issues or concerns about Mr Loch at any point during the day.
43. At 5.00pm, staff began locking prisoners back in their cells. CCTV shows Mr Loch
on the upper landing, and he appeared to receive items from both prisoners that he
had been engaging with throughout the day, before returning to his cell where he
was locked in at 5.05pm. Neither of the prisoners referred to wished to engage with
the investigation and they were not interviewed by the police.
44. Staff completed a routine roll check (a security check to count prisoners and confirm
they are in their correct cells) once prisoners were secured in their cells, and Mr
Loch was seen alive in his cell at 5.11pm.
45. Operational Support Grade (OSG) A was on night duty and was assigned to cover
M wing. OSG A told the investigator that he arrived for his duty at around 7.30pm.
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He received a handover from the outgoing day staff, who reported no concerns,
checked on those subject to suicide and self-harm monitoring (ACCT) and then
completed a roll check at 9.00pm.
46. OSG A said that before starting a roll check, he would be aware of how many
prisoners were on the wing and how many he needed to account for. CCTV from
the evening of 5 April shows OSG A going around the wing completing the count.
However, he did not go to Mr Loch’s cell. When asked why he had not gone to Mr
Loch’s cell, OSG A told the investigation that he was unfamiliar with the layout of M
wing and that he did not know there was a cell where Mr Loch was located. The cell
occupied by Mr Loch was the end cell, on the ground floor and by the wing office.
47. Despite the number of prisoners he had counted not tallying with the number of
prisoners he had been told were held on the wing that day, OSG A reported the
correct roll.
48. At 5.30am on 6 April, OSG A began completing a morning roll check. CCTV shows
that again, OSG A missed Mr Loch’s cell but again he reported the correct
numbers. The investigator asked OSG A how he could have accounted for the right
number of prisoners, even though he had not counted Mr Loch. OSG A said that he
thought he had counted everyone and must have miscounted. OSG A handed over
to the day staff and reported no concerns.
49. At 9.00am on 6 April, Custodial Manager (CM) A was assisting with unlocking
prisoners on M wing. He started at Mr Loch’s cell. When he looked in through the
observation panel, he saw Mr Loch lying on his bed, in what CM A described as a
‘precarious’ position. CM A said that his first thought was that Mr Loch was under
the influence of drugs. He entered the cell and spoke to Mr Loch but received no
response. CM A said that he shook Mr Loch on the shoulder, and it was at this point
he realised that, in his opinion, Mr Loch was dead. CM A described Mr Loch as
rigid, with no natural movement in his body and he observed blood pooling on the
left-hand side of Mr Loch’s body.
50. CM A radioed a medical code blue at 9.01am (indicating a prisoner is unconscious
or is having breathing difficulties). CM A said that he was unable to give
cardiopulmonary resuscitation (CPR) as Mr Loch had rigor mortis.
51. Nurse B responded immediately. Nurse B said that when she entered Mr Loch’s cell
at approximately 9.02am, she observed Mr Loch lying on his bed and on
examination there were clear signs of rigor mortis. She concluded that CPR would
be futile. Nurse B told staff that an ambulance would still be required to pronounce
life extinct.
52. At 9.15am, paramedics arrived at the cell and after completing their own checks,
pronounced Mr Loch’s life extinct at 9.21am.
Contact with Mr Loch’s family
53. The prison appointed Supervising Officer (SO) A to act as family liaison officer.
Initially the next of kin details recorded were for Mr Loch’s probation officer.
However, the prison identified an address for Mr Loch’s father and requested their
colleagues at HMP Frankland (which was closer to the address) to visit the address
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and inform the family, which they did later that day. SO A and his colleague Ms A
remained in contact with the family.
54. The prison contributed towards funeral expenses in line with national policy.
Support for prisoners and staff
55. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoner support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death. Key elements of postvention care include a hot debrief for staff
involved in the emergency response and engaging Listeners to identify prisoners
most affected by the death.
56. After Mr Loch’s death, Ms B, Head of Security, 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 also offered support. Samaritans
were also notified in line with postvention procedures.
57. The prison posted notices informing other prisoners of Mr Loch’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 the death.
Post-mortem report
58. A post-mortem report gave Mr Loch’s cause of death as use of synthetic
cannabinoids.
Inquest
59. An inquest with a jury was completed on 10 August 2026. The jury found that Mr
Loch died as a result of misadventure involving the use of synthetic cannabinoids.
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Findings
Clinical care
60. The clinical reviewer concluded that the clinical care Mr Loch received at Lowdham
Grange was of a good standard and at least equivalent to what he could have
expected to receive in the community.
61. Mr Loch was appropriately referred to the substance misuse team and was on the
waiting list for a detailed assessment, which was expected to take place on 1 April.
The clinical reviewer noted that Mr Loch received structured psychosocial
intervention for substance misuse at his previous prison as part of his substance
use treatment, which suggested he may have engaged with the service at
Lowdham Grange. The clinical reviewer concluded that the care Mr Loch received
for his substance use was equivalent to what he could have expected to receive in
the community.
62. The clinical reviewer has made some recommendations that are not related directly
to Mr Loch’s death, but which the Head of Healthcare will wish to address.
Drug strategy at Lowdham Grange
63. Mr Loch was the sixth drug related death at Lowdham Grange since January 2022.
He was able to access illicit drugs with apparent ease, despite having only been at
the prison for 10 days.
64. Lowdham Grange’s drug strategy dated August 2024 noted significant increases in
finds of illicit items. There had been a 24% increase in illicit drugs being found 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. 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 management of the prison.
65. In September 2024, the HMPPS Substance Misuse Group (SMG) conducted a drug
strategy support visit at the prison to understand the scale and nature of substance
misuse problems and the scale of the prison’s vulnerability to the conveyance of
illicit drugs. They found PS and cannabis were the most commonly used drugs.
They identified some knowledge gaps among staff around substance use and
physical vulnerabilities, including visits and searching. It was positive that they
found that the security and analyst team had developed a strong understanding of
illicit substances in the prison through detailed intelligence reports. This enabled
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 also started.
66. The SMG made six recommendations, including that activity should be undertaken
to raise awareness of substance use and the drug strategy across the prison, drive
understanding of the prison’s policy on managing prisoners under the influence of a
substance, closer strategic alignment between security, safety and drug strategy
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activity, a review of existing visits procedures, review of the parcel process and
photocopying social mail.
67. In January 2025, the Head of Drug Strategy and the Head of Security told the
investigator of one of the other drug related deaths at the prison that since October
2024, the prison had experienced a sharp increase in the number of medical
emergencies related to prisoners suspected of being under the influence of drugs.
Cannabis and PS remained the predominant drugs used. However, prison
intelligence suggested that a variety of other substances, including fentanyl,
ketamine and opiates were being used.
68. The Head of Security and the Head of Drug Strategy said that they worked closely
with the police and had a good relationship with them. However, both said they felt
the approach to managing drones was reactive rather than proactive. Drones were
a significant issue, with attempted drops of packages every other night. There were
examples of collaborative work taking place, particularly in sharing information
about vehicles. This had resulted in arrests. Searching and risk drug testing
remained challenging due to lack of resources.
69. In response to SMG recommendations, the prison is reviewing their drug strategy
and have introduced measures to combat drugs coming into the prison, including
securing funding for netting and window grill replacements and delivering corruption
prevention training, with a recent focus on civilian staff.
Actions taken by Lowdham Grange in response to the drug-related
deaths
70. 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.
71. 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. Recruitment is
underway to employ regional drug and alcohol leads to undertake this role.
72. 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.
73. 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.
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74. 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.
75. 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 C 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.
Roll checks
76. Routine roll checks are primarily a visual security check to count prisoners to
ensure that they are present in their cells, but they are also an opportunity for any
concerns about a prisoner’s safety to be identified and managed. HMPPS’ National
Security Framework expects welfare checks to take place at routine checks
including that staff are able to see the prisoner’s face and satisfy themselves that
they are alive and well.
77. During the investigation, it became apparent that Mr Loch had not been seen since
the last check by day staff at 5.11pm on 5 April. Lowdham Grange’s local security
strategy (LSS) indicates that mandatory roll checks should take place at 6.45am,
5.25pm and 9.00pm daily.
78. Despite OSG A not being able to reconcile the figures for the counts he undertook
against the number of prisoners he knew to be held on M wing, he twice reported
the correct number of prisoners. The prison is conducting an internal investigation
into OSG A’ actions on 5 and 6 April. As a result, we make no recommendation at
this time.
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