David Richards

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Independent investigation into
the death of Mr David Richards,
a prisoner at HMP Lowdham
Grange, on 13 March 2023
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, 2025
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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 then
our recommendations should be focused, evidenced and viable. This is especially the
case if there is evidence of systemic failure.
Mr David Richards was found hanging in his cell at HMP Lowdham Grange on 13 March
2023. Staff and paramedics tried to resuscitate him but were unsuccessful. Mr Richards
was 42 years old. I offer my condolences to his family and friends.
Mr Richards’ death was the second of three self-inflicted deaths at Lowdham Grange in
March 2023. Both HM Inspectorate of Prisons and the Independent Monitoring Board
expressed concerns about the safety of the prison around that time. The transfer of the
management of the prison from Serco to Sodexo in February resulted in an exodus of staff
alongside higher levels of drugs, violence and self-harm, less time out of cells and a
deterioration in staff-prisoner relationships.
While Mr Richards had expressed his discontent about being at Lowdham Grange, there
was no indication that he was at risk of suicide or self-harm in the two and a half weeks he
spent there. I am satisfied that staff could not have foreseen his actions.
Nevertheless, I am concerned about the cluster of deaths that occurred so soon after the
management of the prison was transferred from one private provider to another and the
uncertainty this created among staff and prisoners. HMPPS must consider how smoother
transitions can be achieved in future.
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 2023
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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 4 April 2022, Mr David Richards was remanded to HMP Chelmsford charged
with attempted murder. It was his first time in prison.
2. Mr Richards arrived with a suicide and self-harm warning as he had recently tried to
take his own life. Staff started suicide and self-harm prevention procedures (known
as ACCT), which remained open until 18 April.
3. Staff supported Mr Richards using ACCT from 6 to 26 May and from 15 to 30 June.
Both times he said he had been hearing voices and had been thinking about
suicide. He was prescribed antidepressant and antipsychotic medication.
4. On 17 November, Mr Richards was found guilty of attempted murder. Staff
reviewed his risk and assessed that he did not need the support of ACCT
procedures at that time.
5. On 12 January 2023, Mr Richards was sentenced to 27 years imprisonment. He
told staff he had been expecting it, but because of the length of the sentence, staff
started ACCT procedures. Mr Richards said that he had no thoughts of self-harm
and was aware of the support available. Staff closed the ACCT the next day.
6. On 24 February, Mr Richards was moved to HMP Lowdham Grange. He told staff
that he had no thoughts of harming himself.
7. On 6 March, safer custody staff visited Mr Richards for a wellbeing check. Mr
Richards told them that he had not asked to be moved to Lowdham Grange and
would not be getting any visits from family as they were too far away. He said he
had been shocked at the length of his sentence, felt vulnerable and would like to go
to a “more mature” wing. Staff noted that he told them that he had no thoughts of
harming himself and had never been on ACCT.
8. On the morning of 13 March, Mr Richards telephoned his mother and said that he
needed to talk to his solicitor urgently about money. He asked his mother if she
could ask the solicitor to arrange a time for him to call them. He spoke to his mother
again later who said a call had been arranged for 5.00pm.
9. Mr Richards was due to be moved from the induction wing to a standard wing that
day. At around 11.30am, an officer took some bags to him so he could pack. There
were no apparent issues. At around 1.15pm, a prisoner who had been unlocked for
work, alerted staff that Mr Richards was hanging in his cell. Staff and paramedics
tried to resuscitate him but at 2.12pm, paramedics declared that he had died.
Findings
10. The safer custody staff who saw Mr Richards on 6 March, had been unable to
access his electronic prison record and were therefore unaware that he had been
supported using ACCT several times at Chelmsford. This issue has since been
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rectified. Mr Richards did not appear to be at risk of suicide or self-harm at that
time.
11. While Mr Richards had some risk factors for suicide and self-harm, he gave no
indication that he was at imminent risk of suicide or self-harm during his time at
Lowdham Grange. While he expressed that he felt vulnerable, there is no evidence
that he was under threat from other prisoners. It is unclear why Mr Richards wanted
to speak to his solicitor about money but there is no indication that he was in debt to
other prisoners. We are satisfied that staff could not have foreseen Mr Richards’
actions.
12. The clinical reviewer found that the care Mr Richards received in prison was
equivalent to that which he could have expected to receive in the community. He
found that Mr Richards was well supported by the mental health teams and was
prescribed appropriate medication.
13. We make no recommendations.
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The Investigation Process
14. HMPPS notified us of Mr Richards’ death on 13 March 2023.
15. 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.
16. The investigator obtained copies of relevant extracts from Mr Richards’ prison and
medical records.
17. The investigator interviewed seven members of staff at Lowdham Grange between
May and August 2023.
18. NHS England commissioned two independent clinical reviewers to review Mr
Richards’ clinical care at the prison. The investigator was joined by a clinical
reviewer for some healthcare interviews.
19. 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.
20. The Ombudsman’s family liaison officer contacted Mr Richards’ mother to explain
the investigation and to ask if she had any matters she wanted us to consider. She
had no questions but asked for a copy of the report.
21. We shared our initial report with HMPPS. They found no factual inaccuracies.
22. We sent a copy of our initial report to Mr Richards’ mother. She did not notify us of
any factual inaccuracies.
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Background Information
HMP Lowdham Grange
23. HMP Lowdham Grange is a Category B male adult prison located in Lowdham,
Nottinghamshire, and accommodates up to 888 prisoners. The prison was operated
by Serco for 25 years but in February 2023, Sodexo took over the running of the
prison. Nottinghamshire Healthcare NHS Foundation Trust provides healthcare
services.
HM Inspectorate of Prisons
24. The most recent inspection of HMP Lowdham Grange was in May 2023. Inspectors
reported that the prison was not safe, with high levels of drug use and violence. The
transfer from Serco to Sodexo had led to uncertainty and anxiety among prisoners
and staff, whose numbers were reduced by the loss of some key and specialist
staff. There were high levels of self-harm. The healthcare department was
undermined by significant staff shortages. Access to work and education was poor.
Independent Monitoring Board
25. 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 2023, the IMB
reported that the safety of the prison had deteriorated. There had been an increase
in the number of prisoner-on-prisoner assaults, in self-harm and in weapons finds.
Almost 20% of mandatory drug tests were positive and prisoners under the
influence of psychoactive substances was an almost daily occurrence. The IMB
feared that the prevalence of drugs was likely to increase the negative impact of
gang culture and make prisoners feel less safe.
26. The Board considered that relationships between staff and prisoners had
deteriorated and there had been a significant reduction in purposeful activity which
had led to prisoners spending long periods locked in their cells. Healthcare services
continued to be under great pressure and the IMB considered that physical and
mental healthcare was at a lower standard to that in the community.
27. The Board issued an addendum to their annual report covering the period 1
February to 31 March 2023. The management and operation of the prison passed
from Serco to Sodexo on 16 February 2023. The Board noted serious concerns
relating to the operation of the prison and implications for safety over the next six to
seven weeks. There were three deaths in March. The number of prisoners on
ACCT more than doubled, from 13 to 32, between the end of February and the end
of March. There had been an exodus of staff since the change in contract was
announced in August 2022. IMB members had noticed low staffing levels on all
wings.
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Previous deaths at HMP Lowdham Grange
28. Mr Richards was the seventh prisoner at Lowdham Grange to die since March
2020. Of the previous deaths, two were from natural causes, two were drug related,
and two were self-inflicted. Mr Richards’ death was the second of three self-inflicted
deaths that occurred in March 2023.
Key worker scheme
29. The key worker scheme is a key part of HMPPS’s response to self-inflicted deaths,
self-harm and violence in prisons. It is intended to improve safety by engaging with
people, building better relationships between staff and prisoners and helping people
settle into life in prison. Details of how the scheme should work are set out in
HMPPS’s Manage the Custodial Sentence Policy Framework. This says:
• All prisoners in the male closed estate must be allocated a key worker whose
responsibility is to engage, motivate and support them through the custodial
period.
• Key workers must have completed the required training.
• Governors in the male closed estate must ensure that time is made available
for an average of 45 minutes per prisoner per week for delivery of the key
worker role, which includes individual time with each prisoner.
• Within this allocated time, key workers can vary individual sessions in order
to provide a responsive service, reflecting individual need and stage in the
sentence. A key worker session can consist of a structured interview or a
range of activities such as attending an ACCT review, meeting family during
a visit or engaging in conversation during an activity to build relationships.
30. In 2023/24, due to exceptional staffing and capacity pressures in parts of the estate,
some prisons are delivering adapted versions of the key work scheme while they
work towards full implementation. Any adaptations, and steps being taken to
increase delivery, should be set out in the prison’s overarching Regime Progression
Plan which is agreed locally by Prison Group Directors and Executive Directors and
updated in line with resource availability.
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Key Events
31. Mr David Richards was remanded in prison on 4 April 2022, charged with the
attempted murder of his former partner. He was sent to HMP Chelmsford. It was his
first time in prison.
32. The Person Escort Record (PER) that accompanied Mr Richards noted that he was
at high risk of suicide. He told reception staff that he had been struggling with his
mental health and had recently tried to take his own life. Staff started suicide and
self-harm prevention procedures (known as ACCT). A member of the mental health
team saw Mr Richards and noted that he would be monitored through the ACCT
process. A GP prescribed sertraline (an antidepressant) and promethazine (to aid
sleep).
33. Staff stopped ACCT procedures on 18 April, but reopened them on 6 May, when Mr
Richards said that he was struggling with his mental health, hearing voices and
thinking about suicide. He said that he did not feel safe on the wing, so staff moved
him to the vulnerable prisoners’ unit (VPU), where he said he felt safer.
34. Staff stopped ACCT procedures on 26 May. The same day, Mr Richards agreed to
start taking olanzapine (an antipsychotic).
35. Staff restarted ACCT procedures on 15 June when Mr Richards said he was under
threat from other prisoners and was experiencing auditory and visual hallucinations.
He said he was unable to cope and would take his life if he got the chance. A
mental health nurse reviewed him and noted that his answers appeared to be
purposely vague and generic, and she did not believe that he was experiencing
psychotic symptoms. She noted that his court case was approaching and thought
he might be trying to use his mental health as mitigation.
36. On 23 June, a prison psychiatrist reviewed Mr Richards and noted no evidence of
thought disorder but agreed to increase his prescription of olanzapine. Staff stopped
ACCT procedures on 30 June.
37. Mr Richards had regular sessions with his key worker. He talked about his case and
discussed his children. He took a course to train as a Listener, which he enjoyed.
Mr Richards discussed with his key worker where he might transfer after being
sentenced. He also discussed looking into the possibility of contact with his children
after his trial.
38. On 21 September, the psychiatrist reviewed Mr Richards. He said that he was
happy with his medication, was not suffering from any hallucinations, and
expressed no paranoia or delusional beliefs. The psychiatrist noted that Mr
Richards was not psychotic, though was anxious and possibly suffering from
depression.
39. On 17 November, Mr Richards was found guilty of attempted murder. Staff
monitored his mood and whether he needed the support of ACCT procedures but
assessed that it was not necessary at that time.
40. On 12 January 2023, Mr Richards was sentenced to 27 years imprisonment. He
told staff that he had been expecting this, but due to the length of sentence, staff
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started ACCT procedures. At an ACCT review the next day, Mr Richards said that
he had been anticipating a sentence in the region of 25 years and had been
mentally prepared. He said he had no thoughts of harming himself and felt settled
on his medication. Staff stopped ACCT procedures.
41. Mr Richards continued to see his key worker and his emotional support worker and
interacted positively. He spoke to his mother daily. His prison record showed good
reports from prison staff.
42. At an ACCT post-closure review on 2 February, Mr Richards said that he was
feeling positive, with no thoughts of harming himself and no issues to raise. He was
awaiting news on a transfer. He saw a prison psychiatrist on 8 February, who noted
that he was not acutely mentally unwell, was not psychotic, suicidal or depressed.
He also noted that Mr Richards did not appear to have a long-term psychotic
disorder. He agreed to reduce Mr Richards’ olanzapine dose.
43. On 22 February, Mr Richards told his key worker that he was fine, with no concerns
or issues to raise. He had applied for a mediation course. The following day he had
a session with his emotional support worker. He was in a good mood, and was
keeping busy to avoid focusing on his long sentence. He said that he struggled
most with not seeing his children but had no thoughts of harming himself and was
aware of support available. He said he had no hallucinations, and wanted to come
off all his medication as he felt that he no longer needed it.
HMP Lowdham Grange
44. On 24 February, Mr Richards was moved to HMP Lowdham Grange. The PER that
accompanied him noted that he had previously made attempts on his own life, had
recently been under ACCT management, had VP status, and was on medication for
his mental health. The PER noted that he was at a high risk of suicide.
45. A nurse carried out Mr Richards’ initial health screen. He said that he was happy to
be at Lowdham Grange and looking forward to settling on the wing. He said that he
had no thoughts of harming himself but as he had been under the care of the
mental health team at Chelmsford, the nurse referred him for a mental health
assessment. Staff carried out four standard new-arrival checks on Mr Richards
through the night. He was sleeping at each check and there were no concerns.
46. On 26 February, staff prescribed Mr Richards’ medication and he was allowed to
hold seven days’ worth in possession.
47. On 1 March, a nurse carried out a mental health assessment. Mr Richards said that
he felt like he had a mental breakdown at the time of his offence and felt a lot of
shame and guilt around it. He said that he struggled with prison life, where he did
not feel safe, and had a long sentence. He mentioned a childhood trauma, but did
not disclose any details. He said that his mental state now felt stable. He was trying
to think positively and wanted to engage with any interventions that would help him.
He would like to establish some contact with his children when he was able to. He
was reducing his olanzapine, and wanted to stop all his medication. The nurse said
that stopping medication while adjusting to a new prison was not desirable and
suggested reducing the dose after four weeks when he had settled. He said that he
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had no thoughts of harming himself and that his future relationship with his children
was a big protective factor. The nurse referred him for a psychological assessment.
48. On 6 March, two prison custody officers (PCOs) from the safer custody department
went to see Mr Richards for a new arrival wellbeing check. Mr Richards said that he
had not asked to come to Lowdham Grange and would not be having any visits
from his family as they lived too far away. He said it was his first sentence, he felt
vulnerable among other prisoners, and would like to go to a “more mature” wing. He
said that he had not been under ACCT management, had no thoughts of harming
himself, and would tell staff if he felt low. The safer custody staff were unaware that
Mr Richards had been on several ACCTs at Chelmsford as they had not checked
his electronic prison record. When interviewed, they said that their team of five used
to have a computer each but it had recently reduced to only two, so they had not
been able to access a computer to check Mr Richards’ record.
49. All prisoners’ telephone calls, except those that are legally privileged, are recorded,
and prison staff listen to a random sample. The investigator listened to the calls Mr
Richards made in the week before he died. There was nothing in those calls that
suggested Mr Richards was at imminent risk of suicide or self-harm.
Events of 13 March
50. On the morning of 13 March, Mr Richards telephoned his mother. He said that he
needed to talk to his solicitor urgently about money, and asked his mother if she
could ask the solicitor to arrange a time for him to call. They spoke again, and a call
had been arranged for 5.00pm that afternoon.
51. Mr Richards was due to move wings that afternoon. Staff explained to him that he
had to move from the induction wing, but as he was a Listener and someone wing
staff trusted, they would look to bring him back within a matter of weeks. Although
Mr Richards would have preferred not to move, he accepted that he had to and
seemed pleased that he had earned the opportunity to return.
52. Prisoners were locked into their cells for lunch at approximately 11.30am, and a
PCO went to provide Mr Richards with bags to pack his belongings. He opened the
cell door and handed them over. At interview, the PCO said that there was nothing
out of the ordinary in the interaction, and he had no concerns about Mr Richards at
the time. Another PCO completed a routine check at 11.45am, and again had no
cause for concern about Mr Richards.
53. Prisoners who were due to attend work were unlocked from 1.00pm. At 1.17pm, a
prisoner told a PCO that he was concerned about Mr Richards. The PCO went to
the cell, looked through the observation panel, and saw Mr Richards hanging by a
bedsheet attached to the bed. He radioed a code blue emergency (used when a
prisoner is unconscious or having difficulty breathing) and the control room called
an ambulance. The PCO opened the cell door. He used his anti-ligature knife to cut
the ligature and lowered Mr Richards to the floor. He was not breathing and had no
pulse, so the PCO began CPR. Other staff arrived in response to the code blue and
a PCO applied a defibrillator (an electronic device that gives an electric shock to try
to restart the heart) but the battery was flat. The PCO used his radio to request
another defibrillator and the prison officers continued with CPR. More staff arrived,
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one of them with a defibrillator, and a PCO applied it to Mr Richards. The machine
advised them not to give a shock and to continue with CPR, which they did.
54. Two nurses responded to the code blue. A nurse tried to insert an airway but was
unable to due to the presence of vomit. She used a suction device to try clear the
vomit. She reinserted an airway device, however, there was still vomit present and
she was unable to administer oxygen. She queried whether the suction device was
working properly. Ambulance paramedics arrived at the cell at 1.37pm and took
over. They continued resuscitation attempts, but at 2.12pm, confirmed that Mr
Richards had died.
Contact with Mr Richards’ family
55. Lowdham Grange appointed two PCOs as family liaison officers. They went to Mr
Richards’ mother’s address to notify her of her son’s death. In line with HMPPS
guidance, Lowdham Grange contributed to the costs of Mr Richards’ funeral.
Support for prisoners and staff
56. After Mr Richards’ death, a custodial operations manager (COM) 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.
57. The prison posted notices informing other prisoners of Mr Richards’ 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 Richards’ death.
Post-mortem report
58. The post-mortem report concluded that Mr Richards died from hanging. No illicit
substances were found in his system.
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Findings
Management of Mr Richards’ risk of suicide and self-harm
59. Mr Richards had some important risk factors for suicide. He had been convicted of
the attempted murder of his former partner, had received a long sentence, it was his
first time in prison, he had previously attempted suicide and he suffered with mental
health issues.
60. Mr Richards was managed under ACCT procedures on several occasions at
Chelmsford but had appeared fairly settled in the month or so before his transfer to
Lowdham Grange. After his transfer, he said he felt vulnerable. However, there
were no indications that he had any specific problems with other prisoners. It is
unclear why Mr Richards wanted to speak to his solicitor about money but there is
no evidence that he was being bulled or was under threat. He was not managed
under ACCT procedures at Lowdham Grange and we are satisfied that there was
no indication that Mr Richards was at imminent risk of suicide in the days before his
death.
61. When safer custody staff saw Mr Richards on 6 March, he told them that he had not
been under ACCT management. This was not the case, but the staff said in
interview that they had been unable to access Mr Richards’ electronic record before
seeing him due to a reduction in the number of computers available. This has since
been rectified. Both members of staff said in interview that in the meeting, they
found no reason to be concerned about Mr Richards’ wellbeing.
62. Mr Richards’ death was the second of three self-inflicted deaths that occurred within
the same month at Lowdham Grange. There were no obvious connections between
the circumstances of Mr Richards’ death and the other deaths. However, we are
aware that the prison was particularly unsettled at that time, due to the transfer of
the management of the prison from Serco to Sodexo in February. Both HM
Inspectorate of Prisons and the Independent Monitoring Board reported that the
prison was not safe. There was a high incidence of drug use, self-harm and
violence. Staffing levels were low which resulted in limited time out of cell and a
deterioration in prisoner-staff relationships. We cannot say how these factors
affected Mr Richards but it is possible that they contributed to his feelings of
vulnerability.
63. Lowdham Grange’s transfer from Serco to Sodexo was the first time a prison had
been handed over from one private provider to another. The impact of the changes
had been underestimated, not least the number of managers and staff who
resigned when the contract change was announced. HMPPS will need to review the
lessons learned to ensure smoother transitions between providers in future.
Clinical care
64. The clinical reviewer concluded that the care Mr Richards received in prison was of
a good standard and equivalent to that which he could have expected to receive in
the community. He found that Mr Richards was well supported by the mental health
teams, and seen by mental health professionals on a regular basis. He was
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prescribed antipsychotic medication when required, saw a psychiatrist regularly and
his medication was closely monitored.
Key worker scheme
65. All prisoners in the closed male estate should be allocated a key worker. They
should have an average of 45 minutes a week with their key worker to build rapport
and have meaningful conversations.
66. Mr Richards’ records show that he saw his key worker regularly at Chelmsford and
was open in key work sessions. However, he was not allocated a key worker at
Lowdham Grange. We were told that Lowdham Grange was providing key work
only to vulnerable prisoners due to operational and staffing pressures. Mr Richards
was not classed as a vulnerable prisoner while at Lowdham Grange.
Governor and Head of Healthcare to note
67. The first defibrillator applied to Mr Richards gave a low battery warning and staff
had to fetch another one. A nurse also expressed concerns that the suction
equipment was not working correctly. It is unlikely that these issues affected the
outcome in this case, but we bring them to the attention of the Governor and Head
of Healthcare.
Inquest
An inquest into Mr Richards’ death concluded on 7 February 2025 that his death was
accidental due to self-inflicted ligature asphyxiation.
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