Patrick Maughan

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Independent investigation into
the death of Mr Patrick Maughan,
a prisoner at HMP Lowdham Grange,
on 17 November 2024
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 Patrick Maughan died on 17 November 2024 from the toxic effects of cocaine and
synthetic cannabinoids, while a prisoner at HMP Lowdham Grange. He was 50 years old. I
offer my condolences to Mr Maughan’s family and friends.
Between 17 November 2024 and 6 April 2025, there were five suspected drug-related
deaths at Lowdham Grange, of which Mr Maughan’s was the first.
The substance misuse team supported Mr Maughan and offered opportunities for
meaningful engagement.
The clinical reviewer found that the healthcare that Mr Maughan received was equivalent
to that which 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 November 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 11
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Summary
Events
1. On 8 August 2004, Mr Patrick Maughan was remanded into custody, charged with
robbery. Following convictions for further violent offences committed in prison, he
was sentenced to an indeterminate sentence for public protection in 2009 and an
extended determinate sentence in 2013.
2. On 6 February 2024, Mr Maughan was transferred to HMP Lowdham Grange. He
had a history of using drugs, including psychoactive substances in prison. When he
arrived, he told staff that he had no substance use problems and did not need
support from the substance misuse service.
3. Mr Maughan was suspected of being under the influence of drugs several times.
The substance misuse team regularly offered him support and gave him harm
reduction advice. He told them he was aware of the risks and declined to engage.
4. In April and September, Mr Maughan twice referred himself to the substance
misuse team for assessment. He asked for the assessment to take place on the
wing as he did not want to go to the healthcare unit. He said he did not want to
leave the wing due to his cleaning job. He was told this was not possible and he
would need to attend the healthcare unit. Mr Maughan did not attend either
assessment.
5. At 9.58am on 17 November, Mr Maughan went into another prisoner’s cell. At
10.10am, prisoners in the cell became concerned about Mr Maughan and called
staff who immediately radioed a medical emergency code blue (used when a
prisoner is not breathing or is unconscious). Nurses began cardiopulmonary
resuscitation, and paramedics later assisted. Despite their efforts, at 11.37am,
paramedics pronounced life extinct.
Findings
6. Mr Maughan’s was one of several drug-related deaths at Lowdham Grange within a
short space of time. Mr Maughan frequently used illicit drugs and was suspected of
being under the influence less than a day after he arrived at Lowdham Grange. The
substance misuse team offered him support and interventions to stop and he was
aware of the risks associated with psychoactive substances.
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The Investigation Process
7. HMPPS notified us of Mr Maughan’s death on18 November 2024.
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. Four prisoners responded.
9. The investigator visited HMP Lowdham Grange on 28 November. She obtained
copies of relevant extracts from Mr Maughan’s prison and medical records.
10. The investigator interviewed two members of staff and three prisoners at Lowdham
Grange on 26 November 2024, 13 and 14 January 2025. She interviewed five
members of staff by video conference in January 2025.
11. NHS England commissioned a Clinical Reviewer to review Mr Maughan’s clinical
care at the prison. The investigator and the clinical reviewer jointly conducted
interviews with healthcare staff.
12. We informed HM Coroner for Nottingham City and Nottinghamshire the
investigation. The Coroner gave us the results of the post-mortem examination. We
have sent the Coroner a copy of this report.
13. The Ombudsman’s office contacted Mr Maughan’s sister to explain the investigation
and to ask if she had any matters she wanted us to consider. She wanted to know
Mr Maughan’s cause of death, why he was in another cell when he died, what he
was doing in the cell and whether anything was given to him in that cell. She asked
us to speak to his cellmate and the person in whose cell Mr Maughan died.
14. We have addressed these questions within this report but are unable to say with
certainty why Mr Maughan was in another prisoner’s cell. Mr Maughan did not have
a cellmate. We spoke to a number of prisoners who were in the cell at the time of
the incident. We were unable to speak to the prisoner in whose cell Mr Maughan
died.
15. We shared the initial report with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
16. Mr Maughan’s sister received a copy of the draft report. She did not make any
comments.
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Background Information
HMP Lowdham Grange
17. HMP Lowdham Grange is a category B training prison for adult males in
Nottingham. Northamptonshire NHS Trust provides healthcare services, including
mental health services and substance misuse services.
18. Lowdham Grange was privately managed, first by Serco when the prison opened in
1998 and then Sodexo from February 2023. In December 2023, the government
announced ‘step in’ action to stabilise the prison and took over control on an interim
basis. On 1 August 2024, HMPPS took full public sector control of the prison.
HM Inspectorate of Prisons
19. 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, respect and preparation for
release were not sufficiently good, and outcomes for purposeful activity were poor.
A new Governor had recently arrived and had a clear sense of the challenges and
seriousness of the concerns identified.
20. Inspectors found that drugs were a serious problem. The number of prisoners found
to be under the influence of illicit substances had continued to rise in 2025. Drones
were a particular concern, and many drones were not intercepted. Anti-drone
netting in outdoor areas accessible to prisoners was in the process of being
renewed, and some other measures were in place or planned. The positive rate of
random drug testing for the previous 10 months was 40.6% and 56% of prisoners at
Lowdham Grange said it was easy to get hold of drugs.
21. Prevention and detection of staff corruption had improved, especially through better
collaboration with the police, which had resulted in arrests inside and outside the
prison. Enhanced gate security was also a useful recent addition, but the small
space available created queues of staff outside the prison and an occasionally
rushed searching process, reducing its effectiveness.
Independent Monitoring Board
22. 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 concluded
that safety in the prison deteriorated throughout the whole reporting period. They
noted outcomes were strongly influenced by the ready availability of illegal drugs,
as well as the associated violence and inexperienced staff who lacked the skills and
confidence to manage prisoners with challenging behaviour.
23. By the end of 2023, positive drug test results had gradually increased to over 50%,
and there were daily incidents of prisoners being under the influence of
psychoactive substances and/or alcohol. There was widespread evidence of
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psychoactive substances and drones were increasingly being used to drop off drugs
and other contraband.
24. The board found that since HMPPS took over in December 2023, more thorough
staff and visitor searches had taken place, including wing searches and a full
lockdown in January 2024. There were plans to install mesh over exercise yards to
stop items being dropped by drones.
HMPPS’ Substance Misuse Group
25. In September 2024, following a PPO recommendation in relation to the death of a
prisoner in 2023, 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 misuse problems at Lowdham Grange and understand the
scale of the prison’s vulnerability to the conveyance of illicit drugs.
26. Their findings included:
• Drugs predominantly used were cannabis and synthetic cannabinoid receptor
antagonists (otherwise referred to as psychoactive substances).
• Security & analyst team colleagues had developed a strong understanding of
illicit substances within the prison through detailed intelligence reports, enabling
them to produce a detailed Local Tactical Assessment to shape action plans at
departmental level. There was scope for this to help drive the drug strategy and
safety teams to work collaboratively.
• There were knowledge gaps among staff about substance misuse.
• Several vulnerabilities were observed in the visit area, including staff not being
given a security briefing before 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, yet visitors’
equipment was passed through it which caused further friction between visitors
and staff.
• Legal visits presented a risk of drug ingress, notably in the form of paper-based
illicit substances. The team suggested Lowdham Grange should adopt a digital
approach to minimise the amount of paper coming into the prison.
• The prison highlighted drone incursions as a primary route of ingress.
• Revised monthly drug strategy meetings had started. However, residential staff
had little knowledge of the strategy and how their roles contributed to its
effective delivery.
• Prisoners were frustrated about the lack of activities to keep them occupied,
resulting in increased levels of boredom and frustration, with some using
substances as a coping mechanism.
27. The SMG made six recommendations. These included that:
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• Activity should be undertaken to raise awareness of substance misuse and drug
strategy across the prison.
• Widespread understanding should be driven across the prison to ensure all staff
were aware of what action to take if they found a prisoner under the influence of
a substance.
• 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.
• Social mail should be photocopied.
Previous deaths at HMP Lowdham Grange
28. Mr Maughan was the ninth prisoner to die at Lowdham Grange since November
2021. Of the previous deaths, two were from natural causes, one was drug-related,
and five prisoners took their own lives. There are no similarities between the
findings in our previous investigations and those following our investigation into Mr
Maughan’s death.
29. Since Mr Maughan’s death until the beginning of June 2025, seven prisoners have
died. Three died of natural causes and four were suspected to be drug-related. All
remain under investigation.
Psychoactive substances
30. The term psychoactive substances (PS) is a broad term that refers to a drug or
other substance that affects mental process. Synthetic cannabinoids and synthetic
opioids 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.
31. 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
32. On 8 August 2004, Mr Maughan was remanded into custody at HMP Bedford,
charged with robbery. He had been in prison before. On 14 February 2005, he was
convicted and sentenced to seven years and one month in prison. Mr Maughan was
convicted of further violent offences in custody. In January 2009, he was sentenced
to an indeterminate sentence for public protection, with a minimum tariff of four and
half years. In January 2013, he was sentenced to an extended determinate
sentence, totalling ten years.
33. On 6 February 2024, Mr Maughan was transferred to HMP Lowdham Grange from
HMP Peterborough. He had been at Lowdham Grange before. At 4.47pm, a
reception officer interviewed Mr Maughan and noted he appeared happy to have
moved. The officer recorded no concerns.
34. Nurse A completed Mr Maughan’s initial health screen. Nurse A noted that Mr
Maughan engaged well and told her he had asked to move to Lowdham Grange
and was happy to be there. Nurse A recorded Mr Maughan’s history of drug use but
did not identify any current substance misuse issues.
35. The following day, Officer A met Mr Maughan for a key work session as part of his
induction. Mr Maughan told Officer A he was happy to be at Lowdham Grange and
saw the move as an opportunity for a fresh start. He said he was planning on
keeping his head down and maintaining telephone contact with his sister. Mr
Maughan stated he had no problems with alcohol or drugs and did not need to be
referred to substance misuse support services.
36. At 6.10pm on 8 February, officers radioed a medical emergency code blue (used
when a prisoner is unconscious or not breathing) as they found Mr Maughan
conscious but unresponsive. Staff suspected Mr Maughan was under the influence
of an illicit substance, believed to be PS. Nurses attended and opened a PS log.
37. At around 9.02am on 9 February, a staff member from the substance misuse team
reviewed the PS log and spoke to Mr Maughan. Mr Maughan admitted he had been
under the influence of PS. He said he did not think his PS use was problematic and
was aware of the risks of taking it. The staff member gave harm reduction advice
and told Mr Maughan that if he continued to use illicit substances, his prescribed
medication may be reviewed to manage the increased risk of overdose. Mr
Maughan declined ongoing support. The staff member advised Mr Maughan of the
self-referral process if he changed his mind.
38. Over the next two months, staff suspected Mr Maughan of being under the
influence of PS four times. Prison intelligence during this time suggested Mr
Maughan may have been under threat and being bullied.
39. At 2.20pm on 3 April, the substance misuse team staff member spoke to Mr
Maughan to review the PS log which had been opened the previous day. Mr
Maughan told her he had used PS and wanted support from the substance misuse
team. The staff member told him she would put him on the waiting list for an
assessment and gave further harm reduction advice.
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40. On 16 April, another staff member from the substance misuse team sent Mr
Maughan a letter apologising for a previous cancelled appointment and offering him
an assessment appointment on 24 April. There is no record of this appointment
taking place.
41. Mr Maughan did not attend further assessment appointments offered on 7 and 21
May. On 24 May, a substance misuse team member spoke to Mr Maughan about
his missed appointments. Mr Maughan told her he still wanted support from the
service but preferred an assessment on the wing as he was a wing cleaner. The
staff member told him that the initial assessment needed to happen in the
healthcare unit but work after that could take place on the wing. Mr Maughan
accepted this.
42. Later that day, the staff member sent Mr Maughan a letter offering an assessment
appointment on 3 June in the healthcare unit. Mr Maughan did not attend the
assessment and was discharged. Prison intelligence around this time indicated that
Mr Maughan was under threat and was isolating in his cell.
43. At 2.11pm on 17 June, Officer B observed Mr Maughan and suspected he was
under the influence of drugs. Nurses attended. A substance misuse team staff
member met Mr Maughan the following day. He denied being under the influence of
drugs and said he did not need support from the substance misuse service. The
substance misuse team staff member repeated harm reduction advice and
encouraged Mr Maughan to refer himself to the service if he wanted support.
44. On 31 July, Mr Maughan attended his parole hearing. He told the panel that he was
drug-free. The panel set directions for Mr Maughan and his newly allocated
community offender manager (COM) to spend time getting to know each other by
video conference and telephone.
45. On 11 September, the Deputy Treatment Manager emailed a member of staff from
the substance misuse team to say that Mr Maughan had been offered a place on an
offending behaviour programme. She said Mr Maughan had shared that he had an
addiction to PS and wanted help to manage it so he could engage with the
programme. She recorded that he was very motivated to engage with any support
offered. The member of staff emailed back and asked for Mr Maughan to submit an
application, following several instances of declining support in the past.
46. On 16 September, the Deputy Treatment Manager was walking back to the wing
with Mr Maughan. He told her he had had an altercation with a prisoner the day
before but decided not to stab him and threw his weapon away. He did not give any
further detail.
47. On 20 September, a member of staff from the substance misuse team received an
application from Mr Maughan and added him to the substance misuse assessment
waiting list.
48. At 4.11pm on 22 September, a prisoner assaulted Mr Maughan. He punched Mr
Maughan in the head and told staff this was in response to Mr Maughan threatening
him with a weapon earlier that day. Staff searched Mr Maughan’s cell but nothing
was found. Mr Maughan was referred to Challenge, Support and Intervention
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Planning (CSIP, a scheme to manage the most violent and supporting the most
vulnerable prisoners).
49. At 10.15am on 27 September, staff observed Mr Maughan on CCTV damaging the
cell door observation panel of the prisoner who assaulted him and squirting an
unknown liquid into the cell.
50. On 8 October, a substance misuse team member updated Mr Maughan’s medical
records to say that the substance misuse assessment needed to be rescheduled
due to staff issues. The assessment was rescheduled for 25 October. Mr Maughan
did not attend the assessment.
51. At an unknown time on 27 October, an officer spoke to Mr Maughan following the
CSIP referral on 24 September. Mr Maughan denied the assault took place and
said he did not need any support.
52. Prison intelligence at the end of October continued to suggest Mr Maughan was
involved in the wing drug culture. During interviews, prisoners told the investigator
that Mr Maughan was a frequent PS user and took the drug daily at times.
53. At 10.35am on 5 November, Officer C met Mr Maughan for a keywork session. Mr
Maughan told him he felt safe and settled on the wing. He said he had no
substance use issues, and Officer C noted he often saw Mr Maughan socialising
with others.
54. Mr Maughan continued to maintain telephone contact with his sister and spoke to
her four times about general matters during the first week of November. Mr
Maughan told his sister about another prisoner who had come into his cell and that
the only thing preventing him from reacting was his parole review.
55. At 12.45pm on 7 November, a member of staff from the substance misuse service
recorded in Mr Maughan’s medical records that he was reluctant to leave the wing
and wanted his assessment completed on the wing.
56. Mr Maughan maintained telephone contact with his sister in early November. During
these calls, Mr Maughan appeared positive and said he could not wait to come
home. He said he felt positive about his parole review.
Events of 17 November
57. The investigator watched closed circuit television (CCTV) and body-worn video
camera (BWVC) footage, listened to staff radio communications and obtained
prison statements and East Midlands Ambulance Service records. The following
account is taken from all those sources.
58. Mr Maughan was unlocked at 8.52am. CCTV footage showed Mr Maughan eating
and socialising with prisoners. He appeared calm and relaxed.
59. At 9.58am, an officer unlocked the cell next to Mr Maughan, where Prisoner A lived.
Mr Maughan walked in. CCTV footage showed he did so in a calm manner.
Prisoner B walked in around 25 seconds later.
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60. Prisoner B told the investigator that he was in Prisoner A’s cell when Mr Maughan
came “flying in” and jumped onto the bed. Prisoner B said he looked like he was
having a fit and was not speaking to them. He knew Mr Maughan used PS, but he
had rarely seen him under the influence and thought he would use PS overnight in
his cell. Prisoner B said this seemed different and he did not think Mr Maughan had
used drugs at that time.
61. Two more prisoners went into the cell and at 9.59am, one stood in the cell doorway
and beckoned a prisoner, who ran over. The cell door was closed. Prisoner C told
the investigator that Mr Maughan smoked PS daily. He had sometimes seen him
under the influence during the day but thought he mostly used PS at night. Prisoner
C said he turned Mr Maughan onto his side, wiped his face to make sure his airway
was clear and tried to reassure him. He said he thought he was calming as Mr
Maughan was no longer staring with blankness and started noticing who was in the
cell. Prisoner C said he was then called out of the cell.
62. Prisoner B told the investigator that he and Prisoner A were worried as Mr Maughan
did not seem to be improving. Prisoner B came out of the cell, where Prisoner D
was outside looking in.
63. Officer D and Officer E were on A Wing that morning. At around 10.10am, they
were on the bottom floor of A Wing, moving a mattress from a cell. Prisoner B and
Prisoner D called to them, and they went into Prisoner A’s cell. Officer E
immediately radioed a medical emergency code blue. An officer in the control room
called 999 at 10.13am and told them that a prisoner appeared to be having a
seizure. The call handler advised an ambulance would arrive within an hour.
64. At 10.14, Nurse C arrived with an emergency bag, followed by Nurse D and Nurse
E a minute later. At 10.16am, nurses observed that Mr Maughan had stopped
having seizures but was not talking.
65. At 10.21am, staff moved Mr Maughan onto the landing so they had more space to
treat him. The control room officer telephoned emergency services, told them that
Mr Maughan had deteriorated and asked for an ambulance to be sent immediately.
An ambulance arrived at Lowdham Grange four minutes later.
66. At 10.33am, Mr Maughan stopped breathing. Nurse C began cardiopulmonary
resuscitation. Nurse D assisted. Fire fighters, who were at the prison undertaking a
training exercise, went to the wing at 10.34am and assisted.
67. At 10.35am, paramedics arrived on A Wing and took over resuscitation efforts. At
10.56am, helicopter emergency medical services (HEMS) arrived at the prison. At
11.09am, HEMS paramedics arrived on A Wing and assisted.
68. At 11.37am, paramedics pronounced life extinct.
Contact with Mr Maughan’s family
69. At 11.06am, the prison appointed the Offender Management Unit (OMU) Hub
Manager, as the prison’s family liaison officer. An administrator from the Offender
Management Unit was appointed as the deputy family liaison officer. The OMU Hub
Manager, the OMU administrator and a member of the chaplaincy team tried to visit
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Mr Maughan’s sister at 3.50pm. The occupants at the address told them that she no
longer lived there, and they did not have contact details for her. The OMU Hub
Manager obtained a telephone number from Mr Maughan’s prison records and
informed his sister of his death by telephone a short while later.
70. The prison kept in contact with her subsequently and contributed towards the cost
of Mr Maughan’s funeral in line with national policy.
Support for prisoners and staff
71. 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.
72. After Mr Maughan’s death, the Head of Residence 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.
73. The prison posted notices informing other prisoners of Mr Maughan’s death and
offering support. Staff reviewed all prisoners assessed as at risk of suicide or self-
harm in case they had been adversely affected by Mr Maughan’s death.
Post-mortem report
74. The pathologist established that Mr Maughan died from the toxic effects of cocaine,
MDMB-4en-PINACA, 5F-MDMB-PINACA and ADB-CHMINACA (synthetic
cannabinoids). The post-mortem and toxicology reports identified the presence of
ketamine in Mr Maughan’s system and indicated use in the week before his death.
75. Mr Maughan’s prescribed medications were detected and indicated therapeutic use.
Inquest
76. At an inquest held between 13 and 16 April 2026, the Coroner concluded that Mr
Maughan died due to the use of cocaine and synthetic cannabinoid drugs.
77. The Coroner concluded that the prevalence of drugs at Lowdham Grange was
recognised as being a major problem. Mr Maughan was offered opportunities to
engage in voluntary substance misuse services but did not want to engage with the
programme in the format that was offered and wanted appointments away from the
wing, which was not possible.
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Findings
Clinical review
78. Mr Maughan was suspected of being under the influence of drugs several times,
and staff and prisoners told the investigator that it was well known that he used PS.
The Substance Misuse Service (SMS) appropriately followed up Mr Maughan after
an incident where he was found under the influence of a substance, gave him harm
reduction advice and offered support. In February 2024, Mr Maughan told a nurse
he was aware of the risks associated with taking PS and declined support from the
team. In April and October, Mr Maughan asked the SMS for help with his drug use.
However, he did not attend initial assessments which took place in the healthcare
unit. He told staff he did not want to leave the wing as he was a cleaner. Based on
prison intelligence, it is possible that he may have felt unsafe leaving the wing.
79. The clinical reviewer concluded that the healthcare that Mr Maughan received at
Lowdham Grange was equivalent to that which he could have expected to receive
in the community. Mr Maughan was appropriately referred to the mental health
team on arrival and was repeatedly offered support from the mental health and
substance misuse teams. He often declined to attend. The substance misuse team
always followed up with Mr Maughan after he was suspected of being under the
influence of illicit drugs.
80. We have considered whether the SMS’ refusal to allow assessments to take place
on the wing was an unnecessary barrier to prisoners accessing substance misuse
support. Lowdham Grange has had periods of volatility and at various points it has
been clear that non-HMPPS staff have felt unsafe on the residential wings. The
investigator who visited the prison shortly after Mr Maughan’s death observed that it
was unsettled, and that it might be difficult to hold confidential meetings on the
wing. The substance misuse team manager explained during interview the
challenges in conducting assessments on the wing. She told us it was difficult to
find confidential interview spaces and managing the risks of being alone in rooms
when officers may not be close by.
81. We cannot say whether Mr Maughan’s continued drug use would have been
prevented had he attended the SMS assessments, but we are satisfied that he
understood the risks of using substances and had been offered support to stop.
However, the Governor and Head of Healthcare should review whether non-
operational staff feel safe enough on residential wings to offer interventions to
prisoners who need them.
82. The clinical reviewer found that the healthcare staff interviewed as part of this
investigation portrayed compassion and dedication in their attempts to reduce
deaths at Lowdham Grange. However, the recent spike in deaths had left them
feeling helpless and impacted on their own wellbeing.
83. The clinical reviewer made five recommendations, four of which were not directly
related to Mr Maughan’s death but which the Head of Healthcare will want to
address. The clinical reviewer recommended that the healthcare provider at
Lowdham Grange should ensure that substance misuse education is enhanced.
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This was identified as an area of focus following the regional safety team’s visit and
Lowdham Grange is actively exploring ways to address this gap.
Drug strategy at Lowdham Grange
84. 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.
85. 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.
86. 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
activity, a review of existing visits procedures, review of the parcel process and
photocopying social mail.
87. In January 2025, the Head of Drug Strategy and the Head of Security told the
investigator 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.
88. 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.
89. 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.
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Actions taken by Lowdham Grange since Mr Maughan’s death
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. Recruitment is
underway to employ regional drug and alcohol leads 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, a new Governor was appointed at 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.
Postvention
96. Two officers who immediately responded to the incident told the investigator that
they felt poorly supported afterwards. One officer, who was at Lowdham Grange on
detached duty from another prison, said she was offered little support. She has
since returned to her regular place of work and told the investigator she has been
offered support there. Another officer, who works permanently at Lowdham Grange,
said she had emailed the care team several times and been promised follow-up
telephone contact, which did not happen. She said she had given up trying.
97. At the time of Mr Maughan’s death, there was no stable care team in place. In
December 2024, CM A and CM B took up permanent roles in the care team. As of 7
March 2025, a further four officers completed their training. The care team now has
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six fully trained staff members who are permanent in role. CM A provided
assurances that the team would contact the officer who requested support.
Governor to note
98. Mr Maughan was offered six keywork sessions at Lowdham Grange and accepted
five sessions, out of a possible 40 which should have been offered over his time
there. Each session was with a different officer. While we recognise the significant
challenges faced by the prison during this period, nonetheless, regular sessions
with a consistent keyworker might have offered Mr Maughan the support he
needed.
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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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