Raymond Wallace

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Independent investigation into
the death of Mr Raymond Wallace,
a prisoner at HMP Lowdham Grange,
on 26 January 2025
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 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, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Raymond Wallace died on 26 January 2025 from the effects of synthetic cannabinoids,
while a prisoner at HMP Lowdham Grange. He was 52 years old. I offer my condolences
to Mr Wallace’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 Wallace’s was the fourth.
The clinical reviewer found that the healthcare that Mr Wallace received was good and
equivalent to that which he could have expected to receive in the community.
Prison staff were unclear about when routine roll and welfare checks were meant to be
carried out, and what was required with each check. Welfare and roll checks on 26
January, the day Mr Wallace died, were not carried out properly.
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 am
pleased that the prison has developed an action plan to address these issues, is receiving
additional support from the national safety team and that a new Governor has 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 ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 11
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Summary
Events
1. On 21 March 2022, Mr Raymond Wallace was remanded into custody at HMP
Elmley, charged with attempted murder, possession of an offensive weapon and
other violent offences. He had been in prison before.
2. Mr Wallace had a history of drug use in the community. Prison intelligence reports
from his previous and current sentences suggested Mr Wallace used drugs in
prison and was involved in the drug culture.
3. On 29 March 2023, Mr Wallace was transferred to HMP Lowdham Gange. He
presented as settled and got on well with staff and peers. Mr Wallace was a trusted
prisoner who worked in the prison gardens and supported younger prisoners on his
wing.
4. In May 2024, Mr Wallace failed a mandatory drug test and tested positive for
cannabis and psychoactive substances (commonly referred to as spice).
5. Mr Wallace was not known to the substance misuse service at Lowdham Grange.
Prison staff appeared to be unaware of his drug use, although some prisoners knew
he used cannabis.
6. On 26 January 2025, staff unlocked Mr Wallace’s cell at 8.45am and again at
2.15pm, but did not check on him as they should have done. He was last seen alive
during a roll check at 12.06pm. During an additional roll check at 12.49pm, Mr
Wallace was not checked.
7. At 2.56pm on 26 January 2025, two prisoners found Mr Wallace unconscious in his
cell. They called staff who immediately responded and 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 3.42pm paramedics pronounced life extinct.
Findings
8. Mr Wallace’s was one of several drug-related deaths at Lowdham Grange within a
short space of time. Mr Wallace was a trusted prisoner who, despite a history of
drug use, gave no obvious indications he was using drugs in the months before his
death. A pending disciplinary hearing following a failed mandatory drug test in May
2024 was closed without a referral to the substance misuse service. While there
was some prison intelligence which suggested Mr Wallace might have been using
drugs and was involved in the prison drug culture, there was insufficient evidence to
pursue action, other than monitoring at that stage.
9. Lowdham Grange remains in transition following an unstable period which resulted
in HMPPS taking back control of the prison. The Substance Misuse Group
conducted a diagnostic visit in September 2024, which was followed up in April
2025. Further support has been offered to Lowdham Grange and alongside the
appointment of a new Governor in March 2025, the prison is taking steps to address
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the ingress and use of drugs but we consider that more can be done to ensure
prisoners understand the very real risks of psychoactive substances.
10. On the day of Mr Wallace’s death, routine welfare checks and a roll check were not
conducted in line with policy. While it is impossible to say whether the outcome
would have been different for Mr Wallace had the checks been conducted properly,
staff missed two opportunities to identify any concerns between 12.06pm (when he
was last seen alive) and 2.56pm when he was found unconscious.
11. Roll checks and welfare checks remain fundamental to the security of the prison
and welfare of prisoners. We appreciate Lowdham Grange has begun putting
measures in place, but further work is needed to ensure staff are sufficiently trained
and there is a quality assurance process in place to monitor progress.
Recommendations
• The Governor should ensure there is a robust and auditable programme for
educating and communicating to prisoners the risks of drug use, and
specifically of psychoactive substances.
• The Governor should ensure that there is a robust quality assurance process
in place to ensure that staff are carrying out roll checks and welfare checks
appropriately.
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The Investigation Process
12. HMPPS notified us of Mr Wallace’s death on 27 January 2025.
13. 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. One prisoner responded but subsequently declined to be interviewed.
14. The investigator obtained copies of relevant extracts from Mr Wallace’s prison and
medical records. She watched closed circuit television (CCTV) and body-worn video
camera (BWVC) footage, listened to staff radio traffic and obtained prison
statements and East Midlands Ambulance Service records.
15. The investigator interviewed three members of staff and two prisoners at Lowdham
Grange on 3 March 2025.
16. NHS England commissioned a Clinical Reviewer to review Mr Wallace’s clinical
care at the prison. The investigator and the clinical reviewer jointly interviewed
prison staff, healthcare staff and prisoners on 3 March 2025.
17. We informed HM Coroner for Nottingham City of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
18. The Ombudsman’s office contacted Mr Wallace’s mother and partner to explain the
investigation and to ask if they had any matters they wanted us to consider.
19. Mr Wallace’s mother wanted to know how and why her son had died. She also asked
how long Mr Wallace knew he had heart problems, whether this was treated and with
what medication. These questions are addressed in the clinical review.
20. Mr Wallace’s partner asked why staff had not checked on Mr Wallace between when
his cell was unlocked and when he was found. We have addressed this in this report.
21. We shared the initial report with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies, and we have amended this report
accordingly.
22. Mr Wallace’s mother and partner received a copy of the draft report. They did not
make any comments.
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Background Information
HMP Lowdham Grange
23. HMP Lowdham Grange is a category B training prison for adult men in Nottingham.
Nottinghamshire Healthcare NHS Foundation Trust provides healthcare services,
including mental health services and substance misuse services.
24. 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
25. 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.
26. Inspectors found that drugs were a very 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.
27. Prevention and detection of staff corruption had improved, especially through much
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 very
small space available created queues of staff outside the prison and an
occasionally rushed searching process, reducing its effectiveness.
Independent Monitoring Board
28. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to January 2024, the IMB concluded
that safety in the prison had deteriorated throughout the whole reporting period.
They noted outcomes were strongly influenced by the ready availability of illicit
drugs and the associated violence, combined with inexperienced staff who lacked
the skills and confidence to manage prisoners with challenging behaviour.
29. By the end of 2023, positive drug test results had gradually increased to over 50%
positive, 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.
30. The IMB found that since the arrival of HMPPS 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.
Psychoactive substances
31. 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.
32. 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.
HMPPS Substance Misuse Group
33. In September 2024, following a recommendation from the PPO in relation to the
death of a prisoner in 2023, the HMPPS Substance Misuse Group (SMG)
conducted a drug strategy support visit to understand the scale and nature of
substance misuse at Lowdham Grange and the prison’s vulnerability to the
conveyance of illicit drugs.
34. Their findings included:
• Cannabis and synthetic cannabinoid receptor antagonists (SCRA, a type of PS)
were the drugs predominantly used.
• Security and analyst team colleagues 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) as
the basis for further action plans. However, there was further scope for this to be
used as one of the primary drivers for both drug strategy and safety teams to
work collaboratively.
• There were knowledge gaps among staff about substance misuse.
• There were several vulnerabilities in the visit area, including staff not being given
a security briefing before visits, a lack of zonal patrolling and a lack of secure
communication means between officers and CCTV operators.
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• Staff were not 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 the prison adopted a digital approach to
minimise the amount of paper coming in.
• The prison highlighted drone incursions as one of its primary routes 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 raised frustrations at the lack of activities to keep them occupied,
resulting in increased levels of boredom and frustration, with some using
substances as a coping mechanism.
35. The SMG made six recommendations. These included that:
• 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
are aware of what action to take when they find 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
36. Mr Wallace was the twelfth prisoner to die at Lowdham Grange since January 2022.
Of the previous deaths, two were from natural causes, three were drug-related and
five prisoners took their own lives. One cause of death remains unknown and under
investigation. There are no similarities between the findings in our previous
investigations and those following our investigation into Mr Wallace’s death.
37. Since Mr Wallace’s death up until 8 August 2025, three prisoners have died. Two
died from natural causes and one from an unknown cause. All remain under
investigation.
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Key Events
38. On 21 March 2022, Mr Raymond Wallace was remanded into custody at HMP
Elmley, charged with attempted murder, possession of an offensive weapon and
other violent offences. He had been in prison before. On 1 March 2023, Mr Wallace
was sentenced to nine years imprisonment.
39. Mr Wallace had a history of drug use in the community and prison. Prison
intelligence during previous periods in prison suggested Mr Wallace was involved in
the supply and distribution of drugs and used cannabis.
40. On 29 March 2023, Mr Wallace was transferred to HMP Lowdham Grange. He
appeared to settle well and told staff he was happy to be there. He raised no
concerns and was managed under an enhanced regime (the highest level) as part
of the incentives scheme (which rewards good behaviour by increasing access to
visits, the prison shop and time out of cell).
41. In June, prison intelligence suggested PS and cannabis were prevalent on F Wing,
where Mr Wallace lived, to the extent that staff had become unwell. Mr Wallace was
one of several prisoners suspected to have been under the influence but there is no
evidence that any further action was taken.
42. In September, Mr Wallace completed a cleaning course. Staff recorded positive
behaviour entries in his prison electronic record in September and November.
43. In April 2024, prison intelligence suggested Mr Wallace was involved in the drug
culture, acting as a look out when a package was dropped from a drone onto the
wing exercise yard.
44. On 21 May, Mr Wallace failed a mandatory drug test. He tested positive for
cannabis and PS. He was placed on report pending a disciplinary hearing. Mr
Wallace’s disciplinary hearing summary recorded that the charge was not
proceeded with. Lowdham Grange was unable to provide further documentation,
and we therefore do not know the reason for this. There is no evidence that any
further action to address Mr Wallace’s drug use was taken, including referral to the
substance misuse team.
45. On 27 July, Officer A met Mr Wallace for a keywork session. Officer A told Mr
Wallace she had noticed he seemed stressed recently and asked how he was. Mr
Wallace told her he had been trying to get an inter-prison telephone call (a
supervised call between prisoners in different prisons) with his son. Mr Wallace said
that he was otherwise settled on the wing. Officer A noted she thought other
prisoners saw Mr Wallace as a father figure on the wing and he helped many
younger prisoners, often cooking for them.
46. Officer A met Mr Wallace for another keywork session on 4 September. Mr Wallace
repeated frustrations with his telephone calls but overall appeared well. Prison
electronic records reflected that Mr Wallace continued to comply well with the wing
regime, was polite and had a good rapport with staff and prisoners. (We could not
establish whether or when Mr Wallace was able to speak to his son but there is no
further mention of problems with an inter-prison phone call.)
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47. On 9 January 2025, Officer B met Mr Wallace for a keywork session. Mr Wallace
told him he was doing well, and his health was good. He said he had lots of friends
at Lowdham Grange and kept in touch with his family by telephone. He said he
enjoyed his job, working in the prison gardens. During the remainder of January, Mr
Wallace appeared settled.
Events of 26 January 2025
48. 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.
49. At around 8.45am, Mr Wallace’s cell door was unlocked. Prison staff did not check
on him.
50. At around 10.34am, Mr Wallace left his cell and spent around 90 minutes socialising
with other prisoners and cooking food. At around 11.58am, Officer C locked Mr
Wallace in his cell.
51. At around 12.06pm, Officer D completed a roll check (a manual check by prison
officers of each cell to confirm the presence of prisoners). Officer D observed Mr
Wallace through his cell door observation panel.
52. At around 12.49pm, the control room asked staff to complete a standfast roll check
(an ad hoc roll check in addition to the routine roll checks which requires officers to
carry out a physical headcount of all prisoners). CCTV shows that at around
1.06pm, Officer E checked cells on the bottom landing. He did not check any cells
on the top landing, including where Mr Wallace lived.
53. At around 2.15pm, Officer C unlocked prisoners for afternoon activities. He
unlocked all cells, including Mr Wallace’s, without looking through any observation
panels or checking on prisoners’ welfare.
54. At around 2.40pm, Prisoner A (a prisoner on the wing) briefly looked through Mr
Wallace’s observation panel. He returned at 2.56pm and opened Mr Wallace’s cell
door. At the same time, Prisoner B, a prisoner, was nearby at the end of the
landing. Prisoner A beckoned to Prisoner B. Prisoner B told the investigator that Mr
Wallace had planned to cook food for prisoners that afternoon and Prisoner A had
gone to his cell to ask if he was coming out.
55. Prisoner B told the investigator that Prisoner A shouted to him and said he thought
something was wrong with Mr Wallace. At 2.57pm, Prisoner A went back into Mr
Wallace’s cell, followed by Prisoner B within a minute. Prisoner B told the
investigator that the lights in Mr Wallace’s cell were off, and his music was playing.
He saw Mr Wallace sitting slumped over on the edge of his bed.
56. Prisoner A and Prisoner B immediately went to the staff office and told Officer D
and Officer F that something was wrong, and they thought Mr Wallace was dead.
Officer F immediately ran to Mr Wallace’s cell, followed shortly after by Officer D.
57. Officer F entered Mr Wallace’s cell at 2.58pm, followed by Officer D seconds later.
In his statement, Officer F said he found Mr Wallace sitting slumped forwards, with
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what appeared to be vomit on the floor and coming out of his mouth. He put his
hand on his shoulder to try and get a response. Mr Wallace slumped sidewards,
and Officer F laid him on his bed.
58. Officer D radioed a medical emergency code blue (used when a prisoner is
unconscious or not breathing) at 2.59pm, as Mr Wallace remained unresponsive.
The control room log recorded an ambulance was called at 3.00pm. (There may be
a discrepancy of one minute between the time shown on CCTV footage and the
control room clock. There is no evidence of a delay.)
59. Officer F was unable to find a pulse and began cardiopulmonary resuscitation
(CPR). Officer D assisted.
60. At 3.01pm, Officer F, Officer D and Officer G (who had responded to the code blue)
carried Mr Wallace onto the landing outside his cell. Officer H ran to collect the
defibrillator (a device that can apply an electric charge to the heart to restore a
normal heartbeat).
61. At 3.02pm, Nurse A and Nurse B arrived at Mr Wallace’s cell, followed seconds
later by Nurse I and Nurse J. All carried emergency bags. Officers continued CPR
while nurses administered naloxone (a medication that rapidly reverses an opioid
overdose) and inserted an airway.
62. At 3.15pm the first ambulance with three paramedics arrived at the prison gate.
They reached Mr Wallace at 3.17pm. A minute later, staff moved Mr Wallace to the
end of the landing, where there was more space.
63. At 3.20pm, a second ambulance arrived at the prison gate. A fourth paramedic
arrived on F Wing two minutes later. At 3.22pm, paramedics from the helicopter
emergency medical services (HEMS) arrived at the prison. At 3.24pm, two HEMS
paramedics arrived on F Wing and assisted with resuscitation efforts.
64. Despite their efforts, at 3.42pm, paramedics pronounced life extinct.
Information received after Mr Wallace’s death
65. Prison intelligence received after Mr Wallace’s death suggested he had been using
illicit drugs.
Contact with Mr Wallace’s family
66. At 4.00pm on 26 January, the prison appointed the Offender Management Unit
(OMU) Hub Manager as the prison’s family liaison officer. An Offender Management
Unit administrator was appointed as the deputy family liaison officer. Mr Wallace’s
next of kin lived far from the prison and the OMU Hub Manager arrived at their
address at 10.00pm that night, broke the news of Mr Wallace’s death and offered
support. Another member of staff took over as the family liaison officer on 27
January.
67. The prison contributed toward the cost of Mr Wallace’s funeral in line with national
policy.
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Support for prisoners and staff
68. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners with 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.
69. After Mr Wallace’s death, the Head of Operations 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.
70. The prison posted notices informing other prisoners of Mr Wallace’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 Wallace’s death.
Post-mortem report
71. The pathologist established that Mr Wallace died from the effects of synthetic
cannabinoids (PS). The post-mortem and toxicology reports identified the presence
of ketamine and pregabalin (a medication that was not prescribed to Mr Wallace) in
Mr Wallace’s system which indicated previous use (the post-mortem did not provide
any further information on how recently he might have consumed the substances).
72. The pathologist found a significant degree of cardiac disease, the degree of which
could cause sudden death. The pathologist concluded the presence of synthetic
cannabinoids was the most important acute factor, but the presence of heart
disease most likely indirectly contributed to Mr Wallace’s death.
73. Mr Wallace’s prescribed medication was detected and indicated therapeutic use (in
line with his prescribed doses).
Inquest
74. At an inquest held between 29 June and 2 July 2026, the Coroner concluded that
Mr Wallace death was drug related.
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Findings
Substance use
75. Mr Wallace had some recorded history of substance use both in prison and in the
community. However, he was not known to the substance misuse service at
Lowdham Grange. In May 2024 (when Sodexo managed the prison), he was placed
on report pending a disciplinary hearing after testing positive in a mandatory drugs
test. In January 2025, a decision was made not to proceed with the charge
(following the management ‘step in’ of HMPPS). Lowdham Grange was unable to
provide full documentation so we could not establish the reason the charge was
dropped. However, there is no evidence that Mr Wallace was referred to the
substance misuse service in May 2024, or that any other action was taken to
assess or address his substance use and we have been unable to establish why
not. While we note there are processes already in place at Lowdham Grange which
trigger referrals and information sharing with the substance misuse team, we bring
to the Governor’s attention the importance of sharing intelligence at all stages.
76. After May 2024, there is no record that staff considered Mr Wallace to be under the
influence of drugs again although other prisoners reported that he used drugs.
Drug strategy at Lowdham Grange
77. 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.
78. 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.
79. 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.
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80. 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.
81. 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.
82. 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 since Mr Wallace’s death
83. 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.
84. 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.
85. 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.
86. 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.
87. 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.
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88. 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 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.
89. We welcome the work underway at Lowdham Grange to tackle the availability of
drugs. However, we consider that work to educate and warn prisoners about the
known dangers of using drugs, particularly synthetic cannabinoids and opioids, is
vitally important. We make the following recommendation:
The Governor should ensure there is a robust and auditable programme for
educating and communicating to prisoners the risks of drug use, and
specifically of psychoactive substances.
Security - roll checks
90. The Management of Internal Security Procedures Policy Framework requires at
least four routine roll checks in every 24 hours. An officer’s signature in the wing
residential diary confirms all doors have been checked as locked and secured and
the presence of prisoners in their correct cells. This requires officers to assure
themselves that prisoners are in their cells by obtaining a clear view of their face
and, as far as reasonably possible, that prisoners are alive and well. The same
requirements apply to standfast roll checks.
91. On 26 January, Officer D conducted the lunchtime roll check at 12.06pm. This was
the last time Mr Wallace was seen alive.
92. Following a request from the control room at 12.49pm for a standfast roll check,
Officer E failed to check any cells on the first floor, where Mr Wallace lived. Officer
E’s conduct was subject to an internal prison investigation and progressed to a
disciplinary hearing. The hearing has not yet taken place.
93. The primary purpose of a roll check is to confirm that all prisoners are present and
accounted for. Not completing a roll check of any kind is therefore a serious breach
of security. Roll checks are also an opportunity to check on a prisoner’s welfare and
identify any serious concerns. While it is impossible to say whether the outcome
would have been different for Mr Wallace if he had been checked in line with policy
during the standfast roll check, this was a missed opportunity to identify any
concerns.
Welfare checks
94. Prison Service Instruction 75/2011 on residential services requires staff to ensure
prisoners are supported and their daily needs met. Staff should assure themselves
of the wellbeing of prisoners during or shortly after unlock, even when prisoners are
not expected to leave their cell.
95. During unlock and welfare checks in the morning and afternoon of 26 January,
prisoners on F Wing, including Mr Wallace, were unlocked but not checked. Officer
C failed to look through cell door observation panels before unlocking cells and did
not check on the welfare of any prisoners. The failure to check on Mr Wallace when
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he was unlocked at 2.15pm was a second missed opportunity to identify any
concerns. Failure to look through observation panels before unlocking cell doors
also presents a risk to officers.
96. The Deputy Governor told the investigator that both Officer C and Officer E (who
failed to complete the standfast roll check) were employed by Sodexo. Before
March 2025, all staff were trained by Sodexo. HMPPS have no access to their
training records. We cannot be certain that Officer C and Officer E (and other staff
trained by Sodexo) received sufficient training to enable them to undertake their
roles effectively.
97. Lowdham Grange considered investigating the actions of Officer C. However, due
to the lack of evidence that he had received sufficient training and support to
undertake his role, an investigation was not deemed appropriate.
98. On 14 April, a Governor’s Order was issued to all staff which detailed expectations
to check on prisoners when they are unlocked and how to manage challenges with
this (for example, if an observation panel is blocked).
99. On 28 May, Lowdham Grange held a whole prison training day which focused on
safety. Training on welfare checks and roll checks was also delivered.
100. The senior leadership team is now conducting ad hoc wing visits to monitor that
checks are being completed correctly and the Governor is reinforcing expectations
to wing managers in the morning briefing. However, there is no formal quality
assurance process in place to monitor progress. We therefore make the following
recommendation:
The Governor should ensure that there is a robust quality assurance process
in place to ensure that staff are carrying out roll checks and welfare checks
appropriately.
Clinical review
101. The clinical reviewer concluded that the care Mr Wallace received was of a good
standard and equivalent to that which he could have expected to receive in the
community.
102. The clinical reviewer found some good evidence of information sharing between
healthcare and prison staff. In particular, communication between prison and
healthcare staff during the resuscitation attempt was excellent. There was nothing
in Mr Wallace’s clinical record to suggest he had been using illicit drugs, and he had
been offered harm reduction advice in April 2023 at Lowdham Grange. The clinical
reviewer made two recommendations about moving unresponsive patients and
sharing information with substance misuse services which the Head of Healthcare
will need to address.
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Governor to note
Keywork
103. The investigator found that Mr Wallace had positive relationships with staff and
peers. Staff described him as polite, compliant and settled. Staff to whom we spoke
said they had never seen him under the influence of substances and appeared
unaware of his drug use. Mr Wallace’s prison electronic record detailed 17 entries in
2024: three of these were related to keywork sessions and others were about Mr
Wallace’s behaviour.
104. Although there is evidence that staff and prisoners knew Mr Wallace well, there is
limited evidence that staff had meaningful and in-depth contact with him. In the 22
months that Mr Wallace lived at Lowdham Grange, there are only four recorded key
work sessions, out of a possible 95 that should have been offered. Three of these
took place with different keyworkers.
105. While we recognise the significant challenges Lowdham Grange faced during this
period, regular sessions with a consistent keyworker might have offered Mr Wallace
the support he needed and further opportunities for staff to be professionally curious
and engage him in a more meaningful way.
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