HMP Lowdham Grange: ‘Repeated failures’ at jail where three men died

Three prisoners found hanging in their cells in the space of three weeks died in an “overwhelmed” jail, a jury has found.

Anthony Binfield, Rolandas Karbauskas and David Richards were inmates at HMP Lowdham Grange in Nottinghamshire in March 2023.

An inquest that concluded at Nottingham Coroner’s Court on Friday criticised “repeated failures” at the Category B jail, which was run by Sodexo at the time of the deaths.

The jury said failures in leadership and issues surrounding the first transfer of a prison between private companies in England and Wales, the month before the deaths, had been contributing factors.

The inquest heard Lowdham Grange had been previously run by Serco before it was transferred to Sodexo on 16 February 2023.

A former director described the buildings as being “dirty” when he arrived, while longstanding issues with safety and drug use were also mentioned.

On the day of the handover, staff arrived to find computers leased to Serco had been taken away, and the court heard a number of experienced prison officers had left in the months beforehand.

The jury cited a number of issues around staffing levels and the sharing of “risk-pertinent information”, with “multiple missed opportunities” to provide support.

In all three cases, it said the transfer of the prison’s control “due to poor leadership and supervision” was likely to have “more than minimally contributed” to their deaths.

“It was apparent that senior directors were out of touch with issues being faced on the shop floor,” the jury said.

Anthony Binfield was 30 years old when he was found in his cell on 6 March 2023, just weeks after Lowdham Grange changed hands.

He had first arrived at the jail in August 2021, and after a short period at a different jail returned in November 2022, but he had repeatedly requested a transfer to a different institution.

The court heard he was known to have issues with drugs and had been attacked due to debts, yet in the days before his death, information about his mental health struggles was not passed on properly between staff.

His aunt said he had been “let down” by the prison service, and said Lowdham Grange “couldn’t cope with him, and often didn’t care”.

The jury said Binfield had, on five different occasions, been placed under an ACCT (assessment, care in custody and teamwork), a process used in prison to help those at risk of self-harm or suicide, but it was not in place at the time of his death.

He was placed under half-hourly observations after being found under the influence of Spice, but staff did not carry out the checks properly, with CCTV showing them also not present at his cell when they said they were.

The jury said when the observation hatch to Binfield’s cell door was covered, “there was an 11-minute delay before the prison staff entered the cell”, with “no urgency” to call an emergency.

Returning a conclusion of suicide, it said a note found laid bare how he “felt let down and unheard by the system and by the prison staff”.

“Anthony felt trapped by the system, out of depth, and felt he had no-one to turn to for help,” jurors added.

A week after Binfield’s death, David Richards, 42, was also found hanging in his cell.

He had arrived at the jail on 24 February, and the inquest heard he was “very unhappy” about being moved to a site without a vulnerable prisoner unit due to threats made against him at his previous prison.

The jury found his status as a vulnerable prisoner “was not taken into consideration before his transfer or upon arrival”.

A mental health assessment recorded Richards as being “petrified and unsafe”, with a prison induction officer warning he was like a “rabbit in headlights” when learning there was no dedicated unit for vulnerable prisoners.

When he learned he was due to be transferred from the induction site to a wing on 13 March, Richards “raised multiple concerns to the induction officer regarding his safety”.

“His concerns were not taken into consideration and he was told he would be ‘moved by force’ if he did not co-operate,” the jury said.

“[Richards] had now been consistently lied to regarding the decisions around his move and safety.”

At about 11:35 GMT on 13 March, Richards was last seen alive, before he was discovered hanging in his cell by another prisoner at 13:16.

The jury said his “likely intention when performing this act was a cry for help”, and concluded his death was an accident, but said there was a failure to perform a welfare check when his cell was unlocked at 11:45.

Rolandas Karbauskas arrived at Lowdham Grange on 20 March, five days before he was found hanging in his cell by a fellow prisoner.

The 49-year-old had a history of depression, but the jury heard no formal action was taken to address his mental health issues when he transferred from HMP Lincoln, and found that healthcare staff did not read his history on arrival.

He spoke “little to no English”, which was not flagged as putting him at risk of isolation, and staff used a fellow inmate who was fluent in Lithuanian to assist them, which the jury said was “not appropriate”.

A nurse made an urgent mental health referral and “advised multiple times” for the need for an interpreter, but an interpreter was not booked for the referral on 23 March.

“This was an inadequate provision of care as an interpreter was a vital part of his next appointment,” the jury said.

Despite Karbauskas raising a history of depression at the referral – where a prison officer who spoke Lithuanian and was “by chance” at Lowdham Grange on secondment provided assistance – but no ACCT was opened.

Karbauskas’s wing buddy raised concerns on 24 March, but a prison officer who saw him in his cell for three minutes “took no action”, which the jury said was “a missed opportunity” to monitor him.

He was found hanging in his cell by his wing buddy at about 10:30 on 25 March, and the jury found no adequate welfare check was carried out when his cell was unlocked earlier that morning.

Returning a conclusion of suicide, the jury cited the “questionable” translation service that “led to distinct language barrier issues”, and also highlighted problems as the prison moved from being run by Serco to Sodexo.

Following the jury’s conclusions, area coroner Laurinda Bower thanked the jury for its diligence during an “incredibly protracted inquest”, which began hearing evidence on 4 November last year.

She also raised “a number of concerns” regarding conditions at Lowdham Grange, and the way the inquest was responded to by some parties.

“I’m concerned not only by the failures in Anthony, David and Rolandas’s care, but also by the persistent failure to learn from deaths at Lowdham Grange, and by the manner in which the prison agencies have engaged with this inquest,” she said.

“Getting to the truth has been challenging.”

She issued two prevention of future death reports, one concerning the “multiple failings and missed opportunities” found by the jury in the care of all three.

Another report was issued regarding the death of Binfield and the way Lowdham Grange prison staff managed the covering of observation panels on the door to his cell, which she said “is not a new issue for the prison”, and led her to worry “that the prison has failed to tackle this issue over many years”.

“There is a dangerous culture of staff assuming the prisoner has obscured the observation panel for privacy purposes or as a form of protest against the regime,” she said in her address to the current governor.

“This neglects the obvious and very real risk that the prisoner is seeking to harm themselves, without detection.”

Following the conclusion of the inquest, Amalia King – of Deighton Pierce Glynn – which represents Binfield’s family, said Lowdham Grange “is a stark example of how leadership failures create unsafe conditions for all those living and working in a prison”.

“The chaotic handover led to a cruel and inhumane prison, imperilled the lives of the most vulnerable and as the jury have found, contributed to Anthony’s death and those of David and Rolandas,” she said.

“Without urgent change, further serious incidents and loss of life are inevitable.”

Serco, Sodexo and the Ministry of Justice (MoJ) – which now runs Lowdham Grange – and Nottinghamshire Healthcare NHS Foundation Trust, which manages healthcare at the site, also commented after the inquest.

The MoJ offered “our sincere apologies for the failings in these cases”, and outlined work it had taken to remedy running problems.

“Since 2024, we have boosted staffing levels to better support vulnerable prisoners, reopened education and workshops to provide greater opportunities for offenders and teamed up with Nottinghamshire Police to clamp down on the flow of contraband into the jail – resulting in several arrests,” the statement said.

The MoJ was fined £500 during the course of the inquest for repeated failures to disclose evidence, the first time the coroner said she had taken this “extraordinary” step in the Nottinghamshire jurisdiction.

Ifti Majid, chief executive of the NHS trust, said: “We accept the findings of the jury and the coroner and apologise for those aspects of care which were not of the standard they should have been.”

Sodexo, which was in charge of the jail at the time of the deaths, said it “will fully take on board any learnings” from the inquest.

“HMP Lowdham Grange – at the time we assumed responsibility in February 2023 – was a prison with a unique set of challenges, both old and new,” a spokesperson said.

“These challenges have been fully considered during the course of this inquest and we are grateful to the coroner for her thorough approach.”

Serco said it was “extremely regrettable” the deaths took place “after our handover”, but said it “we will ensure any key learnings are implemented”.

“The handover did present some challenges for all those concerned,” it added.

“We acknowledge that there are lessons to be learned for future transitions across the sector.”

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