Nigel Saunders

serco 

Serco Justice and Immigration 

HMF' Lowdharn Grange 
Old Epperstcne Road 
L.owdham 
Nottinghamshire 
NG14 7DA 

Ms L Bower 
Area Coroner 
The Council House 
Old Market Square 
Nottingham 
NG12DT 

Date 26th September 2022 

Dear Ms Bower, 

Inquest into the death of Nigel Saunders 
Thank you  for your Prevention of Future Deaths  report received on 3 August 2022.  You will 
recall that Mr Saunders sadly passed away on  18 November 2018. 
I  am  responding  to  matters  of concern  that  you  have  raised  relating  to  HMP  Lowdham 
Grange ('the Prison') which is operated by  Serco Limited,  where Mr Saunders was detained 
at the time of his death. 
I am aware that you will  share a copy of this response with Mr Saunders' family, and  I would 
like  to express  my  sincere  condolences  for  their loss.  Every death  in  custody  is  a  tragedy, 
and  the safety of those detained by  the Prison is my absolute priority. 
I am grateful to you for bringing the following matters of concern to my attention : 
(1)  The Prison failed to  comply with its obligations pursuant to National Prison policy to retain and 

preserve evidence likely to assist all agencies to learn from deaths in custody; and 

(2)  The  local system  in  place for the retention and preservation of material likely ta be relevant to 

the circumstances ofdeath is not as robust as it ought to be. 

The  Prison  is  aware  of  its  obligation  to  retain  and  preserve  evidence  following  a  death  in 
custody  ("DIC") as  set out in  National  Prison  Policy,  PSI 6412011  Management of Offenders 
at Risk of Harm to self and others (Safer Custody)  ('the  PSI) and takes its responsibilities  in 
this regard very seriously. 

Policy at time of Mr Saunders' Death 
Document retention  provisions following  DICs were in  place  at the  Prison  at the  time  of Mr 
Saunders'  death,  pursuant  to  the  National  Prison  Policy,  specifically  the  PSI,  and  were 
implemented  at  the  Prison  in  the  form  of  the  Serco  Divisional  Operating  Procedure  -
Investigation  and  Management  of Death  in  Custody  Incidents  ("DSOP'?.  The  DSOP  was, 
and still is,  applicable nationally to all deaths that occurred in Serco's custody. 
The DSOP included: -

• 

• 

A DIC checklist  which  set  out all  of the  documents that were required to be retained and 
available to the Police, the PPO and  HM Coroner when required. 
a Death in Custody Response Plan 

However,  it  is  acknowledged  that  there  were  some  short  comings  in  the  retention  and 
production of some documentation in relation to Mr Saunders' death. 

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 Policy Updates Prior to Inquest 

In  January  2021  the  DSOP was  updated.  The  DSOP  is  reviewed  and  updated  regularly  as 
appropriate and in  any event every two years. 

Policy Changes Post Inquest 

Following this inquest,  the DSOP,  including tne DIC checKllst nas been  reviewed further and 
an  updated  version  is  to  be  rolled  out  to  the  Eng:ish  Serco  prison  estate  by  the  end  of 
October  2022.  The  updated  version  of the  DSOP  will  include  a  statement  that  the  DIC 
Checklist  is  not an  exhaustive  list,  and  the  Prison  should  retain  any  other document that  it 
considers could  be of relevance. 
The updated  DSOP will  be  rolled  out across the  prison  estate and guidance will  be given to 
all staff responsible for collating relevant documentation following a death in  custody. 
I  understand  that a  copy  of the  DIC  checklist that was  in  place  at the time of Mr Saunders 
death and  a  copy  of the  DIC  checklist,  as amended  in  January  2021  were  provided  to you 
during the course of the  Inquest.  The  most recent version  of the checklist is  currently  being 
finalised prior to its roll  out at the end of October 2022. 

Documents of Specific Concern 

During  the  Inquest  I  became  aware  of specific concerns  you  had  in  respect of disclosure, 
and  I would like to offer the following  reassurances,  by way of example: 
ACCT Tick Sheets 
At the time of Mr Saunders' death,  it was standard practice for observation 'tick sheets' to be 
completed  for those prisoners subject to an ACCT.  Despite the requirement to retain the tick 
sheets  in  accordance  with  the  DIC  Checklist  in  place  at  the  time,  it was  accepted  during 
evidence that the tick sheets in  relation to Mr Saunders could not be located. 
Following  the  introduction  of Version  6  of 'ACCT - Policy  Guidance  - Annex',  which  was 
rolled  out  nationally  in  2021  the  use of these  'tick  sheets'  has  been  discontinued  across  all 
prisons  in  the  UK.  All  records  relating  to  the  ACCT  process  are  now contained  within  the 
ACCT book itself. 
Oscar Journal 
You  may  recall  that  the  Oscar  is  the  senior  member  of  prison  staff,  who  has  overall 
operational  responsibility  for  the  Prison  e.g.,  incident  management  etc.  The  Oscar Journal 
('the  Journal'),  is  a  large  leather-bound  folder where  relevant  material  from  each  shift was 
recorded  by  the  Oscar,  for example details  of anyone  who  is  self-harming  and  incidents  of 
violence to aid information sharing. 

Over the years the Journal has been  replaced  by  incident reports,  which  are completed and 
then  reported to and discussed by the Director and the Senior Management Team on a daily 
basis. 
It is accepted that Journal  entries  may  have contained  relevant  information  following  a  DIC 
and  consequently  should  have  been  included  on  the  DIC  checklist  to  ensure  their 
preservation  following  a  death.  The  Journal  is  now  listed  in  the  checklist,  to  ensure  it  is 
produced in Serco prisons that use an Oscars journal. 

Yours sincerely 

Contract Director 
HMP Lowdham Grange

MISS MAIRIN CASEY 
SENIOR CORONER 
Nottingham and Nottinghamshire 

28th September 2022 

Dear 

Prevention of Future Deaths Report  

The Council House 
Old Market Square 
Nottingham, NG1 2DT 

Thank you for your response to the Prevention of Future Deaths report that I issued following the 
inquest touching the death of Nigel John Saunders. 

I am so pleased to read of the broad range of measures you have put in place to address my 
concerns. 

I understand the improvements you have made to the Prison’s investigation of deaths in custody 
processes are now being rolled out across the SERCO English prison estate. This will assist with 
learning from deaths in custody, with the overarching objective of seeking to reduce the number of 
preventable deaths that occur in prisons every year. 

Two further matters occur to me on considering your helpful response. 

Firstly, the Chief Coroner has, very recently, issued Coroners across England and Wales with new 
guidance in relation to Disclosure. At paragraph 4, the Chief Coroner suggests an undertaking be 
lodged by Interested Persons declaring that due diligence has been exercised in relation to the 
retention and disclosure of all relevant material. Consideration might be given to aligning your 
processes to include an undertaking similar to that suggested by the Chief Coroner. My practise in 
Nottingham has been to ask that the Prison Governor and the legal representative sign and lodge 
with the Coroner a copy of the undertaking at the end of the disclosure process. This additional step 
promotes a culture of openness, transparency and accountability, values which are so important to 
these very sensitive investigations. I include a link to the guidance, which is accessible to the public, 
here: GUIDANCE No 44 DISCLOSURE final (judiciary.uk) 

Secondly, it does occur to me that the improvements you have overseen on behalf of SERCO, might 
actually assist the non-SERCO managed prisons estate in seeking to comply with their duties, and for 
that reason, I am going to copy my report and your response, along with this letter, to the Minister 
of State for Justice, Mr Rob Butler MP, purely for information purposes. A copy shall also be shared 
with the family, other Interested Persons and the Chief Coroner. 

There has to be a commitment across all agencies to place bereaved families at the heart of the 
investigation process, and to seek to extract every opportunity for learning from these tragic deaths. 
I am grateful for the work you have undertaken in this regard. 

Yours sincerely 

Miss Laurinda Bower 
HM Area Coroner  
Nottingham City and Nottinghamshire