Anthony Binfield, David Richards and Rolandas Karbauskas

Miss Laurinda Bower 
HM Area Coroner for Nottingham 
City and Nottinghamshire 
The Council House 
Old Market Square 
Nottingham NG1 2DT 

Email: 

Director General of Operations
HM Prison and Probation Service
8th Floor Ministry of Justice
102 Petty France
London
SW1H 9AJ

10 June 2025 

Dear Miss Bower, 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS –  
ANTHONY BINFIED, DAVID WILLIAM RICHARDS, ROLANDAS KARBAUSKAS. 

Thank  you  for your Regulation  28  report of  7  February 2025  following  the  inquests  into  the 
deaths  of  Anthony  Binfield,  David  William  Richards  and  Rolandas  Karbauskas  at  HMP 
Lowdham Grange, which was sent to the Ministry of Justice. I am responding on behalf of His 
Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations. 

Thank you for agreeing an extension to the usual deadline for this response.  As you know 
your report raised a wide range of matters of concern and I am grateful for your understanding 
that it has taken longer than usual to bring together a full response. 

I know that you will share a copy of this response with the bereaved families, and I would firstly 
like to express my condolences for their loss. Every death in custody is a tragedy and the safety 
of those in our care is my absolute priority.  

As you are aware, at the time of the deaths HMP Lowdham Grange had recently transferred 
from  management  by  Serco  to  Sodexo,  with  HMPPS  providing  contract  management.  In 
December 2023 HMPPS, concerned re standards, stepped in and on 1 August 2024 brought 
the prison under HMPPS management and leadership.  

As heard at the inquest, the transition detailed above significantly impacted on a challenging 
recruitment picture and the low staffing levels along with a reduction in staff with a significant 
length  of  service  and  experience.  As  you  are  aware,  healthcare  staffing  is  a  matter  for  the 
healthcare provider, who have responded separately.  

 
 
 
 
 
 
 
 
 
 
 
 
 Since taking over the management of Lowdham Grange HMPPS has taken a number of steps 
to improve recruitment and retention, including the provision of additional support to the prison 
to undertake recruitment activity.   

The  site  has  been  in  receipt  of  support  from  other  establishments  in  the  form  of  National 
Detached Duty of prison officers.  They are also supported by bonus schemes that incentivise 
staff to commit to overtime hours in return for a bonus paid out at the end of a qualifying period.   

Recent recruitment marketing campaigns have included a high-profile national campaign with 
additional support provided to the Long Term High Security Estate (LTHSE), which includes 
Lowdham Grange.  This included TV and local and national radio advertising, and a range of 
digital advertising.  

As a result of this activity the site currently has a pipeline of 275 applicants at various stages 
of the recruitment process and are predicted to be close to full staffing by the end of September 
2025.  

Key to creating a stable, effective prison with a positive culture is a strong Senior Management 
Team  (SMT),  and  I  am  pleased  to  say  that  this this is now in  place,  led  by  an  experienced 
HMPPS Governor and Deputy Governor who are committed to driving improvements. The SMT 
are  overseeing  a  drive  to  create  a  skilled  and  committed  workforce,  and  with  support  from 
national resources have introduced a number of initiatives aimed at ensuring staff are able to 
meet the expectations of their role and understand the importance of doing so.  

Following the introduction of New Colleague Mentors, made up of experienced staff to support 
newly  arrived  prison  officers,  an  ‘Induction  Passport’  has  been  created.  This  document 
provides comprehensive information and guidance on the key duties of staff, as well as detail 
on  how  to  seek  support.  Alongside  the  Induction  Passport  a  ‘buddy’  system  is  in  place, 
providing new recruits with a link to a more experienced member of staff to provide support 
and guidance. Packages have also been delivered to line managers to help them  steer new 
and less experienced staff confidently and effectively. 

At a national level, as we know that sufficient and skilled frontline staffing is fundamental to 
delivering  safe,  secure,  and  rehabilitative  prison  regimes,  the  department  operates  a 
centralised  recruitment  model,  providing  targeted  support  to  prisons  with  acute  local 
recruitment problems - we continuously review our recruitment process to ensure officers are 
best suited to their role. In addition to this, HMPPS have a retention oversight process in place 
- all establishments are required to regularly review their attrition and determine local action 
supported  by a  retention  toolkit  to  tackle  their  main drivers of  attrition. We  have  invested  in 
several new initiatives to improve the experience of our new joiners and increase retention of 
our employees. 

The  identification  and management of  risk  is a  vital element  of  core  prison  officer duties.  A 
range of measures are being introduced by the SMT at Lowdham Grange to ensure risks are 

 
 
 
 
 
 
 
 identified  and  appropriately  shared  across  all  disciplines  and  agencies.  Work  is  ongoing  to 
develop a triggers database, to ensure shift handovers are effective in communicating issues, 
and to improve first night and induction processes.  

Work is also ongoing to create a positive and collaborative relationship between the prison and 
the healthcare provider, to build better working relationships and ensure all are aware of their 
responsibilities in sharing information with colleagues. It will be reinforced to staff in all areas 
that information should be shared using the relevant systems, such as NOMIS, SystmOne, and 
observation books, rather than through emails.  

The Safety Intervention Meeting (SIM) is being refreshed so that it provides a more effective 
mechanism for all those involved in the care of prisoners and to discuss those at risk, share 
information and ensure a strategic overview that pulls in all relevant information and agencies 
to  ensure  support  is  tailored  to  the  individual.  The  Governor  is  committed  to  learning  from 
deaths that have occurred and has introduced a meeting to focus on work to address issues 
raised in Reports to Prevent Future Deaths. 

At national level our policy is clear, both in Prison Service Instruction (PSI) 7/2015, Early Days 
in  Custody  –  reception  in,  first  night  in  custody,  and  induction  to  custody,  which  places  a 
requirement  on  prisons  to make use  of  all  the  information available  for the  purposes  of risk 
assessment  on  reception,  and  in  the  Prison  Safety  Policy  Framework,  which  requires  that 
Governors  put  in place  an  effective  process  to  identify  and  record  a prisoner’s  relevant risk 
information, keep this up to date as the prisoner progresses through their time in custody and 
make it accessible to all staff involved in their care. 

We know that achieving full compliance with these policies can be challenging and we continue 
to  work  with  healthcare  partners  and  others  to  support  Governors  in  implementing  them, 
including  through  the  HMPPS/NHSE  Information  Sharing  Advisory  Group  which  meets 
regularly to tackle issues in this area.  For example, we are currently working with NHSE to 
devise revised guidance on information sharing in prison reception areas, focused particularly 
on healthcare staff access to the digital Person Escort Records (dPER).   

We are also revising the training provided to prison staff deployed in reception areas to provide 
increased  focus  on  their  role  in  identifying  risk,  including  where  to  look  for  risk  information, 
details of cohorts that are known to be at higher risk and a clear warning against relying solely 
on the prisoner’s presentation when making decisions about risk levels. 

The  decision  on  how  men  move  through  the  prison  system  is  determined  by  the  National 
Allocation  Protocol  and  the  National  Offender  Flows,  and  in  line  with  the  Security 
Categorisation Policy Framework and indeterminate prisoners with the Progressive Transfers 
for Indeterminate Sentence Prisoners.  

 
 
 
 
 
 
 
 Since  Mr  Richards’  transfer  from  HMP  Chelmsford  to  HMP  Lowdham  Grange  the  way  that 
prisoners are allocated from reception prisons to appropriate category B prisons has developed 
significantly.  Now,  prisoners  with  27  years  left  to  serve  would  generally  be  allocated  to  a 
dispersal prison, particularly if it is their first time in custody and little is known about them and 
their risk to themselves and others. Where possible prisoners will be allocated to prisons close 
to their home area.  

Decisions to move prisoners between establishments must take into account a range of factors 
including the needs of the prisoner to support their progression, wider population management 
and the stability of prisons. To support this, Category B prisons can arrange transfers between 
establishments, and in the LTHSE this is done by the LTHSE population management team. 
Factors such as vulnerable prisoner (VP) status will be considered. The issues surrounding VP 
status are complex and prisoners are not managed solely based on this status. Some prisoners 
who hold VP status in one prison are able to reside safely on normal location in other prisons  
as the demographics of the population vary significantly and the risk is abated.  

While  appropriate  considerations  will  be  made  regarding  individuals’  wishes  regarding  their 
location,  in  order  to  effectively  manage  the  prison  population  and  stability,  it  is  not  always 
possible or appropriate to move prisoners to a prison of their request. Wherever possible there 
should be discussion with prisoners and where requests are denied reasons should be given 
(unless there are security or other valid consideration that prevent this). Prisoners may appeal 
through  the  prison’s  internal  appeal  process,  and  if  requests  are  still  denied,  or  were  not 
considered within 30 days, they have recourse to complain through the independent Prisons 
and Probation Ombudsman (PPO). 

You raise concerns about services for Foreign National Offenders (FNO) and the risk that 
these individuals may become isolated. HMPPS has several national policies which consider 
the needs of FNOs, including the PSIs on Early Days in Custody and Prisoner 
Communications. These policies set out the support that is available to FNOs to maintain 
contact with their family members.  

During the inquest you heard evidence concerning access to The Big Word translation service. 
The Ministry of Justice is committed to ensuring that the justice system is supported by high-
quality language services that meet the needs of all users. In 2016, Thebigword Group Ltd was 
appointed  as  the  supplier of  language  services,  specifically  spoken  face-to-face,  telephone, 
and  video  interpretation  services,  as  well  as  foreign  language-related  translation  and 
transcription services. The department’s contracts provide a robust governance structure and 
performance regime, including the monitoring of telephone interpretation to ensure compliance 
with the contracted standards. Thebigword has confirmed that their data shows no evidence 
presently of waiting times over an hour to service any calls at Lowdham Grange.  

However,  we  are  committed  to  working  with  both  suppliers  and  venues  to  investigate  any 
connectivity issues or unreasonable waiting times when raised, and  establish the root cause 

 
 
 
 
 
 of  the  issue,  as  it  may  be  that  there  is  another  issue  contributing  to  this  experience  (for 
example, equipment connectivity). 

Locally,  Lowdham  Grange  is  recruiting  for  an  FNO  manager  who  will  ensure  FNOs  are 
effectively managed and supported, as well as developing an assurance process to determine 
the use of Big Word.   

Your  report  identifies  the  significant  risk  posed  by  psychoactive  substances  (PS).  HMPPS 
recognises the risks relating to drug and alcohol use including most significantly the risk to life 
and actively works to reduce these. Evidence obtained through drug testing and intelligence 
identifies  that,  from  a  national  perspective,  the  most  prominent  drugs  used  in  prisons  are 
synthetic cannabinoids (also referred to as SCRAs/PS).  

HMPPS has a prison drug strategy that adopts a whole system approach to restricting supply 
and reducing the demand for drugs and to building recovery.  PS is often used in conjunction 
with other drugs, and as a result our strategy sets out a set of principles and actions that are 
sufficiently flexible to apply across the estate, rather than a drug-specific approach. As the risk 
and impact of drug and alcohol use is variable between prisons it is the responsibility of each 
prison to understand local risk and develop local strategies to ensure the risks are identified, 
understood, and effectively managed.   

However,  to  ensure  staff  understand  the  risks  specific  to  PS  use,  an  eLearning  package  is 
available for all staff to access. This course has been designed to increase awareness of the 
types of synthetic cannabinoids: understanding their effects, how to deal with them and where 
to signpost for support to assist staff in reducing the demand for these substances, managing 
the associated risks and promoting recovery from dependency.  

In addition to this the HMPPS Drug and Alcohol Operational Framework (an internal guidance 
document published in January 2025) has been designed to support frontline staff in their day-
to-day work. It emphasises the importance of taking a person-centred approach when working 
with  people  who  use  drugs  and  alcohol  to  support  individuals  to  access  the  treatment  and 
recovery support they need.  

At Lowdham Grange the drug strategy is overseen at a monthly meeting attended by senior 
leaders and operational managers, and there are two dedicated drug strategy officers in place. 
Supply restriction measures include work to prevent drone drops, body scans for prisoners, 
and a network of security liaison officers are on each houseblock to ensure that information on 
those organising and using illicit items is passed on. Future plans include the installation of 
windows that will prevent the entry of parcels and a publicity programme to raise awareness in 
the community of the drone problem and to encourage the reporting of suspicious behaviour.  
The local drug strategy also includes various measures to reduce demand, enable recovery 
and reduce harm.  These include a video on the dangers of synthetic opioids that was created 

 
 
 
 
 
 
 in  house  and  is  played  on  the  in  cell  TV  system  and  the  availability  of  naloxone,  with  staff 
trained in its use. 

As stated at the inquest, we are committed to learning from the experience of the transfer of 
Lowdham Grange from one provider to another to inform subsequent competitions for contracts 
and their mobilisation, and a number of changes have already been made in response.  

Future competition documentation has been amended to add requirements to develop a culture 
plan to ensure there is a clear focus from operators on assessing and building on the existing 
culture  at  a  prison.  Additionally,  future  competitions  will  see  increased  weighting  in  the 
evaluation  for  the  response  on  safety,  and  all  bidders  are  now  required  to  submit  a  safety 
response which outlines how the supplier intends to understand, identify, monitor and review 
safety risks and achieve their intended outcomes.  

To  assist  bidders  with  a  better  understanding  of  the  prison  at  the  point  of  competition,  the 
project now provides a Current Regime and Services document as part of the Prison Specific  
Competition  Data  Room.  This  amalgamates  previous  disparate  pieces  of  information  and 
provides more detailed data, so bidders have a clear overview of all aspects of the prison. The 
project has also introduced an improved process for operating procedures from HMP Altcourse 
mobilisation  onwards,  which  assists  incoming  Operators  in  identifying  current  processes  in 
place and provides them with clear templates and guidance to streamline the process. 

Improvements have also been made to the mobilisation process as a result of the findings of 
this inquest. Timelines for submission of key mobilisation documents such as local operating 
procedures have been revised to enable a new operator to stagger activity and keep focused 
on operations and critical systems in the lead up to handover and a staff communications toolkit 
has been developed to ensure alignment of messaging between all parties.  

The Mobilisation Blueprint was updated to provide further information about the expectations 
of what activity should take place in each phase to ensure bidders understand what the priority 
is for each phase and include realistic timelines for their activity in their plans.  

Visits  to  expiring  private  prisons  have  been agreed  with  the  HMPPS  National  Safety  Group 
during the mobilisation stage, focusing on  the early days processes including reception, first 
night and induction, with a follow up visit during the transition period. The Safety Group share 
their findings via a report to the site to ensure all parties are aware of what areas need focus.  

We have also agreed with the Performance, Assurance, Risk (PAR) Group to conduct Safety 
Audits  at  these  sites,  closer  to  the  mobilisation  period.  The  Safety  Audits  are  usually 
unannounced, however, given the challenging nature of transferring a site from one Operator 
to another, we have agreed that these safety audits are carried out 6 – 9 months prior to expiry 
for  these  sites  (the  incumbent  operator  still  won’t  be  notified  prior  to  them  going  in).  Final 

 
 
 
 
 
 
 
 Reports and recommendations for the incumbent will be shared with the Private Prison Expiry 
Team and Controller Team to help inform key areas of focus and provide recommendations.  

Your report references the role of Controllers within the contracted estate, particularly in the 
context of learning from deaths in custody.  

The role of the Controller within contracted prisons is vital and is responsible for ensuring the 
establishment operates in line with the contract and to HMPPS standards, and for overseeing 
the processes related to learning from deaths within the private prison estate. This includes 
ensuring that all action plans created following a death are reviewed systematically and 
thoroughly and that the implementation of recommendations is overseen by physically testing 
processes in the prison and reporting on compliance against prison service policy 
frameworks. Controllers work closely with the providers and local Safety teams to ensure that 
changes are made to prevent future deaths and improve care quality and are responsible for 
applying necessary contractual action as required to drive continuous improvement. 

To assure themselves that the provider is learning from deaths, Controllers  conduct  regular 
compliance  and  assurance  testing  of  the  prison’s  safety  strategy  and  processes  to  ensure 
compliance with national guidelines and internal policies. These checks help verify that lessons 
learned are being effectively integrated into practice. Controllers have established governance 
structures  where  findings  from  assurance  are  discussed,  promoting  a  culture  of  continuous 
learning  and  improvement.  Controllers  are  also  responsible  for  monitoring  the  impact  of 
implemented changes through ongoing evaluation. They track the provider’s performance and 
outcomes  to  assess  the  effectiveness  of  actions  taken  and  make  further  offers  of  support 
and/or required challenge to the providers where adjustments are needed.  

By fulfilling these responsibilities, Controllers play a crucial role in ensuring that our provider is 
not only learning from deaths but also continuously improving the quality of care provided to 
prisoners. 

More generally HMPPS is committed to learning from all deaths and to taking action to address 
any issues that are identified as a result.  The Follow-up to Deaths in Custody policy framework 
describes  the  early  learning  review  process  for  all  apparently  non-natural  deaths,  through 
which cases are reviewed by the group safety lead and the resulting report considered by the 
Governor,  the  Prison  Group  Director  and  the  National  Safety  Group.  It  also  explains  our 
commitment to supporting the various independent investigation processes that follow a death 
and particularly to meeting our duty of candour, including by disclosing all relevant documents.  

The National Safety Group uses PFD reports alongside other sources of learning to identify 
themes  to  inform  improved  guidance,  regular learning  bulletins  and  the  development  of our 
approach  to  prison  safety  more  generally.    These  themes  are  also  discussed  at  regular 
meetings of group safety leads who share the learning with the prisons in their groups.  

 
 
 
 
 
 
 
 I am sorry that there were delays in the disclosure of material during these inquests.  We have 
reviewed  the  handling  of  the  inquests  with  Government  Legal  Department  (GLD)  and  we 
believe that this was the result of the unusual circumstances of this case, which had a broad 
scope that reached into areas that are not commonly subject to such investigation. The Follow-
up  to  Deaths  in  Custody  policy  framework  sets  out  very  clearly  the  requirement  to  retain 
documents relevant to the death and specifically notes that there may be a considerable delay 
between  the  death  and  the  inquest,  and  that  the  coroner  may  ask  for  documentation  not 
requested by either the police or the PPO, pointing out that it is therefore crucial that prisons 
retain all documentation available. In the vast majority of cases prisons are complying with this 
guidance and it is proving sufficient to meet the needs of coroners. 

I am committed to a culture of transparency and openness throughout the organisation’s work 
and this extends to our participation in all investigations into deaths in custody.  It is vital that  
individual staff and the organisation is able to reflect on their actions and admit where failures 
have occurred. At an inquest, this approach is reflected in ensuring staff at all grades and in all 
circumstances are aware of our duty of candour and give their evidence honestly.  

To date we have considered this approach to meet our duty of candour and have not routinely 
sought to make formal admissions in the way that you have advocated. Rather it has seemed 
appropriate to us to allow the jury to make their findings based on the evidence, as elicited by 
the Coroner and the representatives of the interested parties. Not making formal admissions 
in the context of the inquest does not imply any reluctance on our part to acknowledge failures 
or any lack of will to learn from them.  

Following this inquest and the concerns that you have expressed about this approach we will 
review and consider this position with GLD and Counsel. If you have further thoughts on this 
issue that you believe would be useful for us to consider during this process we would be very 
glad to hear them.  

Thank you again for bringing your concerns to my attention. I trust that this response provides 
assurance regarding ongoing work at HMP Lowdham Grange.  

Yours sincerely, 

Director General of Operations

Miss Laurinda Bower  
HM Area Coroner 
Nottingham City and Nottinghamshire  
Coroner’s Service  
The Council House 
Old Market Square  
Nottingham  
NG1 2DT  

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

3 April 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Anthony Binfield, David 
William Richards and Rolandas Karbauskas who died at HMP Lowdham 
Grange between the dates of 6 and 25 March 2023 

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  7 
February 2025 concerning the deaths of Anthony Binfield, David William Richards and 
Rolandas  Karbauskas  on  6,  13  and  25  March  2023  respectively.  In  advance  of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to  the families and loved ones of Anthony, David and Rolandas. 
NHS England are keen to assure the families and the Coroner that the concerns raised 
about their care have been listened to and reflected upon.   

I have responded to the concerns raised that sit within NHS England’s remit below.  

1. Recruitment, retention and training of prison and healthcare staff  

Providers of adult healthcare within the prison estate in England experience the same 
types of recruitment and retention workforce issues that are experienced by acute and 
community services. 

However, vacancy rates within the prison estate are significantly higher, which can be 
due  to  the  perceived  risk  and  stigma  attached  to  prison  environments,  and  these 
unfilled  vacancies  can  increase  pressures  on  existing  healthcare  and  prison  staff, 
leading to elevated levels of stress, high turnover and increased absenteeism.  

To help address workforce demands within prisons, nursing within the criminal justice 
system (CJS) needs to be widely promoted as a career option and NHS England is 
supporting  this  promotion  with  the  ‘We  Are  Prison  Nurses”  campaign  and  nursing 
preceptorship  (a  period  of  structured  transition  where  newly  qualified  nurses  are 
supported by an experienced practitioner).  

The ‘We Are the NHS” recruitment campaign has been in operation since 2018 and 
was developed with the aim of increasing positive perceptions of, and pride in, working 
for the NHS across a diverse range of roles. It aims to motivate target audiences to 
undertake a career in the NHS including nursing, the Allied Health Professions and as 
Healthcare Support Workers (HCSWs). 

                                                                                                                       
 
 
 
 
 
  
 
 
 
 
 
 
 
  
 To  target  support  on  recruitment  into  prison  healthcare  and  retention  of  healthcare 
staff, NHS England’s  National Health and Justice Team undertook a programme of 
work  alongside  the  ‘We  Are  the  NHS’  campaign,  specifically  relating  to  prison 
healthcare  which  forms  the  basis  of  the  ‘We  Are  Prison  Nurses”  campaign.  This 
campaign started in December 2023 and targets student nurses to encourage them to 
consider  a  career  in  prisons,  by  increasing  awareness  of,  and  exposure  to,  prison 
nursing roles. The campaign toolkit contains a wide range of resources designed to 
support providers and employers with the recruitment of nurses into prison healthcare 
services: We are Prison Nurses | We Are The NHS | Campaign Resource Centre. 

In  February  2024,  NHS  England  also  published  the  ‘Nursing  preceptorship  in  adult 
prison healthcare – best practice guidance’. Preceptorship is a period where all newly 
qualified practitioners are given guidance and support in their transition from student 
to autonomous practitioner. 

A good preceptorship programme undertakes the following: 

•  Effectively  supports  newly  qualified  nurses  to  become  competent  and 

confident practitioners 

•  Ensures nurses and nursing associates feel valued by their organisation and 

have a positive experience during their first 12 months. 

•  Enhances patient care and experience. 
•  Supports organisations to recruit and retain registered nursing staff.  

The best practice guidance is designed to support staff and organisations in the design 
and  delivery  of  effective  preceptorship  programmes  within  adult  prison  healthcare 
services.  It  is  also  for  registered  nurses  who  are  new  to  prison  healthcare.  The 
guidance  ensures 
these  professionals  understand  how  an  evidence-based 
preceptorship programme can support, develop, and value them in their first year of 
clinical practice.  

To  support  the  quality  performance  assurance  and  oversight  of  prison  healthcare 
providers, there are quality measures in place. The measures identified and included 
are  aligned  to  standard  NHS  contract  quality  measures,  to  ensure  consistency  in 
approach, while avoiding increasing the burden of any reporting.  

Recent data from quality schedules indicates a noticeable increase in compliance with 
mandatory  training  at  HMP  Lowdham  Grange.  This  is  monitored  closely  through 
contract review meetings (CRM) with clinical quality oversight.  

CRMs take place for each site every quarter and review the performance and quality 
(covering safety, effectiveness, and experience) of healthcare services commissioned 
within prison settings, based on key indicators. There will be agreement of remedial 
actions where required.  

Quality and performance (Q&P) meetings also cover the clinical quality of the contract 
monitored  under  the  NHS  England  Direct  Commissioning  Assurance  Framework. 
Review  meetings  and/or  clinical  quality  site  visits  are  determined  by  the  level  of 
surveillance  required.  By  exception,  clinical  quality  representatives  from  both 

 
 
 
 
 
 
 
 
 organisations may be invited to attend the Q&P meeting to discuss any quality related 
matters arising that require in depth review. 

There  is  also  a  monthly  Rapid  Improvement  Group  (RIG)  meeting.  The  RIG  is  an 
improvement methodology where an intense improvement activity occurs over a short 
period.  It  is  hoped  that  this  approach  will  bring  about  a  significant  improvement  in 
performance that can encompass a small number of different work teams or processes 
without a high degree of complexity. This relies on the fact that the participants, who 
do the job every day, are the people best placed to identify process improvements. 
The  methodology  identifies  the  change  required,  offers  solutions,  and  allows 
participants  to  plan the actions required  for  implementation.  NHS  England  provides 
oversight from both commissioning and quality perspectives, with additional support 
for the Trust from NHS England’s improvement teams. 

Healthcare  services  are  commissioned  based  on  patient  need  and  there  should  be 
equivalence to services available in the community. Healthcare services outside of the 
core  working  day  are  commissioned  by  Nottingham  &  Nottinghamshire  Integrated 
Care System (ICS). In January 2018, 24-hour healthcare was implemented when there 
was an escalation in the use of psychoactive substances at HMP Lowdham Grange 
and  this  was  continued  as  a  response  to  the  Covid-19  pandemic,  to  reduce  the 
healthcare impact on the wider health community. 

In September 2022, a Health Needs Assessment focused on the provision of 24-hour 
healthcare across the prison estate in the East Midlands was undertaken. The findings 
for HMP Lowdham Grange did not support continuation of this service, with funding 
invested to support a longer core day to enable patients to access healthcare services 
prior to the prison entering night state. 

2. A  complete  failure to  identify and  share  risk  pertinent  information  between 

prison and healthcare staff, and within those teams  

I recognise that effective information sharing is essential to support the ongoing care 
provided  to  patients  across  the  whole  of  the  CJS  and  information  sharing  is  most 
important when an individual is managed by both healthcare and secure estate staff.  

All staff have a common interest in the wellbeing of patients, reducing risk, keeping 
them safe and treating them appropriately, which requires routine information sharing. 

In 2023, NHS England’s national quality function for health and justice developed the 
Information  Sharing  Position  Statement 
(ISPS).  This  supports  a  common 
understanding  between  NHS  England  and  partners  across  the  CJS  about  patient 
confidentiality and the sharing of health information (UK GDPR) which is considered 
more sensitive and therefore amounts to ‘special category’ data. 

The ISPS sets out NHS England’s position on information sharing and consent and 
supports healthcare staff to make decisions about sharing information.  

The  ISPS  only  relates  to  the  general  and  routine  sharing  of  health  information  for 
purposes connected with the care of individuals in the CJS and is not intended to cover 
the sharing of health information in situations where there is an urgent need to share 

 
 
 
 
 
 
 
 
 
 information for the purposes of providing care, or where there is a safety risk to either 
an individual  or  others.  In  all cases where  there  is a safety  risk,  local safeguarding 
processes should be followed. 

Additionally,  there  are  several  platforms  locally  to  enable  effective  sharing  of 
information.  These  are  morning  briefings,  through  CRMs  as  mentioned  above  and 
local  delivery  boards  (LDB).  Oversight  from  the  clinical  quality  team  at  CRMs  will 
inform quality visits to ensure information sharing is embedded in practice.  

The findings, information and any learning from this Report will be tabled at a future 
NHS England Health and Justice Delivery Oversight Group (HJDOG). The HJDOG is 
the senior leadership forum, which holds responsibility for the oversight of delivery and 
continuous improvement in Health and Justice commissioned services, through both 
national and regional teams. All Health and Justice related Reports to Prevent Future 
Deaths  are  shared  and  discussed  at  the  HJDOG,  and  assurance  is  sought  from 
regions where learning and action is identified.  

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking place around the Reports to Prevent Future Deaths. All reports received are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures  that  key  learnings  and  insights  around  events,  such  as  the  sad  deaths  of 
Anthony,  David  and  Rolandas,  are  shared  across  the  NHS  at  both  a  national  and 
regional level and  helps us to  pay close attention to  any emerging trends  that  may 
require further review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director

Chief Executive Office 
Highbury Hospital 
Highbury Road 
Bulwell 
Nottingham 
NG6 9DR 

E-mail:
Line 

4 April 2025 

Private and Confidential 
HMC Bower 

Dear HMC Bower  

Further  to  the  Joinder  Inquest  into  the  death  of  Anthony  Binfield,  David  William  Richards  and 
Rolandas  Karbauskas,  I  write  on  behalf  of  Nottinghamshire  Healthcare  NHS  Foundation  Trust  in 
response to the Prevention of Future Deaths Report issued on 7 February 2025. 
.  
All three men died as a result of self-inflicted injuries in March 2023 while in state detention at HMP 
Lowdham Grange, within a 19-day period of one another. 

We  accept  the  inquest  conclusion  and  would  like  to  assure  you  that  we  take  the  findings  very 
seriously.  Please see the following, in which we detail the actions we have taken to improve patient 
care and experience subsequently to the inquest.    

The Inquest conclusion identified that there was a complete failure to identify and share risk 
pertinent information between prison and healthcare staff, and within those teams: 
More specifically, there was a concern in relation to risk identification and information sharing, Prison 
and Healthcare staff did not routinely consider information captured within the electronic systems, 
nor did they update the systems with risk pertinent information gathered during interactions with the 
prisoners. The Trust is committed to being compliant with PSI 64/2011 “All staff who have contact 
with  prisoners  must  be  aware  of  the  triggers  that  may  increase  the  risk  of  suicide,  self-harm  or 
violence, and take appropriate action.” 

Improvement  oversight  for  Offender  Health  and  HMP  Lowdham  Grange  -  The  Trust  has 
established  enhanced  Executive  led  oversight  and  assurance  reviews  for  Offender  Health.  This 
comprises  a  weekly  meeting  where  progress  against  the  Transformation  Plan  is  reviewed  with 
individuals held to account.   

The update against the required actions for this PFD will be reviewed as part of this process. 

Reception screening: A new national template for prison reception screening for the male prison 
estate was launched on the 1 April 2025.  Staff are in the process of receiving the Nationally delivered 

Highbury Hospital, Highbury Road, Nottingham, NG6 9DR 

 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
  
 
 training  for  this  and  the  benefits  include  a  standardised  and  simplified  model  of  screening  which 
enable the understanding and recording of previously documented clinical risk which needs to be 
further considered as part of the reception and induction process.  

Part of the reception screening is the ability to access a digital Person Escort Record (PER).  This is 
a prison document which follows the prisoner journey through their custodial sentence and contains 
risk pertinent information.  There is no ability to audit this access however, the supervision proforma 
for the clinical staff in reception will be amended to ensure it forms part of the supervision record.   

The Head of Safer Custody has introduced a new Early Days in Custody (EDIC) booklet along with 
colleagues  from  Reception  and  the  Induction  wing.    This  booklet  has  now  been  in  place  for  one 
month and contains a section for healthcare staff to complete, identifying any immediate risks that 
the  individual  may  present  with  and  including  any  historical  information.  Ideally  the  document  is 
completed in reception and follows the patient to the induction unit.   The Officer in charge of the 
induction unit will meet with the Head of Healthcare to audit the use of the EDIC forms on a monthly 
basis to enable ongoing quality improvement as required.   

Safety Interventions Meeting (SIM): We have worked with Prison colleagues to ensure that SIMs 
are attended on a weekly basis by a member of the Mental Health Team. This meeting is to discuss 
any  patients  of  concern  and  highlight  any  specific  issues  relating  to  that  individual.  A  Prison 
safeguarding referral form (Annex Q) is now in use and concerns can also be raised online via the 
DPS  system.    A  random  spot  check  of  attendance  and  the  quality  of  information  shared  will  be 
randomly reviewed by the Head of Healthcare at HMP Lowdham Grange. 

CSIP: Patients can also be referred to CSIP (Challenge, Support and Intervention Plan).  This is a 
prison risk management system and process that will enable information sharing on risk in the prison 
estate and also support the development of cross professional relationships.  Healthcare staff are 
currently accessing the training for this, and full compliance is aimed to have been achieved by June 
2025. 

Training - Healthcare staff have arranged to attend the Prison staff induction programme so that 
they  can  deliver  health  training  to  the  Prison  Officers.  Initially  this  will  be  focused  on  emergency 
response  but  will  later  include  Mental  Health  awareness  training.  This  was  agreed  at  the  Local 
Delivery Board and the first session was provided on 23 January 2025. Feedback from staff was 
very  positive.  Healthcare  staff  will continue  to  receive  clinical  risk, self-harm  and  suicide  training, 
which is an inhouse training programme.  Compliance will be achieved by July 2025.   

Discussions have taken place with the Head of Residential Services to discuss how appropriate risk 
pertinent information can be shared on the wings as part of effective information sharing with prison 
colleagues.  Systems such as identifying clinical risk by adding a coloured dot to their name on the 
wing prisoner list are being scoped.   Healthcare staff have been informed that they must document 
in  the  wing  observation  book  any  relevant  risk  pertinent  information  to  alert  staff  to  any  potential 
issues.  Again, this will be audited and reviewed for quality by the Head of Healthcare and Safer 
Custody Officer. 

ACCT:  Assessment,  Care  in  Custody  and  Teamwork  processes  are  being  managed  through  a 
booking process with advance notification. All first ACCT reviews are attended by a registered nurse 
in  line  with  the  ACCT  process.    Subsequent  follow  up  reviews  are  attended  where  possible  or 
prioritised  based  on  clinical  risk  and  need.    Phone  and  email  contributions  are  also  supported  if 
required.  The process of our ACCT attendance and contribution will be reviewed as part of the safer 
custody process to ensure the quality is as desired and required.   As part of the ACCT process 

Highbury Hospital, Highbury Road, Nottingham, NG6 9DR 

 
 
 
 
 safety  plans  should  be shared  with  the  Patient  and  with  prison  colleagues  with  escalation  routes 
identified.    This  will  be  reviewed  and  audited  by  the  Head  of  Healthcare  as  part  of  local  quality 
assurance processes.  

Healthcare  daily  handover:    Daily  attendance  at  the  prison  morning  meeting  handover  should 
provide any risk information at the start of the day that may have occurred overnight.  This information 
is then cascaded for action to the Healthcare Team as required.    

The healthcare team have a daily lunch time handover which is designed to capture any matters of 
concern, risk or escalation.  Where appropriate, this should be recorded in the S1 record.  A brief 
note  of  the  risk  should  be  recorded  in  the  meeting  record  along  with  person  responsible  for 
management.  

Email: Healthcare has generic email inboxes which are monitored daily by administrative staff which 
have been provided to the wings as a first point of contact for non-urgent issues. This includes a 
mailbox for each clinical pathway. A reminder has also been sent to Prison staff via the Governors 
secretary,  to  the  wings,  of  the  mailbox  addresses  and  call  signs  on  the  radio  for  contacting 
healthcare. No personal emails should be used for patient related queries.  
I hope this information provides assurance that we have and continue to consider the points 
identified very seriously, and that we are actively seeking to improve the services we provide by 
implementing the actions outlined 

Yours sincerely 

Chief Executive Officer 

Highbury Hospital, Highbury Road, Nottingham, NG6 9DR

serco

Ms Laurinda Bower

HM Area Coroner

ottingham City and Nottinghamshire
The Council House

Old Market Square

ottingham

G1 2DT

Dear Ms Bower,

03 April 2025

Thank you for your Prevention of Future Death Report ('PFDR’) dated 7 February 2025 following the conclusion
of the inquests into the deaths of Mr Binfield, Mr Richards and Mr Karbauskas who all sadly died in March 2023 at
HMP Lowdham Grange.

am responding on behalf of Serco to matters of concern that you have raised in the PFDR, in so far as they relate
o Serco. | am aware that you will share a copy of this response with the families of Mr Binfield, Mr Richards and
Mr Karbauskas and | would like to express my sincere condolences for their loss. Every death in custody is a
ragedy, and the safety of those detained in our prisons is our absolute priority.

am grateful to you for bringing the matters of concern to my attention and have responded to the issues below:
Failure to identify and share risk pertinent information between prison and healthcare staff.

Over the many years that we have been operating prisons on behalf of the MOJ, Serco has established and
maintained excellent working relationships with the various Healthcare providers commissioned by NHS England
o provide Healthcare provision within the prisons we manage. In the prisons that we manage on behalf of the
Ministry of Justice, the Heads of Healthcare meet regularly with the relevant prison Director and the HMPPS
Controller, and they attend our daily Senior Management Team (SMT) morning meetings, so they are able to
engage with the SMT and raise any issues of concern on behalf of their own management team and staff. For
hose prisoners who have been identified as being at risk of self-harm and suicide members of the relevant
Healthcare team are invited to ACCT Case Review and they give invaluable input to assist us in keeping the men
in our care safe. Our staff are also aware of the need to liaise with Healthcare staff and make appropriate referrals
o Healthcare or signpost prisoners to do so. However, as you will be aware, due to medical confidentiality
requirements, custodial staff are not permitted to access the healthcare IT system, System One. As a result, we
rely on healthcare staff communicating any risk pertinent information to custodial staff or our Safer Custody
Departments if and when they feel that medical information, or information disclosed by prisoners which may be
relevant to their risks come to their attention.

As you will appreciate many prisoners have multi-facetted issues including substantive histories of suicide
attempts and self-harm, physical and mental health issues, substance misuse issues, and debt. Assisting them in
managing such issues can be very challenging, particularly when, for whatever reason a prisoner feels unable to
disclose their concerns to either healthcare or custodial staff. As you will no doubt appreciate, when used
correctly, PNOMIS is an invaluable tool for recording and checking risk pertinent information for the prisoners in
our care, particularly as it contains information from previous establishments. Previous ACCTs can also be very
valuable. However, in many cases the PNOMIS account is very lengthy and if a prisoner has been on numerous
ACCTs in a previous prison, the old ACCTs (if closed) may not be received with the prisoner, and even if they are,
they are often too voluminous for staff to review meaningfully. This is particularly the case in local remand prisons,
given the high number of new prisoners arriving daily, many of whom have a substantial history of self-harm
and/or suicidal ideation. In addition, often the risks detailed in old ACCTs are not still relevant at the time a

Serco Justice & Immigration Impact

Serco House, 16 Bartley Wood Business Park, Bartley Way, a better
Hook, Hampshire, RG27 9UY United Kingdom

T: +44 (0)1256 745 900 | www.serco.com futu re

No. 2048608
ss Park, Bartley Way, Hook, Hampshire RG27 9UY, United Kingdom

Serco Lin

<a company registered in England
Serco House, 16 Barth

serco

prisoner is transferred as individuals’ risks can change with their circumstances. Unfortunately, due to resource
constraints, it is not always possible for staff to fully review PNOMIS or old ACCTs, although the expectation would
be that staff prioritise these tasks for prisoners who have only recently been on an ACCT or are on an ACCT at the
time of their arrival. Of course, any risk pertinent information should be communicated to the Safer Custody team
ona prisoner's arrival, so that necessary steps can be put in place to keep that prisoner safe. Serco staff are always
encouraged to record all risk pertinent information and to share this information with each other (via handovers
and wing observations books), with Safer Custody and with Healthcare, where applicable, by telephone or email.
Your concern regarding email being used to communicate with specific members of the healthcare team is also
noted, and | have requested a review of the practice used across the Serco estate to ensure that staff are not just
communicating with specific email addresses, in case the individual to whom the emails are addressed are not on
shift.

Failure to learn from deaths over many years.

By way of background, | can confirm that Inquests relating to deaths of prisoners in Serco's custody are managed
by our in-house Inquest Solicitor. She works closely with the staff and management of the prisons Serco manage,
and particularly with the Heads of Safer Custody. Her role includes reporting to me, the Serco Justice and
Immigration Director, Prison Directors and Prison Heads of Safer Custody throughout the Inquest process, starting
upon notification of a death right through to the inquest conclusion and beyond. She liaises with the Prison
Directors and Heads of Safer Custody to ensure that swift and comprehensive action is taken to remedy any issues
identified following a death in custody, not only in the prison where the death occurred, but across our custodial
estate.

Our Inquest Solicitor reports to and attends quarterly Safety Forum meetings, along with the Heads of Safer
Custody and members of the Serco Psychology Team for each prison. These pan custodial meetings are chaired
by the Head of Prisons and Immigration Removal Centres and a Serco Prison Director. Our Inquest Solicitor
reports on issues arising from investigations, PPO reports and Inquests, so that a full and frank discussion can take
place to ensure that learnings are cascaded, and relevant changes/improvements put in place and are rolled out
across the estate.

am aware of your concern that following previous deaths in custody, learnings do not appear to have been fully
embedded operationally by staff ‘on the ground’; this is also a concern for me, particularly when | learned during
hese Inquests of the ‘cultural issues’ at Lowdham Grange prior to and after the handover of the prison to Sodexo.
As you will no doubt be aware, some of the issues identified during these Inquests are issues that are repeated in
other Inquests involving deaths in custody across the prison estate, not just in Serco-run prisons. Sadly, some of
he issues relate to the most basic requirements upon PCOs such as ensuring that proper checks are completed
o ensure that prisoners are safe at roll counts and welfare checks, the covering of observation hatches is
challenged, and that risk pertinent information is properly recorded in PNOMIS.

am aware that the jury made findings that IT issues, poor staffing levels, and several cultural legacy issues
contributed to the deaths of all three prisoners and that many of the issues have been raised in previous cases at
Lowdham Grange. | note and share your concern that lessons have not been fully learned from previous deaths
in custody. However, it is my understanding that the vast majority of the staff confirmed in evidence that they were
aware of the correct processes, and had received training on the issues, but could either not specifically recall the
detail of such training or re-training, or simply failed to follow the correct processes, despite being aware of them.
tis my understanding that several middle managers at the prison also accepted during their evidence that it was
not only their responsibility to ensure that PCOs were following the correct processes, but that they failed to do
so. Serco is grateful to you for alerting us to this issue, and we are taking steps to ensure that staff in middle
management positions are fully tasked with ensuring that more junior staff are not only aware of the numerous
prison processes, are regularly reminded of them, and that managers ensure that the processes are consistently
followed and enhanced quality control checks are put in place.

As you will be aware, staff receive training in the initial training course and are regularly reminded of issues
identified as requiring updates. Traditionally notices to staff and Toolbox Talks have been utilised to remind staff
of the requirements, but | share your concern that the message is not fully ‘landing with staff’ and unacceptable

serco

practices persist. In light of the concerns that the issues identified, and remedial actions are not fully embedded
across our estate we have recently created a new role of Pan Custodial Safety Lead and appointed an Assistant
Director with extensive operational experience. She is responsible for driving the safety and well-being of
individuals across all custodial sites by leading initiatives that improve outcomes related to self-harm, suicide,
violence, and debt. She will assist in chairing the Safety Forum meetings and will liaise with the Inquest solicitor,
to ensure that lessons are learned and that improvements are fully embedded operationally following review of
investigations, PPO reports, Inquests and any PFDRs issued in the future. Serco sees her appointment as bridging
the gap between the legal team and the operational issues, and it is certainly intended that her appointment will
assist in ensuring that lessons can be fully embedded following all future deaths and Inquests.

As you may also be aware Serco has introduced initiatives across our prison estate, above and beyond the safety
measures required by HMPPS, as a direct result of learnings from previous deaths, which we believe assist staff in
keeping the men in our care safe. Examples of this are ‘Under the Influence’ processes trialled in some of our
prisons and ensuring regular welfare checks are embedded in the prison regimes. We are also in the process of
establishing a joint operational forum with other private providers - to identify common operational issues and
share good practice and lessons learned to assist in keeping the men in our care safe.

| can assure you that Serco will continue to learn lessons from deaths of prisoners across our estate, and we are
continuing to strive to ensure that all remedial actions are embedded operationally, which will continue to be

monitored by our Pan Custodial Lead.

A failure to act with candour when engaging in post-death investigations.

As Serco no longer operated the prison at the time of the deaths of Mr Binfield, Mr Richards or Mr Karbauskas,
we did not receive any official notification of their deaths and initially the only information known to Serco was
that published in the press. We were not made aware that there were issues with the transfer of the prison which
could potentially have impacted on the deaths of the three prisoners until your office notified us. As we no longer
managed the prison when the deaths occurred, we were not entitled to see any documentation relevant to the
three prisoners nor were we entitled to contact any staff involved in the deaths, as by that time they were Sodexo
employees. It was therefore not possible for Serco to carry out investigations into the deaths to ascertain whether
there were any issues which we could assist you with.

Once Serco had been granted IP status, our Inquest solicitor attempted to collate any relevant information and
documentation to assist you in your investigations. As | understand was made clear during the Inquests, there
were some technical issues during the transition to Sodexo, which resulted in difficulties in various documents
being located, for which | apologise.

In relation to the issue of candour, | understand that several issues, including certain points of culture, only came
to light during the oral evidence of the various witnesses through questioning from you, and were not fully
detailed in the written statements disclosed before the Inquest commenced. In addition, the facts that all three
men died after the transfer of the prison to Sodexo, that two of the men arrived at the prison after the transfer and
our lack of visibility of issues prevailing in the prison after the transfer, led to inevitable difficulties in Serco being
in a position to make admissions, to assist the jury by limiting the issues they were required to consider. However,
| understand that the senior Serco leaders who gave evidence did make appropriate concessions during their
evidence. | can however provide an assurance that in similar cases in other jurisdictions the issue of candour is
fully considered and, where appropriate, admissions are considered and made.

In addition to the issues you have raised in you PFDR, given some of the issues aired during the cluster Inquests
we have made a commitment to undertake a ‘lessons learned’ exercise with the MOJ and Sodexo, facilitated by
the Cabinet office to identify aspects of the transition that went wrong, with a view to production of a Transitions
Playbook for future use

serco

Thank you again for bringing your concerns to my attention. | can assure you that Serco is fully committed to
keeping the often-vulnerable men on our care safe and well and | hope you are reassured by this response to the

issues raised .

If | can be of any further assistance, please do not hesitate to contact me.

Yours faithfully

Managing Director, Justice & Immigration
Serco UK & Europe

Miss Laurinda Bower 
HM Area Coroner, for the coroner area of Nottingham City and Nottinghamshire 
The Council House 
Old Market Square 
Nottingham  
NG1 2DT 

4 April 2025 

Dear Miss Bower 

Cluster Inquests into the deaths of Anthony Binfield, David Richards and Rolandas 
Karbauskas 

Thank you for your Regulation 28 Report, issued following the inquest into the deaths of Anthony 
Binfield, David Richards and Rolandas Karbauskas at HMP Lowdham Grange. As you know 
Sodexo Limited took over the operational management of HMP Lowdham Grange on 16 February 
2023, with these deaths occurring on day 18, day 25 and day 37 of the contract commencement.  

Your Regulation 28 report raises 8 numbered concerns, and we have adopted your numbering to 
respond to the two specific concerns directed to Sodexo and others:  

2 
A complete failure to identity and share risk pertinent information between prison and 
healthcare staff, and within those teams (response required from Minister for Prisons, NHSE, 
Serco, Sodexo and Nottinghamshire Healthcare NHS Foundation Trust).  

Sodexo recognises the importance of prison staff capturing and recording risk pertinent 
information.  Whilst Sodexo no longer operates HMP Lowdham Grange, it does operate five 
prisons in England and is able to respond to your concerns on that basis.  

Sodexo complies fully with Early Days In Custody – Reception In, First Night In Custody, And 
Induction To Custody (PSI 07/2015 PI 06/2015, Re-issue date 4 November 2024). As part of this 
compliance, Sodexo routinely operates the following information sharing systems across its 
prisons: 

-  Suicide/Self Harm Warning (SASH) forms are shared with the Reception Nurse 

-  ACCT training is made available to all Healthcare staff, jointly with prison staff, including 

training on triggers and scenarios indicating when an ACCT should be opened 

-  Healthcare staff are invited to attend the following meetings alongside prison staff, where 

cases of concern are discussed. These meetings include  

Sodexo Legal Services, One Southampton Row - London - WC1B 5HA 
Tel.: 0161 872 4781 
Sodexo Limited – No 842846 – England – Registered Office – One Southampton Row – London – WC1B 5HA 
www.sodexo.com 

 
 
 
 
 
 
 
 
 
 
 
 
 
 o  Senior Staff morning meeting, including the Prison Director and Head of Healthcare. 
Within this meeting, prison staff present information about prisoners of concern 
following incidents or receiving of intelligence reports. 

o  Weekly Safety Intervention Meeting (SIM). Attendance includes physical healthcare, 

mental health staff and psychology 

o  Monthly Safer Custody Meeting 
o  Complex case meetings, ad hoc, focusing on prisoners of concern 
o  ACCT reviews 
o  Briefings on each prison wing at each shift change. Staff concerns (prison or 

healthcare staff) are recorded in Wing Observation Book. Staff at all Sodexo prisons 
have been reminded of the importance of recording concerns in NOMIS and the 
wing observation book.  

-  Sodexo ensure that NOMIS is available to healthcare staff, including installing NOMIS-
compatible PCs in healthcare offices, so healthcare can access risk information before 
assessing or treating prisoner/patient. 

-  The Safer Custody Team in each prison share risk information for all new prisoners with 
wing staff and key workers, in different forums depending on the urgency of the risk 
(verbally briefing, email, morning meetings, weekly SIM meeting) as well as within the 
Monthly Safer Custody Meeting.  

-  Sodexo  have recently  introduced  a digital  Reception  Screening  Risk  Assessment  (RSRA) 
tool across its prisons, implemented on CMS following 2 years of development and trialling 
led by Sodexo in partnership with Unilink 

-  The RSRA is completed by operational staff in reception when interviewing the prisoner on 
arrival and guides staff to consider obligatory key pieces of information that might indicate 
risk of harm, either to self or others upon arrival into custody, such as previous history of self-
harm,  information  taken  from  Suicide  /  Self-Harm  Warning  Form  (SASH)  and/or  Person 
Escort Record (PER), which all contribute to staff making appropriate risk decisions in the 
first few hours and days of custody. 

-  Where the prisoner’s responses indicate a potential risk of harm the system will automatically 
generate a digital Early Risk Indicator alert (ERI) and enables consideration of appropriate 
intervention and support to be provided at an early stage to help manage and reduce risks 
identified.    Where  an  increased  risk  is  identified  the  ERI  warning  flag  will  appear  on  the 
prisoner’s CMS record alerting the induction unit staff and directing them to review the risk 
identified.  

-  Staff will not be able to locate the prisoner into a cell until the staff member has acknowledged 
they have read the risks flagged. It will also flag where the RSRA is incomplete, perhaps due 
to the prisoner’s volatility, or physical/mental ability to participate in the interview.  

 
 
 
 
 
 
 
 
 -  The availability of this information is immediately accessible to prison staff on CMS enabling 

prompt sharing of information.    

A failure to act with candour when engaging in post-death investigations (Minister for 

8. 
Prisons, Serco, Sodexo) 

Sodexo’s investigation process following deaths in custody, which has been shared as part of the 
substantive inquest proceedings, is to prioritise and identify risk at the earliest opportunity and to 
implement changes as required by any learning. 

In these inquests, in candour, Sodexo took the decision at an early opportunity to share its death in 
custody investigation reports with the Coroner. The disclosure of the reports was notably before any 
direction for disclosure. The disclosure of the Sodexo investigation was in advance of the Prison and 
Probation Ombudsman’s investigation reports, and indeed the Sodexo reports noted more failures 
than the PPO reports.   

Whilst Sodexo always considers early admissions and agreed facts, the unique circumstances of 
these  cases,  with  the  number  of  overlapping  organisations  involved  and  individual  officers  with 
separate  IP  status,  as  well  as  ongoing  and  late  disclosure  of  relevant  material  by  the  Ministry  of 
Justice, meant that admissions by Sodexo, without trespassing on factual evidence due to be heard 
at the inquest involving other IPs, was more difficult and complex than would usually be the case. 
There are three further inquests involving Sodexo concerning deaths at HMP Lowdham Grange, and 
Sodexo will give careful consideration to admissions and agreement of facts in relation to each. 

We know that you will share a copy of this response with the families, and we would like to again 
express our sincere condolences for their loss. Following the inquests Sodexo have ringfenced key 
safety  tasks  and  safer  custody  staff  in  the  event  of  changes  in  resourcing  pressures.  The 
implementation of learning from these sad deaths is a priority.  

Yours sincerely 

Sodexo Limited