Luke Ashcroft — PFD report 2026-0159

Date of report	20 Mar 2026
Reference	2026-0159
Deceased	Luke Ashcroft
Coroner	Paul Smith
Coroner area	Lincolnshire
Category	State Custody related deaths
Source	judiciary.uk record · original PDF
Responses published	2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Regulation 28: REPORT TO PREVENT FUTURE DEATHS

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT DEATHS

THIS REPORT IS BEING SENT TO:

1 Ministry of Justice
2 Governor HMP Lincoln

1

CORONER

I am Paul D SMITH, HM Senior Coroner for the coroner area of Greater Lincolnshire

2

CORONER’S LEGAL POWERS

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

3

INVESTIGATION and INQUEST

On 06 July 2020 I commenced an investigation into the death of Luke Owen ASHCROFT
aged 33. He died in Lincoln County Hospital on 1 July 2020. He had been admitted to
hospital from his cell within the Care and Separation Unit at HMP Lincoln on 24 June 2020
. At the time he was discovered he was unconscious.

The investigation concluded at the end of the inquest on 16 March 2026.

The findings of the inquest jury were that:

When: Between 06.36 and 06.54 on 24 June 2020.
Where: In cell J 109 within the Care and Separation Unit at HMP Lincoln.

We find that:
An initial screen and subsequent triage by healthcare staff were missed opportunities to
initiate an effective healthcare plan, including medication review and consideration of risk
control measures such as an ACCT from an earlier date.
Risk-pertinent information sharing between disciplines and systems was inadequate;
procedures intended to prompt discussions, including an algorithm, were not followed
correctly. This led to mitigations in place for Luke to be inadequate for his circumstances
when in the CSU.
When the ACCT procedure was implemented on 23 June 2020, the immediate actions and
details of the plan were inadequate to effectively address the risks Luke's circumstances
presented.
Failures by a prison officer to carry out the basic requirements of the ACCT plan led to Luke
being neglected at a time of crisis.

The jury concluded that;
On the balance of probability, considering all the evidence we have heard, we are satisfied
that Luke Ashcroft did not intend to take his own life and therefore record a conclusion of
death by misadventure

4

CIRCUMSTANCES OF THE DEATH

1. The death of Mr Ashcroft was confirmed at Lincoln County Hospital at 08.10 am on 1 July
2020. A later post mortem examination would find that the cause of death was 1a Hypoxic

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

a synthetic

Brain injury 1b consistent with ligature application. A toxicology screen identified a number
of substances not prescribed to Mr Ashcroft together with evidence of “
cannabinoid.
2. Mr Ashcroft had been admitted to Lincoln County Hospital on 24 June 2020 from HMP
Lincoln where he was being detained.
3. Luke Ashcroft was 33 at the time of his death. As a child he had been diagnosed with
ADHD and prescribed medication. His behaviour was on occasion challenging but was
managed by his family.
4. As he grew older his mental health problems worsened. He became addicted to drugs
and that addiction impacted upon his mental health. In 2017 he was formally diagnosed
with schizophrenia and was prescribed medication for that condition.
5. On 21 May 2020 he was released from HMP Humber on licence. As a consequence of his
failure to comply with the term of his release was recalled to prison on 23 May 2020 and
sent to HMP Lincoln. On arrival he tested positive for opiates and cocaine. He was already
on a methadone (heroin substitute) programme, which was continued at Lincoln.
6. Shortly after arriving at HMP Lincoln, on 27 May, he told healthcare staff that he had
spiders living inside his body. He was prescribed antidepressant and antipsychotic
medication but continued to report his belief that he was infested by spiders. As a
consequence, on 14 June he was seen by Healthcare and referred for an urgent
appointment with a psychiatrist. That was fixed for 23 June.
7. On 22 June, Mr Ashcroft became more distressed about the spiders and barricaded
himself in his cell. He was subsequently moved to the segregation unit (known as the Care
and Separation Unit (CSU)). A nurse assessed that he was medically fit to be segregated.
8. On 23 June, a psychiatrist assessed Mr Ashcroft and diagnosed him with a condition of
delusional parasitosis (a fixed but false belief that the body is infested with insects). He
found that Mr Ashcroft was having ‘an acute psychotic episode’. He ordered tests to exclude
any physical cause but considered it likely that Mr Ashcroft would require further
assessment and treatment in a secure psychiatric hospital. He was then moved to another
cell within CSU after causing some damage to his cell.
9. Later that day, a nurse started suicide and self-harm procedures (known as an ACCT)
after Mr Ashcroft told her that he had spiders in his body and was ready to kill himself. He
remained in the CSU after a further assessment.
10. Mr Ashcroft was subject to five observation checks an hour. The officer responsible for
the checks during the night of 23 June into 24 June failed to carry out numerous checks but
falsified the ACCT log to say he had in fact done so. His last entry in the ACCT log was at
6.50am which described that Mr Ashcroft was pacing in his cell. That entry was false. CCTV
showed that his last check was made at 6.36am.
11. At 6.54am upon commencing his shift, the day shift officer checked Mr Ashcroft. He saw
him lying on the cell floor
assistance. As soon as he heard colleagues arrive on the unit, he entered the cell and cut
the ligature from Mr Ashcroft’s neck. Another member of staff called a medical emergency
code and healthcare staff arrived quickly.
12. The emergency services attended and Mr Ashcroft was taken to hospital, where his
death was confirmed on 1 July.

. The officer called for

5

CORONER’S CONCERNS

During the course of the investigation my inquiries revealed matters giving rise to concern.
In my opinion there is a risk that future deaths could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows:
(brief summary of matters of concern)

I received evidence in relation to the availability of telephone access for inmates at HMP
Lincoln. I was told that, in the main, the prison had in-cell telephony, permitting prisoners
access to telephones 24 hours a day, subject to them having sufficient phone credit and
subject also to necessary security restrictions upon the numbers to be called.

The position was said to be different in CSU. I was told that in-cell telephones were

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

precluded by virtue of the construction of the unit, but that each cell was allocated a
corded phone, which remained outside the cell until requested by the inmate. At that point
it would be passed inside for use (as long as the unit was not then on "patrol state" during
which time additional staff would be required to attend to permit the cell door to be
opened). Once provided, the phone would remain in the cell for as long as the prisoner
wished to retain it.

Cell J 109 which housed Mr Ashcroft was said to be equipped with an anti-ligature door
fitting. I was told that as a consequence, it was only possible for the phone to be passed
over the top of the door, where it would dangle on its cord. That position, described from
June 2020 was said to continue.

I was told that cell J 109 was equipped with variable glass panels to the door, permitting
improved observation of the inmate. It was selected for Luke Ashcroft in part as a
consequence of him being subject to the ACCT procedures and subject to regular
observations. It was recognised that he should be provided with telephone access.

My concerns are twofold.

Firstly, whilst not directly relevant to the death of Luke Ashcroft, I am concerned about the
clear and obvious risks of self harm posed by the provision of a corded telephone, secured
at one end, suspended at head height in a cell commonly occupied by prisoners, who may
seek to self harm. I was told that the cell J109 had no ligature points and that the door was
fitted with anti ligature fittings. As a consequence, that was the only method of securing
telephone access. That same issue may extend to other cells in the CSU. Whether at head
height or otherwise, the provision of a corded phone may well be an issue in potential cases
of self harm and appears incongruous in comparison with other steps taken to ensure
safety within that cell. The risks of an inmate utilising that cord in an act of self harm are
self evident.

Secondly, the mechanism of provision of telephone access on CSU appears to require a
prisoner requesting such provision before the cells are locked down. Thereafter, whilst a
request can be made by a prisoner, telephone provision may depend upon the availability
of additional officers to attend whilst the cell is unlocked and the telephone provided. That
is not certain to take place. Given the proper availability to prisoners in crisis of freephone
access to Samaritans and similar services, the possible absence of a handset to access such
services is a matter of concern.

6

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you (and/or
your organisation) have the power to take such action.

7

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by May 15, 2026. I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION

8

I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons

I have also sent it to Nottinghamshire Healthcare, Family of Mr Ashcroft and the Prison and
Probation Ombudsman

who may find it useful or of interest.

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.

I may also send a copy of your response to any person who I believe may find it useful or
of interest.

The Chief Coroner may publish either or both in a complete or redacted or summary form.
He may send a copy of this report to any person who he believes may find it useful or of
interest.

You may make representations to me, the coroner, at the time of your response about the
release or the publication of your response by the Chief Coroner.

9

Dated: 20/03/2026

Paul D SMITH
HM Senior Coroner for
Greater Lincolnshire

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

Responses

2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Hm Prison and Probation Service

Mr Paul D Smith
HM Senior Coroner for the coroner
area of Greater Lincolnshire
The Myle Cross Centre
92 Macaulay Drive
Lincoln
LN2 4EL

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

21 May 2026

Dear Mr Smith,

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR LUKE ASHCROFT

Thank you for your Regulation 28 report of 20 March 2026 following the inquest into the
death of Luke Ashcroft at HMP Lincoln on 1 July 2020. I am providing the response on behalf
of His Majesty’s Prison and Probation Service (HMPPS).

I know that you will share a copy of this response with Mr Ashcroft’s family, and I would first
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.

You have raised concerns regarding the provision of telephones in the Care and Separation
Unit (CSU) at HMP Lincoln, including location of the cord during use and access to
telephones which in the CSU is on request.

The establishment has undertaken a review of the current telephony arrangements within the
CSU. While the relocation of telephone sockets within cells has been considered, this would
require significant structural alteration and capital investment. The Governor of HMP Lincoln
is therefore developing a formal business case to assess the feasibility, proportionality, and
associated operational and security risks of implementing such a longer-term solution.

In the interim, a number of risk reduction measures are being implemented including work to
modify the CSU cell doors to enable telephone cables to be routed securely beneath the
door. This adjustment will remove the requirement for cables to pass over the top of cell
doors, thereby reducing the identified ligature risk.

In addition, telephones will have the ability to be fixed to the internal wall to minimise excess
slack and restrict the potential for inappropriate use. A fixed, non-weight bearing handset
cradle will also be installed within cells using appropriate attachments, ensuring that the
handset can be safely stored without the need for prisoners to maintain tension on the cable
during use.

To support access to telephony for prisoners who may be in crisis, and where it is assessed
as appropriate, telephones may be retained within cells in an adapted cradle designed to
mitigate risk. Such arrangements will be subject to an individual, case-by-case risk
assessment, taking full account of the prisoner’s presentation, including any risks identified
through Assessment, Care in Custody and Teamwork (ACCT) processes, and will be kept
under regular review.

In parallel with these physical adjustments, the establishment is strengthening governance
and oversight within the CSU. There will be enhanced scrutiny of defensible decision-making
documentation to ensure that all decisions relating to regime, risk management, and access
to telephony are clearly recorded, justified, and proportionate. This will be supported through
oversight by senior managers.

The implementation and effectiveness of these measures will be monitored through the
establishment’s safety and assurance frameworks. The controls introduced will be subject to
ongoing review to ensure that they remain effective, proportionate, and responsive to any
emerging risks or learning.

Thank you for bringing these matters to my attention. I trust that this response provides
assurance that appropriate and proportionate action is being taken to address the concerns
identified.

Yours sincerely,

Interim Director General of Operations

Response from Hm Prison and Probation Service

Mr Paul D Smith
HM Senior Coroner for the coroner
area of Greater Lincolnshire
The Myle Cross Centre
92 Macaulay Drive
Lincoln
LN2 4EL

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

Email: DGOperationsHMPPS@justice.gov.uk