Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0277, written 20 May 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 May 2026 |
|---|---|
| Reference | 2026-0277 |
| Coroner | Laurinda Bower |
| Coroner area | Nottingham City and Nottinghamshire |
| Organisation named | Northamptonshire Healthcare NHS Foundation Trust |
| Source | judiciary.uk record |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
1. 2. 3. REPORT TO PREVENT FUTURE DEATHS REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 CORONER I am Miss Laurinda Bower, HM Area Coroner, for the coroner area of Nottingham City & Nottinghamshire. DATE OF REPORT 20 May 2026 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. 4. THIS REPORT IS BEING SENT TO 1. The Governor of HMP Lowdham Grange, Nottingham 2. Head of Healthcare, HMP Lowdham Grange, Northamptonshire Healthcare NHS Foundation Trust (concern 6 only) You are under a duty to respond to this report within 56 days of the date of this report, namely by July 16, 2026. I, the coroner, may extend the period if an appropriate application is made. 5. YOUR RESPONSE 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. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports - Courts and Tribunals Judiciary. 6. SUMMARY OF CORONER’S CONCERN 1. Failure to have in place an appropriately staffed and resourced Safer Custody function 2. Failure to have in place a robust system for managing the safer custody telephone line 3. Failure to provide a safe Care and Separation Unit which adhered to expected policy and minimum standards of decency 4. Persistent failure to have in place a robust system for learning from deaths 5. Failure to retain evidence pertinent to the death 6. Failure to ensure a safe and productive working relationship between prison and healthcare staff 7. 8. ACTION SHOULD BE TAKEN In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action. INVESTIGATION AND INQUEST This court has been concerned with investigating the circumstances of a series of self-inflicted deaths of prisoners at HMP Lowdham Grange, Nottinghamshire. This is the third prevention of future death report to follow the respective inquests. Ricky Crosher died on 11 October 2023. An investigation into his death was opened on 25 October 2023. The inquest into Ricky’s death was held before a jury and concluded on 28 November 2025. Matthew Osborne died on 25 November 2023. An investigation into his death was opened on 7 December 2023. The inquest into Matthew’s death was held before a jury and concluded on Ricky’s was the fourth self-inflicted death to occur at the prison in the first 9 months of the Prison contract being taken over by Sodexo, following the first private provider to private provider operator contract transfer in England (February 2023). Matthew’s was the fifth. HMPPS stepped-in to control the prison in December 2023. The conclusion of the jury at the respective inquests was that: Ricky died as a result of suicide contributed to by neglect, with multiple failings identified as contributing to his death. Matthew died as a result of suicide contributed to by neglect, with multiple failings identified as contributing to his death. 9. CIRCUMSTANCES OF DEATH Ricky Crosher arrived at HMP Lowdham Grange in July 2023. In the months before his death, he was identified as at increased risk of suicide and self- harm, therefore an ACCT was opened. The ACCT was not managed in accordance with the policy. Ricky rang the prison’s Safer Custody telephone line. This was a voicemail box which could be accessed by prisoners using their in-cell telephony. The system was designed as a way for prisoners to request support from Safer Custody by leaving a message with the name and location, and a Safer Custody trained officer would then listen to the message and respond accordingly. Ricky left multiple messages on that voicemail inbox in the days prior to his self-inflicted death. There is no record of whether these messages were listened to, but certainly no action was taken to see Ricky, despite him being on an ACCT and asking for someone to speak with him urgently. In the hours prior to Ricky being discovered deceased in his cell, ACCT checks were documented as having taken place, but CCTV showed these checks did not occur. Further, Ricky’s cell hatch was noted by officers to be covered but no attempts were made to remove the covering despite there being no response from Ricky inside the cell. Matthew arrived at HMP Lowdham Grange on 20 June 2023. He made a number of serious attempts on his life by ligature and was placed on an ACCT. He was detained in the prison’s Care and Separation Unit from 3 October 2023 until he died on 25 November 2023. CSU staff were unaware of the previous attempts he had made on his life, and the prison failed to manage his ACCT in accordance with the policy. Again, ACCT checks were recorded in the documentation which simply had not occurred. Matthew’s mental health deteriorated significantly while on CSU and his continued detention in segregation was not managed in accordance with prison policy. He had no reintegration plan. There was a lack of input from Safer Custody. He was housed in a cell which did not meet basic standards including a lack of mattress. In the hours before his death, segregation staff who were supposed to be on the landing conducting ACCT and welfare checks were instead using the TV in the adjudication room to keep track of the football reporting. Prior to the inquest, the court was informed that the CCTV footage from the unit had corrupted so that certain time frames from certain cameras was lost. Mid-inquest, some of this footage was discovered embedded within folders marked with different dates/time stamps. Some of the footage was never recovered, in particular the footage from outside Mathew’s cell when he was relocated and had been handed fabric item. In each case, there was evidence of a strained relationship between prison and healthcare staff which was to the detriment of prisoner safety. Some of these serious failings in care were repeated from previous deaths in custody at the prison, suggesting a sustained failure to learn from previous deaths, and occurred at a time when there were sustained concerns about Sodexo’s ability to run a safe, secure and decent prison. Whilst I appreciate these failings in care occurred at a time when Sodexo was responsible for the operation of HMP Lowdham Grange and the prison has now transferred to the public sector, this report is concerned with preventing future deaths, and so I alert the current HMPPS Governor of my concerns to ensure that staff, many of whom have TUPED over from Sodexo, do not repeat these mistakes leading to deaths in the future. The same is true in relation to healthcare. The contract has now moved to Northamptonshire Healthcare NHS Foundation Trust, and I would welcome an update from the new provider on steps taken to address the working relationship between the new providers. 10. CORONER’S CONCERNS During the course of the inquest I heard evidence 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: 1. Failure to have in place an appropriately staffed and resourced Safer Custody function 2. Failure to have in place a robust system for managing the safer custody telephone line 3. Failure to provide a safe Care and Separation Unit which adhered to expected policy and minimum standards of decency 4. Persistent failure to have in place a robust system for learning from deaths 5. Failure to retain evidence pertinent to the death 6. Failure to ensure a safe and productive working relationship between prison and healthcare staff 11. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles] Ricky’s Family Matthew’s Family HMPPS Sodexo Northamptonshire NHS Foundation Trust (the new healthcare provider) I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12. SIGNATURE Miss Laurinda Bower HM Area Coroner Nottingham City and Nottinghamshire
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.
Director General of Prisons HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Miss Laurinda Bower, Area Coroner for Nottingham City & Nottinghamshire The Council House Old Market Square Nottingham NG1 2DT 16 July 2026 Dear Miss Bower, Thank you for your Regulation 28 report of 20 May 2026 following the inquests into the deaths of Mr Ricky Crosher on 11 October 2023 and Mr Matthew Osborne on 25 November 2023 at HMP Lowdham Grange. I am responding on behalf of the Governor of HMP Lowdham Grange as the Interim Director General of Prisons. I know that you will share a copy of this response with the families of Mr Crosher and Mr Osborne, 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. Following evidence heard at the inquest you have raised concerns in relation to the operation of both the Safer Custody and Care and Separation Unit functions, as well as the working relationship between prison and healthcare staff. Your first concern is around staffing and resource within the Safer Custody function at HMP Lowdham Grange. As of March 2026, the Safety team now has a full complement of staff, and to enable the team to be consistently visible across the establishment, the resource has been ringfenced, meaning that staff cannot be redeployed to carry out alternative routine duties. This ensures the staff in the team have the opportunity to actively engage with the most vulnerable prisoners and ensure that appropriate care and support is consistently provided. The Safety team are also responsible for the management of the Safer Custody telephone line, which prisoners can call if they need some support. This telephone system was upgraded in March 2026 so that it no longer operates as a standalone system, and calls are now routed to a telephone located within the team’s office, with a designated member of the team responsible for checking messages multiple times throughout the day. All calls are recorded in a logbook which is regularly reviewed by Safety officers, and appropriate action is taken in response to any concerns or queries raised. The improved system allows voicemail messages to be retained for a period of 60 days, and the system has the capacity to store up to 100 messages at any one time. Your third concern relates to the Care and Separation Unit (CSU) provision, which is used to manage and support more complex prisoners. Since August 2024 the running of the CSU has been overseen by a Governor supported by a Custodial Manager, a Supervising Officer, and a team of Band 3 officers. In addition to the above CSU staffing structure the Duty Governor also completes weekly assurance checks to ensure oversight at senior management level. This weekly assurance visit allows for engagement with staff and prisoners and ensures that the unit is being managed as expected, and in line with HMPPS policy. All members of operational staff assigned to work within the CSU are subject to a formal selection process where they must demonstrate their ability to deal with complex behaviours, whilst building and maintaining constructive and professional relationships with prisoners. Successful staff receive additional operational training to further develop their skills in recognising and responding to the diverse needs of the CSU population. CSU staff are rotated from the unit after a maximum of three years to maintain effectiveness and wellbeing. The Governor has assured me that, in line with policy, any prisoner who is located in the CSU while subject to the Assessment, Care in Custody and Teamwork (ACCT) process will have undergone a thorough assessment to determine whether segregation is an appropriate environment for the individual and has determined that no other location is suitable. Should a move from segregation be deemed necessary but no suitable alternative location is available at that time ACCT observation levels are increased, and the prisoner’s status reviewed at the earliest opportunity. A member of the mental health team now attends ACCT reviews on a daily basis, contributing to the review process and helping to identify prisoners who may require additional support. Furthermore, there are clear and effective referral pathways in place for mental health, primary healthcare, and substance misuse services, ensuring that prisoners can access appropriate support in a timely manner. Your fourth concern is in relation to lessons learnt from deaths in custody at HMP Lowdham Grange. In October 2024 the Governor of HMP Lowdham Grange introduced a Prevention of Future Deaths (PFD) meeting where recommendations arising from Early Learning Reviews, Prisons and Probation Ombudsman (PPO) investigations and Regulation 28 reports are regularly reviewed and actions raised. Assurance checks are conducted on all actions once completed to ensure that recommendations have been fully embedded and are operating effectively within the establishment. Additionally, in April 2026 HMP Lowdham Grange appointed an Inquest and PFD Lead who is responsible for coordinating the prison’s response to PFD matters and for providing oversight and assurance that learning is implemented and sustained across the establishment. Your fifth concern relates to the retention of evidence pertinent to a death in custody. In November 2024 a system was introduced whereby all prisoner records are stored electronically and the database acts as a central repository for all relevant documentation, enabling the establishment to collate, manage and securely share documentation with external stakeholders. The introduction of this approach ensures that all documentation is held in a single, controlled, location and access permissions are stringently managed. This system allows for information to be uploaded, tracked, and retrieved with ease, significantly reducing the risk of documents being misplaced or inadvertently destroyed. Access to CCTV footage for Death in Custody purposes is managed by the Safety Team who are responsible for the identification, downloading and secure retention of relevant footage to ensure it is not overwritten. All footage is obtained, and retained, in line with a local protocol. Your sixth concern is in relation to collaborative working between HMP Lowdham Grange and healthcare. In July 2025 Northamptonshire Healthcare NHS Foundation Trust assumed responsibility of HMP Lowdham Grange’s healthcare provider. Since this change in provider communication and working relationships between parties has improved significantly. Healthcare representatives attend the daily morning briefing and provide updates on any issues arising from the previous day. In addition, a structured daily handover takes place between healthcare and prison staff to ensure continuity of care and effective information sharing. HMP Lowdham Grange also detail a minimum of two operational members of staff every day to be designated Healthcare Officers. These officers move around the establishment facilitating the movement of prisoners who are attending healthcare appointments in line with the individual wing regime, supporting the efficient delivery of healthcare services and improving prisoner access to care. There has also been an increase in healthcare staffing levels, enhancing the provision of care within the establishment. I hope the measures outlined above taken by HMP Lowdham Grange provide you with reassurance that learning and appropriate action has been taken from the circumstances of Mr Crosher and Mr Osborne’s deaths. Yours sincerely Interim Director General Prisons
CHIEF EXECUTIVE AND CHAIR’S OFFICE Berrywood Hospital Berrywood Drive NORTHAMPTON NN5 6UD 15 July 2026 FAO Miss Laurinda Bower HM Area Coroner for Nottingham City and Nottinghamshire Dear Miss Bower RE: Regulation 28 Report Concerning Ricky Crosher and Matthew Osborne We write in response to your Prevention of Future Deaths Regulation 28 (‘Report’) dated 20 May 2026 concerning the death(s) of Ricky Crosher, on 11 October 2023, and Matthew Osborne on 25 November 2023 at HMP Lowdham Grange. Before responding to the matters of concern you have included within your Report, I would like to express my condolences to Mr Crosher’s and Mr Osborne’s families and loved ones. From your Report, we understand that you have several concerns about a series of self- inflicted deaths of prisoners at HMP Lowdham Grange. You have asked us to respond to a specific concern regarding safe and productive working relationships between prison and healthcare staff. You have asked Northamptonshire Healthcare NHS Foundation Trust (the ‘Trust’) to either provide details of action taken, or proposed to be taken, setting out the timetable for action. Otherwise, the Trust must explain why no action is proposed. Please find below our response to your concerns detailing the actions being taken. Cont’d/… Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW Failure to ensure a safe and productive working relationship between prison and healthcare staff Your Report notes that, at the time of Messrs Crosher’s and Osborne’s deaths, there was a ‘strained relationship between prison and healthcare staff’ at HMP Lowdham Grange. Whilst recognising both the prison and healthcare services were run by different providers to those in situ today, you also describe the efforts you made to prevent future deaths by alerting the HMPPS Governor of your concerns. Through your Report you are seeking an update from us on the steps taken to address the working relationship between the new providers. The Trust took over healthcare services at HMP Lowdham Grange from Nottinghamshire Healthcare NHS Foundation Trust on 16 July 2025. Since this time, we have led a significant programme of transformational change to improve healthcare service provision within the prison. Patient safety has been at the centre of this programme, supported by work to ensure we have the right culture and leadership in place. Our Head of Healthcare plays a key role in facilitating integrated working practices between healthcare and prison teams. They are a core member of, and consistent attendee at, key meetings at the prison including a new Tri-partite Meeting, which deals with issues concerning safer custody, security, and drug strategy, and the Local Delivery Board, whose members also include NHS England and the Local Authority. A member of the strategic leadership team, the Head of Healthcare has also contributed to an integrated two-year strategy for the prison. If the head of healthcare is unable to attend (e.g., due to annual leave or training), then a suitably competent colleague deputises on their behalf to ensure continuity of services provided and sustained improved working relationships between the Trust and HMP Governor(s). Members of our healthcare team contribute to a range of meetings with prison staff including the Prison Council, the Specialist Interventions meeting, and two new meetings – the ‘Top 30 Most Violent’ meeting, and Segregation meeting. The latter two meetings have been put in place to embed strategies for reducing violence across the prison, and to safely manage transitions between ‘normal location’ and the ‘segregation unit’. Members of our team now attend daily ACCT reviews with prison staff enabling early identification of those that may require additional support. We have welcomed Governor-grade colleagues from the prison team into healthcare staff briefings on at least a monthly basis, which helps reinforce the integrated approach between prison and healthcare teams we know from experience to be the most successful. Cont’d/… Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW Beyond meetings, we have also collaborated with the prison team to establish a Duty Manager Rota. This provides a single point of contact for both prison and healthcare staff during core hours to a senior manager to resolve issues that may arise or to ensure they are escalated to the appropriate organisation for resolution where this is not possible. Since taking over as provider of the healthcare service at HMP Lowdham Grange, we have made significant improvements to the service and its relationship with the prison. As a learning organisation, we will continue to pursue improvement opportunities and a strong working relationship with our partners including the prison Governor and the wider prison team. We hope we have fully addressed the concerns in your Report. Please contact me if you have any further concerns or questions. Yours sincerely Chief Executive NORTHAMPTONSHIRE HEALTHCARE NHS FOUNDATION TRUST Cc: , Chief Medical Officer , Group Chief Nurse , Chief Operating Officer , Manging Director and Deputy Chief Executive Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW
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