‘Repeated failures’ at Nottinghamshire prison where three inmates took their lives

There were several failings and missed opportunities at an overwhelmed prison where three inmates took their lives in the space of three weeks, an inquest jury has found.

Anthony Binfield, 30, Rolandas Karbauskas, 49, and David Richards, 42, were found in their cells at HMP Lowdham Grange in Nottinghamshire between 6-25 March 2023.

An inquest into their deaths that concluded at Nottingham coroner’s court on Friday criticised “repeated failures” at the category B men’s jail, which was run by Sodexo at the time of the deaths.

The jury said “poor leadership and supervision” was likely to have “more than minimally contributed” to their deaths. They cited a number of issues around staffing levels and the sharing of “risk-pertinent information”, with multiple missed opportunities to provide support.

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

She issued two prevention of future deaths reports, which said staff reported being “overwhelmed and overburdened”, there was “widespread evidence of failures to do the basics” and there was need for “a radical change in culture, and reflective learning from deaths”.

The first suicide occurred six weeks after management of the prison changed hands from Serco to Sodexo on 16 February 2023, believed to be the first private-to-private prison transfer in England and Wales.

The facility was taken over permanently by the government in December 2023 due to the suicides, the “ready availability” of illegal drugs, high levels of self-harm and “significant staffing issues”.

Binfield, who had a history of self-harm and substance abuse issues, was under half-hourly observations at the time of his death. CCTV footage played at the inquest showed that checks recorded on prison logs were never actually completed.

Lynda Hurren, Binfield’s aunt, told the inquest that her nephew “tried to get help for himself, but he often felt that he wasn’t given the help that he needed, and he was let down”.

“It seemed to me like the prison couldn’t cope with him, and often didn’t care,” she said.

Richards was found dead a week later on 13 March, two weeks after arriving at the prison. He had been placed in a vulnerable prisoner unit at his previous prison for his own protection, and one staff member described him as like a “rabbit in headlights” on arriving at Lowdham Grange.

Karbauskas, a Lithuanian national who spoke limited English, died five days after his arrival in the prison.

A nurse told the inquest that, when asked questions to assess his risk of suicide, Rolandas made a gesture drawing his hand across his neck, and other inmates raised concerns that he wasn’t eating, but no action was taken.

During the inquest, the Ministry of Justice was fined £500 for failing to meet deadlines to provide documents and evidence, with the coroner saying the penalty was an “extraordinary step”.

A spokesperson for Sodexo said it apologised to the family and friends of the deceased, and said the prison had a “unique set of challenges, both old and new” when it took over.

“These challenges have been fully considered during the course of this inquest and we are grateful to the coroner for her thorough approach. Whilst we have since transferred the management and operation of the prison to HMPPS [HM Prison and Probation Service], we will fully take on board any learnings.”

In a statement, the Ministry of Justice said: “Our thoughts remain with the families of Anthony Binfield, David Richards and Rolandas Karbauskas, and we offer our sincere apologies for the failings in these cases.

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

• In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email [email protected] or [email protected]. In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.org, or text HOME to 741741 to connect with a crisis counselor. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org