‘Missed opportunities’ contributed to three inmates’ deaths, inquest jury finds
An inquest jury has found that failings and “missed opportunities” at a prison contributed to the deaths of three inmates just weeks apart.
Nottingham Coroner’s Court heard a joint inquest for Anthony Binfield, David Richards and Rolandas Karbauskas, who all died at HMP Lowdham Grange in Nottinghamshire.
The three prisoners were found hanging between March 6 and 25 2023 after the prison (pictured), which has a capacity of more than 900, was taken over by private provider Sodexo from the company Serco on February 16 that year.
A jury concluded on Friday that there were multiple failings, including from the transfer process, that probably more than minimally contributed to the deaths, such as poor staffing levels and poor leadership.
They said: “There was also several assessments that were inadequate, resulting in missed opportunities regarding the sharing of risk pertinent information.”
Binfield and Karbauskas’s deaths were recorded as suicide and Richards’s death was recorded as an accident.
The jury concluded that Binfield, 30, who died on March 6 2023, suffered a significant deterioration in his mental health before his death and the response by prison staff “was not appropriate to ensure his safety”.
The inquest was told a note found in Binfield’s waistband said he “felt unheard and let down by the system and prison staff” and “had no one to turn to for help”.
The jury found that Richards, who died on March 13 2023, likely intended to hang himself as a “cry for help”.
Richards, whose status as a vulnerable prisoner was “not taken into consideration” when he was moved to HMP Lowdham Grange, said he “felt petrified and unsafe” in prison during a mental health assessment before his death.
The jury concluded that the 42-year-old inmate was “consistently lied to” about a decision to move him to a different wing, and his feelings of being unsafe had a “detrimental impact” on his mental health.
The inquest heard that Karbauskas, 49, died on March 25 2023 after it was flagged that he looked pale and was giving his food away, but no action was taken.
A mental health referral for Karbauskas was not processed months after staff realised he had been in a psychiatric unit in Lithuania and had previously attempted suicide.
Nottinghamshire coroner Laurinda Bower issued a prevention of future deaths report expressing her “significant concerns” that there may be similar deaths “if urgent action is not taken”.
The areas Ms Bower said concerned her were staffing levels, skill mix, training and the failure to share information between prison and healthcare staff.
The running of the prison was taken over by the Ministry of Justice in December 2023 to improve safety and security.
A spokesperson for Sodexo said: “We deeply regret that Anthony Binfield, David Richards and Rolandas Karbauskas died while they were in our custody, shortly after we took over management of the prison.
“Our thoughts at this time are with their families and friends, we apologise to them and understand how difficult this process must have been.
“HMP Lowdham Grange – at the time we assumed responsibility in February 2023 – was a prison with a unique set of challenges, both old and new.
“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”.
A Serco spokesperson said: “It is extremely regrettable that after our handover of HMP Lowdham Grange, three deaths occurred and our thoughts remain with their families.
“The handover did present some challenges for all those concerned. We acknowledge that there are lessons to be learned for future transitions across the sector.
“Following the conclusion of this inquest, we will ensure any key learnings are implemented.”
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