Inmate 'probably would have lived with proper care'

A jury found Ricky Crosher's life "could have been saved or prolonged"

The life of an inmate at a Nottinghamshire prison "probably would have been saved or prolonged" had he received adequate care, an inquest has found.

Ricky Crosher, from Basildon in Essex, died outside his cell at HMP Lowdham Grange on 11 October 2023.

A jury at Nottingham Coroner's Court on Friday found the 40-year-old died from "ligature compression of the neck", and returned a conclusion of suicide.

They also found neglect during his time in the Category B prison contributed to his death, and pointed to "sustained failure" by then-operator Sodexo.

'Sustained failure'

The court heard Crosher was transferred to Lowdham Grange on 19 July 2023, having been recalled to prison earlier that year.

His paperwork on arrival "included a section which described him as having vulnerabilities and posing a medium risk of harm towards himself through the continued misuse of illicit drugs", the jury said at the end of the inquest, adding he had disclosed three previous attempts to take his own life.

Safer custody staff at the prison "were unaware" of information in his recall papers, they found, though Crosher was described as "seeming a little vulnerable" by healthcare staff at his screening.

Despite being assaulted in August and September there was no welfare check or other follow-up action by prison staff, and when he was found under the influence of drugs he was not checked on to an adequate standard.

On 7 October, Crosher pressed his cell bell to tell staff he had feelings of self-harm and was "under threat on the wing", but there was "a missed opportunity" to prevent self-harm, and despite being placed under a process called assessment, care in custody and teamwork (ACCT), the jury said he was "left unattended, breaking from policy".

He was treated by healthcare staff after self-harming, but only moved from his cell after starting a fire the following morning.

Repeated calls he made to helplines "did not receive a response", and his case was not mentioned at meetings in the days before his death, the inquest heard.

The jury found there were "discrepancies between the recording of ACCT observations in the documentation and the observations actually undertaken by night staff" on 11 October, with a "gross failure" to escalate his ACCT case after he rang his cell bell at 02:30 GMT.

Two officers failed to respond when finding Crosher's cell observation hatch was covered, the jury found, and there was a delay before a code blue was called when he was found at 07:06.

Despite medical attention, he was pronounced deceased outside his cell at 07:48.

HMP Lowdham Grange was taken over by the Ministry of Justice at the end of 2023

The jury noted Sodexo took over running Lowdham Grange in February 2023 from Serco, in what was the first private transfer of a prison in England and Wales.

They said "sustained concerns about [their] ability to run a safe, secure and decent prison" led to the Ministry of Justice (MoJ) assuming control that December.

Listing a series of factors that more than minimally contributed to Crosher's death, the jury said there was a failure by prison staff to investigate his injuries, prevent him from accessing drugs and share "risk pertinent information".

The jury also found the prison operator failed to have sufficient numbers of staff to run the prison, had not "assured themselves of the capabilities of the staffing body and to remedy any deficiencies", and to provide a working safer custody team.

When asked by area coroner Laurinda Bower if there was "a sustained failure by the prison operator to address operational safety concerns" raised between Sodexo taking on the jail and Crosher's death, the jury agreed.

They also found the jail had not learned from previous deaths in custody, such as the deaths of three inmates in March 2023.

Finding neglect had been a factor, the jury said there was "an abundance of risk pertinent information which was not recorded correctly".

"Had adequate care been given, it probably would have saved or prolonged life," the jury found.

Ricky Crosher's family welcomed the jury's conclusions

Ms Bower said the jury's conclusions "very appropriately found that failings in Ricky's care were abundant and sadly shocking in nature".

While noting there had been no "self-inflicted deaths" in Lowdham Grange since November 2023, she said she would issue a prevention of future deaths report and write to the jail's safer custody team to urge them to improve the operation of its phone messaging system.

"I'm concerned that these messages are not being retained and [that] there's still a practice of deleting these messages," she said.

Crosher's mother, Sue Beck, said the jury "did a very thorough and a very honest job", adding: "To make that neglect finding I think was quite brave, but I'm glad they did it."

Faye Crosher said her brother's inquest meant that "after a long time we can finally put it to rest", while Ricky's father Steve Crosher said he hoped no other family would go through what they had.

"We're never going to stop missing him, that's never going to heal, but it feels like some good may come from it," he said.

A Sodexo spokesperson said: "We extend our deepest sympathies to Ricky Crosher's family and all those affected by his death. We apologise to them and recognise how difficult this process must have been.

"HMP Lowdham Grange was a prison facing a unique set of challenges – historic cultural issues, staffing and regime gaps, and the wider pressures of a national population crisis. It is well documented that such deep-rooted cultural change takes years to achieve.

"We understand and accept that none of that excuses the errors highlighted in this case and we accept both the coroner's and jury's findings. Whilst we have since transferred the management and operation of the prison to HMPPS, we will fully take on board all learnings."

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