A coroner has accused prison bosses of “failing to act with candour” as she investigated three self-inflicted deaths in just 19 days at a scandal-hit prison, including that of the former head of the Dreamboys stripper group.
A jury concluded multiple failings helped lead to the deaths of Anthony Binfield, Rolandas Karbauskas and David Richards in a matter of weeks inside HMP Lowdham Grange, a category B men’s prison in Nottinghamshire.
In a scathing Prevention of Future Deaths report, coroner Laurinda Bower hit out prison bosses and the Ministry of Justice (MoJ) for a lack of transparency during her investigation into the deaths in March 2023, noting a “marked discrepancy” between oral testimony in the face of “irrefutable evidence” and written submissions to the court.
“I am troubled that unless there is a radical change in culture, and reflective learning from deaths is prioritised, prisoners will continue to die in custody,” she said, having taken the unusual step of fining the MoJ £500 for failing to disclose evidence.
It comes after damning new figures uncovered by The Independent revealed the scale of neglect inside Britain’s overcrowded prisons, with four in ten prisoners denied adequate healthcare before they took their own lives in custody between 2020 and 2023.
The chairman of the justice committee Andy Slaughter said “we are failing people in custody” after the figures came to light, while the chief inspector of prisons Charlie Taylor warned “without any doubt” there will be more potentially preventable deaths without action to drive up standards.
The inquest found Binfield, 30, had asked to see mental health staff as he was feeling very low a week before his death on 6 March 2023. An email from the prison to mental health staff about this was never received, because it was sent to the new email address for private operator Sodexo, who had taken over from Serco a month earlier in the first-ever private-to-private prison transfer.
On the day of his death he was supposed to be monitored every half hour, but CCTV showed that checks recorded on prison logs were in fact never completed.
There was an 11-minute day in entering his cell after he was found unresponsive at 9.23pm, during which time prison officers used two pens like “chopsticks” to try to move paper obscuring the observation panel. An expert told the inquest if they had entered promptly he would likely have survived.
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”.
A week later, Richards was also found unresponsive having recently been transferred from another prison.
Richards, whose status as a vulnerable prisoner was “not taken into consideration” when he was moved, said he “felt petrified and unsafe” in prison during a mental health assessment before his death.
The 42-year-old former leader the Dreamboys male stripping group, who had been jailed for attempting to murder his wife, had not taken his medication in at least five to six days after the prison allowed him to take it unsupervised.
Just 12 days later, on 25 March, Lithuanian national Karbauskas took his own life five days after arriving at the prison.
Despite speaking no English and telling a nurse on arrival he was depressed, no plan was put in place to address his isolation.
“There is a clear risk of future self-inflicted deaths if language barriers and isolation are not adequately addressed,” the coroner warned.
Binfield and Karbauskas’s deaths were recorded as suicide and Richards’s death was recorded as an accident.
In the report, sent to the prisons minister, Sodexo, Serco and the local NHS Trust, she said “multiple failings and missed opportunities” contributed to the deaths.
These include issues with recruitment, retention and training of staff who were often “overwhelmed, over-burdened and under-supported” and a “complete failure” to identify and share risk information between prison and healthcare teams.
She also called prison transfer system “disorganised and unsafe” and said there was a “persistent failure to learn from deaths over many years”.
The running of the prison was taken over by the Ministry of Justice in December 2023 to improve safety and security.
A Sodexo spokesperson 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, we will fully take on board any learnings".
A Ministry of Justice spokesperson added: “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.”
If you are experiencing feelings of distress, or are struggling to cope, you can speak to the Samaritans, in confidence, on 116 123 (UK and ROI), email jo@samaritans.org, or visit the Samaritans website to find details of your nearest branch.
If you are based in the USA, and you or someone you know needs mental health assistance right now, call or text 988, or visit 988lifeline.org to access online chat from the 988 Suicide and Crisis Lifeline. This is a free, confidential crisis hotline that is available to everyone 24 hours a day, seven days a week. If you are in another country, you can go to www.befrienders.org to find a helpline near you
