An inquest jury has found that neglect contributed to the death of Matthew Osborne, 39. He took his own life at HMP Lowdham Grange on 25 November 2023. Nottingham’s area coroner, Laurinda Bower, said she would write to Nottinghamshire Police. She questioned whether the force had properly considered criminal investigations into individuals or organisations.
Mr Osborne died a few months after the prison passed from Serco to Sodexo on 16 February 2023. That handover was the first transfer of a prison from one private operator to another in England and Wales. He was the fifth prisoner at Lowdham Grange to die in similar circumstances in the year after it.
Months in segregation
Mr Osborne arrived at the prison on 20 June. The court heard that he made three serious attempts on his life the following month. On 29 June staff placed him on an ACCT plan, used for prisoners at risk of suicide or self-harm. By the time of his death, he needed three welfare checks every hour.
He moved to the segregation unit on 3 October. The jury found that healthcare staff had completed an algorithm on his suitability inaccurately. It said the record did not show whether anyone had weighed the risk that segregation might seriously damage his mental health. A care plan drawn up on 10 October followed a template. The jury said it gave a false impression of personalised care.
Staff judged him eligible to return to a wing by 16 November, but he stayed in segregation. The jury described his detention after that date as unlawful. It also found that staff failed to carry out repeated reviews of his fitness for segregation properly. Prison and healthcare teams did not work together on them.
Missed checks and false records
The court heard that staff missed a series of ACCT checks in the days before Mr Osborne died. CCTV showed that several checks entered in the records had not taken place. On 25 November, nobody saw him between 14:32 and 16:22 GMT.
The jury said some staff on the unit had used the television in the adjudication room to follow football reports. It called this a gross failure of their core duties, including ACCT checks. CCTV also showed two officers playing football with a toilet roll on the unit that afternoon. The inquest heard that both lost their jobs for gross misconduct. Sodexo suspended a third officer, who resigned and moved to another prison.
The jury listed failings that contributed more than minimally to his death. They included understaffing, a lack of management oversight and failed ACCT checks. It said staff had not shared information relevant to his risk. Sickness, leave and resignations had left the segregation unit without consistent support from operational managers. The jury called a visit by the prison’s deputy director on 24 November a further missed opportunity. It also agreed that Sodexo and Nottinghamshire Healthcare NHS Foundation Trust had failed to embed lessons from earlier deaths. As a result, past failings recurred.
On the transfer itself, the jury found that Serco had removed necessary technology, cut funding without adequate planning and failed to supply vital documents. It said Sodexo had not recruited enough experienced staff or trained promoted staff properly for their new roles. The Ministry of Justice (MoJ) took over the running of the prison in December 2023, at first on a temporary basis. The arrangement became permanent the following year.
Coroner’s concerns
Ms Bower said she would issue a prevention of future deaths report. Her concerns include the safety and clinical safety of the segregation unit and the retention of information for investigations into deaths in custody. She pointed to other deaths at Lowdham Grange and repeated problems with segregation and healthcare. “I’m concerned that there hasn’t been sufficient consideration given by Nottinghamshire Police,” she said. She also criticised the MoJ over the difficulty of retrieving CCTV evidence, a problem she said other coroners had also met.
After the inquest, Sodexo apologised to the Osborne family and accepted the jury’s findings. It said the actions of some officers appalled it. “Lowdham Grange is a prison with long-standing cultural and operational challenges, which we were working tirelessly to rectify,” the company said. It added that it regretted the lack of sufficient progress.
Diane Hull, chief nurse at the trust, apologised for the parts of Mr Osborne’s care that fell short. The trust no longer provides healthcare at Lowdham Grange or any other prison. The MoJ said it had made progress at the prison since taking it over. It cited stronger safety measures and better support for prisoners at risk of self-harm.
Mr Osborne’s sister, Jasmine Osborne, said the failings shocked the family. She welcomed the jury’s findings and the coroner’s comments. “It’s been very hard, we’re all broken, but hopefully now we’ve got some answers, we can heal the best we can,” she said.
HMP Lowdham Grange is a category B men’s prison in the East Midlands. At its last full inspection before this inquest, in June 2025, inspectors rated safety and respect as poor. They judged purposeful activity and preparation for release not sufficiently good.
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