Benjamin Walter

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Benjamin
Walter, a prisoner at
HMP Lowdham Grange, on
20 August 2021
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2024
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Benjamin Walter died from synthetic cannabinoid (psychoactive substances) toxicity on
20 August 2021 at HMP Lowdham Grange. He was 31 years old. I offer my condolences
to Mr Walter’s family and friends.
Mr Walter was able to access drugs at Lowdham Grange with apparent ease. However, he
was consistently reminded of the risks of using illicit substances but was generally
unwilling to accept support from the substance misuse service. His death appears to have
been an accidental result of drug use.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman April 2024
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. Mr Benjamin Walter was serving an 18 year sentence for murder. He had been in
prison since June 2012 and had been at HMP Lowdham Grange since March 2014.
2. Mr Walter had a long history of substance misuse, including psychoactive
substances (PS) and was generally unreceptive to offers of support from the
substance misuse team. Mr Walter did try to limit his PS use during the early part of
2021, but on 9 June, he told his substance misuse worker that he no longer wished
to curtail his use.
3. During a standard welfare check at 2.07am on 20 August, Mr Walter was seen lying
on his bed in a strange position. Staff radioed a medical emergency code and went
into the cell and commenced resuscitation. A nurse responded quickly and after
noting that Mr Walter had clear signs of death, decided that further efforts to try to
resuscitate him should cease.
4. The post-mortem examination found that Mr Walter died from synthetic cannabinoid
toxicity.
Findings
5. Mr Walter was able to access illicit drugs with apparent ease at Lowdham Grange.
However, he was offered appropriate support from the substance misuse team but
was generally unwilling to accept advice about his PS use.
6. Although Lowdham Grange has put in place extra measures to reduce illicit drug
supply since Mr Walter’s death, there are still weaknesses in the processes. The
prison does not have a specific PS reduction strategy and many of the initiatives to
reduce drug supply and demand are undermined by staff shortages. Staff searching
at the gate is not always completed and the prison is not running intelligence led
drug testing or completing the number of suspicion cell searches requested.
7. The clinical reviewer concluded that the clinical care Mr Walter received at
Lowdham Grange was equivalent to what he could have expected to receive in the
community.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
8. HMPPS informed us of Mr Walter’s death on 20 August 2021.
9. The investigator issued notices to staff and prisoners at HMP Lowdham Grange
informing them of the investigation and asking anyone with relevant information to
contact her. No one responded.
10. The investigator obtained copies of relevant extracts from Mr Walter’s prison and
medical records.
11. The investigator interviewed two members of staff at HMP Lowdham Grange on 20
June 2023. The interviews were conducted via video-link. The investigation was
then transferred to one of the investigator’s colleagues.
12. NHS England commissioned a clinical reviewer to review Mr Walter’s clinical care at
the prison.
13. We informed HM Coroner for Nottingham City and Nottinghamshire of the
investigation. The Coroner gave us the results of the post-mortem examination. We
have sent the Coroner a copy of this report.
14. The Ombudsman’s family liaison officer contacted Mr Walter’s father to explain the
investigation and to ask if he had any matters he wanted us to consider. Mr Walter’s
father did not raise any matters.
15. We shared our initial report with HMPPS and with Mr Walter’s father. HMPPS
pointed out a factual inaccuracy with the name of the prison’s Head of Safety, Heal
and Wellbeing, and this report has been amended accordingly. Mr Walter’s father
did not make any comments.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Lowdham Grange
16. HMP Lowdham Grange is a Category B male adult prison located in Lowdham,
Nottinghamshire, and accommodates up to 888 prisoners. The prison was operated
by Serco for 25 years but on 16 February 2023, Sodexo took over the running of the
prison. This was the first time a prison had transferred from one private contract
manager to another. Nottinghamshire Healthcare NHS Foundation Trust provides
healthcare services.
HM Inspectorate of Prisons
17. The most recent inspection of HMP Lowdham Grange was in May 2023. Inspectors
reported that the prison was not safe, with high levels of drug use and violence. The
transfer from Serco to Sodexo had led to uncertainty and anxiety among prisoners
and staff, with significant numbers of key and specialist staff leaving.
18. The availability of drugs had increased. The security department had lost staff and
there was a backlog of intelligence reports that had not been acted on. Inspectors
were told that the primary source of drugs was staff corruption and smuggling at
social visits. Despite this, staff were not searched often enough, there was no
enhanced gate security and checks on staff and visitors entering the prison were
inadequate.
19. Data, including that on violence and self-harm predating the transfer, was lost which
made it hard for the new leaders to understand the scale of the problems.
Meaningful strategies to tackle drugs, debts, bullying and gang-related violence had
not been developed. Not all violent incidents were investigated, and challenge
support and intervention plans (CSIP) were not being used effectively to manage
perpetrators of bullying or support victims.
20. The restricted regime put in place during the COVID-19 pandemic had continued for
too long and although the new Director had quickly implemented a new regime, too
many prisoners had too little time out of their cell. Access to work and education
was poor and too little keywork was being delivered.
Independent Monitoring Board
21. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 31 January 2023, the IMB
reported that the safety of the prison had deteriorated. There had been an increase
in the number of prisoner-on-prisoner assaults, in self-harm and in weapons finds.
Almost 20% of mandatory drug tests were positive and prisoners under the
influence of psychoactive substances were an almost daily occurrence. The IMB
feared that the prevalence of drugs was likely to increase the negative impact of
gang culture and make prisoners feel less safe.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
22. The Board considered that relationships between staff and prisoners had
deteriorated and there had been a significant reduction in purposeful activity which
had led to prisoners spending long periods locked in their cells. Healthcare services
continued to be under great pressure and the IMB considered that physical and
mental healthcare was at a lower standard to that in the community.
23. The Board issued an addendum to their annual report covering the period 1
February to 31 March 2023. The management and operation of the prison passed
from Serco to Sodexo on 16 February 2023. The Board noted serious concerns
relating to the operation of the prison and implications for safety over the next six to
seven weeks. The number of prisoners on ACCTs more than doubled, from 13 to
32, between the end of February and the end of March. A significant number of staff
had left since the change in contract was announced in August 2022. IMB members
had noticed low staffing levels on all wings.
Previous deaths at HMP Lowdham Grange
24. Mr Walter was the ninth prisoner to die at Lowdham Grange since June 2018. Of
the previous deaths, three were drug related, two were self-inflicted and three were
from natural causes. In our investigation into one of the self-inflicted deaths, we
were concerned about the apparent ease with which the prisoner had been able to
access alcohol, which contributed to but did not cause his death. In our
investigation into a drug related death in July 2021, we were concerned that the
prisoner had been able to access psychoactive substances (PS) with apparent ease
despite the prison being in lockdown due to the COVID-19 pandemic.
25. Up to the end of 2023, there had been six self-inflicted deaths at Lowdham Grange
since Mr Walter’s death, and two deaths from natural causes. In one of the self-
inflicted deaths, we considered the availability of illicit drugs at the prison.
Psychoactive substances (PS)
26. PS (formerly known as ‘legal highs’) continue to be a serious problem across the
prison estate. They can be difficult to detect and can affect people in a number of
ways, including increasing heart rate, raising blood pressure, reducing blood supply
to the heart and vomiting. Prisoners under the influence of PS can present with
marked levels of disinhibition, heightened energy levels, a high tolerance of pain
and a potential for violence. Besides emerging evidence of such dangers to
physical health, the use of PS is associated with the deterioration of mental health,
suicide and self-harm. Testing for PS is in place in prisons as part of existing
mandatory drug testing arrangements.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
27. On 15 June 2012, Mr Benjamin Walter was remanded to HMP Exeter charged with
murder. He was convicted on 3 April 2013 and sentenced to life imprisonment with
a minimum term of 18 years.
28. Following his conviction, Mr Walter spent time at HMP Winchester and HMP Garth
before he was transferred to HMP Lowdham Grange on 27 March 2014.
29. At the end of 2014, Mr Walter was referred to the mental health team and assessed
for an autism spectrum disorder (ASD). He was found not to have ASD and he was
discharged from mental health services.
30. Mr Walter’s records show that he was regularly seen under the influence of drugs,
usually believed to be PS. In addition, he was regularly found in possession of
fermenting liquid (home-made alcohol, known as hooch), and was sometimes
believed to be under the influence of alcohol. Mr Walter’s records suggested that he
held hooch for other prisoners to help pay debts (or for payment) and he also often
cleaned other prisoners’ cells, also for payment. His records indicated that there
were instances when Mr Walter was either subject to violence or had had threats
made against him. These instances appear to have been debt related, but Mr
Walter declined to move wings and indicated that his debts were manageable.
31. Each time Mr Walter was found under the influence, he was monitored until he had
recovered, and he was also seen by the substance misuse team who would advise
him about the dangers associated with drug use. Mr Walter was not generally
receptive to the advice he was given by the substance misuse team so on 5
November 2020, he was referred to mental health services for support for his
substance misuse and for issues relating to his family experiences. Following an
initial assessment, Mr Walter was seen regularly: every three weeks by a mental
health nurse and at two-month intervals by a psychiatrist.
32. Mr Walter’s notes suggested he was experiencing some delusional thoughts. As
there were no other signs of psychosis, his delusional thoughts were considered to
be linked to his PS use and he was advised to reduce his usage.
33. Mr Walter was seen under the influence of drugs on 12 January 2021, and a
member of the substance misuse team went to see him on 19 January. This time,
Mr Walter responded positively and said that he would like to stop using PS
completely before his misuse became a problem again. He said that he had
managed to remain abstinent for two years from 2016 to 2017 when he had been
supported by a friend who was a non-user and a positive influence on him. He told
her that he was presently using PS twice a week. She discussed the various
problems associated with drug misuse and gave Mr Walter a ‘mini target’ to remain
drug free for the remainder of the week.
34. On 15 February, the member of the substance misuse team saw Mr Walter again
when he said that he had reduced his PS to once a week. He said that there were
no set days when he would use PS, but it would be when prisoners offered it to him
as payment to clean their cell. He said that he would use PS at night after lock-up
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
and said he would only use enough PS to ‘pass out’. Mr Walter said his goal was to
attain abstinence in a month’s time and to then become debt free.
35. On the evening of 7 March, Mr Walter was again seen under the influence. The
member of the substance misuse team saw him the following day when he said that
he had not been heavily intoxicated, and he was still only using once a week. When
She saw Mr Walter again on 22 March, he said that he had not used PS for a full
week.
36. Mr Walter continued to limit his PS use over the following weeks however, when the
member of the substance misuse team saw him on 9 June, he said that he had
resumed using around twice a week when alone in his cell. He said using PS made
time pass more quickly. He said that he had no intention of stopping use of PS and
did not consider the drug a problem: he said the only problem was when he could
not afford to buy it. She reminded Mr Walter about the various risks associated with
drug misuse, including the unknown strength of the supply and the dangers of using
drugs when alone. Despite the advice, Mr Walter said repeatedly that he was fine
and did not need any support. She noted that she encouraged Mr Walter to reduce
his use of PS and reminded him about harm reduction. She noted that based on Mr
Walter’s responses, he would be taken off the substance misuse team caseload,
but he could contact her again if he changed his mind and decided he needed
support.
37. On 11 June, Mr Walter attended an adjudication hearing in relation to him having
been found under the influence of drugs the previous month. A prison manager
chaired the hearing and when she asked him if he had used a substance, he said
that he had. He said he was a PS user, that he intended to continue using PS, and
that the prison could not stop him. She told Mr Walter that he would die if he
continued to use PS and he answered that he would not die. After telling Mr Walter
that he was being selfish and that he should imagine his mother being told that he
had died, she imposed a punishment of 14 days’ loss of privileges. (Mr Walter had
also been found guilty and punished at previous adjudication hearings.)
38. On 21 June, the member of the substance misuse team saw Mr Walter again after
he was suspected to be under the influence. Mr Walter said that he had used an
illicit substance, and said “I’m going to use it, I like to use it, it’s not a problem”. Mr
Walter again declined further help from the substance misuse team and she again
warned him about the various risks involved, including risks associated with mixing
substances and the strength of substances.
39. There were no recorded instances of Mr Walter being seen under the influence
during the following two months, although he was found in possession of smoking
paraphernalia on 10 August.
40. Mr Walter’s keyworker saw him for the last time on 11 August. She noted that Mr
Walter appeared settled and he raised no concerns. She noted, however, that Mr
Walter’s hygiene was poor, and she encouraged him to improve.
Events of 20 August
41. At around 2.00am on 20 August, two PCOs began making a standard welfare check
of prisoners on houseblock 2 (where Mr Walter was located). PCO A reached Mr
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Walter’s cell at 2.07am and saw Mr Walter lying on his bed in a strange position.
PCO B was checking cells on the opposite side of the landing and PCO A called to
her to her for assistance. PCO A switched on the in-cell light and then radioed a
code blue emergency (to indicate a prisoner is unconscious or having breathing
difficulties). He also radioed the night orderly officer (the senior officer on duty) for
permission to enter the cell. Permission was given immediately, and the two PCOs
went into the cell. PCO A noted that Mr Walter’s body was cold, stiff, and that he
had no pulse. The PCOs then moved Mr Walter to the floor and PCO A began
cardio-pulmonary resuscitation (CPR).
42. A nurse responded to the code blue call and arrived at Mr Walter’s cell at 2.13am.
While PCO A continued with CPR, the nurse checked Mr Walter with a defibrillator.
The nurse noted that Mr Walter’s clinical observations all indicated that there were
no signs of life, and that rigor mortis was present in his jaws, neck, arms and legs.
The nurse also noted that Mr Walter’s eyes were open, and his pupils were fixed
and dilated. After four cycles of checks with the defibrillator without success, the
nurse told PCO A to stop further efforts to resuscitate Mr Walter as he was dead.
43. Ambulance paramedics were called when the code blue call was made and a first
responder paramedic arrived at 2.32am. The nurse noted that on observing Mr
Walter, the paramedic agreed that the nurse had made the correct decision to
cease resuscitation.
Contact with Mr Walter’s family
44. Lowdham Grange appointed a family liaison officer (FLO). She telephoned Mr
Walter’s father at around 7.40am on 20 August to break the news of his son’s
death. In a follow-up conversation later that day, Mr Walter’s father told her that he
had adopted Mr Walter when he was a young child, and he gave her the first name
of Mr Walter’s birth mother. She obtained full contact details of Mr Walter’s birth
mother and telephoned her to break the news.
45. The prison contributed to the cost of Mr Walter’s funeral in line with national policy.
Support for prisoners and staff
46. One of the prison’s senior managers debriefed the staff involved in the emergency
response to ensure they had the opportunity to discuss any issues arising, and to
offer support. The staff care team also offered support.
47. The prison posted notices informing other prisoners of Mr Walter’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Walter’s death.
Post-mortem report
48. The post-mortem report gave Mr Walter’s cause of death as synthetic cannabinoid
toxicity. Toxicology tests showed that Mr Walter had taken PS before he died. The
pathologist noted that post-mortem examinations confirmed there was no anatomic
(natural) cause for Mr Walter’s death.
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Drug strategy at HMP Lowdham Grange
49. We are concerned that Mr Walter was able to access PS with apparent ease. We
acknowledge the huge challenges inherent in preventing drugs entering Lowdham
Grange. The prison has a large perimeter and is situated in an open and accessible
rural area vulnerable to ‘throw-overs’ and drones. The illicit drugs market in prison is
controlled by organised crime gangs and the scale of the problem requires a co-
ordinated approach. The threat from drugs is constantly evolving and more can
always be done.
50. HMIP and the IMB both raised concerns in their most recent reports that it is easy
for prisoners to access drugs in the prison. Following the transfer to Sodexo, the
security department lost some experienced staff and some important statistical
data. Nevertheless, several important measures have been introduced or are
pending, including:
• A dedicated drug strategy manager was appointed in February 2023.
• 100% staff search was introduced in October 2023.
• Funding has been obtained to replace the netting covering all the exercise
yards.
• The outward opening windows on Houseblocks One and Two are being
replaced with vented windows with meshes in January 2024.
• Since March 2023, six members of staff have been dismissed or resigned for
involvement in bringing drugs or mobile phones into the prison.
51. We note, however, that the prison does not have a specific PS reduction strategy.
Additionally, many of the initiatives to reduce drug supply and demand at Lowdham
Grange are undermined by staff shortages. Staff search at the gate is not always
completed and the prison is not running intelligence led drug testing or completing
the number of suspicion cell searches required. We raised concerns about these
issues in a recently issued self-inflicted death investigation at Lowdham Grange and
recommended that the Director should request support from HMPPS. As we are
awaiting a response to that recommendation, we make no further recommendation
in this case.
Mr Walter’s substance misuse
52. Mr Walter had a long history of using illicit substances in prison. Each time he was
identified as being under the influence he was monitored until he had recovered and
was then seen by the substance misuse team. Mr Walter was generally dismissive
of offers of support, although in January 2021, he said that he would like to stop
using PS. Mr Walter continued to limit his PS use over the next several months,
although he said that he continued to use PS to some extent, However, when Mr
Walter was seen by his substance misuse worker on 9 June, he said that he had
resumed using PS twice a week and said that he had no intention of stopping. The
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
substance misuse worker reminded him of the risks with PS use, including the
unknown strength of the supply.
53. Mr Walter reiterated his attitude to continued PS use at an adjudication hearing on
11 June when he said that the prison could not stop him, and he was dismissive of
the suggestion that he would die if he did not stop.
54. We are satisfied that Mr Walter knew the dangers of PS use and consider he was
offered appropriate support and guidance from the substance misuse team. We
have found no evidence that Mr Walter intended to die on 20 August, but it is clear
that his intention was to continue to use PS.
Clinical care
55. The clinical reviewer concluded that the healthcare Mr Walter received at Lowdham
Grange was equivalent to what he could have expected to receive in the
community.
56. The clinical reviewer has made two recommendations that are not directly linked to
Mr Walter’s death but which the Head of Healthcare will need to address.
Governor to note
57. While Mr Walter was offered ongoing support by the substance misuse team, the
problem with Mr Walter’s substance misuse was not discussed with him during his
periodic key-worker meetings. It is clear that Mr Walter was generally unreceptive to
advice about substance misuse. However, we consider that his keyworkers should
have included discussion about his drug use during their meetings, including his
responses. The Director might wish to consider how key-workers structure meetings
with prisoners to focus on specific areas of concern.
Inquest
58. An inquest into Mr Walter’s death that was held on 26 June 2023 concluded that his
cause of his death was synthetic cannabinoid toxicity.
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE