Ricky Crosher

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Independent investigation into
the death of Mr Ricky Crosher,
a prisoner at HMP Lowdham
Grange, on 11 October 2023
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
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© Crown copyright, 2025
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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 Ricky Crosher died after being found hanged in his cell on 11 October 2023 at HMP
Lowdham Grange. He was 40 years old. I offer my condolences to Mr Crosher’s family and
friends.
Mr Crosher’s was the fifth self-inflicted death at Lowdham Grange since October 2021 and
the fourth of five self-inflicted deaths there during 2023. In February 2023, the
management of the prison transferred from Serco to Sodexo and resulted in an exodus of
staff alongside higher levels of drugs, violence and self-harm, less time out of cells and a
deterioration in staff-prisoner relationships.
In my investigation into the first of the self-inflicted deaths in 2023, I expressed my serious
concern about prisoner safety at Lowdham Grange. Unfortunately, my investigation of Mr
Crosher’s death has only served to prove those concerns fully justified. During the
relatively short period Mr Crosher was there, the prison was not only unable to keep him
safe but failed to recognise, including obvious signs of serious assault, that he needed
support. Perhaps the saddest aspect of this case is that Mr Crosher rang the prison’s safer
custody support line seven times, including four times over the two days before he died
and yet nothing appears to have been done in response to his calls.
In December 2023, HMPPS took back interim control of the prison and on 1 August 2024,
the prison was formally taken back into public sector control. The prison is in transition and
the prison service now faces a significant challenge to restore order and ensure the safety
of the prisoners and staff that live and work there. I make fewer recommendations than I
otherwise might have done in recognition of this period of transition.
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 January 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 8
Findings ......................................................................................................................... 24
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Summary
Events
1. Mr Ricky Crosher had a significant history of alcohol and drug misuse, mental
health issues and self-harm by cutting. On 26 August 2015, he was sentenced to 13
years imprisonment for aggravated burglary with intent.
2. Mr Crosher was released on licence on 2 December 2022 and recalled to prison on
4 March 2023 for breaching his licence by using drugs. He moved to HMP
Lowdham Grange on 19 July 2023.
3. On arrival, Mr Crosher told the prison’s safer custody team that he had last smoked
psychoactive substances (PS) a week before and wanted to make a fresh start and
work with them. He said he had been in debt for PS and vapes before in prison but
either he or his family had managed to pay them off. His prison telephone calls from
Lowdham Grange showed he frequently asked for money from his family to pay
other prisoners.
4. On 22 August, he told his mother he had been beaten up. His substance misuse
nurse noticed he had a black eye two days later and Mr Crosher confided that he
had been assaulted by other prisoners. Another nurse submitted a security
information report about his injuries.
5. On 25 August, Mr Crosher called the advice line staffed by trusted prisoners and
reported a problem with a prisoner on his wing. On 27 August, he was noticed to be
under the influence of a substance suspected to be PS.
6. On 12 September, Mr Crosher received treatment for cuts and bruises to his face.
On 17 September, he told his mother that he had been assaulted again. The lack of
information about this in Mr Crosher’s prison records means we do not know
whether the injuries relate to the same incident.
7. On 18 September, Mr Crosher called the prisoner advice line and told a prisoner he
was under threat, there were a lot of people he did not get on with and he had a
black eye and a broken nose. The prisoner advised Mr Crosher to call the safer
custody line and leave a message. Mr Crosher’s telephone records indicated that
he did this.
8. On 7 October, Mr Crosher told staff he had cut himself with a razor blade. He said
that he wanted to move wings because he was not safe but would not give the
names of the people he was under threat from. Staff began Prison Service suicide
and self-harm monitoring procedures (known as ACCT).
9. Shortly after 2.00am on 8 October, Mr Crosher set fire to a pillow in his cell and was
moved to the adjacent spur on the same wing as his cell was full of water. He
repeated he was under threat and said he would isolate in his cell until he was
moved to a different wing. Later the same day, he told a mental health nurse that
“his head had gone” and he could not cope.
10. Mr Crosher asked to move to another wing at an ACCT review on 9 October but
was advised to try to settle in on his new spur and to ring the safer custody line or
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talk to wing staff if he needed to. On 9 and 10 October he rang the prisoner advice
line and the safer custody line eight times in total.
11. He left a message on the prisoner advice line on 10 October, that he “desperately”
needed to speak to someone. The length of his calls to the safer custody line
indicated he left messages but calls to this line were not recorded. There is no
evidence as to whether staff listened to the messages he left before or after he
died. His telephone calls to his parents indicated that he was very anxious about
being in debt to other prisoners.
12. At 2.25am on 11 October, Mr Crosher asked the night patrol officer for a nurse.
There are no nurses on duty at night in the prison. He did not say why he wanted to
see one. Mr Crosher was last checked and seen to be alive at a routine check at
6.47am. Shortly after 7.00am, an officer completing an ACCT check discovered Mr
Crosher had covered his observation panel and could not get a response from him.
The officer checked the other prisoners on ACCT on that spur and then returned to
Mr Crosher’s cell with a colleague.
13. They opened the inundation point in the cell door and saw Mr Crosher hanging from
the toilet door. Officers and nurses gave Mr Crosher cardio-pulmonary resuscitation
until paramedics took over, however Mr Crosher was declared dead at 7.41am.
Toxicology showed he had taken cannabis and PS at some point before he died.
Findings
14. Throughout the period Mr Crosher was in Lowdham Grange there was a chronic
shortage of operational staff and wing managers. Violence, illegal drugs and debt
increased. Dedicated teams such as safer custody staff were cross deployed to
help run the basic daily regime.
15. These circumstances impacted the ability of staff to identify and support prisoners
at risk. The lack of staff and support services had a significant impact on Mr
Crosher's care including only one keywork session, almost no 1:1 contact with his
allocated substance misuse worker, no evidence of responses to his calls to the
prison telephone support services and that no one answered the main switchboard
number when Mr Crosher’s parents rang the prison on 7 October.
16. Mr Crosher’s profile (with a history of self-harm, debt, substance misuse, assault
victim, under threat) meant that he should have been identified as at risk to himself
and from others, discussed at the Safety Intervention Meeting (SIM) and received
specialised support. There was no evidence Mr Crosher received any meaningful
support or protection from violence.
17. The level of care and support Mr Crosher received at Lowdham Grange was
unacceptably low. Some basic actions were not taken that might have made a
difference, including:
• Intelligence reports were not submitted consistently by staff who noticed his
injuries in August and September and not at all by wing staff.
• The intelligence reports that were submitted were poorly processed and did not
take into account Mr Crosher’s long history of being under threat from his peers.
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• None of the intelligence concerning the assaults was passed to safer custody.
• There were a number of failings in ACCT procedures, most seriously the lack of
a review in response to the cell fire which should have been regarded as an
escalation of risk. Other issues included: healthcare staff not attending reviews,
checks were sometimes chaotic, poor completion of the ACCT document at
times, insufficient management assurance checks and staff being asked to do
case reviews with little notice.
18. The first officer to discover Mr Crosher unresponsive should have called for
assistance immediately. Staff should not have opened the inundation point before
entering Mr Crosher’s cell.
19. The clinical reviewer concluded that the healthcare received by Mr Crosher was
partially equivalent to that he could have expected to receive in the community.
They noted that there were significant restrictions on healthcare input due to the
specific circumstances at Lowdham Grange at the time. The clinical reviewer
concluded that information sharing between healthcare staff and prison staff was
poor, record keeping was variable and no healthcare staff attended Mr Crosher’s
ACCT reviews.
Recommendations
• The Governor should introduce a standalone comprehensive debt strategy which is
communicated to and understood by all staff, including providing appropriate
support and intervention to prisoners where there are any concerns about debt.
• The Governor should evidence how the prison will monitor the challenging of
blocked observation panels to ensure compliance with local processes.
• The Governor should ensure that prisoner telephone calls to the safer custody line
are recorded and monitored in the same way as calls to anyone other than those
organisations contained in Annex B of the Authorised Communications Controls and
Interception Policy Framework.
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The Investigation Process
20. HMPPS notified us of Mr Ricky Crosher’s death on 11 October 2023.
21. 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.
22. The investigator visited Lowdham Grange on 26 October. She obtained copies of
relevant extracts from Mr Crosher’s prison and medical records, CCTV, body-worn
video camera (BWVC) footage and radio traffic from 11 October 2023.
23. The investigator interviewed eleven members of staff between March and August
2024.
24. NHS England commissioned a clinical reviewer to review Mr Crosher’s clinical care
at the prison. The clinical reviewer and the investigator interviewed four healthcare
staff together.
25. We informed HM Coroner for Nottingham of the investigation. The Coroner gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
26. The Ombudsman’s office contacted Mr Crosher’s mother to explain the
investigation and to ask if she had any matters she wanted us to consider. Mr
Crosher’s mother said she was concerned that her son had been assaulted by other
prisoners, had not seen a doctor about his broken arm and had not received
adequate mental health care. She said she and Mr Crosher’s father had both
telephoned the prison to try to relay their concern for his welfare. She asked why
there was so much blood in Mr Crosher’s cell when he was found hanged and why
he was not in a safer cell (a cell with reduced ligature points). We have covered
these issues in this report and in the clinical review.
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Background Information
HMP Lowdham Grange
27. HMP Lowdham Grange is a category B male adult prison located in Lowdham,
Nottinghamshire. The prison was operated by Serco for 25 years until 16 February
2023, when Sodexo Justice Services took over the running of the prison. This was
the first time a prison had transferred from one private contract manager to another.
28. In December 2023, HMPPS took back operational management of the prison for an
interim period, bringing in an experienced governor and additional HMPPS staff,
including officers on detached duty, to improve staffing levels. The interim period of
HMPPS control was initially extended from March to September 2024 but in May
2024, HMPPS decided to take back full control of the prison and terminate the
contract with Sodexo. On 1 August 2024, the prison was formally taken back into
public sector control.
29. Nottinghamshire Healthcare NHS Foundation Trust provides healthcare services.
HM Inspectorate of Prisons
30. 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, whose numbers were reduced by the loss of significant numbers of key
and specialist staff.
31. 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. 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. Access to work and education
was poor and too little keywork was being delivered.
32. HMIP returned to the prison in January 2024 to review progress. Inspectors found
that a shortfall of 51 Prisoner Custody Officers (PCOs) meant that the very basic
needs of prisoners were often not met. Prisoners were often locked up for very long
periods which caused frustration. Violence had increased by 55% and not enough
was being done to investigate incidents or challenge perpetrators. Illicit drug use
had also increased but very few security reports were submitted about this. Since
HMPPS had arrived, the number of searches had increased and therefore so had
the number of illicit items found.
33. The relationship between Sodexo and the healthcare provider was strained.
Concerns from healthcare staff about their safety had resulted in only minimal and
critical health services being delivered.
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Independent Monitoring Board
34. 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 was 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.
35. 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.
36. The investigator spoke to the Chair of Lowdham Grange IMB in October 2023. The
Chair said she was extremely concerned about the safety of staff and prisoners.
Nurses were refusing to go on to the wings except for emergency code calls and
the education provider NOVUS had also told education staff not to go on to wings.
Staffing levels and morale was extremely low. Violence was frequent and a number
of prisoners were in debt because of the prevalence of illicit substances.
Previous deaths at HMP Lowdham Grange
37. Mr Crosher was the eighth prisoner at Lowdham Grange to die since October 2020.
Of the previous deaths, two were from natural causes, one was drug related, and
four were self-inflicted. 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. In our investigation into the self-inflicted death of a
prisoner in March 2023, we were concerned that he was able to access PS with
apparent ease, was in debt and under threat from other prisoners. We did not
consider that the prison had adequately addressed these issues or supported the
prisoner.
38. Up to September 2024, there have been three deaths since Mr Crosher’s, one self-
inflicted, one from natural causes and one drug-related.
Assessment, Care in Custody and Teamwork (ACCT)
39. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner. After an
initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner.
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40. As part of the process, a care plan (a plan of care, support and intervention) is put
in place. The ACCT plan should not be closed until all the actions of the care plan
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
which accompanies the prisoner as they move around the prison. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011.
Psychoactive substances (PS)
41. The term psychoactive substances is a broad term that refers to a drug or other
substance that affects mental process. Synthetic cannabinoids and synthetic
opioids (including nitazene) are substances that mimic the effects of traditional
controlled drugs such as cannabis, cocaine, heroin and amphetamines. Synthetic
cannabinoids and synthetic opioids can be difficult to detect as the compounds
used in their manufacture can vary and use of these substances presents a serious
problem across the prison estate.
42. PS 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 these substances 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.
Key worker scheme
43. The key worker scheme is a key part of HMPPS’s response to self-inflicted deaths,
self-harm and violence in prisons. It is intended to improve safety by engaging with
people, building better relationships between staff and prisoners and helping people
settle into life in prison. Details of how the scheme should work are set out in
HMPPS’s Manage the Custodial Sentence Policy Framework.
44. In 2023/24, due to exceptional staffing and capacity pressures in parts of the estate,
some prisons are delivering adapted versions of the key work scheme while they
work towards full implementation. Any adaptations, and steps being taken to
increase delivery, should be set out in the prison’s overarching Regime Progression
Plan which is agreed locally by Prison Group Directors and Executive Directors and
updated in line with resource availability.
Inundation point
45. Cell doors have inundation points, a removable bung that allows a hose to be used
to spray water into a cell in the event of a fire, without opening the door.
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Key Events
46. Mr Ricky Crosher had a significant history of alcohol and poly-substance misuse,
mental health issues and self-harm by cutting. Mr Crosher’s OASys report (a risk
assessment completed by the Probation Service) recorded three previous suicide
attempts, all by heroin overdose. Mr Crosher had spent a significant part of his life
in prison for offences related to his drug use and was frequently managed under
Prison Service suicide and self-harm monitoring procedures (known as ACCT). On
26 August 2015, he was sentenced to 13 years imprisonment for aggravated
burglary with intent.
47. Mr Crosher was released from HMP High Down on licence on 2 December 2022.
He was recalled to prison on 4 March 2023 for breaching his licence by using drugs
and arrived at HMP Thameside the same day.
HMP Thameside 4 March 2023 – 18 July 2023
48. Mr Crosher told a nurse during an initial health assessment that he smoked crack
cocaine daily and also sometimes used Subutex (buprenorphine - a semi-synthetic
opioid used in detoxification from opioid addiction). His urine tested positive for
opiates, cocaine, cannabis and Subutex. He was prescribed methadone for opiate
withdrawal and venlafaxine for depression and anxiety.
49. Mr Crosher was briefly managed under ACCT procedures twice at Thameside after
he self-harmed by cutting. On 18 May, he had an altercation with another prisoner
and sustained scratches to his face. He lost his job as a wing cleaner the next day
and cut his arm severely enough to need hospital treatment. On 11 June, Mr
Crosher fell in his cell while under the influence of psychoactive substances (PS –
known in prison as Spice). His methadone was reduced as a precaution due to the
danger of mixing opiates and PS. On 29 June, Mr Crosher made superficial cuts to
his arms because he was frustrated with the continued reduction in his methadone.
50. On 18 July 2023, Mr Crosher transferred to HMP Bedford for one night before
moving to HMP Lowdham Grange the next day.
HMP Lowdham Grange 19 July – 6 October 2023
51. When he arrived at Lowdham Grange Mr Crosher told a prisoner custody officer
(PCO) from the prison’s safer custody team that he had last smoked PS a week
before and wanted to make a fresh start and work with the substance misuse team.
He said he had been in debt for PS and vapes before in prison but either he or his
family had managed to pay them off.
52. A nurse completed an initial health assessment. Mr Crosher denied any feelings of
suicide or self-harm. He said he thought he might need mental health support and
the nurse noted that he seemed a little vulnerable. She referred Mr Crosher to the
mental health and substance misuse teams. A GP continued his prescriptions for
methadone and venlafaxine.
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53. Mr Crosher had a keyworker session with another PCO the same day. She noted
he seemed well and happy to be at Lowdham Grange for a fresh start.
54. On 24 July, Mr Crosher told the substance misuse team that he did not want to
work with them. As a methadone patient, he automatically remained on their
caseload and an assessment was re-booked.
55. At 2.53pm on 25 July, Mr Crosher telephoned his mother and asked her if she could
give him £10.00 or £15.00. He sounded anxious but did not have enough credit on
his account to speak for very long.
56. At 3.19pm, Mr Crosher telephoned the prison’s safer custody line (a telephone
support service for prisoners to contact the safer custody team direct from their cell
telephones). Calls to the line are not recorded. (Most calls a prisoner makes from
his prison phone account are recorded and can be listened to later by staff if
evidence suggests it necessary.) The safer custody line’s recorded message lasted
for eight seconds before voicemail connected. Mr Crosher’s call lasted ten seconds
in total.
57. On 31 July, a nurse completed a mental health triage assessment with Mr Crosher.
The nurse noted Mr Crosher appeared in a good mood and was pleasant and co-
operative. He said he had no thoughts of suicide or self-harm and did not need any
mental health support. He said he usually self-harmed out of frustration with the
prison environment. The next day the mental health team allocations meeting
discharged Mr Crosher from their caseload.
58. On 10 August, a nurse completed Mr Crosher’s re-arranged substance misuse
assessment by telephone after Mr Crosher said he was unwilling to attend in
person. The nurse said Mr Crosher appeared guarded and disinterested and did not
want to discuss his history of substance misuse or its role in his offences. He said
he had taken illicit opiates, Subutex and PS in Thameside to cope with the pain of a
broken wrist. The nurse completed a support care plan and planned to visit Mr
Crosher once a month.
59. On 21 August, Mr Crosher telephoned his mother and asked her if he could urgently
borrow £30.00.
60. A nurse saw Mr Crosher on 22 August at the medication hatch. He said Mr Crosher
appeared low in mood. He gave Mr Crosher harm minimisation advice and outlined
the risk of using PS with prescribed medication. At 10.22am, Mr Crosher called his
mother and asked her if she had £10.00 she could lend him. At 8.18pm, he called
his mother back and said he had been in a fight and had a bad nose and eye. He
said someone thought he had taken something from their cell and he thought it was
a set up. His mother asked him if the prison officers had intervened and Mr Crosher
said they had not. There is nothing in Mr Crosher’s prison record to indicate that
staff had either witnessed the fight, or noticed Mr Crosher’s injuries after it.
61. Two days later, on 24 August, the nurse noticed Mr Crosher had bruising on his
face and a black eye. Mr Crosher was reluctant to talk about what had happened so
the nurse told him he would call him on his cell telephone later in the day. He
discussed Mr Crosher in the healthcare lunchtime handover meeting and it was
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decided Mr Crosher should be brought to healthcare for assessment. The nurse
tried to call Mr Crosher as planned but he did not answer his phone.
62. The same day, Mr Crosher moved from the induction unit to a cell on A Wing. (This
was the last entry on his electronic prison record - NOMIS - until 7 October.)
63. Mr Crosher saw the GP about his injuries that afternoon. They also discussed the
injury to his wrist and Mr Crosher asked for tramadol (an opioid painkiller) to
manage the pain. The GP said he would not consider tramadol unless Mr Crosher
first reduced his methadone from 20ml a day to 10ml.
64. The nurse spoke to him after he had seen the GP. Mr Crosher said he was willing to
gradually reduce his methadone in order to be prescribed tramadol. He told the
nurse that he had been “jumped” on his previous wing two days before and still felt
a bit shaken by the experience. Mr Crosher said he thought he had been attacked
due to his offence which had involved stabbing a 17 year old female with a
screwdriver while under the influence of drugs. He told the nurse that safer custody
was aware of him being assaulted and so the nurse did not contact them himself.
We have not seen any evidence that Mr Crosher reported the assault to safer
custody or that anyone from that team saw him. Mr Crosher said he would “keep his
head down”. He denied taking any illicit substances or any thoughts of suicide or
self-harm.
65. At interview, the nurse said this was the only time he had been able to see Mr
Crosher in person in a confidential setting. At the time, healthcare staff had been
told not to attend the wings except for emergencies because senior managers
considered that there were insufficient prison staff to keep them safe. There were
rarely enough staff to escort prisoners to healthcare and limited space there to see
people on their own. He was therefore unable to undertake effective psychosocial
support sessions. The nurse said he tried to mitigate this by telephoning Mr Crosher
in his cell but Mr Crosher did not answer his phone. His work as Mr Crosher’s
substance misuse keyworker was therefore reduced to brief welfare checks when
he saw Mr Crosher at the medication hatch in the presence of other prisoners and
staff.
66. Also on 24 August, another nurse completed an intelligence report (IR) after she too
noticed Mr Crosher’s facial injuries when he attended the healthcare unit to see the
GP. She reported that Mr Crosher had a black eye and when she asked him how he
had got it, he had replied that someone had got the wrong information. There is no
indication in Mr Crosher’s records that any actions were taken in response to this IR
and it does not appear to have been assessed by the security department. The
Head of Safer Custody confirmed that they were unaware of the assault on Mr
Crosher.
67. At 1.30pm on 25 August, Mr Crosher telephoned the Lowdham Grange prisoner
advice line (PAL - a telephone service staffed by trusted prisoners during the day,
regime permitting). The call connected to voicemail after 46 seconds and Mr
Crosher left a message:
“Hello, can someone come over and see me please. You’ve put someone on
the wing, it’s a problem for me and, you know, I need someone to come and
see me please.”
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68. At 1.46pm, Mr Crosher called his mother and told her that he had a problem with a
prisoner that had moved to the wing. He said his black eye had come out and it was
attracting unwanted questions from other prisoners. He asked his mother to put
£25.00 into an account in a woman’s name, indicating that she had paid money to
them before. He said he had to “pay something off” from his previous wing because
he “kept bumping into people and it was no good”.
69. The next day on 26 August, Mr Crosher told his mother that his father was going to
give her £25.00 for him and not to put it in the woman’s account he had mentioned
because he wanted to “save that one for Monday”. He said he would call back with
the details of a different account. When he called his mother back she said
someone else had rung her with the account details. Mr Crosher called her again to
check she had paid the money in and became agitated when she told him that his
father had only given her £20.00 and not £25.00. His mother agreed to make up the
difference.
70. On 27 August, wing staff noticed Mr Crosher was unsteady on his feet with dilated
pupils and slurred speech. A nurse assessed him in his cell and concluded Mr
Crosher was under the influence of an illicit substance. He sent a task to the
substance misuse team and stopped Mr Crosher’s methadone for 24 hours as a
precaution. There is no evidence in the clinical records that Mr Crosher was seen
by the substance misuse team for a follow up appointment after this incident and no
evidence that he was monitored in line with the prison’s policy for monitoring
prisoners suspected of being under the influence of illicit substances.
71. On 5 September, Mr Crosher applied for employment. He said he was depressed
by not working and would work in whatever job came up first. He was placed on the
waiting lists for several workshops and the waiting list for wing cleaner.
72. On 12 September, a nurse saw Mr Crosher to assess cuts and bruises to his face.
The entry in the clinical record refers to an assault but gives no detail of the incident
or what Mr Crosher said about it. At interview the nurse could not recall anything Mr
Crosher told him that day. There is no mention of an assault in Mr Crosher’s prison
records and no evidence that the safer custody team were made aware of the
incident or offered Mr Crosher any support.
73. A nurse saw Mr Crosher at the medication hatch on 17 September and noticed he
had a black eye. She recorded that he declined an assessment. At 4.49pm, Mr
Crosher called his mother and told her he had “had another beating”. He told her he
was still in debt and needed a job. At the end of the call he asked his mother if she
could give him some money. There is no other information in Mr Crosher’s prison
records about this assault and no IR was completed. We do not therefore know
whether this was a separate incident to the one on 12 September.
74. A nurse spoke to Mr Crosher at the medication hatch the next day. He noted that Mr
Crosher had a nasty bruise to one eye but, apart from confirming he had been
assaulted, he was unwilling to discuss details of the incident. At 1.45pm, another
nurse telephoned Mr Crosher to complete an asthma review. He told her he thought
he had broken his nose and asked to see a nurse. The nurse recorded that she had
tasked the nurse in charge with responding to his request.
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75. The same day at 3.19pm, Mr Crosher called the prisoner advice line and spoke to a
prisoner. Mr Crosher said he was under threat, there were a lot of people he did not
get on with and he had a black eye and a broken nose. He said it was the second
time he had “had a kicking” and thought he had some broken ribs. The prisoner
advised Mr Crosher to call the safer custody line and leave a message. Mr Crosher
called the safer custody line at 3.23pm. The call lasted for 22 seconds indicating
that he left a voicemail.
76. The staff member with oversight of the safer custody department at the time told the
investigator that messages to the safer custody line are not recorded and monitored
in the same way as other prisoner telephone calls because of their sensitive nature.
Usual practice was for safer custody staff to listen to messages at the beginning
and end of every shift. Messages were deleted after they had been listened to.
Although he thought some sort of log of the calls was kept, the prison was unable to
provide one. He told us that, at the time, staff shortages meant that safer custody
staff were frequently cross-deployed to wings and were unable to perform their
roles – including checking the voice messages every day.
77. A PCO who was a regular officer on A Wing said that Mr Crosher was polite and
willing to talk to staff when spoken to but did not go out of his way to initiate
conversation. She thought Mr Crosher was vulnerable to being put under pressure
and acted as a ‘runaround’ for other prisoners (he would do things for them so they
did not get into trouble themselves). She knew he used PS and thought that doing
things for other prisoners might be in part how he paid for these. She said that at
the time there was a lot of PS on the wings.
78. The PCO said she had noticed Mr Crosher with a bruised eye but said he had told
staff he had fallen over in his cell. At the time there was a shortage of houseblock
managers and sometimes there was no manager on the houseblock for weeks at a
time. Houseblock managers were responsible for creating support plans for
prisoners in debt and under threat. She said it was therefore extremely difficult for
staff to arrange extra support or wing moves for prisoners vulnerable to being
bullied and threatened. There was also no debt strategy in place for supporting
prisoners and no keywork took place because there were only just enough staff
most days to run the most basic regime.
79. On 21 September, Mr Crosher made another application for a job as he still did not
have one. Staff replied the next day that he was on several waiting lists and they
would allocate him a job when a space became available. Mr Crosher was not given
a job before he died.
80. On 3 October, Mr Crosher saw a nurse in response to his request to see a nurse on
18 September. He said the issue with his ribs had resolved but he had a painful
lump on his wrist. The nurse booked Mr Crosher a GP appointment but this did not
take place before Mr Crosher died.
81. At 5.46pm on 4 October, Mr Crosher called the safer custody line for 19 seconds
(indicating he left a voicemail). He spoke to his mother immediately afterwards but
did not give any indication to her that he had called the safer custody team or why
he might have needed to.
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82. On 5 October, a nurse rang Mr Crosher for a welfare check but he did not answer
his cell telephone.
83. On 6 October, Mr Crosher called his mother at 9.53am. He said, “it had all started
again” and he wondered whether someone had looked him up on the internet. He
said he did not feel paranoid but thought everyone was “plotting” against him. He
said nothing particular had happened but he thought that the female members of
staff were upset with him and other people were talking about him. After a couple of
minutes the conversation reverted to general family news. He called his mother
back at 12.52pm and apologised if he had worried her earlier but “his head was in
bits” and it “was mad in here”. He said he was worried there were rumours about
why he was in prison and his mother tried to reassure him.
84. Mr Crosher spoke to his mother again at 2.05pm. He spoke slowly and sounded
confused. He rang back at 10.37pm and told his mother that he was worried a
woman in the prison had put a hit out on him. His mother tried to reassure him that
his concerns were unfounded.
Events of 7 – 11 October 2023
7 October 2023
85. According to the cell bell record, Mr Crosher pressed his cell bell at 4.12am on
Saturday 7 October. A PCO, the night patrol officer for A Wing, answered the bell at
4.14am and discovered that Mr Crosher had made several cuts to his arm with a
razor. The PCO radioed a code red emergency (which indicates significant blood
loss) and the night orderly officer, a senior prisoner custody officer (SPCO), and two
PCOs responded and entered his cell. The control room officer called an
ambulance in line with the prison’s emergency code policy, but the SPCO told them
to stand it down when it became clear that Mr Crosher’s injuries did not require
hospital treatment. (There are no nurses on duty at Lowdham Grange at night.)
86. The investigator watched body worn video camera footage of the incident. The copy
provided did not show the time of events and started at the point staff entered Mr
Crosher’s cell. There was a significant amount of blood on the floor of the cell just
inside the door. Mr Crosher handed the staff a razor blade which he had used to cut
himself. Mr Crosher appeared calm and allowed staff to dress his wounds.
87. It is not possible to hear the dialogue between the staff and Mr Crosher but staff
reports of the incident said he was under threat on the wing and “had pissed too
many people off”. He asked for a wing move and was advised by the SPCO to
speak to safer custody.
88. A PCO said Mr Crosher said that he needed to move off the wing because he was
not safe there. He would not give the names of the people he was under threat
from. She said she was surprised that Mr Crosher had self-harmed. The PCO said
all three of the officers that spoke to him that night in his cell were A Wing officers
and had a good rapport with Mr Crosher. They told him he could speak to staff if he
had issues and did not have to take such extreme measures. She said Mr Crosher
calmed down and she reassured him that something would be done to help him the
next day.
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89. She said she gave a detailed handover to the incoming day manager when she
went off shift, but she was not aware at that stage that the prison would run a ‘red
regime’ that weekend. This meant that there were not enough staff to unlock
prisoners for any reason. As a result, Mr Crosher was not moved to another cell on
7 October.
90. Staff began ACCT monitoring procedures. A PCO completed the concern and keep
safe form at 4.55am. He reported that Mr Crosher said he would self-isolate until he
was moved, otherwise he would do something “worse than cutting up”.
Observations were set at two every hour with three conversations a day.
91. The immediate action plan contained two sets of entries completed by an SPCO at
4.20am and by another SPCO at 3.00pm. The placement of the first SPCO’s entries
and signature indicated they were added after the other SPCO’s. We do not believe
the first SPCO completed the immediate action plan at the time stated or within an
hour of ACCT procedures being started, as she was required to do.
92. Staff submitted an IR at 5.39am. The author reported that Mr Crosher had cuts to
his hands and believed he was under threat. The intelligence assessment section
said, “It is likely Mr Crosher is suffering from a previous injury to his wrist and this is
causing the pain. He self-harms to distract himself from his personal issues. There
isn’t any intel to suggest he is under threat.”
93. At 8.26am, Mr Crosher told a PCO that he felt under threat. He asked if healthcare
staff could check his cuts and put his bedding in the laundry.
94. A nurse attempted to examine Mr Crosher’s wounds later that morning, but he
refused treatment and asked to be taken to hospital. The nurse explained that he
did not need to go to hospital but Mr Crosher would not change his mind. The nurse
asked his colleague to help and she persuaded Mr Crosher to let them clean, dress
and steri-strip his cuts. The nurse sent an urgent task to the mental health team to
review Mr Crosher.
95. At 12.23pm, Mr Crosher rang his mother and told her that he had cut himself. He
said that his “head was in tatters”. He was tearful and told her that he could not do
another five years in prison. She tried to reassure him and asked him if he was
taking his venlafaxine. He said there were things going on and everyone had been
turned against him. He said he had decided to self-isolate in his cell. Mr Crosher
ended the call abruptly when someone appeared to be at his door and told his
mother he would call her back.
96. At 12.59pm, Mr Crosher phoned his father. He told his father he had cut himself to
get off the wing. He said some men on the wing were getting drunk and were going
to take over the wing. Mr Crosher asked his father to call the police and tell them.
He said he was not under the influence of drugs. His father asked him if people
were coming after him but Mr Crosher ended the call. He made no further calls that
day.
97. An SPCO completed the ACCT assessment in Mr Crosher’s cell at about 3.00pm.
The SPCO said he wanted to take Mr Crosher to a more private location but Mr
Crosher had not wanted to leave his cell. A custodial operational manager (COM)
joined him part way through the assessment. The COM said it was her day off but
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she had been asked to work as the prison was extremely short staffed. She said
she agreed to go in for about three or four hours in the afternoon and shortly before
she left she was asked to complete Mr Crosher’s first ACCT case review. She had
not met Mr Crosher before and knew nothing about him other than the information
written on his ACCT document.
98. During the assessment Mr Crosher said he was feeling low because he did not feel
safe on A Wing. He said he had told staff but nothing had been done to support him
and he felt that he was being ignored. He said he had cut himself to get the
attention of staff. Mr Crosher said he had good family support, especially from his
parents. He said he would like to move to another wing and have support from the
mental health team.
99. The COM and SPCO then held the first case review immediately afterwards. The
COM said there was no opportunity to make the review multi-disciplinary because
no one from the mental health team was available at that time.
100. The COM noted that Mr Crosher said he had no current thoughts of self-harm. He
told her that other prisoners were making threats towards him because of his
offence and that he believed there was a price on his head. He said he wanted to
remain in his cell until he could move to a different part of the prison. Mr Crosher
said he had support from his parents and had spoken to them that morning. She
decided to maintain the level of observations at two an hour and scheduled another
review for Monday 9 October so someone from the mental health team could
attend. She added “wing move” as a single action to the care plan and wrote that it
was “required” and should be actioned by the houseblock manager.
101. The COM said that normally a wing move required some consideration with safer
custody about which location would be safest to move the prisoner to. She said that
if they had known the bigger picture and there had been space it might have been
possible to move Mr Crosher immediately, however she considered that Mr Crosher
would be safe over the weekend because the red regime meant that he would be
locked in his cell.
102. At about 3.10pm, Mr Crosher told a PCO during the afternoon conversation
required by his ACCT management that his “head was a mess” but he felt okay.
103. At 3.40pm, staff submitted a second IR about Mr Crosher. It was titled “self-harmed”
but gave no further details. The security assessment stated, “Crosher self-harms
when frustrated, may also be an avenue to get what he wants.” There is no
evidence that this was analysed or any further actions to be taken identified.
104. At about 5.50pm, Mr Crosher told a PCO that he felt okay and just needed some
hot water, which she got for him.
8 October 2023
105. According to the cell bell record, Mr Crosher pressed his cell bell at 2.03am on 8
October. The operational cell fire report recorded that the fire alarm system
activated automatically at 2.06am. An operational support officer (OSO) answered
the cell bell at 2.12am and found that Mr Crosher had set fire to a pillow on the floor
of the cell near the door. An SPCO, two PCOs and other night staff attended and
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the fire service was called. BWVC from two cameras showed that staff had difficulty
opening the inundation point as the Houseblock 1 inundation key was bent and,
when a different key was obtained, the inundation point was too stiff to open. There
was a delay of around six minutes before the Hydramist unit (a machine that uses
high-pressure water mist to extinguish fires) was turned on and the fire
extinguished.
106. The SPCO said in a written statement provided by the prison to the investigator that
Mr Crosher was happy to stay in his cell but she moved him to cell B-02 because
his cell was full of water. B Wing is next to A Wing and is also on Houseblock 1.
She gave him his TV, telephone, kettle, cutlery and washing bag from his old cell
and he was provided with clean bedding. Mr Crosher told her he would ask to move
from B Wing at his next ACCT review. The fire service arrived after the fire was put
out. The inundation key was replaced after the incident. No ignition source was
found in a subsequent search of Mr Crosher’s cell. The SPCO did not complete a
defensible decision log as required after every cell move for a prisoner subject to
ACCT procedures.
107. A PCO noted in the ACCT record that Mr Crosher had set the fire due to being
under threat on A Wing. There is no evidence that staff considered whether this
change in behaviour with inherent risk involved meant that they should hold an
ACCT review and increase Mr Crosher’s ACCT observations.
108. A PCO told the investigator that there had been a problem with prisoners setting
fires at the time because there were a number of prisoners in debt and cell fires
were seen as a way of forcing a wing move rather than waiting for managers to be
on duty to arrange one. To try to discourage this and prevent bad behaviour being
rewarded, the prison tried to move prisoners setting fires to a different cell on the
same wing or houseblock.
109. At about 8.00am, Mr Crosher told a PCO that he had set the fire in order to move to
another wing. He asked to go to the segregation unit or be moved to a different
prison. He asked the PCO if he had done anything to annoy the staff and she
reassured him that he had not. The daily management check of Mr Crosher’s ACCT
recorded at 9.40am (signature illegible) noted “no increased risk”. There is no
mention that Mr Crosher set a fire during the night. This was the only daily
management check recorded on Mr Crosher’s ACCT over the four full days it was
open.
110. Later that morning and again that afternoon, Mr Crosher asked for a phone (as his
new cell did not have one) so he could call his family to reassure them he was okay
and “clear the air”.
111. A mental health nurse completed a welfare check on Mr Crosher in his cell in
response to the urgent task sent by a nurse. Due to the red regime they spoke in
the open doorway of Mr Crosher’s cell. The mental health nurse said Mr Crosher
was polite, calm, pleasant and engaged well. He said “his head had gone” over the
last few weeks and the day before he had felt like he could not cope. He said he
had a variety of stressors in prison but had self-harmed due to being in pain since
his methadone was reduced. Mr Crosher said he had asked for tramadol and
Subutex which he found better for pain management. The mental health nurse
advised him to speak to the GP about pain management and to the substance
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misuse team about the reduction of his methadone. She explained that Subutex
was a highly tradeable drug in prison and was only usually prescribed closer to
release. She sent a task to the healthcare administrator to book Mr Crosher a GP
appointment. Mr Crosher denied feeling suicidal or like harming himself further.
112. Mr Crosher called his mother at 4.28pm and said he had just been given a phone.
She was extremely relieved to hear from him and told him that everyone had been
in a state of panic since his calls the day before. He told her he had set fire to his
cell because he needed to move to a different location. He said he was being
treated as if he was a “grass” and he did not know why. Mr Crosher said there were
people on the wing with a lot of money encouraging other prisoners to get into debt.
He said he was falling apart physically and was too old to fight. He said the wing
had been locked down for a couple of days and some prisoners whose birthdays it
was had brewed illicit alcohol (known as hooch) which had led to “madness”. There
were hardly any staff on duty and it would be easy for the prisoners to take over. He
said something had been due to happen to him which is why he had to set fire to his
cell to get a move. He said he had wanted to move to the segregation unit but had
been moved to a different spur on the same houseblock. They discussed some
family news and he reassured her that he was safe and was staying in his cell.
113. Mr Crosher called his father at 6.10pm and repeated what he had told his mother.
His father asked him if he could speak to someone about his problems and Mr
Crosher said he had been trying to. Mr Crosher’s father said he had tried to ring the
prison the day before but no one had answered the phone. He advised Mr Crosher
to speak to staff the next morning (Monday) when there would be more of them on
duty. He emphasised to Mr Crosher that he needed to explain that he really needed
to move and should also try to speak to healthcare to have a mental health
assessment.
9 October 2023
114. A PCO noted in the ACCT record that Mr Crosher had slept throughout the night
and woken up at 5.00am.
115. At 8.00am on 9 October, Mr Crosher told a wing officer that he wanted to remain
locked in his cell as he was under threat on the wing. The officer wrote on Mr
Crosher’s ACCT, “he is not as no one knows who he is”.
116. Mr Crosher called his mother at 9.33am. He repeated that he had not been moved
to a different houseblock despite cutting himself badly and then setting a fire. He
said he had not had a shower since the fire and had been coughing up soot. They
discussed family news for the rest of the call.
117. Mr Crosher was charged with breaking prison rules by setting a fire in his cell and
attended a prison disciplinary hearing (known as an adjudication) in the segregation
unit that morning. He asked for legal advice and the hearing was suspended for
seven days to allow him to receive this.
118. At 10.23am, Mr Crosher telephoned the safer custody line. His call lasted 11
seconds.
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119. At about 2.00pm, the Industries COM chaired an ACCT review with Mr Crosher and
a wing officer in the doorway of Mr Crosher’s cell. The Industries COM said she was
not Mr Crosher’s ACCT case manager but had been asked to cover his review that
day due to a lack of staff. She said she tried to get someone from the mental health
team to attend the review but no one was available. Prior to the review, she looked
at Mr Crosher’s electronic prison record but there were no recent entries so she
went to B Wing and read his ACCT document and spoke to staff. None of the staff
knew Mr Crosher well because he had only just moved there. She said she
remembered that Mr Crosher had recently moved from A Wing because he was
under threat.
120. The Industries COM said Mr Crosher would not come out of his cell to complete the
review in a more private setting because he said he was still under threat and had
“pissed a lot of people off”. He would not go into detail about this. He said his move
to B Wing had not made much difference as he was still on Houseblock 1. He said
his mood was up and down. She said Mr Crosher was very polite and respectful
and gave her no cause for concern. He told her he had seen someone from the
mental health team the day before. She said she would invite safer custody and
mental health staff to his next review. Mr Crosher said he had ‘annoyed’ a lot of
people in the prison so he would remain self-isolating in his cell for now. She
planned to hold the next review on 16 October. She advised Mr Crosher that he
should use his cell bell, speak to wing staff or call safer custody for support.
121. Mr Crosher telephoned the prisoner advice line three times between 2.00pm and
2.30pm. No prisoners were on duty answering the line that day. At 2.05pm, Mr
Crosher hung up three seconds after being connected. At 2.07pm, Mr Crosher left a
voicemail:
“Hello there, it’s Ricky Crosher, can you please come and see me on A Spur
please, cell 2, thank you bye.”
On the third call Mr Crosher rang off before the call went to voicemail.
122. At 2.29pm, in between his second and third calls to the prisoner advice line, Mr
Crosher called the safer custody line. The call lasted 24 seconds.
123. At 2.30pm, a PCO noted on his ACCT document that Mr Crosher was out on the
landing and that he told her he felt okay. At 2.59pm, Mr Crosher rang the safer
custody line again but the call only lasted three seconds indicating he did not listen
to the eight second recorded message in full before hanging up.
124. At 5.00pm, Mr Crosher asked another member of wing staff for some clean
dressings for his cuts. There is nothing on the record to indicate that Mr Crosher
was seen by healthcare staff in response to this.
125. At 7.34pm, Mr Crosher called the safer custody line again for 17 seconds.
126. A PCO was the night patrol officer for B wing that week. At the end of his night shift
on 9/10 October, he noted on Mr Crosher’s ACCT record that Mr Crosher had slept
during the night and he had not had any interaction with him.
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10-11 October 2023
127. Mr Crosher called his mother at 10.30am on 10 October. He said he was fine and
they discussed the dogs and what his mother had been up to. He called her back at
11.15am and asked her for £20.00 to buy some canteen items from another
prisoner. He said that some prisoners keep a stock of canteen items and sell them
at higher prices to other prisoners. He said he needed things because all of his
items were still in his previous cell. Mr Crosher’s mother said she would send him
what money she could, and he told her he would ring her back and give her the
account details of who to pay. He rang back at 11.27am and gave her the account
details of a woman. Mr Crosher’s mother said she would make the payment later
and Mr Crosher asked her to do it “now” because they were due to be locked up
soon. He rang his mother back at 11.34am and she said she would not being able
to pay the money until 1.30pm.
128. A PCO completed a significant number of Mr Crosher’s ACCT observations on 10
October. Mr Crosher asked her if she had a problem with him and she reassured
him she did not. Later she noted that Mr Crosher was calmer and interacted with
another prisoner when out of his cell. Staff gave Mr Crosher his clothes from his
previous cell that afternoon. He asked the PCO for a new bandage and she advised
him to ask at the medication hatch.
129. At 1.01pm, Mr Crosher called the safer custody line. The call lasted 24 seconds.
130. At 1.03pm, Mr Crosher rang the prisoner advice line and left a voicemail:
“Hello this is Ricky Crosher. I really desperately need to speak to someone,
can you please ring me up or come see me. Thank you.”
The message was not listened to until after Mr Crosher died.
131. At 1.26pm, Mr Crosher called his mother again. She told him that she had sent the
money he had asked her to send. She asked who the recipient was and Mr Crosher
said it was the girlfriend of the man in cell number nine. Mr Crosher told her that if
he worked with other prisoners and bought things from them, he thought it offered
him a bit of protection. He said there were a lot of rumours about what people were
in prison for. They had a general conversation about what she was doing. Mr
Crosher said he would call his mother again later that day or the next day. This was
the last phone call he made before he died.
132. At 6.01pm, Mr Crosher was locked into his cell for the night. At about 7.00pm, a
PCO and an OSO started their night shift on Houseblock 1. In total there were
seven prisoners on the houseblock subject to ACCT procedures including Mr
Crosher, the prisoner next door but one to him and two prisoners in cells on the
landing above him.
133. The investigator watched the CCTV from 9.00pm that evening. Mr Crosher’s ACCT
checks were completed by the PCO or the OSO. Between them they completed at
least two checks every hour except for the period between 11.00pm and midnight
when a second check was not completed. Between midnight and 6.00am, they
checked Mr Crosher three times every hour. The recorded times on the ACCT
document do not accord with the actual time the checks were made. The PCO told
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the investigator that the ACCT documents are kept in the houseblock office situated
in a central point with the different wings radiating from it known as the ’bubble’. His
practice was to make the checks and then complete the different records when he
returned to the office. The times of the checks were therefore estimated.
134. The PCO said that Mr Crosher moved around his cell a lot during the night. He said
his cell light was on, his TV was on and his observation panel was open which
meant it was easy to see him as he passed his cell.
135. CCTV showed that Mr Crosher pressed his cell bell at 2.25am on 11 October and
the PCO answered it within a minute at 2.26am. Mr Crosher asked to see a nurse.
The PCO said he asked Mr Crosher why he needed a nurse. He said Mr Crosher
became agitated, he would not explain what his issue was and asked again to see a
nurse. The PCO said prisoners were often unwilling to say exactly what they
wanted because it was quiet at night and other prisoners might hear them. He
explained that there were no nurses on duty at night and Mr Crosher appeared to
accept this and seemed calmer, although low in mood. The PCO said he reminded
Mr Crosher he could contact The Samaritans on his cell telephone because it was
the only option available to him until morning. He said Mr Crosher did not give him
any further cause for concern that night. CCTV showed the PCO last checked Mr
Crosher at 5.34am, although he did not record this on the ACCT record.
136. At 5.58am, the OSO completed Mr Crosher’s ACCT check. In a written statement
she noted that Mr Crosher appeared to be in bed asleep and his observation panel
was uncovered. The OSO completed the ACCT document to say that she had
checked Mr Crosher at 6.00am and 6.10am. CCTV showed neither the OSO nor
the PCO checked Mr Crosher at 6.10am. At 6.16am, the OSO checked the prisoner
next door to Mr Crosher but did not check Mr Crosher.
137. Two PCOs took over from night staff on Houseblock 1. They both said they were
told that all the required ACCT checks had been completed for the period 6.00am -
7.00am. (This was not correct as no one had checked Mr Crosher since 5.58am.)
Together they completed a routine check of every prisoner on the houseblock
(known as the early morning roll count). CCTV showed that one PCO got to Mr
Crosher’s cell at 6.47am and looked through the observation panel before closing
the flap and moving to the next cell. The PCO said that he could not remember
what Mr Crosher was doing when he checked him during roll count.
138. At 7.02am, the PCO returned to Mr Crosher’s cell to complete an ACCT check.
CCTV showed the PCO opened the observation panel, then knocked on the door
and tried to see into the cell via the cracks at each side of the door. At 7.03am, he
left the cell and checked the cell next door before moving out of picture. The PCO
said Mr Crosher’s observation panel was covered so he knocked on the door and
turned the cell light on and off. He decided to check the three other B Wing
prisoners on ACCTs and then went to the houseblock office and told the other PCO
that he could not get a response from Mr Crosher and his observation panel was
covered. He told the investigator that on finding an unresponsive prisoner with a
blocked observation panel procedure was to call for assistance to enter the cell. He
did not know why he did not call for assistance immediately but remembered
thinking that the other B Wing prisoners on ACCT needed to be checked.
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Emergency response
139. The investigator watched CCTV footage, body worn video camera (BWVC) footage
and listened to prison radio communications from 13 October. She also obtained
information from the East Midlands Ambulance Service. The following account has
been taken from these sources and staff interviews and statements.
140. At 7.05am, the PCO returned to Mr Crosher’s cell with the other PCO on duty. One
PCO said she took the key for the inundation bung with her as it was her practice to
remove the bung to observe unresponsive prisoners before calling for assistance.
She knocked on Mr Crosher’s door and then used the key to remove the inundation
bung in the cell door. She looked through the inundation point and saw Mr Crosher
standing looking at her in an odd way so she asked the other PCO to look as well.
He said he realised something was wrong and radioed a code blue emergency to
signify a prisoner in breathing difficulty. The control room called 999 immediately
and an ambulance was dispatched with the highest priority.
141. One PCO opened Mr Crosher’s door at 7.06am and he and the other PCO went in.
He said Mr Crosher was suspended from the frame of his toilet door by a sheet. He
used his anti-ligature knife to cut the ligature, laid Mr Crosher on the floor and
started cardio-pulmonary resuscitation (CPR). The other PCO said Mr Crosher let
out a groaning sound as the PCO cut him down and had foam coming from his
mouth. Mr Crosher had used more material to tie his hands to the toilet. She said
Mr Crosher fell heavily to the floor but she did not remember seeing any blood in his
cell when she first went in. The other PCO said he remembered that Mr Crosher
had blood on his chest when he did CPR but he could not remember where this had
come from. He did not think Mr Crosher hit his head as he cut him down.
142. Another PCO arrived within seconds and left immediately returning at 7.07am with a
defibrillator. One PCO attached the defibrillator as another PCO continued CPR.
The defibrillator advised to continue with CPR and two other PCOs took over.
143. At 7.11am, a COM arrived with the green emergency bag followed at 7.12am by
two nurses. One nurse said she and the other nurse had only just arrived at the
prison for the start of their shift and were still in the gate when they heard the radio
call for healthcare staff. She said when she arrived staff were giving Mr Crosher
CPR and the defibrillator had been attached to him. Mr Crosher showed no signs of
life but was warm to the touch. There was some stiffness in Mr Crosher’s jaw but
she inserted an airway and gave Mr Crosher oxygen. The defibrillator advised no
shock. She noticed that Mr Crosher had tied material around his ankles.
144. At 7.30am, the Helicopter Emergency Medical Service (HEMS) arrived and asked
staff to move Mr Crosher to the landing outside his cell. BWVC footage showed that
he had bled from his nose. The emergency services took over CPR. They gave Mr
Crosher adrenaline and fluids and attached a Lucas machine (a mechanical chest
compression machine). At 7.41am, they confirmed that Mr Crosher had died.
145. The staff member with oversight of the safer custody department told the
investigator that after Mr Crosher died safer custody staff listened to the safer
custody line voicemail and that Mr Crosher had left no messages.
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Information received after Mr Crosher’s death
146. On 11 October, a prisoner asked a member of staff who had “done” Mr Crosher and
asked whether he had been stabbed. He said that other prisoners had been “after”
Mr Crosher and that it was “down to Spice”. He would not say who the other
prisoners were.
147. We received an anonymous letter from a prisoner naming another prisoner on A
Wing. The anonymous source said that this prisoner had bullied Mr Crosher
physically and mentally and referred to him as a “lackey”, “joey”, “bitch” and
“minion”. We passed this information on to the prison.
Contact with Mr Crosher’s family
148. The prison appointed two family liaison officers immediately after it was confirmed
that Mr Crosher had died. Mr Crosher did not give a next of kin on arrival at
Lowdham Grange so they listened to his most recent prison telephone calls and
identified his mother from his contact list. At 8.30am, the family liaison officers left
the prison to drive to Mr Crosher’s mother’s address. On arrival, they discovered
that Mr Crosher’s mother had moved and the new occupants of the house did not
know her current address. They rang Mr Crosher’s mother and arranged to meet
her at her new address where they broke the news of his death in person and
offered their condolences. The prison offered a financial contribution to Mr
Crosher’s funeral in line with national guidance.
Support for prisoners and staff
149. After Mr Crosher’s death, the Deputy Director 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. One member
of staff interviewed said she had not received a satisfactory level of support after Mr
Crosher’s death.
150. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoner support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case by case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans
to provide confidential peer-support) to identify prisoners most affected by the
death.
151. The prison posted notices informing other prisoners of Mr Crosher’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 Crosher’s death.
Listeners (prisoners trained by The Samaritans to provide confidential peer support)
were not deployed to the wing in line with postvention procedures because the
prison did not have any trained Listeners operating at the time.
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Post-mortem report
152. The pathologist concluded Mr Crosher’s cause of death was hanging. They also
found that synthetic cannabinoid and cannabis use had contributed to but not
caused Mr Crosher’s death as he tested positive for these drugs.
Coroner’s Inquest
153. The Coroner’s inquest concluded on 28 November 2025. The inquest concluded
that the medical cause of Mr Crosher’s death was ligature compression of the neck.
The verdict was suicide contributed to by neglect. The jury gave a narrative verdict.
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Findings
Staff shortages and risk management
154. Lowdham Grange’s transfer from Serco to Sodexo in February 2023 was the first
time a prison had been handed over from one private provider to another. The
impact of the changes had been underestimated, not least the number of managers
and staff who resigned when the contract change was announced or left in the early
weeks after the transfer. The transfer to Sodexo coincided with Serco’s successful
bid to operate HMP Fosse Way and this might have exacerbated the loss of staff.
155. Throughout the period Mr Crosher was in Lowdham Grange there was a chronic
shortage of operational staff and wing managers. Violence, illegal drugs and debt
increased. Dedicated teams such as safer custody staff were cross deployed to
help run the basic daily regime. The intelligence manager and all but one of the
security department analysts left and the department had to be rebuilt. From June
2023, healthcare staff were told not to go on to the wings while prisoners were
unlocked, except in emergencies. There was often not enough staff to bring
prisoners to healthcare appointments and not enough rooms in healthcare to see
prisoners in confidential settings. Substance misuse support workers and education
staff were told by their employers not to go on the wings at all. In October, the ‘red
regime’ was introduced because weekend staff numbers were so low that prisoners
had to be left locked in their cells.
156. These circumstances impacted the ability of staff to identify and support prisoners
at risk. If the prison was not deemed safe enough for healthcare staff and drug
workers to go on the wings it was certainly not safe for vulnerable men like Mr
Crosher, with a long history of using illicit substances in prison, getting into debt and
coming under threat. The lack of staff and support services had a significant impact
on his care including:
• Mr Crosher only had a single keywork session at Lowdham Grange in July.
• Mr Crosher received very limited psychosocial support from his allocated
substance misuse worker and almost no 1:1 contact.
• Prison telephone support services that he was advised to use if he felt he
needed help were not operating as they should and there is no evidence of
any response to his voicemails.
• No one answered the main switchboard number when Mr Crosher’s parents
rang the prison on 7 October.
157. Additionally, we know from our investigation into a self-inflicted death in March
2023, that a debt strategy, introduced in June 2023, was not embedded and the
Safety Intervention Meeting (SIM) was underdeveloped and poorly used. The
shortage of wing managers reduced violence reduction care planning (the
challenge, support and intervention plan process known as CSIP). Mr Crosher’s
profile (self-harmer, debtor, substance misuser, assault victim, under threat) meant
that he should have been identified as at risk to himself and from others and meant
he should have been discussed at the SIM and received specialised support.
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158. Our own research over the years has shown there are strong links between bullying
and violence and self-inflicted deaths of prisoners of all ages. National guidance for
prisons on violence reduction is contained in PSI 64/2011. This contains a
commitment to zero tolerance of violence in all prisons and affirms a commitment to
the support and protection of victims. There is no evidence Mr Crosher received any
meaningful support or protection from violence.
159. While the circumstances in which the prison was operating provide important
context, this does not diminish the fact that the level of care and support Mr Crosher
received at Lowdham Grange was unacceptably low. Some basic actions were not
taken that might have made a difference, including:
• Intelligence reports were not submitted consistently by staff who noticed his
injuries in August and September and, damningly, not at all by wing staff.
• The intelligence reports that were submitted were badly processed and did
not take into account Mr Crosher’s long history of being under threat from his
peers.
• None of the intelligence concerning the assaults was passed to safer
custody.
• There were a number of failings in ACCT procedures, most seriously the lack
of a review in response to the cell fire which should have been regarded as
an escalation of risk and proper consideration of the appropriate frequency of
checks and removing Mr Crosher to either a safer cell or to a different
houseblock. Other issues included: healthcare staff not attending reviews,
checks were sometimes chaotic, poor completion of the ACCT document at
times, insufficient management assurance checks and staff being asked to
do case reviews with little notice.
160. The two private companies that ran the contract must bear significant responsibility
for these failings, rather than individual staff working in extremely difficult
circumstances. Serco, for the manner in which they left the prison, and Sodexo for
hugely underestimating the requirements of running a safe and secure
establishment in those circumstances.
161. At the time of writing, in August 2024, the current Head of Safety said he had a
team of two custodial managers, three officers and an analyst and was recruiting
second analyst. This helped ensure messages on the safer custody telephone line
were picked up and acted on. The SIM was running regularly. The team looked at
the prison daily briefing sheet for reports of prisoners with evidence of assault in
case they had not been informed by wing officers or the security department.
Regular keywork had restarted for prisoners identified as being vulnerable. The
prison had trained 14 Listeners but the scheme had not yet been launched. The
addition of extra HMPPS staff from December meant there was a regular regime
and therefore the Prisoner Advice Line ran more consistently. Mental health nurses
are made available for ACCT reviews to be booked in advance.
162. We note that despite these early signs of improvement, safer custody staff are still
not ring fenced from cross deployment to fill shortages of wing staff and the debt
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strategy is due for review and is still not embedded. We make the following
recommendation:
The Governor should introduce a standalone comprehensive debt strategy
which is communicated to and understood by all staff, including providing
appropriate support and intervention to prisoners where there are any
concerns about debt.
Blocked observation panels and entering cells
163. In February 2018, HMPPS issued a Safety Bulletin on observation panels. This
said that if a prisoner does not comply with instructions to remove a blockage, staff
must take immediate action to remove the obstruction and check the prisoner’s
welfare. In line with Prison Service Instruction (PSI) 24/2011, Management and
security of prisons at night, at the time Mr Crosher died Lowdham Grange had a
local policy on night duties, issued in February 2023. This instructs staff who find a
covered observation panel and an unresponsive prisoner, to radio the
communications room and ask the night orderly officer (the officer in charge) to
attend.
164. On 13 April 2023, the then Director issued a notice to staff on unresponsive
prisoners. This instructed that staff faced with an unresponsive prisoner or a
covered observation panel and a prisoner not responding, must stay at the cell
door, radio a code blue emergency and make a dynamic risk assessment of
whether it is safe to enter the cell. The notice said staff should enter the cell without
waiting for colleagues unless there is a risk to personal safety.
165. On 1 June 2023, the Director issued an information bulletin on how to deal with
covered observation panels and items hindering visibility into cells. This too
instructed staff that if a prisoner who had covered his observation panel did not
respond then they should enter the cell if it was safe to do so and remove the
obstruction. In night state, unless it was an emergency, two staff should be present
before the cell is entered and the night orderly officer must be informed.
166. On 13 February 2024, the Governor issued a Governor’s Order instructing staff to
adopt a zero tolerance approach to any covered observation panel whatever time of
day or night they discovered one. For prisoner’s subject to ACCT monitoring, staff
were instructed to raise the alarm and enter the cell unless they judged it unsafe to
do so, in which case they should wait for assistance.
167. Removing the inundation bung to see into a cell with a covered observation panel
and an unresponsive prisoner has never formed part of policy or guidance to staff at
Lowdham Grange under Serco or Sodexo. In our investigation into the self-inflicted
death of a prisoner there in October 2018, staff delayed entering the cell of a
prisoner being monitored on ACCT procedures to remove the inundation bung to
see past an obstruction. In March 2023, staff delayed entering the cell of a prisoner
on welfare observations after being found under the influence of PS to remove the
inundation bung to see past an obstruction.
168. The PCO should have immediately radioed for assistance when he discovered Mr
Crosher had blocked his observation panel and did not respond to him. Given his
lack of knowledge of Mr Crosher we consider it was reasonable for him to decide
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not to open and enter the cell alone. We accept he was concerned to check the
other B wing prisoners on ACCT but urgently summoning other staff in line with the
local guidance in place at the time would also have allowed this to be done in a
timely way. The combination of this and the other PCO on duty opening the
inundation point first, meant there was an unnecessary delay in entering Mr
Crosher’s cell of four minutes. We cannot say whether this affected the outcome for
Mr Crosher but in cases of hanging, urgent intervention is crucial to survival.
169. Despite the guidance issued to staff in April and June 2023, it is clear from this
investigation that there remained a culture among staff of removing the inundation
bung instead of following local procedures at the time of Mr Crosher’s death. In
January 2024, we recommended that the prison should evidence how they will
monitor the challenging of blocked observation panels to ensure compliance with
local processes. We acknowledge the further guidance issued to staff in February
2024. However, at the time of writing we have not received HMPPS’ response to
our previous recommendation. Until we receive this we remain concerned that this
issue has not been robustly or adequately addressed. Therefore, given this and the
change in management of the prison, we repeat our previous recommendation:
The Governor should evidence how the prison will monitor the challenging of
blocked observation panels to ensure compliance with local processes.
Drug strategy
170. In our investigation into the self-inflicted death of a prisoner at Lowdham Grange in
March 2023, we were concerned that he was able to access PS with apparent
ease, had got into debt and was under threat from his peers. We remain concerned
about the easy availability of illicit substances at the prison. In our previous
investigation, we spoke to the then Head of Drug Strategy under Sodexo who told
us that he had developed a drug reduction action plan but some key elements such
as searching and testing were underdeveloped due to staff shortages.
171. In May 2024, the investigator spoke to the Head of Regime Services who was given
responsibility for drug strategy following the HMPPS step in. He told us that
mandatory testing had recently begun and suspicion testing was due to start
imminently. Positive drug tests had reduced from 54% in December 2023 to 34% in
February 2024 and he anticipated further reductions. Searching had increased and
the influx of extra staff from HMPSS meant that they were able to respond more
quickly to intelligence received. Substance misuse groupwork had just resumed.
172. A diagnostic support visit from HMPPS Substance Misuse Group due in May 2024
had been postponed due to the need for them to divert to a prison where a high
number of drug related deaths had occurred in a very short space of time. This was
now due to take place in September 2024. Given the comprehensive nature of
diagnostic support visits which produce a detailed analysis of the individual prison’s
substance misuse issues and an action plan of necessary actions, we make no
recommendation.
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Recording of prisoner calls to the safer custody telephone line
173. All calls made on the prisoner telephone system are recorded by default.
Exceptions to this are listed in Annex B of the Authorised Communications Controls
and Interception Policy Framework and include calls to the prisoner’s legal adviser
and organisations with confidential access, such as the PPO, the IMB and The
Samaritans. The list rightly does not include calls to internal safer custody lines run
by individual prisons. However, Mr Crosher’s calls to the safer custody line were not
recorded. We do not consider that such lines have or should have the same status
as independent organisations and the prisoner’s legal representative. Furthermore,
when needed, reviewing such calls might provide valuable evidence about a
prisoner’s risks.
174. While we were told that calls to the safer custody line were logged, the prison was
unable to supply the investigator with a copy of the log. Self-evidently, maintaining a
log of calls allows for identification of repeat callers, repeat issues and serious
concerns. We therefore recommend that:
The Governor should ensure that prisoner telephone calls to the safer
custody line are recorded and monitored in the same way as calls to anyone
other than those organisations contained in Annex B of the Authorised
Communications Controls and Interception Policy Framework.
Clinical care
175. The clinical reviewer concluded it was difficult to draw parallels with community-
based care, due to the unique circumstances at Lowdham Grange when Mr
Crosher died. This led to significant restrictions on healthcare staff’s input and
ability to provide clinical care. The clinical reviewer concluded that the healthcare
received by Mr Crosher was partially equivalent to that he should have expected to
receive in the community. They found that information sharing between healthcare
staff and prison staff was poor, record keeping was variable and no healthcare staff
attended Mr Crosher’s ACCT reviews.
176. The clinical reviewer noted that there should be robust safeguarding processes at
Lowdham Grange to keep prisoners safe and protect them from abuse and neglect.
She said that when prisoners tell healthcare staff they have been assaulted, staff
should record this in the clinical record and ensure that a referral is made to the
safeguarding link in the prison and Nottingham Healthcare NHS Foundation. There
is no evidence that this took place for Mr Crosher. The Head of Healthcare will want
to ensure that these safeguarding processes are embedded, understood by all staff
and routinely followed.
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