An inquest into the death of 39-year-old Matthew Osborne has revealed that multiple systemic failures at HMP Lowdham Grange were contributory to his self-inflicted death in November 2023. 

Osborne, was found ligatured in a segregation unit cell on 25 November 2023. Evidence at the inquest into his death revealed that he had been identified as at risk of suicide and self-harm for several months. 

The investigation found that Sodexo, the private company managing the prison, made multiple failures in safeguarding and welfare that contributed to Osborne’s death. CCTV showed officers repeatedly failing to carry out the required ACCT checks, designed to support prisoners at risk, despite the prison’s policy of three checks per hour. In the three days before his death, Osborne’s cell door was open for less than three minutes. 

Amalia king of Deighton Pierce Glynn, representing Osborne’s family stated, ‘Sodexo knew the prison was unsafe for everyone living and working there… yet four men died in the months before Matthew and still nothing was done to stop the same failings repeating’.

 The independent investigation carried out by the Prison and Probation Ombudsman, found that Osborne had been on ACCT monitoring for nearly five months, he made multiple self-harm attempts during this time, Osborne’s sister Jasmine, told the jury that he ‘did not always have an easy childhood, spending time in foster care, and like the prison system later, he was not given the support he needed’. He was found dead in his cell, two hours after officers were meant to carry out the mandated checks. No disciplinary action took place regarding the failure of the ACCT checks. 

Osborne was the fifth man to die at HMP Lowdham Grange in 2023, prompting renewed concerns over safety at the privately managed prison. Three deaths occurred within just 37 days. Inspectorate reports highlight longstanding problems, including staff shortages, high levels of violence, drug availability, and inadequate mental health support. In the weeks before Osborne’s death, a nurse raised safeguarding concerns via whistleblowing emails, specifically noting Osborne’s deteriorating mental health. The inquest heard that senior officers failed to take sufficient action despite the warnings. 

Selen Cavcav, Senior Caseworker at INQUEST, said: ‘Lowdham Grange’s continued reluctance to learn from previous deaths is nothing short of criminal.  Matthew’s family know that only too well. Matthew’s name joins a long list of people who have died following similar failures at the prison. It is indefensible that the prison has been allowed to continue to operate for so long with no accountability.’

Osborne’s death follows that of Gareth Chumber-Kelly another prison suicide at HMP Pentonville, reported on by The Justice Gap, where an inquest found serious institutional failings.