Nottinghamshire prison officer admits 'critical mistake' before inmate found dead in cell

A prison officer has admitted making a "critical mistake" in the care of one of three inmates who died at a Nottinghamshire prison within three weeks. A joint inquest is being held into the deaths of Anthony Binfield, David Richards and Rolandas Karbauskas in their cells at HMP Lowdham Grange between March 6 and 25 last year.

The seven-week investigation is being held at Nottingham Council House, and on Friday (December 13) heard from prison officer Joe Tomlinson, who was on shift the night Binfield was found hanging in his cell. Giving evidence in front of a jury, he admitted to acting too slowly once Binfield became unresponsive in his cell, admitting it was a "critical mistake".

The prisoner, who was a "prolific self-harmer", drug user and previously attempted suicide in another prison, was subject to regular checks. On the night of March 6, Mr Tomlinson, who was on shift with one other officer, found Binfield's cell window had been obstructed with toilet paper.

The prisoner did not respond to questions, but the officer failed to open the cell door for another 11 minutes. Protocol required Mr Tomlinson to immediately enter and to raise an alarm, but he instead decided to return to the office and retrieve a key for the inundation point, a hole in the cell door that allows a fire hose to be inserted.

When the officer got the hole open with help from security, he found this too was blocked by paper. When he finally opened the door, Binfield was found hanging inside and later pronounced dead.

Coroner Laurinda Bower said Mr Tomlinson's failure to declare a 'code blue' as soon as Binfield was unresponsive was a "serious failure", pointing out this would have triggered an ambulance and wide-scale staff response. The prison officer said he did not have the confidence to recognise the code blue "during the heat of the moment in a stressful situation".

Mr Tomlinson was also accused of “fictionalising” observations of Binfield, who he was required to regularly check on throughout the night. Logs show an observation at 8.10pm, saying Binfield was “laid down” with “no issues”, but CCTV from the time showed no sign of Mr Tomlinson.

The prison officer told the inquest he got Binfield mixed up with another prisoner, but it was pointed out that CCTV also showed this could not be the case. Mr Tomlinson admitted to filling out the entry before checking on Binfield and said he had “no explanation” for this.

He was later accused of falsifying further checks by legal counsel for the family of Binfield. One entry had been heavily scribbled out, causing the paper to rip. “You were seeking to obliterate another wrongful entry,” said Ms Davin.

Mr Tominlson replied: “I was not. I was scribbling out an error.” The three inmate deaths came shortly after management of Lowdham Grange changed hands from Serco to Sodexo, believed to be the first private-to-private company transfer.

The facility was taken over permanently by the Government just over a year later due to deteriorating safety, prisoner conditions and staffing levels. Mr Tomlinson, who began working in 2021 before the transfer, said staffing levels were an issue as the "vast majority" of workers left the prison after the changeover.

"The changeover did limit the amount of staff that were available to conduct the work," he said. I had just over two years of experience and that was seen as quite senior and during that time I would have to take a more senior role." The inquest continues.

Where to find help

The NHS Choices website lists the following helplines and support networks for people to talk to.

• Samaritans (116 123) operates a 24-hour service available every day of the year. If you prefer to write down how you're feeling, or if you're worried about being overheard on the phone, you can email Samaritans at jo@samaritans.org.
• Childline (0800 1111) runs a helpline for children and young people in the UK. Calls are free and the number won't show up on your phone bill.
• PAPYRUS (0800 068 41 41) is an organisation supporting teenagers and young adults who are feeling suicidal.
• Mind (0300 123 3393) is a charity based in England providing advice and support to empower anyone experiencing a mental health problem. They campaign to improve services, raise awareness and promote understanding.
• Students Against Depression is a website for students who are depressed, have a low mood or are having suicidal thoughts.
• Bullying UK is a website for both children and adults affected by bullying.