PFD report

NIGEL JOHN SAUNDERS · Prevention of Future Deaths report

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Issued 3 Aug 2022•Nottinghamshire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
3

Of 1 recipient

Stated actions
4

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to retain and preserve evidence relevant to learning from deaths in custody
    Part of recurring concern: Failure to retain safety-critical source records and evidence
  2. Insufficient robustness of the local system for retaining and preserving material relevant to deaths
    Part of recurring concern: Failure to retain safety-critical source records and evidencePart of recurring concern: Unreliable preservation and disclosure of material for death investigations
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Add the Oscar Journal to the Death in Custody checklist so it is preserved when relevant in Serco prisons using an Oscar journal.

    Stated by Serco LimitedStated completedThe respondent said that this action was complete when they made their response on 7 October 2022.
  2. Action

    Finalise and roll out the updated Death in Custody procedure and checklist across English Serco prisons, with guidance for staff collating relevant documentation.

    Stated by Serco LimitedStated in progressThe respondent said that this action was in progress when they made their response on 7 October 2022.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to retain and preserve evidence relevant to learning from deaths in custody

Wider context from the report

“(1) The Prison failed to comply with its obligations pursuant to National Prison policy to retain and preserve evidence likely to assist all agencies to learn from deaths in custody. (2) The local system in place for the retention and preservation of material likely to be relevant to the circumstances of death is not as robust as it ought to be. This is not the first time serious disclosure irregularities have undermined the veracity of an Article 2 inquest involving this prison in my corner Area. I consider this to be a local issue of significant importance. If the investigations following a death are repeatedly hindered in their full and frank examination of the facts due to missed opportunities by the prison to have retained and preserved evidence, then lessons cannot be learned, and the risk of further deaths shall persist. The Chief Coroner highlights this specific area of risk at paragraph 42 of the revised Guidance Note 5. ”

Is this part of a recurring concern?

Yes — Failure to retain safety-critical source records and evidence.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient robustness of the local system for retaining and preserving material relevant to deaths

Wider context from the report

“(1) The Prison failed to comply with its obligations pursuant to National Prison policy to retain and preserve evidence likely to assist all agencies to learn from deaths in custody. (2) The local system in place for the retention and preservation of material likely to be relevant to the circumstances of death is not as robust as it ought to be. This is not the first time serious disclosure irregularities have undermined the veracity of an Article 2 inquest involving this prison in my corner Area. I consider this to be a local issue of significant importance. If the investigations following a death are repeatedly hindered in their full and frank examination of the facts due to missed opportunities by the prison to have retained and preserved evidence, then lessons cannot be learned, and the risk of further deaths shall persist. The Chief Coroner highlights this specific area of risk at paragraph 42 of the revised Guidance Note 5. ”

Is this part of a recurring concern?

Yes — Failure to retain safety-critical source records and evidence; Unreliable preservation and disclosure of material for death investigations.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Add the Oscar Journal to the Death in Custody checklist so it is preserved when relevant in Serco prisons using an Oscar journal.

Verbatim wording from the response

“Over the years the Journal has been replaced by incident reports, which are completed and then reported to and discussed by the Director and the Senior Management Team on a daily basis. It is accepted that Journal entries may have contained relevant information following a DIC and consequently should have been included on the DIC checklist to ensure their preservation following a death. The Journal is now listed in the checklist, to ensure it is produced in Serco prisons that use an Oscars journal.”

Source location

Response from HMP Lowdham Grange
Page 2 · response
Published 7 October 2022

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Finalise and roll out the updated Death in Custody procedure and checklist across English Serco prisons, with guidance for staff collating relevant documentation.

Verbatim wording from the response

“Following this inquest, the DSOP, including the DIC checklist has been reviewed further and an updated version is to be rolled out to the English Serco prison estate by the end of October 2022. The updated version of the DSOP will include a statement that the DIC Checklist is not an exhaustive list, and the Prison should retain any other document that it considers could be of relevance. The updated DSOP will be rolled out across the prison estate and guidance will be given to all staff responsible for collating relevant documentation following a death in custody. I understand that a copy of the DIC checklist that was in place at the time of Mr Saunders’ death and a copy of the DIC checklist, as amended in January 2021 were provided to you during the course of the inquest.”

Source location

Response from HMP Lowdham Grange
Page 2 · response
Published 7 October 2022

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Roll out the improved deaths-in-custody investigation processes across the SERCO English prison estate.

    Stated by Miss Mairin Casey, Senior CoronerStated in progressThe respondent said that this action was in progress when they made their response on 7 October 2022.
  2. 2

    Improve prison investigations of deaths in custody processes.

    Stated by Miss Mairin Casey, Senior CoronerStated completedThe respondent said that this action was complete when they made their response on 7 October 2022.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Roll out the improved deaths-in-custody investigation processes across the SERCO English prison estate.

Verbatim wording from the response

“I understand the improvements you have made to the Prison’s investigation of deaths in custody processes are now being rolled out across the SERCO English prison estate. This will assist with learning from deaths in custody, with the overarching objective of seeking to reduce the number of preventable deaths that occur in prisons every year.”

Source location

Response to HMP Lowdham Grange
Page 1 · response
Published 7 October 2022

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Improve prison investigations of deaths in custody processes.

Verbatim wording from the response

“I am so pleased to read of the broad range of measures you have put in place to address my concerns.”

Source location

Response to HMP Lowdham Grange
Page 1 · response
Published 7 October 2022

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026