26 June 2019

Before H.M. Assistant Coroner Laurinda Bower
Nottinghamshire Coroner's Court

17 to 26 June 2019

The inquest into the death of Andrew Brown has today concluded with the jury finding that a series of damning failings by HMP Nottingham contributed to his death. They also noted serious issues with the systems of governance at the prison over a two month period in 2017, highlighting that “there had been no improvements made following two inspections from HMIP” where the prison had scored the lowest level for safety. The cause of Andrew’s death was brain injury by hanging.

Andrew Brown was 42 years old when he was found hanging in his cell on the induction wing of HMP Nottingham on 12 September 2017 and died in hospital five days later on 17 September. Andrew was from Chesterfield and his family described him as much-loved brother and a man of strong Christian faith. He was the second of five men to die in HMP Nottingham in less than a month between 13 September and 12 October 2017. The day after Andrew was found hanging, Shane Stroughton also died a self-inflicted death, on the same landing of the same wing.

The jury concluded that the following failures contributed to his death:  

  • Failure to follow systems, processes and procedures including prison service instructions and governor’s orders within the prison and healthcare;
  • Inability to access chaplaincy and bible study;
  • Unsuitable environment on the induction wing and inability to gain access to work, which did not meet Andrew’s basic needs;
  • Failure to respond to the emergency call bell and follow governor’s orders;
  • Failure to investigate, follow up, and record an assault on Andrew on August 2017; and
  • The mistake of taking Andrew for release on 12 September 2017.

The inquest heard that Andrew was recalled to HMP Nottingham on 18 August 2017 having been released on license on 14 August. He had a history of self-harm and suicide attempts. At court Andrew had expressed thoughts of ending his life and was described as “smashing his head against the cell”. When he arrived at the prison, suicide and self-harm monitoring procedures were opened (known as ACCT). The inquest heard evidence that the ACCT was closed on 6 September despite Andrew having disclosed intentions of harming himself. The jury said that In no circumstances was it appropriate to close the ACCT 6 September 2017… no risk assessment was undertaken or recorded”.

On the morning of 12 September 2017, Andrew was brought out of his cell to the prison reception and told in error that he was going to be released. The jury found that the ACCT should have been re-opened... as soon as Andrew was told that the decision to release him had been revoked.”

He was taken back to his cell, where he pressed his cell bell four times in the hour before he placed a ligature around his neck. The last of these emergency calls was not answered for 43 minutes, despite the governors orders to ensure cell bells are answered within five minutes. The jury said that this delay was “completely unacceptable.” At the inquest the prison officer accepted he had been “pottering around the office” rather than answering the emergency call. Evidence was also heard that the emergency cell bell on the induction wing (recognised to accommodate the most vulnerable prisoners) was regularly taped over by staff to muffle the sound. The jury found that the practice of muffling the sounder [on cell bells] was unacceptable”.

After Andrew was taken to hospital a note was found in his cell where he raised a number of concerns, including:

  • His aborted release that morning and failure to explain it to him
  • The lack of a healthcare appointment and to see a doctor about his trouble sleeping, despite the many applications he says he made
  • The lack of access he had to a job, to chapel worship and to consistent hot water

In evidence, the prison accepted that these were “basic” concerns which should have been achieved. 

The jury heard evidence that despite being referred twice for a mental health assessment which should have occurred within five days, an appointment was not made for Andrew for 32 days. He was still waiting to be assessed when he died. The jury found that Andrew did not receive appropriate and timely assessment and support from the mental health team”.

There were seven deaths in HMP Nottingham in 2017 and a further six in 2018. The prison was inspected in January and Her Majesty’s Inspectorate of Prisons (HMIP) took the (then) unprecedented step to issue an Urgent Notification. HMIP found that the prison was “fundamentally unsafe” for the third time in a row, that there was “irrefutable evidence” of a failure to respond to the previous inspection findings, and that it was “extraordinary” there had not been a more “robust” response to the number of deaths in custody.

At the inquest, the current Prison Governor, Phil Novis, accepted that the prison had been in crisis and had failed Andrew. When asked whether what HMIP described as the “shocking” failure to learn lessons from previous tragedies contributed to Andrew’s death, however, he replied: “No”. 

Kevin Brown, brother of Andrew, said: “My brother was badly failed by HMP Nottingham. It would have been obvious to anybody how vulnerable he had become, and it was shocking to hear how unsafe the system in HMP Nottingham was when Andrew was there. He was denied the mental health care he needed and he was let down by those who should have been keeping an eye on him”. 

Deborah Coles, Director of INQUEST said: Nottingham prison had long been forewarned about unsafe practices, including by HM Inspectorate of Prisons. Yet the inquest jury found no improvements had been made prior to Andrew’s death. 

Most of the seven men who died in HMP Nottingham in 2017 did so in the very same unit, raising very similar issues, many of which were well known. Warnings from coroners and inspection and monitoring bodies have been systematically ignored by the prison service and government. The cost paid by this inaction is yet more preventable deaths.”

Jo Eggleton of Deighton Peirce Glynn Solicitors, who represents the family, said: “The failings in this case, as in the others, are numerous, obvious and shocking. The Inspectorate of Prisons, the Prison and Probation Ombudsman and the Independent Monitoring Board had repeatedly pointed out the same basic failings and the prison repeatedly failed to put them into practice. The Governor has accepted that Andrew was failed – but also seemed to demonstrate a worrying lack of understanding of the consequences of failing to learn lessons for the future.” 



For further information please contact Lucy McKay and Sarah Uncles on [email protected] [email protected]

The family is represented by INQUEST Lawyers Group members Jo Eggleton of Deighton Peirce Glynn Solicitors and Tom Stoate of Garden Court Chambers.

The other interested persons represented at the inquest were the Ministry of Justice and Nottinghamshire Healthcare NHS Foundation Trust.

There were seven deaths at HMP Nottingham from February to October 2017, all but one was self-inflicted.

The jury at the inquest into the self-inflicted death of Shane Stroughton, 29, at HMP Nottingham also returned a critical conclusion. They highlighted inadequate care and support from the mental health services, failures in staff communications and multiple issues around the ACCT processes. See the media release.

In 2018, there where a further six deaths, four of which were self-inflicted, one homicide and one non self-inflicted.

Also see:

For information and advice on how to safely report on self-inflicted deaths, please look at the Samaritans Media Guidelines for reporting suicide and self-harm.