23 January 2024

Before HM Area Coroner Miss Laurinda Bower
Nottingham City and Nottinghamshire Coroner’s Court
Hearings 14-24 November 2023, Prevention of Future Deaths report January 2024

Kane Boyce died a self-inflicted death at HMP Lowdham Grange on 3 October 2021. An inquest found that multiple failures by prison staff probably contributed to his death. Now a coroner has raised serious concerns about the risk of future deaths at the prison. 

Kane was the prison barber and used to cook and make cheesecakes for the other men on his wing. Well liked by all who knew Kane, his fiancée, Kate, told the inquest that, "After he died, I received letters from men he’d supported during his time in prison, telling me how much he’d helped them cope with their sentences."

On the evening of Saturday 2 October 2021, Kane was celebrating his 41st birthday and was drinking prison brewed ‘hooch’. Hooch is known to be particularly dangerous because it is impossible to determine the potency of the alcohol. 

Multiple prison staff suspected Kane was under influence of alcohol but did not follow the prison’s under the influence policy, designed to minimise risk. Prison staff’s inaction meant Kane was left unobserved for over an hour and a half when intoxicated. 

At the same time, Kane had no electricity in his cell and wing officers were actively ignoring him pressing his cell bell to get their attention. 

During a routine nightly welfare check, at 1:49 am on 3 October 2021, Kane was discovered ligatured in his cell and unresponsive. He was pronounced dead shortly after.

At the time of his death, Kane was positive and forward thinking. Giving evidence at the inquest, his fiancée said, "there is no way I believe Kane wanted to take his own life. Something went horribly wrong that night."

An inquest jury found that Kane did not intentionally take his own life and that multiple failures by prison staff probably contributed to his death. 

The jury rejected the Custodial Operations Manager’s evidence as the truth and were not satisfied with the accuracy of the evidence given by two prison wing officers. 

At the time of Kane’s death, HMP Lowdham Grange was run by Serco, a private company. Serco did not make any admissions of failings in relation to Kane’s death at the inquest. 

Commenting on this at the inquest, the Coroner asked whether there is "any sort of obligation of candour on these organisations when coming to an inquest in certain circumstances where somebody has died in their care."

In February 2023, another private company, Sodexo, took over the contract to manage the prison. It is the first time a prison has transferred between private providers. Sodexo declined the Coroner’s invitation to come to court to give evidence about learning and current practices at the prison. 

The Coroner said, "I do want to put on record how disappointed the family must have felt that they have been denied in the course of these proceedings, somebody, a human, to sit down in front of them face to face and to explain to them, and explain to me, the learning that has followed from Kane's death and to give some reassurance to the commitment to learning in the future."

After hearing all the evidence and the jury’s conclusions, the Coroner expressed serious concerns about "a number of issues which continue to pose a risk of death to prisoners at the prison in the future."

A prevention of future deaths report has now been issued to Sodexo and the Minister for Prisons, Parole and Probation.

To Sodexo, the report raises systemic concerns about HMP Lowdham Grange, including:

  • The ‘wholly dangerous practice’ of prison staff deliberately ignoring cell bells.
  •  Prison staff isolating power to cells without policies to support this action or consideration of risk factors.
  •  Prison staff failing to follow the local Under the Influence Policy, which requires a medical assessment and observations to be put in place to minimise harm.
  • Prison staff’s lack of understanding of mandatory national policy and failure to consider a birthday a ‘key date or anniversary’ which is capable of being a trigger for self-harm.
  • A lack of evidence of systems in place at HMP Lowdham Grange to seek to learn from deaths in custody at the earliest opportunity. 

To the Minister for Prisons, Parole and Probation, Edward Argar MP, highlighting concerns at a  national level, including:

  • The quality and accuracy of the ‘Early Learning Review’ carried out by HMPPS which concluded that “all procedures were followed” and there were no local or national recommendations for learning lessons.’The Coroner stated that they felt it was difficult to rationalise this conclusion.
  • The lack of duty of candour on prisons and their staff. 

Sodexo and the Minister for Prisons, until 13 March 2024, to respond to the Coroner’s report. 

Kate, Kane's fiancée, said: “Learning that my fiancé was found dead in his cell was hard, and waiting over two years to find out exactly what happened made it even harder. Through the inquest we heard how badly he was failed by the prison who have a duty to safeguard life. 

A senior prison manager blatantly tried to cover up failings. But we had ambulance records to prove he was lying in court. The jury didn't believe the wing officers’ evidence either. We also discovered that officers responsible for others' lives didn't care enough to answer emergency cell bell calls and are not trained on important policy or procedure. The prison seriously failed that night, but Serco don't even seem to care about this or want to change.

The Coroner’s report highlighting that no early lessons, or seemingly, any lessons at all, have been learned by the prison, only goes to reinforce my belief that my fiancé’s death was one of corporate manslaughter.”

Selen Cavcav, Senior Caseworker INQUEST, said:“The self-inflicted deaths of five people within one year at HMP Lowdham Grange shows how deplorable the situation at the prison is. It is a chilling example of what happens when the focus of private providers like Sodexo and Serco is on avoiding responsibility and protecting their reputations rather than protecting lives. 

If it wasn't for Kane's family, their legal team and a thorough coroner, most of the failures identified in Kane's death would have remained hidden.  

To prevent future deaths we need proper scrutiny, transparency and accountability when investigating deaths. This starts with applying duty of candour on prisons and their staff. Anything less than this, is an insult to families left behind and other prisoners reliant on the prison for their health and safety.”

Amalia King of Deighton Pierce Glynn, said: “Kane's inquest has brought to light a troubling culture at HMP Lowdham Grange, including repeated failures to investigate deaths properly. 

The lessons from his inquest are stark: Serco and Sodexo, private companies, are failing to keep people safe and are demonstrating an unwillingness to learn from mistakes. This is leading to missed opportunities to save lives.

The Coroner has now put the Minister on notice that the prison and their staff are not being candid at inquests. Currently, health service bodies have a statutory duty of candour to be open and transparent. Without an equivalent duty for all public authorities, there’s a risk that more people will lose their lives because the truth is not being told.”



For further information, please contact Leila Hagmann on [email protected]

Kane's fiancée, Kate, is represented by INQUEST Lawyers Group members Amalia King of Deighton Pierce Glynn and Taimour Lay of Garden Court Chambers. They are supported by INQUEST Senior Caseworker Selen Cavcav.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

INQUEST is supporting the Hillsborough Law Now Campaign for a Hillsborough Law, formally known as the Public Authorities (Accountability) Bill, to enforce a positive duty for public authorities to tell the truth.

Background information

Today Serco and Sodexo are paid public money to manage 13 prisons in total, with responsibility for over 13,000 people, around 13% of all people in prison in the UK. Since 2019, 14 people have died in HMP Lowdham Grange.

This prevention of future deaths report follows a recent history of escalating concerns about safety at HMP Lowdham Grange, including:

  • In May 2023, the Independent Monitoring Board’s annual report was published and noted ‘serious concerns relating to the operation of the prison and the implications for safety’ since Sodexo’s takeover.
  •  In August 2023, the HM Chief Inspector of Prisons’ critical report was published following an inspection in May 2023. It found ‘the prison was not safe enough’ and highlighting ‘Of greatest concern, however, were the 14 prisoner deaths, including six which were self-inflicted, that had occurred since we last inspected. Three of these had taken place in March, shortly after the transition, prompting speculation among staff and prisoners alike that uncertainty and change were causal factors. The evidence pointed to continuing high levels of self-harm and an indifferent approach to oversight and intervention.'
  • On December 18 2023, the Ministry of Justice announced ‘special measures’ to take over the running of the prison for an interim period to improve safety and security.