15 October 2019

Before HM Assistant Coroner for Nottinghamshire Jonathan Straw
7 to 14 October 2019
The inquest into the death of 23 year old Marc Maltby concluded yesterday with the jury finding that his death, by hanging, was a suicide. On 12 October 2017, the date of Marc’s death, prison officers used a table tennis table to block his cell door after he started throwing objects through the observation hatch. The jury found that the placing of the table in front of the cell door and the subsequent actions of staff were “inadequate”.
Marc was from Chesterfield and was described by his family as being very friendly and with a little cheeky smile which sometimes hid his vulnerability. Marc was the fifth of five prisoners to die at Nottingham in a month from 13 September 2017. Like previous inquests, the jury heard evidence that in 2017 Nottingham prison was “incredibly troubled”. Newly qualified staff were ill equipped to manage widespread violence and drug use, which one officer described as a “war zone.”
The inquest heard that Marc had been recalled to prison and arrived at HMP Nottingham on 22 September 2017. He requested help from the mental health team during his initial health screening. An assessment was scheduled for 8 October but by then, Marc had been moved to a different wing, which had not been communicated to the nurse. The appointment was rescheduled for 20 October which meant a delay of 28 days against a target attendance time of five days.

The jury also heard that Marc faced difficulties in prison. On or around 9 October (the evidence was conflicted, in part because no record had been taken) he had an altercation with his cell mate and the two were separated. A prisoner told the inquest that Marc was aware of further threats of violence but had been initially unconcerned until he learned who the threats were coming from. Marc passed a note to prison staff saying he was under threat, would be staying in his cell for his own protection and that he expected to be “cut”. He also asked to move wings again.
A violence reduction investigation was never opened. Three days later on 12 October, Marc began damaging his cell. The jury heard that this was likely to be an expression of distress or frustration, aimed at getting himself moved. He asked to call his mother but was told it was too late to make calls. Following this, prison officers moved a table tennis table in front of his cell door to block the observation hatch to prevent Marc from throwing objects onto the landing.
The inquest was told a senior prison officer instructed a new officer to keep an eye on Marc, but the new officer could not remember that instruction, nor what he should expect, or monitor. He said he went to the Marc’s cell once after his cell bell was called but did not attempt to engage with Marc. A prisoner told the jury that officers often switched off cell bells without checking in on prisoners.
Shortly before 7pm on 12 October the same prisoner was returning to his cell following an escorted visit to the medication hatch. He moved the table tennis table that had been placed to block the door of Marc’s cell. When the prisoner looked into the cell, he saw that Marc was hanging. He could not be resuscitated and was pronounced dead at 7.18pm.
Sharon Whitford, mother of Marc said: “Nottingham prison was not able to listen and respond to prisoners like Marc. Staff did not have the time, and when they did they did not have the experience. Marc was trying to get attention. I think that if he had managed to speak to me that day I would have been able to calm him down. If staff had been able to spend time with him, and deal with his problems, he would have calmed down. Marc did not intend to die. He just wanted someone to listen.”

Natasha Thompson, Senior Caseworker at INQUEST said: “Marc’s death was entirely preventable. He was in clear distress, but his calls for help were consistently disregarded by those who owed him a duty of care. This once again points to the fundamental failure to treat people in prison with decency and compassion and highlights the systemic inertia to enact changes following previous deaths.
At a time when the government is promising more money for prison places, our ongoing casework shows that expanding the prison system is not the solution to preventing further deaths and harms. We must look beyond the use of prison and act upon what are clear solutions - tackling sentencing policy, reducing the prison population and redirecting resources to community health and welfare services.”

Jo Eggleton of Deighton Pierce Glynn solicitors said: “Yet again we see the results of a prison being chronically under resourced and under staffed. Bench marking did this. The ministers who did this are responsible. Prisons run with cooperation and understanding, and when they are run down to minimum levels things overheat and ultimately explode. That is what happened in Nottingham in 2017. It is only with proper staffing, and focused attention on things like the Violence Reduction policy and the ACCT (suicide and self-harm monitoring) that deaths like this can be avoided.”


For more information contact INQUEST Communications Team on 020 7263 1111 [email protected][email protected].

Marc’s family are represented by INQUEST Lawyers Group members Jo Eggleton from Deighton Pierce Glynn and Nick Armstrong of Matrix Chambers.
The other interested persons represented at the inquest are Nottinghamshire NHS Foundation Trust (who provide healthcare in the prison) and the Ministry of Justice.

Since Marc’s death on 29 September 2017, there has been at least another seven deaths at Nottingham. Of these, six were self-inflicted, one was a homicide and two were non self-inflicted.

Recent inquest conclusions from deaths at HMP Nottingham:

  • Andrew Brown, 42, died a self-inflicted death in September 2017. The inquest concluded that a series of failings contributed to his death and the jury noted serious issues with the systems of governance at the prison over a two month period in 2017. His cell bell was not answered for 43 minutes. Media release, June 2019.
  • Shane Stroughton, 29, died a self-inflicted death on 13 September 2017. The jury at the inquest returned a critical conclusion finding a series of failings contributed to his death. Media release, June 2019.
  • Anthony Solomon, 38, died on 27 September 2017 from the toxic effects of synthetic cannabinoids. The jury returned a narrative conclusion highlighting a failure to answer the cell bell sooner and the prevalence of drugs in Nottingham prison at the time of this death. Media release, September 2019.

In January 2018, HMIP issued a ‘Urgent Notification’ on HMP Nottingham. Media release. In May 2018, Prison Inspectors report found ‘tragic and appalling’ levels of self-inflicted deaths and self-harm at Nottingham Prison. Media release.

Nottingham Prison has to be subject to a new Independent Review of Progress by HMI Prisons to assess progress made in implementing recommendations from the previous inspection report.