3 October 2019

Before HM Assistant Coroner for Nottinghamshire, Jonathan Straw
The Council House, Old Market Square, Nottingham NG1 2DT
Starts 7 October 2019, expected to last 7 days
Marc Maltby was 23 years old when he died on 12 October 2017 in HMP Nottingham after being found unresponsive in his cell. His death was the last of five in a four week period at the prison. The inquest into his death opens on Monday 7 October.
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. He had been in the prison for 21 days after being recalled on licence.
The day before his death, Marc expressed to staff that he felt under threat, would be staying in his cell for his own protection and requested to move to another prison. On 12 October, he repeated his concerns to staff. After staff unlocked prisoners at around 6.50pm so they could collect their medication, a prisoner looked through the observation panel of Marc’s cell and saw him hanging from a ligature. He could not be resuscitated and was pronounced dead at 7.18pm.
Despite being referred to the mental health team on entering the prison on 22 September, no assessment had taken place prior his death. A toxicology examination following his death found the presence of a New Psychoactive Substance (NPS) in Marc’s blood.
The inquest will consider:

  • the actions of the mental health team and healthcare;
  • the response to the concerns raised by Marc on 11 October;
  • whether measures should have been taken to protect Marc;
  • events of 12 October;
  • and the availability of NPS at the prison.

After Marc’s death his family were told that staff had deliberately obscured CCTV cameras near Marc’s cell, threatened Marc, and had entered his cell and forcibly restrained him shortly before his death. These have been extremely distressing things for them to hear. They hope the inquest will explore these issues and provide them with answers.


For more information contact INQUEST Communications Team on 020 7263 1111 or [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.

Following an inspection in January 2018 HMI Prisons took the then unprecedented step to issue an Urgent Notification in relation to HMP Nottingham. Media release. HMIP found the prison to be fundamentally unsafe for the third time in a row. They said there was “irrefutable evidence" of a failure to respond to the previous inspection findings and it was "extraordinary" there had not been a more "robust" response.
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.
Recent inquest conclusions from deaths at HMP Nottingham:

  • Andrew Brown, 42, died a self-inflicted death on 12 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.