18 June 2019

This press release was prepared by Deighton Pierce Glynn solicitors.

Before HM Assistant Coroner for Nottinghamshire, Ivan Cartwright
The Council House, Old Market Square, Nottingham NG1 2DT
3 to 14 June 2019

A jury has returned a critical conclusion in the first of a series of inquests concerned with deaths at HMP Nottingham. They unanimously found there was:

  • inadequate care and support from the mental health services. For instance, failure to re-book missed appointments, not creating a care plan at any time and not following up concerns raised by Shane’s family.
  • a lack of trained ACCT assessors.
  • Unsatisfactory compliance with the ACCT process and documentation not adhered to.
  • A new ACCT should have been opened due to raised concerns from Shane’s mother.
  • Prison staff failed to communicate with family about incidences involving Shane’s time at HMP Nottingham. They were not made aware of Shane’s period of crisis.

Shane Stroughton, 29, was found hanging on 13 September 2017. He had been in prison on an IPP sentence (imprisonment for public protection) imposed when he was just 19. Although he had a minimum term of 2 ½ years, he had remained in prison for nearly ten, and was released from HMP Stocken on 13 June 2017.

The jury heard that one of Shane’s first acts on release had been to go and see the grave of his brother, Liam, who had died a self-inflicted death whilst Shane had been in prison. For three weeks Shane complied with his parole conditions. On 3 July he absconded from Approved Premises to spend a night with his other brother, Kyle. He handed himself in the next day but by then had been recalled. His probation officer had not been able to consider the case herself and the recall was instead actioned by staff at the Approved Premises because it was at night.

When Shane arrived at Nottingham Prison, he was immediately identified as a high risk of suicide having tied a ligature while in police custody. In the few days after arriving at Nottingham prison, he set fire to his cell and rendered himself unconscious with another ligature. The jury heard that Nottingham prison had failed three inspections by HM Inspectorate of Prisons, who noted high levels of violence and inadequate staffing levels. One inspection was shortly after Shane’s death, which resulted in an ‘Urgent Notification’ to the government, and the prison being placed in special measures.

Shane was managed under the suicide and self harm procedures (known as ACCT) on 2 August 2017. He was put in a cell on his own with no TV. The records suggested there was very little interaction with him after that, even after his family rang in to say that he appeared to have lost two stone in weight. The jury heard evidence that that Shane lost 20% of his body weight in six weeks and by the time of his death had a body mass index that meant he was underweight and malnourished, but this was not picked up. Shane’s nonattendance at medical appointments were not followed up by prison staff.

On 11 September, Shane was told he was to be re-released, but his probation officer was working with four or five times the appropriate caseload and could not spend any time with him. The following day another prisoner who Shane knew was found hanging, but no-one checked on Shane. It was heard that checks are only done when someone is monitored under an ACCT, which Shane had been taken off.

Deborah, mother of Shane, said: “So much went wrong in Shane’s case. The IPP was vicious. He had a 2 ½ year term but did 10, and it made his mental health problems worse and also institutionalised him. He could not cope with freedom and so was recalled quickly. Nottingham was a terrible prison for him. With all that was going on there they were never going to notice a quiet boy like my Shane. So they did not notice him losing two stones of weight. And taking his TV from him at the same time as removing support and losing his cell mate was just cruel.”

Alan, father of Shane, added: “Shane needed support, especially mental health support on release, and he did not get it. He was then given four days notice that he was coming out, and was going straight back to the same hostel. He was not prepared for it. He was told he was coming out on the Monday, another prisoner he knew then hanged himself on the Tuesday, but no-one checked on Shane because he was not then seen as a risk, and then he went on the Wednesday. Shane was no trouble, so no-one thought about him. It was all just thoughtless.”

The family were concerned that on the final day of the inquest the prison lawyers argued against a photograph of Shane being shown to the jury.



Shane’s family are represented by INQUEST Lawyers Group members Jo Eggleton from Deighton Pierce Glynn and Nick Armstrong of Matrix Chambers.

Other interested persons represented are Her Majesty’s Prison Service and Nottinghamshire Healthcare NHS Foundation Trust.

There were seven deaths at HMP Nottingham from February to October 2017, all but one was self-inflicted. Shane was the first of five deaths in a month.

Also see:

Other deaths of people on IPP sentences include:

  • Steven Trudghill, 23, who died at HMP Highpoint on 9 January 2014. The coroner at the conclusion of the inquest wrote a Prevention of Future Deaths report addressed to the Ministry of Justice, which raised concerns about other prisoners on IPP sentences who were at continued risk. He said, it is the “case that there are complex mental health needs which might actually be the reason for the continuing risk that keeps them in custody, as with Steven, yet the specific treatments are not available within the prison system”. 

  • Charlotte ‘Charlie’ Nokes, who was 38 when she died at HMP Peterborough on 23, 2016. The inquest into her death is yet to take place. Charlotte’s family spoke to the BBC about her life.

A Westminster Hall debate on Imprisonment for Public Protection (IPP) in June by Tanmanjeet Singh Dhesi MP. A transcript for the debate is available online.

IPP sentences

  • IPP sentences came into use on 4 April 2005, as part of section 225 of the Criminal Justice Act 2003, introduced by then Home Secretary, David Blunkett.
  • In 2007 the Queen's Bench Division of the High Court ruled that the continued incarceration of prisoners serving IPPs after tariff expiry where the prisons lack the facilities and courses required to assess their suitability for release was unlawful.
  • In 2010 a joint report by the chief inspectors of prisons and probation concluded that IPP sentences were unsustainable for prisons in the UK.
  • On 3 December 2012 the IPP sentence for new cases was abolished by the Legal Aid, Sentencing and Punishment of Offenders Act.