Ricky Crosher and Matthew Osborne

I am Miss Laurinda Bower, HM Area Coroner, for the coroner area of Nottingham City & Nottinghamshire.

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online . The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary .

SUMMARY OF CORONER’S CONCERN

1. Failure to have in place an appropriately staffed and resourced

Safer Custody function

1. Failure to have in place a robust system for managing the safer

custody telephone line

1. Failure to provide a safe Care and Separation Unit which adhered

to expected policy and minimum standards of decency

1. Persistent failure to have in place a robust system for learning

from deaths

1. Failure to retain evidence pertinent to the death
2. Failure to ensure a safe and productive working relationship

between prison and healthcare staff