Prison’s failings contributed to Brett Lowe’s death
31 August 2022
A jury has found that Brett Lowe’s death was preventable and that there was a gross failure to take basic steps to safeguard him by HMP Nottingham prison staff who consistently failed to execute their responsibilities.
The jury at the inquest into the death of the 43-year-old, which concluded on Monday, determined that Brett’s murder at the hands of his cellmate was contributed to by neglect, and they also highlighted systemic issues contributing to Brett’s death, including issues with leadership, culture and training.
The inquest heard that Brett took every opportunity available to him to alert staff to the risk to his own life, and that staff failed to intervene at any time in the chain of events.
While on remand awaiting trial, Brett was put into a cell with Ferencz-Rudolf Pusok the same day Pusok’s previous cell mate had reported that he feared Pusok would “hot water” him, after he repeatedly boiled the kettle during the previous night as if preparing to use the boiled water as a weapon. The former cell mate’s concerns were not documented or acted upon, and he was placed back into a cell with Pusok – although he was moved off the wing later for unrelated reasons.
That night Brett awoke to find Pusok attempting to strangle him. He activated his cell bell and reported the incident. The responding officer told the jury that Pusok made no attempt to deny what he had done.
The only action taken was to report this verbally to a Senior Officer.
No action was taken to separate them.
No record was made of the incident.
No reference was made to the incident in the morning handover.
As soon as he was unlocked the following day, Brett reported what had occurred to a Senior Officer who agreed to a cell move, but rather than action that move he told Brett to go to the wing office to facilitate a move by himself. At the office Brett again alerted staff to the incident and requested a cell move but he wasn’t moved, no further investigation of the incident took place, and nothing was recorded to indicate the severity and heightened risk.
Brett was locked back in the cell with Pusok at about 9:00am. Sometime between 9:00am and 10.20am, while locked in the cell, Brett sustained serious injuries as result of an assault by Pusok. He was discovered at 10:21 lying unresponsive on the cell floor. He died that day as a result of ligature and strangulation injuries inflicted by Pusok, who went on to plead guilty to Brett’s murder. No motive was ever provided for the murder.
The jury found that Brett’s death would have been preventable had reasonable actions been taken, but that opportunities were missed due to failures of communication; lack of staff accountability and a failure to provide a safe environment for Brett.
They found that systemic issues regarding staffing, leadership, document reporting, training, communication, culture, and risk assessments all contributed to Brett’s death.
The current Governor of Nottingham, Paul Yates, told the Coroner that the OSG on duty overnight on 17-18 July has been dismissed for gross misconduct and that disciplinary proceedings will be reviewed regarding others following the conclusion of the inquest.