Prisoner died after using Spice, inquest concludes

An inmate at a prison in Nottinghamshire died after using synthetic cannabinoids, an inquest has concluded.

Mark Bates, originally from Bolton, was found in his cell by other inmates at HMP Lowdham Grange on 26 March 2025.

The 32-year-old had three different strains of drugs commonly known as Spice in his system, a post-mortem found.

A jury at Nottingham Coroner's Court returned a conclusion of misadventure on Thursday, but found a failure to arrange a psychiatric review and failures around a system for checking on vulnerable prisoners "significantly contributed" to the death.

The inquest had previously heard Bates was transferred to Lowdham Grange from HMP Forest Bank in Salford on 28 June 2023, where his history of mental health problems was made known to staff.

He spent much of his time in the Category B jail's segregation unit, which he had been in shortly before he died, when he was on a wing.

At the time of his death Bates was being monitored under a process called assessment, care in custody, and teamwork (ACCT), which is used in jails to help people at risk of self-harm or suicide, and was due to be checked on every hour.

A jury said at about 05:00 BST on 26 March 2025, a prison officer tried to carry out an ACCT check on Bates, but the cell window was blocked, leading to him calling for assistance on the radio from a senior officer.

They found the officer was recommended to "make further attempts to rouse [Bates, and] these were unsuccessful", and said there was "no documented evidence" the officer carrying out the checks had been properly trained.

"There was no evidence of communication or briefings, particularly within blocks at [staff] changeover times, therefore, staff were not provided with any concerns raised," they said.

Bates "was found unresponsive shortly after morning unlock" at about 08:25, the jury said, but was declared dead minutes after an ambulance crew arrived at his cell.

The inquest had heard from prison staff who said Spice was a major problem in jails across the country, which the jury found had been "an ongoing challenging issue" since 2017.

Confirming the medical cause of death as being from "use of synthetic cannabinoids", jurors found Bates's death was from "misadventure due to the illicit use of Spice, to which failure to arrange a psychiatric review and failures in the ACCT process... significantly contributed".

Simon Burge, assistant coroner, said he would not be issuing any prevention of future deaths report following the inquest, having heard "at length" from the current governor and healthcare provider about changes made around communication, documentation and other issues.

"I'm impressed that changes have been made and lessons have been learned," he said.

A spokesperson for Nottinghamshire Healthcare NHS Foundation Trust, which provided healthcare at Lowdham Grange at the time of Bates's death but withdrew from its contract last year, said it accepts the findings of the coroner and the jury.

"[The jury] noted that the healthcare provided was appropriate, however, we recognise there was an element of care that was not of the standard Mark deserved and for this we are very sorry," they said.

"Although healthcare services at Lowdham Grange transferred to a new provider in July 2025, we remain committed to supporting them as they continue to build on improvements already made."

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