HMP Lowdham Grange is located about 10 miles north-east of Nottingham. Despite its sedate rural surroundings, operations at the Category B jail have been far from serene, with people describing a picture of chaos following the first private-to-private transfer of a prison in England and Wales.
Issues didn't end there, with safety at the prison becoming such a concern that the government had to step in - and has remained at the helm ever since.
And despite some improvements, families of inmates past and present have said problems at the prison persist.
What were conditions like before the change in management?
Like a lot of prisons, HMP Lowdham Grange - which opened in 1998 under security contractor Serco - has had its issues.
Almost eight years ago, allegations emerged of assaults by prison officers on inmates following several outbreaks of violence at the jail.
But inspectors did reserve praise for several elements of the prison's operation. For example, a programme in which prisoners could read bedtime stories to children, as well as a rehabilitation scheme involving a TV channel run by inmates.
In addition, reports by the Independent Monitoring Board (IMB) for prisons painted a broadly positive picture, with a 2020 document saying the jail "is built on a positive ethos", praising "firm leadership" and regular sampling of paperwork and CCTV to ensure standards are maintained.
What happened when Lowdham Grange changed hands?
The prison - which has a maximum capacity for about 900 inmates - came under the control of another outsourcing firm Sodexo on 16 February 2023. The Sodexo takeover from Serco was a landmark moment, given it was the first time one private operator had taken over from another in England and Wales.
But the transition wasn't smooth. Inquests into inmates' deaths heard claims of strained relations between the two firms, including Serco managers moving to other prisons and trying to recruit officers from Lowdham Grange.
The inquests also heard Sodexo's model was planning on operating with fewer prison officers, despite concerns being raised ahead of the handover.
And a court heard when Sodexo took over, and when staff in the safer custody team arrived, they found some computers in their office had been taken, as they were leased by Serco.
Who has died at Lowdham Grange?
The BBC has reported numerous deaths of inmates, and attended a number of inquests into inmates' deaths.
A number of prevention of future death reports - a mechanism used by coroners to highlight areas where action is needed to stop similar deaths happening again - have been issued in relation to deaths at the prison.
These include:
Nigel Saunders, who died in November 2018. An inquest jury found his death was accidental, and determined there were failings by the Prison Service in his care
Christopher Smith, who died in May 2019. The inquest jury found multiple failings in the care by prison and healthcare staff. His death was contributed to by neglect, the coroner said
Kane Boyce, who was found hanging in his cell in October 2021. An inquest found a number of failings in his care, leading to a coroner issuing another prevention of future deaths report. Regarding failures over Boyce's death, Serco said it "remains committed to ensuring the safety of prisoners in our care"
Anthony Binfield, who died on 6 March 2023, weeks after the Serco to Sodexo transfer. An inquest that looked into his death found he died of suicide, and the jury said a note found laid bare how he "felt let down and unheard by the system and by the prison staff"
David Richards, who was also found hanging in his cell on 13 March 2023. The jury concluded his death was an accident, but said there was a failure to perform a welfare check when his cell was unlocked
Rolandas Karbauskas, who was found hanging in his cell on 25 March 2023. The jury found no adequate welfare check was carried out when his cell was unlocked. Returning a conclusion of suicide, the jury cited the "questionable" translation service that "led to distinct language barrier issues.
In response, Serco, Sodexo and the Ministry of Justice (MoJ) all commented on the conclusion of the inquest into the deaths of Binfield, Richards and Karbauskas.
The MoJ offered "sincere apologies for the failings in these cases", and outlined work it had taken to remedy problems.
Sodexo, which was in charge of the jail at the time of the deaths in March 2023, said it "will fully take on board any learnings" from the inquest. Serco added it was "extremely regrettable" the deaths took place "after our handover", but said it "we will ensure any key learnings are implemented".
Other deaths at the prison include:
A month after Osborne's death, the MoJ stepped in to take over, initially on a temporary basis before assuming permanent control the following year.
Since then, four prisoners died in 2024, nine inmates died in 2025 and no inmates have died this year so far.
These include:
Patrick Maughan, who died on 17 November 2024. A jury said the drug-related death was "due to the use of cocaine and synthetic cannabinoid drugs". The jury also said drug use "was recognised as being a major problem at Lowdham Grange", and also highlighted "staffing issues"
Alvaro Mendoza Sillerico, who died on 18 November 2024. An inquest heard a rupture in the bowel - "caused by disseminated tuberculosis", caused his death
Stephen Metcalfe, who died in December 2024. His medical cause of death was the use of synthetic cannabinoids, known as Spice. The coroner concluded he died by misadventure
Adam Diesa-Green, who was found unresponsive in his cell in January 2025. A jury returned a conclusion of death by misadventure, finding taking Spice in a modified vape was "a reckless act"
Raymond Wallace, who died after being found unconscious in January 2025. A post-mortem examination found the probable cause of death was "the effects of synthetic cannabinoids", while the presence of heart disease "most likely indirectly contributed to Mr Wallace's death"
Mark Bates, who died in March 2025. He had three different strains of Spice in his system. A jury returned a conclusion of misadventure, but found failings "significantly contributed" to the death
What has changed since the government took over?
In June this year, a report by HM Inspectorate of Prisons noted "considerable improvements" at the jail following an inspection in May.
However, that came after serious failings were found in 2025, and even in the more positive report, inspectors said "longstanding problems" still needed to be solved.
In June 2025, another significant change took place, as Nottinghamshire Healthcare NHS Foundation Trust announced it was withdrawing as healthcare provider for the prison, with Northamptonshire Healthcare NHS Foundation Trust taking over.
Staff shortages have continued, leading to numerous instances of the prison being locked down due to a lack of officers, while the leadership of the prison has changed on numerous occasions. Conditions at Lowdham Grange have also been raised in Parliament by Michelle Welsh, the Labour MP for Sherwood Forest, the constituency in which the prison is based.
The BBC has made repeated requests to interview Tyrienna Greenslade, who took over as governor of Lowdham Grange in March 2025, but these have been refused by the MoJ.
However, in a statement, a spokesperson for the MoJ said: "HMP Lowdham Grange is making important progress thanks to expert leadership.
"We have invested over £40m in physical security across the prison estate, and are investing a further £35m this year at high-risk sites. This has helped cut drug use while better staffing has created a safer environment.
"The prison will continue to improve the support it provides to people at risk of self-harm or suicide, alongside better mental health support to help bring self-harm rates down."
How does Lowdham Grange compare to other prisons?
According to figures released by the MoJ on deaths at prisons across England and Wales, 22 inmates at Lowdham Grange have died since 2021.
Not all inquests have taken place, so recent figures on how many of the deaths are self-inflicted are not currently available, so figures for total deaths also include those from natural causes and other factors.
Of those, 19 happened after the Serco-Sodexo transfer, 13 of which have occurred since the government took back control.
Between 2023 and 2025, nine other prisons had a higher number of deaths than Lowdham Grange, the most being 41 at HMP Littlehey, a Category C institution in Cambridgeshire.
HMP Wymott in Lancashire has had 34 deaths in that period, with HMP Parc in Wales in third on 32.
All three prisons have maximum capacities of more than 1,000, higher than Lowdham Grange.
What concerns remain?
Despite inspections finding some improvements, concerns about the prison have persisted among inmates, their families and the authorities.
The BBC has been contacted by more than a dozen relatives of prisoners - some of whom are still serving sentences at the jail - who say they fear for the lives of their loved ones.
More widely, following the conclusion of Matthew Osborne's inquest, coroner Laurinda Bower also said she would write to police over her concerns that "there hasn't been sufficient consideration" over possible criminal inquiries over the failures.
This week the force confirmed it had received a letter from the coroner.
Det Insp Stuart Barson said: "Our thoughts remain with the families affected by the death of their loved ones at HMP Lowdham Grange.
"As a force, we have received an official letter from the coroner highlighting some concerns around a number of deaths at the prison.
"We will now be reviewing these deaths and identifying affected families."
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