A prison director has told an inquest he observed an "extraordinary" culture of "staff not caring" at a jail where an inmate was found dead in his cell.
Matthew Osborne, 39, was found hanging in a cell on the segregation unit in HMP Lowdham Grange on 25 November 2023.
He was the fifth prisoner that year to be discovered in that manner at the jail in Nottinghamshire.
An inquest at Nottingham Coroner's Court heard he had not been checked on for nearly two hours before his body was found.
On Tuesday the court heard from Ian Whiteside, now an operations director of prisons for Sodexo, who was director of Lowdham Grange at the time of Osborne's death.
Sodexo had taken over running the jail on 16 February 2023 from Serco in what was the first direct transfer of a prison between private companies in England and Wales, but jurors were told that within six weeks three prisoners were found hanging in their cells.
'Severe weaknesses'
Mr Whiteside said he was not involved with the transfer process or the prison itself until he was brought in as interim director on 11 October.
That day, Ricky Crosher was also found in his cell, the jury was told.
Mr Whiteside said he was brought in because of previous concerns raised about the prison's management, with numerous improvement notices having been issued by the government.
"The prison was struggling with staffing and [running the jail], and I think both the prison service and Sodexo believed a change in leadership was probably required," he said.
"There were concerns from the previous deaths we had severe weaknesses."
On arrival, Mr Whiteside said he was worried by the way staff behaved towards prisoners and colleagues, saying there was "a culture of staff not caring".
"There was a culture of staff behaviour that I found extraordinary," he said.
"I had never come across behaviours like it in my 30 years [working in prisons]."The court heard Osborne - who was known to have a history of making ligatures - was under a process called assessment, care in custody and teamwork (ACCT), and required three checks per hour.
He had also been placed in the prison's segregation unit on 3 October, but jurors were told records of daily checks were incomplete, and that reviews on keeping him in isolation were not done properly.
Osborne had no phone, radio or TV in his cell, where he was kept for at least 22 hours a day, and ACCT checks were in some cases documented but not carried out.
On 25 November the court heard no checks were made from 14:32 until he was found at 16:22.
Mr Whiteside said he was "very concerned" about the segregation unit's ability to function from the point he arrived.
"I really felt that the management structure wasn't effective in delivering a safe segregation unit," he said.
In December 2023 the Ministry of Justice took over the running of Lowdham Grange, initially on a temporary basis before the move was made permanent the following year.
When asked by area coroner Laurinda Bower about efforts to tackle the jail's problems when he arrived, Mr Whiteside said: "The prison was in real difficulties, and I think at that point it was probably beyond the capabilities of a private organisation."The court also heard from Jasmine Osborne, who said her brother's death had "shattered" his family.
Describing him as a keen sportsman, she said he "struggled with his mental health from his teens" but travelling "gave him peace and helped with his mental state".
She said he had had a difficult time in foster care, where "like the prison service later he wasn't given the support he needed".
Her brother "deteriorated rapidly" after he was transferred to Lowdham Grange on 20 June 2023, she told jurors, but said the family was did not know about his ACCT and what they could do to help.
"We didn't know how much distress [he] was in until after he died," she said.
"It is clear to all of Matthew's family that Lowdham Grange was the most unsafe prison he'd ever been to, and we just wish he had never been sent there."
The inquest continues.
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