Healthcare staff at HMP Nottingham were “often unavailable or uncontactable” for handover meetings before a prisoner was murdered by a fellow inmate who had a “complex” mental health history. Jonathan Thornton , 46, had been on B wing at HMP Nottingham for less than 24 hours when he was assaulted by Andrew Thorpe , who had been remanded to prison for attempted murder, on June 28, 2024. An inquest into Mr Thornton’s death at Nottingham Coroner’s Court in February this year was told that Mr Thornton had been moved to the prison’s B wing from the induction wing on the afternoon of June 27 after he was recalled to prison in breach of his licence. Before the cells were locked for the night, Mr Thornton made racist comments in the presence of three prison officers, who failed to escalate the matter. Although the comments were “general in nature and not directed at any one person”, they put Mr Thornton at increased risk of assault or violence. The following morning, on June 28, Thorpe beat Mr Thornton to death in less than one minute in a shower block, causing him to sustain a serious injury from which he eventually died on July 12. The inquest was told Thorpe had a complex mental health history and, at the time of his arrest, was under the care of the community forensic team, having been released six months previously into the community from a low secure forensic unit. He had been charged with grievous bodily harm after an assault on a fellow inmate at HMP Birmingham in June 2011. He was then sentenced to a hospital order at Rampton Hospital, which is a high-security mental health hospital. He was the subject of an indefinite restriction order and, later, he was placed into 24-hour staffed supported living accommodation in Nottingham city centre in November 2023. When he arrived at HMP Nottingham, Thorpe was referred to the mental health team as he disclosed he had a diagnosis of paranoid schizophrenia, which he was receiving medication for. Coroner Alexandra Pountney has now released a Prevention of Future Deaths Report, highlighting her concerns about the possibility of more prisoners dying in similar circumstances. One of the concerns raised by Ms Pountney is to do with poor information sharing between prison healthcare staff and the community forensic team. She explained there was no formal system in place for the handover of information between the two teams. She said: “Prison healthcare staff were often unavailable or uncontactable for handover meetings. “The handover of information between the community forensic team and prison healthcare is vital for the risk assessment and management of prisoners who are known to the community forensic team (often some of the most complex and high-risk prisoners). “I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death. “This case illustrated a lack of communication and information sharing between Prison Healthcare and the Operational Prison Staff which was concerning to me.” The coroner added that the prison healthcare staff had a quasi “watch and wait” plan for monitoring high-risk prisoners but this wasn’t communicated to everyone on the team. She said: “The operational prison staff told me that having a broad understanding of a prisoner’s mental health risks and triggers would improve the safety and security of the prison for the officers and prisoners. “It would enable them to properly assess and manage risk, but that there was no effective mechanism in place by which to achieve this.” Coroner Pountney also criticised the “preset” categorisation of alerts, which she called “limited and broad”. This means “violent” prisoners are all categorised together, meaning prison staff wouldn’t know whether the violent behaviour was against prison officers, other prisoners or linked to their offending. The report was addressed to the Ministry of Justice, which runs HMP Nottingham, Nottinghamshire Healthcare NHS Foundation Trust, which was in charge of the healthcare provision at the time of the murder, and Northamptonshire Healthcare NHS Foundation Trust, which is now running healthcare services at HMP Nottingham. All three agencies have until June 3 to respond to the coroner’s report. A spokesperson for the Prison Service said: “We will carefully consider the findings of the Prison and Probation Ombudsman and the coroner and respond in due course.” The Prisons and Probation Ombudsman investigates every death in custody but has not yet published its investigation and recommendations into this death. A spokesperson for Nottinghamshire Healthcare NHS Foundation Trust said: “We would like to again extend our condolences to Jonathan’s family and friends for their loss. “As stated at the inquest, as part of the learning identified from the case, the Community Forensic Team Standard Operating Procedure is under review. “However, to ensure immediate clarity, new guidance around information sharing with prison healthcare teams was put in place and this was shared with the incoming new healthcare provider at HMP Nottingham, who took over delivery of healthcare services in November 2025. “We are due to respond to the Coroner by June outlining how we are addressing the issues raised and we would also like to share that information with Jonathan’s family prior to its public release, so will refrain from further comment on the specifics until that time.” A spokesperson for Northamptonshire Healthcare NHS Foundation Trust said: “We are committed to learning from all incidents in our healthcare settings, as well as continuously improving our practices. “Since we began providing healthcare services at HMP Nottingham in November 2025, we have been working to make improvements to healthcare processes and ways of working. “We are preparing a formal response to the coroner to address the concerns raised in this report.