Nickolas Fretwell

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Independent investigation into
the death of Mr Nickolas Fretwell,
a prisoner at HMP Elmley,
on 16 October 2024
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Nickolas Fretwell died on 16 October 2024, after he was found unresponsive with a
ligature around his neck in his cell at HMP Elmley. Staff tried to resuscitate him but were
unsuccessful. He was 49 years old. I offer my condolences to Mr Fretwell’s family and
friends.
Mr Fretwell was the fourth self-inflicted death at Elmley since October 2021. Up to the end
of March 2025, there has been one further self-inflicted death.
Despite Mr Fretwell arriving at Elmley with a suicide and self-harm warning on 14 October,
reception staff failed to start suicide and self-harm prevention procedures (known as
ACCT) for him. No one started ACCT procedures for Mr Fretwell during his two days at
Elmley.
Following an investigation into a previous death at Elmley which found similar failings, I
made a recommendation to the Governor in May 2024 to review the training given to
reception staff on assessing risk of suicide and self-harm. Despite being assured that there
had been a full review of reception procedures and a new process introduced, Mr
Fretwell’s risk of suicide was not identified, and nothing was put in place to help mitigate
his risk.
The identification of risk on reception is a key concern identified repeatedly in my
investigations. The Governor of Elmley is not alone in having introduced what appear to be
sensible measures to support staff’s ability to identify risk that fall short when put to the
test. HMPPS must consider, with urgency, what more can be done to support reception
staff with this vital task.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman June 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ........................................................................................................................... 9
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Summary
Events
1. On 14 October 2024, Mr Nickolas Fretwell was remanded in prison charged with
violent offences against his partner. He was sent to HMP Elmley.
2. Mr Fretwell arrived with a suicide and self-harm warning in his Person Escort
Record (PER). It said that Mr Fretwell was at high risk of suicide, as he had said on
numerous occasions that he would kill himself on release from police custody. It
also said that Mr Fretwell had a history of self-harm.
3. Mr Fretwell told the reception nurse that he had anxiety and depression and
misused alcohol. Both the reception nurse and reception officer said that Mr
Fretwell had told them he had no thoughts of suicide or self-harm and that he
presented well. Neither started suicide and self-harm prevention procedures (known
as ACCT) despite both seeing the PER.
4. Mr Fretwell was placed on an alcohol detoxification programme and admitted to the
prison’s inpatient unit for hourly monitoring by healthcare staff.
5. On 16 October, during a welfare check, a healthcare assistant saw Mr Fretwell lying
face down on his cell floor. The healthcare assistant called to him through the cell
door, but Mr Fretwell did not respond. The healthcare assistant went to the office to
ask officers for help. Officers entered the cell and found Mr Fretwell had tied a
ligature around his neck. An officer radioed a medical emergency code and several
healthcare staff attended.
6. Staff tried to resuscitate Mr Fretwell but were unsuccessful. At 1.19pm, a GP
declared life extinct.
Findings
7. Reception staff failed to start ACCT procedures for Mr Fretwell. They placed too
much reliance on Mr Fretwell’s presentation and disregarded his suicide and self-
harm warning and multiple risk factors.
8. The prison introduced a “Bus to bed checklist” following a previous death, which
requires the reception officer and the officer conducting the first night in prison
(FNIP) interview to record whether they have seen the PER and suicide and self-
harm warning (if applicable) and note any concerns/actions taken. Neither the
reception officer nor the FNIP officer completed the checklist when they processed
Mr Fretwell.
9. We have previously identified poor assessment of risk by reception and induction
staff at Elmley. In response to a previous recommendation, the prison said it was
reviewing reception processes and would deliver more training. It is disappointing
that the same issues have arisen in this case. The Governor and Head of
Healthcare must do more to ensure that staff are following the correct reception and
induction processes and properly consider risk factors for suicide and self-harm,
rather than relying on what the prisoner tells them.
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Recommendation
• The Governor and Head of Healthcare should implement a robust quality assurance
process of reception and FNIP records to ensure that staff are following the agreed
processes and recording and considering all risk factors for suicide and self-harm.
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The Investigation Process
10. HMPPS notified us of Mr Fretwell’s death on 16 October 2024.
11. The investigator issued notices to staff and prisoners at HMP Elmley informing them
of the investigation and asking anyone with relevant information to contact her. No
one responded.
12. The investigator visited Elmley on 29 October. She obtained copies of relevant
extracts from Mr Fretwell’s prison and medical records.
13. The investigator interviewed six members of staff at Elmley on 19 November and
two members of staff over Microsoft Teams on 11 and 29 November.
14. NHS England commissioned an independent clinical reviewer to review Mr
Fretwell’s clinical care at the prison. She conducted eight joint interviews with the
investigator.
15. We informed HM Coroner for Kent and Medway of the investigation. The Coroner
gave us the cause of death. We have sent the Coroner a copy of this report.
16. The Ombudsman’s office contacted Mr Fretwell’s next of kin to explain the
investigation and to ask if she had any matters she wanted us to consider. She
asked if staff were aware of his alcohol misuse issues, what support he was offered
and if he had missed any hospital appointments. These have been addressed in
this report and the clinical review.
17. We shared our initial report with HMPPS and the prison’s healthcare provider,
Oxleas NHS Foundation Trust. They pointed out some factual inaccuracies which
have been amended in this report.
18. We sent a copy of our initial report to Mr Fretwell’s next of kin. They pointed out an
error in the clinical review which said that Mr Fretwell had no outstanding hospital
appointments. This has been amended.
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Background Information
HMP Elmley
19. HMP Elmley holds remand and sentenced prisoners in six houseblocks, with a
mixture of single and double cells. Oxleas NHS Foundation Trust provides
healthcare services.
HM Inspectorate of Prisons
20. The most recent inspection of Elmley was in February and March 2022. Inspectors
reported that reception was a busy environment, and new arrivals were treated well
and the process was relatively swift. All new arrivals had interviews with an officer
and a nurse. However, these lacked sufficient depth to identify risks and
vulnerabilities, but this was offset by other opportunities to identify risk through
health screening. Around 38% of the population were known to the substance
misuse service.
21. Inspectors noted there had been four self-inflicted deaths since the last inspection
and that some new prisoners missed important aspects of induction. The prison had
begun implementing PPO recommendations, but implementation was not monitored
over time to ensure ongoing compliance. Reported self-harm was lower than in
most comparable prisons but had increased since the last inspection.
22. In February 2023, HMIP published an Independent Review of Progress. The report
said that Elmley faced substantial staff shortages, but leaders were focused on how
to make improvements with the resources they had and were delivering more than
many prisons with a similar or better staffing position. However, inspectors were not
confident that the changes were sufficient to care for prisoners on their first night
and early days in custody. Inspectors highlighted the effective changes made to the
induction programme which resulted in prisoners being better prepared for
assessments.
Independent Monitoring Board
23. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 31 October 2024, the IMB noted
that the prison was taking steps to improve the process of reception and induction
for new prisoners but, from the Board’s observations, good practice was not
consistently embedded.
24. The Board noted that the prison had recently put in place a revised procedure
known as “Bus to Bed”, which while in its infancy, seemed to be having a positive
effect. Key to reducing risk at the point of arrival was for officers to take note of the
Person Escort Record (PER) and the suicide and self-harm warning form, where
provided, but because of pressure to get prisoners through reception and onto their
houseblock, this did not take place consistently. The Board also noted that incidents
of self-harm had risen, and prisoners had reported to IMB members that they felt
unsafe due to differing factors which included concerns about their mental health.
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The Board found it regrettable that the in-house Listener scheme (prisoners trained
by the Samaritans to provide peer support) had ceased as a support mechanism for
vulnerable prisoners, who were now directed to the Samaritans.
Previous deaths at HMP Elmley
25. Mr Fretwell was the 12th prisoner to die at Elmley since October 2021. Of the
previous deaths, six were from natural causes, three were self-inflicted and two
were drug related.
26. We have previously made a recommendation about improving the identification of
suicide and self-harm risk during the reception and induction process. In response,
the prison told us they were undertaking a review of the early days in custody
processes and a formalised process had been introduced to ensure that prisoners
received meaningful interactions during their first 48 hours. They also planned to
deliver training to all reception and first night centre staff.
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Key Events
27. On 14 October 2024, Mr Nickolas Fretwell was remanded in prison, charged with
violent offences and coercive behaviour against his partner. He was sent to HMP
Elmley. He had previous convictions but had not been in prison for many years.
28. Mr Fretwell’s Person Escort Record (PER – a document that accompanies
prisoners when they move between police stations, courts and prisons which sets
out the risks they pose) contained a suicide and self-harm warning. It said that Mr
Fretwell was at high risk of suicide as he had said on numerous occasions that he
would kill himself on release from police custody and was being checked every 30
minutes. It noted that on 19 May 2024, Mr Fretwell had punched himself in the head
and headbutted the charge desk while in police custody and had said he would self-
harm or jump off a bridge when released. The form also noted that Mr Fretwell had
Post-Traumatic Stress Disorder (PTSD) and self-harmed by cutting his arms.
29. A Supervising Officer (SO) conducted Mr Fretwell’s reception interview when he
arrived at Elmley. She said at interview that she thought the PER had mentioned Mr
Fretwell’s suicidal thoughts from a few months before and when she had asked him
about this, he had said he was fine. She said Mr Fretwell had presented well and
she found him to be quite jovial. She did not complete a “Bus to bed checklist” for
Mr Fretwell, despite being required to do so, because she did not think the checklist
was in use at the time. (Following previous deaths at Elmley, the prison introduced
a “Bus to bed checklist” in August 2024, which should be completed for each new
arrival by the reception SO and the officer who conducts the First Night in Prison
(FNIP) review. The reception SO and the FNIP officer must each record whether a
PER and suicide and self-harm form was available, whether it was checked, and
any concerns/action taken.)
30. A nurse completed Mr Fretwell’s initial health screen. At interview he confirmed that
he had seen his PER. Mr Fretwell told him he had anxiety and depression, and
misused alcohol. He reported that he had been engaging with a community mental
health service. He said he had a history of bladder cancer and used a colostomy
bag. The nurse noted that Mr Fretwell presented as engaging, calm and coherent
and said he had no current thoughts of suicide or self-harm. He incorrectly noted
that Mr Fretwell did not have a history of self-harm.
31. An officer completed the FNIP review in the First Night Centre. He noted Mr
Fretwell’s offences, that he had a history of self-harm, was violent and had health
issues. There was no mention of the PER or any notes regarding discussions
around thoughts of suicide or self-harm. He did not complete a “Bus to bed
checklist” (probably because the SO had not started the checklist as she was
supposed to).
32. A GP at Elmley reviewed Mr Fretwell and diagnosed alcohol dependence
syndrome. He arranged for him to begin alcohol detoxification and to be admitted to
the prison’s inpatient department (IPD) for hourly monitoring by healthcare staff.
33. A nurse completed the second reception screen when Mr Fretwell was admitted to
the IPD. He noted that Mr Fretwell was mentally stable and had said he had no
thoughts of suicide or self-harm.
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34. Mr Fretwell was checked hourly overnight, and staff recorded no concerns about
him.
35. On 15 October, a nurse completed a mental health assessment. She noted that Mr
Fretwell had been diagnosed with PTSD and had been engaging with talking
therapies in the community. Healthcare staff scheduled a psychology review for 24
October and completed frequent observations of Mr Fretwell’s heart rate, blood
pressure and oxygen levels. All were within a satisfactory range.
36. A healthcare assistant completed a substance misuse review. She noted that Mr
Fretwell appeared to have a low mood and low self-esteem. Mr Fretwell told her
that he had considered suicide when he was drunk but did not think like that when
he was sober. She completed a brief interventions and treatment care plan for
excessive alcohol consumption.
Events of 16 October 2024
37. The investigator watched CCTV footage, body worn video camera (BWVC) footage
and listened to staff radio communications from 16 October. She also obtained
information from the Southeast Coast Ambulance Service.
38. Between 6.00am and 11.00am, three healthcare staff checked Mr Fretwell’s clinical
observations. A nurse checked them at 6.24am, a healthcare assistant checked
them at 9.16am and another nurse checked them at 11.01am. All noted that there
were no concerns.
39. CCTV shows that Mr Fretwell went to the dayroom, stopped briefly at the nurses’
office and returned to his cell at 10.15am. Staff delivered lunch to his cell at
11.00am.
40. At approximately 12.00pm, the healthcare assistant went to Mr Fretwell’s cell door
to complete a welfare check. CCTV footage shows him looking through the flap in
the cell door. At interview, he said that he saw Mr Fretwell standing by the toilet.
When he completed his next welfare check at 12.45pm, he saw Mr Fretwell lying
face down on the floor. He called to him, but Mr Fretwell did not respond. CCTV
shows that at approximately 12.47pm, he went to the office and asked prison staff
to go to the cell with him.
41. CCTV shows at 12.53pm, three prison officers and the healthcare assistant went to
Mr Fretwell’s cell door. Officer A tried to speak to Mr Fretwell through the cell door.
When there was no response, he opened the cell door and went in. He said in his
written statement that Mr Fretwell was lying face down on the floor with his feet
towards the door. He was not moving, and his face was purple. He radioed a code
blue (a medical emergency code used when a prisoner is unconscious or having
breathing difficulties). In his statement, Officer B said that Mr Fretwell had what
appeared to be strips of green bedding wrapped multiple times tightly around his
neck. He cut away the ligature and, together with Officer A, they rolled Mr Fretwell
onto his back, and he began chest compressions. Healthcare staff quickly
responded to the code blue. Officer A also did a round of chest compressions. He
said a nurse shouted for them to move Mr Fretwell out of the cell into the corridor
for more room.
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42. In her interview, a nurse said she was providing lunch time cover in the IPD when
she heard the code blue, so she grabbed the emergency bag and went to Mr
Fretwell’s cell. She said she shouted for staff to move Mr Fretwell out of the cell and
into the corridor for more room. Staff moved Mr Fretwell into the corridor and
continued chest compressions. She assisted with using the defibrillator and helped
with the chest compressions. She said that several nurses and prison officers
assisted with rounds of chest compressions.
43. At interview, a GP at Elmley said that when he arrived at the cell, he saw staff
performing chest compressions and nurses using an ambu bag (a self-inflating bag
used to get air into the lungs during resuscitation). The defibrillator was attached to
Mr Fretwell and it advised staff to continue CPR. He inserted an Igel (an airway
device to secure and maintain the airway and administer oxygen). However, despite
staff’s efforts for 29 minutes, there was no response. He declared life extinct at
1.17pm.
44. The ambulance log noted that the 999 call was received at 12.55pm. There were no
ambulances available at that time and the ambulance operator advised prison staff
to administer CPR until paramedics could get there. CCTV shows ambulance
paramedics arrived at 1.25pm. The prison GP had already declared life extinct.
Contact with Mr Fretwell’s family
45. The prison appointed a family liaison officer. She and a prison chaplain visited Mr
Fretwell’s next of kin at her home on 16 October to tell her Mr Fretwell had died and
offer support.
46. The prison contributed to the cost of Mr Fretwell’s funeral, in line with national
guidelines.
Support for prisoners and staff
47. Staff from the safer custody team went to the IPD to offer support to prisoners and
staff. Formal postvention procedures (a process devised by HMPPS in conjunction
with the Samaritans to ensure staff and prisoners are offered suitable support after
certain incidents including unexpected deaths) were not initiated due to local issues
at the Samaritans branch closest to Elmley.
48. After Mr Fretwell’s death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
49. The prison posted notices informing other prisoners of Mr Fretwell’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Fretwell’s death.
Post-mortem report
50. The post-mortem report has not yet been shared with us, but the Coroner has
advised that asphyxiation was the cause of death.
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Findings
Assessment of Mr Fretwell’s risk of suicide and self-harm
51. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), which was in force at the time of
Mr Fretwell’s death, set out the procedures (known as ACCT) that staff should
follow if they identified that a prisoner was at risk of suicide or self-harm. It required
all staff who had contact with prisoners to be aware of the risk factors and triggers
that might increase the risk of suicide and self-harm and take appropriate action.
(The policy has since been superseded by the Prison Safety Policy Framework
though ACCT processes remain broadly the same.)
52. PSI 07/2015, Early Days in Custody, sets out guidance and mandatory actions for
prison staff during reception, first night in custody and induction. It says that the
PER and any other available documentation must be examined in reception to
assess the risk of suicide and self-harm. It also references a Reception and First
Night Checklist.
53. Mr Fretwell had several risk factors for suicide and self-harm. He had expressed
suicidal intent while in police custody before his remand to Elmley, had a history of
self-harm, mental health difficulties and alcohol misuse, and had been charged with
a violent offence against his partner.
54. Mr Fretwell arrived at Elmley with a PER that set out his risk factors and contained
a suicide and self-harm warning. Despite this, neither the reception SO nor the
reception nurse started ACCT procedures. They both said that Mr Fretwell
presented well and said he had no thoughts of suicide or self-harm and so they
considered ACCT procedures were unnecessary.
55. A prisoner’s presentation can reveal something of their level of risk. However, it is
only a reflection of their state of mind at the time they are seen by the member of
staff and should be considered as a single piece of evidence used to make a
judgement of risk. All risk factors must be collated and considered to ensure that a
prisoner’s level of risk is judged holistically.
56. We identified similar issues in our investigation into a self-inflicted death at Elmley
in 2023. In May 2024, we issued a recommendation to improve training to reception
and induction staff about identifying prisoners at risk of suicide and self-harm. In
response, the prison told us they were undertaking a review of the early days in
custody processes and a formalised process had been introduced to ensure that
prisoners received meaningful interactions during their first 48 hours.
57. Elmley introduced a “Bus to bed checklist” in August 2024, which must be
completed by the reception SO and the FNIP officer for each new arrival. The SO
and FNIP officer must each record whether a PER and suicide and self-harm form
is available, whether it has been checked and any concerns/action taken. Neither
the SO nor an officer completed this for Mr Fretwell. When interviewed, the SO said
that she thought it had not been in place when Mr Fretwell arrived, but other staff
confirmed that it was.
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58. It is frustrating that despite previous PPO recommendations about reception and
induction processes and Elmley itself recognising that processes need to improve,
the same issues persist. In their latest report, the IMB also noted that while it was
key to reducing risk for officers to take note of the PER and suicide and self-harm
warning, this did not happen consistently. We make the following recommendation:
The Governor and Head of Healthcare should implement a robust quality
assurance process of reception and FNIP records to ensure that staff are
following the agreed processes and recording and considering all risk factors
for suicide and self-harm.
Clinical care
59. The clinical reviewer concluded that the clinical care that Mr Fretwell received at
Elmley was of the required standard and equivalent to that which he could have
expected to receive in the community.
60. However, the clinical reviewer made four recommendations about responding to
medical emergencies. She found that no one appeared to be leading the
resuscitation attempt and no privacy screens were used. She also found there was
confusion about who was responsible for the daily checks of emergency equipment
and some checks had been missed. Although the recommendations are not
repeated in this report, the Head of Healthcare will need to address them.
Inquest
61. At the inquest, held from 26 January to 6 February 2026, the jury concluded that Mr
Fretwell died by suicide.
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