Nigel Feckey

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Independent investigation into
the death of Mr Nigel Feckey,
a prisoner at HMP Fosse Way,
on 23 September 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 Nigel Feckey was found hanged in his cell at HMP Fosse Way on 23 September 2024.
He was 64 years old. I offer my condolences to Mr Feckey’s family and friends.
Mr Feckey, who was in prison for sexual offences and arrived at Fosse Way on 1 February
2024, complained repeatedly that he was being bullied by other prisoners after they found
out about his offences. He was assaulted twice.
Mr Feckey was supported using suicide and self-harm prevention procedures (known as
ACCT) for just over three weeks in June and July, after his cellmate told staff that he had
tied a ligature round his neck. Mr Feckey told staff he was still being bullied. In August,
staff moved Mr Feckey to a wing for over 50s and he said the bullying stopped. However,
he took his life just over a month later.
When Mr Feckey was at Fosse Way it did not have a wing for vulnerable prisoners, so Mr
Feckey was located with the main prison population. During the investigation, we were told
that staff were not confident in challenging poor behaviour and bullying. I am aware that
Fosse Way has recently introduced two units for vulnerable prisoners (mixed with
mainstream prisoners), the men located on those wings still have to mix with mainstream
prisoners when they are at work or education. The prison needs to monitor this carefully to
assess whether vulnerable prisoners are being kept safe at Fosse Way.
My investigation also found failings with the ACCT management including missed ACCT
reviews and supervisor checks. This suggests a lack of management oversight and
inadequate quality assurance.
There was a delay in finding Mr Feckey as the officer on duty that morning failed to carry
out the morning roll check, even though he had signed to say he had done it. I would have
recommended a disciplinary investigation, but the officer has since resigned.
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 ......................................................................................................................... 10
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Summary
Events
1. On 12 January 2024, Mr Nigel Feckey was sentenced to four years in prison for
sexual offences. It was Mr Feckey’s first time in prison.
2. On 1 February, Mr Feckey was moved to HMP Fosse Way. Fosse Way did not
have a vulnerable prisoners’ wing (often reserved for prisoners convicted of sexual
offences) at that time, so Mr Feckey was located with the main prison population.
3. On 17 February, Mr Feckey told staff that other prisoners had found out about his
offences and were bullying him. Throughout February, Mr Feckey’s sister called the
safer custody line and told staff that Mr Feckey was being bullied.
4. On 21 March, a prisoner went into Mr Feckey’s cell and threw boiling water over
him, causing a burn to his thigh. Mr Feckey was moved to C Wing.
5. During April and May, Mr Feckey told his key worker that the bullying had stopped.
6. On 19 June, Mr Feckey’s cellmate told staff that Mr Feckey had made a ligature
from a shoelace and had tied it round his neck. Staff started suicide and self-harm
prevention procedures (known as ACCT). Mr Feckey told staff that he was still
being bullied.
7. Staff moved Mr Feckey to a quieter landing but Mr Feckey’s sister continued to call
the safer custody line to report that Mr Feckey was still being bullied. Staff
continued to monitor Mr Feckey under ACCT until 11 July. However, there is no
record of a case review or the reasons why ACCT monitoring was stopped.
8. ACCT monitoring was restarted on 12 July after a teacher at the prison recorded
that Mr Feckey said he intended to take his life. Staff held an ACCT review on 15
July and recorded that Mr Feckey said he had not meant what he had said, and he
was feeling positive with no thoughts of self-harm. Staff stopped ACCT monitoring.
9. On 15 August, staff moved Mr Feckey to B Wing, a newly opened wing for prisoners
aged over 50. Mr Feckey told staff that he was happy on B Wing, felt safe and was
no longer being bullied.
10. At around 7.34am on 23 September, an officer started unlocking prisoners for work.
When she opened Mr Feckey’s cell door, she saw him lying on the floor with a
ligature tied round his neck. Staff started CPR. A prison paramedic responded and
assessed that Mr Feckey had rigor mortis. At 7.42am, staff stopped CPR and the
paramedic pronounced life extinct.
Findings
11. There is no record of any ACCT reviews between 21 June and 15 July, including
when ACCT monitoring was stopped on 11 July. Supervisor checks were missed,
suggesting a lack of management commitment to the ACCT process. Although the
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prison has introduced a quality assurance process, it is unclear from the records
what action has been taken when quality issues have been identified.
12. Fosse Way has an offence neutral ethos and at the time of Mr Feckey’s death, did
not have a vulnerable prisoners’ unit. Mr Feckey was repeatedly bullied and
assaulted while at Fosse Way. A nurse told us that other prisoners convicted of
sexual offences were also being bullied and assaulted by other prisoners. Staff told
the investigator that there were a lot of new officers at the prison who did not have
the confidence to challenge prisoners about their behaviour so much of it went
unreported and unchallenged.
13. Fosse Way has recently introduced two units for vulnerable prisoners (the unit is
mixed with mainstream prisoners), the vulnerable men located on those units still
have to mix with mainstream prisoners for parts of the regime, such as work and
education. Most other prisons with vulnerable prisoner units keep the prisoners
separate for the entire regime so that they do not mix with mainstream prisoners at
all. Fosse Way will need to monitor whether it is keeping vulnerable prisoners safe.
14. An officer signed to say that he had completed the 6.00am routine roll check when
he had not. He said that he had been working alone due to staff shortages and had
not had time to complete the morning roll check. We referred the matter to the
police who took no further action. The officer resigned from his position.
15. Staff did not feel supported after Mr Feckey died. Prison managers sent a generic
email to all staff informing them of Mr Feckey’s death, which contained details of
how to seek help if needed. We consider this inadequate, particularly for staff
involved in the emergency response.
16. The clinical reviewer concluded that overall, the care that Mr Feckey received was
equivalent to that which he could have expected to receive in the community.
Recommendations
• The Director should undertake a review of the ACCT quality assurance process to
satisfy himself that when issues are identified, appropriate remedial actions are
taken in response.
• The Director should review whether:
• Vulnerable prisoners feel safe enough to leave the wing to attend activities.
• Staff have the confidence to challenge poor behaviour including bullying.
• The Director should ensure that staff receive adequate support after a serious
incident.
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The Investigation Process
17. HMPPS notified us of Mr Feckey’s death on 23 September 2024.
18. The investigator issued notices to staff and prisoners at HMP Fosse Way informing
them of the investigation and asking anyone with relevant information to contact
her. One prisoner responded.
19. The investigator visited Fosse Way on 30 September. She obtained copies of
relevant extracts from Mr Feckey’s prison and medical records.
20. NHS England commissioned a clinical reviewer to review Mr Feckey’s clinical care
at the prison. She and the investigator conducted joint interviews with eleven
members of staff.
21. We informed HM Coroner for Leicester City and South Leicestershire of the
investigation. The Coroner gave us the results of the post-mortem examination. We
have sent the Coroner a copy of this report.
22. The Ombudsman’s office contacted Mr Feckey’s sister to explain the investigation
and to ask if she had any matters she wanted us to consider. She asked:
• Why was Mr Feckey not on a wing for vulnerable prisoners?
• What support was Mr Feckey given for his mental and physical health?
• Why did the prison not assist Mr Feckey in pressing charges when he was burnt
with hot water?
• Who was the last person to see Mr Feckey alive?
23. These issues have been addressed in the report. Mr Feckey’s sister also asked
about aspects of Mr Feckey’s healthcare, which have been addressed in the clinical
review.
24. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and this report has been amended
accordingly.
25. We sent a copy of our initial report to Mr Feckey’s next of kin. They did not notify us
of any factual inaccuracies.
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Background Information
HMP Fosse Way
26. HMP Fosse Way opened in May 2023 and is managed by Serco. It is a local
category C prison that holds adult men. Nottinghamshire Healthcare NHS
Foundation Trust provides healthcare services.
HM Inspectorate of Prisons
27. The first inspection of Fosse Way was in March 2025. HMIP have not yet published
their report.
Independent Monitoring Board
28. 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 May 2024, the IMB reported
that during the first operational year, the IMB had been monitoring Fosse Way with
an average of just two experienced members and with just one experienced
member for the last three months of the reporting period. This meant that the usual
IMB duties had not been carried out and in-depth reviews of many of the prison
functions had not been possible.
29. The IMB reported that the opening of Fosse Way was considered successful and,
except for industries and education, opening objectives were achieved. The IMB’s
only real issue during this time was missing property coming from other prisons.
30. With the prisoner intake to Fosse Way increasing from around 25 to around 90
prisoners per week, the prison reached operational capacity five weeks early, in
February 2024. This impacted on the workforce. Except for those seconded from
other prisons, staff were new to prison work and approximately 85% were in the 18-
30 age bracket. With the speedy increase in the prisoner population, pressure on
young, inexperienced staff was high; and with staff levels reducing, the pressure
and strain increased. In the IMB’s opinion, this had resulted in ongoing staff
retention issues, which had impacted on the regime at times during the reporting
year.
Previous deaths at HMP Fosse Way
31. Mr Feckey was the fifth prisoner at Fosse Way to die since it opened in May 2023.
Of the previous deaths, two were from natural causes, one was self-inflicted and
one was an alleged homicide. We have previously made recommendations to
Fosse Way about staff conducting routine roll checks (checks conducted at set
points during the 24-hour period, primarily for security, to assure that that the right
number of prisoners is in each part of the prison, but also serving as an opportunity
to check welfare).
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Assessment, Care in Custody and Teamwork
32. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner.
33. As part of the process, support actions are put in place. The ACCT plan should not
be closed until all the actions of the support actions have been completed. All
decisions made as part of the ACCT process and any relevant observations about
the prisoner should be written in the ACCT booklet, which accompanies the
prisoner as they move around the prison. When Mr Feckey was at Fosse Way,
guidance on ACCT procedures was set out in the Prison Service Instruction (PSI)
64/2011, Management of prisoners at risk of harm to self, to others and from others
(Safer Custody). From January 2025, this was superseded by the Prison Safety
Policy Framework, in which the principles of how an ACCT is managed remain
largely unchanged.
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Key Events
34. On 12 January 2024, Mr Nigel Feckey was sentenced to four years in prison for
sexual offences. He was sent to HMP Nottingham. It was Mr Feckey’s first time in
prison.
35. On 1 February, Mr Feckey was moved to HMP Fosse Way. At that time, Fosse Way
did not have a separate wing for vulnerable prisoners, so Mr Feckey was located on
a standard wing. Mr Feckey told a nurse that he had a history of PTSD, anxiety, and
depression. He was prescribed sertraline (an antidepressant).
36. On 17 February, Mr Feckey told staff that other prisoners were bullying him and
calling him names. Staff told Mr Feckey to put in an application to see safer custody
and noted in the observation book that Mr Feckey was being bullied.
37. On 19 February, Mr Feckey’s sister called the safer custody line and told staff that
that she was concerned for Mr Feckey’s safety. A Prison Custody Officer (PCO)
from safer custody saw Mr Feckey for a welfare check. Mr Feckey told her that he
did not feel safe on the wing and stayed in his cell most of the time. She recorded
that Mr Feckey said he had no thoughts of self-harm.
38. On 21 and 29 February, Mr Feckey’s sister called the safer custody line and told
staff that she was still worried about Mr Feckey and that he was being bullied. After
each call, safer custody staff recorded that they saw Mr Feckey for a welfare check
and that he said he was being bullied. Safer custody staff called Mr Feckey’s sister
back and told her that Mr Feckey had given names of prisoners that were bullying
him, and that staff would investigate further. They also told Mr Feckey’s sister that
he was safe and well.
39. On 29 February, a PCO from safer custody saw Mr Feckey. Mr Feckey told him that
he was under threat on the wing and prisoners call him a ‘paedo’. He said that on
26 February, he was pushed into a washing machine in the laundry room and his
tooth had cracked, and that he was sexually assaulted. Mr Feckey also said that
when he went to collect his dinner, other prisoners working on the servery
sometimes refused to give him any food. The PCO told Mr Feckey that he would
check CCTV, inform wing staff and ask safer custody to investigate. Staff
subsequently reviewed the CCTV footage and recorded that they could not
corroborate Mr Feckey’s version of events. No further action was taken.
40. On 5 March, a nurse saw Mr Feckey. He told her that he had previously been
bullied, but that officers had dealt with it and he was feeling much better. She noted
that Mr Feckey showed some signs of autism and referred him to the neurodiversity
team.
41. According to an intelligence report, on 21 March, a prisoner went into Mr Feckey’s
cell and threw a kettle of water over him. That evening, a PCO saw Mr Feckey to
check he was okay. She noted that Mr Feckey said he had no injuries from the
assault. The following day, Mr Feckey was moved to C Wing.
42. On 23 March, a nurse saw Mr Feckey because he was complaining of a burn to his
leg. Mr Feckey told her that a prisoner had thrown hot water over him two days
before. She recorded that Mr Feckey had a first degree (mild) burn to his thigh. She
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applied a burns gel and a dressing. Mr Feckey identified the prisoner who assaulted
him and an adjudication was held. The prisoner was given 14 days cellular
confinement.
43. On 1 April, a PCO saw Mr Feckey for a welfare check. Mr Feckey asked the PCO
how he could press charges against the prisoner who threw hot water over him. The
PCO told Mr Feckey that he should contact his legal team. Mr Feckey said that he
had already contacted his solicitor and was waiting for a response.
44. Throughout April and May, Mr Feckey had regular key worker sessions and safer
custody conducted several welfare checks. Mr Feckey told staff that the bullying
had stopped, and he felt safe on the wing.
ACCT – 19 June to 15 July
45. On 19 June, Mr Feckey’s cellmate told staff that Mr Feckey had made a ligature
from a shoelace and tied it round his neck. Mr Feckey told staff that he was feeling
depressed because he was being bullied again. Staff started suicide and self-harm
monitoring (known as ACCT) and set observations at two an hour.
46. On 20 June, a Custodial Operations Manager (COM) held a multidisciplinary ACCT
review. Mr Feckey told staff that he was feeling depressed because he was being
bullied. She told Mr Feckey that she would contact safer custody to arrange for him
to be moved to a different wing. The case review team increased observations to
three an hour and arranged a case review for 24 June.
47. Later that day, staff moved Mr Feckey to F Wing.
48. On 21 June, a COM held an ad hoc multidisciplinary case review. Mr Feckey said
that since moving wings, he had already been threatened. Mr Feckey said that he
was feeling anxious and had thoughts of self-harm. The COM told Mr Feckey that
he would move him to a different landing that was quieter and more settled. Mr
Feckey was later moved to a different landing and ACCT monitoring continued with
three observations an hour. There are no further ACCT reviews recorded.
49. The ACCT document shows that staff continued to monitor Mr Feckey three times
an hour until 28 June, when observations reduced to one an hour. The ACCT
document shows that on 5 July, observations reduced to one every two hours but
then increased to one an hour on 7 July. As there is no record of an ACCT review, it
is unclear why observations changed on each occasion or who changed them.
50. Between 21 June and 10 July, Mr Feckey’s sister called the safer custody line five
times and told staff that Mr Feckey was being bullied and that she was worried
about him. Staff carried out a welfare check after each call and recorded that Mr
Feckey said he was okay. They called Mr Feckey’s sister to tell her. There is no
evidence of any action to investigate or address the allegations of bullying was
taken.
51. On 11 July, a COM recorded on Mr Feckey’s case notes that ACCT monitoring had
stopped. There is no record of an ACCT review or any record of how the decision to
end ACCT monitoring was made.
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52. On 12 July, a teacher at Fosse Way recorded that when Mr Feckey was told that he
would have to enrol on the next cohort for a course he wanted to do, he said that he
would take his life. She re-opened Mr Feckey’s ACCT. A PCO recorded on the
ACCT care plan that observations were set at two an hour. There is no record that
the PCO spoke to Mr Feckey and the immediate action plan was not completed
until 15 July.
53. On 15 July, two COMs held an ACCT review. Mr Feckey said that he did not know
why he was being monitored on an ACCT again. Mr Feckey said that he was feeling
positive and had no thoughts of self-harm. Mr Feckey said that there had been a
mistake in education, and he did not mean what he had said to the teacher, and he
did not need to be monitored under ACCT. One of the COMs agreed to stop ACCT
monitoring.
August to September
54. On 15 August, Mr Feckey was moved to B Wing, a wing that had just opened for
prisoners aged over 50.
55. On 14 September, Mr Feckey’s sister called the safer custody line and told staff that
she was concerned about Mr Feckey’s health. A PCO saw Mr Feckey for a welfare
check and he told her he was feeling ‘marvellous’ and felt safe on B Wing.
56. Mr Feckey continued to tell staff that he wanted to press charges against the
prisoner who had thrown hot water over him and in mid-September, an officer
contacted the police liaison officer (PLO). The PLO saw Mr Feckey and said that he
would return to take a formal statement. (This was not done before Mr Feckey
died.)
57. On 21 September, a PCO saw Mr Feckey for a key worker session. Mr Feckey told
her that he had no thoughts of suicide or self-harm and that he felt safe on B Wing.
She reminded Mr Feckey about the support that was available should he need it.
58. At around 5.15pm on 22 September, a PCO completed the afternoon roll check.
CCTV shows that the PCO looked through the observation hatch of Mr Feckey’s
cell. He raised no concerns. This is the last time Mr Feckey was seen alive.
59. At around 9.00pm, PCO A completed the evening roll check. CCTV shows that he
turned the handle on Mr Feckey’s cell door to check it was locked. He did not open
the observation panel or otherwise try to visually check Mr Feckey. In his police
statement, he said he called to Mr Feckey through the cell door, and he responded.
He said he would have opened the observation hatch if he had got no response.
CCTV shows him opening observation hatches on other cell doors.
Events of 23 September
60. The investigator watched CCTV footage, body worn video camera (BWVC) footage
and listened to staff radio communications from 23 September. She also obtained
information from East Midlands Ambulance Service. The following account has
been taken from all sources.
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61. PCO A signed to say he had completed the morning roll check at 6.00am. However,
CCTV shows that he did not complete the check. In his police statement, he said
that there should have been two officers on duty but, due to staff shortages, he was
working alone. He said that it had been a busy night on the wing and that he had
not had time to complete the roll check.
62. At around 7.34am on 23 September, PCO B started unlocking prisoners for work.
When she opened Mr Feckey’s cell door, she saw that he was lying unresponsive
on the floor with a ligature tied round his neck.
63. PCO B radioed a code blue (a medical emergency code used when a prisoner is
unconscious or having breathing difficulties that alerts healthcare staff and tells the
control room to call an ambulance immediately). A COM responded around a
minute later, and they both went into the cell and cut the ligature from Mr Feckey’s
neck.
64. The COM started CPR until a nurse arrived and took over. A prison paramedic also
responded to the code blue. When she arrived, she assessed that Mr Feckey had
rigor mortis (stiffening of the body after death), as he was stiff and cold. At 7.42am,
she pronounced life extinct.
Contact with Mr Feckey’s family
65. At around 9.00am on 23 September, an Assistant Director appointed a PCO and a
COM as family liaison officers. They went to Mr Feckey’s sister’s address to break
the news of his death.
66. The PCO maintained contact with Mr Feckey’s sister and offered ongoing support.
The Prison Service contributed to the funeral expenses in line with national
instructions.
Support for prisoners and staff
67. After Mr Feckey’s death, the Deputy Director debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. When staff were interviewed, they said that they did
not feel that they were supported by prison managers or the care team and that no
one contacted them after Mr Feckey died.
68. The prison posted notices informing other prisoners of Mr Feckey’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 Feckey’s death.
Post-mortem report
69. The post-mortem report concluded that Mr Feckey died from low level ligature
suspension.
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Findings
Management of ACCT
70. 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 Feckey’s death, set out the processes (known as ACCT) that staff should follow
when they identified that a prisoner was at risk of suicide and self-harm. (The policy
has since been superseded by the Prison Safety Policy Framework though ACCT
processes remain broadly the same.)
71. Staff started ACCT monitoring for Mr Feckey on 19 June, after his cellmate told
them that he had tied a shoelace round his neck. Staff stopped ACCT monitoring on
11 July but restarted it on 12 July, when Mr Feckey told a teacher that he intended
to end his life. After a review on 15 July, the ACCT was closed.
72. There is no record of any ACCT reviews between 21 June and 15 July, including
when ACCT monitoring was stopped on 11 July.
73. At interview, the investigator asked the case manager why there was no record of
any ACCT reviews between 21 June and 15 July. He said that it was the first ACCT
he had managed and although he had received training, he had not shadowed
another case manager and lacked experience.
74. A COM said that he remembered holding ACCT reviews, and that he recorded the
ACCT reviews on paper. When the investigator asked him where the paper copies
of the reviews were, he said that he did not know, and thought they might have
been misplaced. Without recorded ACCT reviews, it is impossible for us to consider
whether decisions to increase and decrease observation frequencies were
appropriate and based on the risk presented, or to understand what staff
understood of Mr Feckey’s risk of suicide.
75. Observations and conversations were mostly well documented in the ACCT, but
there were missing supervisor checks which suggests a lack of management
commitment to quality assuring the ACCT process. If there had been sufficient
quality checks, it would have become apparent that there were missing ACCT
reviews.
76. In addition, when staff restarted ACCT monitoring on 12 July, the immediate action
plan should have been completed within one hour and an ACCT review should
have been held within 25 hours. Neither were completed until 15 July.
77. The Head of Safety, who had recently taken over the role, told the investigator that
he had identified a need for ACCT quality assurance checks, and that all ACCTs
were now quality checked by a prison manager weekly. He said that any issues
identified were discussed with the COM on the relevant houseblock.
78. The prison shared copies of the quality checks with the investigator, and while it
showed that issues had been identified, it did not specify the action that had been
taken. We consider that the quality assurance form should be updated so it is clear
what action has been taken to address any identified quality issues.
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79. We make the following recommendation:
The Director should undertake a review of the ACCT quality assurance
process to satisfy himself that when issues are identified, appropriate
remedial actions taken in response.
Bullying of vulnerable prisoners
80. Many prisons have Vulnerable Prisoner Units (VPUs), which keep prisoners at risk
from others separate from the main prison population. Prisoners convicted of sexual
offences are often placed on the VPU as the nature of their offences puts them at
risk of threats and assault by other prisoners.
81. When Mr Feckey was at Fosse Way, it did not have a VPU. Fosse Way was
described as an offence neutral prison and the prison’s ethos was that all prisoners,
regardless of their offence, were integrated.
82. A nurse at Fosse Way told the investigator that prisoners, most of whom were sex
offenders, frequently told healthcare staff that they were being bullied. The nurse
said that all allegations of bullying were reported to safer custody.
83. Mr Feckey and his sister repeatedly told staff that he was being physically and
verbally bullied. He was also assaulted twice. There is very little evidence that staff
took any meaningful action (other than moving Mr Feckey to another wing or
landing) to challenge or address the bullying.
84. A prison manager told the investigator that there were a lot of young, inexperienced
staff at Fosse Way who lacked confidence in challenging prisoners’ behaviour. The
manager also told us that bullying was mostly targeted at prisoners convicted of
sexual offences.
85. In March 2025, Fosse Way introduced two units for vulnerable prisoners. Moves
there were voluntary and vulnerable prisoners could choose to stay on a
mainstream wing if they wished. Men located on the vulnerable prisoner units must
leave the unit to attend activities such as work and education, which are mixed with
mainstream prisoners. This is different to many other prisons with VPUs, which
generally offer completely separate regimes for vulnerable prisoners, so they never
mix with mainstream prisoners. The model at Fosse Way will need to be monitored
to assess whether it is keeping vulnerable prisoners safe. We make the following
recommendation:
The Director should review whether:
• Vulnerable prisoners feel safe enough to leave the wing to attend
activities.
• Staff have the confidence to challenge poor behaviour including
bullying.
86. When Mr Feckey asked staff how he could press charges against the prisoner that
assaulted him they should have promptly directed Mr Feckey to the Police Liaison
Officer (PLO) who is based in the prison, and the PLO would have taken a
statement from Mr Feckey and considered whether criminal charges could have
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been made. Staff told Mr Feckey that if he wanted to press charges, he would need
to contact his legal team, which he had already done.
87. Mr Feckey continued to tell staff that he wanted to press charges and after six
months an officer contacted the PLO. Several days before Mr Feckey died, the PLO
saw Mr Feckey and said that he would come back to take a formal statement. This
had not happened before Mr Feckey died. We bring this issue to the Director’s
attention.
Roll checks
88. According to the Residential House Block Diary form in use at Fosse Way, welfare
checks must be conducted four times a day at 7.15am,1.15pm, 5.00pm and
10.00pm (during roll checks). The form says, “Response required from a prisoner
during the welfare checks conducted to assure staff that there are no issues of
concern.”
89. We are satisfied that a PCO checked on Mr Feckey during the 5.15pm roll check on
22 September. This was the last time Mr Feckey was seen alive.
90. PCO A did not carry out an adequate check at 9.00pm that evening, as he did not
look into Mr Feckey’s cell. Even if he got a verbal response from Mr Feckey as
claimed, he should have carried out a visual check too. CCTV footage shows that
he did not carry out the 6.00am check the next morning, even though he signed to
say he had.
91. We referred this to the police, who decided to take no further action. As PCO A has
resigned from Serco employment, we make no recommendation.
Support for staff
92. Almost all staff that were interviewed told the investigator that they did not feel
supported after Mr Feckey died. Staff said that they had not been spoken to by a
TRiM practitioner or the care team. Staff said that no one had spoken to them since
the debrief to ask if they were okay or if they needed further support. Staff also told
the investigator that after Mr Feckey died, they continued their shift, which they
found difficult.
93. After Mr Feckey’s death, a generic email was sent out to all members of staff in the
prison informing them of his death. The email gave details of who to contact if
further support was needed. We do not think that this generic approach was
enough. We recommend:
The Director should ensure that staff receive adequate support after a serious
incident.
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Clinical care
94. The clinical reviewer found that the care Mr Feckey received was of a good
standard and equivalent to that which he could have expected to receive in the
community. The clinical reviewer made two recommendations, not directly related to
Mr Feckey’s death, which the Head of Healthcare will wish to address.
Inquest
95. At the inquest, held from 12 to 21 January 2026, the jury concluded that Mr Nigel
Feckey died by suicide.
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Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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