Robert Frith

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Independent investigation into
the death of Mr Robert Frith,
a prisoner at HMP Berwyn,
on 14 November 2020
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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© Crown copyright, 2025
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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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Robert Frith was found dead in his cell at HMP Berwyn on 14 November 2020. He had
suffocated himself by placing a plastic bag over his head. He was 65 years old. I offer my
condolences to Mr Frith’s family and friends.
Mr Frith arrived at Berwyn on 9 November, having been remanded for allegedly
kidnapping a child. It was his first time in prison. He was a heavy drinker in the
community and was showing some alcohol withdrawal symptoms.
Staff assessed that Mr Frith was not at risk of suicide or self-harm. However, there is little
evidence that staff had given proper consideration to the nature and high public profile of
Mr Frith’s offence. I have recommended that reception procedures are reviewed to ensure
that staff fully consider all risk factors.
Mr Frith was concerned about being unable to telephone his partner due to the prison’s
security restrictions on his phone. The restrictions were lifted on 13 November, but it
appears Mr Frith was unaware of this as he had not read the electronic message sent to
him. I have recommended that in future, direct contact is made with prisoners about
phone restrictions and the lifting of them, so they understand how they can contact family
and friends. This is particularly important for prisoners who are in prison for the first time.
The clinical reviewer found that Mr Frith received a good standard of care for his alcohol
withdrawal and that his mental health needs were assessed appropriately.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman June 2021
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 1
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
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Summary
Events
1. On 9 November 2020, Mr Robert Frith was remanded in prison custody, charged
with kidnap of a child. This was his first time in prison.
2. When Mr Frith arrived at Berwyn, staff noted that he had no history of attempted
suicide or self-harm and he told them he had no thoughts of suicide.
3. Mr Frith had a long history of alcohol dependence and was prescribed medication to
manage his withdrawal. He was monitored regularly by healthcare staff.
4. Mr Frith told staff that he was anxious as it was his first time in prison and he had
been unable to speak to his partner (one of his co-defendants). He also did not
have the contact details for his brother as his phone had been taken by the police
when he was arrested.
5. Shortly after 8.25am on 14 November, an officer unlocked Mr Frith’s cell. He saw
Mr Frith was in bed but when he called out, Mr Frith did not respond. When he
checked on Mr Frith, he realised that he had a plastic bag over his head. He
removed the bag and called for staff assistance. Another officer radioed a medical
emergency code at 8.27am. Staff did not attempt to resuscitate Mr Frith as it was
clear he was dead. At 8.50am, a paramedic confirmed Mr Frith’s death.
Findings
6. While we accept that Mr Frith arrived with no self-harm warning forms and had no
known history of self-harm, we are concerned that reception staff did not give
proper consideration to the nature of his offence, which had attracted media
interest. We found that the reception procedures for screening those who may be
at risk of suicide and self-harm were not sufficiently robust. The form completed by
prison officers had closed questions that required a simple yes or no response and
little space to record further information or prompt further consideration of known
risk factors.
7. The clinical reviewer concluded the care Mr Frith received for his physical and
mental health care, as well as his withdrawal from alcohol, was equivalent to that
which he would have expected to receive in the community.
8. Mr Frith did not make any telephone calls while he was at Berwyn, because of
security restrictions placed on his PIN phone (the prison phone system). We found
that he was not properly informed of the decisions to restrict his calls, although we
cannot say if this had any bearing on his decision to take his own life.
9. We are also concerned that Mr Frith’s cell was in a poor state when he was placed
there.
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Recommendations
• The Governor should review the first night assessment booklet to assist staff in
identifying other risk factors or triggers that could indicate risk of suicide and self-
harm.
• The Governor should ensure that OMU staff:
• make direct contact with a prisoner to explain any restrictions and to tell them
when they are lifted; and
• alert wing staff to the sharing of any potential bad news, so that they can
manage this appropriately and provide additional support, if necessary.
• The Governor should ensure that:
• cell conditions are properly checked and documented;
• repairs are promptly reported and fully documented and that there is a clear
audit trail showing when the fault has been reported and when it has been
resolved; and
• prisoners are not placed in cells that do not meet the minimum requirements,
in accordance with PSI 17/2012.
• The Head of Healthcare should ensure that:
• healthcare staff working at Berwyn have timely access to advice, support and
guidance from on call healthcare managers; and
• appropriate measures are put in place to offer support to healthcare staff
following their involvement in significant incidents.
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The Investigation Process
10. The investigator issued notices to staff and prisoners at HMP Berwyn, informing
them of the investigation and asking anyone with relevant information to contact
her. Two prisoners responded, but one later refused to be interviewed.
11. The investigator obtained copies of relevant extracts from Mr Frith’s prison and
medical records. Health Inspectorate Wales commissioned a clinical reviewer to
review Mr Frith’s clinical care at the prison.
12. The investigator and clinical reviewer jointly interviewed seven members of staff on
21 December and a prison manager on 8 January 2021. The investigator also
interviewed a prisoner, probation officer and prison chaplain. All the interviews
were conducted by telephone because of the restrictions imposed in response to
COVID-19.
13. We informed HM Coroner for North Wales (East & Central) of the investigation.
The coroner gave us the cause of death. We have sent the coroner a copy of this
report.
14. The PPO’s family liaison officer contacted Mr Frith’s brother to explain the
investigation and to ask if he had any matters that he wanted us to consider. Mr
Frith’s family raised no issues.
15. Mr Frith’s brother received a copy of the initial report. He did not identify any factual
inaccuracies.
16. The prison also received a copy of the report and corrected the name of the
organisation that commissioned a clinical review. No other factual inaccuracies
were identified. An action plan for the recommendations is annexed to the report.
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Background Information
HMP Berwyn
17. HMP Berwyn is a newly built category C training prison near Wrexham. It opened
in 2017 and is designed to hold around 2,100 men. Berwyn is comprised of three
house-blocks or units – Alwen, Bala and Ceiriog – each divided into eight
communities. Healthcare services are provided by Betsi Cadwaladr University
Health Board.
HM Inspectorate of Prisons
18. The most recent inspection of HMP Berwyn was in March 2019. Inspectors
reported that arrangements for the reception and induction of new arrivals were
impressive and first night interviews effectively identified immediate needs and
risks. However, arrangements to support and safeguard those who were vulnerable
were not very good.
19. Inspectors noted that 85% of prisoners said their cell was clean on their first night.
They found the dedicated first night centre provided a comprehensive and well-
coordinated induction, which was a safe place for prisoners to settle, and included
training on how to use the prison issue laptop computer, to access finances, make
requests and other services.
20. Inspectors found that strategic management of suicide and self-harm was under-
developed and triggers that could increase the risk of suicide and self-harm were
not always identified.
Independent Monitoring Board
21. 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 29 February 2020, the IMB noted
that its overall judgement in relation to the effective and efficient operation of
Berwyn was that it was still a work in progress, and was continually evolving and
improving.
Previous deaths at HMP Berwyn
22. Mr Frith was the sixth prisoner to die at Berwyn since November 2018. Of the
previous deaths, four were from natural causes and one was drug-related. There
were no similarities between our findings in our investigation into Mr Frith’s death
and our investigation findings in the previous deaths.
Assessment, Care in Custody and Teamwork
23. 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. Guidance on ACCT procedures is set out in Prison Service Instruction
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(PSI) 64/2011, Managing prisoners at risk of harm to self, to others and from others
(Safer Custody).
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Key Events
24. On 9 November 2020, Mr Robert Frith was remanded in prison custody, charged
with the kidnap of a child, and sent to HMP Berwyn. This was his first time in
prison.
25. Mr Frith arrived at Berwyn around 2.40pm. On his Person Escort Record (PER - a
document that accompanies all prisoners when they move between police stations,
courts and prisons which sets out the risks they pose), court staff had recorded that
Mr Frith was alcohol dependent and withdrawing, and that he was due to appear at
Caernarfon Crown Court on 7 December.
26. An officer completed Mr Frith’s first night in custody assessment. She noted that Mr
Frith had thought he would get bail but as the case was high profile, he had been
remanded. She noted he had no thoughts of self-harm or suicide and was aware of
the support available. The officer completed the cell sharing risk assessment
(CSRA) and again recorded that Mr Frith had no thoughts of self-harm or suicide.
27. A nurse completed Mr Frith’s initial healthscreen. The nurse noted Mr Frith had no
relevant mental health history and no current thoughts of self-harm or suicide. She
recorded that Mr Frith was a heavy smoker and had previously used cannabis but
he declined to be referred for help. She referred Mr Frith to the prison GP because
he was alcohol dependent.
28. A prison GP examined Mr Frith and continued the detoxification medication started
while he was in police custody (chlordiazepoxide and thiamine twice daily).
29. Mr Frith was moved to Ceiriog Wing, the reverse cohorting unit (RCU), in line with
COVID-19 measures. (Newly arrived prisoners are located in the RCU for 14 days
to prevent the spread of COVID-19.) He was allocated a single cell. Healthcare and
prison staff checked Mr Frith during the night.
30. On 10 November, a prison GP reviewed Mr Frith. He noted there was no evidence
of over sedation or alcohol withdrawal, and that Mr Frith was in good spirits and was
not suicidal.
31. Later that morning, a nurse completed the second healthcare screening. She noted
that Mr Frith’s mood was normal. In line with the alcohol detoxification care plan,
healthcare staff observed Mr Frith over the next four days to ensure he was not
over-sedated.
32. An officer noted in Mr Frith’s prison record that Mr Frith was worried about his
partner, who was a co-defendant, and that chaplaincy staff had been asked to see
him. (A prison chaplain, visited Mr Frith that morning.) The officer noted that Mr
Frith said his first night had gone well, that he had no issues, did not feel suicidal
and had been made aware of how to contact safer custody if he did have any
concerns.
33. That afternoon, a member of staff from the substance misuse team, spoke to Mr
Frith over the in-cell telephone. He outlined his drinking history and told her he was
concerned about his partner, who had also been arrested. Mr Frith was unsure if
he would benefit from support, but they agreed that the substance misuse team
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would contact him again. She encouraged Mr Frith to speak to wing staff about
contact with his partner.
34. On 11 November, there were no concerns noted by prison or healthcare staff.
35. On the afternoon of 12 November, a healthcare support worker noted that Mr Frith
appeared short of breath when he was collecting his medication. She spoke to a
nurse and she went to Mr Frith’s cell to take his clinical observations. She noted Mr
Frith was jumpy and anxious and he told her he had panic attacks and was worried
as it was his first time in prison; he said he usually dealt with these feelings by
consuming alcohol. He also said he liked reading and she explained how he could
order some books. Mr Frith’s observations were within normal range, although his
blood pressure was slightly elevated so her referred him to the prison GP.
36. All prisoners’ telephone calls, except those that are legally privileged, are recorded,
and prison staff listen to a random sample. Mr Frith did not make any telephone
calls. He told staff that he wanted to contact his partner, who had also been
remanded, but contact was not authorised until the day before he died.
37. On 13 November at 11.09am, a probation officer recorded on Mr Frith’s prison
record that restrictions had been made on Mr Frith’s PIN phone, to prevent him
contacting his co-defendants (including his partner). However, restrictions on
contacting his partner were later removed, although any telephone and written
contact would continue to be monitored. The probation officer said she updated
the entry on Mr Frith’s prison record at 1.49pm to say that she had sent a message
to Mr Frith via the prisoner kiosk, which is accessed through a device in a prisoner’s
cell, to tell him this. She did not speak directly to Mr Frith and he did not read this
message.
38. At 3.16pm, a healthcare support worker completed Mr Frith’s observations. She
noted that he seemed a little drowsy, but not sedated. He said he felt mildly
anxious but had no other concerns. Mr Frith’s blood pressure was a little high, but
there were no other physical health concerns noted.
39. An officer assisted with evening medication, which was dispensed between 4.30pm
and 5.10pm. He said he did not recall anything out of the ordinary or unusual about
Mr Frith and did not note any change in behaviour or anything to cause concern. At
around 5.30pm, the officer locked Mr Frith in his cell for the night.
Saturday 14 November
40. Closed circuit television (CCTV) shows the last roll check for the night was
completed by an operational support grade (OSG), at 4.59am. The OSG can be
seen shining a torch into Mr Frith’s cell. She said that she saw Mr Frith in bed
under the covers.
41. At around 8.10am, wing staff started to unlock cells on Ceiriog Wing for those
prisoners who required medication. Due to the COVID-19 restrictions, prisoners
were unlocked in small groups in a controlled manner. CCTV shows the officer
unlocked Mr Frith’s cell at around 8.25am. The officer called Mr Frith’s name
several times but did not get a response. He entered the cell, called again as he
approached Mr Frith, shook his foot and shoulder but there was no response. The
officer pulled back the duvet and found Mr Frith lying on his front with a plastic bag
over his head; his hands were clasped around the bag forming a seal around his
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neck. The officer ripped and removed the bag; he briefly left the cell and shouted
for staff assistance before going back to Mr Frith.
42. Four officers who were all close by responded. An officer radioed a code blue
medical emergency (used to indicate a prisoner is unconscious or having breathing
difficulties) at 8.27am. An officer activated his body worn video camera (BWVC).
Healthcare staff were in the nearby medications room and a healthcare assistant,
responded immediately, closely followed by two nurses.
43. Staff did not attempt cardiopulmonary resuscitation (CPR) as there were obvious
signs that Mr Frith had been dead for some time: he had rigor mortis, his blood had
pooled, and he was very cold.
44. Welsh Ambulance Service records show they received a request for an ambulance
at 8.28am. When paramedics arrived on Ceiriog Wing, they examined Mr Frith and
at 8.50am, confirmed he was dead.
After Mr Frith’s death
45. Mr Frith’s cell was reported to be in a poor condition, with graffiti on the walls. The
investigator was not provided with photographs of the cell but from the BWVC
footage it was possible to view part of the cell and there is evidence of some writing.
North Wales Police were contacted, and they reviewed the images taken by the
attending police officers after Mr Frith’s death. They noted there was graffiti on the
walls, including a drawing of a car and a gun.
Contact with Mr Frith’s family
46. Berwyn appointed a Supervising Officer (SO) as the family liaison officer (FLO).
When Mr Frith arrived at Berwyn, he said his brother was his next of kin but he did
not know his contact details because the police had his mobile telephone. The FLO
therefore contacted North Wales Police, and they notified Mr Frith’s family of his
death.
47. A prison manager, and later the FLO, contacted Mr Frith’s family to explain the
circumstances of his death and offered their condolences and ongoing support.
The prison manager also contacted HMP Styal, where Mr Frith’s partner was being
held. The duty governor informed Mr Frith’s partner of his death with the assistance
of a prison chaplain.
48. In line with Prison Service instructions, the prison contributed towards the costs of
Mr Frith’s funeral, which was held on 4 December.
Support for prisoners and staff
49. The deputy governor, and other senior managers held a hot debrief with all staff
involved in the emergency response. Most staff said they felt well supported and
the Post-Incident Care Team spoke to everyone involved and the TRiM (trauma risk
management) manager advised staff of additional support available via the
Regional Safety Team.
50. Healthcare staff told the investigator that support from the on-call healthcare
manager could have been better and they did not feel sufficiently supported,
although they felt well supported by prison staff. All staff were invited to attend a
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TRiM meeting facilitated by the Regional Safety Team, and those who attended
said it was very helpful.
51. The prison posted notices informing other prisoners of Mr Frith’s death and offering
support. Staff reviewed all prisoners considered to be at risk of suicide and self-
harm, in case they had been adversely affected by Mr Frith’s death.
Post-mortem report
52. The post-mortem report gave Mr Frith’s cause of death as plastic bag suffocation.
The toxicology report noted therapeutic levels of Mr Frith’s prescribed medication.
53. The pathologist noted that external examination did not reveal any assault injuries,
restraint injuries or defensive injuries.
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Findings
Assessment of Mr Frith’s risk of suicide and self-harm
54. Prison Service Instruction (PSI) 64/2011, Managing prisoners at risk of harm to self,
to others and from others (Safer Custody), lists several risk factors and potential
triggers for suicide and self-harm. Mr Frith had some risk factors: it was his first
time in prison, he was charged with a serious offence and if found guilty faced a
long prison sentence, and he was withdrawing from alcohol. In addition, he was not
able to contact his partner due to security restrictions, or any other family member
as he did not have access to their contact details.
55. Mr Frith did not arrive with any risk warning form and had no known history of self-
harm or suicide attempts. He told prison and healthcare staff that he had no
thoughts of harming himself. However, he had been charged with a very serious
offence, the kidnap of a child, which had received media attention. We consider
that the reception process at Berwyn needs to improve to highlight those who,
despite their presentation, may be at heightened risk based on the nature of their
offence or other risk factors.
56. In a thematic report about risk factors in self-inflicted deaths published by the
Prisons and Probation Ombudsman in 2014, we identified that too often reception
assessments place too much weight on staff’s perception of the prisoner and do not
consider all relevant information. We reinforced these messages in another
learning lessons bulletin, issued in February 2016, about early days and weeks in
custody.
57. 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. Berwyn’s ‘First Night in Prison Booklet’
has several closed tick box questions about thoughts of self-harm and suicide.
These questions do not require staff to explore the information further and do not
provide any guidance on what other factors may be relevant to the assessment or
which may increase risk, as set out in PSI 64/2011. We therefore make the
following recommendation:
The Governor should review the first night assessment booklet to assist staff
in identifying other risk factors or triggers that could indicate risk of suicide
and self-harm.
Clinical care
58. The clinical reviewer concluded that Mr Frith’s clinical care was equivalent to that
which he could have expected to receive in the community.
Physical health
59. Mr Frith’s physical health needs were appropriately managed. The initial
healthscreen was thorough. Mr Frith was referred to the prison GP, who met face-to
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face with him, and he had a second healthscreen the day after he arrived. Mr Frith
was offered various health screenings and vaccines, as well as support to stop
smoking, but he declined.
Mental health
60. The clinical reviewer found that there was evidence of appropriate and timely
assessment and observation of Mr Frith’s mental state by healthcare staff. He
considered that relevant steps were taken to assess for any current risks of self-
harm or suicide.
Substance misuse
61. Mr Frith had a significant history of alcohol dependency, which the clinical reviewer
concluded was appropriately managed. Mr Frith was assessed during his first and
second healthscreen, as well as by the prison GP. Withdrawal medication
prescribed in police custody was continued and he was observed regularly as part
of his care plan. Mr Frith was referred to the substance misuse service for further
support. Although Mr Frith declined support, the team continued to offer their
availability to him.
Access to the telephone
62. Mr Frith did not make any telephone calls during his time at Berwyn. He mentioned
to prison and healthcare staff that he was anxious and keen to speak to his partner,
but there were restrictions placed on him.
63. PSI 49/2011 – Prisoner Communication Services, sets out the requirements for all
prisoner communication, including telephone use. The PSI says, ‘The checking of
social numbers must be proportionate to risk and checked as necessary in
accordance with the NSF [National Security Framework] and as set out in the local
security strategy.’
64. Due to the nature of Mr Frith’s alleged offence, for security reasons, his contact
telephone numbers had to be verified before he could use his PIN phone (the prison
phone system which only allows prisoners to ring authorised numbers)..
65. On 13 November, a member of staff from the Offender Management Unit (OMU),
who completed the application for restrictions to be placed on Mr Frith’s PIN phone,
contacted him via an electronic message to update him on the restrictions imposed.
Because he did not read the message, Mr Frith would have been unaware that the
restriction on contacting his partner had been removed. He may have been
reassured had he read the message.
66. She said she did not consider contacting Mr Frith directly using his in-cell telephone
to tell him this, as sending an electronic message was the process that had always
been followed at Berwyn. She said in hindsight she thought prisoners should be
spoken to in future rather than just receiving a written message as this would allow
for questions or concerns to be discussed.
67. We cannot know what contributed to Mr Frith’s decision to take his own life.
However, this was his first time in prison, he was not familiar with the restrictions
and regime at Berwyn and he had no contact with his partner. Although the
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restrictions on his PIN were in line with national guidance, we found that this could
have been better explained to Mr Frith. We recommend:
The Governor should ensure that OMU staff:
• make direct contact with a prisoner to explain any restrictions and to
tell them when they are lifted; and
• alert wing staff to the sharing of any potential bad news, so that they
can manage this appropriately and provide additional support, if
necessary.
Cell condition
68. PSI 17/2012 - Certified Prisoner Accommodation, sets out the minimum
requirements for a cell to be occupied by prisoners. Mr Frith’s cell on Ceiriog Wing
was reported to be in a poor state. The investigator viewed BWVC footage which
shows there was some graffiti on the walls, but she could not see the whole cell.
We were not provided with photographs of the cell and were unable to establish
why the graffiti had not been removed before Mr Frith was placed there.
69. Regardless of how or when the damage occurred, the walls were not in an
acceptable state from the time that Mr Frith went into the cell on 9 November. We
consider that the condition of the cell was unacceptable and not in accordance with
PSI 17/2012. We do not consider that any prisoner should have been placed in a
cell like this, as it may have a negative impact on their mental health. We make the
following recommendation:
The Governor should ensure that:
• cell conditions are properly checked and documented;
• repairs are promptly reported and fully documented and that there is a
clear audit trail showing when the fault has been reported and when it
has been resolved; and
• prisoners are not placed in cells that do not meet the minimum
requirements, in accordance with PSI 17/2012.
Staff support
70. Healthcare staff involved in the emergency response said that they needed advice
from their managers following Mr Frith’s death, but that the on-call healthcare
manager had not responded. The staff who attended the emergency response said
that they had received good support from their prison colleagues but felt that
support from their healthcare service had been lacking. We therefore recommend:
The Head of Healthcare should ensure that:
• healthcare staff working at Berwyn have timely access to advice,
support and guidance from on call healthcare managers; and
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• appropriate measures are put in place to offer support to healthcare
staff following their involvement in significant incidents.
Inquest
71. The inquest into Mr Frith’s death concluded in February 2025. Mr Frith’s death was
due to plastic bag suffocation.
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