The inquest into the death of Robert Frejus concluded that failings by the prison and by prison healthcare possibly contributed towards his death. Robert died on 9 October 2018 at HMP Nottingham after self-harming. He was 29 years old at the time of this death.


Robert Frejus was detained at HMP Nottingham between 20 September 2018 – 9 October 2018 when he sadly took his own life. Robert was a polish national with no previous convictions or dealings with the police. He had no known history of mental health problems. He was arrested on 16 and 18 September 2018 following displays of paranoid behaviour.

On 18 September 2018 he was assessed in police custody as displaying possible signs of psychosis and requiring a Mental Health Act assessment. Unfortunately, that assessment did not take place, prior to Robert being produced for court, and latterly remanded into custody.  On 20 September 2018 he arrived at HMP Nottingham. Attempts were made by Criminal Justice Liaison and Diversion team members to have him assessed however these were delayed.

The inquest heard evidence that Robert was placed on an ACCT due to concerns regarding his mental health and expressions of suicidality however it was closed prematurely as staff had not appreciated Robert’s risk factors and had not use an interpreter to speak to Robert contrary to national guidance. Further the inquest heard evidence that it was unknown to most professionals that Robert had been thought to require a Mental Health Act assessment in the police station and had prison and healthcare staff known this they would have treated him as higher priority to receive mental health care.

The inquest heard evidence that those suffering from psychosis, particularly a first episode, like Robert, were more likely to think about suicide, to attempt suicide and die from suicide. The jury heard evidence that it was likely that Robert was suffering from a psychotic episode at the time of his arrest and the time of his death.

On 8 October 2018 Robert attended court and showed increased signs of paranoia. When he returned to prison, he made several phone calls to his family which demonstrated that he may have been suffering from further paranoid delusions. On 9 October 2018 he was found dead in his cell.


After 7 days of evidence on 22 April 2022 the jury found as part of their narrative conclusion that:

  • Robert had intended to take his own life, and
  • It was probable that he was displaying signs and symptoms of a psychotic episode between his arrest on 16 September 2018 and the date of his death on 9 October 2018.

The jury concluded on the balance of probabilities that:

  • There were failings and omissions in completing Robert’s ACCT review in accordance with the Prison Service Instruction.
  • There were failings and omissions in prison and healthcare staff gathering and sharing all relevant risk pertinent information.
  • That there was a delay in assessing Robert’s mental health once he arrived in prison.

The jury concluded that the above failings possibly contributed to Robert’s death.

The family welcomed the conclusions of the jury and thanked both the Coroner and the jury for their service.

Robert’s family were represented by Stuart Withers of No5 Barristers’ Chambers instructed by Debbie Heath of Instalaw Solicitors.