Gary Wrest

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Independent investigation into
the death of Mr Gary Wrest,
a resident at Bowling Green
Approved Premises,
on 6 June 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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© 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.
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 Gary Wrest was found hanged in the community on 6 June 2024, while a resident at
Bowling Green Approved Premises. He was 37 years old. I offer my condolences to Mr
Wrest’s family and friends.
Although Mr Wrest had risk factors for suicide and self-harm, Bowling Green Approved
Premises managed these risks appropriately and they could not reasonably have
prevented his death.
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 February 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ......................................................................................................................... 10
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Summary
Events
1. On 22 May 2023, Mr Gary Wrest was found guilty of actual bodily harm against his
ex-partner, breaching a restraining order and criminal damage. He was sentenced
to two years and four months in prison.
2. On 20 May 2024, Mr Wrest was released on licence from HMP Liverpool to Bowling
Green Approved Premises (AP). One of his licence conditions was not to approach
or communicate with his ex-partner.
3. During Mr Wrest’s induction, AP staff assessed his risk of suicide and self-harm.
They concluded that while he presented as well and positive, he had risk factors for
suicide, they were concerned for his safety and they decided he should receive
additional welfare checks.
4. On 5 June, Mr Wrest’s probation officer told him that the police were investigating
an allegation that he had tried to contact his ex-partner by phone. He was told that
he would receive a warning letter from the Probation Service.
5. Later that day, Mr Wrest left Bowling Green AP and checked into a hotel in
Liverpool. At 7.00pm, one of the AP’s residential workers contacted Mr Wrest
because he had not returned to the AP. Mr Wrest told her that he would not return
that night but would speak to probation staff the next day.
6. At approximately 1.37pm on 6 June, hotel staff discovered that Mr Wrest had
hanged himself in his hotel room.
Findings
7. Mr Wrest had risk factors that indicated that he was at risk of suicide and self-harm.
Because of this, the AP introduced additional welfare checks. We are satisfied that
AP staff took reasonable steps to mitigate Mr Wrest’s known risks. We make no
recommendations.
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The Investigation Process
8. HMPPS notified us of Mr Wrest’s death on 10 June 2024.
9. A PPO investigator issued notices to staff and residents at Bowling Green AP
informing them of the investigation and asking anyone with relevant information to
contact him. No one responded.
10. The investigator obtained copies of relevant extracts from Mr Wrest’s prison and
probation records and statements taken by the police.
11. The investigator interviewed five members of staff by Microsoft Teams.
12. Another PPO investigator took over the investigation in October 2024.
13. We informed HM Coroner for Liverpool and the Wirral of the investigation. The
Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
14. The Ombudsman’s office contacted Mr Wrest’s parents to explain the investigation
and to ask if they had any matters they wanted us to consider. Mr Wrest’s parents
did not have any specific questions.
15. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
16. Mr Wrest’s parents received a copy of the draft report. They did not make any
comments.
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Background Information
Bowling Green Approved Premises
17. Approved Premises (formerly known as probation and bail hostels) provide an
enhanced level of residential supervision in the community. The National Probation
Service, North West Area, manages Bowling Green Approved Premises in Carlisle.
Residents must be aged over 18. Most residents are required to stay as a condition
of a court order or release licence.
18. Residents are required to sign in and out of the building and follow agreed curfews.
During induction, staff tell residents about the premises’ rules and allocate them a
key worker who is their primary contact and who holds one-to-one sessions about
the issues in the offender’s sentence plan. Residents are responsible for their own
health and are required to register at a local doctors’ surgery. As part of the
conditions of residence, staff hold all prescribed medicines and issue them as
prescribed.
Previous deaths at Bowling Green AP
19. In May 2021, a resident of Bowling Green died by suicide in the community. The
resident had some risk factors that indicated he was at risk of suicide and self-harm,
and we were satisfied that AP staff had appropriately assessed his risk.
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Key Events
20. Mr Gary Wrest had a history of domestic violence and harassment towards his ex-
partner. He was subject to restraining orders and was not allowed contact with his
ex-partner, their children or his ex-partner’s mother.
21. On 24 April 2023, Mr Wrest was remanded in custody and was sent to HMP
Liverpool.
22. On 22 May 2023, Mr Wrest was found guilty of actual bodily harm against his ex-
partner, breaching a restraining order and criminal damage. He was sentenced to
two years and four months in prison.
23. Between 7 December 2023 and 4 January 2024, Liverpool monitored Mr Wrest
under suicide and self-harm prevention procedures (known as ACCT) after he told
staff he was hearing voices. He also told staff he had tried to take his life two years
earlier. He was referred to talking therapies and his mental health medications were
revised.
24. In the months before his release, Mr Wrest’s prison records indicated that he was
settled. His good behaviour was rewarded with additional privileges and he received
positive behaviour entries on his record.
25. On 10 April, Mr Wrest discussed his upcoming release with his prison offender
manager (POM) and his probation officer. They told him he would be released to an
approved premises (AP).
26. On 11 April, Mr Wrest was referred to the prison resettlement team. They helped
him obtain identification and a bank account, and completed a referral to Achieve
(an organisation that supports offenders in the community).
27. On 28 April, the Probation Service made a referral for Mr Wrest’s transfer to
Bowling Green Approved Premises as he met the criteria for early release on
licence as part of the Government’s early release scheme, known as the End of
Custody Supervised Licence (ECSL) scheme. (The policy had been introduced to
help reduce prison overcrowding.) Mr Wrest’s release date was calculated as 20
May.
28. The referral noted that Mr Wrest struggled to cope in prison. It also noted that he
had had depression and anxiety for five years, for which he had been prescribed
pregabalin (following a serious assault from another prisoner). Mr Wrest said that
although he had sometimes had thoughts of suicide or self-harm, he would not act
on them.
29. On 7 May, the POM notified Mr Wrest that an AP had been secured in the Carlisle
area. Mr Wrest said that he was unhappy as the AP was too far away from his
family. His probation officer recorded that there were no available AP spaces in
Liverpool.
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Bowling Green Approved Premises
30. On 20 May 2024, Mr Wrest was released on licence from Liverpool to Bowling
Green AP. His licence conditions included the requirement to attend scheduled
appointments with his probation officer and not to have contact with his ex-partner,
their children or his ex-partner’s mother. In addition, Mr Wrest was subject to a
curfew between 7.00pm and 7.00am and he was required to report every lunchtime
to Bowling Green staff.
31. That afternoon, a residential worker at the AP completed Mr Wrest’s induction. He
gave him information about the AP’s rules and regulations, expected behaviours,
curfew arrangements and licence conditions. The residential worker told the
investigator that although Mr Wrest was very anxious, he presented very well and
was positive.
32. Mr Wrest was told that he needed to register with a GP and would not be able to
keep and administer his medication himself. The residential worker noted that Mr
Wrest’s healthcare needs were related to anxiety, post-traumatic stress disorder
(PTSD) and depression. The residential worker told the investigator that before a
resident arrived at the AP, they checked the information available to them to
consider what support may be needed. Mr Wrest confirmed his history of substance
misuse, that he had last used drugs fourteen months earlier before prison and
admitted to smoking cannabis on a couple of occasions in prison. The residential
worker discussed the risks of reduced drug tolerance with Mr Wrest and his
increased risk of overdose after release from prison.
33. At 3.30pm, Mr Wrest had an initial meeting with probation by Microsoft Teams. The
probation officer noted that Mr Wrest expressed concerns about the alcohol tag he
had to wear and asked if he had to remain teetotal. He also asked to be moved to
an AP nearer his home. Mr Wrest was told to speak to his probation officer.
34. The residential worker completed a support and safety plan which is used to
assess, identify and manage residents at risk of suicide and self-harm. Mr Wrest
told the residential worker that he felt okay, was pleased to have been released
from prison and was looking forward to moving on in his life. When asked how he
would deal with things over the coming days, Mr Wrest said he would think first,
keep calm and be positive. Mr Wrest said he wanted to get to the gym and had
good family support.
35. Mr Wrest told the residential worker that he had not harmed himself in the previous
six months but had previously ligatured. Mr Wrest said he had never been subject
to ACCT monitoring, did not need support and everything was fine at present.
36. The residential worker noted that Mr Wrest presented well, and although it was
clear he was anxious about his move to Bowling Green, there was no imminent
concern that he was at an increased risk of suicide or self-harm. However, given his
history of anxiety, depression, substance misuse and previous self-harm, the
residential worker assessed that Mr Wrest should have two additional welfare
checks during the day and night and that going forward, staff would need to
consider his risk history.
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37. On 20 May, Mr Wrest’s ex-partner reported to the police that Mr Wrest had made
four attempts to contact her by phone.
38. On 21 May, the AP manager reviewed Mr Wrest’s probation file and prison record
and noted that he had been monitored under ACCT procedures in prison. He
recorded that he wanted staff to carry out two extra checks during the day, one
meaningful conversation and one night check. He noted that this could be reviewed
on 10 June.
39. On 22 May, a residential officer noted that Mr Wrest had not taken his medications.
40. On 23 May, another residential officer, who was Mr Wrest’s keyworker, completed a
welfare assessment and individual support plan which included his triggers, needs
and other risk information. She noted that self-harm triggers for Mr Wrest included
not having contact with his children and his struggles following a past assault. Mr
Wrest told her that he had identified his own warning signs of when things could get
out of control and these were getting involved in altercations and drug and alcohol
use. The residential officer noted that Mr Wrest had previously harmed himself by
making ligatures when he struggled to cope but he was unsure how to mitigate
against this.
41. The residential officer noted that Mr Wrest had said he wanted to go back to the
Liverpool area and had asked to transfer to Southwood AP but there were no beds.
Mr Wrest had said he was depressed at Bowling Green and when asked about not
taking his medication, he said he could not be bothered to take it and had no
motivation. Mr Wrest’s compliance with his medication remained erratic during his
time at the AP. Staff encouraged him twice after his induction to sign up with a GP
(this did not happen) and also to comply with his medication.
42. On 28 May, Mr Wrest’s probation officer noted in probation records that a reportable
incident from Merseyside Police had occurred.
43. On 30 May, a probation officer noted that she had spoken to Mr Wrest a few times
on the phone about his request to move to Southwood AP. She told him that she
had made enquiries but there was no bed availability.
44. On 31 May, a residential officer met Mr Wrest for his keywork session. She noted
that they spoke about his drug test which was positive for cannabis and pregabalin
and they discussed his poor medication compliance. Mr Wrest asked if he could
keep and administer his medication himself rather than collecting it from staff. She
noted Mr Wrest had also asked for his 1.00pm curfew to be lifted to allow him to go
to Liverpool to sort out housing. She said if he made some appointments, it could
be lifted for one day. She noted that he was desperate to return to Liverpool but
was compliant and she had no concerns.
45. On 4 June, Mr Wrest’s probation officer met her probation supervisor to discuss the
notification from the police about their investigation into a potential breach of the
restraining order. They concluded that as three weeks had passed since the alleged
breach and they had not been notified of any other incidents, a compliance letter
would be the most appropriate course of action.
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Events of 5 June
46. At 2.00pm, Mr Wrest met a residential officer at Bowling Green AP and his
probation officer by video link. During their meeting, Mr Wrest said that everything
was fine at the AP but he wanted to move to Southwood. They discussed Mr Wrest
making an application for a personal independence payment and Mr Wrest’s
probation officer agreed to chase up the Crisis worker who was supporting Mr
Wrest find accommodation.
47. Mr Wrest’s probation officer told Mr Wrest that the police were investigating an
allegation that he had contacted his ex-partner on the day of his release and that
they wanted to interview him. She told him that she was going to issue him with a
compliance letter. She recorded that Mr Wrest had insisted that he had not made
any contact and that he felt he was being unfairly treated because of things that had
happened in the past. They talked about housing and Mr Wrest told them that he
was keen to start a railway course. Their next meeting was scheduled for 14 June.
48. At 2.25pm, Mr Wrest signed out of the AP. He recorded on the signing in/out sheet
that he was going to the shop.
49. At approximately 5.37pm, Mr Wrest checked in to the Adelphi Hotel in Liverpool. He
had made an online booking for the room earlier that day. The hotel receptionist told
the police that he did not note anything unusual about Mr Wrest. He said that after
he checked in, he returned a short while later and asked if he could change to a
room at the front of the hotel. This was agreed and Mr West was given a new room.
50. At 7.00pm, a residential officer noticed that Mr Wrest had not returned to the AP so
she called him on his mobile. She noted that Mr Wrest told her that he was in
Preston and was going to see his probation officer the next day. He said he needed
to speak to probation and police in Liverpool about the allegation that he had
contacted his ex-partner. He said he did not want Cumbria police to investigate him
because of the risk that he could be recalled to a prison far away from his family.
51. The residential officer told the investigator that she tried to encourage him to return
to the AP and explained that if he did not return, this would be a breach of his
licence conditions. She said that Mr Wrest mentioned the probation warning letter,
that he felt that he should not have been given one and he did not want to be
investigated by Cumbria police. She asked him where he was but he did not tell her.
She said that he was not rude and throughout the conversation, he seemed calm.
The residential officer said that Mr Wrest ended the conversation, saying that he
had said everything that he wanted to say and she believed the call lasted for
approximately fifteen minutes.
52. Following the conversation, the residential officer contacted a senior probation
officer who was on call that evening, and told her about the conversation with Mr
Wrest.
53. The senior probation officer told the investigator that following her call with the
residential officer, she checked Mr Wrest’s information for any alerts. She identified
that he had vulnerabilities and had previously breached restraining orders.
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54. At 8.13pm, the senior probation officer updated the probation record with the details
of her conversation with the residential officer. She noted that she contacted the
Head of Service at North West Lancashire Probation Delivery Unit, and following a
discussion, they decided to recall Mr Wrest.
55. The senior probation officer told the investigator she then completed the recall
paperwork in which she highlighted Mr Wrest’s risk of suicide and self-harm and the
risk he posed to his ex-partner. She said that she phoned the AP and spoke to the
duty residential worker, and asked her to contact Merseyside police to ask them to
carry out a welfare check on his ex-partner.
56. At 8.51pm, the duty residential worker telephoned Merseyside police to request a
welfare check. They said they would not conduct a check on Mr Wrest’s ex-partner
as there was no confirmed contact from Mr Wrest and it was not enough of a risk
that he had not returned for his curfew. The duty residential worker recorded in Mr
Wrest’s probation file that she notified the senior probation officer of the
conversation and that she would email the police once the recall paperwork had
been received.
57. At 9.10pm, the senior probation officer updated the probation file. She recorded that
the public protection casework section had processed the recall and the revocation
notification had been sent to Cumbria and Merseyside police. She said she would
ask in writing for Merseyside police to undertake a welfare check.
58. At 9.16pm, the senior probation officer emailed the duty residential worker and Mr
Wrest’s probation officer confirming the recall paperwork had been completed for
Mr Wrest. She said that she had asked Merseyside police to undertake a welfare
check for his ex-partner (she later recorded that the email to the police had been
returned as undeliverable). She said that she would also ask for a welfare check for
Mr Wrest but his location remained unknown.
59. At 9.49pm, an officer from Merseyside Police emailed the duty residential worker
and asked if she could provide any information for Mr Wrest’s family or ex-partner.
60. At 9.57pm, the duty residential worker emailed the Police National Computer
Bureau at Merseyside police on the senior probation officer’s behalf. She advised
that Mr Wrest had been recalled and his whereabouts were unknown. In her email,
she gave an overview of Mr Wrest’s offending history and their concerns for his ex-
partner’s safety. She also stated that Mr Wrest had a history of vulnerabilities,
including self-harm and making ligatures.
61. At 10.23pm, the duty residential worker replied to the police’s email. She provided
the name and address of Mr Wrest’s ex-partner (along with an overview of his
offence) and the name, telephone number and possible address of Mr Wrest’s
mother. The email also included details of Mr Wrest’s vulnerabilities and his risk of
suicide and self-harm.
Events of 6 June
62. At approximately 1.17pm, hotel staff contacted one of the hotel managers as the
cleaners had not been able to get into Mr Wrest’s room. The manager told the
police that he immediately went to Mr Wrest’s hotel room but the door would not
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open properly. He said he was able to open the door enough to put his head inside.
He saw Mr Wrest hanging from the automatic door closing mechanism. He said that
he immediately left the room and asked a colleague to call emergency services.
63. At 1.29pm, the police and paramedics arrived. While the paramedics attended to
Mr Wrest, the police officer searched the room and found a note (addressed to Mr
Wrest’s parents) and a will. Mr Wrest had written that he could not go back to
prison. A bag of property and a phone was also found in the room.
64. At 3.15pm, a victim liaison officer contacted Mr Wrest’s probation officer. He said Mr
Wrest’s ex-partner had told him she had received a call from Mr Wrest at 7.30am
and he had told her he was going to kill himself. She said she had reported this to
the police.
7 June
65. At approximately 1.54pm, a family member of Mr Wrest contacted the AP manager
to notify him of Mr Wrest’s death.
66. Mr Wrest’s room at Bowling Green was searched and a large amount of his
prescribed medication was found in his room.
Contact with Mr Wrest’s family
67. On 10 June, the AP manager wrote to Mr Wrest’s parents to offer his condolences
and to provide them with a point of contact who would assist them. This was
followed up with a telephone conversation with Mr Wrest’s father on 12 June. On 17
June, the AP manager updated the probation record. He stated that Mr Wrest’s
parents had visited the AP and collected Mr Wrest’s property. He said that he had
spent about 30-40 minutes with them. The probation service offered to contribute to
Mr Wrest’s funeral costs in line with national policy.
Support for residents and staff
68. At 3.00pm on 7 June, the AP manager held a meeting for AP staff and residents to
inform them of Mr Wrest’s death. The AP manager said that staff and residents
were told that support was available to them if they needed it.
Post-mortem report
69. The post-mortem report gave Mr Wrest’s death as hanging. Mr Wrest had also
ingested cocaine which contributed to but did not cause his death. The toxicology
report identified that alcohol and cocaine had been detected in Mr Wrest’s system
but the significance was low and unlikely to have contributed to his death. The
pathologist noted that it was not possible to determine whether or not the use of
cocaine and alcohol (or the degree) had had an effect on Mr Wrest’s state of mind.
Inquest into Mr Wrest’s death
70. The inquest into Mr Wrest’s death was held on 23 August 2024 and a verdict of
suicide was recorded.
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Findings
Assessment of Mr Wrest’s risk
71. When Mr Wrest arrived at Bowling Green AP, staff completed a support and safety
plan, a tool used to assess and manage residents at risk of suicide and self-harm.
Mr Wrest’s keyworker completed a welfare assessment and an individual support
plan for him.
72. The officer who completed the support and safety plan correctly identified a number
of risk factors based on Mr Wrest’s history of PTSD, substance misuse, attempted
suicide and self-harm. He concluded that while Mr Wrest had presented as well, his
risk factors warranted additional welfare checks during the day and night.
73. Although not known at the time, within hours of Mr Wrest’s release, it was alleged
that he had tried to contact his ex-partner in breach of his licence condition and the
restraining order.
74. While it is evident that Mr Wrest was unhappy with the location of the AP, as he
wanted to be closer to Liverpool, staff explained it was not possible because there
were no spaces available and they made enquiries on his behalf when he raised
this with them.
75. Having been notified by the police that they were investigating an alleged breach of
the restraining order, it was appropriate that the probation officer raised this issue
with Mr Wrest during their meeting and that they told him what action they would
take (essentially to issue him with a warning letter). Based on the officer’s accounts
of that meeting, there is no evidence to suggest that staff should have considered
that Mr Wrest’s risk of suicide and self-harm had increased and we note that he was
still receiving additional welfare checks at the time.
76. We are satisfied that staff could not reasonably have foreseen the actions Mr Wrest
took. When Mr Wrest failed to return to Bowling Green AP that evening, staff took
appropriate action and we note the efforts made by the duty residential officer and
the senior probation officer to alert Merseyside police to the potential risk to Mr
Wrest’s ex-partner and that Mr Wrest was also vulnerable.
Bowling Green AP Manager to note
77. Although there was evidence that the AP had conducted additional welfare checks
for Mr Wrest, staff had not kept detailed records of the daily meaningful
conversations they had had, or should have had, with him.
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