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Prisons and Probation Ombudsman should improve transparency in death investigations to improve prison safety, report finds

Monday, 20 February 2023

The UK Prisons and Probation Ombudsman (PPO) must improve transparency when investigating prisoner deaths, according to a new report and policy brief by prison safety experts at the University of Nottingham.

The report, written by Dr Sharon Shalev, draws on research led by Dr Philippa Tomczak in the Faculty of Social Sciences, which offers recommendations to the PPO and policymakers for improving prisoner death investigations and promoting change.

Every year, hundreds of prisoners die in England and Wales — in the 12 months to September 2022, there were 307 deaths in prison custody1. These deaths will almost always be investigated by the Prisons and Probation Ombudsman (PPO) after a police investigation and before a Coroner’s inquest.

The academics highlight that PPO reports could be a valuable catalyst for changes that improve prison safety, particularly as the PPO reports are produced far more quickly than inquest findings. However, sustained high numbers of prisoner deaths in England and Wales suggest that this potential is not being realised.

The report and associated policy brief outline three key findings and recommendations:

  1. Prisoner death investigations should start naming the underpinning systemic issues that may have contributed to a death, such as too many prisoners, record numbers of prisoners on remand and too few staff. In one example used in the brief, where a prisoner died after their ultimately fatal symptoms of pneumonia were overlooked for four days, it was noted that just one nurse and one senior healthcare assistant were responsible for the 800 prisoners held at the time. However, the academics found that the PPO very rarely mentioned systemic issues such as those which contributed to this prisoner’s death.

  2. The PPO should either broaden its activities to reflect its existing Terms of Reference, or more accurately reflect its focus on investigating prison staff compliance with local and national prison policies. Such transparency will have widespread benefits, being particularly useful for the understanding of coroners, bereaved families and prison staff, and will avoid creating unrealistic expectations and further upset.

  3. The PPO should publish the methodology it uses to investigate prisoner deaths, transparently setting out the evidence base for its judgements and recommendations. No detailed methodology is available and recommendations are not sufficiently underpinned by an evidence base on the type of changes that are most likely to contribute to a reduction in self-inflicted prisoner deaths. The PPO should also clearly explain the basis upon which they judge a death to be (un)predictable or (un)preventable: ultimately almost all prison deaths could have been prevented, hence judgements should be contextualised.
Philippa Tomczak by Alex Wilkinson Media resize 2
Investigations into deaths in custody are often traumatic for all involved. The guiding principle behind these recommendations is the need and obligation to reduce the number of self-inflicted deaths in prisons and to reduce the pain and harm they cause, in particular to the loved ones of those who die but also other prisoners, prison staff and indeed PPO death investigators.
Dr Philippa Tomczak, Principal Research Fellow in the School of Sociology and Social Policy

Dr Tomczak continued: “Transparency is imperative to reduce the likelihood of the same things happening again. Acknowledgement of systemic hazards, new Terms of Reference and an explicit methodology would be a significant contribution.”

The research team conducted interviews with PPO staff, prison governors, coroners, Group Safer Custody Leads and a bereaved family member between 2017 and 2020. Dr Tomczak also reviewed 145 PPO fatal incident reports between the same period.

This research was funded by the ESRC Impact Acceleration Account, SPF-QR funding from Research England and UK Research and Innovation.

Story credits

More information is available from Dr Philippa Tomczak in the School of Sociology and Social Policy at the University of Nottingham at 

Notes to editors:      

  1. Safety in Custody Statistics, England and Wales: Deaths in Prison Custody to September 2022 Assaults and Self-harm to June 2022:
Katie Andrews - Media Relations Manager for the Faculty of Social Sciences
Phone: 0115 951 5751

Notes to editors:

About the University of Nottingham

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