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48 people a year die in the first 2 weeks after prison release
Ombudsman publishes first investigations into people dying in the first 2 weeks after prison release.

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Learning lessons

Last week (25 January 2023), the Prisons and Probation Ombudsman published two important reports on people who die immediately after being released from prison. The two reports are a learning lessons bulletin and a pilot evaluation of this form of investigation, which the Ombudsman piloted for the very fist time from September 2021.

This blog post concentrates on the learning lessons bulletin.

The bulletin

The bulletin summarises the learning from PPO investigations into the deaths of those who died within 14 days of release from prison. It covers investigations started between 6 September 2021 and 5 September 2022. The PPO saw this as a pilot where it could test its approach. It has continued to investigate post-release deaths after this period but the findings from those investigations are not included in the bulletin.

The overall conclusion is the acute vulnerability of people leaving prison and the learning includes findings about homelessness, accommodation, substance misuse and mental health.

The Ombudsman was notified about 48 deaths in this time period of people who died two weeks post release. 42 of these were men and 90% were white British. Their ages ranged from 28-62 years but 26 of those who died were aged between 40-49 years old. 

Half of the deaths that were investigated were related to deaths. The full breakdown is shown in the table I reproduce below.

Drug-related deaths

Recommendations from investigations into drug-related deaths covered the lack of naloxone (a medicine that rapidly reverses an opioid overdose) provision at the point of release and the lack of ‘through the gate’ support for individuals who were at risk of substance misuse more generally. The PPO notes that some people refuse naloxone and recommends further work on understanding why this is and ways of reducing the stigma associated with naloxone.

The PPO also highlighted the importance of detailed handovers, information sharing, and timely referrals. The bulletin includes a case study of a women whose death was linked to poor information sharing. She received a good service from drug workers in prison but the prison’s Offender Management Unit who referred her to the Bail Accommodation Support Service (BASS) as part of the Home Detention Curfew process recorded that she had no substance misuse needs.

Self-inflicted deaths

The PPO’s main recommendations around people who committed suicide on release was about better information sharing between the prison and probation, particularly if the prisoner was being managed under the Prison Service suicide and self-harm prevention procedures (known as ACCT) right up to the time of their release.

The bulletin includes a tragic case study of a man who hanged himself two days after release with probation staff not informed that he had been assessed as being at risk of suicide and self-harm at the time of his release.


The issue of accommodation and homelessness emerged as a concern in post-release death investigations. This relates to the challenges of multi-agency involvement and in some cases, is the result of a lack of communication between external agencies and prisons and probation.

In another sad case, a woman died of a drug overdose the day after her release from prison. The day before her release, her community offender manager secured temporary accommodation for her. This was done belatedly and it appeared that the community offender manager was unclear about the accommodation referral processes and how to complete this. The woman being released was not told about this accommodation and was under the impression she was homeless.

Friday release

Another emerging theme relating to prison leavers is the potential impact of being released from prison on a Friday. For those individuals at risk of substance misuse, being released towards the weekend was perceived to be a risk factor towards a drug-related death.

Support for staff

The Ombudsman was also concerned that all probation staff should receive support following the death of a person they were supervising.


Thanks to Sandy Millar for kind permission to use the header image in this post which was previously published on Unsplash.

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