The research

The report offers recommendations to the Prisons and Probation Ombudsman (PPO) and policy makers and linked bodies for improving investigations into prisoner self-inflicted deaths. 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.

The researched is based on extensive documentary analysis of PPO fatal incident reports, a total of 45 interviews with: PPO staff; prison governors; regional Prison Service Group Safer Custody Leads; Coroners; and bereaved families. The researchers praised the Ombudsman for engagingly openly with the study and facilitating broader action.

Findings

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.

Dr Philippa Tomczak, said:

“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.

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.”

Thanks to Andy Aitchison for kind permission to use the images in this post. You can see Andy’s work here