PPO Annual Report 2018/19: Learning Lessons from Fatal Incidents in Prisons

In October 2019, the Prisons and Probation Ombudsman published their report for 2018/19. For this period, the PPO began 334 fatal incident investigations, representing a 23% increase in self-inflicted deaths.

Despite a continuing increase in the number of the prison population who are aged over 50, it’s interesting to note that deaths from natural causes, including those which are foreseeable and, therefore, not preventable, actually fell by 4%.

Fatal Incidents

In 2018/19, the PPO started investigations into 334 deaths, which represents a 6% increase overall when compared to last year. The majority of these deaths were of prisoners (96%). Here’s the breakdown:

  • 180 deaths from natural causes, 4% fewer than last year
  • 91 self-inflicted deaths, 23% more than last year
  • 4 apparent homicides, a decrease from 7 last year
  • 36 other non-natural deaths, a slight decrease from 39 last year
  • 12 deaths of residents living in probation approved premises, one more death than was investigated last year
  • 1 death of a resident of the immigration removal estate, 4 fewer than last year
  • 1 discretionary case – the death of an individual who died four days after being released from prison custody

In 2018/19 the PPO made 723 recommendations following deaths in custody:

  • 138 related to healthcare provision (19%).
  • 117 related to emergency response (16%).
  • 86 related to general prison administration (12%).
  • 80 related to suicide and self-harm prevention (11%)

The PPO take the view that although it is not realistic to expect that establishments will ever be able to prevent all such deaths, there are some established lessons about actions that can be taken to help to reduce the number of self-inflicted deaths, including:

  • good quality risk assessment to identify those at most risk of suicide and self-harm (particularly in the early days in custody),
  • appropriate action to minimise or resolve the reasons for distress,
  • safety checks at appropriate intervals for those at risk,
  • multi-disciplinary working, especially for those with mental illness and substance misuse issues,
  • an effective strategy to reduce the supply of and demand for illicit drugs (which are so often associated with debt and bullying),
  • a prompt and effective emergency response to suicide attempts.

Self-Inflicted Deaths


After an initial assessment of the prisoner’s main concerns, levels of supervision and interactions are set according to the perceived risk of harm. Checks should be carried out at irregular intervals to prevent the prisoner anticipating when they will occur. Regular multi-disciplinary review meetings involving the prisoner should be held.

As part of the process, a CAREMAP (a plan of care, support and intervention) is put in place. The ACCT plan should not be closed until all the actions of the CAREMAP have been completed.

Assessment of Risk

One of the most frequent concerns is that staff have not adequately assessed the level of risk the individual poses to him or herself. The Prison Service Instruction 2011/64 lists a number of risk factors and potential triggers for suicide and self-harm and it is important that staff take these into account.

Unfortunately, in the case of mental health some conditions cause sufferers to present difficult and challenging behaviour, which staff may deal with as a behavioural rather than a mental health problem. When this leads to a punitive rather than a therapeutic response, this may only worsen the prisoner’s underlying mental ill-health.

Segregation Units

Segregation is an extreme and isolating form of custody used for prisoners who pose a threat to the good order and discipline of the establishment (often through misbehaving) or who cannot be kept safely in normal prison accommodation. It inherently reduces protective factors against suicide and self-harm, such as activity and interaction with others, and for this reason should only be used in exceptional circumstances for those known to be at risk of taking their own life.

Emergency Response

In addition to the number of self-inflicted deaths, there were also incidents where a prisoner was successfully resuscitated after a suicide attempt, albeit sometimes with life-changing injuries. A confident and effective emergency response can save lives. To achieve this, it is essential that uniformed and healthcare staff understand their responsibilities during medical emergencies, including:

  • using the correct emergency code to communicate the nature of a medical emergency,
  • entering the cell to provide assistance where it is safe to do so,
  • arriving at the scene with relevant emergency equipment,
  • ensuring there are no delays in calling an emergency ambulance,
  • escorting paramedics through the prison promptly to the scene.

Deaths From Natural Causes


In many of the investigations, the PPO found evidence that healthcare staff had treated prisoners who had died from natural causes in a caring and compassionate manner, which was judged by the clinical reviewers to be equivalent to the treatment they could have expected to receive in the community.

However, it is noted that not all prisoners receive this standard of care. Too many investigations found instances of healthcare staff failing to make urgent referrals to specialists when they had concerns that a prisoner might have cancer. Delays can prevent early diagnosis, early treatment and even result in unnecessary deaths. Similar problems arose when healthcare staff failed to review and treat abnormal blood test results, for example. Investigations also found instances where clinicians were unaware of, or failing to keep up to date with, NICE guidelines for managing chronic conditions, such as chronic obstructive pulmonary disease or heart disease.

End-Of-Life Care

The ageing prison population means that the prison service now has to accommodate prisoners with terminal and incurable illnesses. This has brought new challenges for both prison regimes and facilities. To overcome these challenges, a number of prisons have built palliative care cells or units for prisoners requiring specialist end-of-life care. Other prisons have developed links with local hospices to enable prisoners to receive treatment outside the prison.


When prisoners have to travel outside the prison, for example to attend hospital, a risk assessment is conducted to determine the level of the security arrangements required, including restraints.

Unfortunately, there continues to be very many cases in which very elderly, frail and/or very unwell prisoners with limited mobility were escorted to hospital in handcuffs and some remained restrained until shortly before they died. This is uncomfortable and undignified for prisoners and upsetting for their families. It is also distressing for prison staff to be chained to a dying prisoner.

Drug-Related Deaths

These figures captured cover deaths where an accidental or intentional drug overdose was the primary cause of death or where drug use was a contributory cause of death. However, that does not give the full picture of the damage that drugs are causing in prisons, approved premises and immigration removal centres. Toxicology tests are not always undertaken and, even where they are, they will not always detect some of the many strains of psychoactive substances (PS). Although PS was involved in many drug-related deaths, cocaine, heroin and prescription drugs were also involved.

PS continued to be a serious problem across the prison estate, and increasingly in immigration removal centres and probation approved premises as well.

People under the influence of PS can present with marked levels of disinhibition, heightened energy levels, a high tolerance of pain and a potential for violence. Besides emerging evidence of such dangers to physical health, there is also potential for precipitating or exacerbating the deterioration of mental health with links to suicide or self-harm.


Homicides remain at mercifully low levels: there were 4 in 2018/19, just 1% of the total of 334 deaths and a drop from 7 homicides the previous year. However, and while uncommon, the killing of those in the care of the state is a particularly shocking and serious matter. At the same time, these are some of the hardest deaths to learn lessons from, not least because the PPO can only complete an investigation once any criminal proceedings have been completed.

Women prisoners

In 2018/19, there were 11 deaths of women prisoners, a slight increase from 8 deaths in 2017–18. Three were self-inflicted deaths, an increase from one in 2017–18. Of the remaining 8 deaths, 5 were from natural causes, one was apparently drugs-related and 2 were awaiting classification.

Approved premises

There were 12 deaths of residents of probation approved premises (APs) in 2018/19. All were male. Of these, three were self-inflicted deaths, 4 were from natural causes, 4 were from other non-natural causes, and one is still awaiting classification. This was one more death than in 2017/18, when the deaths also included one female AP resident.

The majority of AP residents are former prisoners. Given the prevalence of PS use among prisoners, the PPO are concerned that the National Probation Service has still not developed an effective strategy and testing regime to deal with suspected PS use in approved premises, although the PPO are told this is under consideration.

Court Cells

The PPO investigated a death in court cells for the first time in 2018/19. The circumstances of the death were very disturbing, that centered around the inadequate contingency plans when the court’s air-conditioning failed.

Immigration detainees

There was only one death of a detainee at an immigration removal centre (IRC) in 2018/19 (a death from natural causes). This was a welcome reduction from 4 deaths at IRCs, 2 of which were self-inflicted in 2017/18.

Under 21s

There was only one death of a young person under 21 in 2018/19, compared to 4 the year before.

For this one death, there were a number of significant risk factors present: he was very young; this was his first time in custody and he had only been at the YOI for 5 weeks; he had a history of serious self-harm, substance abuse and mental health issues; and he had no contact with his family.


In 2018/19, the PPO issued 262 final investigation reports following deaths in custody, and made recommendations in 224 of these cases. 723 recommendations were made, at an average of 3 per case, and there were 20 cases in which the PPO made 7 or more recommendations. The PPO made more recommendations per investigation for self-inflicted deaths: an average of 5.

The majority of the recommendations related to healthcare provision (19%), emergency response (16%), general prison administration (12%) and suicide and self-harm prevention (11%).

For natural cause deaths, 31% of the recommendations related to healthcare provision, 19% related to the inappropriate use of escorts and restraints and 12% related to general prison administration.

For self-inflicted deaths, 24% of recommendations related to suicide and self-harm prevention and 18% related to emergency response.

For other non-natural deaths, 26% of recommendations related to substance misuse and 24% related to emergency response.

Full report here: PPO Report 2081–19

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.