Learning Lessons Bulletin Issue 19: Post-release death investigations 2

By Adrian Usher, the Prisons and Probation Ombudsman (PPO)

This learning lessons bulletin summarises the learning from Prisons and Probation Ombudsman (PPO) investigations into the deaths of those who died within 14 days of release from prison. Prison leavers often have multiple and chronic co-morbidities or risk factors, including substance misuse and mental health issues. This can present difficulties with release planning, especially when combined with external factors, such as a lack of available accommodation. Homelessness on release was a considerable issue in our investigations and has a detrimental impact on the individuals involved. Based on our period of research and reporting 32% of the prisoners who died within two weeks of release were homeless. When viewed in the context of other MOJ research, it seems that prisoners who are released homeless may be overrepresented in our post release death investigations. While we are seeing positive changes to policy and examples of positive practice, analysis of our investigations also found that of those who died within 14 days, just over 50% died within the first four days of being released. This stark finding demonstrates how acutely vulnerable prison leavers are, especially in those first few days after release. There is a desperate need for more joined-up and partnership working between HM Prison and Probation Service (HMPPS) and community services. More needs to be done to ensure that prisoners are released with suitable accommodation and that support measures (such as substance misuse or mental health services) are in place and readily available on release.