Improving Prisoner Death Investigations and Promoting Change in Prisons: A Findings and Recommendations Report

By Sharon Shalev and Philippa Tomczak

Hundreds of prisoners die every year in England and Wales, resulting in tremendous harms and costs. These deaths will almost always be investigated by the Prisons and Probation Ombudsman (PPO) after a police investigation and before a Coroner’s inquest. PPO reports are usually produced far more quickly than inquest findings, hence could be a valuable catalyst for improved prison safety. The sustained high numbers of prisoner deaths in England and Wales suggest this potential is not being realized. This guide reports on extensive qualitative research carried out with PPO staff, prison staff, coroners and bereaved families. It also highlights the policy implications of the research findings.  

Nottingham, UK: University of Nottingham, 2023.  35p.