10 October 2019

The Prisons and Probation Ombudsman (PPO), who investigate deaths in prison, probation and immigration detention, have today released their annual report. The PPO report that they started 334 fatal incident investigations in the past year, of which 91 deaths are classified as self-inflicted deaths, a 23% increase on last year.  

In the 262 final fatal investigation reports issued in this period, the PPO made a total of 723 recommendations. The majority of recommendations related to healthcare provision (19%), emergency response (16%), general prison administration (12%) and suicide and self-harm prevention (11%). Sue McAllister, the Prison and Probation Ombudsman, said “We continue to make the same recommendations repeatedly, sometimes in the same establishments and, often, after those recommendations have previously been accepted and action plans agreed to implement them”.

The report highlights that in the period 2018/2019:

  • PPO fatal incident investigations were opened following 334 deaths, 6% more than in the previous year and the second highest number in a year since the PPO started investigating deaths in 2004.
  • 96% of these deaths were of people in prison. Of the remaining 4%, 12 deaths were of residents living in probation approved premises, one death was of someone held in immigration detention and one death was a discretionary case of an individual that died four days after release from prison.
  • There were 11 deaths in women’s prisons, an increase from eight the previous year.

Deborah Coles, Director of INQUEST said: "As deaths remain at historically high levels, the PPO continues to find the same fatal failures in the state’s duty of care in prisons across England and Wales. The recommendations made are ultimately only as good as their implementation. Yet there exists a shocking accountability gap that allows lifesaving recommendations to disappear into the ether.

There is an urgent need for a national oversight mechanism to monitor and audit action taken following deaths to ensure critical changes are enacted. Without this, more preventable deaths will leave more families needlessly traumatised and devastated.”



For further information and interview requests please contact Sarah Uncles on 020 7263 1111 or [email protected]
The PPO annual report is available online.

Inquests held following deaths in prison that have concluded in the past year:

Jury highlights series of failings at inquest into death of Anthony Solomon at Nottingham Prison.
Media Release, September 2019.
Anthony, 38, died from the toxic effects of synthetic cannabinoids. The jury returned a narrative conclusion highlighting a failure to answer the cell bell sooner and the prevalence of drugs in Nottingham prison at the time of this death.
Jury finds failure to adequately assess risk of self harm and suicide contributed to death of Rocky Stenning at HMP Chelmsford. Media Release, July 2019.
Rocky, 26, died a self-inflicted death on 19 July 2018, just nine days after entering prison. Despite a history of mental ill health and recommendations of a psychiatric report, ACCT processes were not opened.

Teenager Jordon Hullock whose meningitis and heart condition was overlooked was failed by HMP Doncaster healthcare staff, inquest finds. Media Release, July 2019.
Jordan, 19, died on 30 June 2015. The inquest jury concluded Jordan’s death was by natural causes, and that there were serious failures and shortcomings in his care in the days leading up to his death. 

Inquest concludes a series of failings contributed to death of Shane Stroughton in HMP Nottingham. Media Release, June 2019.
Shane, 29, died a self-inflicted death on 13 September 2017. The jury unanimously agreed that there was inadequate mental health care, a lack of trained ACCT assessors and a failure of prison staff to communicate with Shane’s family regarding incidents involving him at HMP Nottingham. 

Jury returns damning conclusion at inquest of Andrew Brown at HMP Nottingham. Media Release, June 2019.
Andrew, 42, died a self-inflicted death on 17 September 2017. The inquest concluded that there were numerous failings which contributed to his death, including a failure to follow procedures, an unsuitable environment which did not meet his basic needs, failure to respond to the emergency bell and a failure to investigate an earlier assault on Andrew. 

Inquest in to the death of Marcus McGuire highlights failings at HMP Birmingham. Media Release, June 2019. Marcus, 35, died on April 2018. The jury found a lack of mental health assessment and issues with ACCT procedures were possible causative of his self-inflicted death. He was recalled to prison in November 2017, shortly after being discharged from a psychiatric hospital where he had been detained after making threats to his life.

Inquest finds serious failures at Sodexo run HMP Peterborough contributed to death of Annabella Landsberg. Media Release, April 2019.
Annabella, 45, died from complications relating to her Type 2 diabetes on 6 September 2017. The inquest jury found failings on the part of the prison, healthcare staff, GPs and custody officers contributed to the death of Annabella Landsberg. 

Father of four, Sean Mccann, died after a catalogue of errors and neglect by prison staff. Media Release, 15 February 2019.Sean, 32, died in March 2016 at Peterborough prison. The jury concluded staff failed to properly assess his mental health, officers were not sufficiently trained and staff failed to take the cell with the ‘ligature point’ out of use. They ruled that his death was an ‘accident’ contributed to by neglect.
Jury conclusion highlights numerous failings contributed to the death of Michael Judge at HMP Swaleside. Media Release, 1 February 2019.
Michael, 32, died a self-inflicted death at HMP Swaleside. The jury highlighted numerous failings at the prison which contributed to his death.
Critical inquest finds systemic failures and missed opportunities contributed to death of Tyrone Givans at HMP Pentonville. Media Release, January 2019.
Tyrone, 32, died a self-inflicted death on 26 February 2018. The jury found that his substance abuse and profound deafness were insufficiently processed and addressed, staff communication was unsatisfactory, prison record IT systems were unfit for purpose and the inadequate recording of prison patient records. 

Inquest concludes that systematic failures and consistently missed opportunities caused death of Ryan Harvey at Woodhill prison, Media Release, January 2019.
Ryan died aged 23 on 8 May 2015. The jury found a failure by healthcare staff to undertake an adequate assessment of Ryan’s learning disability, and to conduct an assessment of his mental health, may have contributed to his death. 

Critical inquest highlights Home Office failures following death of immigration detainee, Michal Netyks, in prison. Media Release, December 2018.
Michal died aged 35. The inquest jury concluded that his death was the result of suicide, which was in part contributed to by the immigration deportation process. 

Neglect and serious medical failures in Sodexo run prison contributed to death of Natasha Chin. Media Release, December 2018.
Natasha, 39, died less than 36 hours after entering Sodexo run HMP Bronzefield on 19 July 2016. The inquest jury concluded her death was caused by healthcare failures and contributed to by neglect. 

Inquest finds death of Wayne Moore in HMP Nottingham was preventable. Media Release, November 2018.
Wayne, 46, was found collapsed in HMP Nottingham and later died in hospital on 16 December 2013. The inquest jury found inadequacies in ensuring Wayne’s health records were transferred from the hospital to prison staff, and in the communication of potential warning signs between prison staff and healthcare when his condition was deteriorating.
Inquest concludes into death of Tommy Nicol who ‘lost hope’ on IPP sentence. Media Release, November 2018.
Tommy, 37, was found with a ligature in his cell at HMP The Mount and died four days later in hospital in September 2015. Tommy made a complaint to the prison six months prior, in which he described his inability to progress in his IPP sentence towards release as “psychological torture”.
“Deeply inadequate” prison procedures contributed to death of Jessica Whitchurch. Media Release, November 2018.Jess, 31, died two days after being found with a ligature in her cell in Eastwood Park prison in May 2016. The jury returning a damning conclusion identifying multiple failures that contributed to her death.

Recent inquest conclusions following deaths in immigration detention:

  • Bai Bai Ahmed Kabia, 49, from Sierra Leone collapsed in Morton Hall IRC and died one day after in December 2016. The jury found that there was a missed opportunity for his ill health to be diagnosed and treated; and that treatment could possibly have prevented his death. See media release
  • Marcin Gwozdzinski, a 28 year old Polish national died at Heathrow IRC in September 2017. The inquest in June this year found serious failings which contributed to his death. See media release.
  • Amir Siman-Tov, a 41 year old Moroccan national, was being held at Colnbrook IRC when he died in the early hours of 17 February 2016, having ingested painkillers the day before. An inquest concluded on 30 May 2019, finding that he died as a result of ‘misadventure’ with a critical narrative conclusion. See media release.
  • Tarek Chowdhury, 64, was killed by another detainee who was experiencing serious mental ill health in Colnbrook IRC on 1 December 2017. The inquest concluded in March 2019, finding that the man who killed Tarek had been inappropriately placed in immigration detention, alongside numerous other critical failings. See media release.
  • Branko Zdravkovic, a 43 year old Slovenian national, died a self-inflicted death at The Verne IRC. The inquest identified serious failings, with the coroner writing a critical report to prevent future deaths highlighting failings in ACDT and Rule 35 procedures, published recently.