4 November 2020

The Prisons and Probation Ombudsman has today (4 November 2020) released their annual report for the financial year 2019/2020. The report details the PPO’s work investigating deaths and complaints, prior to the pandemic.

Over the year  311 investigations into deaths were started, the fourth highest figure in the last ten years. Of those, 83 deaths were self-inflicted, 31 were other non-natural deaths, 176 were from ‘natural causes’ (though often relating to issues with healthcare), and there were still 19 deaths awaiting classification. The majority (93%) were  deaths in prison. Six of the deaths in prison were women, while four were of young men under the age of 21.

There was one investigation into a death of a person in immigration detention, 17 deaths of people in probation approved premises (five more than last year). Significantly, there were also three ‘discretionary’ investigations, two relating to court and one on a stillbirth in prison.

The PPO also highlighted their first complaint about the use of PAVA incapacitant spray, which has recently been rolled out in all adult male closed prisons despite significant concern from the public and human rights bodies. The PPO’s investigation found it had not been used in accordance with the requirements of the policy.

Over the year the PPO made 1,050 recommendations arising from deaths in custody. They shared continued frustration at the number of recommendations they have had to repeat from previous investigations. The majority of recommendations (312) related to healthcare provision, 161 were on emergency response, 90 on substance misuse, and 89 on suicide and self-harm prevention.

The report noted that, “too many of our recommendations about improvements in primary and mental healthcare are repeated year after year.” Their investigations found the healthcare provided in some cases was poor, did not meet the required standard, and was not equivalent to that in the community. They also found shortages of healthcare staff are endemic in some prisons.

The PPO continued to see examples of poor healthcare for prisoners whose behaviour is challenging in some way, with some fatal cases showing behaviour which is perhaps caused by mental ill health can mean physical health problems are misinterpreted or overlooked.  In many of the self-inflicted deaths they investigated, the PPO found that the prisoner’s mental health issues were not adequately addressed or that they were too severe to be managed in prison.

This report follows shortly after HM Inspectorate of Prisons highlighted an inadequate response to PPO recommendations in 40% of prisons in its own annual report. It comes  only days after the latest Safety in Custody statistics by the Ministry of Justice showed the number of deaths in the 12 months to September 2020 remains at historically high levels, with around five deaths in prison every week.

INQUEST recently submitted evidence to a Ministry of Justice consultation on Strengthening the Independent Scrutiny Bodies through Legislation, supporting proposals to put the PPO on a statutory footing, a change which is long overdue. INQUEST also called for a framework which would place a duty on relevant ministers to respond to PPO recommendations.

Deborah Coles, Director of INQUEST, said: “The number of deaths in prison remain at historically high levels, with investigations finding many are preventable. The work of the PPO is essential, but their recommendations are ultimately only as good as their implementation. Today's report provides yet more evidence of the shameful lack of action and change.

At a time when people in prison are living through extreme restrictions, in conditions that amount to solitary confinement, we are deeply frustrated to read yet another report shedding light on the failures of mental healthcare, even before these restrictions were introduced. To protect lives, we need to dramatically reduce the prison population and reallocate resources to health and welfare services. As the second wave of the pandemic begins to hit, effective action is urgently needed.”

Donna Mooney, sister of Tommy Nicol said: “There are no words to fully explain the everlasting pain and damage that has been caused by my brother’s preventable suicide. It became very evident from the thorough PPO report that he was pushed to the brink by a cruel prison system, compounded by an absence of support for his mental ill health.

We felt that all of the PPO recommendations were accurate and we hoped that deaths would be prevented as a result. Sadly, this has not been the case. Very few of these recommendations have been implemented and people have continued to die in exactly the same sort of circumstances. Without an independent agency, ensuring these recommendations are implemented effectively, deaths will continue to happen and the devastation will continue to flood across families.”

Dita Saliuka, sister of Liridon Saliuka said: On the 2nd January 2020 I lost my dear brother while he was on remand at HMP Belmarsh. The devastation caused by his death has been immeasurable and I am left with endless questions as to how his death was able to happen in the care of the state. Exactly ten months after Liridon's passing I was forced to relive the pain after I found out another person had died at the same prison. No other family should have to go through this. Our fight for the truth goes on…”



For further information, interview requests and to note your interest, please contact [email protected] or call 020 7263 1111 (option 3). 

Please refer to the Samaritans Media Guidelines for reporting suicide and self-harm.  

The Prisons and Probation Ombudsman annual report is available here, alongside their media release.

INQUEST has been supporting Donna Mooney and Dita Saliuka following the deaths of their brothers.

Tommy Nicol, 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 indeterminate IPP sentence towards release as “psychological torture”. The inquest into his death concluded in November 2018. The PPO report is available here.

Liridon Saliuka, 29, died whilst at HMP Belmarsh in January 2020. The PPO are investigating his death and the inquest is awaited.

Also see:

COVID-19 and the second lockdown in prisons:

  • On March 24,the Secretary of State for Justice placed prisons across England and Wales under immediate lock down. There were widespread calls, including a letter organised by Women in Prison and INQUEST signed by over 100 organisations, to release significant numbers of people prison to protect their mental and physical health.
  • The government’s own End of Custody Temporary Release programme was barely implemented, with only 275 people released when it was paused in August.  Announcement of the government’s action plan on prisons for this second lockdown is awaited.
  • Yesterday (3 November) Lucy Frazer MP, Minister for Prisons, told parliament, “We are, of course, now reassessing the position and we will be having an action plan, following the imposition of further national restrictions on Thursday.” She did not outline any plans.
  • On 22 October Robert Buckland QC MP, Lord Chancellor & Secretary of State for Justice, wrote to Juliet Lyon and the Independent Advisory Panel on Deaths in Custody responding to their concerns about the previous iteration of the Early Release scheme and plans for the second wave. He outlined the potential contingency measures for the winter.

National Oversight Mechanism on deaths in detention

INQUEST have long campaigned for a national oversight mechanism which would monitor and audit recommendations of the various investigations and inquests which follow deaths in places of detention. While this has been supported in parliamentary inquiries and independent reports, we are yet to see steps towards a national oversight mechanism, which INQUEST believes would strengthen the work of the PPO and help ensure their recommendations are enacted and change is sustained.