22 January 2020

On 22 January INQUEST will publish a report exposing dangerous, longstanding failures across the prison estate and historically high levels of deaths in custody. Deaths in prison: A national scandal offers unique insight and analysis into findings from 61 prison inquests in England and Wales in 2018 and 2019.

The report details repeated safety failures including mental and physical healthcare, communication systems, emergency responses, and drugs and medication. It also looks at the wider statistics and historic context, showing the repetitive and persistent nature of such failings.

Every four days a person takes their life in prison, and rising numbers of ‘natural’ and unclassified deaths are too often found to relate to serious failures in healthcare. The lack of government action on official recommendations is leading to preventable deaths. With case studies of deaths and inquest findings, the report tells the harrowing human stories behind the statistics (see page 9). INQUEST also details the experiences of bereaved families who struggle to access minimal legal aid for inquests, while prisons automatically receive millions in public funding.

The report sets out recommendations to improve safety and prevent future deaths including:

  • a new national oversight mechanism, to monitor and enforce the implementation of recommendations from investigations, inquests and inquiries on state related deaths,
  • significantly reducing the prison population,
  • reallocating resources from criminal justice to community-based health and welfare services.

Deborah Coles, Director of INQUEST, said: “This report exposes indefensible levels of neglect and despair in prison. Officials and Ministers repeat the empty words that ‘lessons will be learned’. Yet the recommendations of coroners, the prison ombudsman and inspectorate are being systematically ignored. This is a national scandal.

The personal stories of those who died show prisons failing in their duty of care towards people long failed by struggling health, education, welfare and social services. The system is also failing their families whose trauma over deaths is compounded by the struggle for truth, justice and change. In the long term, protecting both prisoners and the public from more harm will require investment in our communities, not ineffective punitive policies.”         


For further information and interview requests please contact INQUEST Communications Team: 020 7263 1111 or [email protected]; [email protected]

See the full report for more information: Deaths in prison: A national scandal. 

Official statistics: INQUEST’s report is released ahead of the Ministry of Justice statistics on Safety in Custody the latest data on deaths and self-harm in prisons, due to be released on 30 January 2020.

The previous quarterly statistics for the 12 months to September 2019 (released in October 2019) shows that 308 people died in prison - six deaths every week. Every four days, someone died from a self-inflicted death. 56 deaths are of unknown cause, and 158 were logged as ‘natural’. Media release, October 2019.

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

National Oversight Mechanism
A new and independent body tasked with the duty to collate, analyse and monitor learning and implementation arising out of post death investigations, inquiries and inquests. This body must be accountable to parliament to ensure the advantage of parliamentary oversight and debate. It should provide a role for bereaved families and community groups to voice concerns and provide a mandate for its work.

Legal aid for inquests
In 2017, the MOJ spent £4.2million on Prison and Probation Service legal representation at prison inquests, while granting just £92k in legal aid to bereaved families through the Exceptional Case Funding scheme. Media release, 10 April 2019.

Deaths in women’s prisons
INQUEST has also published reports focused on deaths in women’s prisons. See the briefing (June 2019) and the full report Still Dying on the Inside (May 2018).