How we investigate fatal incidents

Every time someone dies in custody, we are notified by the prison, probation area or immigration removal centre where the death occured.

We then go through the following procedure:

Checking the incident is within our remit to investigate

 We assess the details to decide whether we can investigate. We can investigate deaths of:

• prisoners, including young people held in young offender institutions
• residents of probation approved premises, including voluntary residents
• residents of immigration removal centres and those under immigration service managed escort
  

Investigating the death

If we can investigate the death, a named investigator will lead the investigation and a family liaison officer will liaise with the bereaved family.

The investigator will find out as much as possible about what was happening to the person before their death. This includes examining all the relevant documents and policies, together with interviews with relevant staff and prisoners or residents, if required. 

We investigate the circumstances around the death, asking questions such as:

• safety - is the institution safe?
• standards - does the care provided meet national and local standards?
• governance - is the institution run well and in a safe manner?
• people-centred - are the services organised around the needs of those held in the institution?
• accessible - is the care and support individuals need accessible without delays?
• environment and amenities - is the institution well maintained and fit for purpose?
• public health - does the environment and regime improve, promote and protect health and social well-being?
  

The local Primary Care Trust will also carry out a clinical review of the health care provided to the person before their death.

Liaising with the bereaved family

A family liaison officer will be in touch with the bereaved family within four weeks of the death occurring. He or she will support the family through the investigation process, offering them the opportunity to ask any questions and raise any concerns so these can be considered as part of the investigation.

The family liaison officer will keep the bereaved family informed about the progress of the investigation and be available to them throughout.

The draft report

After the investigation is complete we will produce a report. This report will outline the investigation findings.

It may also recommend changes to improve the quality of care given by the prison, approved premises or immigration removal centre in the future.

The report will first be produced as a draft. A copy will be sent to the bereaved family and to the relevant service, accompanied by other documents which are annexes of the report. These will include the review of healthcare by the Primary Care Trust, records of interviews, and other relevant documents.

Both the bereaved family and the service can comment on the draft report before the final version is published.

The final report

 After we have looked at any comments from both parties, the Ombudsman will produce the final report. This is sent to the bereaved family and the service. It is also sent to the Coroner who will conduct the inquest to establish how the person died.

Publishing the report

After the inquest we will publish the report in the Fatal incident reports area of the Publications section on this website. Before this is done, all names are removed so that no one can be identified.