Investigating the death

If the death is within our remit, a named investigator will lead the investigation and a family liaison officer will liaise with the bereaved family.

The investigator will gather evidence about what was happening to the person before their death. This includes examining all the relevant records and policies, together with interviews with relevant staff and prisoners or residents, if required.

We work with NHS England to commission an independent clinical review of the health care provided while in custody to the person before their death.

Liaising with the bereaved family

Family liaison is an important part of the PPO investigation. A family liaison officer will be in touch with the bereaved family within four weeks of the death occurring or after the funeral, whichever is sooner. 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. For more information see the PPO Family Liaison page

The initial 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 in initial form. 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, records of interviews, and other relevant documents.

Both the bereaved family and the service can comment on the factual accuracy of the initial report before the final version is issued. Our Disclosure Policy sets out how and when we will share information before the final report is issued.

The final report

After we have considered at any comments, 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.

Making recommendations

Our reports often include recommendations we are making relating to what we found during the investigation. These focus on what could be done to prevent similar situations in the future.

The prison, probation and immigration services must tell us whether they accept our recommendations and let us know when they will implement them.

We have published a thematic report about the recommendations we make.

Learning Lessons from investigations

Since Nigel Newcomen came into office as the Ombudsman in September 2012, he has placed greater emphasis on learning lessons from collective analysis of our investigations, in order to contribute to improvements in the services we investigate and potentially help to avoid preventable deaths. A wide range of Learning Lessons bulletins and thematic reports have been published and are available on the Learning Lessons page.

Publishing the report

After the inquest has concluded we will publish the report in the Fatal incident reports section of this website. All reports published until March 2015 have been completely anonymised, with all names removed, including that of the deceased. From 1st March 2015, the Ombudsman will no longer remove the name of the deceased from the reports, although other names, such as those of prison staff, will continue to be redacted.

Although the reports are not published until after the inquest, they are not amended to take into account anything which happens during the proceedings. It is therefore possible that the cause of death shown in the report may, on rare occasions, differ from the inquest verdict.

Suspending an investigation

Sometimes the Ombudsman cannot progress an investigation and it has to be suspended for a time. This is usually when the police are investigating a possible crime in relation to the death. The Ombudsman’s investigation will continue once the police investigation and any subsequent court action has been completed. This can mean that the Ombudsman’s investigation is suspended for many months. Our family liaison officer will stay in touch with the bereaved family during this time.