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Adrian Usher calls for creation of independent body to scrutinise prison staff conduct in new report 

Published:

9 July 2026 – In his third Annual Report published today, Prisons and Probation Ombudsman Adrian Usher shared his most serious concern that impacts prison and probation’s service delivery. 

“HMPPS is the largest public service body that I can bring to mind that has no independent oversight of staff conduct. Investigations into staff conduct, and any subsequent disciplinary hearings… take place within the very institution where the member of staff works”, said Adrian. 

This highlights the “very stark and obvious difference between the consequences for police officers compared to prison officers who are facing investigations, often for actions taken in very similar circumstances. I believe it is the right time”.  

Click here to read the executive summary 

Complaint investigations 

The Annual Report reflects the PPO’s output throughout the 2025 to 2026 financial year. Demand for our investigative services remained high as we received 5,226 complaints, 5,022 of which were from prisoners.

Complaints about property constitute the most voluminous category for us, and it is noteworthy that they also attract the highest uphold rate at just over 50%. As in most years, property remained the most common complaint category we completed this year (34%), and we are working with HMPPS on a pilot with 10 prisons to explore a more efficient way of addressing property complaints. 

“I believe that prisons are still not incentivised to focus upon early complaint resolutions properly”, said Adrian.  

We pushed back 95 complaints received to the relevant establishment to reconsider this year as we assessed there had been an insufficient attempt by them to resolve the matter.  

Death investigations 

The number of deaths in custody remains high as we started 455 fatal incident investigations this year.  

Self-inflicted deaths: 

“The rate of self-inflicted deaths means that a prisoner in England and Wales will kill themselves approximately every five days” said Adrian, and this year, we sadly started investigations into 84 self-inflicted deaths.  

Adrian and Deputy Ombudsman for fatal incident investigations Susannah Eagle expressed their concerns as our investigations this year revealed that the risk of self-inflicted deaths in prisons is not evenly spread. Our research revealed that the Long-Term High Security Estate and reception prisons present the highest level of self-inflicted deaths: in a bulletin published this year, we revealed that of those who take their own lives, 11% of them do so within the first 48 hours of entering a reception prison – a sobering statistic. 

This year, we also highlighted the risk of placing prisoners in segregation, which we found can reduce the protective factors against suicide and self-harm. 8 individuals from our sample located in a segregation unit who died were on an open ACCT at the time of their death.  

Drug-related deaths: 

Drug-related deaths made up 13% of prison deaths we investigated this year. In a world of increasingly sophisticate drone technology, this number is fuelled by unknown chemical compounds with unpredictable effects. Adrian stressed the need for prison drug strategies to combat both the supply of drugs and the demand. Concerningly, other non-natural deaths (what we typically class as drug-related) also made up 54% of post-release deaths we investigated. 

Natural cause deaths: 

The 235 deaths from natural causes this year continued to raise important issues about the healthcare and treatment offered to prisoners. Our learning published this year revealed the need for better practice to support those in prison with epilepsy, who have a lower remission rate than those in the community. 

Homicides: 

We began investigations into 8 homicides – 60% more than the previous year. We continue to monitor our investigations for themes or significant issues of concern that we can share with HMPPS while awaiting the completion of criminal proceedings. 

Special investigations 

Investigation into the failing of Medomsley Detention Centre:  

We delivered a report that revealed the full scale and horror of what happened to thousands of victims at Medomsley Detention Centre this year. It resulted in the victims receiving public apologies from the government, Durham Police and the Independent Monitoring Board, as well as the establishment of the Youth Custody Safeguarding Panel. The report was well received by victims and represented a monumental victory for them. 

The restraint of pregnant women in prison during pregnancy-related hospital escorts: 

We also began our independent review of the restraint of pregnant women who attended medical appointments this year. The report will be delivered in the next financial year.  

“The 12 months covered in this report represent a huge amount of effort in delivering a substantially improved output and performance while accommodating rising demand and no greater resource. All three areas of focus for the PPO… have risen to these challenges impressively. My last word will, as always, go to my staff. The successes described in this report belong to them.”
Adrian Usher

Click here to read the 2025 to 2026 Annual Report and statistics