The initial report
After the investigation is completed, we’ll write a report and send it to the bereaved family. This report will contain what we have found during the investigation. It will also be sent to the relevant service – for example (HMPPS, Home Office, the healthcare provider).
It may contain other information such as the clinical review, records of interviews, and other relevant documents.
We will give family members the chance to check the facts in the report before issuing the final version. We also share it with the relevant service for the same reason.
The final report
We’ll send the final report to the bereaved family and the service. It is also sent to the coroner who will conduct an inquest to establish how the person died.
The report may also recommend changes to improve the quality of care given in the future.
Publishing the report
After the coroner’s inquest into the death, we will publish an anonymised version of the report in the death investigation reports section of this website. The report will include the name of the person who died but other names such as those of staff will be removed.