Fatal Incident investigation reports

As well as investigating complaints from those in custody, the PPO carries out independent investigations into the deaths of prisoners or detained individuals in:

  • Prisons
  • Young Offenders Institutions and Secure Training Centres
  • Secure Children’s Homes
  • Immigration Removal Centres
  • Probation Approved Premises
  • The custody of Prisoner Escort and Custody Service (PECS) in court premises or on escort

The Ombudsman can also investigate the death of someone who has recently been released from custody at their discretion.


image of fatal incidents web page on PPO website

If a death is within our remit, an investigator will lead the investigation and a PPO family liaison officer will liaise with the bereaved family. The investigator will gather evidence about the individual’s time in custody, and the circumstances leading up to their death and immediately afterwards. This includes examining all the relevant records and policies, together with interviewing staff and prisoners or residents, if required. We also work with NHS England, who commission (where necessary) an independent clinical review of the health care provided while in custody to the person before their death.

After the investigation is complete, we will produce an initial report outlining the findings of the investigation and this will be shared with the next of kin and the establishment to check its accuracy. After we have considered any comments, we will produce a final report which is shared again with the next of kin and the establishment, but also the Coroner who conducts the inquest to establish how the person died.

Our reports often contain recommendations which aim to improve the quality of care given by the establishment and they can focus on what could be done to prevent similar situations happening in the future. The service in remit must tell us whether they accept our recommendations and let us know when they will implement them. The response to our recommendations are shared as actions plans on our website, along with the report.

It is important to note that the PPO will only publish a report on our website once the inquest has concluded: https://ppo.gov.uk/document/fii-report/. The FII reports page is a searchable record of our final reports which are published once they have been shared with next of kin and the coroner’s inquest has taken place. Reports are sometimes uploaded to our website many years after a person’s death, and this is because there are sometimes delays to an inquest being concluded or we may have to pause our investigation, for example due to a police investigation.

Please check the PPO website for reports before contacting us. You can use the filters to limit the display to specific case types, and the sort buttons to reorder by date of death or date the report was uploaded to the website. If you would like an update on a report that you cannot find on the website, please email: ppocomms@ppo.gov.uk