Fatal incidents and remand

When we talk about the remand population in prisons, we are referring to individuals who are in prison until their trial begins or those who have been convicted but are awaiting sentencing. To give a full picture of remand prisoners as a proportion of the population, between July and September 2022, there was a total of 15,817 prisoners received into prison custody for the first time and of these, 10,295 were on remand[1].

The remand population has increased steadily since the start of the COVID-19 pandemic, largely due to disruptions in the court system. Recent statistics from the Ministry of Justice (MoJ) have indicated this trend has continued post-pandemic, with an 11% increase between 31 December 2021 and 31 December 2022. This has also been driven partly by the recent strike action of the Criminal Bar Association (now resolved). On 31 December 2022, the remand population was 14,143[2], the highest it has been for at least 50 years.

In their Safety in Custody quarterly update, MoJ have also stated that prisoners on remand had the highest rate of self-inflicted deaths and in 2022, 35% of all self-inflicted deaths were of prisoners on remand.[3]

What we know about the deaths of those on remand

At the PPO, we do not currently hold sentencing data on our case management system, however, our investigators usually record basic sentencing details as part of their reporting of a fatal incident. This may be relevant, particularly when making recommendations following an investigation. In the cases of deaths of individuals on remand, recommendations commonly related to issues around reception, initial assessment, and the identification of risk factors and potential triggers for self-harm or suicide (e.g., upcoming court appearances and/or sentencing).

Recommendations we have made in cases identified as remand can usually be grouped into the following themes:

Examining and recording all documentation (including ACCT documentation) that arrives with the prisoner and ensuring it travels with them on transfer

We have frequently made recommendations reminding reception staff to consider all documentation that arrives with a prisoner to properly assess their risk of suicide and self-harm.

For example, Mr A died of self-inflicted causes within a month of being remanded to prison for the first time. When he arrived, his Person Escort Record (PER) was not reviewed, meaning significant information about his risk of suicide and self-harm was missed. A reception nurse also gave too much weight to Mr A’s presentation rather than his range of significant risk factors and staff did not start ACCT measures (the Prison Service suicide and self-harm prevention procedures).

Considering risk factors over how a prisoner presents

We have also made recommendations in remand cases that all risk factors should be considered and recorded when assessing a prisoner’s level of risk – staff should not just rely on what the prisoner says or how they appear at the time.

Mr B, who despite telling the reception nurse he had attempted suicide several times (most recently the same month he was remanded into custody), stated he had no current thoughts of suicide. As a result, the decision was made not to start ACCT measures. Like Mr A, in the case of Mr B, we found that staff did not properly assess his risk of suicide and self-harm based on his known risk factors. We recommended that healthcare staff should not rely solely on the prisoner’s stated intentions.

Flagged triggers for potential self-harm and suicide

In our investigations, we have also highlighted that court dates for trials and sentencing hearings are potential triggers for self-harm and suicide. These triggers should be identified and flagged to relevant staff and following court dates and hearings, prisoners should be re-assessed for their risk of suicide and self-harm.

For example, Mr C was attending court daily for his trial. Following the trial, he was convicted and was due to attend court the next day for sentencing. However, staff who saw him when he returned to the establishment were unaware of his change in status [from being on remand to convicted awaiting sentencing]. The following morning, during a roll check, Mr C was found dead on the floor of his cell. After Mr C’s death, a prisoner told staff that Mr C had said he would take an overdose if found guilty at court. Mr C’s change in status from a remand prisoner to a convicted prisoner should have triggered a reassessment of his risk of suicide and self-harm and a referral to healthcare staff based on this risk assessment.

In addition to the change in status from remanded to awaiting sentencing, court appearances more generally are potential triggers, and it is important that staff speak to prisoners following court appearances to assess whether their risk has changed and take appropriate action.

For example, Mr D was on remand and attending trial via video link. He was found, two days after his trial began, unresponsive with drug paraphernalia in his cell. There was no record that staff followed local practice and spoke to Mr D about any concerns he might have had following his court appearances in the days leading up to his death.


The remand population has increased since 2020, and it is important to acknowledge the impact this may have on cases investigated by the PPO. The case studies used in this article illustrate some of the issues experienced by prisoners on remand and recommendations we have made as a result of our investigations. They highlight the continuing need for thorough reception procedures, including examining of all documentation that arrives with the prisoner, identifying and assessing risk factors over how an individual may present, record-keeping and making appropriate referrals or application of ACCT procedures. It is also important to highlight triggers for self-harm and suicide specific to those on remand, such as court appearances and sentencing.

In the future, we hope to have access to more sentencing data as part of our ongoing case management improvement project and welcome future data sharing with HMPPS and MoJ. This will allow us to provide greater insight into trends that may be occurring around deaths in prisons and under probation supervision, particularly in relation to prisoners’ sentencing status.

Author: Dr Sarah Welland, Research Officer, Research, Data and Analysis team

[1] Offender management statistics quarterly: July to September 2022 – GOV.UK (www.gov.uk)

[2] Offender management statistics quarterly: July to September 2022 – GOV.UK (www.gov.uk)

[3] Safety in custody quarterly: update to September 2022 – GOV.UK (www.gov.uk)