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Adrian Usher shares concern for prison capacity issues in new Annual Report 

Published:

10 July 2025 – Today, Prisons and Probation Ombudsman Adrian Usher publishes his second Annual Report, covering the year 2024 to 2025. 

“The year has been another in which the PPO has implemented significant internal change while meeting increased external demand”, said Adrian. 

“As capacity issues continue to challenge the services in remit, this report highlights both the challenges and the successes we have had in raising standards of safety and fairness. As prisoner numbers approach the operational limit, the delivery of routine regime, education, work and meaningful activity becomes more difficult.” 

During this time, we saw a 15% increase in complaints sent to us, and it is undeniable that some of the rise will be due to a system under strain.  

Complaints investigations in figures from 1 April 2024 to 31 March 2025:  

  • Received 5,267 complaints, an increase of 15% 
  • 5,100 of these were about prisons, 755 more than last year 
  • The most common complaint categories of the 2,471 complaints completed were: 
  • Property (35%) 
  • Staff behaviour (9%) 
  • Administration (6%) 
  • We also received an increase in correspondence sent to us from prisoners, from 500 to 800 pieces of correspondence received per month  

There was a 35% increase in deaths this year as we started investigations into 486 deaths, 100 of which were self-inflicted. This is too many. 

The prison population is getting older, influenced by sentence inflation and a significant rise in historic sexual offence convictions which has inevitably given a rise in the number of people dying while in prison. This year, we started investigations into 84 more cases than in the previous year of the deaths of older people (aged 50 and over). 

Fatal incidents investigations in figures from 1 April 2024 to 31 March 2025: 

  • Started investigations into 486 deaths, a 35% increase 
  • 398 of these deaths were in prisons and 73 of these occurred post-release 
  • 506 recommendations were made to the services in our remit: 
  • 165 were about healthcare provision 
  • 62 were about general administration 
  • 62 were about suicide and self-harm prevention 
  • 37 were about emergency response 

Other key areas of impact worth noting are: 

Making pleas to prisoners  

When several suspected drug-related deaths happened at HMP/YOI Parc, we took an unusual step and made a public plea to prisoners to dispose of any drugs they had in their possession.  

Developing a better approach to investigating systemic issues such as the falsification of records and focusing on making more strategic recommendations 

Sharing concerns around widespread falsification of records by staff, particularly relating to ACCT checks and routine checks which also serve as an opportunity to check on prisoners’ welfare, we recommended that staff who have been found to falsify records should face disciplinary action.  

In one case, we were able to identify through the reviewing of CCTV whether there was a systemic issue of falsification. Whilst in this case there was no evidence of a systemic issue, Governors and Directors were instructed by Phil Copple, Director General Chief Executive HMPPS, to build reviewing CCTV into their quality assurance processes in response to the PPO’s investigation. 

Senior leaders should be able to identify policy and practice failures to prevent deaths, rather than in the wake of a death. HMPPS now routinely use their own CCTV systems to ensure processes designed to ensure prisoner safety are carried out correctly. 

Establishing a more mature and consistent approach to returning complaints to prisons where we assessed there had been an insufficient attempt by them to resolve the matter 

Getting things sorted quickly, and locally, is the best outcome when things have gone wrong for prisoners, so we pushed back 170 complaints received to ensure prisons start investigating complaints properly first. 

Launching the IPCI Ambassadors scheme in 47 prisons 

We recognised the valuable role that volunteer prisoners play in understanding the local complaints processes and the scheme enables Ambassadors to guide others in how to make a complaint, and to know when and how to contact IPCI.   

Sharing learning with stakeholders  

A continued priority for the PPO, we held a joint symposium on post-release deaths with HMPPS, drove consistency in clinical reviews, and issued learning publications for frontline and policy staff on property complaints, handling prisoners’ property and the handling of property complaints, emergency response and post-release deaths.  

Adrian said: “This report focuses on what we have delivered and our collective achievements as an office, and I am very proud of the difference my staff have made in pursuing just outcomes for those for whom we provide a service. I am concerned about the rise in complaints and deaths we have seen, and we are working closely with the services in remit to understand what the causes may be. 

Our work has a real impact on people’s lives, and I believe it is important that those people also have an impact on how we do our work.” 

Click here to read the 2024 to 2025 Annual Report and statistics