PPO share learning from 12-month post-release death investigations pilot

After a 12-month pilot into the investigations of those who die within 14 days of release from prison, the Prisons and Probation Ombudsman (PPO) have released a bulletin summarising their learning and an evaluation of the pilot.

Post-release death investigations learning lessons bulletin cover


Between 6 September 2021 and 5 September 2022, we were notified of 61 post-release deaths and started investigations into 48 of those cases. The majority of the deaths were of men and were classified as ‘other non-natural’ which are largely drug-related. This is different to prison deaths where the majority of deaths are through natural causes.

In summary, the learning identified by our investigations highlight that strong partnerships and joint working across all sectors and services are needed to address the important findings highlighted in the bulletin. The acute vulnerability of those being released from prison was apparent throughout our investigations and more needs to be done to support prison leavers throughout that process.

Alongside the bulletin, we have also published our full evaluation research report which provides more detailed data from the pilot. The PPO continues to investigate post-release deaths and we will publish more data on these cases in future.

Click here to read the Learning lessons bulletin: Post-release death investigations

Click here to read our full evaluation report of the pilot