The PPO’s post-release death investigations pilot: the importance of evaluation

I recently read an article titled ‘Evaluation: the icing on the cake?’[1]. This article described how sometimes evaluation is described as the ‘icing on the cake’ and a ‘nice to have’, when it is actually not the icing on the cake, it is the egg! The article explained that evaluation is a crucial ingredient. The PPO’s recent evaluation of its post-release death investigations pilot demonstrates why evaluation is an important factor.

Why did the pilot start?

In 2020, at the PPO, we started to think more about our remit and the types of investigations we carried out. We were very aware of the high number of deaths following release from prison and started to have conversations with stakeholders and academics about this. We also carried out further research into the number of deaths and how long after release they occurred. Following this, we bid for additional funding to enable us to investigate more post-release deaths. This bid was successful and in September 2021 we started a 12-month pilot to investigate all deaths (except homicide) that occurred within 14 days of release from prison.

This pilot was a joint project between our Fatal Incident Investigation team, Research team and Strategy team. This project showed the benefits of thinking about the evaluation process from the start. As a result of this joined-up approach, our lead researcher on the project was able to advise from the start on what data to collect and how best to collate this.

As a project team we thought about what needed to be in place for the PPO to carry out these investigations. This included training for our investigators, an effective notification process so that the PPO would be notified of the deaths and an investigation methodology.

It was established that the post-release death investigations would focus on pre-release planning and post-release supervision. This included factors such as:

  • identification of risk of suicide or self-harm,
  • appropriate continuity of care on release for matters such as medication or follow up appointments,
  • referrals to the appropriate services in the community; and
  • appropriate handovers.

The pilot ran from 6 September 2021 to 5 September 2022. Although the pilot has ended, we have continued to investigate post-release deaths.

What did the evaluation show?

The PPO’s evaluation process looked at all areas of the pilot, including the notification process, the investigation process and the learning identified from the investigations.

During the 12-month pilot, the PPO were notified of 61 post-release deaths and started investigations into 48 of these cases. 50% of these investigations were into drug-related deaths. There were also 10 self-inflicted deaths and 5 natural cause deaths.

The percentage of self-inflicted deaths that occurred in prison (22%) and within 14 days of release from prison (21%) were very similar. This demonstrates that as much attention needs to be given to identifying risk factors on release as it does when the individual is in prison.


Breakdown of categories for PRD's Other non-natural 58% Self-inflicted 21% Natural causes 10% Awaiting classification 10% Comparison of above to all prison deaths in same time range Other non-natural 5% Self-inflicted 22% Natural causes 69% Awaiting classification 4%

Death classification breakdown for investigations started from 6 September 2021 to 5 September 2022 for post-release and prison deaths.

The evaluation of the pilot looked at the thematic learning from the investigations. The learning included findings about information sharing, homelessness, accommodation, substance misuse and mental health. The evaluation identified the importance of strong partnerships and joint working across all sectors and services to address these findings.

Importance of information sharing, detailed handovers and timely referrals

Information sharing, including detailed handovers and timely referrals are crucial. The evaluation showed that we made three recommendations about information sharing between prisons and probation. Two of these recommendations related to self-inflicted deaths. It is vital that prison staff give a full handover to probation staff so that the community offender manager is aware of any important risks or triggers.

The importance of detailed handovers and timely referrals was not just identified in self-inflicted death investigations, it is just as important in cases involving substance misuse. In one case we found that gaps in information sharing hindered release preparations and the prison resettlement team and substance misuse team only found out about the release the day before the release date.

The evaluation also identified that it can be difficult to establish exactly who is responsible for handing over key information from the prison to the community. It can also be difficult for those involved in release planning to identify who is or should be responsible for different aspects of care, for example substance misuse or mental health. The evaluation suggested this can become complex when there are a number of external agencies who might be involved.

As well as identifying the areas where the PPO had made recommendations, the evaluation also explored wider findings. For example, the issue of accommodation and homelessness emerged as a topic of concern. This relates to the challenges of multi-agency involvement and ensuring that staff understand who is responsible for making the relevant referrals.

The PPO will investigate whether the prison leaver left prison with accommodation arranged or homeless and whether appropriate referrals were made. However, some of the agencies involved in the process fall outside of the PPO’s remit. Despite this, we have been recording our findings in relation to homelessness and accommodation so that the learning can be evaluated and shared more widely.

In this article I have demonstrated the importance of thinking about evaluation from the start of the project and shared some of the learning that the evaluation into the post-release death investigations pilot found.

You can read more about the learning from the PPO’s post-release death investigations in our Learning Lessons Bulletin here and you can access the full pilot evaluation research paper here.

Author: Nikki Robinson, Acting Deputy Ombudsman (Research, Strategy and Corporate Services)

[1] Evaluation: the icing on the cake? – Civil Service (