Death in custody reviews

We contribute to death in custody investigations by undertaking a clinical review

The Prisons and Probation Ombudsman (PPO) is required to undertake an investigation of every death that occurs in a prison setting. 

We contribute to these investigations by undertaking a clinical review for all deaths within a Welsh Prison or Approved Premises. This arrangement is defined within a Memorandum of Understanding between the PPO and HIW.

These reviews critically examine the systems, processes and quality of healthcare services provided to prisoners during their time within prison or Approved Premises.

Such reviews take into consideration issues including, but not limited to:

  • How and when did the prisoner die?
  • Is there any root cause(s) of the death?
  • Was the clinical care equitable with the wider community?
  • Are there any learning opportunities?
  • Were local and national policies and procedures (both prison and NHS) followed?
  • Is there an opportunity to prevent future deaths in similar circumstances?
  • Are there any examples of good practice?
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