Death in Prison Custody- A Clinical Review Series

When a person dies in prison custody the Prison and Probation Ombudsman (PPO) will investigate that person’s death, irrespective of how they died. It might be a natural cause death, a self-inflicted death, substance misuse death or other non-natural deaths (such as homicide). 

The PPO independently investigates deaths in prison custody in England and Wales, and they will request NHS England (NHSE) or Health Inspectorate of Wales (HIW) to commission an independent clinical review that forms part of the PPO investigation.

A PPO Investigator will lead on the investigation from a prison perspective, and a Clinical Reviewer is appointed to lead on the investigation from a healthcare perspective. The overall objective of a clinical review is to determine whether the healthcare the person received in prison was equivalent to what they would have received in the community, but the process also allows to identify good practice and any areas for learning to improve clinical care provided within a prison setting. 

There are three potential levels of a clinical review:

1. Level one - which is typically a desktop review of the records, conversations with interested parties (primarily the healthcare provider within the prison) and the PPO Investigator, producing an overall clinical review report.
2. Level two - includes all of those elements but will also include formal interviews which are conducted jointly by the PPO Investigator and the Clinical Reviewer.
3. Level three - a more complex review which includes the above methodology, but the findings are brought together and analysed by a multidisciplinary panel.

Hill Dickinson is one of the leading lawyers providing legal advice and support to national and international healthcare organisations. We have a wealth of knowledge and experience in handling complex cases involving NHS and Public Health authorities and the health and justice system. 

Our legal expertise spans across multiple NHS and public health sectors from mental health and social care, mental capacity, clinical negligence to inquiries and investigations. 

This article was co-authored by Lorna Warriner, RMN, Clinical Reviewer, on behalf of NHSE and HIW. 

This article is part 1 in a series of pieces on clinical reviews in death in prison custody inquests. Part 2 is here.