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INQUEST is a charity that provides a free advice service to bereaved people on contentious deaths and their investigation with a particular focus on deaths in custody. Casework also informs our research, parliamentary, campaigning and policy work.

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The Prison Service should develop an information leaflet along the lines suggested, or require Governors to distribute the leaflet and Information Pack produced by INQUEST. — Stephen Shaw, former Prisons & Probation Ombusdman

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Section 5.2: Deaths in prison

This section gives you specific information about the investigation of deaths that occur in prison. You should read this section with the general sections in the guide.

What happens if my relative dies in prison?

You will be informed of the death by the Prison Service through a phone call or a visit to your home by a member of prison staff or a police officer. If it is not the prison who have informed you, they should give you details of a contact person at the prison for you to speak to. The prison should tell you where the body has been taken and that the death has been reported to the coroner, the police and the Prisons and Probation Ombudsman (PPO). They should also have given you a copy of this guide.

Who should I contact at the prison to find out more information?

The prison should appoint a senior member of staff, known as a family liaison officer (FLO), to be the family’s main point of contact in the prison. They should be able to explain what will happen and provide information about where to get further assistance. The named person should give you a factual account of the events leading up to the death and how your relative was discovered. There is a Prison Service Standing Order, called PSI 16/2011 (links to Word document), which details how you should be treated and the information that you should receive from the prison.

Will I be able to visit the prison and see where my relative died?

The prison should invite you to visit if you want to. You should be able to see the cell or other place where the person died. The prison may also arrange a memorial service in the prison which you can attend if you want.

How do I get my relative’s property back?

The coroner or the police will decide whether any property needs to be kept for evidence. The prison should release any cash or property not needed as evidence when the coroner authorises them to do so. Most items can be released at an early stage and the prison should contact you to let you know when you can recover the deceased’s belongings.

Unfortunately, personal items such as letters or other writings are usually needed as evidence. This sometimes means that the person a letter was written to may not be given it until quite some time after the death. The coroner may use their discretion to release a copy of any such letter earlier on to try to reduce any distress this may cause.

Will the Prison Service help with funeral costs?

Yes. There is a Prison Service Order that states that prisons should offer to pay “reasonable” funeral expenses or make a contribution if the family want to pay for something more expensive. The money will be paid direct to the funeral directors. If you or your partner receives benefits you may also be entitled to financial help – talk to your local JobCentre Plus advisor or go to the www.direct.gov.uk website. The prison may also offer to help with making the funeral arrangements and offer to attend the funeral if the family wish.

Will there always be an inquest?

Yes. The only exception is if there is also a criminal prosecution the coroner might decide that a separate inquest is not necessary. A criminal trial will not look at wider issues about how the prison cared for the deceased, just who was directly responsible for their death and so it might still be important for there to be an inquest.

You should probably seek advice from a solicitor about this. A death in prison is automatically referred to the coroner and to the Prisons and Probation Ombudsman (PPO) and the inquest will be held with a jury.

Should I contact INQUEST?

Yes, INQUEST is the only independent organisation that works with families following a death in prison and can provide advice and support throughout the whole process and with help in finding a solicitor who can assist you. We can help after any death in prison, whether it is self-inflicted or due to other non-natural causes such as restraint or homicide, or from natural causes where issues of care the deceased received in prison are raised.

INQUEST’s specialist advice service and its associated policy work means it can provide helpful background – for example information about other deaths in similar circumstances, relevant policies and practices on the care of people in prison, inquest verdicts, etc..

Will there be a post-mortem?

Yes, and it is usual practice that there is a post-mortem done almost immediately. This will be conducted by a Home Office registered pathologist. If you have any concerns about the physical cause of the death you may need to think about whether a further post-mortem should be carried out (see Section 2.2 on post-mortems). This is particularly important where the death followed the use of restraint, or concern about medical care or treatment.

Should I contact a solicitor?

In most cases, yes. It can really help you play a part in the inquest process. You should contact a solicitor who has experience of the law in relation to prisons and inquests as soon as possible. You should contact INQUEST who will either work with your solicitor to help if she or he has not dealt with a death in prison before, or put you in touch with a solicitor experienced in prison deaths.

Your solicitor should take a detailed statement from you about what you know about the circumstances of the death. If you have not been able to find a solicitor immediately, you should take a note of all the relevant information about the circumstances to help you in making a statement to your solicitor when you have one. Your solicitor should then request copies of the relevant documents such as the PPO’s report, and any records from the Treasury Solicitors who are responsible for legal preparation for inquests on behalf of the Prison Service.

What does the Prisons and Probation Ombudsman do?

Since 1 April 2004 the Prisons and Probation Ombudsman (PPO) has responsibility for investigating all deaths in prison, approved premises (formerly probation hostels), secure training centres, court cells and immigration and detention centres. The PPO is funded by the government, but is independent of all these agencies.

What investigations will take place?

At least two investigations take place – by the police and by the PPO. After someone has died in prison the police and the coroner will be informed and initial inquiries made. The police investigate every death in prison both on behalf of the coroner and to assess whether there are any suspicious circumstances. If the police decide there should be a criminal investigation this will happen before the PPO investigation. In these circumstances the police will appoint a family liaison officer to keep in contact with you.

What happens at the end of the police investigation?

The report and file will be passed to the Crown Prosecution Service (CPS) who will decide if criminal charges are to be brought, which is very rare. If it is decided not to prosecute anyone in relation to the death there will then be an inquest. The coroner will already have a copy of the report.

If the police do prosecute someone will there still be a PPO investigation?

Even if the police decide to charge someone with a criminal offence, there should still be an investigation by the PPO. This is because the PPO will look at whether or not the prison could have managed the situation better and whether future deaths can be prevented.

The coroner will also have to decide whether to hold an inquest. If the coroner decides that an inquest is not necessary, you should seek advice from INQUEST or your solicitor.

How does the PPO investigate a death in prison?

The PPO investigation is intended to establish the circumstances and events surrounding the death, particularly how the person who died was looked after while they were in custody. The Secretary of State sets terms of reference for the PPO and this is the starting point for their investigation plan. The investigator will have access to all the prisoner’s records, including medical records and any other documents they think are relevant. They will interview prison, healthcare and other staff and any prisoners who may have useful information.

The PPO will always get a clinical review of the person’s medical care while in prison. This review is usually carried out by the primary care trust that provides medical services for the particular prison. If the PPO finds out information which they think could lead to criminal charges, they can contact the police at any time. You can read about how the PPO investigates deaths in prison on their website.

What information will the PPO give me?

The PPO will appoint an investigator (sometimes a team of investigators) and a Family Liaison Officer (FLO) to keep you informed of what is happening with the investigation. The FLO should contact you within 15 working days and usually after the funeral. They will be your link with the PPO during the investigation. You will be given the opportunity to meet the FLO and the investigator early on to tell them any concerns you have about what has happened. Your solicitor and/or INQUEST caseworker may be able to attend this meeting with you. If you do not hear from the PPO within 15 days of the death, you should consider contacting them directly. When you contact them you should ask to speak to someone in the Fatal Incidents Investigation Team. The PPO contact details can be found on their website.

At the end of the investigation, the PPO will produce a draft report, explaining their findings, including whether the prison’s actions were appropriate and any recommendations to prevent deaths in the future. This draft report will be sent to the prison and family at the same time, unless advance disclosure to the prison is necessary. You are entitled to make comments and ask questions. If you have a solicitor they can help you to do this.

You will be given eight weeks to respond to the draft report and then the PPO will send their report with any changes to you or your solicitor, as well as to the coroner and to the prison. If you need more time to consider the report you should contact your Family Liaison Officer to let them know.

Who else will see the PPO report?

Before the inquest, anyone who the coroner has designated as a properly interested person will be given a copy of the report. After the inquest a final version of the report is put on the PPO website. All the names, including the name of the person who died, will be removed before it is published.

Can I use these documents for campaigning or talking to the media before the inquest?

No. You are given the documents on a confidential basis and they can only be used for preparing for the inquest. If you are in contact with INQUEST, you can give your solicitor permission to share the report with your caseworker and it will be treated with the same rules of confidentiality that apply to you and your solicitor. It is important not to disclose anything publicly which could be seen to influence the verdict at the inquest. If you are thinking about making a press statement it is wise to talk to your solicitor and INQUEST first.

Who else will be represented at the inquest?

It is usually the case that the Prison Service is legally represented, and sometimes individual prison officers through their trade union, the Prison Officers Association. If a prison doctor or nurse has been involved they may also be represented separately through the local NHS trust responsible for the delivery of prison health care.

After the inquest

See Section 4.4: After the inquest.

In addition you may want to raise concerns with:

You can discuss these options with your solicitor and INQUEST.

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