Prisons & Probation
Joint Report
No formal response
Avoidable Natural Deaths in Prison Custody: Putting Things Right
Joint report with the Royal College of Nursing examining avoidable natural deaths in prison custody. Contains 15 recommendations for improving healthcare provision and reducing preventable deaths.
15
Recommendations
15
Open
Government Response
No formal government response published. Recommendations informed the IAPDC-HMPPS agreement on reducing and preventing deaths in prison (July 2023). The IAPDC states the 2020 recommendations "still stand" as of 2025, suggesting limited implementation.
Recommendations (15)
Recommendation 1
Develop extended health information sharing, involving prisoners' families where possible, improving and sharing information in person escort records (PERS) and introducing prisoner 'medical passports' to facilitate a continuation of prescribing.
Recommendation 2
Implement clinical coding systems across prison healthcare departments to ensure standardisation of reporting and data transfer.
Recommendation 3
Implement a uniform comprehensive care pathway across prison healthcare that is evidence based and applies a joint approach across all agencies, departments and services.
Recommendation 4
Implement the Quality Outcomes Framework (QOF) across the prison estate, including employing administrators to update records and make summaries and Code diagnoses.
Recommendation 5
Overhaul secondary care referrals, including through developing: secondary care clinics in prisons in major specialities; an escort algorithm to prioritise outpatient visits and escorts; a contracted out service to conduct escorts as in the court service; a halt to, and clear policy guidance on, any unnecessary use of restraints; and a more comprehensive use of telemedicine where appropriate.
Recommendation 6
Conduct an in-depth review of the characteristics of natural deaths in women and BAME individuals and make specific amendments where appropriate.
Recommendation 7
Develop a joint health and justice older persons strategy for the criminal justice system. This should be integrated with local social care plans and provision.
Recommendation 8
Develop a dementia care pathway across the prison estate including making all prisons dementia friendly, with clear signage, well-lit areas preferably with as much natural light as possible, and consistently plain and levelled flooring.
Recommendation 9
Reassess the policy on Do Not Resuscitate decisions and their use within the prison healthcare system to make clear at what time and in which situations it is appropriate to administer CPR.
Recommendation 10
Review and overhaul the process of compassionate release from custody to make sure that it is clear, transparent, timely and fair.
Recommendation 11
Review the application of the Care Act in prisons and for people on release from custody with a view to establishing minimum standards, sharing good practice and identifying poor or unacceptable performance under the Act.
Recommendation 12
Implement the 'Dying Well in Custody' charter across prisons to maintain dignity, better support families and deliver uniform palliative care.
Recommendation 13
Encourage student placements and rotational training schemes across disciplines. Streamline security clearance arrangements. Develop a forensic training academy and skills lab. Establish prison medicine as a sub-speciality.
Recommendation 14
Convene regular standing meetings between the Prison and Probation Ombudsman, the office of the Chief Coroner, prison governors and healthcare managers to consider often repeated recommendations with solutions found and actioned. Create a national oversight mechanism to monitor deaths in custody, specifically the implementation of official recommendations arising from post death investigations.
Recommendation 15
Improve standards of post-death investigations so that failures are identified and changes made. Ensure that non self-inflicted deaths are fully investigated by independent specialists.