After a death in custody

 When someone dies in custody it can have a significant impact on those around them and may leave questions about what happens next. In this article, we focus on what happens after a death in prison, what investigations take place, how you can feed your concerns into the process if you want to, and how to get support if you need it. This information is set out in the Follow-up to Deaths in Custody Policy Framework. 

If someone dies in custody, it triggers several investigations:

• prisons must carry out an Early Learning Review (ELR) in cases of apparently self-inflicted death or unexpected death, to identify immediate learning. 
• police will gather facts about the death on behalf of the coroner and, if necessary, undertake a criminal investigation.
• the Prisons and Probation Ombudsman, and his or her staff – known collectively as the PPO – investigate all deaths in custody, regardless of cause. The PPO are independent of the prison service. They investigate the circumstances of the death and produce a report setting out their findings, with recommendations for any actions required to mitigate the risk of further deaths.
• a coroner’s inquest will take place. This is a public hearing, sometimes with a jury, where an independent coroner looks at the facts of a death to understand who died, when and where they died, and how it happened. It does not involve deciding blame or guilt.

Prisons must cooperate fully with all these investigations. This includes facilitating access for investigators, providing relevant documents, and enabling interviews with prisoners and staff.

Shortly after the death, the prison should display a notice about the PPO investigation around the prison, inviting anyone with relevant information to contact the PPO directly. The PPO investigator may then ask to interview you. They may also want to interview people who knew the prisoner who died, and those living in cells close by. You should not face any negative consequences for speaking to the PPO.

If you have an interview with the PPO, it will normally take place within sight, but out of the hearing of staff, unless you or the PPO, request that it takes place within hearing. You may be allowed to have a friend or adviser present, so long as that person would normally be allowed to visit you. The PPO will normally provide a written summary of the interview to any prisoner interviewed. If the PPO wishes to speak to you by telephone, they will contact the prison to arrange this. You must not lose pay as a result of an interview or telephone conversation that takes place at the request of the PPO.

If you think you have important information to share with the PPO after someone has died in custody you can do so. You can write to them for free at: 

Prisons and Probation Ombudsman, Third Floor, 10 South Colonnade, London, E14 4PU.

The coroner may also decide to call a prisoner as a witness to the inquest. Prisons are required to facilitate this so that the evidence can be heard in the most appropriate way. 

Prisons must have procedures in place to support prisoners who have been affected by a death in custody. Appropriate care and support must be offered to the cellmate and any other prisoners affected by the death. This includes allowing Listeners to offer support to prisoners on the wing where an unexpected death has occurred and to others who may have been connected to the person who died. 

The policy states that local Samaritans staff must be able to see the Listener team as soon as possible after a death. If a Listener is asked to see the police, Coroner’s Officer, or an investigating officer after a death, Samaritans staff must be given the opportunity to be present at the interview.

If you feel that you have been affected by a death in custody and need support, it is worth speaking to someone about this. You could also speak to:

• prison staff, such as staff on your wing or a keyworker
• staff from the safer custody team
• healthcare staff
• chaplaincy
• a Listener

Mouldy wing

 HMP Exeter is a remand prison with one wing closed for renovations. D-wing is for security-vetted prisoners because of cell doors being unlocked as there are communal toilets. Over a year ago, engineers managed to somehow block the air-conditioning ventilation system for the wing.

Now there is no airflow, and as our wing is on the outside wall, our windows do not open. As a consequence our cells are constantly mouldy due to condensation. A governor came to have a look and said “It just needs a cleaner who is over 6-foot tall to wipe the mould off the walls every couple of days with warm soapy water.”

Meanwhile, the lads who have asthma, lung problems and COPD are stuck on remand in conditions that the lady from the IMB called “slums” and “a disgrace”. Only one prisoner on this wing is convicted, the rest of us are ‘innocent until proven guilty’.  The prisons are all overcrowded so there is no chance of transfer.

The attitude of staff and governors is ‘wipe it off and shut up’. I wonder if any of them would put up with this in their homes.

Deaths in prison at the highest level ever, according to Ministry of Justice Statistics

 A statistical bulletin, published by the Ministry of Justice, shows that 394 people in prison died in 2025 – a 15% increase on the previous year. They included 79 people who died in circumstances recorded as “self-inflicted”. The number of women who died rose sharply to 13, up from nine in 2024.

The total death toll in 2025 exceeds the previous high of 373 which was recorded in 2021, when prisons were effectively in lockdown during the Covid-19 pandemic.

However, there was a 4.3% drop in self-harm in prisons, with 74,521 incidents of self-harm in the 12 months to the end of September 2025. The rate of self-harm incidents fell by 3.2% in men’s prisons and fell by 2.8% in women’s prisons.

Over the same period, prisons recorded 31,555 assaults – a 6% rise on the figures for the previous 12 months. The rate of assaults was 83% higher in female establishments than in male establishments.

Commenting on these figures, Andrea Coomber KC (Hon.) Chief Executive of the Howard League for Penal Reform, said: “The dire state of our prisons is revealed starkly in today’s figures. When almost 400 people die behind bars in a single year, it is a national scandal, and it overshadows the otherwise encouraging slight decrease in the very high rates of self-harm. More needs to be done to reduce pressure on the prison population, and further action will save lives, protect staff, and help more people to move on from crime.”

Violence, overcrowding, self-harm: BBC goes inside one of Britain’s most dangerous prisons

Source: BBC

 There’s chaos in HMP Pentonville.

A piercing alarm alerts us to what prison officers describe as an “incident”. There’s a cacophony of slamming metal doors, keys jangling, and shouts and screams from inmates as officers race to see what’s happened. We run behind as they head to where the trouble is.

Cell doors and chipped painted white bars are just about the only scenery as we move through this chaotic and nerve-jangling environment.

A muffled walkie-talkie tells us it’s a case of self-harm. An inmate who’s been locked up for most of the day has carved “mum and dad” into his arm with a sharp object. A quick glance into the cell and the sight of blood. A prison officer crouches down, stemming the flow.

The BBC has been given rare access to HMP Pentonville men's prison in north London at a time of major crisis for jails in England and Wales.

Next week, with prisons across the country running out of cells for new inmates, the government will release some offenders early in a controversial scheme aimed at easing the overwhelming pressure on a system on the brink of collapse.

Over the course of two days inside Pentonville this week, we were confronted with the stark reality of this crisis.

The pressure on staff is immense. In just half a day, we hear six alarms. The day before there were more than 30. Prison officers don’t know what they’re running towards behind those locked and bolted doors. Blood, violence or even death are all possibilities.

Shay Dhury has been a prison officer here for almost five years and says she’s never seen it this bad. Recently, both her wrists were broken as she tried to separate two gang members during a fight. She believes gang-related crime is one of the main reasons there are so many people in prisons, especially Pentonville.

“They go for each other - and when two people go, other people go,” she says. “It ends up us just trying to stop the fight. It gets really messy sometimes - stressful, yeah.”

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HMP Pentonville was built in 1842 and is largely unchanged structurally in 180 years. Originally designed to hold 520 people in single cells, it now has an operational capacity of 1,205, with two prisoners packed into each cell.

The jail is dangerously close to capacity - with just nine beds remaining when we are there. And humans are not the only inmates here: mice and cockroaches are rife.

The government says Pentonville epitomises the challenges facing ageing, inner-city prisons with transient populations who have varied and complex needs.

More than 80% of Pentonville inmates are on remand, which means they are awaiting trial. The rest have been convicted of serious crimes including murder, rape, and drug offences.

Remand is at a 50-year high across England and Wales - and that’s partly down to a backlog in the criminal courts. Ministry of Justice (MoJ) figures show the Crown Court system has a backlog of more than 60,000 cases. The Magistrates Court has a backlog of more than 300,000 cases.

Tom - not his real name - is on remand. His cell is tiny. It’s around seven feet by six feet (2m x 1.8m) and has a pungent smell of urine, faeces, and rotten food. A bunk bed takes up most of the space. The toilet, in the corner beside the sink, is leaking and there are wet splashes on the floor.

“I've been telling them about that for three weeks,” Tom says. “I could fix it - I'm actually a plumber - but it had no washers in there.”

Overcrowding impacts all areas of life inside. With fewer officers to inmates, prisoners’ needs can’t always be met, which means some, like Tom, are living in cells that aren’t properly operational for several weeks when repairs are needed.

Michael Lewis is inside for drug offences. He’s 38 and has been in and out of jail for several years, but hopes this will be his last stint.

“It’s hard to rehabilitate yourself in a place where you've got gang violence, postcode wars, drug violence, money wars,” he says, highlighting how overstretched staff are.

“They're trying to do this, this, this and this - but now you want help as well? So it's hard.”

He tells me about the night he woke to find his former cellmate trying to hang himself.

“I could tell he wasn't dead because he was still breathing, he’s still warm,” Lewis says, describing the wait for a prison officer to come to help.

“He can't open the door on his own at night - keys and everything, security risk,” Lewis explains. “Waited for another staff member - and as soon as he came in he saw to him.

“He survived.”

'I would rather die'

I’ve been to several prisons and the situation at Pentonville is the worst I have seen.

The staff seem to be doing what they can in very difficult circumstances, fighting problems, crises, and violence - but they are often struggling to cope.

Sixteen people will be released from here next week when the government releases thousands of offenders early. The prison’s governor, Simon Drysdale, says that will alleviate some of the pressure and mean more people who’ve been sent to Pentonville - a reception prison serving all London courts - can be transferred on to other jails because they too will have more available cells.

“Our total focus is on making sure that we've got space and capacity,” Mr Drysdale says. “That takes up a large proportion of our thinking space and a lot of the staff's time, and because of that we don't get as much time as we would like to think about things like getting men into more meaningful work.”

But some Pentonville inmates are doubtful that 16 inmates being released from here will make a difference. One, who didn’t want to be filmed, speaks to us while crouched on the floor with his back against the wall.

“Nothing will ever change,” he says, sobbing.

“They don’t care about us. I would rather die.”