to investigate the
Secure Training Centres)
Residents of Approved Premises (including voluntary residents)
Residents of Immigration Reception and Removal Centres, short term holding
centres and persons under managed escort.
People in court premises or accommodation who have been sentenced or
(for example under escort, at court or in hospital). It also includes those on Release
on Temporary Licence.
care provided by the relevant Service, including those recently released from
independent of the National Offender Management Service (covering Prisons and
Probation Services), Youth Justice Board and Home Office. As part of the PPO
investigation, clinical issues relevant to any death in custody are required to be
healthcare services in all prisons (and shortly all immigration facilities) in England. A
death in custody is regarded as a Serious Incident (SI) in line with similar incidents in
relation to community NHS funded services, and as such should be subject to an
will take the lead
England the local Area Team (or equivalent) in respect of all prisons and
investigation of the clinical care provided, including whether referrals to secondary
healthcare were made appropriately. By agreement, Healthcare Inspectorate Wales
(HIW) will review the clinical care provided to those who die in the custody of prisons
based in Wales. In both cases the clinical review will form part of the PPO
investigation and subsequent PPO report.
so long as this is carried out by a clinician who is not involved in, or responsible for,
the commissioning or provision of the healthcare service where the death occurred.
This ensures objectivity and independence, a PPO requirement. However a clinical
For the purposes of clinical review, the following NHS definition of a Serious Incident
The Ombudsman’s full Fatal Incidents remit is available www.ppo.gov.uk
‘A serious incident requiring investigation is defined as an incident that occurred
death of one or more patients’
In addition, the PPO also investigates deaths by natural causes, which are also
subject to a clinical review.
1.9 This document covers the clinical review commissioning arrangements for deaths that
Young Offender Institutions
Secure Training Centres
Immigration Reception and Removal Centres
Court premises (when the deceased has been remanded or sentenced into
Persons released on temporary licence are also included.
their own healthcare and usually register with a General Practitioner. However on
occasions, there may be particular clinical concerns that require a clinical review. In
such cases the Area Team (or equivalent) will be asked to provide a clinical review.
mail usually within 1 working day of receiving the notification. This will include
contact details of the PPO investigator. The Area Team should commission the
review within 5 working days of the request and inform the PPO investigator of the
name and contact details of the reviewer.
The final clinical review should be received
environment in which the offender/detainee was held, will be responsible for
commissioning the clinical review.
(SI) reporting process and the NHS Strategic Executive Information System (STEIS)
will be used.
records to assist the clinical reviewer. Suggesting wording is attached to this
guidance at Annex B.
The relevant NHS Area Team should arrange for the prison healthcare records to be
provided to the clinical reviewer. The PPO will arrange for any other relevant records
from the establishment concerned to be provided to the clinical reviewer (this will
include any ACCT documents in the event of a self-inflicted death).
Level 1 - Single clinical reviewer - Desk based review of records and report
at the establishment and report
healthcare staff and others as appropriate – complex case with multi-disciplinary
The level of review must be agreed (within five days of the appointment of the
default position. The level of review must be documented with the reasons for that
level. On occasions, evidence may come to light that requires the level of review to
be reconsidered – in such cases the PPO investigator
clinical reviewer and
the main area to be covered by the review
An appropriately qualified multi-disciplinary review panel (members should
specialists relevant to the death, PPO investigator, Governor or prison
representative, lay person).
reviewer must not be involved in, or responsible for, the commissioning or provision
of the healthcare service where the death in custody occurred. (Clinical reviews
through a private contractor may be commissioned but the cost will be borne by the
the PPO investigator, before commencing any work, to agree parameters of the
investigation and to discuss any interviews which should be conducted jointly with the
PPO investigator. The PPO has a preference for joint interviews, which give a
greater understanding and clearer picture of the care received across disciplines. In
addition the PPO record and provide transcripts of all interviews. Clearly recorded
interviews are a Coroner’s requirement.
The clinical reviewer should be the lead interviewer for any interviews with healthcare
staff. There is no expectation the clinical reviewer attends any other interviews,
however the investigator may ask for the clinical reviewer to attend relevant
interviews (for example where a member of prison staff has attempted resuscitation).
gain access to relevant NHS records (see para 2.5) and key health professionals
who are relevant to the investigation.
resources, including administrative support, necessary to enable them to carry out
and complete the review within the agreed timetable.
100 working days (20 weeks) and the draft report of any other death within 130
working days (26 weeks). To allow clinical matters to be fully integrated into the PPO
report, the finalised clinical review report should be with the PPO investigator within
weeks) for other deaths, of the initial correspondence from the PPO.
equivalent) for quality assurance with 35 working days (7 weeks) for natural causes
deaths and 45 working days (9 weeks) for other deaths. At this time it should be
copied to the PPO investigator to ensure it meets the needs of the investigation. The
PPO investigator will give feedback with 5 working days.
to the clinical reviewer within 10 working days to allow any changes to be made prior
to sending the final report to the PPO investigator. NB: It is not necessary to redact
or anonymise the clinical review report. The PPO investigation report will name any
individual pertinent to the case, this will include healthcare staff. The PPO report is
anonymised before being made public and the clinical review report is not made
there are matters which require further exploration, clarification or correction. Ideally
this will be within 30 working days of receipt of the final clinical review report.
However Area Teams (or equivalent) should note that issues of clarification
sometimes arise following the consultation period (see para
The commissioner is responsible for putting the incident onto STEIS
All requests from the PPO to be logged.
Identify the commissioner of the clinical review and send out the template, written
Receive copy of draft report (35/45 days) for quality assurance at appropriate
Return the draft (with 10 working days) to the reviewer with
Receive the final report and collate the recommendations – send final report to
Recommendations and any learning to be shared at the Strategic Safer Custody
a) The PPO investigator writes a draft report including the clinical issues and
b) The draft report is issued to the family (who have up to a maximum of 8 weeks to
feed back) and the service (who have 4 weeks to feed back). In addition the
Area Team (or equivalent and clinical reviewer receive a full copy of the draft
c) The service and healthcare provider are asked to provide an action plan in
response to any recommendations.
d) More questions may be asked, and occasionally it may be necessary for
further investigation to take place, which may include clinical matters.
e) The report is finalised, including the response to any recommendations, and is
used by the Coroner to prepare for the inquest.
f) Both the PPO investigator and clinical reviewer may be called to give evidence at
g) After the inquest, the annexes (including the clinical review report) are removed
from the PPO report – the PPO report is anonymised and published on the PPO
NOTE: At the consultation stage (b) advanced disclosure is made if an individual member of
staff is criticised (see para 2.19 below).
If the final report (e) goes on to make serious
are implemented, and may in extreme cases, recommend referral to the appropriate
regulatory body. The Area Team (or equivalent) should undertake such a referral.
disclosure to all parties to the investigation. However from time to time, specific and
substantial criticisms are made of individuals in the draft report. In these cases the
draft report will be advanced disclosed to the service in remit. The purpose of this is
to allow the individual who has been criticised the opportunity to check that their
actions and accounts are described accurately.
and applies to both the PPO investigation report and the clinical
and learning lessons on how things should be improved. All establishments and
Area Teams (or equivalent bodies) should have processes in place for making sure
that lessons are learned, recommendations are implemented and improvements are
recommendations and any learning from the clinical review with partner
organisations. This should be achieved through a Safer Custody Forum or similar
regular meeting of partners.
this information should be passed to the Area Team (or equivalent body) and the
establishment without delay, so that appropriate action may be taken promptly.
through NOMs (Equality, Decency and Rights Group) and Department of Health
be submitted to the PPO six months after the release of the final PPO investigation
report. This is co-ordinated by NOMS Equality, Decency and Rights Group (EDRG).
PPO support team (on behalf of investigator) will contact Area Team (or equivalent)
Commissioning Officer to inform investigator of clinical reviewer within 5 working days.
If investigator has not been informed of clinical reviewer within 5 working days, they will e
mail a reminder to the Commissioning Officer, copying to the Assistant Ombudsman.
– after a further 5 working days, if a reviewer has not been identified, the
Assistant Ombudsman will e mail the Commissioning Officer reminding them of the
timescales involved and their responsibility to commission the review.
– if a clinical reviewer has not been appointed within 3 working weeks of the
original commissioning letter, the Deputy Ombudsman will write to the National
Commissioning Board to raise the concern that the review is unlikely to be completed and
the final report available to the Prisons and Probation Ombudsman within the agreed
timescale of 10 working weeks.
Re: Investigation into the circumstances surrounding the death of (enter name) while
The Prisons and Probation Ombudsman is investigating the death of the above named
integral part of the process.
The clinical care is reviewed under the Ombudsman’s Terms of Reference, by an
panel. This review is commissioned by the Area Team (or equivalent).
In order to complete a thorough and reasoned review, the clinical reviewer requires access
made available through the Ombudsman’s unfettered access to all records within the
service. Similarly records held in the community should be released to the NHS Area
Team/Clinical reviewer. The Ombudman’s terms of reference state:
“The Head of the relevant authority (or the Secretary of State for Justice, Home
appropriate) will ensure that the Ombudsman has unfettered access to the relevant
documents. This includes classified material and information entrusted to that
authority by other organisations, provided this is solely for the purpose of
investigations within the Ombudsman’s Terms of Reference.”
The health records of a deceased person can lawfully be disclosed to the PPO, as such
means there is no breach of confidence.
Please would you release the medical records of (insert name of deceased) with immediate
Thank you for your co-operation.