Report of the independent review of deaths and serious incidents in police custody. 2017. (accessed 3 March 2021)

Inquest. Death in prison: a national scandal. 2020. (accessed 3 March 2021)

Prisons and Probation Ombudsman. Annual report 2019/20. 2020. (accessed 3 March 2021)

United Nations Office on Drugs and Crime. The United Nations standard minimum rules for the treatment of prisoners (the Nelson Mandela rules). 2015. (accessed 3 March 2021)

A failure of care in custody

11 March 2021
Volume 30 · Issue 5

In 2017 an independent review into deaths and serious incidents in custody was published, with calls for reform of the police, justice system and health service (Angiolini, 2017). Although 110 recommendations were made, there has been little progress in implementing them.

The recommendations focused on improving the way the police and health authorities in England and Wales manage and care for vulnerable people. One key finding that emerged is the failure to learn lessons and to properly consider and implement recommendations and advice from previous reports and studies (Angiolini, 2017). Four years on, it would appear that little learning has taken place, the key recommendations have not been acted upon.

The Prisons and Probation Ombudsman (PPO) is an operationally impartial office. The PPO reports on facilities provided by Her Majesty's Prison and Probation Service (HMPPS), the National Probation Service for England and Wales and other detention and justice services. In 2019-2020 the PPO investigated 311 deaths, including 176 from natural causes (61% occurring in men over the age of 60 years dying of circulatory or respiratory problems or cancer); 83 self-inflicted deaths, two apparent homicides and 31 other non-natural deaths. There were also 17 deaths of residents living in probation-approved premises, and one death of a resident of the immigration removal estate (PPO, 2020).

Register now to continue reading

Thank you for visiting British Journal of Nursing and reading some of our peer-reviewed resources for nurses. To read more, please register today. You’ll enjoy the following great benefits:

What's included

  • Limited access to clinical or professional articles

  • Unlimited access to the latest news, blogs and video content