Get help now Make a donation

INQUEST report: Deaths of people following release from prison

This report was published in November 2019 because of concerns that more people were dying following release from prison.

The Ministry of Justice collects and publishes the number of people who die while under probation supervision every year. In 2018/19 ten people died each week following release from prison.

The suicide rate amongst people leaving prison in 2018/19 was 212 per 100,000 whilst the rate for prisoners is 83 per 100,000 and the suicide rate amongst the general population is 13.6 per 100,000.

The report highlighted that although men are more likely to die by suicide than women, whether in the prison or under probation supervision women are at a higher risk of self-inflicted death.

Worryingly, there is a lack of oversight. Probation must complete an internal review but research shows that this is not an investigation and there are gaps in the data. For example, the forms are often not updated after an inquest.

Normally when the state is involved, there will be an independent body that will investigate deaths for example, the Prison and Probation Ombudsman (PPO) and the Independent Office for Police Conduct. They will often be subject to an Article 2 inquest with a coroner who has the power to issue a "Prevention of Future Death" highlighting any failures and asking the relevant agencies to address them.

In 2018/19 out of 515 deaths, the Prison and Probation Ombudsman investigated only 12 of them who were residents living in probation approved premises.

The House of Commons Health and Social Care Committee looked at health and social care in English prisons. They were concerned that there isn't any form of investigation and follow-up when something happens to somebody on post-custody supervision.

The report made four recommendations:

  1. National review: The government should proceed with the "national review of deaths under post-release supervision with the aim of identifying what further actions may be appropriate to prevent such deaths" as committed to in its response to the Health and Social Care Committee.
  2. Data: More detailed and accurate data should be made available. This should include ethnicity and the time elapsed between release and death. There should be more accurate recorded data by probation providers which are kept up-to-date. There needs to be regular reporting to the Minister responsible and Parliament alongside the publication of an annual report.
  3. Investigations: Deaths of people on post custody supervision should be investigated by an independent body, for example the PPO, with adequate resources allocated to allow this to happen.
  4. Improve scrutiny and learning: The Government needs to confirm who has oversight at a local and national level. Probation providers could have their responsibilities strengthened and Her Majesty's Inspectorate of Probation could monitor deaths as part of its inspection activities.

The report can be found by clicking this link here.


England and Wales has the highest imprisonment rate in Western Europe and the prison population has risen by 77% in the last 30 years.

Mind has repeatedly raised concerns about the prison system and the negative impact that it has on people with mental health problems.

Unfortunately, there is no up to date reliable data on the prevalence of mental illness in prisons in England, there are other sources of information which suggest that the incidence of mental health problems is higher in prisons than it is in the community.

For example, a recent study of 469 male and female prisoners in English prisons found that:

  1. 66.7% of the prisoners screened positive for at least one type of mental disorder
  2. 47.5% of the prisoners screened positive for two of more types of mental disorder

It is well documented that demand for healthcare is high amongst prisoners yet they struggle to receive treatment and those that did were not satisfied with the care received.

When someone comes out of prison, it is a huge transition and it's important to get the right care and support to get their life back on track.

We have heard similar experiences from people when they have left hospital after a mental health crisis and have therefore launched our leaving hospital campaign which you can find out more about here.

It's really important that you're aware of your health and social care rights in the community so you can read our guide here.

Legal newsletter

Our legal newsletter provides a regular update on cases and policy in relation to mental health, mental capacity, discrimination and community care. To receive the newsletter by email please click the link below.


Other ways to get involved

arrow_upwardBack to Top