The fate of people in prison who have died from COVID

Work with Offenders on today’s Prisons Ombudsman report

Sue McAllister, the Prisons and Probation Ombudsman (PPO), has published a ‘Learning Lessons Bulletin’ analysing investigations into 107 deaths of people in prison related to COVID-19. This is the second such analysis published by the Ombudsman, the deaths analysed in this bulletin occurred during the “second wave” of the virus last winter – between 8 October 2020 and 20 April 2021.

The Ombudsman has a duty to investigate every single death that occurs in prison and she acknowledges the terrible pressures on both prisoners and staff during the pandemic. The PPO says that her investigations “have continued to show the care and compassion that prisoners and their families and friends have received from prison and healthcare staff.” However she says that the PPO team also found cases where the correct procedures were not followed and the care was not good enough.

The people who died 

Of the 107 COVID-19 related deaths investigated by the PPO in the second wave, 106 were prisoners and 1 was a resident at a probation hostel (known as “Approved Premises”). 104 were men and 3 were women. The youngest was 36 years old and the oldest was 98 years old. The PPO was not able to ascertain how many of the people who died caught COVID in prison and how many in hospital. 

The PPO bulletin includes eight anonymised case studies including both good and poor practice. There were examples of people with COVID being Released on Temporary Licence which enabled them to remain in hospital without a prison escort.

Lessons learned by the Ombudsman included:

  • The importance of identifying and recording long-term medical conditions promptly – there were cases where people with illnesses which made them vulnerable to the virus were not advised to shield. (There were also examples of people who refused the advice to shield.)
  • The importance of regularly using the NEWS tool (National Early Warning Score) is a tool used to assess clinical deterioration in adult patients and the key way to tell whether someone needs hospitalisation).
  • The need to isolate people as soon as they say they are unwell. In some cases COVID test results were not properly recorded putting individuals and everyone they were in contact with at risk.
  • There were also cases where people with COVID symptoms were not regularly monitored by healthcare staff, meaning that there were delays in sending people to hospital to get possibly life-saving treatment.
  • In another case, the prison did not inform the next of kin of someone who was hospitalised with COVID until three days later, the day that he died.


There is one particularly sad case study when a 76 year old man was found dead in his cell some days after testing positive for COVID. He had clearly been dead for some hours as rigor mortis has already set in. This person was not checked by healthcare staff during the week after he tested positive. Although this was in line with healthcare policy at the time, the policy has been changed so that vulnerable people (through age, ethnicity or underlying health conditions) are identified and receive regular checks. It is hard not to be upset at the thought of a human being dying alone in his cell without the presence of any other person.

Another case which makes for very grim reading is the case of someone placed in handcuffs in hospital just 20 minutes before he died from COVID-19. Although this person had a history of hostage taking, he was clearly much too unwell to need, or suffer the indignity, of being handcuffed in a public hospital so close to his death.

As we all struggle with the renewed restrictions imposed by the omicron variant, we would do well to remember the plight of all the men and women in prison and do our best to contain the spread of this deadly virus.

Readers who would like to read the bulletin in full can find it here.