Contents
CHALLENGING TIMES 7
Quicker and better information to bereaved families and coroners 9
Improving our handling of complaints 10
Learning lessons 11
Enhancing independence 12
THE YEAR IN FIGURESChapter 13
Fatal incidents 14
Complaints 15
INVESTIGATING FATAL INCIDENTS 17
Learning lessons about fatal incidents 18
Individual investigations 19
Reception health screening 19
Checking prisoners at unlock 21
Emergency response 22
Diabetes care 23
Food refusal 25
Enhanced case reviews 26
Personality disorders 27
Emerging themes from homicide investigations 28
Family liaison 30
INVESTIGATING COMPLAINTS 33
Learning lessons about complaints 34
Individual complaints 35
Serious complaints 36
Links with the outside world 40
Property 41
Adjudications 42
Religious issues 44
Categorisation 44
Early release 45
Women and young offenders 45
Immigration detention 47
Probation 48
APPENDICES 49
Statistical tables 50
Prisons and Probation Ombudsman Financial data 60
Stakeholder feedback 61
Learning lessons publications 2012-13 63
Performance against business plan 64
Prisons and Probation Ombudsman Terms of Reference 71
Staff list 77