Death in Custody Clinical Review Service

Spectrum’s Death in Custody Clinical Review Service is the only service of its kind in the UK. We are commissioned by NHS England to carry out independent clinical reviews for all deaths occurring in prisons and detention centres, in:

  • Yorkshire and the Humber
  • North East
  • North West
  • East of England


When a person dies in custody in England, the Prisons and Probation Ombudsman (PPO) has a legal obligation to investigate the circumstances surrounding the death. The investigation looks to answer some key questions, such as:

  • How and when did the person die?
  • What was the root cause of death?
  • What clinical care was provided to them, and was it equitable to that which they might receive in the community?
  • Were local and national policies and procedures followed?
  • Are there any learning opportunities?

To answer these questions, it is important to understand the healthcare the person received in the period leading up to their death.

Independent clinical reviews

Spectrum’s Death in Custody Clinical Review Service supports the PPO investigation by coordinating and managing all aspects of the clinical review process.

By analysing healthcare records, reports, statements and sometimes interviews, the clinical reviewers investigate the clinical care provided to the deceased person. A chronology of healthcare events leading up to the death is created.

The reviewers also:

  • look at local policies and practices
  • consider and note any instances where care might have fallen below standard
  • consider where learning could be shared
  • make recommendations for the healthcare service, based on the findings of the clinical review

Sharing learning and best practice

Spectrum shares learning from our death in custody clinical reviews with our NHS partners and across our health and justice networks.
In addition to our current service, we have previously been approached to support reviews for:

  • The Learning Disabilities Mortality Review (LeDeR) Programme, which investigates the deaths of people with learning disabilities
  • Independent Root Cause Analysis (RCA) investigations for Serious Incidents


If you would like to learn more about Spectrum’s Death in Custody Clinical Review Service, or to request support with clinical reviews, please get in touch.