The inevitable presence, challenges and opportunities of blame in Prisons and Probation Ombudsman self-inflicted death investigations

Prisoner deaths are significantly increasing in England and Wales. The Prisons and Probation Ombudsman investigates circumstances around self-inflicted deaths, including how a prisoner’s risks have been managed. Our empirical study demonstrates that the ombudsman’s approach inadvertently and inevitably contains blame: negative affects, emotions and judgements combined with the attribution of responsibility. Investigations usually fail as prison staff fear and withdraw, anticipating the transfer of blame between the ombudsman and other investigative mechanisms (e.g. inquests). Ombudsman and prison staff also contest analyses of a death (e.g. individual staff performance vs complex prison conditions), so frustration and tension escalate between the ombudsman and prison staff. We innovatively conceptualise the ombudsman’s approach as a blaming assemblage that combines opportunities and challenges. Consequently, we defy the standard call for discrete and ostensibly ‘blame-free’ accountability and learning mechanisms, instead suggesting how the Prisons and Probation Ombudsman could more productively name blame and engage with accountability and learning.