Because states must rebut the presumption of responsibility, all prisoner deaths must be investigated. These investigations frequently illustrate the tip of an iceberg of rights abuses and systemic hazards but have largely escaped analysis in prison-monitoring scholarship. Focusing on suicides, we assemble some of the first evidence illustrating how the staff of the Prisons and Probation Ombudsman, who investigate prisoner deaths in England and Wales, seek to prevent further deaths. Ombudsman investigations are widely regarded as ineffective, yet there are competing constructions regarding why this is and what could be done to improve outcomes. As a result of organizational norms and constraints, ombudsman staff have offered narrow accounts of prisoner suicides, focusing on the failure of frontline staff to comply with prison policies. By contrast, prison staff and coroners have focused on systemic hazards or “accidents waiting to happen,” including imprisoning people with severe mental illness, illegal drugs, unsafe facilities, and inadequate staffing. These differing constructions lock penal actors into an unproductive cycle of blame shifting that contributes to high suicide numbers. We reconceptualize prisoner deaths as occurring at the intersection of systemic hazards, organizational contexts, and individual errors. We hope that this reconceptualization facilitates broader investigations that are more likely to prevent prisoner deaths.

中文翻译：

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（重新）构建囚犯死亡调查：英格兰和威尔士自杀调查案例研究

由于各国必须反驳责任推定，因此必须对所有囚犯死亡进行调查。这些调查经常揭示侵犯权利和系统性危害的冰山一角，但在很大程度上逃脱了监狱监控学术界的分析。我们以自杀为重点，收集了一些初步证据，说明负责调查英格兰和威尔士囚犯死亡的监狱和缓刑监察员的工作人员如何努力防止更多死亡。人们普遍认为监察员调查是无效的，但对于其原因以及如何改善结果存在相互竞争的解释。由于组织规范和限制，监察员工作人员对囚犯自杀事件的描述很狭隘，重点关注一线工作人员未能遵守监狱政策。相比之下，监狱工作人员和验尸官则关注系统性危害或“即将发生的事故”，包括监禁患有严重精神疾病的人、非法毒品、不安全的设施和人员配备不足。这些不同的结构使刑事行为者陷入了一种无益的指责循环，从而导致了高自杀率。我们将囚犯死亡重新概念化为系统性危害、组织环境和个人错误的交叉点。我们希望这种重新概念化能够促进更广泛的调查，更有可能防止囚犯死亡。