Source · Deaths in custody

PPO Fatal Incident Reports

6,470 incidents 5,745 published 1,502 recommendations 1,653 self-inflicted 3,404 natural causes

Deaths in custody investigated by the Prisons and Probation Ombudsman. 26% of deaths are self-inflicted. Source: PPO.

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Learning & thematic publications

75 cross-establishment publications

Learning Lessons Bulletins (50), thematic reviews (2), consultation responses (11), Policy into Practice (5) and annual reports (7): the systemic patterns the Ombudsman draws from many investigations.

TitleTypeDateSource
Annual Report 2025 to 2026 Annual report Jul 2026 PDF
PPO response to JSC Inquiry into Children and Young Adults in the Secure Estate  Consultation response Jun 2026 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 21: Segregation Learning Lessons Bulletin Mar 2026 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 22: Self-inflicted deaths in reception prisons Learning Lessons Bulletin Mar 2026 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 20: Epilepsy Learning Lessons Bulletin Nov 2025 PDF
Annual Report 2024 to 2025 Annual report Jul 2025 PDF
Policy into Practice: Handling of prisoners’ property Policy into Practice Mar 2025 PDF
Policy into Practice: Handling of property complaints Policy into Practice Mar 2025 PDF
Complaints Investigations Learning Lessons Bulletin Issue 11: Property complaints Learning Lessons Bulletin Mar 2025 PDF
PPO response to JSC inquiry into Rehabilitation and Resettlement Consultation response Feb 2025 PDF
PPO response to JHAC Inquiry into Prison Culture Consultation response Feb 2025 PDF
PPO response to JSC Tackling Drugs in Prison Inquiry Consultation response Feb 2025 PDF
Policy into Practice: Emergency Response Policy into Practice Jan 2025 PDF
PPO response to the Independent Sentencing Review 2024/25 call for evidence Consultation response Jan 2025 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 19: Post-release death investigations 2 Learning Lessons Bulletin Jul 2024 PDF
Annual report 2022-23 Annual report Jul 2024 PDF
Annual Report 2023-24 Annual report Jul 2024 PDF
Policy into practice: Use of force Policy into Practice Feb 2024 PDF
PPO response to the inquiry into prison population and capacity Consultation response Nov 2023 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 18: Self-inflicted deaths of IPP prisoners Learning Lessons Bulletin Sep 2023 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 17: Post-release death investigations Learning Lessons Bulletin Jan 2023 PDF
Investigating deaths after release from prison – a pilot evaluation Learning Lessons Bulletin Jan 2023 PDF
PPO response to the inquiry into the Prison Operational Workforce Consultation response Jan 2023 PDF
Annual Report 2021-22 Annual report Oct 2022 PDF
Policy into Practice: Use of restraints on escort Policy into Practice Sep 2022 PDF
PPO Response to the Inquiry into IPP sentences Consultation response Jan 2022 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 16: Second wave COVID-19 related deaths Learning Lessons Bulletin Dec 2021 PDF
Annual Report 2020-21 Annual report Sep 2021 PDF
PPO responses to the Inquiry into Women in Prison Consultation response Aug 2021 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 15: COVID-19 PPO fatal incident investigations Learning Lessons Bulletin Feb 2021 PDF

Incidents

94 records
Name Establishment Cause Status Date of death Recs
Samuel Omar HMP Stafford Natural Published 3
Lee Chignell HMP Peterborough Other Published 1
Andrew Clark HMP Norwich Natural Published 2
Georgie Smith HMP Bristol Self-inflicted Published 3
Hallum Elgood HMP Norwich Self-inflicted Published 2
Peter Hopkins HMP/YOI Doncaster Natural Published 4
Colin Storr HMP Durham Self-inflicted Published 4
Uziel Mendoza-Sillerico HMP Lowdham Grange Natural Published 10
Jake O’Brien HMP Forest Bank Self-inflicted Published 12
Colin Bell HMP Stafford Natural Published 1
Kien Vuong HMP Leeds Self-inflicted Published 4
Leon Hughes Deer Park Approved Premises Other Published 1
Andrew Neal HMP Wayland Self-inflicted Published 5
Simon Gerrard HMP Isle of Wight Natural Published 1
Luke Ashcroft HMP Lincoln Self-inflicted Published 3
Frazer Williams HMP Guys Marsh Self-inflicted Published 9
Taylor Atkinson HMP/YOI Eastwood Park Self-inflicted Published 6
James Lawson HMP Channings Wood Self-inflicted Published 3
Michael Quinn HMP Berwyn Natural Published 6
Benjamin Harrison HMP Rochester Other Published 5
Lionel Newbon HMP Frankland Natural Published 9 Nov 2024 1
Brian Acott HMP Lewes Natural Published 17 Sep 2024 2
Colin Harding HMP Stafford Natural Published 3 Aug 2024 2
Igor Vujkovic HMP Maidstone Natural Published 11 May 2024 4
Richard Cosgrove HMP Humber Other Published 18 Apr 2024 2
Mark Johnston HMP Swansea Other Published 7 Apr 2024 2
Barry Rossiter HMP Northumberland Natural Published 23 Mar 2024 2
Stuart Berry HMP Chelmsford Self-inflicted Published 1 Feb 2024 3
Patryk Gladysz HMP Wandsworth Self-inflicted Published 19 Jan 2024 3
Daniel Fielding HMP Liverpool Self-inflicted Published 19 Jan 2024 6
Kevin Noel HMP Leyhill Natural Published 18 Jan 2024 2
Darren Boamah HMP Wormwood Scrubs Natural Published 3 Jan 2024 2
Gavin Cox HMP Wymott Self-inflicted Published 14 Oct 2023 1
Muxsin Awjama HMP Nottingham Self-inflicted Published 5 Oct 2023 2
Filmon Brhane HMP Maidstone Self-inflicted Published 12 Jun 2023 8
Kirsten Hocking HMP/YOI Downview Other Published 24 May 2023 2
Dean Graham HMP Northumberland Natural Published 11 Apr 2023 3
Rolandas Karbauskas HMP Lowdham Grange Self-inflicted Published 25 Mar 2023 6
Shafaq Khan HMP Hindley Natural Published 28 Feb 2023 2
Roy King HMP Littlehey Self-inflicted Published 30 Jan 2023 5
Ian Deavall HMP Forest Bank Natural Published 24 Jan 2023 3
Curtis Cadman HMP Lincoln Natural Published 21 Nov 2022 2
Ewan Homer HMP Stafford Natural Published 6 Nov 2022 3
Colin Lovett HMP The Verne Self-inflicted Published 29 Oct 2022 4
John Warry HMP Stafford Natural Published 25 Sep 2022 10
Anthony O’Connell HMP Swaleside Self-inflicted Published 18 Sep 2022 9
Thomas Oleisky HMP Wealstun Self-inflicted Published 11 Sep 2022 5
Anthony Christian HMP Littlehey Natural Published 18 Aug 2022 1
Neil McKenna HMP Littlehey Natural Published 19 Jul 2022 2
Nathaniel Humphreys HMP Littlehey Self-inflicted Published 11 Jul 2022 2