Source · Deaths in custody

PPO Fatal Incident Reports

6,395 incidents 5,660 published 1,165 recommendations 1,632 self-inflicted 3,362 natural causes

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

Clear

Learning & thematic publications

74 cross-establishment publications

Learning Lessons Bulletins (50), thematic reviews (2), consultation responses (11), Policy into Practice (5) and annual reports (6): the systemic patterns the Ombudsman draws from many investigations.

TitleTypeDateSource
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 Tackling Drugs in Prison Inquiry Consultation response Feb 2025 PDF
PPO response to JHAC Inquiry into Prison Culture Consultation response Feb 2025 PDF
PPO response to JSC inquiry into Rehabilitation and Resettlement 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 2023-24 Annual report Jul 2024 PDF
Annual report 2022-23 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
Investigating deaths after release from prison – a pilot evaluation Learning Lessons Bulletin Jan 2023 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 17: Post-release death investigations 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
Complaints Investigations Learning Lessons Bulletin Issue 10: COVID-19 PPO Complaints Learning Lessons Bulletin Dec 2020 PDF

Incidents

140 records
Name Establishment Cause Status Date of death Recs
Nigel Malt HMP Gartree Natural Published 29 Apr 2025 1
Peter Long HMP Oakwood Natural Published 10 Mar 2025 1
Glen Candler HMP Wakefield Natural Published 6 Mar 2025 1
Christopher Tatton HMP Rye Hill Natural Published 28 Feb 2025 1
Raymond Connor HMP Whatton Natural Published 22 Feb 2025 2
Timothy Frank HMP Ranby Natural Published 10 Feb 2025 2
Christopher Walton HMP Ranby Natural Published 6 Feb 2025 7
Lorna Carter HMP/YOI Styal Natural Published 27 Jan 2025 1
Brian Kemp HMP Fosse Way Natural Published 26 Jan 2025 3
Alan Hughes HMP Risley Natural Published 6 Jan 2025 2
Brian Hayes HMP/YOI High Down Natural Published 1 Jan 2025 1
Carl Forrester HMP Exeter Natural Published 13 Nov 2024 2
John Corran Isle of Man Natural Published 12 Nov 2024 1
John Freer HMP Northumberland Natural Published 29 Oct 2024 1
David Evans HMP Fosse Way Natural Published 26 Jul 2024 2
Phillip Sheridan HMP Full Sutton Natural Published 21 Jul 2024 2
Michelle Saunders HMP Littlehey Natural Published 9 Jul 2024 1
Raymond Paterson HMP Fosse Way Natural Published 1 Jul 2024 1
Peter Honnor HMP Wandsworth Natural Published 27 Jun 2024 4
John Chambers HMP Hull Natural Published 17 Jun 2024 1
Paul Dixon HMP Preston Natural Published 16 Jun 2024 1
Anthony Matthews HMP Hollesley Bay Natural Published 13 Jun 2024 2
David Baxter HMP Wealstun Natural Published 26 May 2024 5
Edward Lomas HMP Pentonville Self-inflicted Published 22 May 2024 4
Catherine Botwright HMP/YOI New Hall Natural Published 18 May 2024 1
Igor Vujkovic HMP Maidstone Natural Published 11 May 2024 4
Stephen Jones HMP Peterborough Natural Published 5 May 2024 3
Terrence Clover HMP Swaleside Natural Published 27 Feb 2024 1
Henry Bangs HMP Frankland Natural Published 2 Feb 2024 2
John Leadbitter HMP Hull Natural Published 31 Jan 2024 3
Gerard Browne HMP Wymott Natural Published 19 Jan 2024 3
Kevin Giles HMP Hollesley Bay Natural Published 13 Jan 2024 1
Frederick Williams HMP The Verne Natural Published 12 Jan 2024 2
Kim Chapman HMP Send Natural Published 6 Jan 2024 1
John Kelk HMP Wakefield Natural Published 30 Dec 2023 2
Azhar Hussain HMP Bedford Natural Published 27 Dec 2023 1
John Rigby HMP Wymott Natural Published 17 Dec 2023 4
Jamie Funnell HMP Lewes Other Published 16 Dec 2023 3
Sidney Hughes HMP Wymott Natural Published 24 Nov 2023 2
Solomon Bamidele HMP Pentonville Natural Published 16 Nov 2023 2
Roy Whitehouse HMP Oakwood Natural Published 21 Oct 2023 2
George Haslam HMP Wymott Natural Published 21 Oct 2023 1
Darren Barker HMP Peterborough Natural Published 12 Sep 2023 2
John Woodland HMP Frankland Natural Published 5 Sep 2023 3
Frank Salmon HMP Channings Wood Natural Published 6 Aug 2023 1
Daniel Rocks HMP Hull Natural Published 26 Jul 2023 1
Barry Wemyss HMP Northumberland Natural Published 17 Jul 2023 1
Anthony Kwan HMP Channings Wood Natural Published 8 Jul 2023 3
Lee Kenyon HMP Altcourse Self-inflicted Published 24 Jun 2023 2
Satish Kumar HMP Oakwood Natural Published 15 May 2023 1