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.

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

6,395 records
Name Establishment Cause Status Date of death Recs
Gordon Suckley HMP Channings Wood Pending inquest
Amanda Fitzpatrick Edith Rigby House Approved Premises Other Published
Ryan Martin HMP Winchester Pending inquest
Anthony Copeland HMP Forest Bank Pending inquest
Adam Goulding Albion Street Approved Premises In progress
Tony Collins HMP Rochester Pending inquest
Lucal Brady HMP Isle of Wight Natural Published
Morgan Sullivan HMP Wandsworth Pending inquest
Shamraze Hussain HMP/YOI Doncaster In progress
Philip Walton HMP Stafford Natural Published
Richard Hunt HMP Stocken In progress
Paul Hoskins HMP Bedford In progress
Samuel Ross HMP Long Lartin Pending inquest
Ionica Profor HMP Belmarsh Pending inquest
Brian Wade HMP Long Lartin Pending inquest
Michael Jones HMP Liverpool Pending inquest
Peter Smith HMP Wayland Pending inquest
Paul Pickerill HMP Garth Pending inquest
Shareen Akhtar HMP/YOI Foston Hall In progress
Mohamed Bah HMP Elmley In progress
Kasey Rolfe HMP/YOI High Down Pending inquest
William Prince HMP Preston Pending inquest
Geoffrey Bradley HMP Elmley In progress
Joshua Price HMP Leeds In progress
Jamie Hammond HMP Bristol Pending inquest
Filmon Andmichaen HMP Full Sutton Pending inquest
Joe Lynch HMP Leeds Pending inquest
Solomon Loveridge HMP Onley Pending inquest
Dean Clementson HMP Forest Bank Pending inquest
Dirk Weissenbruch HMP Channings Wood Pending inquest
Darren Irving HMP Highpoint In progress
Raymond Noble HMP Leyhill Natural Published
Brian David HMP Channings Wood Pending inquest
Ifor Whittaker HMP Littlehey Pending inquest
Keiron Birks HMP Fosse Way Pending inquest
Ronald Carter HMP Durham Pending inquest
Maurice Mcentire HMP Swaleside Pending inquest
Alan May HMP/YOI Doncaster In progress
Norman Heaton HMP Full Sutton Pending inquest
Sidique Govinden HMP Wandsworth Pending inquest
Christopher Evans HMP Swansea In progress
Gavin Sever HMP Liverpool In progress
Ace Wilson HMP Leeds In progress
Robert Butler HMP Fosse Way In progress
Mark Jones HMP Oakwood In progress
John Digweed HMP Garth Pending inquest
Alan Priestley HMP Oakwood In progress
Shehroz Iqbal Joyce Meggie House Approved Premises In progress
Sean Sewell HMP Thameside In progress
Warren Arter HMP Wandsworth Pending inquest