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.

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

6,470 records
Name Establishment Cause Status Date of death Recs
Kian Parmee HMP Swansea Pending inquest
Martin Ramus HMP Exeter Pending inquest
James Goulding HMP Featherstone Pending inquest
Charlie Leat HMP Exeter In progress
Paul Withnell HMP/YOI Parc In progress
Scarlet Witch HMP Send Pending inquest
Quomars Haghighi HMP The Mount Pending inquest
Brian White HMP Featherstone Pending inquest
Bernard Grainger HMP Hull In progress
Christopher Sanderson HMP Hull In progress
Aaron House HMP Cookham Wood In progress
Kenneth Grubb HMP Five Wells In progress
Marlon Kelly HMP Swaleside Pending inquest
Shareen Akhtar HMP/YOI Foston Hall In progress
Sidique Govinden HMP Wandsworth Pending inquest
Daniel Alexander HMP Long Lartin Pending inquest
George Hall HMP Littlehey Pending inquest
Ahmed Said HMP Wandsworth In progress
Mason King HMP Channings Wood In progress
Michael Maharaj HMP Brixton Pending inquest
Barry Kelly HMP Kirklevington Grange In progress
Paul Pickerill HMP Garth Pending inquest
Charles Stevens HMP Swaleside Other Published 2
Paul Hoskins HMP Bedford In progress
Steven Cleverley HMP The Verne In progress
Victor Fisher HMP Stoke Heath In progress
Michael Shilton HMP Stafford Natural Published
David Baxendale HMP Frankland In progress
Takauda Zinyoro HMP Stocken Pending inquest
Luke Kelsall HMP/YOI Portland Pending inquest
Jason Hayward HMP Birmingham In progress
Anthony Chetham HMP Millsike Pending inquest
Dalton Barnett HMP Holme House Pending inquest
McCauley Doran HMP Brinsford Pending inquest
Alfred Davies HMP Usk In progress
Dean Taylor HMP Stoke Heath Pending inquest
Matthew Bouldin HMP Fosse Way In progress
James Glendenning HMP Manchester Pending inquest
Wesley Martin HMP Lincoln Pending inquest
Laura Sharman HMP/YOI Drake Hall In progress
Michael Walls HMP Humber Pending inquest
Andrew Eggington HMP Altcourse Pending inquest
Roger Robinson Guernsey Prison In progress
Paul Charmley HMP Altcourse In progress
Quang Nguyen HMP Thameside Pending inquest
Darren Salituri Guernsey Prison In progress
Jordan Tams HMP Deerbolt In progress
Simon Dunn HMP Garth Self-inflicted Published 4
Stephen Hughes HMP Northumberland In progress
Viktors Dembovskis HMP Frankland Pending inquest