Source · Deaths in custody

PPO Fatal Incident Reports

6,401 incidents 5,674 published 1,165 recommendations 1,633 self-inflicted 3,373 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 22: Self-inflicted deaths in reception prisons Learning Lessons Bulletin Mar 2026 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 21: Segregation 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 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
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

6,401 records
Name Establishment Cause Status Date of death Recs
Individual at Coldingley HMP Coldingley Natural Published 29 Apr 2011
Individual at Styal HMP Styal Natural Published 27 Apr 2011
Individual at Risley HMP Risley Self-inflicted Published 25 Apr 2011
Individual at Rye Hill HMP Rye Hill Natural Published 24 Apr 2011
Individual at Ozanam House Ozanam House Natural Published 24 Apr 2011
Individual at Wymott HMP Wymott Natural Published 22 Apr 2011
Individual at Doncaster HMP Doncaster Self-inflicted Published 22 Apr 2011
Individual at Preston HMP Preston Self-inflicted Published 22 Apr 2011
Individual at Wakefield HMP Wakefield Natural Published 19 Apr 2011
Individual at Wetherby HMP Wetherby Self-inflicted Published 18 Apr 2011
Individual at New Hall HMP New Hall Self-inflicted Published 17 Apr 2011
Individual at Sycamore Lodge Sycamore Lodge Self-inflicted Published 16 Apr 2011
Individual at Wymott HMP Wymott Self-inflicted Published 14 Apr 2011
Individual at Albion Street Albion Street Other Published 13 Apr 2011
Individual at Full Sutton HMP Full Sutton Natural Published 13 Apr 2011
Individual at Rye Hill HMP Rye Hill Other Published 7 Apr 2011
Individual at Leicester HMP Leicester Self-inflicted Published 6 Apr 2011
Individual at Wakefield HMP Wakefield Natural Published 4 Apr 2011
Individual at Altcourse HMP Altcourse Self-inflicted Published 4 Apr 2011
Individual at Shepton Mallet HMP Shepton Mallet Self-inflicted Published 3 Apr 2011
Individual at Risley HMP Risley Self-inflicted Published 2 Apr 2011
Individual at Stoke Heath HMP Stoke Heath Self-inflicted Published 2 Apr 2011
Individual at Downview HMP Downview Self-inflicted Published 30 Mar 2011
Individual at Holme House HMP Holme House Natural Published 30 Mar 2011
Individual at Usk and Prescoed HMP Usk and Prescoed Natural Published 30 Mar 2011
Individual at Bedford HMP Bedford Self-inflicted Published 28 Mar 2011
Individual at Guys Marsh HMP Guys Marsh Natural Published 26 Mar 2011
Individual at Norwich HMP Norwich Natural Published 24 Mar 2011
Individual at Swaleside HMP Swaleside Self-inflicted Published 20 Mar 2011
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 17 Mar 2011
Individual at Wolds HMP Wolds Natural Published 17 Mar 2011
Individual at Aylesbury HMP Aylesbury Self-inflicted Published 16 Mar 2011
Individual at Manchester HMP Manchester Other Published 16 Mar 2011
Individual at Lowdham Grange HMP Lowdham Grange Self-inflicted Published 15 Mar 2011
Individual at Hull HMP Hull Natural Published 15 Mar 2011
Individual at Altcourse HMP Altcourse Natural Published 14 Mar 2011
Individual at Holme House HMP Holme House Self-inflicted Published 14 Mar 2011
Individual at Lindholme HMP Lindholme Natural Published 11 Mar 2011
Individual at Long Lartin HMP Long Lartin Natural Published 11 Mar 2011
Individual at Littlehey HMP Littlehey Natural Published 10 Mar 2011
Individual at Elmley HMP Elmley Natural Published 8 Mar 2011
Individual at Bronzefield HMP Bronzefield Other Published 7 Mar 2011
Individual at Parc HMP Parc Natural Published 6 Mar 2011
Individual at Clarks House Approved Premises Clarks House Approved Premises Other Published 6 Mar 2011
Individual at High Down HMP High Down Natural Published 6 Mar 2011
Individual at Winchester HMP Winchester Natural Published 5 Mar 2011
Individual at Hull HMP Hull Self-inflicted Published 2 Mar 2011
Individual at Isle of Wight HMP Isle of Wight Natural Published 1 Mar 2011
Individual at Full Sutton HMP Full Sutton Natural Published 28 Feb 2011
Individual at Leicester HMP Leicester Self-inflicted Published 27 Feb 2011