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 Hewell HMP Hewell Natural Published 25 Feb 2011
Individual at Full Sutton HMP Full Sutton Homicide Published 22 Feb 2011
Individual at Isle of Wight HMP Isle of Wight Natural Published 16 Feb 2011
Individual at Elmley HMP Elmley Natural Published 8 Feb 2011
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 6 Feb 2011
Individual at Pentonville HMP Pentonville Self-inflicted Published 3 Feb 2011
Individual at Cardiff HMP Cardiff Other Published 29 Jan 2011
Individual at Long Lartin HMP Long Lartin Natural Published 25 Jan 2011
Individual at Maidstone HMP Maidstone Natural Published 22 Jan 2011
Individual at Ty Newydd Ty Newydd Self-inflicted Published 22 Jan 2011
Individual at Cardiff HMP Cardiff Natural Published 21 Jan 2011
Individual at Isle of Wight HMP Isle of Wight Natural Published 17 Jan 2011
Individual at Hollesley Bay HMP Hollesley Bay Other Published 15 Jan 2011
Individual at Plas-Y-Wern Plas-Y-Wern Natural Published 15 Jan 2011
Individual at Gartree HMP Gartree Natural Published 15 Jan 2011
Individual at Maidstone HMP Maidstone Natural Published 11 Jan 2011
Individual at Shepton Mallet HMP Shepton Mallet Natural Published 10 Jan 2011
Individual at Cardiff HMP Cardiff Natural Published 10 Jan 2011
Individual at Durham HMP Durham Other Published 9 Jan 2011
Individual at Manchester HMP Manchester Self-inflicted Published 1 Jan 2011
Individual at Bullingdon HMP Bullingdon Natural Published 31 Dec 2010
Individual at Wandsworth HMP Wandsworth Natural Published 28 Dec 2010
Individual at Glen Parva HMP Glen Parva Self-inflicted Published 25 Dec 2010
Individual at Woodhill HMP Woodhill Natural Published 25 Dec 2010
Individual at Frankland HMP Frankland Natural Published 23 Dec 2010
Individual at Swaleside HMP Swaleside Natural Published 22 Dec 2010
Individual at Stoke Heath HMP Stoke Heath Self-inflicted Published 22 Dec 2010
Individual at Ellison House Ellison House Natural Published 20 Dec 2010
Individual at Forest Bank HMP Forest Bank Natural Published 19 Dec 2010
Individual at Wakefield HMP Wakefield Self-inflicted Published 16 Dec 2010
Individual at St Leonards St Leonards Other Published 14 Dec 2010
Individual at Pentonville HMP Pentonville Natural Published 13 Dec 2010
Individual at Elmley HMP Elmley Self-inflicted Published 12 Dec 2010
Individual at Wakefield HMP Wakefield Natural Published 11 Dec 2010
Individual at Forest Bank HMP Forest Bank Natural Published 10 Dec 2010
Individual at Holme House HMP Holme House Natural Published 9 Dec 2010
Individual at Isle of Wight HMP Isle of Wight Natural Published 6 Dec 2010
Individual at East Sutton Park HMP East Sutton Park Natural Published 6 Dec 2010
Individual at Victoria House Victoria House Other Published 4 Dec 2010
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 3 Dec 2010
Individual at Brixton HMP Brixton Natural Published 2 Dec 2010
Individual at Sudbury HMP Sudbury Natural Published 1 Dec 2010
Individual at Wandsworth HMP Wandsworth Natural Published 1 Dec 2010
Individual at Durham HMP Durham Natural Published 28 Nov 2010
Individual at New Hall HMP New Hall Natural Published 26 Nov 2010
Individual at Doncaster HMP Doncaster Natural Published 25 Nov 2010
Individual at Risley HMP Risley Self-inflicted Published 23 Nov 2010
Individual at Wandsworth HMP Wandsworth Natural Published 21 Nov 2010
Individual at Doncaster HMP Doncaster Other Published 20 Nov 2010
Individual at Wakefield HMP Wakefield Natural Published 16 Nov 2010