Source · Deaths in custody

PPO Fatal Incident Reports

6,488 incidents 5,759 published 1,642 recommendations 1,658 self-inflicted 3,411 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 property complaints Policy into Practice Mar 2025 PDF
Policy into Practice: Handling of prisoners’ property Policy into Practice Mar 2025 PDF
Complaints Investigations Learning Lessons Bulletin Issue 11: Property complaints Learning Lessons Bulletin Mar 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
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 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

Incidents

6,488 records
Name Establishment Cause Status Date of death Recs
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 Usk and Prescoed HMP Usk and Prescoed Natural Published 30 Mar 2011
Individual at Holme House HMP Holme House Natural Published 30 Mar 2011
Individual at Downview HMP Downview Self-inflicted 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 Wolds HMP Wolds Natural Published 17 Mar 2011
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 17 Mar 2011
Individual at Manchester HMP Manchester Other Published 16 Mar 2011
Individual at Aylesbury HMP Aylesbury Self-inflicted Published 16 Mar 2011
Individual at Hull HMP Hull Natural Published 15 Mar 2011
Individual at Lowdham Grange HMP Lowdham Grange Self-inflicted Published 15 Mar 2011
Individual at Holme House HMP Holme House Self-inflicted Published 14 Mar 2011
Individual at Altcourse HMP Altcourse Natural Published 14 Mar 2011
Individual at Long Lartin HMP Long Lartin Natural Published 11 Mar 2011
Individual at Lindholme HMP Lindholme 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 Clarks House Approved Premises Clarks House Approved Premises Other Published 6 Mar 2011
Individual at Parc HMP Parc Natural 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
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 Ty Newydd Ty Newydd Self-inflicted Published 22 Jan 2011
Individual at Maidstone HMP Maidstone Natural 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 Gartree HMP Gartree Natural Published 15 Jan 2011