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 Frankland HMP Frankland Natural Published 4 May 2010
Individual at Wandsworth HMP Wandsworth Natural Published 29 Apr 2010
Individual at Stafford HMP Stafford Natural Published 28 Apr 2010
Individual at Wandsworth HMP Wandsworth Natural Published 26 Apr 2010
Individual at Manchester HMP Manchester Self-inflicted Published 25 Apr 2010
Individual at Bedford HMP Bedford Natural Published 22 Apr 2010
Individual at Cuthbert House Cuthbert House Self-inflicted Published 21 Apr 2010
Individual at Nottingham HMP Nottingham Natural Published 21 Apr 2010
Individual at Isle of Wight HMP Isle of Wight Self-inflicted Published 21 Apr 2010
Individual at Nottingham HMP Nottingham Natural Published 20 Apr 2010
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 18 Apr 2010
Individual at Winchester HMP Winchester Natural Published 17 Apr 2010
Individual at Acklington HMP Acklington Natural Published 16 Apr 2010
Individual at Manchester HMP Manchester Natural Published 15 Apr 2010
Individual at Oakington IRC Oakington Natural Published 15 Apr 2010
Individual at Cardiff HMP Cardiff Self-inflicted Published 12 Apr 2010
Individual at Eastwood Park HMP Eastwood Park Natural Published 10 Apr 2010
Individual at Maidstone HMP Maidstone Natural Published 8 Apr 2010
Individual at The Verne HMP The Verne Self-inflicted Published 8 Apr 2010
Individual at Swaleside HMP Swaleside Self-inflicted Published 3 Apr 2010
Individual at Cardiff HMP Cardiff Natural Published 2 Apr 2010
Individual at Birmingham HMP Birmingham Natural Published 31 Mar 2010
Individual at Bristol HMP Bristol Self-inflicted Published 31 Mar 2010
Individual at Peterborough HMP Peterborough Natural Published 28 Mar 2010
Individual at Bristol HMP Bristol Self-inflicted Published 26 Mar 2010
Individual at Wandsworth HMP Wandsworth Other Published 26 Mar 2010
Individual at Winchester HMP Winchester Natural Published 24 Mar 2010
Individual at Swaleside HMP Swaleside Natural Published 22 Mar 2010
Individual at Styal HMP Styal Natural Published 20 Mar 2010
Individual at Wellingborough HMP Wellingborough Natural Published 17 Mar 2010
Individual at Wormwood Scrubs HMP Wormwood Scrubs Natural Published 15 Mar 2010
Individual at Acklington HMP Acklington Natural Published 15 Mar 2010
Individual at Quay House Quay House Natural Published 14 Mar 2010
Individual at Sudbury HMP Sudbury Self-inflicted Published 13 Mar 2010
Individual at Birmingham HMP Birmingham Self-inflicted Published 13 Mar 2010
Individual at Isle of Wight HMP Isle of Wight Natural Published 10 Mar 2010
Individual at Brigstocke Road Brigstocke Road Other Published 9 Mar 2010
Individual at Stocken HMP Stocken Natural Published 9 Mar 2010
Individual at Garth HMP Garth Natural Published 6 Mar 2010
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 5 Mar 2010
Individual at Leeds HMP Leeds Natural Published 5 Mar 2010
Individual at Whatton HMP Whatton Natural Published 4 Mar 2010
Individual at Long Lartin HMP Long Lartin Natural Published 1 Mar 2010
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 1 Mar 2010
Individual at Garth HMP Garth Natural Published 28 Feb 2010
Individual at Birmingham HMP Birmingham Self-inflicted Published 23 Feb 2010
Individual at Ranby HMP Ranby Natural Published 22 Feb 2010
Individual at Liverpool HMP Liverpool Self-inflicted Published 18 Feb 2010
Individual at Woodhill HMP Woodhill Natural Published 16 Feb 2010
Individual at Wandsworth HMP Wandsworth Natural Published 15 Feb 2010