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 Wandsworth HMP Wandsworth Natural Published 15 Feb 2010
Individual at Frankland HMP Frankland Natural Published 10 Feb 2010
Individual at Doncaster HMP Doncaster Self-inflicted Published 9 Feb 2010
Individual at Long Lartin HMP Long Lartin Natural Published 6 Feb 2010
Individual at Frankland HMP Frankland Natural Published 5 Feb 2010
Individual at Leeds HMP Leeds Other Published 5 Feb 2010
Individual at Erlestoke House HMP Erlestoke House Self-inflicted Published 4 Feb 2010
Individual at Wakefield HMP Wakefield Natural Published 3 Feb 2010
Individual at Birmingham HMP Birmingham Self-inflicted Published 2 Feb 2010
Individual at Lindholme HMP Lindholme Natural Published 2 Feb 2010
Individual at Liverpool HMP Liverpool Self-inflicted Published 1 Feb 2010
Individual at Leeds HMP Leeds Self-inflicted Published 31 Jan 2010
Individual at Full Sutton HMP Full Sutton Natural Published 26 Jan 2010
Individual at Dovegate HMP Dovegate Natural Published 26 Jan 2010
Individual at Garth HMP Garth Self-inflicted Published 25 Jan 2010
Individual at Bullingdon HMP Bullingdon Natural Published 25 Jan 2010
Individual at Woodhill HMP Woodhill Natural Published 24 Jan 2010
Individual at Wakefield HMP Wakefield Natural Published 22 Jan 2010
Individual at Maidstone HMP Maidstone Natural Published 22 Jan 2010
Individual at Stoke Heath HMP Stoke Heath Self-inflicted Published 17 Jan 2010
Individual at Quay House Quay House Other Published 10 Jan 2010
Individual at Highpoint HMP Highpoint Natural Published 9 Jan 2010
Individual at Forest Bank HMP Forest Bank Self-inflicted Published 8 Jan 2010
Individual at Bristol HMP Bristol Natural Published 7 Jan 2010
Individual at Isle of Wight HMP Isle of Wight Natural Published 6 Jan 2010
Individual at Leeds HMP Leeds Natural Published 6 Jan 2010
Individual at Woodhill HMP Woodhill Natural Published 3 Jan 2010
Individual at Wealstun HMP Wealstun Natural Published 3 Jan 2010
Individual at Wakefield HMP Wakefield Self-inflicted Published 2 Jan 2010
Individual at Exeter HMP Exeter Natural Published 2 Jan 2010
Individual at Preston HMP Preston Natural Published 1 Jan 2010
Individual at Deerbolt HMP Deerbolt Natural Published 28 Dec 2009
Individual at Gloucester HMP Gloucester Self-inflicted Published 27 Dec 2009
Individual at Lewes HMP Lewes Natural Published 23 Dec 2009
Individual at Kingston HMP Kingston Natural Published 22 Dec 2009
Individual at Parc HMP Parc Natural Published 22 Dec 2009
Individual at Acklington HMP Acklington Natural Published 20 Dec 2009
Individual at Swaleside HMP Swaleside Natural Published 20 Dec 2009
Individual at Manchester HMP Manchester Self-inflicted Published 19 Dec 2009
Individual at Spring Hill HMP Spring Hill Natural Published 15 Dec 2009
Individual at Durham HMP Durham Natural Published 15 Dec 2009
Individual at Birmingham HMP Birmingham Natural Published 12 Dec 2009
Individual at Ozanam House Ozanam House Self-inflicted Published 12 Dec 2009
Individual at High Down HMP High Down Natural Published 12 Dec 2009
Individual at Wealstun HMP Wealstun Self-inflicted Published 11 Dec 2009
Individual at Cardiff HMP Cardiff Natural Published 9 Dec 2009
Individual at Peterborough HMP Peterborough Natural Published 8 Dec 2009
Individual at Tulse Hill Tulse Hill Other Published 6 Dec 2009
Individual at Styal HMP Styal Natural Published 4 Dec 2009
Individual at Parc HMP Parc Natural Published 2 Dec 2009