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 Altcourse HMP Altcourse Natural Published 2 Dec 2009
Individual at Wakefield HMP Wakefield Natural Published 30 Nov 2009
Individual at Norwich HMP Norwich Natural Published 25 Nov 2009
Individual at Portland HMP Portland Self-inflicted Published 22 Nov 2009
Individual at Cardiff HMP Cardiff Self-inflicted Published 13 Nov 2009
Individual at Leicester HMP Leicester Self-inflicted Published 13 Nov 2009
Individual at Leicester HMP Leicester Natural Published 11 Nov 2009
Individual at Whatton HMP Whatton Natural Published 9 Nov 2009
Individual at Peterborough HMP Peterborough Natural Published 9 Nov 2009
Individual at Frankland HMP Frankland Natural Published 9 Nov 2009
Individual at Exeter HMP Exeter Self-inflicted Published 8 Nov 2009
Individual at Manchester HMP Manchester Natural Published 5 Nov 2009
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 31 Oct 2009
Individual at Leeds HMP Leeds Self-inflicted Published 27 Oct 2009
Individual at Peterborough HMP Peterborough Natural Published 26 Oct 2009
Individual at Ranby HMP Ranby Natural Published 25 Oct 2009
Individual at Risley HMP Risley Natural Published 23 Oct 2009
Individual at Brinsford HMP Brinsford Self-inflicted Published 22 Oct 2009
Individual at Belmarsh HMP Belmarsh Natural Published 20 Oct 2009
Individual at Cardiff HMP Cardiff Self-inflicted Published 19 Oct 2009
Individual at Whatton HMP Whatton Natural Published 15 Oct 2009
Individual at Hewell HMP Hewell Self-inflicted Published 14 Oct 2009
Individual at Ashwell HMP Ashwell Natural Published 12 Oct 2009
Individual at Chorlton Chorlton Self-inflicted Published 11 Oct 2009
Individual at Durham HMP Durham Natural Published 8 Oct 2009
Individual at Peterborough HMP Peterborough Natural Published 7 Oct 2009
Individual at Bullingdon HMP Bullingdon Natural Published 6 Oct 2009
Individual at Dovegate HMP Dovegate Natural Published 6 Oct 2009
Individual at Wymott HMP Wymott Natural Published 5 Oct 2009
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 1 Oct 2009
Individual at Nottingham HMP Nottingham Other Published 30 Sep 2009
Individual at Grendon HMP Grendon Self-inflicted Published 26 Sep 2009
Individual at Bristol HMP Bristol Self-inflicted Published 25 Sep 2009
Individual at Dovegate HMP Dovegate Other Published 24 Sep 2009
Individual at Frankland HMP Frankland Natural Published 23 Sep 2009
Individual at Pentonville HMP Pentonville Natural Published 22 Sep 2009
Individual at Isle of Wight HMP Isle of Wight Natural Published 21 Sep 2009
Individual at Southampton Southampton Other Published 18 Sep 2009
Individual at Wandsworth HMP Wandsworth Other Published 17 Sep 2009
Individual at Whatton HMP Whatton Natural Published 14 Sep 2009
Individual at Littlehey HMP Littlehey Natural Published 10 Sep 2009
Individual at Felmores Felmores Natural Published 7 Sep 2009
Individual at Leeds HMP Leeds Natural Published 5 Sep 2009
Individual at Norwich HMP Norwich Other Published 4 Sep 2009
Individual at Altcourse HMP Altcourse Natural Published 3 Sep 2009
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 24 Aug 2009
Individual at Wandsworth HMP Wandsworth Natural Published 23 Aug 2009
Individual at Shrewsbury HMP Shrewsbury Self-inflicted Published 22 Aug 2009
Individual at Frankland HMP Frankland Self-inflicted Published 21 Aug 2009
Individual at Ozanam House Ozanam House Natural Published 16 Aug 2009