Source · Deaths in custody

PPO Fatal Incident Reports

6,395 incidents 5,660 published 1,165 recommendations 1,632 self-inflicted 3,362 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 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 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 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
Complaints Investigations Learning Lessons Bulletin Issue 10: COVID-19 PPO Complaints Learning Lessons Bulletin Dec 2020 PDF

Incidents

6,395 records
Name Establishment Cause Status Date of death Recs
James Rutherford HMP Humber In progress
Carl Hyde HMP Stocken Pending inquest
Mark Collins HMP Berwyn Pending inquest
Daniel Childs HMP Bristol Pending inquest
Kian Parmee HMP Swansea Pending inquest
Martin Ramus HMP Exeter Pending inquest
James Goulding HMP Featherstone Pending inquest
Aaron House HMP Cookham Wood In progress
Marlon Kelly HMP Swaleside Pending inquest
Michael Maharaj HMP Brixton Pending inquest
Douglas Sirrell HMP Hewell In progress
Brian White HMP Featherstone Pending inquest
Jordan Donnell HMP Holme House Pending inquest
Bernard Grainger HMP Hull In progress
Christopher Sanderson HMP Hull In progress
Barry Kelly HMP Kirklevington Grange In progress
Kenneth Grubb HMP Five Wells In progress
Takauda Zinyoro HMP Stocken In progress
Shareen Akhtar HMP/YOI Foston Hall In progress
Sidique Govinden HMP Wandsworth Pending inquest
Daniel Alexander HMP Long Lartin Pending inquest
el Waleed Mohamed HMP Thameside Pending inquest
Alex Graham HMP Thameside In progress
Nicholas Robinson HMP Oakwood Pending inquest
Anthony Chetham HMP Millsike Pending inquest
Michael Dyer HMP Woodhill Pending inquest
Paul Pickerill HMP Garth Pending inquest
Simon Dunn HMP Garth Self-inflicted Published
Paul Hoskins HMP Bedford In progress
Steven Cleverley HMP The Verne In progress
Victor Fisher HMP Stoke Heath In progress
Matthew Bouldin HMP Fosse Way In progress
David Clairmonte HMP Full Sutton Pending inquest
Tony Collins HMP Rochester Pending inquest
Charles Pratt HMP Leeds Pending inquest
Luke Kelsall HMP/YOI Portland Pending inquest
Jason Hayward HMP Birmingham In progress
Roger Robinson Guernsey Prison In progress
Darren Salituri Guernsey Prison In progress
Andrew Eggington HMP Altcourse Pending inquest
Alfred Davies HMP Usk In progress
Jordan Tams HMP Deerbolt In progress
Stephen Hughes HMP Northumberland In progress
Scott Napier HMP Swaleside In progress
Toby Smith HMP Onley In progress
Laura Sharman HMP/YOI Drake Hall In progress
Lewis Goulding HMP Stoke Heath Pending inquest
Malcolm MacDougal HMP Full Sutton Pending inquest
Nicholas Braham HMP Dovegate In progress
Anthony Bullett HMP Norwich Pending inquest