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 Stafford HMP Stafford Self-inflicted Published 17 Jan 2009
Individual at Garth HMP Garth Natural Published 13 Jan 2009
Individual at Bullingdon HMP Bullingdon Self-inflicted Published 9 Jan 2009
Individual at Parc HMP Parc Natural Published 9 Jan 2009
Individual at Acklington HMP Acklington Natural Published 9 Jan 2009
Individual at Styal HMP Styal Self-inflicted Published 8 Jan 2009
Individual at Leeds HMP Leeds Natural Published 7 Jan 2009
Individual at Gloucester HMP Gloucester Self-inflicted Published 6 Jan 2009
Individual at Parc HMP Parc Self-inflicted Published 4 Jan 2009
Individual at Deerbolt HMP Deerbolt Self-inflicted Published 4 Jan 2009
Individual at Lewes HMP Lewes Natural Published 3 Jan 2009
Individual at Usk and Prescoed HMP Usk and Prescoed Natural Published 1 Jan 2009
Individual at Parc HMP Parc Natural Published 31 Dec 2008
Individual at Featherstone HMP Featherstone Self-inflicted Published 30 Dec 2008
Individual at Pentonville HMP Pentonville Self-inflicted Published 29 Dec 2008
Individual at Exeter HMP Exeter Natural Published 28 Dec 2008
Individual at Wymott HMP Wymott Natural Published 27 Dec 2008
Individual at Wymott HMP Wymott Natural Published 27 Dec 2008
Individual at Aylesbury HMP Aylesbury Self-inflicted Published 26 Dec 2008
Individual at Norwich HMP Norwich Natural Published 25 Dec 2008
Individual at Moorland Closed HMP Moorland Closed Natural Published 21 Dec 2008
Individual at Full Sutton HMP Full Sutton Natural Published 21 Dec 2008
Individual at Parc HMP Parc Natural Published 20 Dec 2008
Individual at Norwich HMP Norwich Natural Published 20 Dec 2008
Individual at Norwich HMP Norwich Self-inflicted Published 20 Dec 2008
Individual at Norwich HMP Norwich Natural Published 18 Dec 2008
Individual at Altcourse HMP Altcourse Self-inflicted Published 16 Dec 2008
Individual at Sycamore Lodge Sycamore Lodge Other Published 15 Dec 2008
Individual at Victoria House Victoria House Self-inflicted Published 10 Dec 2008
Individual at Leicester HMP Leicester Self-inflicted Published 5 Dec 2008
Individual at Isle of Wight HMP Isle of Wight Natural Published 4 Dec 2008
Individual at Elliott House Elliott House Natural Published 3 Dec 2008
Individual at Birmingham HMP Birmingham Natural Published 30 Nov 2008
Individual at Whatton HMP Whatton Natural Published 30 Nov 2008
Individual at Birmingham HMP Birmingham Natural Published 28 Nov 2008
Individual at Acklington HMP Acklington Natural Published 25 Nov 2008
Individual at St Josephs St Josephs Natural Published 23 Nov 2008
Individual at New Hall HMP New Hall Natural Published 20 Nov 2008
Individual at Belmarsh HMP Belmarsh Self-inflicted Published 18 Nov 2008
Individual at Queens Road Queens Road Natural Published 17 Nov 2008
Individual at Winchester HMP Winchester Self-inflicted Published 17 Nov 2008
Individual at Lindholme HMP Lindholme Self-inflicted Published 16 Nov 2008
Individual at Holme House HMP Holme House Natural Published 15 Nov 2008
Individual at Birmingham HMP Birmingham Self-inflicted Published 14 Nov 2008
Individual at Shrewsbury HMP Shrewsbury Natural Published 13 Nov 2008
Individual at Manchester HMP Manchester Natural Published 11 Nov 2008
Individual at Lewes HMP Lewes Natural Published 3 Nov 2008
Individual at Erlestoke House HMP Erlestoke House Natural Published 2 Nov 2008
Individual at Belmarsh HMP Belmarsh Natural Published 2 Nov 2008
Individual at Isle of Wight HMP Isle of Wight Self-inflicted Published 27 Oct 2008