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 Usk and Prescoed HMP Usk and Prescoed Natural Published 27 Oct 2008
Individual at Hewell HMP Hewell Natural Published 26 Oct 2008
Individual at Moorland Closed HMP Moorland Closed Natural Published 25 Oct 2008
Individual at Manchester HMP Manchester Self-inflicted Published 13 Oct 2008
Individual at Wayland HMP Wayland Other Published 7 Oct 2008
Individual at Shepton Mallet HMP Shepton Mallet Natural Published 7 Oct 2008
Individual at Wymott HMP Wymott Natural Published 5 Oct 2008
Individual at Isle of Wight HMP Isle of Wight Natural Published 4 Oct 2008
Individual at Whatton HMP Whatton Natural Published 4 Oct 2008
Individual at Frankland HMP Frankland Natural Published 3 Oct 2008
Individual at Wakefield HMP Wakefield Natural Published 2 Oct 2008
Individual at Wymott HMP Wymott Other Published 28 Sep 2008
Individual at Maidstone HMP Maidstone Self-inflicted Published 27 Sep 2008
Individual at Manchester HMP Manchester Natural Published 27 Sep 2008
Individual at Woodhill HMP Woodhill Self-inflicted Published 26 Sep 2008
Individual at Shepton Mallet HMP Shepton Mallet Natural Published 23 Sep 2008
Individual at Frankland HMP Frankland Natural Published 22 Sep 2008
Individual at Wormwood Scrubs HMP Wormwood Scrubs Natural Published 21 Sep 2008
Individual at Chelmsford HMP Chelmsford Self-inflicted Published 20 Sep 2008
Individual at Forest Bank HMP Forest Bank Homicide Published 19 Sep 2008
Individual at Leeds HMP Leeds Natural Published 16 Sep 2008
Individual at Durham HMP Durham Natural Published 15 Sep 2008
Individual at Mandeville House Mandeville House Natural Published 12 Sep 2008
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 12 Sep 2008
Individual at Shrewsbury HMP Shrewsbury Self-inflicted Published 11 Sep 2008
Individual at Peterborough HMP Peterborough Homicide Published 11 Sep 2008
Individual at Colnbrook IRC Colnbrook Natural Published 1 Sep 2008
Individual at Edmunds Hill HMP Edmunds Hill Self-inflicted Published 27 Aug 2008
Individual at Isle of Wight HMP Isle of Wight Natural Published 26 Aug 2008
Individual at Moorland Closed HMP Moorland Closed Natural Published 26 Aug 2008
Individual at Whatton HMP Whatton Homicide Published 25 Aug 2008
Individual at High Down HMP High Down Self-inflicted Published 23 Aug 2008
Individual at Frankland HMP Frankland Natural Published 23 Aug 2008
Individual at Altcourse HMP Altcourse Natural Published 22 Aug 2008
Individual at Norwich HMP Norwich Natural Published 22 Aug 2008
Individual at Dovegate HMP Dovegate Natural Published 16 Aug 2008
Individual at Parc HMP Parc Self-inflicted Published 16 Aug 2008
Individual at Bedford HMP Bedford Self-inflicted Published 14 Aug 2008
Individual at Bristol HMP Bristol Natural Published 14 Aug 2008
Individual at Hewell HMP Hewell Natural Published 12 Aug 2008
Individual at Derby Crown Court Derby Crown Court Self-inflicted Published 7 Aug 2008
Individual at Birmingham HMP Birmingham Self-inflicted Published 4 Aug 2008
Individual at Lincoln HMP Lincoln Self-inflicted Published 29 Jul 2008
Individual at Manchester HMP Manchester Natural Published 28 Jul 2008
Individual at Winchester HMP Winchester Self-inflicted Published 28 Jul 2008
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 20 Jul 2008
Individual at Durham HMP Durham Natural Published 16 Jul 2008
Individual at Haworth House Haworth House Natural Published 15 Jul 2008
Individual at The Verne HMP The Verne Natural Published 13 Jul 2008
Individual at Elmley HMP Elmley Natural Published 12 Jul 2008