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 Elmley HMP Elmley Self-inflicted Published 12 Jul 2008
Individual at Hull HMP Hull Natural Published 11 Jul 2008
Individual at Guernsey State Prison Guernsey State Prison Natural Published 11 Jul 2008
Individual at Whatton HMP Whatton Natural Published 7 Jul 2008
Individual at Doncaster HMP Doncaster Other Published 6 Jul 2008
Individual at Featherstone HMP Featherstone Self-inflicted Published 4 Jul 2008
Individual at Altcourse HMP Altcourse Natural Published 27 Jun 2008
Individual at Doncaster HMP Doncaster Natural Published 17 Jun 2008
Individual at The Verne HMP The Verne Natural Published 16 Jun 2008
Individual at High Down HMP High Down Self-inflicted Published 14 Jun 2008
Individual at Lincoln HMP Lincoln Self-inflicted Published 13 Jun 2008
Individual at Wymott HMP Wymott Natural Published 13 Jun 2008
Individual at Risley HMP Risley Natural Published 10 Jun 2008
Individual at Isle of Wight HMP Isle of Wight Natural Published 9 Jun 2008
Individual at Shrewsbury HMP Shrewsbury Self-inflicted Published 9 Jun 2008
Individual at Dovegate HMP Dovegate Self-inflicted Published 8 Jun 2008
Individual at Bristol HMP Bristol Natural Published 8 Jun 2008
Individual at Wymott HMP Wymott Self-inflicted Published 7 Jun 2008
Individual at Wakefield HMP Wakefield Self-inflicted Published 6 Jun 2008
Individual at Holme House HMP Holme House Natural Published 4 Jun 2008
Individual at Belmarsh HMP Belmarsh Natural Published 2 Jun 2008
Individual at Isle of Wight HMP Isle of Wight Natural Published 28 May 2008
Individual at Victoria House Victoria House Natural Published 18 May 2008
Individual at Norwich HMP Norwich Natural Published 15 May 2008
Individual at High Down HMP High Down Self-inflicted Published 14 May 2008
Individual at High Down HMP High Down Natural Published 13 May 2008
Individual at Leicester HMP Leicester Natural Published 12 May 2008
Individual at Risley HMP Risley Natural Published 9 May 2008
Individual at Bristol HMP Bristol Self-inflicted Published 8 May 2008
Individual at Styal HMP Styal Natural Published 7 May 2008
Individual at Highpoint HMP Highpoint Natural Published 6 May 2008
Individual at Littlehey HMP Littlehey Self-inflicted Published 29 Apr 2008
Individual at Altcourse HMP Altcourse Self-inflicted Published 29 Apr 2008
Individual at Chorlton Chorlton Self-inflicted Published 29 Apr 2008
Individual at Styal HMP Styal Natural Published 28 Apr 2008
Individual at Altcourse HMP Altcourse Self-inflicted Published 26 Apr 2008
Individual at Liverpool HMP Liverpool Self-inflicted Published 22 Apr 2008
Individual at Gloucester HMP Gloucester Natural Published 21 Apr 2008
Individual at Elmley HMP Elmley Self-inflicted Published 17 Apr 2008
Individual at Isle of Wight HMP Isle of Wight Self-inflicted Published 14 Apr 2008
Individual at Pentonville HMP Pentonville Self-inflicted Published 9 Apr 2008
Individual at Lawson House Lawson House Other Published 7 Apr 2008
Individual at Featherstone HMP Featherstone Self-inflicted Published 6 Apr 2008
Individual at Norwich HMP Norwich Natural Published 5 Apr 2008
Individual at Swaleside HMP Swaleside Other Published 4 Apr 2008
Individual at Norwich HMP Norwich Natural Published 31 Mar 2008
Individual at Hull HMP Hull Natural Published 31 Mar 2008
Individual at Pentonville HMP Pentonville Self-inflicted Published 30 Mar 2008
Individual at Bullingdon HMP Bullingdon Self-inflicted Published 29 Mar 2008
Individual at Isle of Wight HMP Isle of Wight Natural Published 29 Mar 2008