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 Whatton HMP Whatton Natural Published 26 Dec 2007
Individual at Chelmsford HMP Chelmsford Self-inflicted Published 25 Dec 2007
Individual at Birmingham City Hospital HMP Birmingham City Hospital Natural Published 25 Dec 2007
Individual at Nottingham HMP Nottingham Self-inflicted Published 24 Dec 2007
Individual at Braley House Braley House Natural Published 24 Dec 2007
Individual at Holme House HMP Holme House Self-inflicted Published 20 Dec 2007
Individual at Lincoln HMP Lincoln Self-inflicted Published 20 Dec 2007
Individual at Reading HMP Reading Self-inflicted Published 19 Dec 2007
Individual at Garth HMP Garth Natural Published 13 Dec 2007
Individual at Ascot House Ascot House Self-inflicted Published 13 Dec 2007
Individual at High Down HMP High Down Self-inflicted Published 11 Dec 2007
Individual at Holloway HMP Holloway Other Published 10 Dec 2007
Individual at Whitemoor HMP Whitemoor Self-inflicted Published 10 Dec 2007
Individual at Wakefield HMP Wakefield Natural Published 9 Dec 2007
Individual at Wakefield HMP Wakefield Natural Published 9 Dec 2007
Individual at Whatton HMP Whatton Natural Published 7 Dec 2007
Individual at Garth HMP Garth Natural Published 2 Dec 2007
Individual at Lancaster Farms HMP Lancaster Farms Self-inflicted Published 29 Nov 2007
Individual at Chelmsford HMP Chelmsford Self-inflicted Published 27 Nov 2007
Individual at Holme House HMP Holme House Natural Published 26 Nov 2007
Individual at Wymott HMP Wymott Natural Published 22 Nov 2007
Individual at Whitemoor HMP Whitemoor Self-inflicted Published 20 Nov 2007
Individual at Doncaster HMP Doncaster Natural Published 19 Nov 2007
Individual at Frankland HMP Frankland Natural Published 19 Nov 2007
Individual at Leicester HMP Leicester Self-inflicted Published 16 Nov 2007
Individual at Augustus House Augustus House Other Published 14 Nov 2007
Individual at Canterbury HMP Canterbury Self-inflicted Published 13 Nov 2007
Individual at Manchester HMP Manchester Natural Published 13 Nov 2007
Individual at Peterborough HMP Peterborough Natural Published 8 Nov 2007
Individual at Belmarsh HMP Belmarsh Self-inflicted Published 8 Nov 2007
Individual at Hopwood House Hopwood House Other Published 4 Nov 2007
Individual at Wandsworth HMP Wandsworth Natural Published 4 Nov 2007
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 30 Oct 2007
Individual at Haverigg HMP Haverigg Self-inflicted Published 28 Oct 2007
Individual at Winchester HMP Winchester Natural Published 27 Oct 2007
Individual at Lincoln HMP Lincoln Self-inflicted Published 26 Oct 2007
Individual at Rye Hill HMP Rye Hill Natural Published 26 Oct 2007
Individual at Bullingdon HMP Bullingdon Natural Published 23 Oct 2007
Individual at Canning House Canning House Natural Published 22 Oct 2007
Individual at Bristol HMP Bristol Self-inflicted Published 14 Oct 2007
Individual at Gartree HMP Gartree Self-inflicted Published 14 Oct 2007
Individual at Usk and Prescoed HMP Usk and Prescoed Natural Published 12 Oct 2007
Individual at Chelmsford HMP Chelmsford Natural Published 8 Oct 2007
Individual at The Mount HMP The Mount Self-inflicted Published 7 Oct 2007
Individual at Manchester HMP Manchester Self-inflicted Published 6 Oct 2007
Individual at Wakefield HMP Wakefield Natural Published 30 Sep 2007
Individual at Leeds HMP Leeds Self-inflicted Published 27 Sep 2007
Individual at Hull HMP Hull Natural Published 22 Sep 2007
Individual at Wenger House Wenger House Natural Published 20 Sep 2007
Individual at Norwich HMP Norwich Natural Published 20 Sep 2007