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 Blakenhurst HMP Blakenhurst Self-inflicted Published 14 Sep 2007
Individual at Sudbury HMP Sudbury Natural Published 12 Sep 2007
Individual at Send HMP Send Self-inflicted Published 11 Sep 2007
Individual at Exeter HMP Exeter Self-inflicted Published 11 Sep 2007
Individual at Swaleside HMP Swaleside Natural Published 10 Sep 2007
Individual at Brixton HMP Brixton Self-inflicted Published 5 Sep 2007
Individual at Sudbury HMP Sudbury Self-inflicted Published 3 Sep 2007
Individual at Wayland HMP Wayland Natural Published 31 Aug 2007
Individual at Chorlton Chorlton Self-inflicted Published 29 Aug 2007
Individual at Acklington HMP Acklington Self-inflicted Published 29 Aug 2007
Individual at Moorland Closed HMP Moorland Closed Self-inflicted Published 22 Aug 2007
Individual at Sycamore Lodge Sycamore Lodge Natural Published 21 Aug 2007
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 20 Aug 2007
Individual at Erlestoke House HMP Erlestoke House Natural Published 19 Aug 2007
Individual at Blakenhurst HMP Blakenhurst Natural Published 18 Aug 2007
Individual at Birmingham HMP Birmingham Self-inflicted Published 18 Aug 2007
Individual at Birmingham HMP Birmingham Self-inflicted Published 18 Aug 2007
Individual at Exeter HMP Exeter Self-inflicted Published 17 Aug 2007
Individual at Leicester HMP Leicester Self-inflicted Published 13 Aug 2007
Individual at Swansea HMP Swansea Self-inflicted Published 12 Aug 2007
Individual at Gartree HMP Gartree Natural Published 8 Aug 2007
Individual at Whatton HMP Whatton Natural Published 8 Aug 2007
Individual at Acklington HMP Acklington Self-inflicted Published 7 Aug 2007
Individual at Lowdham Grange HMP Lowdham Grange Natural Published 28 Jul 2007
Individual at Dorchester HMP Dorchester Self-inflicted Published 27 Jul 2007
Individual at Whitemoor HMP Whitemoor Self-inflicted Published 26 Jul 2007
Individual at Norwich HMP Norwich Natural Published 25 Jul 2007
Individual at Lewes HMP Lewes Self-inflicted Published 24 Jul 2007
Individual at Standford Hill HMP Standford Hill Natural Published 23 Jul 2007
Individual at Maidstone HMP Maidstone Natural Published 19 Jul 2007
Individual at Manchester HMP Manchester Other Published 16 Jul 2007
Individual at Forest Bank HMP Forest Bank Self-inflicted Published 15 Jul 2007
Individual at Isle of Wight HMP Isle of Wight Self-inflicted Published 14 Jul 2007
Individual at Wakefield HMP Wakefield Self-inflicted Published 13 Jul 2007
Individual at Standford Hill HMP Standford Hill Natural Published 7 Jul 2007
Individual at Haverigg HMP Haverigg Self-inflicted Published 5 Jul 2007
Individual at Glen Parva HMP Glen Parva Self-inflicted Published 4 Jul 2007
Individual at Risley HMP Risley Natural Published 3 Jul 2007
Individual at Long Lartin HMP Long Lartin Self-inflicted Published 3 Jul 2007
Individual at Holme House HMP Holme House Self-inflicted Published 1 Jul 2007
Individual at Holloway HMP Holloway Self-inflicted Published 30 Jun 2007
Individual at Isleworth Crown Court Isleworth Crown Court Self-inflicted Published 28 Jun 2007
Individual at Holme House HMP Holme House Self-inflicted Published 27 Jun 2007
Individual at Doncaster HMP Doncaster Natural Published 26 Jun 2007
Individual at Bristol HMP Bristol Natural Published 24 Jun 2007
Individual at Whatton HMP Whatton Natural Published 24 Jun 2007
Individual at Cardiff HMP Cardiff Natural Published 20 Jun 2007
Individual at Pentonville HMP Pentonville Self-inflicted Published 19 Jun 2007
Individual at The Mount HMP The Mount Natural Published 15 Jun 2007
Individual at Wakefield HMP Wakefield Natural Published 14 Jun 2007