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 Swansea HMP Swansea Natural Published 13 Jun 2007
Individual at Leeds HMP Leeds Natural Published 12 Jun 2007
Individual at Cardiff HMP Cardiff Self-inflicted Published 10 Jun 2007
Individual at Isle of Wight HMP Isle of Wight Natural Published 8 Jun 2007
Individual at Leeds HMP Leeds Self-inflicted Published 8 Jun 2007
Individual at Cardiff HMP Cardiff Self-inflicted Published 4 Jun 2007
Individual at Styal HMP Styal Self-inflicted Published 3 Jun 2007
Individual at Leicester HMP Leicester Self-inflicted Published 1 Jun 2007
Individual at Highpoint HMP Highpoint Natural Published 31 May 2007
Individual at Long Lartin HMP Long Lartin Self-inflicted Published 31 May 2007
Individual at Northallerton HMP Northallerton Natural Published 31 May 2007
Individual at Highpoint HMP Highpoint Self-inflicted Published 30 May 2007
Individual at Frankland HMP Frankland Natural Published 28 May 2007
Individual at Risley HMP Risley Self-inflicted Published 24 May 2007
Individual at Standford Hill HMP Standford Hill Natural Published 23 May 2007
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 23 May 2007
Individual at Gartree HMP Gartree Natural Published 22 May 2007
Individual at Swaleside HMP Swaleside Self-inflicted Published 19 May 2007
Individual at Doncaster HMP Doncaster Natural Published 18 May 2007
Individual at High Down HMP High Down Self-inflicted Published 17 May 2007
Individual at Brixton HMP Brixton Other Published 15 May 2007
Individual at North Sea Camp HMP North Sea Camp Natural Published 14 May 2007
Individual at Featherstone HMP Featherstone Self-inflicted Published 14 May 2007
Individual at Wakefield HMP Wakefield Natural Published 14 May 2007
Individual at Elm Bank Elm Bank Natural Published 12 May 2007
Individual at Norwich HMP Norwich Natural Published 7 May 2007
Individual at Featherstone HMP Featherstone Self-inflicted Published 4 May 2007
Individual at Lincoln HMP Lincoln Natural Published 4 May 2007
Individual at Leeds HMP Leeds Natural Published 3 May 2007
Individual at Sycamore Lodge Sycamore Lodge Self-inflicted Published 3 May 2007
Individual at Lindholme HMP Lindholme Natural Published 29 Apr 2007
Individual at Whatton HMP Whatton Self-inflicted Published 28 Apr 2007
Individual at Lewes HMP Lewes Homicide Published 24 Apr 2007
Individual at Whatton HMP Whatton Natural Published 23 Apr 2007
Individual at Winchester HMP Winchester Natural Published 20 Apr 2007
Individual at Liverpool HMP Liverpool Natural Published 20 Apr 2007
Individual at Send HMP Send Self-inflicted Published 19 Apr 2007
Individual at Foston Hall HMP Foston Hall Self-inflicted Published 18 Apr 2007
Individual at Brixton HMP Brixton Self-inflicted Published 18 Apr 2007
Individual at Bedford HMP Bedford Self-inflicted Published 17 Apr 2007
Individual at Elliott House Elliott House Self-inflicted Published 15 Apr 2007
Individual at Preston HMP Preston Self-inflicted Published 15 Apr 2007
Individual at Bridge House Bridge House Natural Published 14 Apr 2007
Individual at Norwich HMP Norwich Natural Published 11 Apr 2007
Individual at Wayland HMP Wayland Natural Published 11 Apr 2007
Individual at Wormwood Scrubs HMP Wormwood Scrubs Natural Published 11 Apr 2007
Individual at Lewes HMP Lewes Self-inflicted Published 10 Apr 2007
Individual at Frankland HMP Frankland Natural Published 5 Apr 2007
Individual at Wakefield HMP Wakefield Natural Published 1 Apr 2007
Individual at Long Lartin HMP Long Lartin Self-inflicted Published 1 Apr 2007