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 Doncaster HMP Doncaster Natural Published 30 Mar 2007
Individual at Hollesley Bay HMP Hollesley Bay Other Published 30 Mar 2007
Individual at Brinsford HMP Brinsford Self-inflicted Published 23 Mar 2007
Individual at Highpoint HMP Highpoint Self-inflicted Published 21 Mar 2007
Individual at Woodhill HMP Woodhill Natural Published 20 Mar 2007
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 13 Mar 2007
Individual at Birmingham HMP Birmingham Homicide Published 12 Mar 2007
Individual at East Sutton Park HMP East Sutton Park Other Published 12 Mar 2007
Individual at Wandsworth HMP Wandsworth Natural Published 11 Mar 2007
Individual at Hull HMP Hull Self-inflicted Published 11 Mar 2007
Individual at Ozanam House Ozanam House Other Published 11 Mar 2007
Individual at Gartree HMP Gartree Self-inflicted Published 7 Mar 2007
Individual at Nottingham HMP Nottingham Other Published 6 Mar 2007
Individual at Belmarsh HMP Belmarsh Self-inflicted Published 3 Mar 2007
Individual at Brixton HMP Brixton Self-inflicted Published 27 Feb 2007
Individual at Isle of Wight HMP Isle of Wight Self-inflicted Published 23 Feb 2007
Individual at Town Moor Town Moor Other Published 22 Feb 2007
Individual at Leeds HMP Leeds Self-inflicted Published 22 Feb 2007
Individual at Bedford HMP Bedford Self-inflicted Published 22 Feb 2007
Individual at Parc HMP Parc Natural Published 18 Feb 2007
Individual at Whitemoor HMP Whitemoor Self-inflicted Published 17 Feb 2007
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 11 Feb 2007
Individual at Dartmoor HMP Dartmoor Natural Published 11 Feb 2007
Individual at Belmarsh HMP Belmarsh Self-inflicted Published 10 Feb 2007
Individual at Lowdham Grange HMP Lowdham Grange Natural Published 9 Feb 2007
Individual at Woodhill HMP Woodhill Natural Published 9 Feb 2007
Individual at Glen Parva HMP Glen Parva Natural Published 5 Feb 2007
Individual at Gartree HMP Gartree Natural Published 4 Feb 2007
Individual at Birmingham HMP Birmingham Natural Published 1 Feb 2007
Individual at Preston HMP Preston Self-inflicted Published 29 Jan 2007
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 29 Jan 2007
Individual at Nottingham HMP Nottingham Self-inflicted Published 28 Jan 2007
Individual at Whatton HMP Whatton Natural Published 28 Jan 2007
Individual at Littlehey HMP Littlehey Natural Published 25 Jan 2007
Individual at Leicester HMP Leicester Self-inflicted Published 25 Jan 2007
Individual at Winchester HMP Winchester Natural Published 24 Jan 2007
Individual at Reading HMP Reading Natural Published 23 Jan 2007
Individual at Channings Wood HMP Channings Wood Natural Published 22 Jan 2007
Individual at Maidstone HMP Maidstone Natural Published 22 Jan 2007
Individual at Garth HMP Garth Natural Published 21 Jan 2007
Individual at Holloway HMP Holloway Other Published 21 Jan 2007
Individual at Acklington HMP Acklington Self-inflicted Published 21 Jan 2007
Individual at Norwich HMP Norwich Natural Published 19 Jan 2007
Individual at Lincoln HMP Lincoln Natural Published 19 Jan 2007
Individual at Whitemoor HMP Whitemoor Self-inflicted Published 15 Jan 2007
Individual at Frankland HMP Frankland Natural Published 14 Jan 2007
Individual at Staitheford House Staitheford House Other Published 12 Jan 2007
Individual at Lancaster Farms HMP Lancaster Farms Self-inflicted Published 12 Jan 2007
Individual at Ty Newydd Ty Newydd Natural Published 7 Jan 2007
Individual at Cardiff HMP Cardiff Natural Published 6 Jan 2007