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 Chelmsford HMP Chelmsford Self-inflicted Published 6 Jan 2007
Individual at Whitemoor HMP Whitemoor Self-inflicted Published 5 Jan 2007
Individual at Bullingdon HMP Bullingdon Natural Published 5 Jan 2007
Individual at Felmores Felmores Natural Published 5 Jan 2007
Individual at Frankland HMP Frankland Natural Published 1 Jan 2007
Individual at Maidstone HMP Maidstone Natural Published 31 Dec 2006
Individual at Channings Wood HMP Channings Wood Natural Published 28 Dec 2006
Individual at Norwich HMP Norwich Natural Published 27 Dec 2006
Individual at Stafford HMP Stafford Natural Published 26 Dec 2006
Individual at Wakefield HMP Wakefield Self-inflicted Published 18 Dec 2006
Individual at Stafford HMP Stafford Self-inflicted Published 15 Dec 2006
Individual at Isle of Wight HMP Isle of Wight Natural Published 8 Dec 2006
Individual at Littlehey HMP Littlehey Natural Published 7 Dec 2006
Individual at Leeds HMP Leeds Self-inflicted Published 6 Dec 2006
Individual at Leeds HMP Leeds Natural Published 5 Dec 2006
Individual at Norwich Crown Court Norwich Crown Court Self-inflicted Published 4 Dec 2006
Individual at Leeds HMP Leeds Natural Published 30 Nov 2006
Individual at Liverpool HMP Liverpool Self-inflicted Published 29 Nov 2006
Individual at Nottingham HMP Nottingham Natural Published 25 Nov 2006
Individual at Durham HMP Durham Self-inflicted Published 22 Nov 2006
Individual at Linden Bank Linden Bank Self-inflicted Published 19 Nov 2006
Individual at Whitemoor HMP Whitemoor Self-inflicted Published 19 Nov 2006
Individual at Frankland HMP Frankland Natural Published 15 Nov 2006
Individual at Wellingborough HMP Wellingborough Natural Published 12 Nov 2006
Individual at Lincoln HMP Lincoln Self-inflicted Published 10 Nov 2006
Individual at Rye Hill HMP Rye Hill Natural Published 10 Nov 2006
Individual at Wilton Place Wilton Place Natural Published 3 Nov 2006
Individual at Acklington HMP Acklington Natural Published 31 Oct 2006
Individual at Gartree HMP Gartree Natural Published 26 Oct 2006
Individual at Northallerton HMP Northallerton Other Published 25 Oct 2006
Individual at Maidstone HMP Maidstone Natural Published 25 Oct 2006
Individual at Dartmoor HMP Dartmoor Other Published 25 Oct 2006
Individual at Isle of Wight HMP Isle of Wight Self-inflicted Published 23 Oct 2006
Individual at Everthorpe HMP Everthorpe Self-inflicted Published 22 Oct 2006
Individual at Channings Wood HMP Channings Wood Natural Published 20 Oct 2006
Individual at Cardiff HMP Cardiff Natural Published 19 Oct 2006
Individual at Cookham Wood HMP Cookham Wood Natural Published 15 Oct 2006
Individual at Wormwood Scrubs HMP Wormwood Scrubs Natural Published 14 Oct 2006
Individual at Chelmsford HMP Chelmsford Self-inflicted Published 14 Oct 2006
Individual at Gartree HMP Gartree Natural Published 12 Oct 2006
Individual at Acklington HMP Acklington Natural Published 11 Oct 2006
Individual at Manchester HMP Manchester Self-inflicted Published 9 Oct 2006
Individual at Blakenhurst HMP Blakenhurst Self-inflicted Published 9 Oct 2006
Individual at Whatton HMP Whatton Self-inflicted Published 8 Oct 2006
Individual at Eastwood Park HMP Eastwood Park Self-inflicted Published 2 Oct 2006
Individual at Bristol HMP Bristol Self-inflicted Published 1 Oct 2006
Individual at North Sea Camp HMP North Sea Camp Natural Published 1 Oct 2006
Individual at Ford HMP Ford Other Published 30 Sep 2006
Individual at Whatton HMP Whatton Natural Published 29 Sep 2006
Individual at Peterborough HMP Peterborough Other Published 29 Sep 2006