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 Channings Wood HMP Channings Wood Self-inflicted Published 28 Sep 2006
Individual at Bullingdon HMP Bullingdon Self-inflicted Published 26 Sep 2006
Individual at Kingston HMP Kingston Self-inflicted Published 25 Sep 2006
Individual at Garth HMP Garth Natural Published 21 Sep 2006
Individual at Littlehey HMP Littlehey Self-inflicted Published 18 Sep 2006
Individual at Bullingdon HMP Bullingdon Self-inflicted Published 18 Sep 2006
Individual at Norwich HMP Norwich Natural Published 14 Sep 2006
Individual at Pentonville HMP Pentonville Natural Published 10 Sep 2006
Individual at Isle of Wight HMP Isle of Wight Natural Published 10 Sep 2006
Individual at Bowling Green Bowling Green Self-inflicted Published 9 Sep 2006
Individual at Manchester HMP Manchester Self-inflicted Published 8 Sep 2006
Individual at Frankland HMP Frankland Self-inflicted Published 8 Sep 2006
Individual at Norwich HMP Norwich Natural Published 8 Sep 2006
Individual at Moorland Closed HMP Moorland Closed Natural Published 6 Sep 2006
Individual at Whatton HMP Whatton Natural Published 5 Sep 2006
Individual at Doncaster HMP Doncaster Natural Published 5 Sep 2006
Individual at Jersey HMP Jersey Self-inflicted Published 2 Sep 2006
Individual at Dartmoor HMP Dartmoor Natural Published 2 Sep 2006
Individual at Winchester HMP Winchester Natural Published 1 Sep 2006
Individual at Augustus House Augustus House Other Published 30 Aug 2006
Individual at Manchester HMP Manchester Self-inflicted Published 26 Aug 2006
Individual at Lindholme HMP Lindholme Natural Published 26 Aug 2006
Individual at Liverpool HMP Liverpool Self-inflicted Published 23 Aug 2006
Individual at Altcourse HMP Altcourse Natural Published 17 Aug 2006
Individual at Preston HMP Preston Self-inflicted Published 16 Aug 2006
Individual at Whitemoor HMP Whitemoor Natural Published 14 Aug 2006
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 11 Aug 2006
Individual at Shrewsbury HMP Shrewsbury Self-inflicted Published 11 Aug 2006
Individual at Bullingdon HMP Bullingdon Natural Published 4 Aug 2006
Individual at Tulse Hill Tulse Hill Natural Published 25 Jul 2006
Individual at Wakefield HMP Wakefield Natural Published 24 Jul 2006
Individual at Stafford HMP Stafford Natural Published 22 Jul 2006
Individual at Swaleside HMP Swaleside Natural Published 19 Jul 2006
Individual at Southwood Southwood Natural Published 17 Jul 2006
Individual at Birmingham HMP Birmingham Natural Published 17 Jul 2006
Individual at Bedford HMP Bedford Self-inflicted Published 15 Jul 2006
Individual at Leeds HMP Leeds Self-inflicted Published 6 Jul 2006
Individual at Durham HMP Durham Self-inflicted Published 5 Jul 2006
Individual at Leeds HMP Leeds Other Published 4 Jul 2006
Individual at Doncaster HMP Doncaster Self-inflicted Published 3 Jul 2006
Individual at Holme House HMP Holme House Natural Published 2 Jul 2006
Individual at Parc HMP Parc Self-inflicted Published 29 Jun 2006
Individual at Brixton HMP Brixton Natural Published 25 Jun 2006
Individual at Askham Grange HMP Askham Grange Homicide Published 24 Jun 2006
Individual at Glen Parva HMP Glen Parva Self-inflicted Published 24 Jun 2006
Individual at Liverpool HMP Liverpool Self-inflicted Published 23 Jun 2006
Individual at Standford Hill HMP Standford Hill Natural Published 23 Jun 2006
Individual at Brixton HMP Brixton Natural Published 15 Jun 2006
Individual at Leicester HMP Leicester Natural Published 13 Jun 2006
Individual at Brixton HMP Brixton Self-inflicted Published 13 Jun 2006