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 Leicester HMP Leicester Self-inflicted Published 18 Feb 2006
Individual at Dovegate HMP Dovegate Self-inflicted Published 16 Feb 2006
Individual at Norwich HMP Norwich Natural Published 15 Feb 2006
Individual at Foston Hall HMP Foston Hall Natural Published 14 Feb 2006
Individual at Guys Marsh HMP Guys Marsh Self-inflicted Published 14 Feb 2006
Individual at Gloucester HMP Gloucester Natural Published 14 Feb 2006
Individual at Lewes HMP Lewes Natural Published 10 Feb 2006
Individual at Wordsworth House Wordsworth House Natural Published 8 Feb 2006
Individual at Cardiff HMP Cardiff Self-inflicted Published 6 Feb 2006
Individual at Southwell House Southwell House Other Published 5 Feb 2006
Individual at Doncaster HMP Doncaster Natural Published 31 Jan 2006
Individual at Manchester HMP Manchester Natural Published 30 Jan 2006
Individual at Birmingham HMP Birmingham Self-inflicted Published 20 Jan 2006
Individual at Leicester HMP Leicester Natural Published 20 Jan 2006
Individual at Blakenhurst HMP Blakenhurst Self-inflicted Published 20 Jan 2006
Individual at Harmondsworth IRC Harmondsworth Self-inflicted Published 19 Jan 2006
Individual at Norwich HMP Norwich Self-inflicted Published 19 Jan 2006
Individual at Lowdham Grange HMP Lowdham Grange Natural Published 16 Jan 2006
Individual at Birmingham HMP Birmingham Natural Published 15 Jan 2006
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 13 Jan 2006
Individual at Parc HMP Parc Natural Published 13 Jan 2006
Individual at Leeds HMP Leeds Natural Published 11 Jan 2006
Individual at Channings Wood HMP Channings Wood Natural Published 10 Jan 2006
Individual at Altcourse HMP Altcourse Other Published 8 Jan 2006
Individual at Holme House HMP Holme House Self-inflicted Published 7 Jan 2006
Individual at Whatton HMP Whatton Natural Published 6 Jan 2006
Individual at Manchester HMP Manchester Self-inflicted Published 5 Jan 2006
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 29 Dec 2005
Individual at Preston HMP Preston Self-inflicted Published 27 Dec 2005
Individual at Wakefield HMP Wakefield Natural Published 22 Dec 2005
Individual at Cardiff HMP Cardiff Self-inflicted Published 22 Dec 2005
Individual at Nottingham HMP Nottingham Natural Published 20 Dec 2005
Individual at Coldingley HMP Coldingley Natural Published 20 Dec 2005
Individual at Leeds HMP Leeds Natural Published 18 Dec 2005
Individual at Swaleside HMP Swaleside Natural Published 17 Dec 2005
Individual at Belmarsh HMP Belmarsh Natural Published 15 Dec 2005
Individual at Peterborough HMP Peterborough Natural Published 12 Dec 2005
Individual at Lewes HMP Lewes Self-inflicted Published 11 Dec 2005
Individual at North Sea Camp HMP North Sea Camp Natural Published 6 Dec 2005
Individual at Birmingham HMP Birmingham Self-inflicted Published 6 Dec 2005
Individual at Belmarsh HMP Belmarsh Self-inflicted Published 1 Dec 2005
Individual at Winchester HMP Winchester Self-inflicted Published 29 Nov 2005
Individual at Luton Luton Other Published 20 Nov 2005
Individual at Holme House HMP Holme House Self-inflicted Published 20 Nov 2005
Individual at Woodhill HMP Woodhill Natural Published 18 Nov 2005
Individual at Risley HMP Risley Homicide Published 17 Nov 2005
Individual at St Josephs St Josephs Other Published 15 Nov 2005
Individual at Leeds HMP Leeds Natural Published 12 Nov 2005
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 11 Nov 2005
Individual at Parc HMP Parc Natural Published 10 Nov 2005