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 Elmley HMP Elmley Natural Published 9 Nov 2005
Individual at Swansea HMP Swansea Natural Published 7 Nov 2005
Individual at Merseybank Merseybank Self-inflicted Published 6 Nov 2005
Individual at Norwich HMP Norwich Natural Published 6 Nov 2005
Individual at Manchester HMP Manchester Natural Published 5 Nov 2005
Individual at Forest Bank HMP Forest Bank Natural Published 4 Nov 2005
Individual at Frankland HMP Frankland Natural Published 2 Nov 2005
Individual at High Down HMP High Down Natural Published 31 Oct 2005
Individual at Beckenham Road Beckenham Road Other Published 31 Oct 2005
Individual at Rye Hill HMP Rye Hill Natural Published 29 Oct 2005
Individual at Holloway HMP Holloway Self-inflicted Published 28 Oct 2005
Individual at Isle of Wight HMP Isle of Wight Natural Published 26 Oct 2005
Individual at Pentonville HMP Pentonville Self-inflicted Published 25 Oct 2005
Individual at Acklington HMP Acklington Natural Published 24 Oct 2005
Individual at Isle of Wight HMP Isle of Wight Natural Published 22 Oct 2005
Individual at Holme House HMP Holme House Natural Published 22 Oct 2005
Individual at Bronzefield HMP Bronzefield Natural Published 20 Oct 2005
Individual at Channings Wood HMP Channings Wood Natural Published 14 Oct 2005
Individual at Winchester HMP Winchester Natural Published 8 Oct 2005
Individual at Rye Hill HMP Rye Hill Natural Published 5 Oct 2005
Individual at Elmley HMP Elmley Other Published 5 Oct 2005
Individual at Swaleside HMP Swaleside Natural Published 2 Oct 2005
Individual at Pentonville HMP Pentonville Natural Published 2 Oct 2005
Individual at Norwich HMP Norwich Self-inflicted Published 30 Sep 2005
Individual at Manchester HMP Manchester Self-inflicted Published 22 Sep 2005
Individual at Woodhill HMP Woodhill Natural Published 21 Sep 2005
Individual at Guys Marsh HMP Guys Marsh Other Published 20 Sep 2005
Individual at Doncaster HMP Doncaster Self-inflicted Published 20 Sep 2005
Individual at Bronzefield HMP Bronzefield Natural Published 18 Sep 2005
Individual at Sudbury HMP Sudbury Natural Published 17 Sep 2005
Individual at Ashwell HMP Ashwell Natural Published 17 Sep 2005
Individual at Belmarsh HMP Belmarsh Natural Published 16 Sep 2005
Individual at Full Sutton HMP Full Sutton Homicide Published 16 Sep 2005
Individual at Yarls Wood IRC Yarls Wood Self-inflicted Published 15 Sep 2005
Individual at Hindley HMP Hindley Self-inflicted Published 15 Sep 2005
Individual at Wymott HMP Wymott Self-inflicted Published 14 Sep 2005
Individual at Wakefield HMP Wakefield Natural Published 10 Sep 2005
Individual at Chelmsford HMP Chelmsford Natural Published 9 Sep 2005
Individual at Reading HMP Reading Self-inflicted Published 7 Sep 2005
Individual at Elmley HMP Elmley Natural Published 7 Sep 2005
Individual at Altcourse HMP Altcourse Natural Published 1 Sep 2005
Individual at Bedford HMP Bedford Self-inflicted Published 1 Sep 2005
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 29 Aug 2005
Individual at Linden Bank Linden Bank Other Published 26 Aug 2005
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 26 Aug 2005
Individual at Isle of Wight HMP Isle of Wight Natural Published 24 Aug 2005
Individual at Durham HMP Durham Natural Published 23 Aug 2005
Individual at Leeds HMP Leeds Self-inflicted Published 21 Aug 2005
Individual at Durham HMP Durham Self-inflicted Published 21 Aug 2005
Individual at Wymott HMP Wymott Natural Published 20 Aug 2005