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 Glen Parva HMP Glen Parva Self-inflicted Published 19 Aug 2005
Individual at Isle of Wight HMP Isle of Wight Natural Published 19 Aug 2005
Individual at Westbourne House Westbourne House Other Published 17 Aug 2005
Individual at Rye Hill HMP Rye Hill Natural Published 9 Aug 2005
Individual at Onley HMP Onley Self-inflicted Published 9 Aug 2005
Individual at Swaleside HMP Swaleside Natural Published 7 Aug 2005
Individual at Stonnall Road Stonnall Road Natural Published 2 Aug 2005
Individual at Liverpool HMP Liverpool Self-inflicted Published 2 Aug 2005
Individual at Woodhill HMP Woodhill Self-inflicted Published 1 Aug 2005
Individual at Norwich HMP Norwich Self-inflicted Published 29 Jul 2005
Individual at Altcourse HMP Altcourse Self-inflicted Published 29 Jul 2005
Individual at Castington HMP Castington Other Published 28 Jul 2005
Individual at Glen Parva HMP Glen Parva Self-inflicted Published 28 Jul 2005
Individual at Birmingham HMP Birmingham Natural Published 25 Jul 2005
Individual at Dartmoor HMP Dartmoor Natural Published 24 Jul 2005
Individual at Holme House HMP Holme House Natural Published 23 Jul 2005
Individual at Woodhill HMP Woodhill Self-inflicted Published 20 Jul 2005
Individual at Blakenhurst HMP Blakenhurst Natural Published 16 Jul 2005
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 13 Jul 2005
Individual at Altcourse HMP Altcourse Self-inflicted Published 12 Jul 2005
Individual at Altcourse HMP Altcourse Self-inflicted Published 11 Jul 2005
Individual at Stocken HMP Stocken Natural Published 10 Jul 2005
Individual at Altcourse HMP Altcourse Natural Published 8 Jul 2005
Individual at Norwich HMP Norwich Self-inflicted Published 5 Jul 2005
Individual at Nottingham HMP Nottingham Self-inflicted Published 4 Jul 2005
Individual at Reading HMP Reading Self-inflicted Published 3 Jul 2005
Individual at Ranby HMP Ranby Self-inflicted Published 30 Jun 2005
Individual at Campsfield House IRC Campsfield House Self-inflicted Published 27 Jun 2005
Individual at Liverpool HMP Liverpool Self-inflicted Published 26 Jun 2005
Individual at Reading HMP Reading Self-inflicted Published 26 Jun 2005
Individual at Ashley House Ashley House Self-inflicted Published 24 Jun 2005
Individual at Liverpool HMP Liverpool Self-inflicted Published 21 Jun 2005
Individual at Kirkham HMP Kirkham Natural Published 19 Jun 2005
Individual at Pentonville HMP Pentonville Self-inflicted Published 15 Jun 2005
Individual at Durham HMP Durham Self-inflicted Published 15 Jun 2005
Individual at Dorchester HMP Dorchester Self-inflicted Published 14 Jun 2005
Individual at Gloucester HMP Gloucester Self-inflicted Published 14 Jun 2005
Individual at Leicester HMP Leicester Self-inflicted Published 13 Jun 2005
Individual at Pentonville HMP Pentonville Self-inflicted Published 12 Jun 2005
Individual at Liverpool HMP Liverpool Self-inflicted Published 11 Jun 2005
Individual at Norwich HMP Norwich Self-inflicted Published 11 Jun 2005
Individual at Liverpool HMP Liverpool Self-inflicted Published 9 Jun 2005
Individual at Acklington HMP Acklington Natural Published 8 Jun 2005
Individual at Wymott HMP Wymott Natural Published 8 Jun 2005
Individual at Isle of Wight HMP Isle of Wight Natural Published 6 Jun 2005
Individual at Bristol HMP Bristol Self-inflicted Published 5 Jun 2005
Individual at Littlehey HMP Littlehey Natural Published 4 Jun 2005
Individual at Eastwood Park HMP Eastwood Park Other Published 4 Jun 2005
Individual at Gloucester HMP Gloucester Self-inflicted Published 3 Jun 2005
Individual at The Weare HMP The Weare Self-inflicted Published 3 Jun 2005