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 Gloucester HMP Gloucester Natural Published 2 Jun 2005
Individual at Withington Road Withington Road Natural Published 1 Jun 2005
Individual at Lowdham Grange HMP Lowdham Grange Natural Published 31 May 2005
Individual at Parc HMP Parc Natural Published 30 May 2005
Individual at Ealing Ealing Self-inflicted Published 29 May 2005
Individual at Wormwood Scrubs HMP Wormwood Scrubs Natural Published 28 May 2005
Individual at Wandsworth HMP Wandsworth Natural Published 21 May 2005
Individual at Kirkham HMP Kirkham Natural Published 20 May 2005
Individual at Rye Hill HMP Rye Hill Natural Published 17 May 2005
Individual at Leicester HMP Leicester Self-inflicted Published 17 May 2005
Individual at Swansea HMP Swansea Self-inflicted Published 15 May 2005
Individual at Forest Bank HMP Forest Bank Other Published 11 May 2005
Individual at Guys Marsh HMP Guys Marsh Natural Published 9 May 2005
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 8 May 2005
Individual at St Johns St Johns Other Published 4 May 2005
Individual at Linden Bank Linden Bank Self-inflicted Published 29 Apr 2005
Individual at Frankland HMP Frankland Natural Published 28 Apr 2005
Individual at Gloucester HMP Gloucester Self-inflicted Published 28 Apr 2005
Individual at Lewes HMP Lewes Natural Published 27 Apr 2005
Individual at Chorlton Chorlton Other Published 22 Apr 2005
Individual at Wakefield HMP Wakefield Natural Published 19 Apr 2005
Individual at Brixton HMP Brixton Self-inflicted Published 19 Apr 2005
Individual at Swaleside HMP Swaleside Natural Published 17 Apr 2005
Individual at Rye Hill HMP Rye Hill Homicide Published 13 Apr 2005
Individual at St Leonards St Leonards Self-inflicted Published 11 Apr 2005
Individual at Braley House Braley House Self-inflicted Published 2 Apr 2005
Individual at Usk and Prescoed HMP Usk and Prescoed Natural Published 2 Apr 2005
Individual at Lowdham Grange HMP Lowdham Grange Self-inflicted Published 27 Mar 2005
Individual at Woodhill HMP Woodhill Natural Published 25 Mar 2005
Individual at Rye Hill HMP Rye Hill Self-inflicted Published 24 Mar 2005
Individual at Wakefield HMP Wakefield Self-inflicted Published 20 Mar 2005
Individual at Liverpool HMP Liverpool Other Published 20 Mar 2005
Individual at Chelmsford HMP Chelmsford Self-inflicted Published 20 Mar 2005
Individual at Leeds HMP Leeds Self-inflicted Published 19 Mar 2005
Individual at Hull HMP Hull Other Published 18 Mar 2005
Individual at Oakington IRC Oakington Natural Published 14 Mar 2005
Individual at Full Sutton HMP Full Sutton Self-inflicted Published 13 Mar 2005
Individual at Elmley HMP Elmley Natural Published 12 Mar 2005
Individual at Leeds HMP Leeds Natural Published 11 Mar 2005
Individual at Manchester HMP Manchester Natural Published 9 Mar 2005
Individual at Wandsworth HMP Wandsworth Natural Published 9 Mar 2005
Individual at Preston HMP Preston Self-inflicted Published 9 Mar 2005
Individual at Bullingdon HMP Bullingdon Natural Published 8 Mar 2005
Individual at Holloway HMP Holloway Other Published 8 Mar 2005
Individual at Holme House HMP Holme House Self-inflicted Published 5 Mar 2005
Individual at Pentonville HMP Pentonville Natural Published 2 Mar 2005
Individual at Wymott HMP Wymott Natural Published 1 Mar 2005
Individual at Acklington HMP Acklington Natural Published 26 Feb 2005
Individual at Frankland HMP Frankland Natural Published 25 Feb 2005
Individual at Gloucester HMP Gloucester Self-inflicted Published 21 Feb 2005