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 Dartmoor HMP Dartmoor Self-inflicted Published 23 Aug 2004
Individual at Parc HMP Parc Natural Published 21 Aug 2004
Individual at Kingston HMP Kingston Natural Published 20 Aug 2004
Individual at Southwood Southwood Self-inflicted Published 17 Aug 2004
Individual at Shrewsbury HMP Shrewsbury Self-inflicted Published 16 Aug 2004
Individual at Exeter HMP Exeter Self-inflicted Published 14 Aug 2004
Individual at Leeds HMP Leeds Self-inflicted Published 12 Aug 2004
Individual at Wakefield HMP Wakefield Self-inflicted Published 11 Aug 2004
Individual at Rye Hill HMP Rye Hill Natural Published 9 Aug 2004
Individual at Hassockfield Hassockfield Self-inflicted Published 9 Aug 2004
Individual at Elmley HMP Elmley Self-inflicted Published 8 Aug 2004
Individual at Birmingham HMP Birmingham Self-inflicted Published 8 Aug 2004
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 7 Aug 2004
Individual at Stafford HMP Stafford Natural Published 7 Aug 2004
Individual at Westbourne House Westbourne House Natural Published 3 Aug 2004
Individual at Eastwood Park HMP Eastwood Park Natural Published 1 Aug 2004
Individual at Winchester HMP Winchester Natural Published 31 Jul 2004
Individual at Braley House Braley House Other Published 31 Jul 2004
Individual at Kingston HMP Kingston Natural Published 31 Jul 2004
Individual at New Hall HMP New Hall Self-inflicted Published 29 Jul 2004
Individual at Blakenhurst HMP Blakenhurst Self-inflicted Published 27 Jul 2004
Individual at Low Newton HMP Low Newton Self-inflicted Published 27 Jul 2004
Individual at Wymott HMP Wymott Natural Published 26 Jul 2004
Individual at Liverpool HMP Liverpool Self-inflicted Published 26 Jul 2004
Individual at Dungavel IRC Dungavel Self-inflicted Published 23 Jul 2004
Individual at Leicester HMP Leicester Natural Published 18 Jul 2004
Individual at Harmondsworth IRC Harmondsworth Self-inflicted Published 18 Jul 2004
Individual at Discretionary HMP Discretionary Other Published 16 Jul 2004
Individual at The Weare HMP The Weare Natural Published 10 Jul 2004
Individual at Kingston HMP Kingston Natural Published 7 Jul 2004
Individual at High Down HMP High Down Self-inflicted Published 7 Jul 2004
Individual at Bridge House Bridge House Other Published 6 Jul 2004
Individual at Shepton Mallet HMP Shepton Mallet Natural Published 6 Jul 2004
Individual at Belmarsh HMP Belmarsh Natural Published 4 Jul 2004
Individual at Bristol HMP Bristol Natural Published 4 Jul 2004
Individual at Manchester HMP Manchester Self-inflicted Published 3 Jul 2004
Individual at Parc HMP Parc Natural Published 3 Jul 2004
Individual at Hull HMP Hull Natural Published 1 Jul 2004
Individual at Kingston HMP Kingston Natural Published 30 Jun 2004
Individual at Whatton HMP Whatton Natural Published 28 Jun 2004
Individual at Bristol HMP Bristol Natural Published 27 Jun 2004
Individual at Pentonville HMP Pentonville Self-inflicted Published 25 Jun 2004
Individual at Durham HMP Durham Natural Published 25 Jun 2004
Individual at Bristol HMP Bristol Self-inflicted Published 23 Jun 2004
Individual at Dickson House Dickson House Other Published 23 Jun 2004
Individual at Bristol HMP Bristol Natural Published 23 Jun 2004
Individual at Holloway HMP Holloway Natural Published 22 Jun 2004
Individual at Isle of Wight HMP Isle of Wight Natural Published 22 Jun 2004
Individual at Southwood Southwood Natural Published 21 Jun 2004
Individual at Manchester HMP Manchester Self-inflicted Published 21 Jun 2004