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 Woodhill HMP Woodhill Self-inflicted Published 20 Jun 2004
Individual at Kirkham HMP Kirkham Natural Published 19 Jun 2004
Individual at Birmingham HMP Birmingham Natural Published 18 Jun 2004
Individual at Swaleside HMP Swaleside Natural Published 14 Jun 2004
Individual at Nottingham HMP Nottingham Self-inflicted Published 11 Jun 2004
Individual at Eastwood Park HMP Eastwood Park Natural Published 7 Jun 2004
Individual at Lewes HMP Lewes Natural Published 6 Jun 2004
Individual at Holme House HMP Holme House Other Published 6 Jun 2004
Individual at Foston Hall HMP Foston Hall Natural Published 2 Jun 2004
Individual at Buckley Hall HMP Buckley Hall Self-inflicted Published 1 Jun 2004
Individual at Maidstone HMP Maidstone Natural Published 30 May 2004
Individual at Whitemoor HMP Whitemoor Natural Published 26 May 2004
Individual at Shepton Mallet HMP Shepton Mallet Natural Published 26 May 2004
Individual at Hull HMP Hull Self-inflicted Published 25 May 2004
Individual at Lincoln HMP Lincoln Self-inflicted Published 25 May 2004
Individual at Durham HMP Durham Self-inflicted Published 24 May 2004
Individual at Chelmsford HMP Chelmsford Natural Published 22 May 2004
Individual at Wayland HMP Wayland Natural Published 21 May 2004
Individual at Lewes HMP Lewes Self-inflicted Published 19 May 2004
Individual at Blakenhurst HMP Blakenhurst Self-inflicted Published 18 May 2004
Individual at Leicester HMP Leicester Self-inflicted Published 15 May 2004
Individual at Lincoln HMP Lincoln Other Published 11 May 2004
Individual at Bridge House Bridge House Other Published 9 May 2004
Individual at Rye Hill HMP Rye Hill Natural Published 9 May 2004
Individual at Shrewsbury HMP Shrewsbury Self-inflicted Published 8 May 2004
Individual at Durham HMP Durham Self-inflicted Published 8 May 2004
Individual at Holloway HMP Holloway Self-inflicted Published 8 May 2004
Individual at Haverigg HMP Haverigg Natural Published 7 May 2004
Individual at Wakefield HMP Wakefield Natural Published 3 May 2004
Individual at Victoria House Victoria House Other Published 2 May 2004
Individual at Haslar IRC Haslar Natural Published 1 May 2004
Individual at St Christophers House St Christophers House Homicide Published 29 Apr 2004
Individual at Woodhill HMP Woodhill Self-inflicted Published 28 Apr 2004
Individual at Whatton HMP Whatton Natural Published 24 Apr 2004
Individual at Doncaster HMP Doncaster Other Published 21 Apr 2004
Individual at Holme House HMP Holme House Natural Published 20 Apr 2004
Individual at Send HMP Send Self-inflicted Published 18 Apr 2004
Individual at New Hall HMP New Hall Self-inflicted Published 18 Apr 2004
Individual at Holloway HMP Holloway Self-inflicted Published 17 Apr 2004
Individual at Liverpool HMP Liverpool Self-inflicted Published 16 Apr 2004
Individual at Wymott HMP Wymott Natural Published 15 Apr 2004
Individual at Frankland HMP Frankland Self-inflicted Published 15 Apr 2004
Individual at Hull HMP Hull Natural Published 11 Apr 2004
Individual at Preston HMP Preston Natural Published 10 Apr 2004
Individual at Pennywell Pennywell Natural Published 6 Apr 2004
Individual at Bristol HMP Bristol Natural Published 6 Apr 2004
Individual at Brockhill HMP Brockhill Self-inflicted Published 3 Apr 2004
Individual at Leeds HMP Leeds Homicide Published 2 Apr 2004
Individual at Wakefield HMP Wakefield Self-inflicted Published 13 Jan 2004
Individual at Styal HMP Styal Other Published 12 Aug 2003