Source · Deaths in custody

PPO Fatal Incident Reports

6,395 incidents 5,660 published 1,165 recommendations 1,632 self-inflicted 3,362 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 21: Segregation Learning Lessons Bulletin Mar 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 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 2023-24 Annual report Jul 2024 PDF
Annual report 2022-23 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

6,395 records
Name Establishment Cause Status Date of death Recs
Lee Gowton HMP Bristol Pending inquest
Lawrence Hunter HMP Ranby Pending inquest
Jacob Bean HMP Rochester Pending inquest
Nicholas Brown HMP Isle of Wight Pending inquest
Matthew Pickles HMP/YOI High Down In progress
John Hyde HMP/YOI Parc Pending inquest
Wesley Martin HMP Lincoln Pending inquest
Jack Bawden HMP Chelmsford In progress
Robert Harvey HMP Durham In progress
Robert Henry Royan HMP/YOI Parc Pending inquest
Lisa Clarke HMP/YOI Styal In progress
Benjamin Onyeabo HMP Pentonville Self-inflicted Published
Pawel Kowalski HMP Winchester Pending inquest
James Nanson HMP Northumberland In progress
Colleen Madden HMP Bronzefield Pending inquest
Michael Jones HMP Liverpool Pending inquest
Lucal Brady HMP Isle of Wight Natural Published
Scott Sansome HMP Cardiff Pending inquest
Gary Cooper HMP Littlehey In progress
Tristan Roberts HMP Exeter Pending inquest
Jason Sedgwick HMP Littlehey Pending inquest
Louis Maniatt Ty Newydd Approved Premises Pending inquest
Adrian Stanton HMP Featherstone Pending inquest
Sarah Jackson HMP/YOI Styal Pending inquest
Wayne Hay HMP/YOI Parc Pending inquest
Gary Winters HMP Whatton Natural Published
Ivor Manton HMP Chelmsford In progress
Theophile Kaliviotis Brook House Immigration Removal Centre Pending inquest
Manuel Bello Box Tree Cottage Approved Premises Pending inquest
David Stingemore HMP Isle of Wight In progress
Raymond Billam HMP/YOI Moorland In progress
Michael Maharaj HMP Brixton Pending inquest
Lee Sentance HMP Lincoln Pending inquest
Simon Kubalik HMP/YOI Doncaster Pending inquest
James Smyth HMP Gartree Pending inquest
Baby D HMP Peterborough Natural Published
Aleksandras Maslennikovas HMP Wandsworth Pending inquest
Andrew Cooper HMP Winchester Pending inquest
Lloyd Ramsbottom HMP Stoke Heath In progress
John Mclaren HMP Hull In progress
Thomas Haigh HMP Manchester In progress
Stanley Brown HMP Liverpool In progress
Christopher Anderson HMP Dovegate Pending inquest
Ian Coates HMP Deerbolt In progress
Michael Fabian HMP Winchester Natural Published
Derrion Adams HMP Birmingham Pending inquest
Ian Huntley HMP Frankland In progress
Thomas Griffiths Pending inquest
Jamie Evans HMP Kirkham In progress
Piran Khan HMP Wakefield Pending inquest