Source · Deaths in custody

PPO Fatal Incident Reports

6,470 incidents 5,745 published 1,502 recommendations 1,653 self-inflicted 3,404 natural causes

Deaths in custody investigated by the Prisons and Probation Ombudsman. 26% of deaths are self-inflicted. Source: PPO.

Learning & thematic publications

75 cross-establishment publications

Learning Lessons Bulletins (50), thematic reviews (2), consultation responses (11), Policy into Practice (5) and annual reports (7): the systemic patterns the Ombudsman draws from many investigations.

TitleTypeDateSource
Annual Report 2025 to 2026 Annual report Jul 2026 PDF
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 inquiry into Rehabilitation and Resettlement Consultation response Feb 2025 PDF
PPO response to JHAC Inquiry into Prison Culture Consultation response Feb 2025 PDF
PPO response to JSC Tackling Drugs in Prison Inquiry 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
Fatal Incident Investigations Learning Lessons Bulletin Issue 17: Post-release death investigations Learning Lessons Bulletin Jan 2023 PDF
Investigating deaths after release from prison – a pilot evaluation 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

Incidents

6,470 records
Name Establishment Cause Status Date of death Recs
Stanley Richardson HMP Garth Pending inquest
Isaiah Olugosi HMP Wormwood Scrubs Pending inquest
Michael Fensom HMP Littlehey Pending inquest
William Clark HMP Wormwood Scrubs Pending inquest
Liban Bore HMP Belmarsh Pending inquest
Matthew Harris HMP Hull Pending inquest
Thomas James HMP Wandsworth In progress
John Shannon HMP Bure In progress
Jordan Harvey HMP Humber Pending inquest
David Ridgeway HMP/YOI Parc Pending inquest
Vasilev Pachev HMP Wormwood Scrubs Pending inquest
Andrew Thompson HMP/YOI Doncaster Natural Published
Colin McSweeny HMP Gartree Pending inquest
Ben Merritt In progress
John Cox HMP Bristol Pending inquest
Matthew Bryant HMP Channings Wood In progress
Dean Boness In progress
Daniel Serban HMP Lewes Pending inquest
Stephen Ansbro HMP Frankland In progress
Rebecca Oliver HMP Wakefield In progress
Thomas McMurray HMP Brixton Pending inquest
David Jervis HMP Liverpool Pending inquest
Daniel Farrier HMP Garth In progress
Lawrence Hunter HMP Ranby Pending inquest
Warren Manners HMP/YOI Parc Pending inquest
Wayne Cooper HMP Onley Pending inquest
Emma Borowy HMP/YOI New Hall Pending inquest
Scarlet Witch HMP Send Pending inquest
Colin Clapham HMP Littlehey In progress
William Hardacre HMP Nottingham In progress
Lisa Clarke HMP/YOI Styal In progress
Mark Merron HMP Gartree Pending inquest
Shamraze Hussain HMP/YOI Doncaster In progress
Brian Sheridan HMP Liverpool In progress
Tony Phillips HMP Frankland In progress
Jonathan Ross HMP Highpoint Pending inquest
William Glasgow HMP Wymott Pending inquest
Thomas Brain HMP Winchester In progress
Moses Hailemichel HMP Pentonville Pending inquest
John Bain HMP The Mount Pending inquest
Radoslaw Czubinski HMP Hull Pending inquest
Wesley Martin HMP Lincoln Pending inquest
Andrew Newton HMP Leicester In progress
Kamal Uddin HMP Wandsworth In progress
Leslie Fry HMP Hewell In progress
Leon Coombes HMP Winchester Pending inquest
Norman Heaton HMP Full Sutton Natural Published
Thomas Spry HMP Frankland In progress
Ryan Martin HMP Winchester Pending inquest
Ian Henderson HMP Isle of Wight Natural Published