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
Steven Cleverley HMP The Verne In progress
Ian Delaney HMP Frankland In progress
Victor Fisher HMP Stoke Heath In progress
Eduard Millar HMP Wymott In progress
Reece Grinnell HMP Leeds In progress
Reginald Robinson HMP The Verne In progress
Anthony Doyle HMP Altcourse Pending inquest
Andrew Newton HMP Leicester In progress
Takauda Zinyoro HMP Stocken Pending inquest
Steven Wood HMP Frankland Pending inquest
Luke Kelsall HMP/YOI Portland Pending inquest
Darren Cleaver HMP/YOI Portland In progress
Jason Hayward HMP Birmingham In progress
Paul Griffiths HMP Wymott In progress
Anthony Chetham HMP Millsike Pending inquest
David Holyoak HMP Berwyn Pending inquest
John Reay HMP Northumberland Pending inquest
Adam Clark HMP Hewell Pending inquest
Steven Mullen HMP Leeds Self-inflicted Published
Jordan Logan HMP Leeds In progress
Alfred Davies HMP Usk In progress
Anthony Povey HMP Whatton In progress
Daniel Farrier HMP Garth In progress
David Wood HMP Oakwood Pending inquest
Matthew Bouldin HMP Fosse Way In progress
Gary Cartwright HMP Wayland Pending inquest
Gerard Doyle HMP Lancaster Farms Other Published
Siobhan Osborne HMP/YOI Eastwood Park In progress
Lee Brown HMP Garth Pending inquest
Jonathan Thornton HMP Nottingham In progress
Laura Sharman HMP/YOI Drake Hall In progress
Ahmed Said HMP Wandsworth In progress
Michael Walls HMP Humber Pending inquest
Aaron Duffy HMP Isle of Wight In progress
Andrew Eggington HMP Altcourse Pending inquest
Wayne Cooper HMP Onley Pending inquest
John Wilkes HMP Fosse Way Pending inquest
Roger Robinson Guernsey Prison In progress
Paul Charmley HMP Altcourse In progress
Nigel Keenan HMP Haverigg Pending inquest
Quang Nguyen HMP Thameside Pending inquest
Michael King Brigstocke Road Approved Premises Pending inquest
Darren Salituri Guernsey Prison In progress
Liban Bore HMP Belmarsh Pending inquest
Jordan Tams HMP Deerbolt In progress
Matthew Toms HMP Guys Marsh Pending inquest
Simon Dunn HMP Garth Self-inflicted Published 4
Jordan Nuttall HMP Gartree In progress
Stephen Hughes HMP Northumberland In progress
Arthur Smith HMP Wakefield Natural Published 1