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
Michael Crews HMP Oakwood Natural Published 4 Jun 2024
Andrew Barraclough HMP Stafford Natural Published 30 May 2024
Malcolm Fairley HMP Hull Natural Published 28 May 2024
Eric Pyle HMP Littlehey Natural Published 28 May 2024 1
Lewis Brown HMP Birmingham Self-inflicted Published 27 May 2024 3
David Baxter HMP Wealstun Natural Published 26 May 2024 5
Michael Johnson HMP Altcourse Other Published 25 May 2024
Daniel Evans HMP Stoke Heath Natural Published 22 May 2024
Edward Lomas HMP Pentonville Self-inflicted Published 22 May 2024 4
Jamie Scargill HMP Lincoln Self-inflicted Published 20 May 2024
Rakeem Malik HMP Long Lartin Natural Published 20 May 2024 1
Catherine Botwright HMP/YOI New Hall Natural Published 18 May 2024 1
Helena Viljoen HMP Bronzefield Natural Published 17 May 2024
Sebastian Szlaski HMP Long Lartin Natural Published 17 May 2024
Daniel Swierczek HMP Ranby Other Published 17 May 2024
Richard Keeling HMP Stafford Natural Published 17 May 2024
Brian Burrows HMP Leeds Self-inflicted Published 15 May 2024 3
Igor Vujkovic HMP Maidstone Natural Published 11 May 2024 4
David Maggs HMP/YOI Parc Natural Published 7 May 2024 1
Stephen Jones HMP Peterborough Natural Published 5 May 2024 3
Victor Farrant HMP Wakefield Natural Published 3 May 2024
Robert Connolly HMP Featherstone Self-inflicted Published 29 Apr 2024
Rhys Willis HMP Cardiff Other Published 29 Apr 2024
Renny Edwards HMP Swansea Other Published 25 Apr 2024 1
Stephen Dixon HMP Nottingham Other Published 23 Apr 2024
James Murphy HMP Brixton Other Published 23 Apr 2024
Lee Amos HMP Oakwood Natural Published 22 Apr 2024
Raymond Cheshire HMP Peterborough Natural Published 21 Apr 2024
Richard Cosgrove HMP Humber Other Published 18 Apr 2024 2
Victor Todd HMP/YOI Moorland Natural Published 14 Apr 2024
Anthony Payne HMP Forest Bank Other Published 8 Apr 2024
Ross Parker HMP Holme House Other Published 7 Apr 2024
Malcolm Burwood HMP Holme House Natural Published 7 Apr 2024
Damian Round HMP Nottingham Natural Published 7 Apr 2024
Mark Johnston HMP Swansea Other Published 7 Apr 2024 2
David Leary HMP Wymott Natural Published 5 Apr 2024
Luke Sykes HMP Ranby Self-inflicted Published 5 Apr 2024
Rana Khan HMP Wandsworth Natural Published 5 Apr 2024 4
Graham Daggett HMP Lincoln Natural Published 3 Apr 2024 1
Sean Spencer Ty Newydd Approved Premises Other Published 31 Mar 2024
David Pates HMP Birmingham Natural Published 28 Mar 2024
William Jolly HMP Wymott Natural Published 26 Mar 2024
David Butler HMP Holme House Natural Published 25 Mar 2024
Kenneth Barnes HMP Manchester Natural Published 25 Mar 2024
Bernard Grace HMP Forest Bank Natural Published 25 Mar 2024
Stephen Smith HMP Liverpool Natural Published 24 Mar 2024 2
Barry Rossiter HMP Northumberland Natural Published 23 Mar 2024 2
Neil McCarthy HMP Hollesley Bay Other Published 20 Mar 2024
Garth Walker HMP Altcourse Natural Published 17 Mar 2024
Mohammed Ahmed HMP Frankland Self-inflicted Published 13 Mar 2024