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
William Dawson HMP Holme House Natural Published 11 Mar 2024 2
Shyrel Grant HMP/YOI Drake Hall Other Published 10 Mar 2024
Dominic Davies HMP Bullingdon Other Published 9 Mar 2024
Taklus Hussain HMP Littlehey Natural Published 8 Mar 2024 2
Scott Howley HMP Wealstun Self-inflicted Published 6 Mar 2024 1
Anthony Bancroft HMP Stocken Natural Published 5 Mar 2024
Jason Rae HMP Forest Bank Natural Published 4 Mar 2024
John Rose HMP/YOI Parc Natural Published 27 Feb 2024
Terrence Clover HMP Swaleside Natural Published 27 Feb 2024 1
Abdul Ghani HMP The Mount Natural Published 25 Feb 2024
Raymond Hodges HMP Usk Natural Published 24 Feb 2024
Lisa Docherty HMP Peterborough Other Published 21 Feb 2024
Mohamed Izem Harmondsworth Immigration Removal Centre Other Published 20 Feb 2024
Alan Burnell HMP The Verne Natural Published 17 Feb 2024
Marc Walker HMP Nottingham Natural Published 16 Feb 2024
Edward Hands HMP Bedford Other Published 16 Feb 2024 4
Ashley Ferrie HMP Fosse Way Self-inflicted Published 13 Feb 2024 3
James Maughan Trent House Approved Premises Other Published 11 Feb 2024
Jackie Stewart-Murphy HMP Whatton Natural Published 11 Feb 2024 1
Mani Kurian Kattampakkal HMP Littlehey Self-inflicted Published 9 Feb 2024
Dean Gathercole HMP Littlehey Natural Published 8 Feb 2024
Kyle Tyler HMP/YOI High Down Other Published 8 Feb 2024 1
David Smith HMP Northumberland Other Published 8 Feb 2024 1
Sean Higgins HMP Rochester Self-inflicted Published 7 Feb 2024 6
Kevin Porter HMP Wandsworth Natural Published 6 Feb 2024
Mark Woolley HMP Wayland Natural Published 5 Feb 2024
Tony Williams HMP Littlehey Natural Published 4 Feb 2024
Brian Field HMP Full Sutton Natural Published 4 Feb 2024 1
John Thirling HMP/YOI Moorland Natural Published 3 Feb 2024
Paul Mallin HMP/YOI High Down Natural Published 3 Feb 2024
Henry Bangs HMP Frankland Natural Published 2 Feb 2024 2
Stuart Berry HMP Chelmsford Self-inflicted Published 1 Feb 2024 3
John Leadbitter HMP Hull Natural Published 31 Jan 2024 3
Kevin Kane HMP Grendon Self-inflicted Published 29 Jan 2024 3
Kevan Mulligan HMP Forest Bank Natural Published 29 Jan 2024
James Green Elm Bank Approved Premises Self-inflicted Published 27 Jan 2024
Colin Evans HMP Full Sutton Natural Published 26 Jan 2024
Brian Nichols HMP Whatton Natural Published 23 Jan 2024
Gerard Browne HMP Wymott Natural Published 19 Jan 2024 3
Daniel Fielding HMP Liverpool Self-inflicted Published 19 Jan 2024 6
Colin Cambray HMP Haverigg Natural Published 19 Jan 2024
Patryk Gladysz HMP Wandsworth Self-inflicted Published 19 Jan 2024 3
Kevin Noel HMP Leyhill Natural Published 18 Jan 2024 2
George Rose HMP Wymott Natural Published 18 Jan 2024
Nathan Shepherd Ascot House Approved Premises Self-inflicted Published 16 Jan 2024 3
Kevin Giles HMP Hollesley Bay Natural Published 13 Jan 2024 1
Lawrence Johnson HMP Frankland Natural Published 13 Jan 2024 3
Leanne Lytollis HMP/YOI New Hall Other Published 13 Jan 2024
Frederick Williams HMP The Verne Natural Published 12 Jan 2024 2
Gerald Raffell HMP Littlehey Natural Published 9 Jan 2024