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
Kim Chapman HMP Send Natural Published 6 Jan 2024 1
Darren Boamah HMP Wormwood Scrubs Natural Published 3 Jan 2024 2
Clive Manning HMP Swaleside Natural Published 31 Dec 2023
David Howarth HMP Full Sutton Natural Published 30 Dec 2023 1
John Kelk HMP Wakefield Natural Published 30 Dec 2023 2
Azhar Hussain HMP Bedford Natural Published 27 Dec 2023 1
Robert Astley HMP Norwich Natural Published 27 Dec 2023
Dean Sheppard HMP Stoke Heath Natural Published 25 Dec 2023
Dean Holland HMP Featherstone Natural Published 22 Dec 2023
Scott Walker HMP Full Sutton Natural Published 22 Dec 2023 1
Greg Coleman HMP Wealstun Other Published 21 Dec 2023
John Foreman HMP/YOI Doncaster Natural Published 20 Dec 2023
Paul Pesticcio HMP/YOI Parc Natural Published 19 Dec 2023 1
Isa Sule HMP/YOI High Down Self-inflicted Published 19 Dec 2023 1
John Rigby HMP Wymott Natural Published 17 Dec 2023 4
Patrick Mugford HMP Littlehey Natural Published 17 Dec 2023
Jamie Funnell HMP Lewes Other Published 16 Dec 2023 3
John Robinson HMP Lancaster Farms Other Published 14 Dec 2023
Frederick Stallwood HMP Littlehey Natural Published 10 Dec 2023
Amos Ndemo HMP Norwich Self-inflicted Published 10 Dec 2023
Derek Holmes HMP Birmingham Natural Published 8 Dec 2023
Jack Edwards Trent House Approved Premises Homicide Published 8 Dec 2023
Alan Giles HMP Wayland Other Published 7 Dec 2023
Lance Winkle Elm Bank Approved Premises Self-inflicted Published 5 Dec 2023
Jason McDonagh HMP Five Wells Natural Published 4 Dec 2023
Stephen Hopkins HMP Cardiff Natural Published 2 Dec 2023
Jason Cutts HMP Norwich Natural Published 30 Nov 2023
Aaron Gornall HMP Holme House Other Published 30 Nov 2023
Martin Collins HMP Highpoint Self-inflicted Published 25 Nov 2023 1
Matthew Osborne HMP Lowdham Grange Self-inflicted Published 25 Nov 2023 1
Hughie Hendry HMP/YOI Doncaster Other Published 25 Nov 2023
Ellis Wood HMP Lincoln Other Published 24 Nov 2023 2
Sidney Hughes HMP Wymott Natural Published 24 Nov 2023 2
Farokh Sahab HMP Wormwood Scrubs Natural Published 24 Nov 2023
John Evans HMP Stocken Natural Published 24 Nov 2023
Melvin Grant HMP Bedford Self-inflicted Published 21 Nov 2023 3
Jason Barnes HMP Elmley Natural Published 21 Nov 2023
David Budd HMP Hollesley Bay Natural Published 21 Nov 2023
Simon Faherty HMP Elmley Self-inflicted Published 20 Nov 2023 4
Alfred Dosku Brook House Immigration Removal Centre Self-inflicted Published 17 Nov 2023
Solomon Bamidele HMP Pentonville Natural Published 16 Nov 2023 2
Paul Roberts HMP Preston Self-inflicted Published 14 Nov 2023 1
Wolten, Alan HMP Liverpool Natural Published 10 Nov 2023
Graham Williams HMP Prescoed Natural Published 10 Nov 2023
Terence Lobb HMP Oakwood Natural Published 10 Nov 2023
Damian Bugno-Swierz HMP Wandsworth Self-inflicted Published 7 Nov 2023
Ian Bains Ozanam House Approved Premises Self-inflicted Published 6 Nov 2023
Haigh, Glen HMP Stafford Natural Published 3 Nov 2023
Alan Knight HMP Lowdham Grange Natural Published 2 Nov 2023
Josh Tarrant HMP Elmley Other Published 1 Nov 2023 2