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
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
Damian Round HMP Nottingham Natural Published 7 Apr 2024
Ross Parker HMP Holme House Other Published 7 Apr 2024
Malcolm Burwood HMP Holme House Natural Published 7 Apr 2024
Mark Johnston HMP Swansea Other Published 7 Apr 2024 2
Rana Khan HMP Wandsworth Natural Published 5 Apr 2024 4
Luke Sykes HMP Ranby Self-inflicted Published 5 Apr 2024
David Leary HMP Wymott Natural Published 5 Apr 2024
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
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
Terrence Clover HMP Swaleside Natural Published 27 Feb 2024 1
John Rose HMP/YOI Parc Natural Published 27 Feb 2024
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
Edward Hands HMP Bedford Other Published 16 Feb 2024 4
Marc Walker HMP Nottingham Natural Published 16 Feb 2024
Ashley Ferrie HMP Fosse Way Self-inflicted Published 13 Feb 2024 3
Jackie Stewart-Murphy HMP Whatton Natural Published 11 Feb 2024 1
James Maughan Trent House Approved Premises Other Published 11 Feb 2024
Mani Kurian Kattampakkal HMP Littlehey Self-inflicted Published 9 Feb 2024
Kyle Tyler HMP/YOI High Down Other Published 8 Feb 2024 1
Dean Gathercole HMP Littlehey Natural Published 8 Feb 2024
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