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
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
Kevan Mulligan HMP Forest Bank Natural Published 29 Jan 2024
Kevin Kane HMP Grendon Self-inflicted Published 29 Jan 2024 3
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
Colin Cambray HMP Haverigg Natural Published 19 Jan 2024
Daniel Fielding HMP Liverpool Self-inflicted Published 19 Jan 2024 6
Patryk Gladysz HMP Wandsworth Self-inflicted Published 19 Jan 2024 3
Gerard Browne HMP Wymott Natural Published 19 Jan 2024 3
George Rose HMP Wymott Natural Published 18 Jan 2024
Kevin Noel HMP Leyhill Natural Published 18 Jan 2024 2
Nathan Shepherd Ascot House Approved Premises Self-inflicted Published 16 Jan 2024 3
Leanne Lytollis HMP/YOI New Hall Other Published 13 Jan 2024
Lawrence Johnson HMP Frankland Natural Published 13 Jan 2024 3
Kevin Giles HMP Hollesley Bay Natural Published 13 Jan 2024 1
Frederick Williams HMP The Verne Natural Published 12 Jan 2024 2
Gerald Raffell HMP Littlehey Natural Published 9 Jan 2024
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
John Kelk HMP Wakefield Natural Published 30 Dec 2023 2
David Howarth HMP Full Sutton Natural Published 30 Dec 2023 1
Robert Astley HMP Norwich Natural Published 27 Dec 2023
Azhar Hussain HMP Bedford Natural Published 27 Dec 2023 1
Dean Sheppard HMP Stoke Heath Natural Published 25 Dec 2023
Scott Walker HMP Full Sutton Natural Published 22 Dec 2023 1
Dean Holland HMP Featherstone Natural Published 22 Dec 2023
Greg Coleman HMP Wealstun Other Published 21 Dec 2023
John Foreman HMP/YOI Doncaster Natural Published 20 Dec 2023
Isa Sule HMP/YOI High Down Self-inflicted Published 19 Dec 2023 1
Paul Pesticcio HMP/YOI Parc Natural 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