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
Christopher Baptiste HMP Swaleside Other Published 31 Oct 2023 4
Thomas McMahon HMP Nottingham Other Published 31 Oct 2023 1
Michael Waters HMP Dartmoor Natural Published 29 Oct 2023
Jonathan Leask HMP Winchester Self-inflicted Published 28 Oct 2023
Frederick Vickery HMP Dartmoor Natural Published 27 Oct 2023
Davey Price HMP Forest Bank Self-inflicted Published 27 Oct 2023 3
Coleman, Kevin HMP Wymott Natural Published 25 Oct 2023
Karl Quincey HMP Wakefield Self-inflicted Published 21 Oct 2023 2
John Kenny HMP/YOI Parc Natural Published 21 Oct 2023 1
Roy Whitehouse HMP Oakwood Natural Published 21 Oct 2023 2
Scott Berry HMP Humber Self-inflicted Published 21 Oct 2023
Susan Truscott HMP Peterborough Natural Published 21 Oct 2023
George Haslam HMP Wymott Natural Published 21 Oct 2023 1
Raymond Catchpole HMP Durham Natural Published 20 Oct 2023
Sean Harknett HMP Rye Hill Natural Published 20 Oct 2023
Lucas Kidd HMP Ranby Other Published 19 Oct 2023 2
Jonathan Lawlor HMP Elmley Other Published 19 Oct 2023
Steven Lee HMP Preston Natural Published 19 Oct 2023 2
Daniel Beresford HMP Chelmsford Self-inflicted Published 15 Oct 2023 1
Andrew Hague HMP Wealstun Other Published 15 Oct 2023 2
Gavin Cox HMP Wymott Self-inflicted Published 14 Oct 2023 1
William Bissett HMP Wymott Self-inflicted Published 13 Oct 2023
Ricky Crosher HMP Lowdham Grange Self-inflicted Published 11 Oct 2023 3
David Leach HMP Ashfield Natural Published 10 Oct 2023
John Brumpton HMP Holme House Natural Published 9 Oct 2023
Giles Harvey HMP Dovegate Self-inflicted Published 9 Oct 2023 1
Gallop, David HMP Forest Bank Natural Published 7 Oct 2023
Leo Henshaw HMP Bristol Self-inflicted Published 7 Oct 2023
Muxsin Awjama HMP Nottingham Self-inflicted Published 5 Oct 2023 2
David Nash HMP Bure Natural Published 2 Oct 2023
William Smith Landguard Road Natural Published 1 Oct 2023
Jason Lyons HMP Brixton Other Published 26 Sep 2023
Matthews, Elliot HMP Preston Natural Published 26 Sep 2023
Wayne Simmonds HMP Leyhill Natural Published 22 Sep 2023
Donald Willis HMP Isle of Wight Natural Published 21 Sep 2023
Julian Woollon HMP Channings Wood Self-inflicted Published 21 Sep 2023
Jones, Richard HMP Littlehey Natural Published 16 Sep 2023
Philip Sleigh HMP Littlehey Natural Published 16 Sep 2023
David Marshall HMP Hull Natural Published 16 Sep 2023
Darren Barker HMP Peterborough Natural Published 12 Sep 2023 2
Colin Black HMP Bullingdon Other Published 11 Sep 2023
Bull, Malcolm HMP Stocken Natural Published 10 Sep 2023
Piotr Zmijewski HMP Maidstone Self-inflicted Published 9 Sep 2023 3
Stephen Bird HMP Altcourse Self-inflicted Published 8 Sep 2023
John Woodland HMP Frankland Natural Published 5 Sep 2023 3
James Wood HMP Hull Natural Published 4 Sep 2023 1
Thomas Dowson HMP/YOI Doncaster Other Published 2 Sep 2023
John Sykes HMP Holme House Natural Published 31 Aug 2023
Mapp, Theophilus HMP Birmingham Natural Published 29 Aug 2023
Declan Carr HMP Humber Self-inflicted Published 28 Aug 2023