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
Florence Johnson HMP/YOI Styal Self-inflicted Published 27 Aug 2023
Carl Bennett HMP Oakwood Natural Published 25 Aug 2023 2
Ian Taylor HMP Kirkham Natural Published 23 Aug 2023
Richardson, John Rye Hill Post-release Natural Published 23 Aug 2023
Louis Dalmasso HMP Bristol Other Published 22 Aug 2023
Farrow, Stephen HMP Frankland Natural Published 21 Aug 2023
Cheryl Thompson HMP/YOI New Hall Natural Published 21 Aug 2023
Ged Corbett HMP Thameside Other Published 19 Aug 2023
Darren Ankers HMP Wymott Natural Published 18 Aug 2023
Bonner, Arthur Hollesley Bay Post-release Natural Published 15 Aug 2023
Stephen Riley HMP Bure Natural Published 13 Aug 2023
Darren Docherty HMP Stoke Heath Self-inflicted Published 10 Aug 2023
Andrew Winspear HMP Hull Self-inflicted Published 8 Aug 2023 1
Amer Fareed HMP/YOI High Down Other Published 8 Aug 2023 1
Mark Apperley HMP Long Lartin Natural Published 7 Aug 2023 1
Frank Salmon HMP Channings Wood Natural Published 6 Aug 2023 1
Hayward, Derek HMP Wakefield Natural Published 6 Aug 2023
Raymond Cartwright HMP Risley Natural Published 6 Aug 2023 2
Goldburn, Brian HMP Littlehey Natural Published 2 Aug 2023
Tunstill, Rachel HMP Styal Natural Published 1 Aug 2023
Andrew Lancaster-Madeley HMP Isle of Wight Natural Published 29 Jul 2023
Davina Canning HMP Hewell Self-inflicted Published 29 Jul 2023 3
Daniel Rocks HMP Hull Natural Published 26 Jul 2023 1
Hayes, Dennis HMP Leeds Natural Published 24 Jul 2023
Michael Whittemore HMP Isle of Wight Natural Published 23 Jul 2023
Katy Ross HMP/YOI Foston Hall Other Published 22 Jul 2023
Dean Hood HMP Nottingham Other Published 22 Jul 2023 1
Liam Darby HMP Erlestoke Other Published 21 Jul 2023 1
James O’Brien HMP Littlehey Natural Published 18 Jul 2023
Van Rooyen, Julian The Mount Post-release Other Published 17 Jul 2023
John Rombach HMP Stafford Natural Published 17 Jul 2023 2
Barry Wemyss HMP Northumberland Natural Published 17 Jul 2023 1
Stewart Hirst HMP Littlehey Natural Published 16 Jul 2023
Andrew Flanagan HMP Wormwood Scrubs Other Published 16 Jul 2023
Samuel Stewart HMP Wormwood Scrubs Other Published 15 Jul 2023 1
Anthony Milgate HMP Swaleside Natural Published 14 Jul 2023
Boswell, Malcolm HMP Bure Natural Published 12 Jul 2023
Cook, Robert Bullingdon Post-release Other Published 9 Jul 2023
Lee Gilligan HMP Forest Bank Other Published 9 Jul 2023
Anthony Kwan HMP Channings Wood Natural Published 8 Jul 2023 3
Simon Parkinson HMP Durham Natural Published 7 Jul 2023 1
Mark Beresford HMP Ranby Self-inflicted Published 7 Jul 2023 1
Donald Moore HMP Wymott Natural Published 7 Jul 2023
Colin Milner HMP Wandsworth Natural Published 5 Jul 2023
Yousefe El Briri HMP Woodhill Natural Published 4 Jul 2023
Liam Cronin HMP Ranby Other Published 2 Jul 2023
Phillip Chell HMP Oakwood Natural Published 28 Jun 2023
Warrener, Michael HMP Holme House Natural Published 26 Jun 2023
Mark Conway HMP Isle of Wight Natural Published 25 Jun 2023 4
Rajwinder Singh HMP Wandsworth Self-inflicted Published 25 Jun 2023 6