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
Lee Kenyon HMP Altcourse Self-inflicted Published 24 Jun 2023 2
John Devers HMP Oakwood Natural Published 21 Jun 2023 1
Harvey, Peter HMP Wymott Natural Published 20 Jun 2023
Harmer, Marc HMP Forest Bank Natural Published 15 Jun 2023
Filmon Brhane HMP Maidstone Self-inflicted Published 12 Jun 2023 8
Howard Davies HMP/YOI Parc Natural Published 10 Jun 2023
Amy Cross HMP/YOI Eastwood Park Other Published 10 Jun 2023 2
Damon Hardman HMP Lewes Self-inflicted Published 8 Jun 2023 3
Tyrone Bwerinofa HMP Wayland Other Published 8 Jun 2023 1
Mark Powell HMP Wymott Natural Published 4 Jun 2023
Keegan, Mark Lightfoot House Natural Published 1 Jun 2023
Seaman, Paul HMP Wakefield Natural Published 29 May 2023
George Bull HMP Stafford Other Published 29 May 2023
John Williams HMP Isle of Wight Natural Published 29 May 2023
Donald McKean HMP Leeds Natural Published 28 May 2023
George Emmett HMP Aylesbury Other Published 25 May 2023
Kirsten Hocking HMP/YOI Downview Other Published 24 May 2023 2
Stephen Currington HMP/YOI High Down Natural Published 24 May 2023
Stacey, Neal Lewes Post-release Other Published 20 May 2023
Richard Campbell HMP Channings Wood Natural Published 19 May 2023
Michael Hillitt HMP/YOI Parc Natural Published 18 May 2023
Valentine, Anthony HMP Wakefield Natural Published 16 May 2023
Darren Stokes HMP Cardiff Other Published 16 May 2023
Alan Haldane HMP Littlehey Natural Published 16 May 2023
Mohammed Azizi HMP Norwich Natural Published 15 May 2023
Satish Kumar HMP Oakwood Natural Published 15 May 2023 1
Glody Muyeki HMP Aylesbury Other Published 15 May 2023 2
Higgins, Shaun Birmingham Post-release Other Published 13 May 2023
Gale, Alan HMP Stafford Natural Published 12 May 2023
Michael Kinnear HMP Wymott Natural Published 11 May 2023 1
Mehdi Ghorbani HMP Leeds Self-inflicted Published 11 May 2023
Selby Wardle HMP Hull Natural Published 8 May 2023
Connor, Terrence HMP Preston Natural Published 6 May 2023
Mark Smith HMP Risley Self-inflicted Published 3 May 2023
Simon Lightfoot HMP Dovegate Self-inflicted Published 29 Apr 2023 1
Steven Blake HMP Haverigg Self-inflicted Published 28 Apr 2023 2
Joseph Louis HMP Wormwood Scrubs Natural Published 26 Apr 2023 4
Neil Yates HMP Altcourse Other Published 25 Apr 2023
Lee Gorst HMP Manchester Self-inflicted Published 25 Apr 2023 1
Yates, Craig Wealstun Post-release Other Published 22 Apr 2023
William McKee HMP Channings Wood Natural Published 22 Apr 2023 1
Mark Ziemiecki HMP Leeds Self-inflicted Published 22 Apr 2023
Kevin Smith HMP/YOI Doncaster Self-inflicted Published 22 Apr 2023 2
Nathan Walters HMP Lancaster Farms Natural Published 22 Apr 2023 1
Kenneth Light HMP Stafford Natural Published 20 Apr 2023
Paul Bryant HMP Stocken Self-inflicted Published 19 Apr 2023
Lee Gresham HMP Hull Other Published 17 Apr 2023
Martin, Edward HMP Moorland Closed Natural Published 14 Apr 2023
Mockford, Kenneth HMP Bure Natural Published 14 Apr 2023
Dean Graham HMP Northumberland Natural Published 11 Apr 2023 3