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.
Top recommendation themes
Learning & thematic publications
| Title | Type | Date | Source |
|---|---|---|---|
| PPO response to JSC Inquiry into Children and Young Adults in the Secure Estate | Consultation response | Jun 2026 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 21: Segregation | Learning Lessons Bulletin | Mar 2026 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 22: Self-inflicted deaths in reception prisons | Learning Lessons Bulletin | Mar 2026 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 20: Epilepsy | Learning Lessons Bulletin | Nov 2025 | |
| Annual Report 2024 to 2025 | Annual report | Jul 2025 | |
| Policy into Practice: Handling of prisoners’ property | Policy into Practice | Mar 2025 | |
| Policy into Practice: Handling of property complaints | Policy into Practice | Mar 2025 | |
| Complaints Investigations Learning Lessons Bulletin Issue 11: Property complaints | Learning Lessons Bulletin | Mar 2025 | |
| PPO response to JSC Tackling Drugs in Prison Inquiry | Consultation response | Feb 2025 | |
| PPO response to JHAC Inquiry into Prison Culture | Consultation response | Feb 2025 | |
| PPO response to JSC inquiry into Rehabilitation and Resettlement | Consultation response | Feb 2025 | |
| Policy into Practice: Emergency Response | Policy into Practice | Jan 2025 | |
| PPO response to the Independent Sentencing Review 2024/25 call for evidence | Consultation response | Jan 2025 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 19: Post-release death investigations 2 | Learning Lessons Bulletin | Jul 2024 | |
| Annual Report 2023-24 | Annual report | Jul 2024 | |
| Annual report 2022-23 | Annual report | Jul 2024 | |
| Policy into practice: Use of force | Policy into Practice | Feb 2024 | |
| PPO response to the inquiry into prison population and capacity | Consultation response | Nov 2023 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 18: Self-inflicted deaths of IPP prisoners | Learning Lessons Bulletin | Sep 2023 | |
| Investigating deaths after release from prison – a pilot evaluation | Learning Lessons Bulletin | Jan 2023 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 17: Post-release death investigations | Learning Lessons Bulletin | Jan 2023 | |
| PPO response to the inquiry into the Prison Operational Workforce | Consultation response | Jan 2023 | |
| Annual Report 2021-22 | Annual report | Oct 2022 | |
| Policy into Practice: Use of restraints on escort | Policy into Practice | Sep 2022 | |
| PPO Response to the Inquiry into IPP sentences | Consultation response | Jan 2022 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 16: Second wave COVID-19 related deaths | Learning Lessons Bulletin | Dec 2021 | |
| Annual Report 2020-21 | Annual report | Sep 2021 | |
| PPO responses to the Inquiry into Women in Prison | Consultation response | Aug 2021 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 15: COVID-19 PPO fatal incident investigations | Learning Lessons Bulletin | Feb 2021 | |
| Complaints Investigations Learning Lessons Bulletin Issue 10: COVID-19 PPO Complaints | Learning Lessons Bulletin | Dec 2020 |
Incidents
| Name | Establishment | Cause | Status | Date of death | Recs |
|---|---|---|---|---|---|
| Ian Smith | HMP Stafford | Natural | Published | 10 Apr 2023 | — |
| McDowall, Iain | HMP Haverigg | Natural | Published | 10 Apr 2023 | — |
| Woodward, Michael | Altcourse Post-release | Other | Published | 8 Apr 2023 | — |
| Alan Hines | HMP Oakwood | Natural | Published | 7 Apr 2023 | 1 |
| Pearce, Luke | HMP Swinfen Hall | Self-inflicted | Published | 6 Apr 2023 | — |
| Winfield, Richard | HMP Elmley | Natural | Published | 6 Apr 2023 | — |
| Colin Hudson | HMP/YOI High Down | Natural | Published | 5 Apr 2023 | 2 |
| Uddin, Zamad | Parc Post-release | Other | Published | 5 Apr 2023 | — |
| Wilkinson, Ian | HMP Liverpool | Natural | Published | 5 Apr 2023 | — |
| Mouncer, Percy | HMP Norwich | Natural | Published | 4 Apr 2023 | — |
| Francis Graham | HMP Dovegate | Natural | Published | 4 Apr 2023 | — |
| Robin Matthews | HMP Isle of Wight | Natural | Published | 1 Apr 2023 | — |
| Laurence Hughes | HMP Littlehey | Natural | Published | 1 Apr 2023 | — |
| Gardner, Anthony | HMP Stafford | Natural | Published | 31 Mar 2023 | — |
| Gordon, Anthony | HMP Birmingham | Natural | Published | 30 Mar 2023 | — |
| Steven Hart | HMP Bedford | Self-inflicted | Published | 29 Mar 2023 | 4 |
| Warry, Reginald | HMP Ashfield | Natural | Published | 27 Mar 2023 | — |
| Frank Ospina | Colnbrook Immigration Removal Centre | Self-inflicted | Published | 26 Mar 2023 | 4 |
| Nugent, Andrew | HMP Garth | Natural | Published | 26 Mar 2023 | — |
| Zold, David | HMP Wakefield | Natural | Published | 25 Mar 2023 | — |
| Rolandas Karbauskas | HMP Lowdham Grange | Self-inflicted | Published | 25 Mar 2023 | 6 |
| Philip Warne | HMP The Verne | Natural | Published | 24 Mar 2023 | — |
| Tucker, Michael | HMP Wayland | Self-inflicted | Published | 22 Mar 2023 | — |
| Michael Tucker | HMP Wayland | Self-inflicted | Published | 22 Mar 2023 | 2 |
| Weyman, Peter | HMP The Verne | Natural | Published | 19 Mar 2023 | — |
| Stephen Rees | HMP/YOI Parc | Other | Published | 18 Mar 2023 | — |
| John Kenny | HMP Preston | Natural | Published | 18 Mar 2023 | — |
| Thompson, Peter | HMP Stocken | Natural | Published | 17 Mar 2023 | — |
| John Tunney | HMP Northumberland | Natural | Published | 16 Mar 2023 | 1 |
| Copley, Michael | HMP Altcourse | Natural | Published | 14 Mar 2023 | — |
| Johnson, Paul | HMP Whatton | Natural | Published | 14 Mar 2023 | — |
| Lee Walker | Clarks House Approved Premises | Other | Published | 13 Mar 2023 | 1 |
| William Evans | HMP Ashfield | Natural | Published | 13 Mar 2023 | 1 |
| David Richards | HMP Lowdham Grange | Self-inflicted | Published | 13 Mar 2023 | — |
| Melvin McFadden | HMP Northumberland | Natural | Published | 12 Mar 2023 | 2 |
| Malcolm Vickery | HMP/YOI Parc | Natural | Published | 11 Mar 2023 | 1 |
| McAuley, John | Rye Hill Post-release | Natural | Published | 11 Mar 2023 | — |
| Smallman, Rodney | HMP Risley | Natural | Published | 11 Mar 2023 | — |
| David Bentley | HMP/YOI High Down | Natural | Published | 10 Mar 2023 | 1 |
| Ruslan Voitkun | HMP Bullingdon | Self-inflicted | Published | 10 Mar 2023 | — |
| Keith Gadd | HMP Bristol | Self-inflicted | Published | 9 Mar 2023 | 2 |
| Glen Adrian | HMP Durham | Self-inflicted | Published | 8 Mar 2023 | 3 |
| Kulik, Piotr | HMP Gartree | Natural | Published | 7 Mar 2023 | — |
| William Stapylton | HMP Holme House | Natural | Published | 6 Mar 2023 | — |
| Anthony Binfield | HMP Lowdham Grange | Self-inflicted | Published | 6 Mar 2023 | 4 |
| Haydar Jefferies | HMP Coldingley | Self-inflicted | Published | 5 Mar 2023 | 2 |
| Brown, Michael | HMP Leeds | Natural | Published | 4 Mar 2023 | — |
| Ford, Duncan | HMP Chelmsford | Natural | Published | 2 Mar 2023 | — |
| Shafaq Khan | HMP Hindley | Natural | Published | 28 Feb 2023 | 2 |
| Merritt, John | HMP Wymott | Natural | Published | 26 Feb 2023 | — |