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 Beddall HMP Dovegate Self-inflicted Published 26 Feb 2023 1
Yeomans, Alan Ranby Post-release Self-inflicted Published 26 Feb 2023
Sean Davies HMP Swaleside Self-inflicted Published 25 Feb 2023 1
Christopher Corkill Isle of Man Self-inflicted Published 24 Feb 2023 15
Reece Godward HMP Leeds Self-inflicted Published 23 Feb 2023 2
Orme, Peter HMP Bullingdon Natural Published 22 Feb 2023
Karl Reavy HMP Liverpool Other Published 15 Feb 2023 1
Austin, Eric HMP Bullingdon Natural Published 15 Feb 2023
John Hartshorne HMP Stafford Natural Published 14 Feb 2023 1
Duncan, Ian HMP Woodhill Natural Published 13 Feb 2023
Joseph Davies HMP Northumberland Self-inflicted Published 12 Feb 2023 1
Anthony Kennedy HMP Altcourse Other Published 12 Feb 2023
Fallon Adams HMP Peterborough Other Published 9 Feb 2023 1
Cavendish-Coulson, Keith HMP Bullingdon Natural Published 5 Feb 2023
Hodge, Lawrence HMP Holme House Natural Published 4 Feb 2023
Neville, John HMP Wymott Natural Published 4 Feb 2023
Stephen Hodgson HMP Full Sutton Self-inflicted Published 3 Feb 2023
Andrew Hadwin HMP Durham Natural Published 2 Feb 2023 4
Morgan, Kevin HMP Liverpool Natural Published 31 Jan 2023
Anthony Mitchell HMP Dartmoor Natural Published 30 Jan 2023 2
Mohammed Eumda HMP Chelmsford Self-inflicted Published 30 Jan 2023 2
Roy King HMP Littlehey Self-inflicted Published 30 Jan 2023 5
Fell, Simon HMP Wymott Natural Published 29 Jan 2023
Colin Ryan HMP Bristol Self-inflicted Published 29 Jan 2023 1
Milad Fathy HMP Leeds Self-inflicted Published 29 Jan 2023 1
Coleman, Mark HMP Peterborough Natural Published 25 Jan 2023
Ian Deavall HMP Forest Bank Natural Published 24 Jan 2023 3
Smith, David Ranby Post-release Other Published 22 Jan 2023
Ian Wadsworth Elm Bank Approved Premises Other Published 21 Jan 2023 2
Skinner, Stephen Forest Bank Post-release Other Published 20 Jan 2023
Ross Appleby HMP/YOI Parc Other Published 18 Jan 2023 1
Cox, John HMP Littlehey Natural Published 17 Jan 2023
Paul Paget HMP Swaleside Natural Published 17 Jan 2023 3
John Collyer HMP Peterborough Natural Published 14 Jan 2023
Smith, Graham HMP Rye Hill Natural Published 14 Jan 2023
Barton, Ben HMP Doncaster Self-inflicted Published 13 Jan 2023
Botham, John HMP Nottingham Natural Published 13 Jan 2023
Johnson, Geoffrey HMP Wandsworth Natural Published 12 Jan 2023
Haworth, Colin HMP Stafford Natural Published 10 Jan 2023
Ryan Harding HMP/YOI Parc Other Published 8 Jan 2023 3
McCall, Peter HMP Wakefield Natural Published 8 Jan 2023
Murphy, John HMP Altcourse Natural Published 6 Jan 2023
Weighman, Daniel HMP Chelmsford Self-inflicted Published 6 Jan 2023
Lawrence Dugbazah HMP Littlehey Natural Published 6 Jan 2023 3
Dean Leach HMP Forest Bank Natural Published 4 Jan 2023
Henly, Stephen HMP The Verne Natural Published 3 Jan 2023
Sawyer, John HMP Hull Natural Published 3 Jan 2023
Oliver Davies HMP Hewell Self-inflicted Published 31 Dec 2022 3
Akash Akeel HMP Leeds Self-inflicted Published 31 Dec 2022 2
Burnip, John Durham Post-release Other Published 29 Dec 2022