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
Burnip, John Durham Post-release Other Published 29 Dec 2022
Beaumont, Francis HMP Moorland Closed Natural Published 28 Dec 2022
Marc Uzzell HMP Bristol Natural Published 28 Dec 2022 4
Uddin, Mohammed Sayeef HMP Highpoint Self-inflicted Published 28 Dec 2022
Cain, Robert HMP Leyhill Natural Published 28 Dec 2022
Wathen, Keith HMP The Verne Natural Published 28 Dec 2022
Herbert, Adam Leicester Post-release Other Published 27 Dec 2022
Harrison, Keith HMP Liverpool Natural Published 27 Dec 2022
Jackson, JT Lightfoot House Natural Published 24 Dec 2022
Murray, Peter HMP Littlehey Natural Published 24 Dec 2022
Rusling, Douglas HMP Doncaster Natural Published 23 Dec 2022
Hutchinson, John HMP Preston Natural Published 22 Dec 2022
McLoughlin, Daniel Leeds Post-release Self-inflicted Published 21 Dec 2022
Steven Sargeant HMP Swansea Natural Published 21 Dec 2022
Nadeem, Mohammed HMP Forest Bank Natural Published 20 Dec 2022
Benjamin Donnelly HMP Cardiff Self-inflicted Published 20 Dec 2022 1
de Launay, Nicolas Lewes Post-release Other Published 19 Dec 2022
James Trewick HMP Northumberland Natural Published 17 Dec 2022 1
Matthew Xavier HMP Highpoint Natural Published 16 Dec 2022 2
Jonusas, Ricardas HMP Swaleside Self-inflicted Published 16 Dec 2022
Cunningham, Robert HMP Holme House Natural Published 16 Dec 2022
George Day HMP Ranby Other Published 15 Dec 2022
Cartell, Leonard HMP Rye Hill Natural Published 12 Dec 2022
Orme, Mel HMP Wymott Natural Published 12 Dec 2022
Lee Robinson HMP Leeds Self-inflicted Published 11 Dec 2022
Ben Hyland HMP Leeds Self-inflicted Published 11 Dec 2022 1
Rageh, Osman Maidstone Post-release Natural Published 10 Dec 2022
Ronnie Stewart HMP Holme House Natural Published 9 Dec 2022
Mark Mason HMP Durham Self-inflicted Published 8 Dec 2022 2
Baddiley, Arthur HMP Oakwood Natural Published 7 Dec 2022
Steven Hatch HMP Cardiff Other Published 6 Dec 2022
Wayne Franks HMP Wakefield Natural Published 5 Dec 2022 1
Jamie Andrews HMP Bristol Natural Published 4 Dec 2022 2
Brightmore, Scott Moorland Closed Post-release Other Published 1 Dec 2022
Stewart, Ian HMP Altcourse Self-inflicted Published 1 Dec 2022
David Lancaster HMP Durham Self-inflicted Published 30 Nov 2022
Pinkney, Michael The Crescent Other Published 26 Nov 2022
Anderson, Craig Isle of Man Prison Self-inflicted Published 25 Nov 2022
Raymon, Coburn HMP Rye Hill Natural Published 25 Nov 2022
Shaw, George HMP Doncaster Natural Published 24 Nov 2022
Joseph Jukes HMP Holme House Natural Published 22 Nov 2022
Curtis Cadman HMP Lincoln Natural Published 21 Nov 2022 2
John Eyre HMP Swaleside Natural Published 20 Nov 2022 1
Skinner, Ricky Durham Post-release Other Published 19 Nov 2022
Bate, Keith HMP Forest Bank Natural Published 18 Nov 2022
Michael Phillips HMP Stoke Heath Other Published 18 Nov 2022
Inch, Brian HMP The Mount Natural Published 17 Nov 2022
Graham Boyle HMP/YOI Parc Natural Published 14 Nov 2022
Sheldon Jeans HMP Guys Marsh Other Published 13 Nov 2022
Ian Kettles HMP Bristol Self-inflicted Published 11 Nov 2022 4