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
Birdie, Michael HMP Peterborough Natural Published 10 Nov 2022
Ahmed Alshbli HMP Durham Self-inflicted Published 10 Nov 2022 2
Jason Kennedy HMP/YOI High Down Other Published 9 Nov 2022 4
Holden, George HMP Doncaster Natural Published 7 Nov 2022
Russell Irvine HMP Durham Self-inflicted Published 7 Nov 2022 5
Ewan Homer HMP Stafford Natural Published 6 Nov 2022 3
Roach, Reginald Ty Newydd Self-inflicted Published 5 Nov 2022
Edward Owens HMP Dartmoor Natural Published 4 Nov 2022
Ewing, Robert HMP Long Lartin Natural Published 4 Nov 2022
Thompson, Adam HMP Northumberland Self-inflicted Published 4 Nov 2022
Harmon, Liam Forest Bank Post-release Other Published 3 Nov 2022
Aaron Harte HMP Peterborough Other Published 3 Nov 2022 4
Meason, Bernard HMP Ashfield Natural Published 2 Nov 2022
Bone, Frank HMP Whatton Natural Published 2 Nov 2022
Shaine Tester HMP Gartree Self-inflicted Published 1 Nov 2022 2
Colin Lovett HMP The Verne Self-inflicted Published 29 Oct 2022 4
Smith, Ryan Winchester Post-release Other Published 27 Oct 2022
Stephen Sleaford HMP Gartree Self-inflicted Published 27 Oct 2022
Neil Ballard HMP Risley Self-inflicted Published 26 Oct 2022
Tyrone Richards HMP Manchester Self-inflicted Published 25 Oct 2022 1
Lyons, Paul HMP Wakefield Natural Published 25 Oct 2022
Pearson, John HMP Holme House Natural Published 24 Oct 2022
Individual at Nottingham HMP Nottingham Natural Published 23 Oct 2022
Barraclough, Robert Ranby Post-release Other Published 22 Oct 2022
Alan Hutchinson HMP Isle of Wight Natural Published 21 Oct 2022
Anderson Barker HMP Peterborough Natural Published 21 Oct 2022 2
Lee Burnard HMP Guys Marsh Other Published 20 Oct 2022
Taylor, Louis Parc Post-release Natural Published 18 Oct 2022
Walker, Edwin HMP Ashfield Natural Published 18 Oct 2022
Individual at Durham Post-release Durham Post-release Natural Published 15 Oct 2022
Lees, Jamie HMP Birmingham Natural Published 13 Oct 2022
Kelly, Stephen HMP Whatton Natural Published 9 Oct 2022
Knight, Christopher Portland Post-release Other Published 7 Oct 2022
Doab, Mark St Leonards Other Published 5 Oct 2022
Walsh, Christopher Parc Post-release Natural Published 4 Oct 2022
Ben Skivington HMP Hull Other Published 2 Oct 2022
Cameron, Kevin HMP Lindholme Natural Published 1 Oct 2022
Petre, Catalin Nottingham Post-release Natural Published 1 Oct 2022
Individual at Norwich HMP Norwich Natural Published 30 Sep 2022
Kevin McDonnel HMP Nottingham Self-inflicted Published 29 Sep 2022 2
Individual at Wakefield HMP Wakefield Natural Published 27 Sep 2022
Sawyer, Graham HMP Bure Natural Published 26 Sep 2022
Individual at Stoke Heath HMP Stoke Heath Natural Published 26 Sep 2022
Dale Samm HMP The Mount Self-inflicted Published 25 Sep 2022 2
John Warry HMP Stafford Natural Published 25 Sep 2022 10
Lewis Skelton HMP Durham Other Published 23 Sep 2022
Individual at Risley Post-release Risley Post-release Natural Published 23 Sep 2022
Individual at Whatton HMP Whatton Natural Published 21 Sep 2022
Terrance Dass HMP Littlehey Natural Published 20 Sep 2022 1
Mitchell, Raymond HMP Exeter Natural Published 19 Sep 2022