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 Scott HMP Humber Self-inflicted Published 14 Jun 2022 4
Trowbridge, Mark HMP Standford Hill Natural Published 13 Jun 2022
Rider, Scott HMP Woodhill Self-inflicted Published 13 Jun 2022
Brown, William Lancaster Farms Post-release Other Published 13 Jun 2022
Uden, Craig Nelson House Other Published 11 Jun 2022
Individual at Littlehey HMP Littlehey Natural Published 9 Jun 2022
Individual at Leyhill Post-release Leyhill Post-release Natural Published 9 Jun 2022
Bentley, Liam HMP Swaleside Self-inflicted Published 6 Jun 2022
Michael Higginbottom HMP Stafford Natural Published 5 Jun 2022 4
Blanchard, Robert HMP Parc Natural Published 4 Jun 2022
Huston, Trevor HMP Forest Bank Natural Published 4 Jun 2022
Fairbrother, Keith HMP Wakefield Natural Published 4 Jun 2022
Dowman, Jamie Chelmsford Post-release Other Published 3 Jun 2022
Individual at Moorland Closed HMP Moorland Closed Natural Published 1 Jun 2022
Jones, Craig Cardiff Post-release Other Published 1 Jun 2022
Pearson, Harief HMP Swaleside Other Published 1 Jun 2022
Feltham, Paul HMP Northumberland Self-inflicted Published 31 May 2022
Harris, Matthew HMP Long Lartin Self-inflicted Published 29 May 2022
Lamb, Paul HMP Hull Natural Published 27 May 2022
Individual at Wandsworth HMP Wandsworth Natural Published 26 May 2022
Individual at Hewell HMP Hewell Natural Published 26 May 2022
Moran, Colin Northumberland Post-release Other Published 25 May 2022
Charleston Cullen HMP Nottingham Natural Published 25 May 2022 3
Bond, Martin Cardiff Post-release Other Published 24 May 2022
Green, Colin HMP Northumberland Natural Published 24 May 2022
Armstrong, Karl Merseybank Other Published 23 May 2022
John Hooper HMP Channings Wood Natural Published 20 May 2022
Cox, Louise HMP Downview Natural Published 20 May 2022
Individual at Manchester HMP Manchester Natural Published 19 May 2022
Individual at Whatton HMP Whatton Natural Published 18 May 2022
Individual at Swaleside HMP Swaleside Natural Published 17 May 2022
Wayne Bayley HMP Pentonville Other Published 17 May 2022 7
Isaac Ayeni HMP Aylesbury Other Published 16 May 2022 2
Payne, Richard HMP Wayland Self-inflicted Published 15 May 2022
Thomas Cole HMP Northumberland Natural Published 13 May 2022 2
Individual at Preston HMP Preston Natural Published 8 May 2022
Green, Adrian HMP Altcourse Natural Published 6 May 2022
Coster, Stephen HMP Lewes Natural Published 5 May 2022
Smith, Anthony HMP Preston Self-inflicted Published 4 May 2022
Jeremie Simmons HMP Wakefield Self-inflicted Published 4 May 2022 6
Individual at Littlehey HMP Littlehey Natural Published 30 Apr 2022
Pulami, Anthony HMP Hull Natural Published 28 Apr 2022
Joseph Hall Carpenter House Approved Premises Other Published 27 Apr 2022 2
Landymore, Michael HMP Winchester Natural Published 25 Apr 2022
Ricardo Cotteral HMP Sudbury Homicide Published 24 Apr 2022 5
Individual at Doncaster HMP Doncaster Natural Published 23 Apr 2022
Wilkinson, Mark HMP Lewes Natural Published 22 Apr 2022
Individual at Leeds HMP Leeds Natural Published 22 Apr 2022
Palin, David HMP Altcourse Natural Published 22 Apr 2022
Reay, Jamie Wealstun Post-release Other Published 21 Apr 2022