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
Bracey, Greg High Down Post-release Other Published 21 Apr 2022
Individual at Stoke Heath HMP Stoke Heath Natural Published 21 Apr 2022
Thomas Simmons HMP Humber Natural Published 20 Apr 2022 3
Individual at Leeds HMP Leeds Natural Published 17 Apr 2022
Andrew Clark HMP Peterborough Natural Published 16 Apr 2022
Kelly, Margaret Eastwood Park Post-release Other Published 16 Apr 2022
Lewis Petryszyn HMP/YOI Parc Other Published 15 Apr 2022 4
Angela Thompson HMP/YOI Styal Self-inflicted Published 11 Apr 2022 3
Thompson, Neil HMP Doncaster Natural Published 10 Apr 2022
Individual at Bradshaw House Bradshaw House Other Published 9 Apr 2022
Aravindan Balakrishnan HMP Dartmoor Natural Published 8 Apr 2022
Individual at Nottingham HMP Nottingham Natural Published 8 Apr 2022
Guy, John HMP Liverpool Natural Published 6 Apr 2022
Individual at Hindley Post-release Hindley Post-release Other Published 3 Apr 2022
Mervyn Tedbury HMP Isle of Wight Natural Published 3 Apr 2022 3
Brinton, Matthew Channings Wood Post-release Other Published 2 Apr 2022
Sparks, Luke HMP Swaleside Self-inflicted Published 2 Apr 2022
Individual at Leyhill HMP Leyhill Natural Published 1 Apr 2022
Mehrban Hussain HMP Wormwood Scrubs Natural Published 1 Apr 2022 5
Gordon Dunn HMP The Verne Natural Published 31 Mar 2022 5
Skrzypek, Mirsoslaw Doncaster Post-release Self-inflicted Published 28 Mar 2022
Mousah, Martin HMP Leyhill Natural Published 27 Mar 2022
Leslie Moulden HMP Northumberland Natural Published 26 Mar 2022
Individual at Foston Hall Post-release Foston Hall Post-release Other Published 26 Mar 2022
Individual at Berwyn HMP Berwyn Natural Published 23 Mar 2022
Individual at Cardiff Post-release Cardiff Post-release Other Published 22 Mar 2022
King, Alun HMP Winchester Natural Published 22 Mar 2022
Michael Fox HMP Humber Other Published 15 Mar 2022 1
Cunningham, Kenneth HMP Liverpool Natural Published 14 Mar 2022
Francis, John HMP Littlehey Natural Published 14 Mar 2022
Coleman, Christopher Risley Post-release Natural Published 13 Mar 2022
Individual at Manchester HMP Manchester Natural Published 11 Mar 2022
Individual at Leeds HMP Leeds Self-inflicted Published 10 Mar 2022
Traverso, Charles Elmley Post-release Other Published 9 Mar 2022
Norton, David HMP Dartmoor Natural Published 9 Mar 2022
Saxon, Emma HMP New Hall Self-inflicted Published 7 Mar 2022
Individual at Littlehey HMP Littlehey Natural Published 7 Mar 2022
Individual at Preston HMP Preston Natural Published 5 Mar 2022
Simmons, Jamie HMP Swaleside Self-inflicted Published 4 Mar 2022
Individual at Norwich Post-release Norwich Post-release Other Published 1 Mar 2022
James Bailey HMP The Mount Self-inflicted Published 1 Mar 2022 6
Individual at Highpoint Post-release Highpoint Post-release Other Published 27 Feb 2022
Thurling, Darren Peterborough Post-release Other Published 27 Feb 2022
Craig Steadman HMP Winchester Self-inflicted Published 27 Feb 2022 5
Michael Grimes HMP Isle of Wight Natural Published 26 Feb 2022 1
Individual at Bristol HMP Bristol Natural Published 25 Feb 2022
McLellan, Scott HMP Frankland Self-inflicted Published 24 Feb 2022
Hassan, Ahsan HMP Highpoint Self-inflicted Published 20 Feb 2022
Individual at Brigstocke Road Brigstocke Road Self-inflicted Published 18 Feb 2022
Individual at Moorland Closed HMP Moorland Closed Natural Published 18 Feb 2022