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.
Top recommendation themes
Learning & thematic publications
| Title | Type | Date | Source |
|---|---|---|---|
| PPO response to JSC Inquiry into Children and Young Adults in the Secure Estate | Consultation response | Jun 2026 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 21: Segregation | Learning Lessons Bulletin | Mar 2026 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 22: Self-inflicted deaths in reception prisons | Learning Lessons Bulletin | Mar 2026 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 20: Epilepsy | Learning Lessons Bulletin | Nov 2025 | |
| Annual Report 2024 to 2025 | Annual report | Jul 2025 | |
| Policy into Practice: Handling of prisoners’ property | Policy into Practice | Mar 2025 | |
| Policy into Practice: Handling of property complaints | Policy into Practice | Mar 2025 | |
| Complaints Investigations Learning Lessons Bulletin Issue 11: Property complaints | Learning Lessons Bulletin | Mar 2025 | |
| PPO response to JSC Tackling Drugs in Prison Inquiry | Consultation response | Feb 2025 | |
| PPO response to JHAC Inquiry into Prison Culture | Consultation response | Feb 2025 | |
| PPO response to JSC inquiry into Rehabilitation and Resettlement | Consultation response | Feb 2025 | |
| Policy into Practice: Emergency Response | Policy into Practice | Jan 2025 | |
| PPO response to the Independent Sentencing Review 2024/25 call for evidence | Consultation response | Jan 2025 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 19: Post-release death investigations 2 | Learning Lessons Bulletin | Jul 2024 | |
| Annual Report 2023-24 | Annual report | Jul 2024 | |
| Annual report 2022-23 | Annual report | Jul 2024 | |
| Policy into practice: Use of force | Policy into Practice | Feb 2024 | |
| PPO response to the inquiry into prison population and capacity | Consultation response | Nov 2023 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 18: Self-inflicted deaths of IPP prisoners | Learning Lessons Bulletin | Sep 2023 | |
| Investigating deaths after release from prison – a pilot evaluation | Learning Lessons Bulletin | Jan 2023 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 17: Post-release death investigations | Learning Lessons Bulletin | Jan 2023 | |
| PPO response to the inquiry into the Prison Operational Workforce | Consultation response | Jan 2023 | |
| Annual Report 2021-22 | Annual report | Oct 2022 | |
| Policy into Practice: Use of restraints on escort | Policy into Practice | Sep 2022 | |
| PPO Response to the Inquiry into IPP sentences | Consultation response | Jan 2022 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 16: Second wave COVID-19 related deaths | Learning Lessons Bulletin | Dec 2021 | |
| Annual Report 2020-21 | Annual report | Sep 2021 | |
| PPO responses to the Inquiry into Women in Prison | Consultation response | Aug 2021 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 15: COVID-19 PPO fatal incident investigations | Learning Lessons Bulletin | Feb 2021 | |
| Complaints Investigations Learning Lessons Bulletin Issue 10: COVID-19 PPO Complaints | Learning Lessons Bulletin | Dec 2020 |
Incidents
| Name | Establishment | Cause | Status | Date of death | Recs |
|---|---|---|---|---|---|
| Individual at Altcourse | HMP Altcourse | Natural | Published | 18 Feb 2022 | — |
| Individual at Birmingham | HMP Birmingham | Self-inflicted | Published | 15 Feb 2022 | — |
| Individual at Norwich | HMP Norwich | Natural | Published | 15 Feb 2022 | — |
| Brian Johncock | HMP Lewes | Natural | Published | 15 Feb 2022 | 5 |
| Individual at Whatton | HMP Whatton | Natural | Published | 13 Feb 2022 | — |
| Esson, Stuart | HMP Rochester | Self-inflicted | Published | 12 Feb 2022 | — |
| Trevor Burchell | HMP Elmley | Self-inflicted | Published | 12 Feb 2022 | — |
| Benjamin, Gene | HMP Wakefield | Natural | Published | 11 Feb 2022 | — |
| Individual at Nottingham | HMP Nottingham | Natural | Published | 10 Feb 2022 | — |
| Burges, Dominic | HMP Bullingdon | Other | Published | 10 Feb 2022 | — |
| Daniel Hayfield | HMP Durham | Other | Published | 8 Feb 2022 | — |
| Individual at Forest Bank | HMP Forest Bank | Natural | Published | 4 Feb 2022 | — |
| Reed, Thomas | HMP Holme House | Natural | Published | 3 Feb 2022 | — |
| Andrew Hill | HMP Holme House | Self-inflicted | Published | 3 Feb 2022 | 2 |
| Individual at Northumberland | HMP Northumberland | Natural | Published | 3 Feb 2022 | — |
| Individual at Moorland Closed Post-release | Moorland Closed Post-release | Self-inflicted | Published | 30 Jan 2022 | — |
| Spreckley, Wayne | HMP Leeds | Natural | Published | 27 Jan 2022 | — |
| Individual at Wealstun | HMP Wealstun | Natural | Published | 27 Jan 2022 | — |
| Individual at Birmingham | HMP Birmingham | Self-inflicted | Published | 27 Jan 2022 | — |
| Individual at Peterborough | HMP Peterborough | Natural | Published | 27 Jan 2022 | — |
| John Creevy | HMP Garth | Natural | Published | 25 Jan 2022 | 2 |
| Richardson, Albert | HMP Oakwood | Natural | Published | 25 Jan 2022 | — |
| Christopher Reed | HMP Isle of Wight | Natural | Published | 24 Jan 2022 | 4 |
| Edward Teague | HMP Humber | Natural | Published | 22 Jan 2022 | 1 |
| Individual at Littlehey | HMP Littlehey | Natural | Published | 22 Jan 2022 | — |
| Individual at Full Sutton | HMP Full Sutton | Natural | Published | 21 Jan 2022 | — |
| Davies, Robert | HMP Durham | Natural | Published | 21 Jan 2022 | — |
| Individual at Frankland | HMP Frankland | Natural | Published | 20 Jan 2022 | — |
| Pisani, Jonathan | HMP Forest Bank | Other | Published | 19 Jan 2022 | — |
| Individual at Wayland | HMP Wayland | Natural | Published | 19 Jan 2022 | — |
| Rudge, Gareth | Swansea Post-release | Other | Published | 17 Jan 2022 | — |
| Masters, Anthony | HMP Lewes | Natural | Published | 17 Jan 2022 | — |
| Aaron Bridges | Albion Street Approved Premises | Self-inflicted | Published | 17 Jan 2022 | 1 |
| Williams, John | HMP Birmingham | Natural | Published | 16 Jan 2022 | — |
| Individual at Gartree | HMP Gartree | Natural | Published | 16 Jan 2022 | — |
| Individual at Stafford | HMP Stafford | Natural | Published | 16 Jan 2022 | — |
| Marsden, Brooke | HMP Lincoln | Natural | Published | 14 Jan 2022 | — |
| Alaa Ghanem | HMP Exeter | Other | Published | 14 Jan 2022 | 1 |
| Musse, Hamdi | Bullingdon Post-release | Natural | Published | 13 Jan 2022 | — |
| Lawrence, George | HMP Garth | Natural | Published | 11 Jan 2022 | — |
| Individual at Nottingham | HMP Nottingham | Natural | Published | 5 Jan 2022 | — |
| Bouquet, Steven | HMP Elmley | Natural | Published | 5 Jan 2022 | — |
| Davie, Michael | HMP Ashfield | Natural | Published | 3 Jan 2022 | — |
| Blake Wallis | HMP Lincoln | Self-inflicted | Published | 3 Jan 2022 | 1 |
| Revill, Robert | HMP Lowdham Grange | Natural | Published | 3 Jan 2022 | — |
| Individual at Whatton | HMP Whatton | Natural | Published | 2 Jan 2022 | — |
| Ross, Donald | HMP Manchester | Other | Published | 31 Dec 2021 | — |
| John O’Driscoll | HMP Cardiff | Self-inflicted | Published | 29 Dec 2021 | 2 |
| Individual at Norwich | HMP Norwich | Self-inflicted | Published | 29 Dec 2021 | — |
| Individual at Bullingdon | HMP Bullingdon | Natural | Published | 28 Dec 2021 | — |