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 |
|---|---|---|---|---|---|
| Davies, Shaun | HMP Ranby | Self-inflicted | Published | 28 Dec 2021 | — |
| Dylan Davies | HMP Cardiff | Other | Published | 28 Dec 2021 | 1 |
| Ian Stokes | HMP Rye Hill | Natural | Published | 27 Dec 2021 | — |
| Individual at Gartree | HMP Gartree | Natural | Published | 26 Dec 2021 | — |
| Hughes, Lee | HMP Wandsworth | Other | Published | 25 Dec 2021 | — |
| Individual at The Verne | HMP The Verne | Natural | Published | 24 Dec 2021 | — |
| Individual at East Sutton Park | HMP East Sutton Park | Natural | Published | 24 Dec 2021 | — |
| Strand, Gemma | New Hall Post-release | Other | Published | 23 Dec 2021 | — |
| Individual at Elliott House | Elliott House | Natural | Published | 23 Dec 2021 | — |
| Horne, Michael | HMP Winchester | Natural | Published | 21 Dec 2021 | — |
| Individual at Stoke Heath | HMP Stoke Heath | Self-inflicted | Published | 20 Dec 2021 | — |
| Baldwin, John | HMP Garth | Natural | Published | 20 Dec 2021 | — |
| Hampson, Kelly | Eastwood Park Post-release | Self-inflicted | Published | 20 Dec 2021 | — |
| Individual at Wymott | HMP Wymott | Natural | Published | 20 Dec 2021 | — |
| Duggan, Kenny | HMP Nottingham | Self-inflicted | Published | 18 Dec 2021 | — |
| Graham Taylor | HMP Dartmoor | Self-inflicted | Published | 17 Dec 2021 | 1 |
| Individual at Gartree | HMP Gartree | Natural | Published | 17 Dec 2021 | — |
| Individual at Frankland | HMP Frankland | Natural | Published | 17 Dec 2021 | — |
| Individual at Isle of Wight | HMP Isle of Wight | Natural | Published | 16 Dec 2021 | — |
| Rowntree, Kevin | HMP Holme House | Self-inflicted | Published | 16 Dec 2021 | — |
| Individual at Lancaster Farms | HMP Lancaster Farms | Natural | Published | 16 Dec 2021 | — |
| David Wise | HMP Wandsworth | Other | Published | 15 Dec 2021 | 2 |
| Individual at Warren Hill | HMP Warren Hill | Natural | Published | 13 Dec 2021 | — |
| Individual at Gartree | HMP Gartree | Natural | Published | 12 Dec 2021 | — |
| Individual at Leeds Post-release | Leeds Post-release | Other | Published | 11 Dec 2021 | — |
| Calaroi, Alexandru | Highpoint Post-release | Other | Published | 9 Dec 2021 | — |
| Individual at Hewell | HMP Hewell | Natural | Published | 7 Dec 2021 | — |
| Liam Turner | HMP Manchester | Other | Published | 6 Dec 2021 | 2 |
| Ian Davies | HMP Bristol | Self-inflicted | Published | 6 Dec 2021 | 7 |
| Hart, Thomas | HMP Ranby | Natural | Published | 5 Dec 2021 | — |
| Price, Damien | HMP Swaleside | Self-inflicted | Published | 2 Dec 2021 | — |
| Individual at Altcourse Post-release | Altcourse Post-release | Natural | Published | 1 Dec 2021 | — |
| Haygarth, Mark | HMP Wymott | Natural | Published | 29 Nov 2021 | — |
| O'Donnell , Michael | HMP Leeds | Natural | Published | 28 Nov 2021 | — |
| Individual at Elmley | HMP Elmley | Natural | Published | 22 Nov 2021 | — |
| Individual at Stafford | HMP Stafford | Natural | Published | 22 Nov 2021 | — |
| Singh, Amarjit | HMP Pentonville | Natural | Published | 21 Nov 2021 | — |
| Burdon, Jerry | HMP Leyhill | Natural | Published | 21 Nov 2021 | — |
| William Roalfe | HMP Channings Wood | Natural | Published | 20 Nov 2021 | 9 |
| Diana Grant | HMP Bronzefield | Self-inflicted | Published | 20 Nov 2021 | 6 |
| Individual at Stafford | HMP Stafford | Natural | Published | 18 Nov 2021 | — |
| Maqsood Asif | HMP Stafford | Natural | Published | 18 Nov 2021 | 5 |
| Doherty, James | HMP Wormwood Scrubs | Self-inflicted | Published | 18 Nov 2021 | — |
| Individual at Bedford | HMP Bedford | Natural | Published | 18 Nov 2021 | — |
| Individual at Parc | HMP Parc | Natural | Published | 17 Nov 2021 | — |
| Individual at Wymott | HMP Wymott | Natural | Published | 15 Nov 2021 | — |
| Livesey, Donald | HMP Leeds | Self-inflicted | Published | 15 Nov 2021 | — |
| Cunningham, Stuart | HMP Dovegate | Natural | Published | 13 Nov 2021 | — |
| Individual at Whatton | HMP Whatton | Natural | Published | 12 Nov 2021 | — |
| Individual at Littlehey | HMP Littlehey | Natural | Published | 12 Nov 2021 | — |