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 Wymott | HMP Wymott | Natural | Published | 11 Nov 2021 | — |
| Individual at Long Lartin | HMP Long Lartin | Natural | Published | 11 Nov 2021 | — |
| Groman, Jonathan | HMP Wormwood Scrubs | Natural | Published | 11 Nov 2021 | — |
| Azroy Dawes-Clarke | HMP Elmley | Self-inflicted | Published | 10 Nov 2021 | 8 |
| Individual at Wymott | HMP Wymott | Natural | Published | 8 Nov 2021 | — |
| Burnley, John | HMP Stafford | Natural | Published | 7 Nov 2021 | — |
| Paul Gobell | HMP Whatton | Self-inflicted | Published | 6 Nov 2021 | 3 |
| Individual at Holme House | HMP Holme House | Natural | Published | 5 Nov 2021 | — |
| Rollins, John | HMP Wymott | Natural | Published | 5 Nov 2021 | — |
| Snashfold, Gordon | HMP The Verne | Natural | Published | 4 Nov 2021 | — |
| Wilton, Thomas | Preston Post-release | Other | Published | 4 Nov 2021 | — |
| Khan, Salim | HMP Leyhill | Natural | Published | 1 Nov 2021 | — |
| Individual at Littlehey | HMP Littlehey | Natural | Published | 29 Oct 2021 | — |
| Justin MacDonald | HMP Exeter | Other | Published | 29 Oct 2021 | — |
| Richell, Colin | HMP Rye Hill | Natural | Published | 25 Oct 2021 | — |
| Individual at Altcourse Post-release | Altcourse Post-release | Other | Published | 23 Oct 2021 | — |
| Individual at Garth | HMP Garth | Natural | Published | 20 Oct 2021 | — |
| Individual at Full Sutton | HMP Full Sutton | Natural | Published | 18 Oct 2021 | — |
| Individual at Warren Hill | HMP Warren Hill | Natural | Published | 17 Oct 2021 | — |
| Individual at High Down Post-release | High Down Post-release | Other | Published | 17 Oct 2021 | — |
| McLelland, Justin | HMP Northumberland | Self-inflicted | Published | 15 Oct 2021 | — |
| Lockwood, Trevor | HMP Wormwood Scrubs | Natural | Published | 14 Oct 2021 | — |
| MacGillivray, Christopher | Durham Post-release | Self-inflicted | Published | 14 Oct 2021 | — |
| Individual at Hull | HMP Hull | Natural | Published | 13 Oct 2021 | — |
| Individual at Frankland | HMP Frankland | Natural | Published | 12 Oct 2021 | — |
| Individual at Elmley Post-release | Elmley Post-release | Natural | Published | 10 Oct 2021 | — |
| Individual at Dovegate | HMP Dovegate | Natural | Published | 9 Oct 2021 | — |
| Individual at Ashfield | HMP Ashfield | Natural | Published | 7 Oct 2021 | — |
| Bozek, Rafal | HMP Altcourse | Self-inflicted | Published | 7 Oct 2021 | — |
| Individual at Altcourse | HMP Altcourse | Natural | Published | 6 Oct 2021 | — |
| Individual at Wayland | HMP Wayland | Natural | Published | 6 Oct 2021 | — |
| Individual at Swaleside | HMP Swaleside | Other | Published | 5 Oct 2021 | — |
| Boyce, Kane | HMP Lowdham Grange | Self-inflicted | Published | 3 Oct 2021 | — |
| Individual at Nelson House | Nelson House | Natural | Published | 2 Oct 2021 | — |
| Individual at Wymott | HMP Wymott | Natural | Published | 2 Oct 2021 | — |
| Individual at Doncaster | HMP Doncaster | Natural | Published | 1 Oct 2021 | — |
| Ryan Harris | HMP Cardiff | Self-inflicted | Published | 1 Oct 2021 | 3 |
| Tinsley, Barry | Altcourse Post-release | Other | Published | 1 Oct 2021 | — |
| Ann-Marie Pyle | HMP/YOI Drake Hall | Natural | Published | 30 Sep 2021 | 1 |
| Individual at Winchester Post-release | Winchester Post-release | Self-inflicted | Published | 27 Sep 2021 | — |
| Individual at Whitemoor | HMP Whitemoor | Natural | Published | 26 Sep 2021 | — |
| Individual at Leeds | HMP Leeds | Natural | Published | 26 Sep 2021 | — |
| David Tilley | HMP Isle of Wight | Natural | Published | 26 Sep 2021 | — |
| McDermott, Christopher | HMP Wymott | Natural | Published | 24 Sep 2021 | — |
| Trevor Coady | HMP Bullingdon | Natural | Published | 24 Sep 2021 | — |
| Brotherton, Thomas | HMP Preston | Self-inflicted | Published | 22 Sep 2021 | — |
| Jackson , Aiden | HMP Gartree | Self-inflicted | Published | 20 Sep 2021 | — |
| Individual at Liverpool | HMP Liverpool | Natural | Published | 18 Sep 2021 | — |
| Kelly, Phillip | HMP Garth | Self-inflicted | Published | 17 Sep 2021 | — |
| Individual at Risley | HMP Risley | Natural | Published | 17 Sep 2021 | — |