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
Claire Taylor HMP/YOI Eastwood Park Pending inquest
Steven Watson HMP Highpoint Pending inquest
Amie Keeling HMP/YOI Foston Hall In progress
Lee Wilson HMP Leeds In progress
Stephen Proctor Elm Bank Approved Premises In progress
Uttam Thapa HMP Belmarsh Pending inquest
Emma Kent HMP/YOI Foston Hall Pending inquest
Philip Eldridge HMP The Verne Pending inquest
Paul Thompson HMP Norwich Pending inquest
Marlon Kelly HMP Swaleside Pending inquest
Christopher Hennigan HMP Manchester In progress
Steven Davidson HMP Chelmsford Pending inquest
Mark Williams HMP Bullingdon In progress
Nicholas Braham HMP Dovegate In progress
Geoffrey Cheffings HMP Winchester In progress
George Richards HMP Lincoln In progress
Stephen Taylor HMP Altcourse Natural Published
Geoffrey Collett HMP Rye Hill In progress
Ricky Gray HMP The Mount In progress
Danny Smith HMP Risley In progress
Michael Harrison HMP Manchester In progress
Toby Greenwell HMP Humber Pending inquest
Wayne Price Canadian Avenue Approved Premises Pending inquest
Daniel Woods HMP Cardiff Self-inflicted Published
Abdul Abrar HMP The Mount In progress
Sarah Boyle HMP/YOI Styal In progress
Daniel Girdlestone HMP Holme House In progress
Jeffrey Long HMP/YOI Moorland In progress
David Sharp HMP Littlehey Pending inquest
Anthony Bell HMP Hewell In progress
Anthony Shackell HMP Bullingdon In progress
John Phillips HMP Isle of Wight Pending inquest
Adam Diesa-Green HMP Lowdham Grange Other Published
Kelly Day HMP Bronzefield In progress
Juan Garcia Hernandez HMP Garth In progress
Glenn Brown Holbeck House Approved Premises Pending inquest
Stefan Adi HMP Maidstone Pending inquest
Matthew Pickles HMP/YOI High Down In progress
Robert Harvey HMP Durham In progress
Lee Nation HMP Swansea In progress
Scott Sansome HMP Cardiff Pending inquest
Stewart Bird HMP Isle of Wight Pending inquest
Gary Winters HMP Whatton Natural Published
Kerim Saparov HMP Belmarsh Pending inquest
Simon Kubalik HMP/YOI Doncaster Pending inquest
Kasim Hussain HMP Preston In progress
David Wright HMP Fosse Way In progress
Maurice Mcentire HMP Swaleside Pending inquest
Jamie Evans HMP Kirkham In progress
Craig Gordon HMP Wandsworth Pending inquest