Source · Deaths in custody
PPO Fatal Incident Reports
6,488 incidents
5,759 published
1,642 recommendations
1,658 self-inflicted
3,411 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 |
|---|---|---|---|
| Annual Report 2025 to 2026 | Annual report | Jul 2026 | |
| 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 property complaints | Policy into Practice | Mar 2025 | |
| Policy into Practice: Handling of prisoners’ property | Policy into Practice | Mar 2025 | |
| Complaints Investigations Learning Lessons Bulletin Issue 11: Property complaints | Learning Lessons Bulletin | Mar 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 | |
| PPO response to JSC Tackling Drugs in Prison Inquiry | 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 |
Incidents
| Name | Establishment | Cause | Status | Date of death | Recs |
|---|---|---|---|---|---|
| Individual at Durham | HMP Durham | Natural | Published | 6 Sep 2021 | — |
| Dougan, Ashley | HMP Altcourse | Self-inflicted | Published | 3 Sep 2021 | — |
| Individual at Leeds | HMP Leeds | Natural | Published | 31 Aug 2021 | — |
| Individual at Woodhill | HMP Woodhill | Natural | Published | 29 Aug 2021 | — |
| Smith, Vincent | HMP Durham | Natural | Published | 27 Aug 2021 | — |
| Individual at Peterborough | HMP Peterborough | Natural | Published | 27 Aug 2021 | — |
| Pokuta, Marian | HMP Doncaster | Self-inflicted | Published | 26 Aug 2021 | — |
| Individual at Littlehey | HMP Littlehey | Natural | Published | 21 Aug 2021 | — |
| Benjamin Walter | HMP Lowdham Grange | Other | Published | 20 Aug 2021 | 1 |
| Individual at Long Lartin | HMP Long Lartin | Natural | Published | 20 Aug 2021 | — |
| Individual at Littlehey | HMP Littlehey | Natural | Published | 20 Aug 2021 | — |
| Individual at Northumberland | HMP Northumberland | Natural | Published | 17 Aug 2021 | — |
| David Mears | HMP Channings Wood | Natural | Published | 17 Aug 2021 | 6 |
| Matthew Braben | HMP Wormwood Scrubs | Self-inflicted | Published | 16 Aug 2021 | 5 |
| Kock, Johnny | HMP Berwyn | Natural | Published | 16 Aug 2021 | — |
| Tomlinson, Stuart | HMP Rye Hill | Natural | Published | 16 Aug 2021 | — |
| Phillipson, Jack | HMP Northumberland | Self-inflicted | Published | 15 Aug 2021 | — |
| Elsworth, Mark | HMP Humber | Natural | Published | 13 Aug 2021 | — |
| Chadwick, Francis | HMP Altcourse | Self-inflicted | Published | 10 Aug 2021 | — |
| Individual at Full Sutton | HMP Full Sutton | Natural | Published | 7 Aug 2021 | — |
| Individual at Leeds | HMP Leeds | Natural | Published | 4 Aug 2021 | — |
| Britton, Barry | HMP Whatton | Natural | Published | 3 Aug 2021 | — |
| Individual at Cardiff | HMP Cardiff | Natural | Published | 2 Aug 2021 | — |
| Individual at Leeds | HMP Leeds | Natural | Published | 1 Aug 2021 | — |
| Dealey, Paul | HMP Swaleside | Self-inflicted | Published | 1 Aug 2021 | — |
| Individual at Hatfield | HMP Hatfield | Other | Published | 31 Jul 2021 | — |
| Daniel Ayers | HMP Winchester | Self-inflicted | Published | 25 Jul 2021 | 14 |
| Anne-Marie Roberts | HMP/YOI Eastwood Park | Natural | Published | 24 Jul 2021 | 6 |
| Individual at Westbourne House | Westbourne House | Other | Published | 23 Jul 2021 | — |
| Individual at Hewell | HMP Hewell | Self-inflicted | Published | 21 Jul 2021 | — |
| Simmons, Robert | HMP Cardiff | Natural | Published | 20 Jul 2021 | — |
| Individual at Birmingham | HMP Birmingham | Natural | Published | 18 Jul 2021 | — |
| Pioro, Mariusz | HMP Bedford | Natural | Published | 16 Jul 2021 | — |
| Individual at Swaleside | HMP Swaleside | Self-inflicted | Published | 15 Jul 2021 | — |
| Seal, Andrew | HMP Parc | Natural | Published | 13 Jul 2021 | — |
| Keith Williams | HMP Dovegate | Self-inflicted | Published | 12 Jul 2021 | 14 |
| Individual at Elmley | HMP Elmley | Natural | Published | 11 Jul 2021 | — |
| Individual at Norwich | HMP Norwich | Natural | Published | 9 Jul 2021 | — |
| Individual at Northumberland | HMP Northumberland | Natural | Published | 9 Jul 2021 | — |
| Individual at Hewell | HMP Hewell | Natural | Published | 8 Jul 2021 | — |
| Akhtar Hussain | HMP Manchester | Self-inflicted | Published | 8 Jul 2021 | 12 |
| Individual at Moorland Closed | HMP Moorland Closed | Natural | Published | 6 Jul 2021 | — |
| Individual at Dartmoor | HMP Dartmoor | Natural | Published | 3 Jul 2021 | — |
| Individual at Littlehey | HMP Littlehey | Natural | Published | 27 Jun 2021 | — |
| Edward McCulloch | HMP Isle of Wight | Natural | Published | 25 Jun 2021 | — |
| Individual at Northumberland | HMP Northumberland | Natural | Published | 25 Jun 2021 | — |
| Daniel Beckford | HMP Wandsworth | Self-inflicted | Published | 23 Jun 2021 | 6 |
| Individual at Wymott | HMP Wymott | Natural | Published | 22 Jun 2021 | — |
| Shahrooz Ghassemian | HMP Wandsworth | Self-inflicted | Published | 21 Jun 2021 | 10 |
| Individual at Cuthbert House | Cuthbert House | Self-inflicted | Published | 20 Jun 2021 | — |