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 |
|---|---|---|---|---|---|
| Jones, Samuel | HMP Portland | Self-inflicted | Published | 1 May 2021 | — |
| Individual at Send | HMP Send | Natural | Published | 1 May 2021 | — |
| Coysh, Edward | HMP Wymott | Natural | Published | 26 Apr 2021 | — |
| Raymond Allison | HMP Holme House | Other | Published | 25 Apr 2021 | — |
| Individual at Bure | HMP Bure | Natural | Published | 25 Apr 2021 | — |
| Individual at Braley House | Braley House | Other | Published | 25 Apr 2021 | — |
| Individual at Woodhill | HMP Woodhill | Self-inflicted | Published | 25 Apr 2021 | — |
| Individual at Altcourse | HMP Altcourse | Self-inflicted | Published | 25 Apr 2021 | — |
| Individual at Moorland Closed | HMP Moorland Closed | Other | Published | 21 Apr 2021 | — |
| Individual at Norwich | HMP Norwich | Natural | Published | 20 Apr 2021 | — |
| Individual at Bullingdon | HMP Bullingdon | Self-inflicted | Published | 20 Apr 2021 | — |
| Individual at Frankland | HMP Frankland | Natural | Published | 18 Apr 2021 | — |
| Monerville, Trevor | HMP Lewes | Natural | Published | 18 Apr 2021 | — |
| Richardson, Alan | Brighton | Natural | Published | 18 Apr 2021 | — |
| Individual at North Sea Camp | HMP North Sea Camp | Natural | Published | 17 Apr 2021 | — |
| Individual at Littlehey | HMP Littlehey | Natural | Published | 17 Apr 2021 | — |
| Connolly, Martin | HMP Dartmoor | Natural | Published | 16 Apr 2021 | — |
| Individual at Gartree | HMP Gartree | Self-inflicted | Published | 16 Apr 2021 | — |
| Individual at Holme House | HMP Holme House | Natural | Published | 14 Apr 2021 | — |
| Individual at Liverpool | HMP Liverpool | Natural | Published | 13 Apr 2021 | — |
| Individual at Pentonville | HMP Pentonville | Natural | Published | 13 Apr 2021 | — |
| Individual at Long Lartin | HMP Long Lartin | Natural | Published | 13 Apr 2021 | — |
| Beadman, Stephen | HMP Wakefield | Self-inflicted | Published | 8 Apr 2021 | — |
| Individual at Ford | HMP Ford | Natural | Published | 4 Apr 2021 | — |
| Individual at The Verne | HMP The Verne | Natural | Published | 31 Mar 2021 | — |
| Williams, Ellis | HMP Parc | Natural | Published | 31 Mar 2021 | — |
| Individual at Stocken | HMP Stocken | Self-inflicted | Published | 30 Mar 2021 | — |
| Individual at Littlehey | HMP Littlehey | Natural | Published | 29 Mar 2021 | — |
| Individual at Humber | HMP Humber | Natural | Published | 28 Mar 2021 | — |
| Individual at Isle of Wight | HMP Isle of Wight | Natural | Published | 27 Mar 2021 | — |
| Sprackling, Bradley | HMP Forest Bank | Other | Published | 27 Mar 2021 | — |
| Manson, Patrick | St Christophers House | Other | Published | 27 Mar 2021 | — |
| Individual at Lewes | HMP Lewes | Self-inflicted | Published | 26 Mar 2021 | — |
| Individual at Moorland Closed | HMP Moorland Closed | Natural | Published | 25 Mar 2021 | — |
| Warburton, Peter | HMP Berwyn | Natural | Published | 25 Mar 2021 | — |
| Peter Coulthard | HMP Whatton | Natural | Published | 23 Mar 2021 | 4 |
| Flanagan, Ryan | HMP Chelmsford | Natural | Published | 23 Mar 2021 | — |
| Individual at Hewell | HMP Hewell | Self-inflicted | Published | 23 Mar 2021 | — |
| Rimantas Zalalis | HMP Thameside | Other | Published | 22 Mar 2021 | 4 |
| Individual at Swaleside | HMP Swaleside | Natural | Published | 22 Mar 2021 | — |
| Individual at Elmley | HMP Elmley | Natural | Published | 22 Mar 2021 | — |
| Individual at Humber | HMP Humber | Natural | Published | 22 Mar 2021 | — |
| Individual at Nelson House | Nelson House | Other | Published | 21 Mar 2021 | — |
| Individual at Pentonville | HMP Pentonville | Natural | Published | 21 Mar 2021 | — |
| Individual at Leeds | HMP Leeds | Natural | Published | 21 Mar 2021 | — |
| Nicholas, Delphon | HMP Whitemoor | Other | Published | 21 Mar 2021 | — |
| Springham, Ross | HMP Wandsworth | Self-inflicted | Published | 20 Mar 2021 | — |
| Zarrop, Jack | HMP Wormwood Scrubs | Self-inflicted | Published | 20 Mar 2021 | — |
| Mark Jozunas | HMP Chelmsford | Self-inflicted | Published | 20 Mar 2021 | — |
| Individual at Humber | HMP Humber | Natural | Published | 20 Mar 2021 | — |