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 |
|---|---|---|---|---|---|
| Khyber Nasim | HMP Pentonville | Self-inflicted | Published | 17 Jun 2021 | 3 |
| Individual at Bedford | HMP Bedford | Self-inflicted | Published | 15 Jun 2021 | — |
| Individual at Leyhill | HMP Leyhill | Natural | Published | 15 Jun 2021 | — |
| Individual at Elmley | HMP Elmley | Natural | Published | 14 Jun 2021 | — |
| Individual at Birmingham | HMP Birmingham | Natural | Published | 14 Jun 2021 | — |
| Individual at Wakefield | HMP Wakefield | Natural | Published | 10 Jun 2021 | — |
| Individual at Moorland Closed | HMP Moorland Closed | Natural | Published | 9 Jun 2021 | — |
| Rahman, Syed | HMP Forest Bank | Self-inflicted | Published | 8 Jun 2021 | — |
| Piotr Marszalek | HMP Wandsworth | Self-inflicted | Published | 8 Jun 2021 | 8 |
| Individual at Leeds | HMP Leeds | Natural | Published | 6 Jun 2021 | — |
| James Kiteley | HMP Sudbury | Other | Published | 5 Jun 2021 | 3 |
| Individual at Ashfield | HMP Ashfield | Natural | Published | 3 Jun 2021 | — |
| Individual at Norwich | HMP Norwich | Natural | Published | 3 Jun 2021 | — |
| Jake Swords | HMP Peterborough | Other | Published | 2 Jun 2021 | 2 |
| Individual at Altcourse | HMP Altcourse | Natural | Published | 2 Jun 2021 | — |
| McCollin, Rohan | HMP Chelmsford | Self-inflicted | Published | 2 Jun 2021 | — |
| Robert Stephens | HMP The Verne | Natural | Published | 28 May 2021 | 5 |
| Individual at Rochester | HMP Rochester | Natural | Published | 27 May 2021 | — |
| Lukasz Lukasik | HMP Hull | Self-inflicted | Published | 27 May 2021 | 6 |
| Salt, Harold | HMP Littlehey | Natural | Published | 27 May 2021 | — |
| Individual at Stafford | HMP Stafford | Natural | Published | 27 May 2021 | — |
| Individual at Bullingdon | HMP Bullingdon | Natural | Published | 26 May 2021 | — |
| Mark Tyrer | Bunbury House | Natural | Published | 25 May 2021 | — |
| Individual at Durham | HMP Durham | Natural | Published | 25 May 2021 | — |
| Individual at Norwich | HMP Norwich | Self-inflicted | Published | 21 May 2021 | — |
| Individual at Crowley House (female) | Crowley House (female) | Other | Published | 17 May 2021 | — |
| Individual at High Down | HMP High Down | Natural | Published | 17 May 2021 | — |
| Individual at Lewes | HMP Lewes | Self-inflicted | Published | 16 May 2021 | — |
| Individual at Wayland | HMP Wayland | Natural | Published | 15 May 2021 | — |
| Individual at Littlehey | HMP Littlehey | Natural | Published | 14 May 2021 | — |
| Sebastião Lucas | HMP Wandsworth | Self-inflicted | Published | 12 May 2021 | 6 |
| Individual at Isle of Wight | HMP Isle of Wight | Natural | Published | 12 May 2021 | — |
| Individual at Forest Bank | HMP Forest Bank | Natural | Published | 12 May 2021 | — |
| Port, David | HMP Hull | Self-inflicted | Published | 11 May 2021 | — |
| Barry Lightbown | Bowling Green Approved Premises | Self-inflicted | Published | 11 May 2021 | — |
| Individual at Ashley House | Ashley House | Self-inflicted | Published | 7 May 2021 | — |
| Individual at Bure | HMP Bure | Natural | Published | 6 May 2021 | — |
| Individual at Manchester | HMP Manchester | Natural | Published | 5 May 2021 | — |
| Individual at Swaleside | HMP Swaleside | Natural | Published | 5 May 2021 | — |
| Individual at Manchester | HMP Manchester | Self-inflicted | Published | 4 May 2021 | — |
| Godfrey Muzhuzha | HMP The Mount | Natural | Published | 3 May 2021 | 4 |
| Individual at Elmley | HMP Elmley | Other | Published | 2 May 2021 | — |
| Individual at Send | HMP Send | Natural | Published | 1 May 2021 | — |
| Individual at Warren Hill | HMP Warren Hill | Other | Published | 1 May 2021 | — |
| Jones, Samuel | HMP Portland | Self-inflicted | Published | 1 May 2021 | — |
| Coysh, Edward | HMP Wymott | Natural | Published | 26 Apr 2021 | 8 |
| 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 Altcourse | HMP Altcourse | Self-inflicted | Published | 25 Apr 2021 | — |