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
Individual at Birmingham HMP Birmingham Natural Published 19 Mar 2021
Individual at Isle of Wight HMP Isle of Wight Natural Published 18 Mar 2021
Individual at Wakefield HMP Wakefield Natural Published 16 Mar 2021
Individual at Leeds HMP Leeds Natural Published 16 Mar 2021
Individual at The Mount HMP The Mount Natural Published 14 Mar 2021
Tate, Jamie HMP Manchester Other Published 14 Mar 2021
Brown, Alan HMP Littlehey Natural Published 14 Mar 2021
Individual at Featherstone HMP Featherstone Natural Published 13 Mar 2021
Individual at Bure HMP Bure Natural Published 12 Mar 2021
Hayden, Samuel HMP Liverpool Self-inflicted Published 12 Mar 2021
Individual at Oakwood HMP Oakwood Natural Published 11 Mar 2021
Individual at Bullingdon HMP Bullingdon Natural Published 11 Mar 2021
Individual at Winchester HMP Winchester Natural Published 10 Mar 2021
Individual at Isle of Wight HMP Isle of Wight Natural Published 9 Mar 2021
Individual at Stafford HMP Stafford Natural Published 9 Mar 2021
Individual at Wakefield HMP Wakefield Natural Published 9 Mar 2021
Individual at Isle of Wight HMP Isle of Wight Natural Published 8 Mar 2021
Carl Sheldon Wharflane House Approved Premises Other Published 8 Mar 2021 3
Fenna, Dylan HMP Humber Natural Published 8 Mar 2021
Individual at Wakefield HMP Wakefield Natural Published 7 Mar 2021
Individual at Liverpool HMP Liverpool Natural Published 7 Mar 2021
Individual at Bure HMP Bure Natural Published 7 Mar 2021
Individual at Wayland HMP Wayland Natural Published 7 Mar 2021
Individual at Leeds HMP Leeds Natural Published 5 Mar 2021
Individual at Brixton HMP Brixton Natural Published 4 Mar 2021
Individual at Ashley House Ashley House Self-inflicted Published 3 Mar 2021
Individual at Whatton HMP Whatton Natural Published 3 Mar 2021
Jason McQuoid HMP Risley Self-inflicted Published 2 Mar 2021 5
Joseph, Paul HMP Chelmsford Self-inflicted Published 2 Mar 2021
Individual at Isle of Wight HMP Isle of Wight Natural Published 2 Mar 2021
Individual at Oakwood HMP Oakwood Natural Published 1 Mar 2021
George Petrou HMP Pentonville Self-inflicted Published 1 Mar 2021 7
Individual at Stocken HMP Stocken Natural Published 1 Mar 2021
Individual at Manchester HMP Manchester Natural Published 1 Mar 2021
Individual at New Hall HMP New Hall Natural Published 1 Mar 2021
Individual at Leeds HMP Leeds Natural Published 28 Feb 2021
Individual at Whatton HMP Whatton Natural Published 27 Feb 2021
Individual at Oakwood HMP Oakwood Natural Published 27 Feb 2021
Individual at Rye Hill HMP Rye Hill Natural Published 26 Feb 2021
Individual at Erlestoke HMP Erlestoke Natural Published 25 Feb 2021
Individual at Doncaster HMP Doncaster Natural Published 24 Feb 2021
Individual at Swaleside HMP Swaleside Natural Published 24 Feb 2021
Individual at The Verne HMP The Verne Natural Published 24 Feb 2021
Individual at Wakefield HMP Wakefield Natural Published 23 Feb 2021
Individual at New Hall HMP New Hall Natural Published 23 Feb 2021
Individual at Rye Hill HMP Rye Hill Natural Published 22 Feb 2021
Individual at Durham HMP Durham Natural Published 22 Feb 2021
Individual at The Verne HMP The Verne Natural Published 22 Feb 2021
Individual at Doncaster HMP Doncaster Other Published 21 Feb 2021
Individual at Norwich HMP Norwich Natural Published 21 Feb 2021