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 |
|---|---|---|---|---|---|
| Individual at Altcourse | HMP Altcourse | Natural | Published | 21 Jan 2021 | — |
| Individual at Liverpool | HMP Liverpool | Natural | Published | 21 Jan 2021 | — |
| Individual at Norwich | HMP Norwich | Natural | Published | 21 Jan 2021 | — |
| Individual at Whitemoor | HMP Whitemoor | Natural | Published | 21 Jan 2021 | — |
| Individual at Doncaster | HMP Doncaster | Self-inflicted | Published | 20 Jan 2021 | — |
| Watson, Lawrence | HMP Brixton | Natural | Published | 20 Jan 2021 | — |
| Kalay, Alpha | HMP Hull | Natural | Published | 19 Jan 2021 | — |
| Individual at Stafford | HMP Stafford | Natural | Published | 19 Jan 2021 | — |
| Individual at Hull | HMP Hull | Natural | Published | 19 Jan 2021 | — |
| Individual at Littlehey | HMP Littlehey | Natural | Published | 19 Jan 2021 | — |
| Individual at Manchester Post-release | Manchester Post-release | Natural | Published | 19 Jan 2021 | — |
| Individual at North Sea Camp | HMP North Sea Camp | Natural | Published | 19 Jan 2021 | — |
| Cussans, Paul | HMP Lincoln | Natural | Published | 17 Jan 2021 | — |
| Individual at Birmingham | HMP Birmingham | Natural | Published | 16 Jan 2021 | — |
| Cree, Samuel | HMP Wymott | Natural | Published | 14 Jan 2021 | — |
| Individual at Birmingham | HMP Birmingham | Natural | Published | 12 Jan 2021 | — |
| Salmond, Kathleen | HMP Foston Hall | Natural | Published | 11 Jan 2021 | — |
| Joshua Esberger | HMP Hull | Self-inflicted | Published | 11 Jan 2021 | 5 |
| David Reid | HMP Rye Hill | Natural | Published | 11 Jan 2021 | 5 |
| Individual at Garth | HMP Garth | Self-inflicted | Published | 9 Jan 2021 | — |
| Individual at Mandeville House | Mandeville House | Other | Published | 9 Jan 2021 | — |
| Individual at Littlehey | HMP Littlehey | Natural | Published | 9 Jan 2021 | — |
| Individual at Aylesbury | HMP Aylesbury | Self-inflicted | Published | 8 Jan 2021 | — |
| Individual at Maidstone | HMP Maidstone | Natural | Published | 8 Jan 2021 | — |
| Individual at Stoke Heath | HMP Stoke Heath | Natural | Published | 6 Jan 2021 | — |
| Individual at Littlehey | HMP Littlehey | Natural | Published | 6 Jan 2021 | — |
| Individual at Brigstocke Road | Brigstocke Road | Natural | Published | 6 Jan 2021 | — |
| Individual at Bure | HMP Bure | Natural | Published | 5 Jan 2021 | — |
| Individual at Lewes | HMP Lewes | Self-inflicted | Published | 4 Jan 2021 | — |
| Individual at Swaleside | HMP Swaleside | Natural | Published | 31 Dec 2020 | — |
| Individual at Stocken | HMP Stocken | Other | Published | 31 Dec 2020 | — |
| Individual at Garth | HMP Garth | Natural | Published | 29 Dec 2020 | — |
| Individual at Nottingham | HMP Nottingham | Natural | Published | 29 Dec 2020 | — |
| Jenkins, Thomas | HMP Parc | Natural | Published | 26 Dec 2020 | — |
| Individual at Long Lartin | HMP Long Lartin | Natural | Published | 26 Dec 2020 | — |
| Individual at Exeter | HMP Exeter | Natural | Published | 26 Dec 2020 | — |
| Individual at Elmley | HMP Elmley | Natural | Published | 26 Dec 2020 | — |
| Individual at Liverpool | HMP Liverpool | Natural | Published | 25 Dec 2020 | — |
| Individual at Parc | HMP Parc | Natural | Published | 25 Dec 2020 | — |
| Individual at Highpoint | HMP Highpoint | Natural | Published | 25 Dec 2020 | — |
| Individual at Frankland | HMP Frankland | Natural | Published | 24 Dec 2020 | — |
| Individual at Parc | HMP Parc | Natural | Published | 24 Dec 2020 | — |
| Individual at Wakefield | HMP Wakefield | Natural | Published | 23 Dec 2020 | — |
| Individual at Doncaster | HMP Doncaster | Natural | Published | 22 Dec 2020 | — |
| Individual at Dartmoor | HMP Dartmoor | Natural | Published | 22 Dec 2020 | — |
| Individual at Lincoln | HMP Lincoln | Self-inflicted | Published | 22 Dec 2020 | — |
| Sanderson, Annelise | HMP Styal | Self-inflicted | Published | 22 Dec 2020 | — |
| Colverson, Frederick | HMP Coldingley | Natural | Published | 21 Dec 2020 | — |
| Gibbs, George | HMP Rye Hill | Natural | Published | 21 Dec 2020 | — |
| Individual at Doncaster | HMP Doncaster | Natural | Published | 21 Dec 2020 | — |