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 Risley HMP Risley Natural Published 20 Dec 2020
Individual at Northumberland HMP Northumberland Natural Published 18 Dec 2020
Individual at Stafford HMP Stafford Natural Published 17 Dec 2020
Individual at Moorland Closed HMP Moorland Closed Natural Published 17 Dec 2020
James, Lee HMP Long Lartin Self-inflicted Published 16 Dec 2020
O'Rourke, Stephen HMP Wandsworth Self-inflicted Published 16 Dec 2020
Harvey, Vincent HMP Elmley Natural Published 15 Dec 2020
Individual at Doncaster HMP Doncaster Natural Published 13 Dec 2020
Individual at Channings Wood HMP Channings Wood Natural Published 13 Dec 2020
Individual at Doncaster HMP Doncaster Self-inflicted Published 10 Dec 2020
Keith Morgan HMP Cardiff Natural Published 10 Dec 2020
Individual at Doncaster HMP Doncaster Natural Published 9 Dec 2020
Individual at Garth HMP Garth Natural Published 9 Dec 2020
Individual at High Down HMP High Down Natural Published 8 Dec 2020
Individual at Birmingham HMP Birmingham Natural Published 8 Dec 2020
Individual at Lincoln HMP Lincoln Natural Published 7 Dec 2020
Individual at Brinsford HMP Brinsford Homicide Published 6 Dec 2020
Decland Mooney HMP Cardiff Natural Published 6 Dec 2020 3
Individual at Wakefield HMP Wakefield Natural Published 6 Dec 2020
Individual at Whatton HMP Whatton Natural Published 4 Dec 2020
Individual at High Down HMP High Down Self-inflicted Published 4 Dec 2020
Individual at Littlehey HMP Littlehey Natural Published 4 Dec 2020
Individual at Whatton HMP Whatton Natural Published 1 Dec 2020
Individual at Elmley HMP Elmley Natural Published 29 Nov 2020
Individual at Frankland HMP Frankland Natural Published 25 Nov 2020
Individual at Stocken HMP Stocken Self-inflicted Published 25 Nov 2020
Individual at Stonnall Road Stonnall Road Other Published 25 Nov 2020
Individual at Altcourse HMP Altcourse Natural Published 24 Nov 2020
Individual at Full Sutton HMP Full Sutton Natural Published 23 Nov 2020
Individual at Liverpool HMP Liverpool Natural Published 23 Nov 2020
Individual at Littlehey HMP Littlehey Natural Published 23 Nov 2020
Individual at Leeds HMP Leeds Self-inflicted Published 22 Nov 2020
Individual at Littlehey HMP Littlehey Natural Published 21 Nov 2020
Individual at Manchester HMP Manchester Other Published 20 Nov 2020
Coleman, Emile HMP Isis Natural Published 20 Nov 2020
Individual at Full Sutton HMP Full Sutton Natural Published 19 Nov 2020
Individual at Leeds HMP Leeds Self-inflicted Published 18 Nov 2020
Individual at Haverigg HMP Haverigg Natural Published 17 Nov 2020
Vassantlal, Priyank HMP Wormwood Scrubs Self-inflicted Published 17 Nov 2020
Individual at Whatton HMP Whatton Natural Published 17 Nov 2020
Individual at Moorland Closed HMP Moorland Closed Natural Published 16 Nov 2020
Individual at Hull HMP Hull Natural Published 15 Nov 2020
Robert Frith HMP Berwyn Self-inflicted Published 14 Nov 2020 8
Individual at Frankland HMP Frankland Natural Published 13 Nov 2020
Individual at Frankland HMP Frankland Natural Published 13 Nov 2020
Michael Lavin HMP Altcourse Natural Published 12 Nov 2020 6
Christopher Parker HMP Holme House Self-inflicted Published 12 Nov 2020 4
Mason, Andrew HMP Lancaster Farms Natural Published 12 Nov 2020
Individual at Doncaster HMP Doncaster Natural Published 11 Nov 2020
Individual at Wymott HMP Wymott Natural Published 11 Nov 2020