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 Risley | HMP Risley | Natural | Published | 27 Aug 2020 | — |
| Baltrunas, Karolis | HMP The Mount | Self-inflicted | Published | 27 Aug 2020 | — |
| Individual at Bure | HMP Bure | Self-inflicted | Published | 25 Aug 2020 | — |
| Individual at Askham Grange | HMP Askham Grange | Self-inflicted | Published | 19 Aug 2020 | — |
| Judge, Darryl | HMP North Sea Camp | Natural | Published | 19 Aug 2020 | — |
| Individual at Manchester | HMP Manchester | Other | Published | 18 Aug 2020 | — |
| Crowther, Simon | HMP Doncaster | Natural | Published | 17 Aug 2020 | — |
| Taylor, Robert | HMP Leeds | Self-inflicted | Published | 17 Aug 2020 | — |
| Individual at Doncaster | HMP Doncaster | Other | Published | 16 Aug 2020 | — |
| Individual at Leeds | HMP Leeds | Self-inflicted | Published | 15 Aug 2020 | — |
| Individual at Parc | HMP Parc | Other | Published | 15 Aug 2020 | — |
| Individual at Lindholme | HMP Lindholme | Other | Published | 13 Aug 2020 | — |
| Charnley, Bradley | HMP Risley | Self-inflicted | Published | 13 Aug 2020 | — |
| Individual at North Sea Camp | HMP North Sea Camp | Natural | Published | 12 Aug 2020 | — |
| Individual at Garth | HMP Garth | Other | Published | 11 Aug 2020 | — |
| Individual at Forest Bank | HMP Forest Bank | Natural | Published | 10 Aug 2020 | — |
| Individual at The Verne | HMP The Verne | Natural | Published | 10 Aug 2020 | — |
| Individual at Wandsworth | HMP Wandsworth | Natural | Published | 8 Aug 2020 | — |
| Individual at The Verne | HMP The Verne | Natural | Published | 7 Aug 2020 | — |
| Individual at Holme House | HMP Holme House | Natural | Published | 7 Aug 2020 | — |
| Individual at Oakwood | HMP Oakwood | Natural | Published | 6 Aug 2020 | — |
| Individual at Holme House | HMP Holme House | Natural | Published | 4 Aug 2020 | — |
| Individual at Hewell | HMP Hewell | Natural | Published | 4 Aug 2020 | — |
| Individual at Liverpool | HMP Liverpool | Other | Published | 1 Aug 2020 | — |
| Individual at Wymott | HMP Wymott | Other | Published | 1 Aug 2020 | — |
| Individual at Bure | HMP Bure | Natural | Published | 1 Aug 2020 | — |
| Gabay, Dean | HMP Lowdham Grange | Other | Published | 1 Aug 2020 | — |
| Collier, Richard | HMP Chelmsford | Self-inflicted | Published | 1 Aug 2020 | — |
| Individual at Guys Marsh | HMP Guys Marsh | Other | Published | 31 Jul 2020 | — |
| Individual at Hull | HMP Hull | Natural | Published | 31 Jul 2020 | — |
| Individual at Liverpool | HMP Liverpool | Natural | Published | 30 Jul 2020 | — |
| Individual at Gartree | HMP Gartree | Natural | Published | 28 Jul 2020 | — |
| Individual at Altcourse | HMP Altcourse | Natural | Published | 27 Jul 2020 | — |
| Individual at St Leonards | St Leonards | Self-inflicted | Published | 25 Jul 2020 | — |
| Individual at Frankland | HMP Frankland | Natural | Published | 24 Jul 2020 | — |
| Pace, John-Paul | HMP Chelmsford | Other | Published | 22 Jul 2020 | — |
| Individual at Durham | HMP Durham | Self-inflicted | Published | 21 Jul 2020 | — |
| Individual at Dovegate | HMP Dovegate | Other | Published | 20 Jul 2020 | — |
| Dean Briant | HMP Littlehey | Self-inflicted | Published | 18 Jul 2020 | 2 |
| Individual at Bedford | HMP Bedford | Self-inflicted | Published | 15 Jul 2020 | — |
| Boultbee, Luisa | HMP Foston Hall | Natural | Published | 15 Jul 2020 | — |
| Stanley, Stewart | HMP Exeter | Self-inflicted | Published | 13 Jul 2020 | — |
| Individual at Durham | HMP Durham | Self-inflicted | Published | 13 Jul 2020 | — |
| Individual at Ford | HMP Ford | Natural | Published | 11 Jul 2020 | — |
| Marek Witulski | HMP Peterborough | Self-inflicted | Published | 9 Jul 2020 | 5 |
| Walker, Thomas | HMP Pentonville | Self-inflicted | Published | 9 Jul 2020 | — |
| Nixon, Ian | HMP Brixton | Natural | Published | 8 Jul 2020 | — |
| Individual at Bullingdon | HMP Bullingdon | Other | Published | 8 Jul 2020 | — |
| Individual at Wymott | HMP Wymott | Natural | Published | 7 Jul 2020 | — |
| Carroll, Paul | HMP Ranby | Self-inflicted | Published | 7 Jul 2020 | — |