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
McAllister, Addy Burdett Lodge Other Published 6 Jul 2020
James Drury HMP Exeter Natural Published 23 Jun 2020 1
Individual at Gartree HMP Gartree Natural Published 23 Jun 2020
Individual at Doncaster HMP Doncaster Self-inflicted Published 21 Jun 2020
Individual at Hull HMP Hull Self-inflicted Published 21 Jun 2020
Individual at Exeter HMP Exeter Natural Published 19 Jun 2020
Individual at Styal HMP Styal Natural Published 18 Jun 2020
Individual at Frankland HMP Frankland Natural Published 18 Jun 2020
Individual at Durham HMP Durham Other Published 16 Jun 2020
Individual at Wymott HMP Wymott Natural Published 7 Jun 2020
Individual at Hewell HMP Hewell Natural Published 6 Jun 2020
Individual at Littlehey HMP Littlehey Natural Published 5 Jun 2020
Individual at Maidstone HMP Maidstone Self-inflicted Published 4 Jun 2020
Individual at Winchester HMP Winchester Self-inflicted Published 29 May 2020
Individual at Oakwood HMP Oakwood Natural Published 27 May 2020
Carr, Lee Durham Post-release Other Published 27 May 2020
Individual at Berwyn HMP Berwyn Natural Published 26 May 2020
Individual at Eastwood Park Post-release Eastwood Park Post-release Self-inflicted Published 26 May 2020
Individual at Risley HMP Risley Natural Published 26 May 2020
Individual at Bullingdon HMP Bullingdon Other Published 25 May 2020
Terence Devereux HMP Channings Wood Self-inflicted Published 24 May 2020 5
Individual at Elmley HMP Elmley Other Published 22 May 2020
Individual at Bure HMP Bure Natural Published 22 May 2020
Carl Kent HMP Dartmoor Self-inflicted Published 21 May 2020 4
Individual at Cardiff HMP Cardiff Self-inflicted Published 20 May 2020
Individual at Frankland HMP Frankland Natural Published 20 May 2020
Timothy Smith HMP Risley Self-inflicted Published 20 May 2020 3
Individual at Littlehey HMP Littlehey Natural Published 20 May 2020
Individual at North Sea Camp HMP North Sea Camp Natural Published 19 May 2020
Individual at Durham HMP Durham Natural Published 17 May 2020
Individual at Bure HMP Bure Self-inflicted Published 17 May 2020
Individual at Aylesbury HMP Aylesbury Self-inflicted Published 16 May 2020
Individual at Dickson House Dickson House Other Published 12 May 2020
Individual at Lincoln HMP Lincoln Self-inflicted Published 8 May 2020
Sean Huntroyd HMP Winchester Natural Published 7 May 2020 2
Individual at Holme House HMP Holme House Natural Published 7 May 2020
Individual at Norwich HMP Norwich Natural Published 5 May 2020
Individual at Channings Wood HMP Channings Wood Natural Published 4 May 2020
Individual at Wakefield HMP Wakefield Natural Published 3 May 2020
Individual at Durham HMP Durham Self-inflicted Published 2 May 2020
Individual at Norfolk Park Norfolk Park Other Published 2 May 2020
Jeffery, Terence HMP Brixton Natural Published 1 May 2020
Roberts, Ashley HMP Bristol Self-inflicted Published 1 May 2020
Individual at Hull HMP Hull Natural Published 1 May 2020
Individual at Wakefield HMP Wakefield Natural Published 1 May 2020
Individual at Bullingdon HMP Bullingdon Natural Published 1 May 2020
Individual at Dovegate HMP Dovegate Natural Published 30 Apr 2020
Ryan Nash HMP Bedford Self-inflicted Published 30 Apr 2020 10
Individual at Lindholme HMP Lindholme Natural Published 29 Apr 2020
Individual at Channings Wood HMP Channings Wood Natural Published 29 Apr 2020