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
Kate Allen HMP/YOI Low Newton In progress
Jeffrey Long HMP/YOI Moorland In progress
John Phillips HMP Isle of Wight Pending inquest
Arthur Warwick HMP Frankland In progress
Glenn Brown Holbeck House Approved Premises Pending inquest
Darren Thomas HMP/YOI Parc In progress
Uttam Thapa HMP Belmarsh Pending inquest
Gerald Martin HMP Wymott In progress
Adrian O’Reilly HMP Littlehey In progress
Toby Smith HMP Onley In progress
Ben Merritt In progress
Wayne Hay HMP/YOI Parc Pending inquest
Thomas McMurray HMP Brixton Pending inquest
Warren Manners HMP/YOI Parc Pending inquest
David Brooks HMP Rye Hill In progress
Bobby Kennedy Penrose Drive Approved Premises Pending inquest
John Saterlay HMP Fosse Way Pending inquest
Phillip Lawson HMP Wealstun In progress
Radoslaw Czubinski HMP Hull Pending inquest
Leslie Fry HMP Hewell In progress
Norman Hitchings HMP Lowdham Grange In progress
Lee Wilson HMP Leeds In progress
Klayton Smith HMP Lowdham Grange In progress
Rebecca McBrien HMP/YOI New Hall Pending inquest
Gordon Suckley HMP Channings Wood Pending inquest
Stephen Ansbro HMP Frankland In progress
Adam Goulding Albion Street Approved Premises In progress
Alan Byrne HMP Liverpool In progress
Shamraze Hussain HMP/YOI Doncaster In progress
Richard Hunt HMP Stocken In progress
Sam French HMP Cardiff In progress
Peter Cooper HMP Fosse Way In progress
Stephen Hughes HMP Northumberland In progress
George Hall HMP Littlehey In progress
William Prince HMP Preston Pending inquest
Geoffrey Bradley HMP Elmley In progress
Filmon Andmichaen HMP Full Sutton Pending inquest
Liam Watson-Hunter HMP Holme House In progress
Dirk Weissenbruch HMP Channings Wood Pending inquest
Darren Irving HMP Highpoint In progress
Brian David HMP Channings Wood Pending inquest
Kyle Bevan HMP Wakefield In progress
Maurice Mcentire HMP Swaleside Pending inquest
Norman Heaton HMP Full Sutton Pending inquest
Stewart Bird HMP Isle of Wight Pending inquest
Ace Wilson HMP Leeds In progress
Mark Jones HMP Oakwood In progress
Charlie Leat HMP Exeter In progress
Shaun Grieves HMP Garth Pending inquest
Sean Sewell HMP Thameside In progress