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 Bedford HMP Bedford Natural Published 28 Apr 2020
Individual at Winchester HMP Winchester Natural Published 28 Apr 2020
Miah, Mohammed HMP Rye Hill Natural Published 27 Apr 2020
Individual at Exeter HMP Exeter Natural Published 25 Apr 2020
Individual at Rye Hill HMP Rye Hill Natural Published 25 Apr 2020
Individual at Gartree HMP Gartree Natural Published 25 Apr 2020
Individual at Altcourse HMP Altcourse Natural Published 25 Apr 2020
Individual at Whatton HMP Whatton Natural Published 23 Apr 2020
Individual at Cardiff HMP Cardiff Self-inflicted Published 23 Apr 2020
Individual at Wayland HMP Wayland Self-inflicted Published 22 Apr 2020
Individual at Stafford HMP Stafford Natural Published 21 Apr 2020
Individual at Usk and Prescoed HMP Usk and Prescoed Natural Published 17 Apr 2020
Individual at New Hall HMP New Hall Natural Published 17 Apr 2020
Individual at Frankland HMP Frankland Natural Published 17 Apr 2020
Individual at Styal HMP Styal Natural Published 16 Apr 2020
Individual at Oakwood HMP Oakwood Natural Published 16 Apr 2020
Battensby, Peter HMP Full Sutton Self-inflicted Published 16 Apr 2020
William Robinson HMP Forest Bank Other Published 15 Apr 2020 1
Ronnie Gaunt HMP Risley Natural Published 15 Apr 2020 1
Individual at Stafford HMP Stafford Natural Published 15 Apr 2020
Individual at Wakefield HMP Wakefield Natural Published 10 Apr 2020
Individual at Leicester HMP Leicester Natural Published 9 Apr 2020
Individual at Nottingham HMP Nottingham Natural Published 7 Apr 2020
Individual at Altcourse HMP Altcourse Natural Published 7 Apr 2020
Individual at Ashfield HMP Ashfield Natural Published 7 Apr 2020
Clarke, Luke HMP Wormwood Scrubs Self-inflicted Published 7 Apr 2020
Martin Oakman HMP Littlehey Natural Published 5 Apr 2020
Individual at Altcourse HMP Altcourse Natural Published 5 Apr 2020
Individual at Holme House HMP Holme House Natural Published 5 Apr 2020
Individual at Sudbury HMP Sudbury Natural Published 5 Apr 2020
Individual at Low Newton HMP Low Newton Natural Published 4 Apr 2020
Individual at Whatton HMP Whatton Natural Published 4 Apr 2020
Individual at Birmingham HMP Birmingham Natural Published 3 Apr 2020
Individual at Rye Hill HMP Rye Hill Natural Published 3 Apr 2020
Individual at Styal HMP Styal Natural Published 3 Apr 2020
Individual at Belmarsh HMP Belmarsh Natural Published 2 Apr 2020
Individual at Hewell HMP Hewell Natural Published 1 Apr 2020
Individual at Whatton HMP Whatton Natural Published 30 Mar 2020
Individual at Wandsworth HMP Wandsworth Natural Published 29 Mar 2020
Individual at Leeds HMP Leeds Other Published 29 Mar 2020
Jordan, Samuel HMP Exeter Self-inflicted Published 27 Mar 2020
Anthony Kimmins HMP Littlehey Natural Published 27 Mar 2020 2
Individual at Hull HMP Hull Self-inflicted Published 26 Mar 2020
Individual at Manchester HMP Manchester Natural Published 26 Mar 2020
Individual at Leyhill HMP Leyhill Natural Published 23 Mar 2020
Individual at Lincoln HMP Lincoln Natural Published 22 Mar 2020
Individual at Littlehey HMP Littlehey Natural Published 22 Mar 2020
White, Lenford HMP Manchester Natural Published 19 Mar 2020
Individual at Peterborough HMP Peterborough Natural Published 18 Mar 2020
Individual at Winchester HMP Winchester Natural Published 15 Mar 2020