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 Wymott HMP Wymott Natural Published 13 Mar 2020
Individual at Northumberland HMP Northumberland Natural Published 10 Mar 2020
Individual at Lewes HMP Lewes Natural Published 10 Mar 2020
Peter Tauroza HMP Wandsworth Self-inflicted Published 6 Mar 2020 8
Dawood, Esam HMP Bristol Self-inflicted Published 4 Mar 2020
Individual at Stafford HMP Stafford Natural Published 3 Mar 2020
Individual at Altcourse HMP Altcourse Self-inflicted Published 29 Feb 2020
Individual at Frankland HMP Frankland Natural Published 29 Feb 2020
Individual at Swaleside HMP Swaleside Natural Published 28 Feb 2020
Individual at Gartree HMP Gartree Self-inflicted Published 26 Feb 2020
Individual at Isle of Wight HMP Isle of Wight Natural Published 24 Feb 2020
Individual at Bullingdon HMP Bullingdon Natural Published 24 Feb 2020
Individual at Holme House HMP Holme House Natural Published 24 Feb 2020
Coath, Andy HMP Pentonville Self-inflicted Published 23 Feb 2020
Individual at Dartmoor HMP Dartmoor Natural Published 22 Feb 2020
Individual at Rye Hill HMP Rye Hill Natural Published 21 Feb 2020
Individual at Leyhill HMP Leyhill Natural Published 20 Feb 2020
Individual at Doncaster HMP Doncaster Self-inflicted Published 20 Feb 2020
Sundeep Ghuman HMP Belmarsh Homicide Published 19 Feb 2020 3
Individual at Holme House HMP Holme House Natural Published 15 Feb 2020
Individual at Cardiff HMP Cardiff Natural Published 13 Feb 2020
Individual at Swaleside HMP Swaleside Natural Published 13 Feb 2020
Individual at Elmley HMP Elmley Natural Published 13 Feb 2020
Individual at Leyhill HMP Leyhill Natural Published 10 Feb 2020
Individual at Leicester HMP Leicester Natural Published 9 Feb 2020
Individual at High Down HMP High Down Natural Published 6 Feb 2020
Individual at Oakwood HMP Oakwood Natural Published 6 Feb 2020
Individual at Manchester HMP Manchester Natural Published 4 Feb 2020
Individual at Rye Hill HMP Rye Hill Natural Published 2 Feb 2020
Individual at Wakefield HMP Wakefield Natural Published 1 Feb 2020
Individual at Leeds HMP Leeds Self-inflicted Published 31 Jan 2020
Individual at Manchester HMP Manchester Natural Published 30 Jan 2020
Individual at Erlestoke HMP Erlestoke Natural Published 29 Jan 2020
Individual at Wymott HMP Wymott Natural Published 27 Jan 2020
Individual at Featherstone HMP Featherstone Other Published 26 Jan 2020
Individual at Berwyn HMP Berwyn Natural Published 23 Jan 2020
Whitehead, Nicholas HMP Sudbury Other Published 23 Jan 2020
Individual at Bure HMP Bure Natural Published 21 Jan 2020
Individual at Full Sutton HMP Full Sutton Natural Published 18 Jan 2020
Individual at Durham HMP Durham Self-inflicted Published 14 Jan 2020
Individual at Leeds HMP Leeds Natural Published 13 Jan 2020
Alex John HMP Pentonville Natural Published 13 Jan 2020 2
Individual at Thameside HMP Thameside Self-inflicted Published 12 Jan 2020
Individual at Lewes HMP Lewes Natural Published 11 Jan 2020
Individual at Wandsworth HMP Wandsworth Natural Published 10 Jan 2020
Keith Turner HMP Humber Self-inflicted Published 9 Jan 2020 11
Individual at Ranby HMP Ranby Self-inflicted Published 8 Jan 2020
Individual at Parc HMP Parc Natural Published 8 Jan 2020
Individual at Whatton HMP Whatton Natural Published 6 Jan 2020
Liridon Saliuka HMP Belmarsh Self-inflicted Published 2 Jan 2020 15