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 Swaleside | HMP Swaleside | Other | Published | 3 Nov 2019 | — |
| Individual at Weston AP | Weston AP | Other | Published | 2 Nov 2019 | — |
| Individual at Lancaster Farms | HMP Lancaster Farms | Natural | Published | 31 Oct 2019 | — |
| Individual at Oakwood | HMP Oakwood | Natural | Published | 29 Oct 2019 | — |
| Individual at Oakwood | HMP Oakwood | Natural | Published | 29 Oct 2019 | — |
| Individual at Hull | HMP Hull | Natural | Published | 28 Oct 2019 | — |
| Individual at Coldingley | HMP Coldingley | Other | Published | 28 Oct 2019 | — |
| Individual at Dartmoor | HMP Dartmoor | Natural | Published | 26 Oct 2019 | — |
| Individual at Westgate | Westgate | Other | Published | 25 Oct 2019 | — |
| Individual at Hewell | HMP Hewell | Natural | Published | 24 Oct 2019 | — |
| Individual at Isle of Wight | HMP Isle of Wight | Self-inflicted | Published | 24 Oct 2019 | — |
| Individual at Winchester | HMP Winchester | Natural | Published | 23 Oct 2019 | — |
| Individual at Norwich | HMP Norwich | Natural | Published | 22 Oct 2019 | — |
| Individual at Berwyn | HMP Berwyn | Natural | Published | 22 Oct 2019 | — |
| Individual at Nottingham | HMP Nottingham | Natural | Published | 21 Oct 2019 | — |
| Individual at Swaleside | HMP Swaleside | Natural | Published | 19 Oct 2019 | — |
| Individual at Littlehey | HMP Littlehey | Natural | Published | 16 Oct 2019 | — |
| Individual at Doncaster | HMP Doncaster | Natural | Published | 14 Oct 2019 | — |
| Individual at Frankland | HMP Frankland | Natural | Published | 13 Oct 2019 | — |
| Huckle, Richard | HMP Full Sutton | Homicide | Published | 13 Oct 2019 | — |
| Saria Hart | HMP/YOI Foston Hall | Self-inflicted | Published | 12 Oct 2019 | 5 |
| Individual at Frankland | HMP Frankland | Natural | Published | 12 Oct 2019 | — |
| Individual at Manchester | HMP Manchester | Natural | Published | 10 Oct 2019 | — |
| Individual at Holme House | HMP Holme House | Self-inflicted | Published | 7 Oct 2019 | — |
| Individual at Parc | HMP Parc | Natural | Published | 7 Oct 2019 | — |
| Individual at Altcourse | HMP Altcourse | Natural | Published | 6 Oct 2019 | — |
| Individual at Leicester | HMP Leicester | Self-inflicted | Published | 5 Oct 2019 | — |
| Individual at Parc | HMP Parc | Other | Published | 4 Oct 2019 | — |
| Individual at Peterborough | Peterborough | Other | Published | 1 Oct 2019 | — |
| Individual at Wymott | HMP Wymott | Natural | Published | 1 Oct 2019 | — |
| Individual at Norwich | HMP Norwich | Natural | Published | 29 Sep 2019 | — |
| Individual at Bullingdon | HMP Bullingdon | Natural | Published | 27 Sep 2019 | — |
| Individual at Bronzefield | HMP Bronzefield | Natural | Published | 27 Sep 2019 | — |
| Individual at Hull | HMP Hull | Self-inflicted | Published | 27 Sep 2019 | — |
| Jason Birch | HMP Whitemoor | Self-inflicted | Published | 26 Sep 2019 | 5 |
| Heeney, Sean | Bridgewood House | Other | Published | 26 Sep 2019 | — |
| Individual at Cardiff | HMP Cardiff | Self-inflicted | Published | 25 Sep 2019 | — |
| Individual at Elizabeth Fry | Elizabeth Fry | Natural | Published | 25 Sep 2019 | — |
| Individual at Altcourse | HMP Altcourse | Other | Published | 25 Sep 2019 | — |
| Individual at Lindholme | HMP Lindholme | Other | Published | 25 Sep 2019 | — |
| Tilbury, Kristopher | HMP The Mount | Other | Published | 24 Sep 2019 | — |
| Individual at Doncaster | HMP Doncaster | Self-inflicted | Published | 23 Sep 2019 | — |
| Individual at Usk and Prescoed | HMP Usk and Prescoed | Self-inflicted | Published | 21 Sep 2019 | — |
| Individual at Dovegate | HMP Dovegate | Natural | Published | 18 Sep 2019 | — |
| Individual at Littlehey | HMP Littlehey | Natural | Published | 17 Sep 2019 | — |
| Individual at Holme House | HMP Holme House | Natural | Published | 16 Sep 2019 | — |
| Individual at Stafford | HMP Stafford | Natural | Published | 14 Sep 2019 | — |
| Individual at Risley | HMP Risley | Natural | Published | 14 Sep 2019 | — |
| Individual at Garth | HMP Garth | Other | Published | 12 Sep 2019 | — |
| Brandon Johnson | HMP Wandsworth | Other | Published | 12 Sep 2019 | 5 |