Source · Deaths in custody

PPO Fatal Incident Reports

6,401 incidents 5,674 published 1,165 recommendations 1,633 self-inflicted 3,373 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 22: Self-inflicted deaths in reception prisons Learning Lessons Bulletin Mar 2026 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 21: Segregation 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 2022-23 Annual report Jul 2024 PDF
Annual Report 2023-24 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

6,401 records
Name Establishment Cause Status Date of death Recs
Individual at Wealstun HMP Wealstun Other Published 31 May 2019
Individual at Durham HMP Durham Natural Published 29 May 2019
Individual at Dovegate HMP Dovegate Self-inflicted Published 27 May 2019
Individual at Exeter HMP Exeter Natural Published 27 May 2019
Individual at Exeter HMP Exeter Natural Published 27 May 2019
Individual at Leeds HMP Leeds Natural Published 26 May 2019
Individual at Lowdham Grange HMP Lowdham Grange Other Published 26 May 2019
Individual at Featherstone HMP Featherstone Self-inflicted Published 23 May 2019
Individual at Albion Street Albion Street Natural Published 22 May 2019
Individual at Lindholme HMP Lindholme Natural Published 21 May 2019
Individual at Peterborough HMP Peterborough Natural Published 20 May 2019
Individual at Lowdham Grange HMP Lowdham Grange Natural Published 19 May 2019
Individual at Guys Marsh HMP Guys Marsh Other Published 19 May 2019
Individual at Hewell HMP Hewell Self-inflicted Published 19 May 2019
Individual at Warren Hill HMP Warren Hill Self-inflicted Published 11 May 2019
Individual at Pennywell Pennywell Other Published 11 May 2019
Susan Knowles HMP/YOI Styal Self-inflicted Published 10 May 2019 2
Individual at Woodhill HMP Woodhill Self-inflicted Published 9 May 2019
Individual at North Sea Camp HMP North Sea Camp Natural Published 4 May 2019
Individual at Wakefield HMP Wakefield Natural Published 4 May 2019
Individual at Leicester Magistrates’ Court Leicester Magistrates’ Court Self-inflicted Published 3 May 2019
Individual at Woodhill HMP Woodhill Self-inflicted Published 30 Apr 2019
Individual at Littlehey HMP Littlehey Natural Published 27 Apr 2019
Individual at Littlehey HMP Littlehey Natural Published 27 Apr 2019
Individual at Leeds HMP Leeds Self-inflicted Published 26 Apr 2019
Individual at Forest Bank HMP Forest Bank Natural Published 26 Apr 2019
Individual at Isle of Wight HMP Isle of Wight Natural Published 25 Apr 2019
Individual at Woodhill HMP Woodhill Self-inflicted Published 24 Apr 2019
Individual at Sudbury HMP Sudbury Natural Published 22 Apr 2019
Individual at Altcourse HMP Altcourse Natural Published 21 Apr 2019
Individual at North Sea Camp HMP North Sea Camp Natural Published 19 Apr 2019
Individual at Hull HMP Hull Natural Published 15 Apr 2019
Individual at Dartmoor HMP Dartmoor Self-inflicted Published 15 Apr 2019
Individual at Wakefield HMP Wakefield Natural Published 14 Apr 2019
Individual at Chelmsford HMP Chelmsford Natural Published 14 Apr 2019
Individual at Wakefield HMP Wakefield Natural Published 12 Apr 2019
Individual at Full Sutton HMP Full Sutton Natural Published 12 Apr 2019
Individual at Leeds HMP Leeds Self-inflicted Published 12 Apr 2019
Individual at Wandsworth HMP Wandsworth Natural Published 11 Apr 2019
Individual at Gartree HMP Gartree Natural Published 11 Apr 2019
Individual at Bullingdon HMP Bullingdon Natural Published 8 Apr 2019
Williamson, Karen HMP Peterborough Self-inflicted Published 8 Apr 2019
Individual at Liverpool HMP Liverpool Natural Published 6 Apr 2019
Individual at Bullingdon HMP Bullingdon Self-inflicted Published 6 Apr 2019
Individual at Manchester HMP Manchester Self-inflicted Published 5 Apr 2019
Individual at Stafford HMP Stafford Natural Published 5 Apr 2019
Individual at Wakefield HMP Wakefield Natural Published 3 Apr 2019
Individual at Doncaster HMP Doncaster Natural Published 3 Apr 2019
Individual at Belmarsh HMP Belmarsh Self-inflicted Published 2 Apr 2019
Individual at Isle of Wight HMP Isle of Wight Natural Published 1 Apr 2019