Source · Deaths in custody
PPO Fatal Incident Reports
6,488 incidents
5,759 published
1,642 recommendations
1,658 self-inflicted
3,411 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 |
|---|---|---|---|
| Annual Report 2025 to 2026 | Annual report | Jul 2026 | |
| 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 property complaints | Policy into Practice | Mar 2025 | |
| Policy into Practice: Handling of prisoners’ property | Policy into Practice | Mar 2025 | |
| Complaints Investigations Learning Lessons Bulletin Issue 11: Property complaints | Learning Lessons Bulletin | Mar 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 | |
| PPO response to JSC Tackling Drugs in Prison Inquiry | 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 |
Incidents
| Name | Establishment | Cause | Status | Date of death | Recs |
|---|---|---|---|---|---|
| Individual at Oakwood | HMP Oakwood | Natural | Published | 7 Sep 2019 | — |
| Individual at Leeds | HMP Leeds | Self-inflicted | Published | 5 Sep 2019 | — |
| Individual at Ashfield | HMP Ashfield | Natural | Published | 5 Sep 2019 | — |
| Stainton, Daniel | HMP Peterborough | Natural | Published | 4 Sep 2019 | — |
| Individual at Elmley | HMP Elmley | Self-inflicted | Published | 2 Sep 2019 | — |
| Individual at Durham | HMP Durham | Self-inflicted | Published | 2 Sep 2019 | — |
| Dougherty, Sean | Guernsey State Prison | Natural | Published | 1 Sep 2019 | — |
| Nastase, Vasile | HMP Forest Bank | Self-inflicted | Published | 1 Sep 2019 | — |
| Individual at Wymott | HMP Wymott | Natural | Published | 1 Sep 2019 | — |
| Individual at Long Lartin | HMP Long Lartin | Natural | Published | 31 Aug 2019 | — |
| Individual at Moorland Closed | HMP Moorland Closed | Natural | Published | 30 Aug 2019 | — |
| Individual at Doncaster | HMP Doncaster | Natural | Published | 30 Aug 2019 | — |
| Individual at High Down | HMP High Down | Self-inflicted | Published | 29 Aug 2019 | — |
| Individual at Pentonville | HMP Pentonville | Self-inflicted | Published | 28 Aug 2019 | — |
| Individual at Birmingham | HMP Birmingham | Natural | Published | 27 Aug 2019 | — |
| Individual at Rye Hill | HMP Rye Hill | Natural | Published | 26 Aug 2019 | — |
| Individual at Parc | HMP Parc | Natural | Published | 25 Aug 2019 | — |
| Malacai Samson | HMP Pentonville | Self-inflicted | Published | 23 Aug 2019 | 7 |
| Individual at Cardigan House | Cardigan House | Natural | Published | 19 Aug 2019 | — |
| Individual at Chelmsford | HMP Chelmsford | Self-inflicted | Published | 15 Aug 2019 | — |
| Daniel Short | Glogan House Approved Premises | Other | Published | 14 Aug 2019 | 8 |
| Frederick Heard | HMP/YOI Parc | Natural | Published | 9 Aug 2019 | 4 |
| Individual at Isis | HMP Isis | Self-inflicted | Published | 9 Aug 2019 | — |
| Individual at Frankland | HMP Frankland | Natural | Published | 8 Aug 2019 | — |
| Individual at Holme House | HMP Holme House | Natural | Published | 7 Aug 2019 | — |
| Individual at Doncaster | HMP Doncaster | Natural | Published | 6 Aug 2019 | — |
| Thomas Moffett | HMP Preston | Natural | Published | 6 Aug 2019 | 5 |
| Individual at Leeds | HMP Leeds | Natural | Published | 6 Aug 2019 | — |
| Individual at Lowdham Grange | HMP Lowdham Grange | Natural | Published | 5 Aug 2019 | — |
| Davide Parra | HMP Erlestoke | Self-inflicted | Published | 5 Aug 2019 | 4 |
| Individual at Leeds | HMP Leeds | Natural | Published | 4 Aug 2019 | — |
| Individual at Humber | HMP Humber | Self-inflicted | Published | 2 Aug 2019 | — |
| Individual at Oakwood | HMP Oakwood | Natural | Published | 31 Jul 2019 | — |
| Individual at Swaleside | HMP Swaleside | Self-inflicted | Published | 29 Jul 2019 | — |
| Individual at Channings Wood | HMP Channings Wood | Self-inflicted | Published | 27 Jul 2019 | — |
| Individual at Dovegate | HMP Dovegate | Natural | Published | 27 Jul 2019 | — |
| Individual at Chelmsford | HMP Chelmsford | Natural | Published | 27 Jul 2019 | — |
| Hellyer, Lee | HMP Exeter | Self-inflicted | Published | 26 Jul 2019 | — |
| Individual at Doncaster | HMP Doncaster | Self-inflicted | Published | 24 Jul 2019 | — |
| Individual at Holme House | HMP Holme House | Natural | Published | 23 Jul 2019 | — |
| Individual at Wakefield | HMP Wakefield | Natural | Published | 23 Jul 2019 | — |
| Individual at Long Lartin | HMP Long Lartin | Other | Published | 14 Jul 2019 | — |
| Individual at Whatton | HMP Whatton | Natural | Published | 13 Jul 2019 | — |
| Individual at Durham | HMP Durham | Natural | Published | 12 Jul 2019 | — |
| Individual at Leeds | HMP Leeds | Natural | Published | 11 Jul 2019 | — |
| Individual at Parc | HMP Parc | Self-inflicted | Published | 11 Jul 2019 | — |
| Lucy, Raymond | HMP Forest Bank | Natural | Published | 11 Jul 2019 | — |
| Individual at Wymott | HMP Wymott | Natural | Published | 7 Jul 2019 | — |
| Individual at Quay House | Quay House | Natural | Published | 7 Jul 2019 | — |
| Individual at Hewell | HMP Hewell | Self-inflicted | Published | 6 Jul 2019 | — |