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.
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 22: Self-inflicted deaths in reception prisons | Learning Lessons Bulletin | Mar 2026 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 21: Segregation | 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 2022-23 | Annual report | Jul 2024 | |
| Annual Report 2023-24 | 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 Isle of Wight | HMP Isle of Wight | Natural | Published | 1 Apr 2019 | — |
| Individual at St Josephs | St Josephs | Natural | Published | 1 Apr 2019 | — |
| Individual at Exeter | HMP Exeter | Natural | Published | 31 Mar 2019 | — |
| Individual at Swaleside | HMP Swaleside | Natural | Published | 31 Mar 2019 | — |
| Individual at Norwich | HMP Norwich | Natural | Published | 31 Mar 2019 | — |
| Individual at Exeter | HMP Exeter | Natural | Published | 30 Mar 2019 | — |
| Individual at Dartmoor | HMP Dartmoor | Natural | Published | 30 Mar 2019 | — |
| Individual at Littlehey | HMP Littlehey | Natural | Published | 25 Mar 2019 | — |
| Individual at Fleming House | Fleming House | Natural | Published | 24 Mar 2019 | — |
| Individual at Moorland Closed | HMP Moorland Closed | Natural | Published | 24 Mar 2019 | — |
| Individual at Leeds | HMP Leeds | Natural | Published | 24 Mar 2019 | — |
| Individual at Winchester | HMP Winchester | Natural | Published | 22 Mar 2019 | — |
| Individual at Whatton | HMP Whatton | Natural | Published | 20 Mar 2019 | — |
| Individual at Liverpool | HMP Liverpool | Natural | Published | 19 Mar 2019 | — |
| Individual at Winchester | HMP Winchester | Self-inflicted | Published | 17 Mar 2019 | — |
| Individual at Bullingdon | HMP Bullingdon | Self-inflicted | Published | 17 Mar 2019 | — |
| Individual at Liverpool | HMP Liverpool | Natural | Published | 16 Mar 2019 | — |
| Individual at Wormwood Scrubs | HMP Wormwood Scrubs | Self-inflicted | Published | 16 Mar 2019 | — |
| Individual at Cardiff | HMP Cardiff | Natural | Published | 15 Mar 2019 | — |
| Individual at Leeds | HMP Leeds | Natural | Published | 14 Mar 2019 | — |
| Individual at Garth | HMP Garth | Self-inflicted | Published | 13 Mar 2019 | — |
| Individual at Wakefield | HMP Wakefield | Natural | Published | 12 Mar 2019 | — |
| Individual at Risley | HMP Risley | Natural | Published | 11 Mar 2019 | — |
| Nikolyan, Haik | HMP Aylesbury | Self-inflicted | Published | 11 Mar 2019 | — |
| Individual at Whitemoor | HMP Whitemoor | Natural | Published | 10 Mar 2019 | — |
| Individual at Northumberland | HMP Northumberland | Natural | Published | 9 Mar 2019 | — |
| Individual at Durham | HMP Durham | Self-inflicted | Published | 9 Mar 2019 | — |
| Individual at Gartree | HMP Gartree | Natural | Published | 8 Mar 2019 | — |
| Individual at Lindholme | HMP Lindholme | Self-inflicted | Published | 6 Mar 2019 | — |
| Individual at Humber | HMP Humber | Other | Published | 4 Mar 2019 | — |
| Individual at Northumberland | HMP Northumberland | Natural | Published | 3 Mar 2019 | — |
| Christine McDonald | HMP/YOI Styal | Self-inflicted | Published | 3 Mar 2019 | 9 |
| Individual at Swaleside | HMP Swaleside | Natural | Published | 3 Mar 2019 | — |
| Individual at Humber | HMP Humber | Other | Published | 27 Feb 2019 | — |
| Individual at Kirkham | HMP Kirkham | Natural | Published | 26 Feb 2019 | — |
| Individual at Elmley | HMP Elmley | Natural | Published | 25 Feb 2019 | — |
| Individual at Whatton | HMP Whatton | Natural | Published | 25 Feb 2019 | — |
| Allsop, Tudor | HMP Cardiff | Natural | Published | 25 Feb 2019 | — |
| Individual at Garth | HMP Garth | Other | Published | 22 Feb 2019 | — |
| Individual at Exeter | HMP Exeter | Natural | Published | 22 Feb 2019 | — |
| Individual at Frankland | HMP Frankland | Natural | Published | 21 Feb 2019 | — |
| Individual at Long Lartin | HMP Long Lartin | Natural | Published | 20 Feb 2019 | — |
| McDonagh, Michael | HMP Forest Bank | Other | Published | 19 Feb 2019 | — |
| Individual at Stafford | HMP Stafford | Natural | Published | 17 Feb 2019 | — |
| Individual at Durham | HMP Durham | Self-inflicted | Published | 17 Feb 2019 | — |
| Individual at Oakwood | HMP Oakwood | Natural | Published | 15 Feb 2019 | — |
| Individual at Rookwood | Rookwood | Other | Published | 15 Feb 2019 | — |
| Individual at Wakefield | HMP Wakefield | Natural | Published | 13 Feb 2019 | — |
| Mulvey, Robert | Wealstun Post-release | Self-inflicted | Published | 12 Feb 2019 | — |
| Individual at Wakefield | HMP Wakefield | Natural | Published | 12 Feb 2019 | — |