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 Leyhill HMP Leyhill Natural Published 12 Feb 2019
Individual at Durham HMP Durham Self-inflicted Published 11 Feb 2019
Individual at Meneghy House Meneghy House Other Published 10 Feb 2019
Individual at Long Lartin HMP Long Lartin Self-inflicted Published 8 Feb 2019
Individual at Birmingham HMP Birmingham Natural Published 7 Feb 2019
Individual at Lewes HMP Lewes Self-inflicted Published 7 Feb 2019
Individual at Parc HMP Parc Natural Published 5 Feb 2019
Individual at Channings Wood HMP Channings Wood Other Published 3 Feb 2019
Individual at Garth HMP Garth Other Published 2 Feb 2019
Individual at Birmingham HMP Birmingham Natural Published 2 Feb 2019
Individual at Risley HMP Risley Natural Published 28 Jan 2019
Individual at Rye Hill HMP Rye Hill Natural Published 27 Jan 2019
Individual at Littlehey HMP Littlehey Natural Published 26 Jan 2019
Individual at Cardiff HMP Cardiff Natural Published 25 Jan 2019
Individual at Nelson House Nelson House Natural Published 25 Jan 2019
Finlayson, Finlay HMP Lewes Natural Published 25 Jan 2019
Individual at Manchester HMP Manchester Self-inflicted Published 19 Jan 2019
Individual at Full Sutton HMP Full Sutton Natural Published 18 Jan 2019
Individual at Humber HMP Humber Natural Published 17 Jan 2019
Individual at Isle of Wight HMP Isle of Wight Natural Published 16 Jan 2019
Individual at Wandsworth HMP Wandsworth Natural Published 16 Jan 2019
Individual at Wormwood Scrubs HMP Wormwood Scrubs Natural Published 16 Jan 2019
Individual at Leicester HMP Leicester Self-inflicted Published 13 Jan 2019
Individual at Long Lartin HMP Long Lartin Other Published 11 Jan 2019
Individual at Wilton Place Wilton Place Self-inflicted Published 10 Jan 2019
Individual at Doncaster HMP Doncaster Self-inflicted Published 10 Jan 2019
Individual at Liverpool HMP Liverpool Natural Published 10 Jan 2019
Individual at Low Newton HMP Low Newton Natural Published 7 Jan 2019
Individual at Stocken HMP Stocken Self-inflicted Published 6 Jan 2019
Individual at Woodhill HMP Woodhill Self-inflicted Published 4 Jan 2019
Individual at Manchester HMP Manchester Other Published 2 Jan 2019
Individual at Parc HMP Parc Natural Published 1 Jan 2019
Individual at Altcourse HMP Altcourse Natural Published 30 Dec 2018
Individual at Wormwood Scrubs HMP Wormwood Scrubs Other Published 29 Dec 2018
Individual at Isle of Wight HMP Isle of Wight Natural Published 26 Dec 2018
Individual at Dovegate HMP Dovegate Other Published 25 Dec 2018
Individual at Humber HMP Humber Self-inflicted Published 21 Dec 2018
Individual at Swaleside HMP Swaleside Natural Published 20 Dec 2018
Individual at Hull HMP Hull Self-inflicted Published 20 Dec 2018
Individual at Lindholme HMP Lindholme Other Published 16 Dec 2018
Salim Sakaria HMP Risley Natural Published 14 Dec 2018 3
Individual at Ranby HMP Ranby Other Published 14 Dec 2018
Individual at Nottingham HMP Nottingham Self-inflicted Published 13 Dec 2018
Individual at Dartmoor HMP Dartmoor Self-inflicted Published 12 Dec 2018
Individual at Rye Hill HMP Rye Hill Natural Published 12 Dec 2018
Individual at Eastwood Park HMP Eastwood Park Natural Published 12 Dec 2018
Individual at North Sea Camp HMP North Sea Camp Natural Published 11 Dec 2018
Individual at Hollesley Bay HMP Hollesley Bay Natural Published 10 Dec 2018
Individual at Lancaster Farms HMP Lancaster Farms Other Published 10 Dec 2018
Individual at Exeter HMP Exeter Self-inflicted Published 7 Dec 2018