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 Southwood Southwood Natural Published 5 Dec 2018
Individual at Holme House HMP Holme House Other Published 2 Dec 2018
Individual at Harmondsworth IRC Harmondsworth Natural Published 2 Dec 2018
Individual at Holme House HMP Holme House Natural Published 30 Nov 2018
Individual at Belmarsh HMP Belmarsh Natural Published 30 Nov 2018
Individual at Pentonville HMP Pentonville Self-inflicted Published 29 Nov 2018
Individual at Long Lartin HMP Long Lartin Self-inflicted Published 29 Nov 2018
Individual at Altcourse HMP Altcourse Natural Published 25 Nov 2018
Individual at Altcourse HMP Altcourse Natural Published 25 Nov 2018
Individual at Winchester HMP Winchester Natural Published 24 Nov 2018
Individual at Doncaster HMP Doncaster Natural Published 23 Nov 2018
Individual at Leeds HMP Leeds Natural Published 23 Nov 2018
Individual at Parc HMP Parc Self-inflicted Published 22 Nov 2018
Individual at Isle of Wight HMP Isle of Wight Natural Published 22 Nov 2018
Individual at Garth HMP Garth Self-inflicted Published 22 Nov 2018
Individual at Preston HMP Preston Natural Published 21 Nov 2018
Individual at Swaleside HMP Swaleside Self-inflicted Published 20 Nov 2018
Individual at High Down HMP High Down Natural Published 19 Nov 2018
Individual at Lowdham Grange HMP Lowdham Grange Self-inflicted Published 18 Nov 2018
Jones, Christopher HMP Parc Other Published 18 Nov 2018
Individual at Leeds HMP Leeds Self-inflicted Published 17 Nov 2018
Individual at Lowdham Grange HMP Lowdham Grange Other Published 15 Nov 2018
Individual at Winchester HMP Winchester Self-inflicted Published 14 Nov 2018
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 13 Nov 2018
Individual at Altcourse HMP Altcourse Natural Published 13 Nov 2018
Individual at Parc HMP Parc Natural Published 10 Nov 2018
Individual at Doncaster HMP Doncaster Natural Published 10 Nov 2018
Individual at Isle of Wight HMP Isle of Wight Self-inflicted Published 10 Nov 2018
Individual at Lincoln HMP Lincoln Self-inflicted Published 10 Nov 2018
Individual at Garth HMP Garth Natural Published 8 Nov 2018
Individual at Nottingham HMP Nottingham Natural Published 7 Nov 2018
Individual at Littlehey HMP Littlehey Natural Published 6 Nov 2018
Individual at Nottingham HMP Nottingham Self-inflicted Published 6 Nov 2018
Individual at Wakefield HMP Wakefield Self-inflicted Published 5 Nov 2018
Individual at Brixton HMP Brixton Natural Published 4 Nov 2018
Individual at Swaleside HMP Swaleside Natural Published 3 Nov 2018
Individual at Isle of Wight HMP Isle of Wight Natural Published 30 Oct 2018
Individual at Garth HMP Garth Self-inflicted Published 30 Oct 2018
Individual at Chelmsford HMP Chelmsford Natural Published 28 Oct 2018
Individual at Liverpool HMP Liverpool Self-inflicted Published 24 Oct 2018
Individual at Littlehey HMP Littlehey Self-inflicted Published 24 Oct 2018
Individual at Manchester HMP Manchester Natural Published 23 Oct 2018
Individual at Wakefield HMP Wakefield Natural Published 22 Oct 2018
Individual at Winchester HMP Winchester Self-inflicted Published 22 Oct 2018
Individual at Eastwood Park HMP Eastwood Park Other Published 21 Oct 2018
Individual at Wormwood Scrubs HMP Wormwood Scrubs Natural Published 21 Oct 2018
Individual at Wymott HMP Wymott Natural Published 20 Oct 2018
Individual at Parc HMP Parc Natural Published 19 Oct 2018
Individual at Grendon HMP Grendon Natural Published 19 Oct 2018
Individual at Chelmsford HMP Chelmsford Other Published 17 Oct 2018