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 High Down HMP High Down Self-inflicted Published 17 Oct 2018
Individual at Whatton HMP Whatton Natural Published 14 Oct 2018
Individual at Liverpool HMP Liverpool Self-inflicted Published 14 Oct 2018
Individual at Drake Hall HMP Drake Hall Natural Published 13 Oct 2018
Individual at Lindholme HMP Lindholme Self-inflicted Published 13 Oct 2018
Lawrence, Thomas HMP Risley Other Published 12 Oct 2018
Individual at Wandsworth HMP Wandsworth Natural Published 10 Oct 2018
Individual at Nottingham HMP Nottingham Self-inflicted Published 9 Oct 2018
Individual at Parc HMP Parc Other Published 9 Oct 2018
Carl Russell HMP Thorn Cross Homicide Published 7 Oct 2018
Individual at Holme House HMP Holme House Natural Published 7 Oct 2018
Individual at Humber HMP Humber Other Published 6 Oct 2018
Kettle, Patrick HMP Stocken Other Published 6 Oct 2018
Individual at Stocken HMP Stocken Natural Published 6 Oct 2018
Individual at Lowdham Grange HMP Lowdham Grange Self-inflicted Published 4 Oct 2018
Individual at Wakefield HMP Wakefield Natural Published 1 Oct 2018
Individual at Bullingdon HMP Bullingdon Natural Published 30 Sep 2018
Individual at Dovegate HMP Dovegate Self-inflicted Published 29 Sep 2018
Individual at Durham HMP Durham Other Published 29 Sep 2018
Degg, Paul HMP Risley Self-inflicted Published 29 Sep 2018
Individual at Birmingham HMP Birmingham Natural Published 27 Sep 2018
Individual at Liverpool HMP Liverpool Self-inflicted Published 26 Sep 2018
Individual at Manchester HMP Manchester Self-inflicted Published 25 Sep 2018
Individual at Rye Hill HMP Rye Hill Natural Published 25 Sep 2018
Individual at High Down HMP High Down Natural Published 24 Sep 2018
Individual at Dovegate HMP Dovegate Natural Published 22 Sep 2018
Individual at North Sea Camp HMP North Sea Camp Other Published 22 Sep 2018
Individual at Leeds HMP Leeds Other Published 22 Sep 2018
Individual at Usk and Prescoed HMP Usk and Prescoed Natural Published 20 Sep 2018
Individual at Wymott HMP Wymott Natural Published 19 Sep 2018
Individual at Hull HMP Hull Self-inflicted Published 16 Sep 2018
Individual at Hewell HMP Hewell Natural Published 16 Sep 2018
Individual at Chelmsford HMP Chelmsford Self-inflicted Published 16 Sep 2018
Individual at Full Sutton HMP Full Sutton Natural Published 15 Sep 2018
Individual at Wayland HMP Wayland Self-inflicted Published 13 Sep 2018
Individual at Coldingley HMP Coldingley Self-inflicted Published 13 Sep 2018
Individual at Lindholme HMP Lindholme Other Published 11 Sep 2018
Winchcole, John HMP Forest Bank Self-inflicted Published 10 Sep 2018
Individual at Leeds HMP Leeds Natural Published 9 Sep 2018
Individual at Rye Hill HMP Rye Hill Natural Published 9 Sep 2018
Individual at Liverpool HMP Liverpool Natural Published 8 Sep 2018
Individual at Hewell HMP Hewell Other Published 7 Sep 2018
Individual at Doncaster HMP Doncaster Self-inflicted Published 5 Sep 2018
Individual at Wymott HMP Wymott Other Published 4 Sep 2018
Individual at Norwich HMP Norwich Natural Published 4 Sep 2018
Individual at Manchester HMP Manchester Natural Published 3 Sep 2018
Individual at Bronzefield HMP Bronzefield Natural Published 3 Sep 2018
Henshaw, Georgina HMP Foston Hall Other Published 31 Aug 2018
Morgan, David HMP Chelmsford Other Published 30 Aug 2018
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 30 Aug 2018