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 Wymott HMP Wymott Natural Published 28 Aug 2018
Individual at Wandsworth HMP Wandsworth Natural Published 27 Aug 2018
Individual at Leeds HMP Leeds Self-inflicted Published 26 Aug 2018
Individual at Hull HMP Hull Natural Published 26 Aug 2018
Individual at Hull HMP Hull Natural Published 26 Aug 2018
Individual at Thameside HMP Thameside Natural Published 26 Aug 2018
Individual at Durham HMP Durham Natural Published 25 Aug 2018
Individual at Downview HMP Downview Self-inflicted Published 25 Aug 2018
Individual at Wakefield HMP Wakefield Natural Published 19 Aug 2018
Individual at Woodhill HMP Woodhill Other Published 18 Aug 2018
Individual at Whatton HMP Whatton Natural Published 18 Aug 2018
Individual at Coldingley HMP Coldingley Other Published 18 Aug 2018
Individual at Full Sutton HMP Full Sutton Natural Published 14 Aug 2018
Individual at Swaleside HMP Swaleside Natural Published 12 Aug 2018
Jonathan McCarthy HMP Onley Natural Published 12 Aug 2018 2
Individual at Durham HMP Durham Other Published 7 Aug 2018
Individual at Littlehey HMP Littlehey Natural Published 6 Aug 2018
Individual at Durham HMP Durham Other Published 6 Aug 2018
Individual at Long Lartin HMP Long Lartin Self-inflicted Published 5 Aug 2018
Individual at Birmingham HMP Birmingham Natural Published 5 Aug 2018
Individual at Whatton HMP Whatton Natural Published 5 Aug 2018
Individual at Channings Wood HMP Channings Wood Other Published 5 Aug 2018
Individual at High Down HMP High Down Natural Published 4 Aug 2018
Individual at Leeds HMP Leeds Other Published 3 Aug 2018
Individual at Norwich HMP Norwich Self-inflicted Published 31 Jul 2018
Individual at Hull HMP Hull Natural Published 30 Jul 2018
Individual at Elmley HMP Elmley Other Published 24 Jul 2018
Individual at Isle of Wight HMP Isle of Wight Natural Published 23 Jul 2018
Individual at Chelmsford HMP Chelmsford Self-inflicted Published 19 Jul 2018
Individual at Nottingham HMP Nottingham Homicide Published 18 Jul 2018
Individual at Exeter HMP Exeter Self-inflicted Published 18 Jul 2018
Individual at Whatton HMP Whatton Natural Published 16 Jul 2018
Individual at Dovegate HMP Dovegate Other Published 16 Jul 2018
Individual at Parc HMP Parc Natural Published 15 Jul 2018
Individual at Woodhill HMP Woodhill Natural Published 15 Jul 2018
Individual at Leeds HMP Leeds Self-inflicted Published 15 Jul 2018
Individual at Isle of Wight HMP Isle of Wight Natural Published 14 Jul 2018
Individual at St Catherine’s Priory St Catherine’s Priory Other Published 14 Jul 2018
Individual at Drake Hall HMP Drake Hall Other Published 12 Jul 2018
West, Russell HMP Forest Bank Natural Published 8 Jul 2018
Individual at Thameside HMP Thameside Natural Published 6 Jul 2018
Individual at Altcourse HMP Altcourse Self-inflicted Published 6 Jul 2018
Individual at Onley HMP Onley Self-inflicted Published 4 Jul 2018
Individual at Featherstone HMP Featherstone Other Published 4 Jul 2018
Individual at Littlehey HMP Littlehey Natural Published 30 Jun 2018
Individual at Isle of Wight HMP Isle of Wight Natural Published 29 Jun 2018
Individual at Rye Hill HMP Rye Hill Natural Published 25 Jun 2018
Individual at Durham HMP Durham Self-inflicted Published 25 Jun 2018
Individual at Guys Marsh HMP Guys Marsh Other Published 24 Jun 2018
Individual at Oakwood HMP Oakwood Natural Published 24 Jun 2018