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 Hull HMP Hull Natural Published 12 May 2018
Individual at Woodhill HMP Woodhill Self-inflicted Published 11 May 2018
Individual at Elmley HMP Elmley Natural Published 10 May 2018
Individual at Liverpool HMP Liverpool Other Published 9 May 2018
Individual at North Sea Camp HMP North Sea Camp Natural Published 5 May 2018
Individual at Brixton HMP Brixton Other Published 4 May 2018
Individual at Belmarsh HMP Belmarsh Natural Published 3 May 2018
Individual at Manchester HMP Manchester Self-inflicted Published 2 May 2018
Individual at Liverpool HMP Liverpool Other Published 1 May 2018
Carley, Edmund HMP Hindley Natural Published 1 May 2018
Individual at Lincoln HMP Lincoln Self-inflicted Published 27 Apr 2018
Individual at Winchester HMP Winchester Natural Published 26 Apr 2018
Individual at Wandsworth HMP Wandsworth Natural Published 25 Apr 2018
Individual at Usk and Prescoed HMP Usk and Prescoed Natural Published 25 Apr 2018
Individual at Cardiff HMP Cardiff Natural Published 24 Apr 2018
Individual at Birmingham HMP Birmingham Self-inflicted Published 24 Apr 2018
Individual at Wymott HMP Wymott Natural Published 22 Apr 2018
Individual at High Down HMP High Down Natural Published 22 Apr 2018
Individual at Oakwood HMP Oakwood Natural Published 21 Apr 2018
Individual at Rochester HMP Rochester Self-inflicted Published 18 Apr 2018
Individual at Bullingdon HMP Bullingdon Self-inflicted Published 17 Apr 2018
Individual at Bristol HMP Bristol Self-inflicted Published 13 Apr 2018
Individual at Guys Marsh HMP Guys Marsh Other Published 9 Apr 2018
Individual at St Johns St Johns Other Published 9 Apr 2018
Individual at Moorland Closed HMP Moorland Closed Natural Published 8 Apr 2018
Individual at Staitheford House Staitheford House Self-inflicted Published 5 Apr 2018
Individual at Durham HMP Durham Natural Published 3 Apr 2018
Individual at Downview HMP Downview Self-inflicted Published 3 Apr 2018
Individual at Leeds HMP Leeds Self-inflicted Published 3 Apr 2018
Individual at Hewell HMP Hewell Natural Published 1 Apr 2018
Individual at Berwyn HMP Berwyn Other Published 31 Mar 2018
Individual at Full Sutton HMP Full Sutton Self-inflicted Published 31 Mar 2018
Individual at Birmingham HMP Birmingham Other Published 31 Mar 2018
Individual at Birmingham HMP Birmingham Other Published 29 Mar 2018
Individual at Durham HMP Durham Self-inflicted Published 29 Mar 2018
Kevin Delahunty HMP Risley Self-inflicted Published 29 Mar 2018 8
Individual at Elmley HMP Elmley Natural Published 27 Mar 2018
Individual at Birmingham HMP Birmingham Other Published 26 Mar 2018
Individual at Frankland HMP Frankland Self-inflicted Published 26 Mar 2018
Individual at Brinsford HMP Brinsford Self-inflicted Published 25 Mar 2018
Individual at Oakwood HMP Oakwood Natural Published 24 Mar 2018
Individual at Stocken HMP Stocken Other Published 24 Mar 2018
Individual at Guys Marsh HMP Guys Marsh Self-inflicted Published 21 Mar 2018
Individual at Rye Hill HMP Rye Hill Natural Published 19 Mar 2018
Individual at Long Lartin HMP Long Lartin Self-inflicted Published 19 Mar 2018
Individual at Lewes HMP Lewes Other Published 18 Mar 2018
Individual at Rochester HMP Rochester Other Published 17 Mar 2018
Individual at Whatton HMP Whatton Natural Published 13 Mar 2018
Individual at Stafford HMP Stafford Natural Published 11 Mar 2018
Individual at Lindholme HMP Lindholme Other Published 11 Mar 2018