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 Preston HMP Preston Natural Published 10 Mar 2018
Individual at Wakefield HMP Wakefield Natural Published 8 Mar 2018
Individual at Birmingham HMP Birmingham Self-inflicted Published 5 Mar 2018
Individual at Dovegate HMP Dovegate Natural Published 4 Mar 2018
Individual at Preston HMP Preston Natural Published 4 Mar 2018
Individual at Birmingham HMP Birmingham Natural Published 3 Mar 2018
Individual at Holme House HMP Holme House Natural Published 2 Mar 2018
Individual at Wandsworth HMP Wandsworth Other Published 28 Feb 2018
Individual at Humber HMP Humber Other Published 28 Feb 2018
Individual at Frankland HMP Frankland Natural Published 26 Feb 2018
Individual at Bristol HMP Bristol Natural Published 26 Feb 2018
Individual at Pentonville HMP Pentonville Self-inflicted Published 26 Feb 2018
Individual at Moorland Closed HMP Moorland Closed Natural Published 26 Feb 2018
Individual at Manchester HMP Manchester Self-inflicted Published 25 Feb 2018
Weatherley, Stephen HMP Thameside Other Published 24 Feb 2018
Individual at Lindholme HMP Lindholme Other Published 24 Feb 2018
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 23 Feb 2018
Individual at Belmarsh HMP Belmarsh Natural Published 22 Feb 2018
Individual at Lindholme HMP Lindholme Other Published 22 Feb 2018
Individual at Whatton HMP Whatton Natural Published 21 Feb 2018
Individual at Durham HMP Durham Other Published 19 Feb 2018
Anthony Paine HMP Liverpool Self-inflicted Published 19 Feb 2018 5
Individual at Durham HMP Durham Self-inflicted Published 16 Feb 2018
Individual at Stafford HMP Stafford Natural Published 16 Feb 2018
Individual at Bunbury House Bunbury House Other Published 14 Feb 2018
Individual at Norwich HMP Norwich Natural Published 12 Feb 2018
Individual at Ashfield HMP Ashfield Natural Published 10 Feb 2018
Individual at Hull HMP Hull Natural Published 9 Feb 2018
Individual at Pentonville HMP Pentonville Natural Published 7 Feb 2018
Individual at Nottingham HMP Nottingham Self-inflicted Published 7 Feb 2018
Individual at Wakefield HMP Wakefield Natural Published 7 Feb 2018
Individual at Southwell House Southwell House Natural Published 7 Feb 2018
Individual at Braley House Braley House Self-inflicted Published 6 Feb 2018
Individual at Norwich HMP Norwich Self-inflicted Published 5 Feb 2018
Individual at Long Lartin HMP Long Lartin Self-inflicted Published 5 Feb 2018
Individual at Belmarsh HMP Belmarsh Natural Published 5 Feb 2018
Individual at Stafford HMP Stafford Natural Published 5 Feb 2018
Nicola Birchall HMP/YOI Styal Other Published 4 Feb 2018 4
Individual at Humber HMP Humber Natural Published 3 Feb 2018
Individual at Wakefield HMP Wakefield Natural Published 1 Feb 2018
Saleh, Khader HMP Wormwood Scrubs Homicide Published 31 Jan 2018
Individual at Eastwood Park HMP Eastwood Park Natural Published 28 Jan 2018
Individual at Channings Wood HMP Channings Wood Other Published 28 Jan 2018
Individual at Hewell HMP Hewell Homicide Published 23 Jan 2018
Individual at Exeter HMP Exeter Natural Published 23 Jan 2018
Individual at Parc HMP Parc Natural Published 22 Jan 2018
Individual at Dovegate HMP Dovegate Natural Published 20 Jan 2018
Individual at Haverigg HMP Haverigg Self-inflicted Published 20 Jan 2018
Individual at Holme House HMP Holme House Natural Published 18 Jan 2018
Individual at Rye Hill HMP Rye Hill Natural Published 17 Jan 2018