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 Forest Bank HMP Forest Bank Natural Published 16 Jan 2018
Individual at Humber HMP Humber Other Published 16 Jan 2018
Individual at Bristol HMP Bristol Natural Published 15 Jan 2018
Individual at Swaleside HMP Swaleside Natural Published 14 Jan 2018
Individual at Swansea HMP Swansea Self-inflicted Published 14 Jan 2018
Individual at Hull HMP Hull Other Published 13 Jan 2018
Individual at High Down HMP High Down Natural Published 13 Jan 2018
Individual at Manchester HMP Manchester Natural Published 13 Jan 2018
Individual at Chelmsford HMP Chelmsford Self-inflicted Published 13 Jan 2018
Individual at Isle of Wight HMP Isle of Wight Self-inflicted Published 12 Jan 2018
Individual at Bullingdon HMP Bullingdon Self-inflicted Published 12 Jan 2018
Individual at Leyhill HMP Leyhill Natural Published 11 Jan 2018
Individual at Exeter HMP Exeter Natural Published 11 Jan 2018
Individual at Manchester HMP Manchester Natural Published 10 Jan 2018
Individual at Onley HMP Onley Natural Published 10 Jan 2018
Individual at Channings Wood HMP Channings Wood Natural Published 9 Jan 2018
Individual at Altcourse HMP Altcourse Natural Published 6 Jan 2018
Individual at Manchester HMP Manchester Self-inflicted Published 4 Jan 2018
Individual at Swaleside HMP Swaleside Natural Published 1 Jan 2018
Individual at Whitemoor HMP Whitemoor Other Published 30 Dec 2017
Individual at Lindholme HMP Lindholme Other Published 30 Dec 2017
Individual at Lindholme HMP Lindholme Natural Published 27 Dec 2017
Individual at Whatton HMP Whatton Natural Published 25 Dec 2017
Individual at Styal HMP Styal Natural Published 25 Dec 2017
Individual at Kirklevington Grange HMP Kirklevington Grange Other Published 24 Dec 2017
Individual at Durham HMP Durham Self-inflicted Published 23 Dec 2017
Individual at Stafford HMP Stafford Natural Published 22 Dec 2017
Individual at Dovegate HMP Dovegate Other Published 22 Dec 2017
Individual at Ellison House Ellison House Natural Published 22 Dec 2017
Individual at Durham HMP Durham Natural Published 21 Dec 2017
Individual at Drake Hall HMP Drake Hall Natural Published 21 Dec 2017
Individual at Oakwood HMP Oakwood Natural Published 19 Dec 2017
Individual at Lowdham Grange HMP Lowdham Grange Other Published 18 Dec 2017
Individual at Birmingham HMP Birmingham Natural Published 17 Dec 2017
Individual at Doncaster HMP Doncaster Natural Published 16 Dec 2017
Individual at Garth HMP Garth Natural Published 16 Dec 2017
Individual at Dartmoor HMP Dartmoor Natural Published 16 Dec 2017
Individual at Bullingdon HMP Bullingdon Self-inflicted Published 15 Dec 2017
Individual at Hatfield HMP Hatfield Natural Published 15 Dec 2017
Individual at Hewell HMP Hewell Natural Published 13 Dec 2017
Individual at Haverigg HMP Haverigg Self-inflicted Published 13 Dec 2017
Individual at Hull HMP Hull Natural Published 13 Dec 2017
Individual at Leicester HMP Leicester Self-inflicted Published 11 Dec 2017
Individual at Littlehey HMP Littlehey Natural Published 10 Dec 2017
Individual at Littlehey HMP Littlehey Natural Published 10 Dec 2017
Individual at Littlehey HMP Littlehey Natural Published 9 Dec 2017
Individual at Stafford HMP Stafford Natural Published 9 Dec 2017
Individual at Altcourse HMP Altcourse Self-inflicted Published 7 Dec 2017
Individual at Rye Hill HMP Rye Hill Natural Published 6 Dec 2017
Individual at Lincoln HMP Lincoln Natural Published 5 Dec 2017