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 Hewell HMP Hewell Natural Published 3 Dec 2017
Individual at Elmley HMP Elmley Other Published 3 Dec 2017
Individual at Wakefield HMP Wakefield Natural Published 1 Dec 2017
Individual at Isle of Wight HMP Isle of Wight Natural Published 1 Dec 2017
Individual at Onley HMP Onley Natural Published 1 Dec 2017
Individual at Holme House HMP Holme House Natural Published 30 Nov 2017
Individual at Northumberland HMP Northumberland Self-inflicted Published 28 Nov 2017
Individual at Wymott HMP Wymott Other Published 26 Nov 2017
Individual at Elmley HMP Elmley Natural Published 26 Nov 2017
Individual at Oakwood HMP Oakwood Natural Published 25 Nov 2017
Individual at High Down HMP High Down Natural Published 23 Nov 2017
Individual at Exeter HMP Exeter Self-inflicted Published 22 Nov 2017
Individual at Leeds HMP Leeds Self-inflicted Published 22 Nov 2017
Individual at Doncaster HMP Doncaster Natural Published 20 Nov 2017
Individual at Hewell HMP Hewell Natural Published 19 Nov 2017
Individual at Morton Hall IRC IRC Morton Hall IRC Self-inflicted Published 19 Nov 2017
Individual at The Grange The Grange Self-inflicted Published 16 Nov 2017
Individual at Littlehey HMP Littlehey Natural Published 16 Nov 2017
Individual at Frankland HMP Frankland Natural Published 16 Nov 2017
Individual at Frankland HMP Frankland Natural Published 15 Nov 2017
Individual at Highpoint HMP Highpoint Natural Published 14 Nov 2017
Individual at Hewell HMP Hewell Other Published 14 Nov 2017
Individual at Lindholme HMP Lindholme Self-inflicted Published 13 Nov 2017
Individual at Leeds HMP Leeds Homicide Published 12 Nov 2017
Individual at Liverpool HMP Liverpool Natural Published 11 Nov 2017
Individual at Dovegate HMP Dovegate Self-inflicted Published 9 Nov 2017
Individual at Leeds HMP Leeds Self-inflicted Published 7 Nov 2017
Individual at Parc HMP Parc Other Published 4 Nov 2017
Individual at Exeter HMP Exeter Self-inflicted Published 31 Oct 2017
Individual at Wandsworth HMP Wandsworth Natural Published 31 Oct 2017
Individual at Woodhill HMP Woodhill Natural Published 31 Oct 2017
Individual at Stocken HMP Stocken Natural Published 30 Oct 2017
Individual at Stoke Heath HMP Stoke Heath Other Published 27 Oct 2017
Individual at Leicester HMP Leicester Self-inflicted Published 22 Oct 2017
Individual at Cardiff HMP Cardiff Self-inflicted Published 21 Oct 2017
Individual at Lancaster Farms HMP Lancaster Farms Other Published 21 Oct 2017
Individual at Ranby HMP Ranby Self-inflicted Published 19 Oct 2017
Individual at Exeter HMP Exeter Self-inflicted Published 18 Oct 2017
Individual at Chelmsford HMP Chelmsford Self-inflicted Published 16 Oct 2017
Individual at Bure HMP Bure Natural Published 16 Oct 2017
Individual at Manchester HMP Manchester Natural Published 14 Oct 2017
Individual at New Hall HMP New Hall Self-inflicted Published 13 Oct 2017
Individual at Cardiff HMP Cardiff Other Published 12 Oct 2017
Individual at Stocken HMP Stocken Natural Published 12 Oct 2017
Individual at Nottingham HMP Nottingham Self-inflicted Published 12 Oct 2017
Individual at Swaleside HMP Swaleside Other Published 11 Oct 2017
Individual at Isle of Wight HMP Isle of Wight Natural Published 11 Oct 2017
Individual at Holme House HMP Holme House Natural Published 6 Oct 2017
Individual at Liverpool HMP Liverpool Self-inflicted Published 6 Oct 2017
Individual at Nottingham HMP Nottingham Self-inflicted Published 6 Oct 2017