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 Camden House Camden House Other Published 7 Aug 2017
Individual at Burdett Lodge Burdett Lodge Homicide Published 6 Aug 2017
Individual at Birmingham HMP Birmingham Natural Published 5 Aug 2017
Individual at Elmley HMP Elmley Natural Published 1 Aug 2017
Individual at Wymott HMP Wymott Other Published 30 Jul 2017
Individual at Isle of Wight HMP Isle of Wight Natural Published 30 Jul 2017
Individual at Whatton HMP Whatton Natural Published 30 Jul 2017
Individual at Wymott HMP Wymott Natural Published 28 Jul 2017
Individual at Hewell HMP Hewell Natural Published 27 Jul 2017
Individual at Humber HMP Humber Self-inflicted Published 24 Jul 2017
Individual at Littlehey HMP Littlehey Natural Published 23 Jul 2017
Individual at Lewes HMP Lewes Natural Published 22 Jul 2017
Individual at Stonnall Road Stonnall Road Other Published 21 Jul 2017
Individual at Norwich HMP Norwich Natural Published 18 Jul 2017
Individual at Exeter HMP Exeter Self-inflicted Published 17 Jul 2017
Individual at Norwich HMP Norwich Natural Published 16 Jul 2017
Individual at Stafford HMP Stafford Natural Published 16 Jul 2017
Individual at Littlehey HMP Littlehey Natural Published 15 Jul 2017
Individual at Garth HMP Garth Natural Published 13 Jul 2017
Individual at Coldingley HMP Coldingley Self-inflicted Published 8 Jul 2017
Individual at Standford Hill HMP Standford Hill Natural Published 6 Jul 2017
Individual at Wymott HMP Wymott Natural Published 2 Jul 2017
Individual at Bronzefield HMP Bronzefield Natural Published 1 Jul 2017
Individual at Chelmsford HMP Chelmsford Natural Published 1 Jul 2017
Individual at Elmley HMP Elmley Natural Published 30 Jun 2017
Individual at Isle of Wight HMP Isle of Wight Natural Published 30 Jun 2017
Individual at Wymott HMP Wymott Other Published 29 Jun 2017
Individual at Doncaster HMP Doncaster Natural Published 28 Jun 2017
Individual at Manchester HMP Manchester Natural Published 27 Jun 2017
Individual at The Mount HMP The Mount Self-inflicted Published 21 Jun 2017
Individual at Westminster Magistrates’ Court Westminster Magistrates’ Court Natural Published 21 Jun 2017
Individual at Standford Hill HMP Standford Hill Natural Published 20 Jun 2017
Individual at Bronzefield HMP Bronzefield Natural Published 15 Jun 2017
Individual at Elmley HMP Elmley Natural Published 14 Jun 2017
Individual at Erlestoke HMP Erlestoke Natural Published 14 Jun 2017
Individual at Altcourse HMP Altcourse Natural Published 13 Jun 2017
Individual at Birmingham HMP Birmingham Self-inflicted Published 11 Jun 2017
Individual at Durham HMP Durham Natural Published 10 Jun 2017
Individual at Swaleside HMP Swaleside Natural Published 9 Jun 2017
Individual at Norwich HMP Norwich Natural Published 7 Jun 2017
Individual at Long Lartin HMP Long Lartin Homicide Published 7 Jun 2017
Individual at Littlehey HMP Littlehey Natural Published 6 Jun 2017
Individual at Oakwood HMP Oakwood Natural Published 5 Jun 2017
Individual at Ranby HMP Ranby Natural Published 3 Jun 2017
Individual at Swaleside HMP Swaleside Self-inflicted Published 3 Jun 2017
Individual at Norwich HMP Norwich Self-inflicted Published 2 Jun 2017
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 1 Jun 2017
Individual at Rye Hill HMP Rye Hill Natural Published 1 Jun 2017
Individual at Guys Marsh HMP Guys Marsh Natural Published 1 Jun 2017
Individual at Bristol HMP Bristol Other Published 31 May 2017