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 Manchester HMP Manchester Natural Published 30 May 2017
Individual at Elmley HMP Elmley Natural Published 27 May 2017
Individual at Garth HMP Garth Self-inflicted Published 27 May 2017
Individual at Highpoint HMP Highpoint Self-inflicted Published 26 May 2017
Individual at Leeds HMP Leeds Other Published 23 May 2017
Individual at Exeter HMP Exeter Natural Published 22 May 2017
Individual at Fleming House Fleming House Natural Published 21 May 2017
Individual at Gartree HMP Gartree Natural Published 20 May 2017
Individual at Northumberland HMP Northumberland Other Published 19 May 2017
Individual at Oakwood HMP Oakwood Natural Published 18 May 2017
Individual at Wayland HMP Wayland Natural Published 18 May 2017
Individual at Swaleside HMP Swaleside Natural Published 18 May 2017
Individual at Stoke Heath HMP Stoke Heath Natural Published 14 May 2017
Individual at High Down HMP High Down Natural Published 14 May 2017
Individual at Swinfen Hall HMP Swinfen Hall Self-inflicted Published 8 May 2017
Individual at Oakwood HMP Oakwood Natural Published 7 May 2017
Individual at Bure HMP Bure Natural Published 6 May 2017
Individual at Bure HMP Bure Natural Published 5 May 2017
Individual at Winchester HMP Winchester Self-inflicted Published 3 May 2017
Individual at Rye Hill HMP Rye Hill Natural Published 3 May 2017
Baker, Brian HMP Sudbury Natural Published 1 May 2017
Individual at Leyhill HMP Leyhill Natural Published 28 Apr 2017
Individual at Buckley Hall HMP Buckley Hall Natural Published 28 Apr 2017
Individual at High Down HMP High Down Natural Published 27 Apr 2017
Individual at Pentonville HMP Pentonville Self-inflicted Published 27 Apr 2017
Individual at Rye Hill HMP Rye Hill Natural Published 27 Apr 2017
Individual at Lewes HMP Lewes Self-inflicted Published 26 Apr 2017
Individual at Forest Bank HMP Forest Bank Natural Published 26 Apr 2017
Individual at Exeter HMP Exeter Self-inflicted Published 24 Apr 2017
Individual at Bullingdon HMP Bullingdon Natural Published 24 Apr 2017
Individual at Leeds HMP Leeds Natural Published 21 Apr 2017
Individual at Doncaster HMP Doncaster Natural Published 20 Apr 2017
Individual at Whatton HMP Whatton Natural Published 20 Apr 2017
Individual at Wymott HMP Wymott Natural Published 19 Apr 2017
Individual at Oakwood HMP Oakwood Natural Published 17 Apr 2017
Individual at Leyhill HMP Leyhill Natural Published 16 Apr 2017
Individual at Birmingham HMP Birmingham Natural Published 15 Apr 2017
Individual at Garth HMP Garth Natural Published 14 Apr 2017
Individual at Bristol HMP Bristol Self-inflicted Published 13 Apr 2017
Individual at The Mount HMP The Mount Natural Published 13 Apr 2017
Individual at The Verne IRC IRC The Verne IRC Self-inflicted Published 9 Apr 2017
Individual at Frankland HMP Frankland Natural Published 9 Apr 2017
Individual at Norwich HMP Norwich Self-inflicted Published 5 Apr 2017
Individual at Exeter HMP Exeter Natural Published 2 Apr 2017
Individual at Wymott HMP Wymott Natural Published 1 Apr 2017
Individual at Durham HMP Durham Natural Published 30 Mar 2017
Individual at Ripon House Ripon House Other Published 29 Mar 2017
Individual at Cardiff HMP Cardiff Natural Published 29 Mar 2017
Individual at Pentonville HMP Pentonville Self-inflicted Published 28 Mar 2017
Haynes, Daniel HMP Risley Other Published 28 Mar 2017