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
Rawlinson, Darren HMP Forest Bank Other Published 29 Jan 2017
Individual at Hewell HMP Hewell Natural Published 29 Jan 2017
Individual at Liverpool HMP Liverpool Self-inflicted Published 27 Jan 2017
Individual at Forest Bank HMP Forest Bank Self-inflicted Published 26 Jan 2017
Individual at Whatton HMP Whatton Natural Published 25 Jan 2017
Individual at Oakwood HMP Oakwood Natural Published 23 Jan 2017
Individual at Lincoln HMP Lincoln Natural Published 20 Jan 2017
Individual at Lincoln HMP Lincoln Natural Published 20 Jan 2017
Individual at Preston HMP Preston Natural Published 19 Jan 2017
Individual at Birmingham HMP Birmingham Natural Published 17 Jan 2017
Individual at Leeds HMP Leeds Natural Published 17 Jan 2017
Individual at Swaleside HMP Swaleside Self-inflicted Published 17 Jan 2017
Individual at Lincoln HMP Lincoln Natural Published 16 Jan 2017
Individual at Norwich HMP Norwich Natural Published 16 Jan 2017
Individual at Durham HMP Durham Self-inflicted Published 15 Jan 2017
Individual at Exeter HMP Exeter Natural Published 15 Jan 2017
Individual at Oakwood HMP Oakwood Natural Published 15 Jan 2017
Individual at Durham HMP Durham Natural Published 12 Jan 2017
Individual at Morton Hall IRC IRC Morton Hall IRC Self-inflicted Published 11 Jan 2017
Individual at Garth HMP Garth Natural Published 11 Jan 2017
Individual at Westgate Westgate Other Published 10 Jan 2017
Individual at Exeter HMP Exeter Natural Published 9 Jan 2017
Individual at Belmarsh HMP Belmarsh Natural Published 9 Jan 2017
Individual at Bedford HMP Bedford Natural Published 9 Jan 2017
Individual at Warren Hill HMP Warren Hill Natural Published 9 Jan 2017
Individual at Risley HMP Risley Natural Published 8 Jan 2017
Individual at Holme House HMP Holme House Natural Published 7 Jan 2017
Individual at Hatfield HMP Hatfield Other Published 7 Jan 2017
Individual at Belmarsh HMP Belmarsh Natural Published 6 Jan 2017
Individual at Frankland HMP Frankland Natural Published 6 Jan 2017
Individual at Rye Hill HMP Rye Hill Natural Published 5 Jan 2017
Individual at Peterborough HMP Peterborough Natural Published 4 Jan 2017
Individual at Isle of Wight HMP Isle of Wight Natural Published 3 Jan 2017
Individual at Altcourse HMP Altcourse Natural Published 1 Jan 2017
Individual at Elmley HMP Elmley Natural Published 31 Dec 2016
Individual at Belmarsh HMP Belmarsh Self-inflicted Published 30 Dec 2016
Individual at Doncaster HMP Doncaster Self-inflicted Published 30 Dec 2016
Individual at Whatton HMP Whatton Natural Published 29 Dec 2016
Individual at Bristol HMP Bristol Other Published 27 Dec 2016
Individual at Chelmsford HMP Chelmsford Self-inflicted Published 25 Dec 2016
Individual at St Josephs St Josephs Other Published 22 Dec 2016
Individual at Ashfield HMP Ashfield Natural Published 22 Dec 2016
Individual at Elmley HMP Elmley Self-inflicted Published 20 Dec 2016
Individual at Gartree HMP Gartree Other Published 19 Dec 2016
Individual at Pentonville HMP Pentonville Natural Published 16 Dec 2016
Individual at Stoke Heath HMP Stoke Heath Other Published 15 Dec 2016
Individual at Rye Hill HMP Rye Hill Natural Published 15 Dec 2016
Individual at Wakefield HMP Wakefield Natural Published 15 Dec 2016
Individual at Norwich HMP Norwich Natural Published 14 Dec 2016
Individual at Norwich HMP Norwich Natural Published 14 Dec 2016