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 Parc HMP Parc Natural Published 13 Dec 2016
Individual at Woodhill HMP Woodhill Self-inflicted Published 11 Dec 2016
Individual at Long Lartin HMP Long Lartin Self-inflicted Published 11 Dec 2016
Individual at Moorland Closed HMP Moorland Closed Self-inflicted Published 11 Dec 2016
Individual at Winchester HMP Winchester Natural Published 10 Dec 2016
Individual at Birmingham HMP Birmingham Self-inflicted Published 9 Dec 2016
Individual at Oakwood HMP Oakwood Other Published 8 Dec 2016
Individual at Birmingham HMP Birmingham Natural Published 8 Dec 2016
Individual at Cardiff HMP Cardiff Natural Published 6 Dec 2016
Individual at Morton Hall IRC IRC Morton Hall IRC Natural Published 6 Dec 2016
Individual at Elmley HMP Elmley Natural Published 3 Dec 2016
Individual at Cardiff HMP Cardiff Natural Published 3 Dec 2016
Individual at Littlehey HMP Littlehey Natural Published 2 Dec 2016
Individual at Colnbrook IRC Colnbrook Homicide Published 1 Dec 2016
Individual at Doncaster HMP Doncaster Natural Published 1 Dec 2016
Individual at Foston Hall HMP Foston Hall Self-inflicted Published 29 Nov 2016
Individual at Leeds HMP Leeds Natural Published 28 Nov 2016
Individual at Bristol HMP Bristol Self-inflicted Published 28 Nov 2016
Individual at Elmley HMP Elmley Natural Published 27 Nov 2016
Individual at Elmley HMP Elmley Natural Published 25 Nov 2016
Individual at Pentonville HMP Pentonville Self-inflicted Published 21 Nov 2016
Individual at Littlehey HMP Littlehey Natural Published 21 Nov 2016
Individual at Leicester HMP Leicester Self-inflicted Published 21 Nov 2016
Individual at Lowdham Grange HMP Lowdham Grange Self-inflicted Published 20 Nov 2016
Individual at Thameside HMP Thameside Natural Published 20 Nov 2016
Individual at Holme House HMP Holme House Self-inflicted Published 18 Nov 2016
Individual at Wormwood Scrubs HMP Wormwood Scrubs Natural Published 18 Nov 2016
Individual at Hindley HMP Hindley Natural Published 17 Nov 2016
Individual at Rye Hill HMP Rye Hill Natural Published 16 Nov 2016
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 14 Nov 2016
Individual at North Sea Camp HMP North Sea Camp Natural Published 14 Nov 2016
Individual at Isle of Wight HMP Isle of Wight Natural Published 14 Nov 2016
Adams, Yasmin HMP Foston Hall Self-inflicted Published 13 Nov 2016
Individual at Drake Hall HMP Drake Hall Self-inflicted Published 11 Nov 2016
Individual at Birmingham HMP Birmingham Natural Published 11 Nov 2016
Individual at Exeter HMP Exeter Natural Published 10 Nov 2016
Individual at Lewes HMP Lewes Natural Published 9 Nov 2016
Individual at Exeter HMP Exeter Natural Published 7 Nov 2016
Individual at Birmingham HMP Birmingham Natural Published 7 Nov 2016
Individual at Dartmoor HMP Dartmoor Natural Published 6 Nov 2016
Individual at Garth HMP Garth Other Published 5 Nov 2016
Individual at Gartree HMP Gartree Self-inflicted Published 4 Nov 2016
Individual at Northumberland HMP Northumberland Self-inflicted Published 4 Nov 2016
Individual at Bristol HMP Bristol Self-inflicted Published 3 Nov 2016
Individual at Howard House Howard House Other Published 31 Oct 2016
Individual at Thameside HMP Thameside Natural Published 31 Oct 2016
Individual at Cardiff HMP Cardiff Self-inflicted Published 31 Oct 2016
Individual at Manchester HMP Manchester Natural Published 30 Oct 2016
Individual at Durham HMP Durham Self-inflicted Published 27 Oct 2016
Individual at Rye Hill HMP Rye Hill Natural Published 25 Oct 2016