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 Wymott HMP Wymott Natural Published 24 Oct 2016
Individual at Southwood Southwood Homicide Published 24 Oct 2016
Individual at Liverpool HMP Liverpool Self-inflicted Published 23 Oct 2016
Celeste Craig HMP/YOI Styal Self-inflicted Published 23 Oct 2016 5
Individual at Full Sutton HMP Full Sutton Natural Published 20 Oct 2016
Individual at Dartmoor HMP Dartmoor Natural Published 19 Oct 2016
Individual at Manchester HMP Manchester Self-inflicted Published 19 Oct 2016
Individual at Pentonville HMP Pentonville Homicide Published 18 Oct 2016
Individual at Manchester HMP Manchester Natural Published 18 Oct 2016
Individual at Wymott HMP Wymott Natural Published 17 Oct 2016
Individual at Dartmoor HMP Dartmoor Natural Published 16 Oct 2016
Individual at Hull HMP Hull Self-inflicted Published 16 Oct 2016
Individual at Lewes HMP Lewes Natural Published 14 Oct 2016
Individual at Stocken HMP Stocken Natural Published 14 Oct 2016
Individual at Parc HMP Parc Natural Published 14 Oct 2016
Individual at Garth HMP Garth Self-inflicted Published 14 Oct 2016
Individual at Erlestoke HMP Erlestoke Natural Published 12 Oct 2016
Individual at Exeter HMP Exeter Natural Published 11 Oct 2016
Individual at Parc HMP Parc Self-inflicted Published 8 Oct 2016
Individual at Woodhill HMP Woodhill Natural Published 6 Oct 2016
Individual at Oakwood HMP Oakwood Natural Published 5 Oct 2016
Individual at Bristol HMP Bristol Natural Published 4 Oct 2016
Individual at Norwich HMP Norwich Natural Published 3 Oct 2016
Williams, David HMP Swansea Self-inflicted Published 3 Oct 2016
Individual at Eastwood Park HMP Eastwood Park Natural Published 1 Oct 2016
Individual at Altcourse HMP Altcourse Self-inflicted Published 1 Oct 2016
Individual at Garth HMP Garth Self-inflicted Published 30 Sep 2016
Individual at Chelmsford HMP Chelmsford Self-inflicted Published 28 Sep 2016
Individual at Littlehey HMP Littlehey Natural Published 25 Sep 2016
Individual at New Hall HMP New Hall Other Published 24 Sep 2016
Individual at Lewes HMP Lewes Natural Published 24 Sep 2016
Individual at Lincoln HMP Lincoln Natural Published 24 Sep 2016
Individual at Wymott HMP Wymott Natural Published 22 Sep 2016
Individual at Hewell HMP Hewell Other Published 21 Sep 2016
Individual at Chelmsford HMP Chelmsford Natural Published 20 Sep 2016
Individual at Winchester HMP Winchester Self-inflicted Published 18 Sep 2016
Individual at Guys Marsh HMP Guys Marsh Other Published 16 Sep 2016
Individual at Portland HMP Portland Self-inflicted Published 16 Sep 2016
Individual at Exeter HMP Exeter Self-inflicted Published 16 Sep 2016
Individual at Bedford HMP Bedford Self-inflicted Published 15 Sep 2016
Individual at Whatton HMP Whatton Natural Published 14 Sep 2016
Individual at Luton Luton Natural Published 13 Sep 2016
Individual at Wakefield HMP Wakefield Natural Published 13 Sep 2016
Individual at Manchester HMP Manchester Self-inflicted Published 13 Sep 2016
Individual at Swansea HMP Swansea Self-inflicted Published 13 Sep 2016
Individual at Altcourse HMP Altcourse Natural Published 12 Sep 2016
Individual at Wandsworth HMP Wandsworth Natural Published 9 Sep 2016
Individual at Eastwood Park HMP Eastwood Park Natural Published 8 Sep 2016
Individual at Doncaster HMP Doncaster Natural Published 7 Sep 2016
Individual at Onley HMP Onley Natural Published 6 Sep 2016