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 Hull HMP Hull Natural Published 4 Sep 2016
Individual at Ashfield HMP Ashfield Natural Published 1 Sep 2016
Individual at Humber HMP Humber Self-inflicted Published 1 Sep 2016
Individual at Hull HMP Hull Self-inflicted Published 1 Sep 2016
Individual at Thameside HMP Thameside Natural Published 31 Aug 2016
Individual at Birmingham HMP Birmingham Natural Published 31 Aug 2016
Individual at Oakwood HMP Oakwood Natural Published 30 Aug 2016
Individual at Lindholme HMP Lindholme Natural Published 29 Aug 2016
Individual at Bedford HMP Bedford Self-inflicted Published 29 Aug 2016
Individual at Whitemoor HMP Whitemoor Self-inflicted Published 28 Aug 2016
Individual at Leyhill HMP Leyhill Natural Published 28 Aug 2016
Individual at Parc HMP Parc Natural Published 26 Aug 2016
Individual at Thameside HMP Thameside Natural Published 26 Aug 2016
Individual at Woodhill HMP Woodhill Self-inflicted Published 25 Aug 2016
Individual at Parc HMP Parc Natural Published 24 Aug 2016
Individual at Wakefield HMP Wakefield Natural Published 23 Aug 2016
Individual at Northumberland HMP Northumberland Natural Published 22 Aug 2016
Individual at Peterborough HMP Peterborough Other Published 22 Aug 2016
Individual at Durham HMP Durham Natural Published 21 Aug 2016
Individual at Nottingham HMP Nottingham Self-inflicted Published 15 Aug 2016
Richard Hogarth HMP Risley Self-inflicted Published 14 Aug 2016 4
Individual at Pentonville HMP Pentonville Natural Published 13 Aug 2016
Individual at Glen Parva HMP Glen Parva Self-inflicted Published 12 Aug 2016
Individual at Swaleside HMP Swaleside Self-inflicted Published 9 Aug 2016
Individual at Eastwood Park HMP Eastwood Park Self-inflicted Published 8 Aug 2016
Individual at Bedford Approved Premises for Women Bedford Approved Premises for Women Natural Published 8 Aug 2016
Individual at Leyhill HMP Leyhill Natural Published 6 Aug 2016
Individual at Exeter HMP Exeter Self-inflicted Published 6 Aug 2016
Individual at Eastwood Park HMP Eastwood Park Natural Published 6 Aug 2016
Individual at Birmingham HMP Birmingham Natural Published 5 Aug 2016
Individual at Woodhill HMP Woodhill Self-inflicted Published 2 Aug 2016
Individual at Exeter HMP Exeter Self-inflicted Published 2 Aug 2016
Individual at Woodhill HMP Woodhill Natural Published 29 Jul 2016
Individual at Featherstone HMP Featherstone Natural Published 24 Jul 2016
Individual at Peterborough HMP Peterborough Natural Published 23 Jul 2016
Individual at Winchester HMP Winchester Natural Published 22 Jul 2016
Individual at Altcourse HMP Altcourse Self-inflicted Published 21 Jul 2016
Individual at Channings Wood HMP Channings Wood Natural Published 21 Jul 2016
Individual at Whatton HMP Whatton Natural Published 21 Jul 2016
Individual at Highpoint HMP Highpoint Other Published 19 Jul 2016
Individual at Moorland Closed HMP Moorland Closed Natural Published 19 Jul 2016
Individual at Wayland HMP Wayland Self-inflicted Published 19 Jul 2016
Individual at Bronzefield HMP Bronzefield Other Published 19 Jul 2016
Individual at Preston HMP Preston Self-inflicted Published 18 Jul 2016
Individual at Bristol HMP Bristol Self-inflicted Published 16 Jul 2016
Individual at Liverpool HMP Liverpool Self-inflicted Published 16 Jul 2016
Individual at Stafford HMP Stafford Natural Published 15 Jul 2016
Individual at Haverigg HMP Haverigg Self-inflicted Published 15 Jul 2016
Individual at Humber HMP Humber Self-inflicted Published 14 Jul 2016
Individual at Bedford HMP Bedford Self-inflicted Published 13 Jul 2016