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 Oakwood HMP Oakwood Natural Published 12 Jul 2016
Individual at Bullingdon HMP Bullingdon Self-inflicted Published 11 Jul 2016
Individual at Whatton HMP Whatton Natural Published 9 Jul 2016
Individual at Birmingham HMP Birmingham Natural Published 8 Jul 2016
Individual at Manchester HMP Manchester Natural Published 8 Jul 2016
Individual at Woodhill HMP Woodhill Natural Published 3 Jul 2016
Individual at Northumberland HMP Northumberland Self-inflicted Published 1 Jul 2016
Individual at Forest Bank HMP Forest Bank Natural Published 30 Jun 2016
Individual at Haverigg HMP Haverigg Other Published 30 Jun 2016
Individual at Thameside HMP Thameside Natural Published 29 Jun 2016
Individual at Nottingham HMP Nottingham Self-inflicted Published 28 Jun 2016
Individual at Altcourse HMP Altcourse Natural Published 27 Jun 2016
Individual at Woodhill HMP Woodhill Self-inflicted Published 26 Jun 2016
Individual at Pentonville HMP Pentonville Self-inflicted Published 26 Jun 2016
Individual at Leeds HMP Leeds Self-inflicted Published 24 Jun 2016
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 23 Jun 2016
Individual at Exeter HMP Exeter Self-inflicted Published 21 Jun 2016
Individual at Lincoln HMP Lincoln Self-inflicted Published 21 Jun 2016
Individual at Littlehey HMP Littlehey Natural Published 20 Jun 2016
Individual at Long Lartin HMP Long Lartin Homicide Published 20 Jun 2016
Individual at Kirkham HMP Kirkham Natural Published 19 Jun 2016
Individual at Leeds HMP Leeds Natural Published 19 Jun 2016
Individual at Lewes HMP Lewes Natural Published 16 Jun 2016
Individual at Lewes HMP Lewes Natural Published 14 Jun 2016
Individual at Humber HMP Humber Self-inflicted Published 14 Jun 2016
Individual at Leeds HMP Leeds Self-inflicted Published 14 Jun 2016
Individual at New Hall HMP New Hall Other Published 11 Jun 2016
Individual at Wakefield HMP Wakefield Natural Published 11 Jun 2016
Individual at Hindley HMP Hindley Other Published 10 Jun 2016
Individual at Channings Wood HMP Channings Wood Self-inflicted Published 10 Jun 2016
Individual at Manor Lodge Manor Lodge Natural Published 8 Jun 2016
Individual at Liverpool HMP Liverpool Natural Published 8 Jun 2016
Individual at Winchester HMP Winchester Natural Published 8 Jun 2016
Individual at Hewell HMP Hewell Natural Published 8 Jun 2016
Individual at Lewes HMP Lewes Natural Published 7 Jun 2016
Individual at Lincoln HMP Lincoln Self-inflicted Published 7 Jun 2016
Individual at Holme House HMP Holme House Natural Published 7 Jun 2016
Individual at Exeter HMP Exeter Natural Published 4 Jun 2016
Individual at Wakefield HMP Wakefield Natural Published 2 Jun 2016
Individual at Eastwood Park HMP Eastwood Park Other Published 2 Jun 2016
Individual at Rye Hill HMP Rye Hill Natural Published 2 Jun 2016
Individual at Altcourse HMP Altcourse Natural Published 1 Jun 2016
Individual at Wymott HMP Wymott Natural Published 31 May 2016
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 31 May 2016
Individual at Gartree HMP Gartree Natural Published 30 May 2016
Individual at The Mount HMP The Mount Self-inflicted Published 29 May 2016
Individual at Littlehey HMP Littlehey Natural Published 28 May 2016
Individual at Bure HMP Bure Natural Published 27 May 2016
Individual at Parc HMP Parc Self-inflicted Published 26 May 2016
Individual at Wakefield HMP Wakefield Natural Published 24 May 2016