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 Wakefield HMP Wakefield Natural Published 24 May 2016
Individual at Exeter HMP Exeter Natural Published 24 May 2016
Individual at Isle of Wight HMP Isle of Wight Natural Published 24 May 2016
Individual at Lindholme HMP Lindholme Self-inflicted Published 23 May 2016
Individual at Wayland HMP Wayland Self-inflicted Published 23 May 2016
Individual at Norwich HMP Norwich Natural Published 21 May 2016
Individual at Leyhill HMP Leyhill Natural Published 21 May 2016
Individual at Eastwood Park HMP Eastwood Park Self-inflicted Published 20 May 2016
Individual at Full Sutton HMP Full Sutton Natural Published 19 May 2016
Individual at Moorland Closed HMP Moorland Closed Self-inflicted Published 18 May 2016
Individual at Gartree HMP Gartree Natural Published 16 May 2016
Individual at Hull HMP Hull Natural Published 15 May 2016
Individual at Nottingham HMP Nottingham Natural Published 13 May 2016
Individual at Stafford HMP Stafford Natural Published 12 May 2016
Individual at Cardiff HMP Cardiff Natural Published 11 May 2016
Individual at Bullingdon HMP Bullingdon Other Published 10 May 2016
Individual at Hewell HMP Hewell Self-inflicted Published 9 May 2016
Individual at Altcourse HMP Altcourse Natural Published 8 May 2016
Individual at Bure HMP Bure Natural Published 8 May 2016
Individual at Sudbury HMP Sudbury Natural Published 7 May 2016
Individual at Exeter HMP Exeter Natural Published 5 May 2016
Individual at Liverpool HMP Liverpool Natural Published 5 May 2016
Individual at Peterborough HMP Peterborough Natural Published 2 May 2016
Individual at Deerbolt HMP Deerbolt Self-inflicted Published 2 May 2016
Individual at Leeds HMP Leeds Natural Published 2 May 2016
Individual at Eastwood Park HMP Eastwood Park Self-inflicted Published 2 May 2016
Individual at Wakefield HMP Wakefield Natural Published 1 May 2016
Individual at Usk and Prescoed HMP Usk and Prescoed Natural Published 1 May 2016
Individual at Liverpool HMP Liverpool Natural Published 29 Apr 2016
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 29 Apr 2016
Individual at Hull HMP Hull Natural Published 28 Apr 2016
Individual at Huntercombe HMP Huntercombe Self-inflicted Published 28 Apr 2016
Individual at Woodhill HMP Woodhill Self-inflicted Published 28 Apr 2016
Individual at The Mount HMP The Mount Natural Published 27 Apr 2016
Individual at Risley HMP Risley Natural Published 26 Apr 2016
Individual at The Pines The Pines Self-inflicted Published 25 Apr 2016
Individual at Hull HMP Hull Natural Published 24 Apr 2016
Individual at Wormwood Scrubs HMP Wormwood Scrubs Other Published 24 Apr 2016
Individual at Manchester HMP Manchester Natural Published 24 Apr 2016
Individual at New Hall HMP New Hall Self-inflicted Published 23 Apr 2016
Individual at Littlehey HMP Littlehey Natural Published 23 Apr 2016
Individual at Southview Southview Other Published 22 Apr 2016
Individual at Doncaster HMP Doncaster Self-inflicted Published 22 Apr 2016
Individual at Bedford HMP Bedford Self-inflicted Published 18 Apr 2016
Individual at Lindholme HMP Lindholme Self-inflicted Published 17 Apr 2016
Individual at Garth HMP Garth Natural Published 14 Apr 2016
Individual at Wymott HMP Wymott Natural Published 14 Apr 2016
Individual at Swansea HMP Swansea Self-inflicted Published 10 Apr 2016
Individual at Exeter HMP Exeter Natural Published 9 Apr 2016
Individual at Oakwood HMP Oakwood Natural Published 7 Apr 2016