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 7 Apr 2016
Individual at Moorland Closed HMP Moorland Closed Self-inflicted Published 6 Apr 2016
Individual at Durham HMP Durham Natural Published 5 Apr 2016
Individual at Littlehey HMP Littlehey Natural Published 4 Apr 2016
Individual at Westbourne House Westbourne House Other Published 2 Apr 2016
Individual at Liverpool HMP Liverpool Self-inflicted Published 1 Apr 2016
Individual at Full Sutton HMP Full Sutton Natural Published 1 Apr 2016
Individual at Coldingley HMP Coldingley Homicide Published 1 Apr 2016
Individual at Lindholme HMP Lindholme Other Published 30 Mar 2016
Individual at Manchester HMP Manchester Self-inflicted Published 30 Mar 2016
Individual at Wormwood Scrubs HMP Wormwood Scrubs Other Published 29 Mar 2016
Individual at Featherstone HMP Featherstone Natural Published 27 Mar 2016
Individual at Liverpool HMP Liverpool Natural Published 27 Mar 2016
Individual at Northumberland HMP Northumberland Natural Published 27 Mar 2016
Individual at Elmley HMP Elmley Natural Published 26 Mar 2016
Individual at Lowdham Grange HMP Lowdham Grange Self-inflicted Published 24 Mar 2016
Individual at Guys Marsh HMP Guys Marsh Self-inflicted Published 24 Mar 2016
Individual at Pentonville HMP Pentonville Natural Published 24 Mar 2016
Individual at Withington Road Withington Road Self-inflicted Published 23 Mar 2016
Individual at Humber HMP Humber Self-inflicted Published 22 Mar 2016
Individual at Northumberland HMP Northumberland Other Published 20 Mar 2016
Individual at Elmley HMP Elmley Natural Published 20 Mar 2016
Individual at New Hall HMP New Hall Self-inflicted Published 19 Mar 2016
Individual at Exeter HMP Exeter Natural Published 16 Mar 2016
Individual at Wayland HMP Wayland Self-inflicted Published 14 Mar 2016
Individual at Peterborough HMP Peterborough Self-inflicted Published 13 Mar 2016
Individual at Littlehey HMP Littlehey Natural Published 10 Mar 2016
Individual at Wymott HMP Wymott Natural Published 7 Mar 2016
Individual at Lewes HMP Lewes Natural Published 7 Mar 2016
Fenlon, Robert HMP Woodhill Self-inflicted Published 5 Mar 2016
Individual at Exeter HMP Exeter Natural Published 4 Mar 2016
Individual at Liverpool HMP Liverpool Natural Published 4 Mar 2016
Individual at Featherstone HMP Featherstone Self-inflicted Published 3 Mar 2016
Individual at Wakefield HMP Wakefield Natural Published 3 Mar 2016
Individual at Wakefield HMP Wakefield Natural Published 3 Mar 2016
Individual at Norwich HMP Norwich Natural Published 2 Mar 2016
Individual at Bristol HMP Bristol Self-inflicted Published 2 Mar 2016
Individual at Stafford HMP Stafford Natural Published 1 Mar 2016
Individual at Wormwood Scrubs HMP Wormwood Scrubs Natural Published 1 Mar 2016
Individual at Hull HMP Hull Natural Published 29 Feb 2016
Individual at Hull HMP Hull Natural Published 29 Feb 2016
Individual at Holme House HMP Holme House Natural Published 29 Feb 2016
Individual at Wakefield HMP Wakefield Natural Published 28 Feb 2016
Individual at Leeds HMP Leeds Natural Published 26 Feb 2016
Individual at Leeds HMP Leeds Self-inflicted Published 25 Feb 2016
Individual at Frankland HMP Frankland Natural Published 25 Feb 2016
Individual at Littlehey HMP Littlehey Natural Published 24 Feb 2016
Individual at Leyhill HMP Leyhill Natural Published 22 Feb 2016
Individual at Wakefield HMP Wakefield Natural Published 21 Feb 2016
Aaron Nunes HMP/YOI Parc Natural Published 21 Feb 2016 25