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 Woodhill HMP Woodhill Other Published 20 Feb 2016
Individual at Hindley HMP Hindley Self-inflicted Published 20 Feb 2016
Individual at Holme House HMP Holme House Other Published 20 Feb 2016
Individual at Stocken HMP Stocken Natural Published 20 Feb 2016
Individual at Winchester HMP Winchester Natural Published 18 Feb 2016
Individual at Stafford HMP Stafford Natural Published 17 Feb 2016
Individual at Colnbrook IRC Colnbrook Self-inflicted Published 17 Feb 2016
Individual at Bullingdon HMP Bullingdon Natural Published 16 Feb 2016
Individual at Bullingdon HMP Bullingdon Natural Published 16 Feb 2016
Individual at Forest Bank HMP Forest Bank Other Published 15 Feb 2016
Individual at Lewes HMP Lewes Self-inflicted Published 12 Feb 2016
Individual at Whitemoor HMP Whitemoor Natural Published 12 Feb 2016
Individual at Parc HMP Parc Self-inflicted Published 11 Feb 2016
Individual at Channings Wood HMP Channings Wood Natural Published 11 Feb 2016
Individual at Littlehey HMP Littlehey Natural Published 8 Feb 2016
Individual at Stafford HMP Stafford Natural Published 6 Feb 2016
Individual at Sudbury HMP Sudbury Other Published 5 Feb 2016
Individual at Isis HMP Isis Other Published 4 Feb 2016
Individual at Altcourse HMP Altcourse Natural Published 3 Feb 2016
Individual at Low Newton HMP Low Newton Self-inflicted Published 2 Feb 2016
Individual at Peterborough HMP Peterborough Natural Published 1 Feb 2016
Individual at Norwich HMP Norwich Natural Published 31 Jan 2016
Individual at Norwich HMP Norwich Natural Published 31 Jan 2016
Individual at Woodhill HMP Woodhill Self-inflicted Published 31 Jan 2016
Individual at Wymott HMP Wymott Natural Published 29 Jan 2016
Individual at Moorland Closed HMP Moorland Closed Self-inflicted Published 28 Jan 2016
Individual at Full Sutton HMP Full Sutton Natural Published 27 Jan 2016
Individual at Felmores Felmores Natural Published 24 Jan 2016
Individual at Rye Hill HMP Rye Hill Natural Published 24 Jan 2016
Individual at High Down HMP High Down Natural Published 22 Jan 2016
Individual at Parc HMP Parc Other Published 21 Jan 2016
Individual at Dovegate HMP Dovegate Natural Published 21 Jan 2016
Individual at Wayland HMP Wayland Natural Published 19 Jan 2016
Individual at Usk and Prescoed HMP Usk and Prescoed Natural Published 19 Jan 2016
Individual at Pentonville HMP Pentonville Self-inflicted Published 19 Jan 2016
Individual at Guys Marsh HMP Guys Marsh Natural Published 18 Jan 2016
Individual at Bristol HMP Bristol Self-inflicted Published 17 Jan 2016
Individual at Leeds HMP Leeds Self-inflicted Published 17 Jan 2016
Individual at Humber HMP Humber Natural Published 17 Jan 2016
Individual at Rye Hill HMP Rye Hill Natural Published 15 Jan 2016
Individual at Manchester HMP Manchester Self-inflicted Published 15 Jan 2016
Individual at Gartree HMP Gartree Natural Published 15 Jan 2016
Individual at Holloway HMP Holloway Self-inflicted Published 11 Jan 2016
Individual at Isle of Wight HMP Isle of Wight Natural Published 10 Jan 2016
Individual at Northumberland HMP Northumberland Self-inflicted Published 8 Jan 2016
Individual at Frankland HMP Frankland Natural Published 8 Jan 2016
Individual at Channings Wood HMP Channings Wood Self-inflicted Published 6 Jan 2016
Individual at Isle of Wight HMP Isle of Wight Natural Published 4 Jan 2016
Individual at Chelmsford HMP Chelmsford Self-inflicted Published 4 Jan 2016
Individual at Garth HMP Garth Natural Published 3 Jan 2016