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 Self-inflicted Published 3 Jan 2016
Individual at Peterborough HMP Peterborough Natural Published 2 Jan 2016
Individual at High Down HMP High Down Other Published 31 Dec 2015
Individual at Exeter HMP Exeter Self-inflicted Published 30 Dec 2015
Individual at Warren Hill HMP Warren Hill Natural Published 30 Dec 2015
Individual at Woodhill HMP Woodhill Self-inflicted Published 29 Dec 2015
Individual at Brinsford HMP Brinsford Self-inflicted Published 25 Dec 2015
Individual at Wormwood Scrubs HMP Wormwood Scrubs Natural Published 25 Dec 2015
Individual at Stocken HMP Stocken Natural Published 25 Dec 2015
Individual at Southview Southview Natural Published 21 Dec 2015
Individual at Channings Wood HMP Channings Wood Natural Published 19 Dec 2015
Individual at Grendon HMP Grendon Self-inflicted Published 18 Dec 2015
Individual at Isle of Wight HMP Isle of Wight Natural Published 16 Dec 2015
Individual at Low Newton HMP Low Newton Self-inflicted Published 16 Dec 2015
Individual at Wayland HMP Wayland Natural Published 13 Dec 2015
Individual at Humber HMP Humber Natural Published 12 Dec 2015
Individual at Altcourse HMP Altcourse Natural Published 12 Dec 2015
Individual at Bullingdon HMP Bullingdon Self-inflicted Published 11 Dec 2015
Individual at Peterborough HMP Peterborough Homicide Published 9 Dec 2015
Individual at Leyhill HMP Leyhill Natural Published 8 Dec 2015
Individual at Nottingham HMP Nottingham Homicide Published 3 Dec 2015
Individual at Staitheford House Staitheford House Other Published 3 Dec 2015
Individual at Lindholme HMP Lindholme Other Published 30 Nov 2015
Individual at Highpoint HMP Highpoint Self-inflicted Published 28 Nov 2015
Individual at Woodhill HMP Woodhill Self-inflicted Published 27 Nov 2015
Individual at Dartmoor HMP Dartmoor Homicide Published 26 Nov 2015
Individual at Stocken HMP Stocken Self-inflicted Published 25 Nov 2015
Individual at Wandsworth HMP Wandsworth Natural Published 20 Nov 2015
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 19 Nov 2015
Individual at Exeter HMP Exeter Self-inflicted Published 18 Nov 2015
Individual at Isle of Wight HMP Isle of Wight Natural Published 16 Nov 2015
Individual at Victoria House Victoria House Natural Published 15 Nov 2015
Individual at Leeds HMP Leeds Self-inflicted Published 13 Nov 2015
Individual at Glen Parva HMP Glen Parva Self-inflicted Published 12 Nov 2015
Individual at Full Sutton HMP Full Sutton Natural Published 12 Nov 2015
Individual at Humber HMP Humber Natural Published 11 Nov 2015
Individual at Dartmoor HMP Dartmoor Natural Published 10 Nov 2015
Individual at Swaleside HMP Swaleside Self-inflicted Published 9 Nov 2015
Individual at Pentonville HMP Pentonville Self-inflicted Published 9 Nov 2015
Individual at Bedford HMP Bedford Natural Published 7 Nov 2015
Individual at Moorland Closed HMP Moorland Closed Natural Published 6 Nov 2015
Individual at Grendon HMP Grendon Natural Published 3 Nov 2015
Individual at Highfield House Highfield House Self-inflicted Published 3 Nov 2015
Individual at Lowdham Grange HMP Lowdham Grange Other Published 31 Oct 2015
Individual at Bure HMP Bure Natural Published 31 Oct 2015
Individual at Full Sutton HMP Full Sutton Natural Published 29 Oct 2015
Individual at Isle of Wight HMP Isle of Wight Natural Published 29 Oct 2015
Individual at Swaleside HMP Swaleside Natural Published 28 Oct 2015
Individual at Cardiff HMP Cardiff Self-inflicted Published 27 Oct 2015
Individual at Durham HMP Durham Natural Published 21 Oct 2015