Source · Deaths in custody

PPO Fatal Incident Reports

6,395 incidents 5,660 published 1,165 recommendations 1,632 self-inflicted 3,362 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 21: Segregation Learning Lessons Bulletin Mar 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 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 2023-24 Annual report Jul 2024 PDF
Annual report 2022-23 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

6,395 records
Name Establishment Cause Status Date of death Recs
Anthony Wray HMP Swansea In progress
Siobhan Cox Hestia Highbury In progress
Jamie Musgrave HMP Peterborough In progress
Darren Russell HMP Holme House In progress
Anthony Bugingo HMP Thameside In progress
John Boswell HMP Five Wells In progress
Mohammad Khaliq HMP Hull In progress
Anthony Strand HMP Risley In progress
William Reynolds HMP Leyhill Natural Published
Akiel Flemming HMP Wakefield In progress
Carl Mason HMP Liverpool Pending inquest
John Rytting HMP Hull In progress
Kevin Nolan HMP Coldingley Pending inquest
Stephen Dixon-Waterworth HMP Wealstun In progress
Robert Butler HMP Fosse Way In progress
Shehroz Iqbal Joyce Meggie House Approved Premises In progress
Adam Diesa-Green HMP Lowdham Grange Other Published
Gavin Sever HMP Liverpool In progress
Kelly Day HMP Bronzefield In progress
Peter Smith HMP Wayland Pending inquest
Juan Garcia Hernandez HMP Garth In progress
Martin Ryan HMP Cookham Wood In progress
Gary Taylor HMP Littlehey Natural Published
Craig Gordon HMP Wandsworth Pending inquest
Lee Gowton HMP Bristol Pending inquest
Jacob Bean HMP Rochester Pending inquest
Matthew Pickles HMP/YOI High Down In progress
Alfred Davies HMP Usk In progress
Robert Harvey HMP Durham In progress
Robert Wiseman Lightfoot House Approved Premises In progress
James Nanson HMP Northumberland In progress
Andrew Martin HMP Elmley In progress
Scott Sansome HMP Cardiff Pending inquest
James Goulding HMP Featherstone Pending inquest
Dean Clementson HMP Forest Bank Pending inquest
Grenville Blower HMP Littlehey In progress
Wayne Hay HMP/YOI Parc Pending inquest
Ivor Manton HMP Chelmsford In progress
David Stingemore HMP Isle of Wight In progress
Raymond Billam HMP/YOI Moorland In progress
Lee Sentance HMP Lincoln Pending inquest
James Smyth HMP Gartree Pending inquest
Alan Priestley HMP Oakwood In progress
Mark Wright HMP Wealstun In progress
David Wright HMP Fosse Way In progress
Christopher Anderson HMP Dovegate Pending inquest
Michael Fabian HMP Winchester Natural Published
Ian Huntley HMP Frankland In progress
Jamie Evans HMP Kirkham In progress
Peter Campbell HMP Pentonville Pending inquest