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 Low Newton HMP Low Newton Natural Published 20 Oct 2015
Individual at Lewes HMP Lewes Natural Published 19 Oct 2015
Individual at Preston HMP Preston Natural Published 14 Oct 2015
Individual at Altcourse HMP Altcourse Natural Published 13 Oct 2015
Individual at Winchester HMP Winchester Natural Published 12 Oct 2015
Individual at Wakefield HMP Wakefield Natural Published 12 Oct 2015
Individual at Coldingley HMP Coldingley Natural Published 6 Oct 2015
Individual at Isle of Wight HMP Isle of Wight Natural Published 6 Oct 2015
Individual at Exeter HMP Exeter Natural Published 5 Oct 2015
Individual at Chelmsford HMP Chelmsford Self-inflicted Published 4 Oct 2015
Individual at Stoke Heath HMP Stoke Heath Natural Published 4 Oct 2015
Individual at Frankland HMP Frankland Natural Published 2 Oct 2015
Individual at Bullingdon HMP Bullingdon Self-inflicted Published 1 Oct 2015
Individual at Exeter HMP Exeter Natural Published 30 Sep 2015
Individual at Bedford HMP Bedford Self-inflicted Published 30 Sep 2015
Individual at Foston Hall HMP Foston Hall Self-inflicted Published 29 Sep 2015
Individual at Forest Bank HMP Forest Bank Self-inflicted Published 28 Sep 2015
Individual at Maidstone HMP Maidstone Self-inflicted Published 28 Sep 2015
Individual at Bronzefield HMP Bronzefield Self-inflicted Published 27 Sep 2015
Individual at The Mount HMP The Mount Self-inflicted Published 25 Sep 2015
Individual at Littlehey HMP Littlehey Natural Published 25 Sep 2015
Individual at Lindholme HMP Lindholme Natural Published 24 Sep 2015
Individual at Forest Bank HMP Forest Bank Natural Published 23 Sep 2015
Individual at Cuthbert House Cuthbert House Other Published 20 Sep 2015
Individual at Northumberland HMP Northumberland Self-inflicted Published 18 Sep 2015
Individual at Highfield House Highfield House Natural Published 17 Sep 2015
Individual at Leicester HMP Leicester Self-inflicted Published 16 Sep 2015
Individual at Buckley Hall HMP Buckley Hall Natural Published 15 Sep 2015
Individual at Whatton HMP Whatton Natural Published 14 Sep 2015
Individual at Coldingley HMP Coldingley Natural Published 14 Sep 2015
Individual at Parc HMP Parc Natural Published 12 Sep 2015
Individual at St Josephs St Josephs Other Published 11 Sep 2015
Individual at Bullingdon HMP Bullingdon Natural Published 10 Sep 2015
Individual at Whatton HMP Whatton Natural Published 7 Sep 2015
Individual at Thameside HMP Thameside Self-inflicted Published 6 Sep 2015
Individual at Sudbury HMP Sudbury Other Published 4 Sep 2015
Individual at Lincoln HMP Lincoln Natural Published 4 Sep 2015
Individual at Chelmsford HMP Chelmsford Self-inflicted Published 4 Sep 2015
Individual at Ozanam House Ozanam House Self-inflicted Published 3 Sep 2015
Individual at Swinfen Hall HMP Swinfen Hall Self-inflicted Published 3 Sep 2015
Individual at Norwich HMP Norwich Natural Published 2 Sep 2015
Individual at Winchester HMP Winchester Self-inflicted Published 2 Sep 2015
Individual at Exeter HMP Exeter Natural Published 1 Sep 2015
Individual at Holme House HMP Holme House Natural Published 1 Sep 2015
Individual at Doncaster HMP Doncaster Natural Published 31 Aug 2015
Individual at Littlehey HMP Littlehey Natural Published 30 Aug 2015
Individual at North Sea Camp HMP North Sea Camp Natural Published 30 Aug 2015
Individual at Wakefield HMP Wakefield Natural Published 28 Aug 2015
Individual at Wormwood Scrubs HMP Wormwood Scrubs Natural Published 27 Aug 2015
Individual at Risley HMP Risley Natural Published 27 Aug 2015