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 Hatfield HMP Hatfield Natural Published 24 Aug 2015
Individual at Ashfield HMP Ashfield Natural Published 23 Aug 2015
Individual at Norwich HMP Norwich Natural Published 20 Aug 2015
Individual at The Mount HMP The Mount Self-inflicted Published 17 Aug 2015
Individual at Winchester HMP Winchester Other Published 17 Aug 2015
Individual at Buckley Hall HMP Buckley Hall Natural Published 17 Aug 2015
Individual at Littlehey HMP Littlehey Natural Published 15 Aug 2015
Individual at Guys Marsh HMP Guys Marsh Self-inflicted Published 15 Aug 2015
Individual at Foston Hall HMP Foston Hall Self-inflicted Published 9 Aug 2015
Individual at Hull HMP Hull Self-inflicted Published 8 Aug 2015
Individual at Garth HMP Garth Self-inflicted Published 8 Aug 2015
Individual at Guys Marsh HMP Guys Marsh Natural Published 8 Aug 2015
Individual at The Verne IRC IRC The Verne IRC Self-inflicted Published 6 Aug 2015
Individual at Elmley HMP Elmley Natural Published 6 Aug 2015
Individual at Leeds HMP Leeds Natural Published 6 Aug 2015
Individual at Nottingham HMP Nottingham Natural Published 5 Aug 2015
Individual at Pentonville HMP Pentonville Self-inflicted Published 2 Aug 2015
Individual at Ranby HMP Ranby Self-inflicted Published 1 Aug 2015
Individual at Staitheford House Staitheford House Other Published 31 Jul 2015
Individual at Full Sutton HMP Full Sutton Natural Published 29 Jul 2015
Individual at Whatton HMP Whatton Natural Published 29 Jul 2015
Individual at Manchester HMP Manchester Other Published 29 Jul 2015
Individual at Bullingdon HMP Bullingdon Natural Published 27 Jul 2015
Individual at Whatton HMP Whatton Natural Published 27 Jul 2015
Individual at Whatton HMP Whatton Natural Published 23 Jul 2015
Individual at Isle of Wight HMP Isle of Wight Natural Published 21 Jul 2015
Individual at Exeter HMP Exeter Natural Published 20 Jul 2015
Individual at Onley HMP Onley Natural Published 20 Jul 2015
Individual at Swansea HMP Swansea Self-inflicted Published 20 Jul 2015
Individual at Belmarsh HMP Belmarsh Self-inflicted Published 19 Jul 2015
Individual at Woodhill HMP Woodhill Self-inflicted Published 19 Jul 2015
Individual at Winchester HMP Winchester Self-inflicted Published 19 Jul 2015
Individual at Winchester HMP Winchester Self-inflicted Published 18 Jul 2015
Individual at Littlehey HMP Littlehey Natural Published 16 Jul 2015
Individual at Foston Hall HMP Foston Hall Self-inflicted Published 14 Jul 2015
Individual at Dartmoor HMP Dartmoor Other Published 14 Jul 2015
Individual at Lancaster Farms HMP Lancaster Farms Other Published 12 Jul 2015
Individual at Wealstun HMP Wealstun Self-inflicted Published 8 Jul 2015
Individual at Birmingham HMP Birmingham Natural Published 8 Jul 2015
Individual at Doncaster HMP Doncaster Natural Published 7 Jul 2015
Individual at Preston HMP Preston Natural Published 7 Jul 2015
Individual at Holme House HMP Holme House Self-inflicted Published 4 Jul 2015
Individual at Durham HMP Durham Self-inflicted Published 4 Jul 2015
Individual at Cookham Wood HMP Cookham Wood Natural Published 4 Jul 2015
Individual at Isle of Wight HMP Isle of Wight Natural Published 2 Jul 2015
Individual at Doncaster HMP Doncaster Natural Published 30 Jun 2015
Individual at Ranby HMP Ranby Self-inflicted Published 29 Jun 2015
Individual at Ranby HMP Ranby Other Published 25 Jun 2015
Individual at Norwich HMP Norwich Natural Published 24 Jun 2015
Individual at Holme House HMP Holme House Natural Published 21 Jun 2015