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 Yarls Wood IRC Yarls Wood Natural Published 20 Apr 2015
Individual at Birmingham HMP Birmingham Other Published 17 Apr 2015
Individual at Frankland HMP Frankland Natural Published 17 Apr 2015
Individual at Exeter HMP Exeter Self-inflicted Published 15 Apr 2015
Individual at Wakefield HMP Wakefield Natural Published 12 Apr 2015
Individual at Preston HMP Preston Natural Published 9 Apr 2015
Individual at Lowdham Grange HMP Lowdham Grange Natural Published 8 Apr 2015
Individual at Whitemoor HMP Whitemoor Natural Published 8 Apr 2015
Individual at Ranby HMP Ranby Self-inflicted Published 7 Apr 2015
Individual at High Down HMP High Down Self-inflicted Published 6 Apr 2015
Individual at Norwich HMP Norwich Natural Published 3 Apr 2015
Individual at Lindholme HMP Lindholme Natural Published 1 Apr 2015
Individual at Swaleside HMP Swaleside Homicide Published 25 Mar 2015
Individual at Ellison House Ellison House Natural Published 25 Mar 2015
Individual at Glen Parva HMP Glen Parva Self-inflicted Published 24 Mar 2015
Individual at Isle of Wight HMP Isle of Wight Natural Published 22 Mar 2015
Individual at Full Sutton HMP Full Sutton Self-inflicted Published 17 Mar 2015
Individual at Norwich HMP Norwich Self-inflicted Published 14 Mar 2015
Individual at Preston HMP Preston Natural Published 13 Mar 2015
Individual at Winchester HMP Winchester Self-inflicted Published 12 Mar 2015
Individual at Holloway HMP Holloway Natural Published 10 Mar 2015
Individual at Haverigg HMP Haverigg Natural Published 10 Mar 2015
Individual at Risley HMP Risley Natural Published 8 Mar 2015
Individual at Dartmoor HMP Dartmoor Self-inflicted Published 8 Mar 2015
Individual at Dovegate HMP Dovegate Natural Published 6 Mar 2015
Individual at Leicester HMP Leicester Natural Published 6 Mar 2015
Individual at Manchester HMP Manchester Natural Published 5 Mar 2015
Individual at Chelmsford HMP Chelmsford Self-inflicted Published 3 Mar 2015
Individual at Leyhill HMP Leyhill Natural Published 2 Mar 2015
Individual at Dartmoor HMP Dartmoor Natural Published 1 Mar 2015
Individual at Bure HMP Bure Natural Published 1 Mar 2015
Individual at Woodhill HMP Woodhill Self-inflicted Published 27 Feb 2015
Individual at Doncaster HMP Doncaster Homicide Published 27 Feb 2015
Individual at Liverpool HMP Liverpool Other Published 26 Feb 2015
Individual at Moorland Open HMP Moorland Open Self-inflicted Published 25 Feb 2015
Individual at Altcourse HMP Altcourse Natural Published 25 Feb 2015
Individual at Belmarsh HMP Belmarsh Natural Published 24 Feb 2015
Individual at Channings Wood HMP Channings Wood Natural Published 24 Feb 2015
Individual at Usk and Prescoed HMP Usk and Prescoed Natural Published 23 Feb 2015
Individual at Northumberland HMP Northumberland Natural Published 23 Feb 2015
Individual at Norwich HMP Norwich Natural Published 23 Feb 2015
Individual at Elmley HMP Elmley Natural Published 22 Feb 2015
Individual at Lincoln HMP Lincoln Self-inflicted Published 22 Feb 2015
Individual at Rye Hill HMP Rye Hill Natural Published 15 Feb 2015
Individual at McIntyre House McIntyre House Other Published 14 Feb 2015
Individual at Northumberland HMP Northumberland Natural Published 14 Feb 2015
Individual at Great Holm Great Holm Other Published 13 Feb 2015
Individual at Stafford HMP Stafford Natural Published 11 Feb 2015
Individual at Whatton HMP Whatton Natural Published 7 Feb 2015
Individual at Bowling Green Bowling Green Self-inflicted Published 7 Feb 2015