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 Hull HMP Hull Self-inflicted Published 6 Feb 2015
Individual at Winchester HMP Winchester Natural Published 5 Feb 2015
Individual at Peterborough HMP Peterborough Self-inflicted Published 2 Feb 2015
Individual at High Down HMP High Down Natural Published 2 Feb 2015
Individual at Exeter HMP Exeter Natural Published 1 Feb 2015
Individual at Bristol HMP Bristol Natural Published 28 Jan 2015
Individual at Liverpool HMP Liverpool Self-inflicted Published 28 Jan 2015
Individual at Hewell HMP Hewell Self-inflicted Published 25 Jan 2015
Individual at Hull HMP Hull Self-inflicted Published 25 Jan 2015
Individual at Whatton HMP Whatton Natural Published 24 Jan 2015
Individual at Bristol HMP Bristol Self-inflicted Published 22 Jan 2015
Individual at Forest Bank HMP Forest Bank Natural Published 22 Jan 2015
Individual at High Down HMP High Down Natural Published 21 Jan 2015
Individual at Manchester HMP Manchester Natural Published 20 Jan 2015
Individual at Altcourse HMP Altcourse Natural Published 18 Jan 2015
Individual at Long Lartin HMP Long Lartin Self-inflicted Published 18 Jan 2015
Individual at Parc HMP Parc Natural Published 14 Jan 2015
Individual at Channings Wood HMP Channings Wood Natural Published 13 Jan 2015
Individual at Full Sutton HMP Full Sutton Natural Published 12 Jan 2015
Individual at Bristol HMP Bristol Self-inflicted Published 10 Jan 2015
Individual at Foston Hall HMP Foston Hall Other Published 10 Jan 2015
Individual at Peterborough HMP Peterborough Natural Published 7 Jan 2015
Individual at Holme House HMP Holme House Natural Published 5 Jan 2015
Individual at Northumberland HMP Northumberland Natural Published 4 Jan 2015
Individual at Wymott HMP Wymott Natural Published 4 Jan 2015
Individual at Wymott HMP Wymott Natural Published 31 Dec 2014
Individual at Swaleside HMP Swaleside Natural Published 29 Dec 2014
Individual at Peterborough HMP Peterborough Natural Published 28 Dec 2014
Individual at Long Lartin HMP Long Lartin Self-inflicted Published 28 Dec 2014
Individual at Doncaster HMP Doncaster Natural Published 25 Dec 2014
Individual at Liverpool HMP Liverpool Other Published 23 Dec 2014
Individual at Peterborough HMP Peterborough Natural Published 23 Dec 2014
Individual at The Mount HMP The Mount Self-inflicted Published 22 Dec 2014
Individual at Isle of Wight HMP Isle of Wight Natural Published 21 Dec 2014
Individual at Exeter HMP Exeter Self-inflicted Published 20 Dec 2014
Individual at Bowling Green Bowling Green Natural Published 19 Dec 2014
Individual at Tulse Hill Tulse Hill Natural Published 18 Dec 2014
Individual at Liverpool HMP Liverpool Self-inflicted Published 16 Dec 2014
Individual at Pentonville HMP Pentonville Self-inflicted Published 9 Dec 2014
Individual at Frankland HMP Frankland Self-inflicted Published 7 Dec 2014
Individual at Doncaster HMP Doncaster Self-inflicted Published 5 Dec 2014
Individual at Dartmoor HMP Dartmoor Natural Published 4 Dec 2014
Individual at Parc HMP Parc Natural Published 4 Dec 2014
Individual at Thameside HMP Thameside Other Published 4 Dec 2014
Individual at Preston HMP Preston Self-inflicted Published 4 Dec 2014
Individual at Wandsworth HMP Wandsworth Natural Published 3 Dec 2014
Individual at Swaleside HMP Swaleside Natural Published 3 Dec 2014
Individual at Northumberland HMP Northumberland Natural Published 3 Dec 2014
Individual at Bristol HMP Bristol Natural Published 3 Dec 2014
Individual at Risley HMP Risley Self-inflicted Published 3 Dec 2014