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 Elmley HMP Elmley Self-inflicted Published 2 Dec 2014
Individual at Usk and Prescoed HMP Usk and Prescoed Natural Published 1 Dec 2014
Individual at Wayland HMP Wayland Self-inflicted Published 1 Dec 2014
Individual at Wymott HMP Wymott Natural Published 1 Dec 2014
Individual at Humber HMP Humber Self-inflicted Published 28 Nov 2014
Individual at Wymott HMP Wymott Natural Published 28 Nov 2014
Individual at Elmley HMP Elmley Self-inflicted Published 27 Nov 2014
Individual at Exeter HMP Exeter Natural Published 26 Nov 2014
Individual at Winchester HMP Winchester Natural Published 25 Nov 2014
Individual at Wandsworth HMP Wandsworth Natural Published 20 Nov 2014
Individual at Hewell HMP Hewell Natural Published 18 Nov 2014
Individual at Ranby HMP Ranby Natural Published 18 Nov 2014
Individual at Lewes HMP Lewes Natural Published 17 Nov 2014
Individual at Usk and Prescoed HMP Usk and Prescoed Natural Published 16 Nov 2014
Individual at Stafford HMP Stafford Natural Published 15 Nov 2014
Individual at Nottingham HMP Nottingham Self-inflicted Published 14 Nov 2014
Individual at Altcourse HMP Altcourse Homicide Published 14 Nov 2014
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 13 Nov 2014
Individual at Lewes HMP Lewes Natural Published 12 Nov 2014
Individual at Elmley HMP Elmley Self-inflicted Published 12 Nov 2014
Individual at Holme House HMP Holme House Self-inflicted Published 8 Nov 2014
Individual at Featherstone HMP Featherstone Self-inflicted Published 5 Nov 2014
Individual at Northumberland HMP Northumberland Natural Published 3 Nov 2014
Individual at Frankland HMP Frankland Natural Published 2 Nov 2014
Individual at Gartree HMP Gartree Natural Published 1 Nov 2014
Individual at Thameside HMP Thameside Natural Published 31 Oct 2014
Individual at Pentonville HMP Pentonville Other Published 31 Oct 2014
Individual at Portland HMP Portland Self-inflicted Published 24 Oct 2014
Individual at Peterborough HMP Peterborough Natural Published 23 Oct 2014
Individual at Birmingham HMP Birmingham Natural Published 22 Oct 2014
Individual at Long Lartin HMP Long Lartin Natural Published 20 Oct 2014
Individual at Rochester HMP Rochester Homicide Published 19 Oct 2014
Individual at Liverpool HMP Liverpool Natural Published 15 Oct 2014
Individual at Woodhill HMP Woodhill Self-inflicted Published 14 Oct 2014
Individual at Nottingham HMP Nottingham Natural Published 14 Oct 2014
Individual at Leyhill HMP Leyhill Natural Published 13 Oct 2014
Individual at Brixton HMP Brixton Self-inflicted Published 11 Oct 2014
Individual at Wandsworth HMP Wandsworth Natural Published 11 Oct 2014
Individual at Leyhill HMP Leyhill Natural Published 11 Oct 2014
Individual at Forest Bank HMP Forest Bank Natural Published 10 Oct 2014
Individual at Preston HMP Preston Natural Published 8 Oct 2014
Individual at Preston HMP Preston Self-inflicted Published 2 Oct 2014
Individual at Rochester HMP Rochester Natural Published 1 Oct 2014
Individual at Hull HMP Hull Natural Published 1 Oct 2014
Individual at Norwich HMP Norwich Natural Published 26 Sep 2014
Individual at Long Lartin HMP Long Lartin Self-inflicted Published 26 Sep 2014
Individual at Isle of Wight HMP Isle of Wight Natural Published 23 Sep 2014
Individual at Highpoint HMP Highpoint Self-inflicted Published 20 Sep 2014
Individual at Whatton HMP Whatton Natural Published 20 Sep 2014
Individual at Gartree HMP Gartree Natural Published 17 Sep 2014