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 Gartree HMP Gartree Natural Published 17 Sep 2014
Individual at Leeds HMP Leeds Self-inflicted Published 16 Sep 2014
Individual at Manchester HMP Manchester Natural Published 16 Sep 2014
Individual at Durham HMP Durham Other Published 14 Sep 2014
Individual at Drake Hall HMP Drake Hall Natural Published 10 Sep 2014
Individual at Morton Hall IRC IRC Morton Hall IRC Self-inflicted Published 6 Sep 2014
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 6 Sep 2014
Individual at Wakefield HMP Wakefield Natural Published 4 Sep 2014
Individual at Altcourse HMP Altcourse Self-inflicted Published 4 Sep 2014
Individual at Northumberland HMP Northumberland Self-inflicted Published 1 Sep 2014
Individual at Leicester HMP Leicester Self-inflicted Published 1 Sep 2014
Individual at Whitemoor HMP Whitemoor Self-inflicted Published 1 Sep 2014
Individual at Bedford HMP Bedford Natural Published 31 Aug 2014
Individual at Usk and Prescoed HMP Usk and Prescoed Natural Published 30 Aug 2014
Individual at Peterborough HMP Peterborough Self-inflicted Published 28 Aug 2014
Individual at Durham HMP Durham Self-inflicted Published 28 Aug 2014
Individual at Woodhill HMP Woodhill Natural Published 25 Aug 2014
Individual at Frankland HMP Frankland Natural Published 25 Aug 2014
Individual at Elmley HMP Elmley Natural Published 22 Aug 2014
Individual at Hewell HMP Hewell Other Published 17 Aug 2014
Individual at Leeds HMP Leeds Natural Published 14 Aug 2014
Individual at Exeter HMP Exeter Natural Published 12 Aug 2014
Individual at High Down HMP High Down Natural Published 12 Aug 2014
Individual at Humber HMP Humber Self-inflicted Published 8 Aug 2014
Individual at Norwich HMP Norwich Natural Published 5 Aug 2014
Individual at Whatton HMP Whatton Natural Published 4 Aug 2014
Individual at Northumberland HMP Northumberland Natural Published 3 Aug 2014
Individual at Altcourse HMP Altcourse Other Published 2 Aug 2014
Individual at Littlehey HMP Littlehey Natural Published 2 Aug 2014
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 29 Jul 2014
Individual at Holme House HMP Holme House Natural Published 29 Jul 2014
Individual at Exeter HMP Exeter Natural Published 29 Jul 2014
Individual at Wandsworth HMP Wandsworth Other Published 28 Jul 2014
Individual at Leeds HMP Leeds Natural Published 26 Jul 2014
Individual at Holloway HMP Holloway Self-inflicted Published 22 Jul 2014
Individual at Hull HMP Hull Natural Published 21 Jul 2014
Individual at Hull HMP Hull Natural Published 21 Jul 2014
Individual at Manchester HMP Manchester Natural Published 20 Jul 2014
Individual at Hewell HMP Hewell Natural Published 19 Jul 2014
Individual at Wakefield HMP Wakefield Natural Published 16 Jul 2014
Individual at Belmarsh HMP Belmarsh Natural Published 14 Jul 2014
Individual at Whatton HMP Whatton Natural Published 13 Jul 2014
Individual at Bronzefield HMP Bronzefield Natural Published 12 Jul 2014
Individual at Risley HMP Risley Natural Published 11 Jul 2014
Individual at Gartree HMP Gartree Natural Published 10 Jul 2014
Individual at Whitemoor HMP Whitemoor Natural Published 8 Jul 2014
Individual at Preston HMP Preston Natural Published 8 Jul 2014
Individual at Wymott HMP Wymott Natural Published 4 Jul 2014
Individual at North Sea Camp HMP North Sea Camp Natural Published 2 Jul 2014
Individual at Whatton HMP Whatton Natural Published 2 Jul 2014