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 Highpoint HMP Highpoint Natural Published 1 Jul 2014
Individual at Parc HMP Parc Natural Published 30 Jun 2014
Individual at Elmley HMP Elmley Natural Published 27 Jun 2014
Individual at Wymott HMP Wymott Natural Published 22 Jun 2014
Individual at Brixton HMP Brixton Natural Published 22 Jun 2014
Individual at Manchester HMP Manchester Natural Published 21 Jun 2014
Individual at Wakefield HMP Wakefield Natural Published 20 Jun 2014
Individual at Hewell HMP Hewell Self-inflicted Published 19 Jun 2014
Individual at Norwich HMP Norwich Natural Published 17 Jun 2014
Individual at Pentonville HMP Pentonville Natural Published 16 Jun 2014
Individual at Bedford HMP Bedford Self-inflicted Published 15 Jun 2014
Individual at Leeds HMP Leeds Natural Published 15 Jun 2014
Individual at Hewell HMP Hewell Natural Published 15 Jun 2014
Individual at Winchester HMP Winchester Self-inflicted Published 12 Jun 2014
Individual at Bullingdon HMP Bullingdon Self-inflicted Published 12 Jun 2014
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 12 Jun 2014
Individual at Glen Parva HMP Glen Parva Self-inflicted Published 11 Jun 2014
Individual at Norwich HMP Norwich Natural Published 9 Jun 2014
Individual at Moorland Closed HMP Moorland Closed Natural Published 7 Jun 2014
Individual at Eastwood Park HMP Eastwood Park Natural Published 6 Jun 2014
Individual at Whatton HMP Whatton Natural Published 6 Jun 2014
Individual at Styal HMP Styal Natural Published 5 Jun 2014
Individual at The Verne HMP The Verne Natural Published 4 Jun 2014
Individual at Wymott HMP Wymott Natural Published 31 May 2014
Individual at Ford HMP Ford Natural Published 29 May 2014
Individual at Parc HMP Parc Self-inflicted Published 28 May 2014
Individual at Elmley HMP Elmley Other Published 26 May 2014
Individual at Whitemoor HMP Whitemoor Natural Published 26 May 2014
Individual at Altcourse HMP Altcourse Natural Published 25 May 2014
Individual at Highpoint HMP Highpoint Self-inflicted Published 24 May 2014
Individual at Channings Wood HMP Channings Wood Natural Published 20 May 2014
Individual at Risley HMP Risley Self-inflicted Published 19 May 2014
Individual at Wandsworth HMP Wandsworth Natural Published 18 May 2014
Individual at Erlestoke HMP Erlestoke Other Published 18 May 2014
Individual at Wakefield HMP Wakefield Self-inflicted Published 17 May 2014
Individual at Doncaster HMP Doncaster Self-inflicted Published 17 May 2014
Individual at Moorland Closed HMP Moorland Closed Natural Published 16 May 2014
Individual at Peterborough HMP Peterborough Self-inflicted Published 16 May 2014
Individual at Isle of Wight HMP Isle of Wight Natural Published 14 May 2014
Individual at Ranby HMP Ranby Self-inflicted Published 13 May 2014
Individual at Leeds HMP Leeds Self-inflicted Published 12 May 2014
Individual at Preston HMP Preston Self-inflicted Published 11 May 2014
Individual at Holme House HMP Holme House Self-inflicted Published 11 May 2014
Individual at Haverigg HMP Haverigg Self-inflicted Published 9 May 2014
Individual at Hewell HMP Hewell Natural Published 6 May 2014
Individual at Stonnall Road Stonnall Road Natural Published 1 May 2014
Individual at Birmingham HMP Birmingham Natural Published 30 Apr 2014
Individual at Styal HMP Styal Natural Published 29 Apr 2014
Individual at Eastwood Park HMP Eastwood Park Natural Published 26 Apr 2014
Individual at Birmingham HMP Birmingham Natural Published 21 Apr 2014