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 Ranby HMP Ranby Self-inflicted Published 17 Apr 2014
Individual at Liverpool HMP Liverpool Self-inflicted Published 14 Apr 2014
Individual at Howard House Howard House Natural Published 10 Apr 2014
Individual at Winchester HMP Winchester Natural Published 8 Apr 2014
Individual at Whatton HMP Whatton Natural Published 6 Apr 2014
Individual at Doncaster HMP Doncaster Natural Published 5 Apr 2014
Individual at Featherstone HMP Featherstone Self-inflicted Published 4 Apr 2014
Individual at Woodhill HMP Woodhill Self-inflicted Published 4 Apr 2014
Individual at The Mount HMP The Mount Natural Published 3 Apr 2014
Individual at Parc HMP Parc Self-inflicted Published 3 Apr 2014
Individual at Birmingham HMP Birmingham Self-inflicted Published 2 Apr 2014
Individual at Full Sutton HMP Full Sutton Natural Published 31 Mar 2014
Individual at Bure HMP Bure Natural Published 31 Mar 2014
Individual at Yarls Wood IRC Yarls Wood Natural Published 30 Mar 2014
Individual at Stafford House Stafford House Other Published 27 Mar 2014
Individual at Swinfen Hall HMP Swinfen Hall Self-inflicted Published 26 Mar 2014
Individual at Hewell HMP Hewell Self-inflicted Published 25 Mar 2014
Individual at Cardiff HMP Cardiff Self-inflicted Published 24 Mar 2014
Individual at Elmley HMP Elmley Natural Published 24 Mar 2014
Individual at Chelmsford HMP Chelmsford Self-inflicted Published 23 Mar 2014
Individual at Elmley HMP Elmley Self-inflicted Published 22 Mar 2014
Individual at Liverpool HMP Liverpool Self-inflicted Published 21 Mar 2014
Individual at Wymott HMP Wymott Self-inflicted Published 21 Mar 2014
Individual at Leyhill HMP Leyhill Natural Published 19 Mar 2014
Individual at Channings Wood HMP Channings Wood Natural Published 13 Mar 2014
Individual at Altcourse HMP Altcourse Self-inflicted Published 13 Mar 2014
Individual at Whitemoor HMP Whitemoor Natural Published 13 Mar 2014
Individual at Holme House HMP Holme House Natural Published 13 Mar 2014
Individual at Swansea HMP Swansea Self-inflicted Published 11 Mar 2014
Individual at Preston HMP Preston Natural Published 11 Mar 2014
Individual at Styal HMP Styal Natural Published 8 Mar 2014
Individual at Cardiff HMP Cardiff Homicide Published 6 Mar 2014
Individual at Forest Bank HMP Forest Bank Self-inflicted Published 4 Mar 2014
Individual at Wandsworth HMP Wandsworth Self-inflicted Published 3 Mar 2014
Individual at Ranby HMP Ranby Natural Published 1 Mar 2014
Individual at Leeds HMP Leeds Natural Published 26 Feb 2014
Individual at Wayland HMP Wayland Self-inflicted Published 23 Feb 2014
Individual at Exeter HMP Exeter Self-inflicted Published 22 Feb 2014
Individual at Wealstun HMP Wealstun Natural Published 22 Feb 2014
Individual at Stafford HMP Stafford Natural Published 19 Feb 2014
Individual at Isle of Wight HMP Isle of Wight Natural Published 19 Feb 2014
Individual at Hewell HMP Hewell Other Published 14 Feb 2014
Individual at Nottingham HMP Nottingham Natural Published 14 Feb 2014
Individual at Isle of Wight HMP Isle of Wight Natural Published 13 Feb 2014
Individual at Exeter HMP Exeter Natural Published 13 Feb 2014
Individual at Wandsworth HMP Wandsworth Natural Published 12 Feb 2014
Individual at New Hall HMP New Hall Self-inflicted Published 12 Feb 2014
Individual at Brixton HMP Brixton Self-inflicted Published 11 Feb 2014
Individual at Moorland Closed HMP Moorland Closed Self-inflicted Published 10 Feb 2014
Individual at Elmley HMP Elmley Natural Published 7 Feb 2014