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 Frankland HMP Frankland Natural Published 7 Feb 2014
Individual at Cardiff HMP Cardiff Natural Published 5 Feb 2014
Individual at Isle of Wight HMP Isle of Wight Natural Published 3 Feb 2014
Individual at Whatton HMP Whatton Natural Published 2 Feb 2014
Individual at Parc HMP Parc Natural Published 1 Feb 2014
Individual at Maidstone HMP Maidstone Other Published 29 Jan 2014
Individual at Kirkham HMP Kirkham Natural Published 27 Jan 2014
Individual at Isle of Wight HMP Isle of Wight Natural Published 26 Jan 2014
Individual at Leeds HMP Leeds Self-inflicted Published 25 Jan 2014
Individual at Lancaster Farms HMP Lancaster Farms Self-inflicted Published 24 Jan 2014
Individual at Ford HMP Ford Natural Published 24 Jan 2014
Individual at Manchester HMP Manchester Self-inflicted Published 22 Jan 2014
Individual at High Down HMP High Down Natural Published 21 Jan 2014
Individual at High Down HMP High Down Natural Published 20 Jan 2014
Individual at Belmarsh HMP Belmarsh Self-inflicted Published 20 Jan 2014
Individual at Northumberland HMP Northumberland Natural Published 16 Jan 2014
Individual at Ozanam House Ozanam House Other Published 13 Jan 2014
Individual at Bullingdon HMP Bullingdon Self-inflicted Published 13 Jan 2014
Individual at Littlehey HMP Littlehey Natural Published 12 Jan 2014
Individual at Everthorpe HMP Everthorpe Self-inflicted Published 10 Jan 2014
Individual at Highpoint HMP Highpoint Self-inflicted Published 9 Jan 2014
Individual at Liverpool HMP Liverpool Natural Published 7 Jan 2014
Individual at Dartmoor HMP Dartmoor Natural Published 6 Jan 2014
Individual at Low Newton HMP Low Newton Natural Published 4 Jan 2014
Individual at Winchester HMP Winchester Self-inflicted Published 3 Jan 2014
Individual at Full Sutton HMP Full Sutton Self-inflicted Published 3 Jan 2014
Individual at Exeter HMP Exeter Self-inflicted Published 1 Jan 2014
Individual at Hewell HMP Hewell Self-inflicted Published 31 Dec 2013
Individual at Leeds HMP Leeds Self-inflicted Published 30 Dec 2013
Individual at Holme House HMP Holme House Natural Published 29 Dec 2013
Individual at Spring Hill HMP Spring Hill Self-inflicted Published 28 Dec 2013
Individual at Durham HMP Durham Self-inflicted Published 28 Dec 2013
Individual at Preston HMP Preston Natural Published 27 Dec 2013
Individual at Dovegate HMP Dovegate Self-inflicted Published 27 Dec 2013
Individual at Maidstone HMP Maidstone Natural Published 26 Dec 2013
Individual at Parc HMP Parc Natural Published 25 Dec 2013
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 23 Dec 2013
Individual at Lindholme HMP Lindholme Homicide Published 21 Dec 2013
Individual at Ford HMP Ford Self-inflicted Published 21 Dec 2013
Individual at Doncaster HMP Doncaster Natural Published 20 Dec 2013
Individual at Elmley HMP Elmley Self-inflicted Published 20 Dec 2013
Individual at Birmingham HMP Birmingham Self-inflicted Published 19 Dec 2013
Individual at Swaleside HMP Swaleside Natural Published 19 Dec 2013
Individual at Albion Street Albion Street Homicide Published 16 Dec 2013
Individual at Nottingham HMP Nottingham Natural Published 16 Dec 2013
Individual at Norwich HMP Norwich Self-inflicted Published 15 Dec 2013
Individual at Woodhill HMP Woodhill Self-inflicted Published 12 Dec 2013
Individual at Thameside HMP Thameside Self-inflicted Published 11 Dec 2013
Individual at Isle of Wight HMP Isle of Wight Natural Published 11 Dec 2013
Individual at Moorland Closed HMP Moorland Closed Natural Published 10 Dec 2013