Source · Deaths in custody

PPO Fatal Incident Reports

6,395 incidents 5,660 published 1,165 recommendations 1,632 self-inflicted 3,362 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 21: Segregation Learning Lessons Bulletin Mar 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 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 2023-24 Annual report Jul 2024 PDF
Annual report 2022-23 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

6,395 records
Name Establishment Cause Status Date of death Recs
Kyle Watts Deer Park Approved Premises In progress
David Hancock HMP Nottingham Pending inquest
Kate Allen HMP/YOI Low Newton In progress
Charles Pratt HMP Leeds Pending inquest
Jeffrey Long HMP/YOI Moorland In progress
Lee Clay HMP Nottingham In progress
John Phillips HMP Isle of Wight Pending inquest
Jason Simmons HMP Exeter Pending inquest
Harry Edwards HMP Ranby Pending inquest
Arthur Warwick HMP Frankland In progress
Peter Dodd HMP North Sea Camp Pending inquest
Glenn Brown Holbeck House Approved Premises Pending inquest
Darren Thomas HMP/YOI Parc In progress
Stephen Dixon-Waterworth HMP Wealstun In progress
Martin Ryan HMP Cookham Wood In progress
Robert Wiseman Lightfoot House Approved Premises In progress
Gerald Martin HMP Wymott In progress
Daniel Alexander HMP Long Lartin Pending inquest
Lucal Brady HMP Isle of Wight Natural Published
Connor Bresland HMP Exeter In progress
James Goulding HMP Featherstone Pending inquest
Ifor Whittaker HMP Littlehey Pending inquest
Ben Merritt In progress
David McVicker HMP Channings Wood Pending inquest
Jason Hayward HMP Birmingham In progress
Kian Parmee HMP Swansea Pending inquest
Thomas McMurray HMP Brixton Pending inquest
John Sadler HMP Liverpool Pending inquest
Warren Manners HMP/YOI Parc Pending inquest
Richard Scaife HMP Isle of Wight In progress
Quang Nguyen HMP Thameside Pending inquest
Jordan Harvey HMP Humber Pending inquest
Michael Pigott HMP Birmingham In progress
Colin McSweeny HMP Gartree Pending inquest
John Cox HMP Bristol Pending inquest
Dean Boness In progress
Phillip Lawson HMP Wealstun In progress
Daniel Childs HMP Bristol Pending inquest
Radoslaw Czubinski HMP Hull Pending inquest
Mark Collins HMP Berwyn Pending inquest
Emma Borowy HMP/YOI New Hall Pending inquest
Leslie Fry HMP Hewell In progress
Norman Hitchings HMP Lowdham Grange In progress
Robert Butler HMP Fosse Way In progress
Lee Wilson HMP Leeds In progress
Edwin Withers HMP Holme House Pending inquest
Thomas Brain HMP Winchester In progress
Moses Hailemichel HMP Pentonville Pending inquest
Rebecca McBrien HMP/YOI New Hall Pending inquest
Douglas Slade HMP Isle of Wight Natural Published