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 Thameside HMP Thameside Natural Published 13 Jan 2013
Individual at Elmley HMP Elmley Self-inflicted Published 10 Jan 2013
Individual at Whatton HMP Whatton Natural Published 8 Jan 2013
Individual at Full Sutton HMP Full Sutton Natural Published 8 Jan 2013
Individual at Altcourse HMP Altcourse Self-inflicted Published 2 Jan 2013
Individual at Long Lartin HMP Long Lartin Other Published 2 Jan 2013
Individual at Altcourse HMP Altcourse Self-inflicted Published 31 Dec 2012
Individual at Bedford HMP Bedford Natural Published 30 Dec 2012
Individual at Northallerton HMP Northallerton Self-inflicted Published 28 Dec 2012
Individual at Norwich HMP Norwich Self-inflicted Published 28 Dec 2012
Individual at Lewes HMP Lewes Natural Published 25 Dec 2012
Individual at Risley HMP Risley Natural Published 23 Dec 2012
Individual at Cardiff HMP Cardiff Self-inflicted Published 18 Dec 2012
Individual at Littlehey HMP Littlehey Natural Published 17 Dec 2012
Individual at Isle of Wight HMP Isle of Wight Self-inflicted Published 16 Dec 2012
Individual at Risley HMP Risley Self-inflicted Published 15 Dec 2012
Individual at Manchester HMP Manchester Self-inflicted Published 13 Dec 2012
Individual at Foston Hall HMP Foston Hall Self-inflicted Published 10 Dec 2012
Individual at Parc HMP Parc Natural Published 7 Dec 2012
Individual at Acklington HMP Acklington Natural Published 6 Dec 2012
Individual at Elmley HMP Elmley Self-inflicted Published 28 Nov 2012
Individual at Ozanam House Ozanam House Natural Published 22 Nov 2012
Individual at Exeter HMP Exeter Other Published 22 Nov 2012
Individual at The Mount HMP The Mount Natural Published 21 Nov 2012
Individual at Whatton HMP Whatton Natural Published 20 Nov 2012
Individual at Parc HMP Parc Natural Published 19 Nov 2012
Individual at Cardiff HMP Cardiff Self-inflicted Published 17 Nov 2012
Individual at Cardiff HMP Cardiff Natural Published 17 Nov 2012
Individual at Belmarsh HMP Belmarsh Other Published 15 Nov 2012
Individual at Hewell HMP Hewell Self-inflicted Published 13 Nov 2012
Individual at Full Sutton HMP Full Sutton Natural Published 13 Nov 2012
Individual at Mandeville House Mandeville House Self-inflicted Published 13 Nov 2012
Individual at Shrewsbury HMP Shrewsbury Natural Published 8 Nov 2012
Individual at Parc HMP Parc Other Published 6 Nov 2012
Individual at Frankland HMP Frankland Natural Published 6 Nov 2012
Individual at Trent House Trent House Natural Published 2 Nov 2012
Individual at Burdett Lodge Burdett Lodge Other Published 1 Nov 2012
Individual at Isle of Wight HMP Isle of Wight Natural Published 1 Nov 2012
Individual at Norwich HMP Norwich Natural Published 30 Oct 2012
Individual at Harmondsworth IRC Harmondsworth Natural Published 30 Oct 2012
Individual at Elmley HMP Elmley Self-inflicted Published 28 Oct 2012
Individual at Wayland HMP Wayland Natural Published 28 Oct 2012
Individual at Isle of Wight HMP Isle of Wight Natural Published 22 Oct 2012
Individual at Isle of Wight HMP Isle of Wight Natural Published 20 Oct 2012
Individual at Wormwood Scrubs HMP Wormwood Scrubs Other Published 17 Oct 2012
Individual at Gloucester HMP Gloucester Self-inflicted Published 14 Oct 2012
Individual at Isle of Wight HMP Isle of Wight Natural Published 12 Oct 2012
Individual at Chelmsford HMP Chelmsford Natural Published 11 Oct 2012
Individual at Parc HMP Parc Natural Published 8 Oct 2012
Individual at Peterborough HMP Peterborough Natural Published 7 Oct 2012