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 Pentonville HMP Pentonville Natural Published 3 Oct 2012
Individual at Pentonville HMP Pentonville Self-inflicted Published 2 Oct 2012
Individual at Forest Bank HMP Forest Bank Natural Published 28 Sep 2012
Individual at Hull HMP Hull Natural Published 25 Sep 2012
Individual at Wakefield HMP Wakefield Natural Published 25 Sep 2012
Individual at Full Sutton HMP Full Sutton Natural Published 17 Sep 2012
Individual at Chelmsford HMP Chelmsford Self-inflicted Published 15 Sep 2012
Individual at Whitemoor HMP Whitemoor Self-inflicted Published 13 Sep 2012
Individual at Isle of Wight HMP Isle of Wight Natural Published 12 Sep 2012
Individual at Woodhill HMP Woodhill Natural Published 3 Sep 2012
Individual at Gartree HMP Gartree Self-inflicted Published 3 Sep 2012
Individual at Liverpool HMP Liverpool Natural Published 30 Aug 2012
Individual at Channings Wood HMP Channings Wood Natural Published 27 Aug 2012
Individual at Altcourse HMP Altcourse Natural Published 25 Aug 2012
Individual at Isle of Wight HMP Isle of Wight Natural Published 24 Aug 2012
Individual at Bullingdon HMP Bullingdon Other Published 21 Aug 2012
Individual at Standford Hill HMP Standford Hill Natural Published 20 Aug 2012
Individual at Preston HMP Preston Natural Published 17 Aug 2012
Individual at Winchester HMP Winchester Natural Published 14 Aug 2012
Individual at Channings Wood HMP Channings Wood Natural Published 14 Aug 2012
Individual at Wormwood Scrubs HMP Wormwood Scrubs Natural Published 14 Aug 2012
Individual at Lincoln HMP Lincoln Self-inflicted Published 13 Aug 2012
Individual at Peterborough HMP Peterborough Self-inflicted Published 10 Aug 2012
Individual at Littlehey HMP Littlehey Self-inflicted Published 9 Aug 2012
Individual at Edith Rigby House Edith Rigby House Natural Published 7 Aug 2012
Individual at Dovegate HMP Dovegate Natural Published 7 Aug 2012
Individual at Liverpool HMP Liverpool Self-inflicted Published 6 Aug 2012
Individual at Preston HMP Preston Self-inflicted Published 6 Aug 2012
Individual at Forest Bank HMP Forest Bank Natural Published 5 Aug 2012
Individual at Wymott HMP Wymott Natural Published 30 Jul 2012
Individual at Lewes HMP Lewes Self-inflicted Published 30 Jul 2012
Individual at Belmarsh HMP Belmarsh Natural Published 27 Jul 2012
Individual at Lewes HMP Lewes Self-inflicted Published 27 Jul 2012
Individual at Bristol HMP Bristol Natural Published 26 Jul 2012
Individual at Guys Marsh HMP Guys Marsh Natural Published 23 Jul 2012
Individual at Preston HMP Preston Natural Published 22 Jul 2012
Individual at Swaleside HMP Swaleside Self-inflicted Published 20 Jul 2012
Individual at Leeds HMP Leeds Natural Published 15 Jul 2012
Individual at Rye Hill HMP Rye Hill Other Published 12 Jul 2012
Individual at Full Sutton HMP Full Sutton Self-inflicted Published 12 Jul 2012
Individual at Holme House HMP Holme House Self-inflicted Published 11 Jul 2012
Individual at Leyhill HMP Leyhill Natural Published 9 Jul 2012
Individual at Bowling Green Bowling Green Self-inflicted Published 7 Jul 2012
Individual at Cardiff HMP Cardiff Self-inflicted Published 7 Jul 2012
Individual at Bronzefield HMP Bronzefield Natural Published 6 Jul 2012
Individual at Birmingham HMP Birmingham Natural Published 5 Jul 2012
Individual at Winchester HMP Winchester Self-inflicted Published 4 Jul 2012
Individual at Kingston HMP Kingston Natural Published 3 Jul 2012
Individual at Whatton HMP Whatton Natural Published 3 Jul 2012
Individual at Nelson House Nelson House Other Published 2 Jul 2012