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 Lewes HMP Lewes Self-inflicted Published 1 Jul 2012
Individual at Wymott HMP Wymott Natural Published 1 Jul 2012
Individual at Cardiff HMP Cardiff Self-inflicted Published 30 Jun 2012
Individual at Channings Wood HMP Channings Wood Natural Published 28 Jun 2012
Individual at Wilton Place Wilton Place Natural Published 25 Jun 2012
Individual at Wakefield HMP Wakefield Other Published 25 Jun 2012
Individual at Holme House HMP Holme House Self-inflicted Published 23 Jun 2012
Individual at Garth HMP Garth Self-inflicted Published 23 Jun 2012
Individual at Manchester HMP Manchester Natural Published 22 Jun 2012
Individual at North Sea Camp HMP North Sea Camp Natural Published 22 Jun 2012
Individual at Dorchester HMP Dorchester Natural Published 21 Jun 2012
Individual at Northumberland HMP Northumberland Self-inflicted Published 18 Jun 2012
Individual at Gartree HMP Gartree Natural Published 16 Jun 2012
Individual at Chelmsford HMP Chelmsford Self-inflicted Published 16 Jun 2012
Individual at Peterborough HMP Peterborough Natural Published 15 Jun 2012
Individual at Swansea HMP Swansea Self-inflicted Published 13 Jun 2012
Individual at Wakefield HMP Wakefield Natural Published 4 Jun 2012
Individual at Pentonville HMP Pentonville Natural Published 2 Jun 2012
Individual at Maidstone HMP Maidstone Natural Published 29 May 2012
Individual at Whatton HMP Whatton Natural Published 26 May 2012
Individual at Standford Hill HMP Standford Hill Natural Published 25 May 2012
Individual at Dartmoor HMP Dartmoor Natural Published 24 May 2012
Individual at North Sea Camp HMP North Sea Camp Natural Published 22 May 2012
Individual at Durham HMP Durham Self-inflicted Published 21 May 2012
Individual at North Sea Camp HMP North Sea Camp Natural Published 20 May 2012
Individual at Dovegate HMP Dovegate Natural Published 20 May 2012
Individual at Littlehey HMP Littlehey Natural Published 19 May 2012
Individual at Isle of Wight HMP Isle of Wight Natural Published 12 May 2012
Individual at Wakefield HMP Wakefield Natural Published 8 May 2012
Individual at Maidstone HMP Maidstone Natural Published 7 May 2012
Individual at Holme House HMP Holme House Natural Published 1 May 2012
Individual at Parc HMP Parc Natural Published 28 Apr 2012
Individual at Norwich HMP Norwich Natural Published 24 Apr 2012
Individual at Durham HMP Durham Self-inflicted Published 24 Apr 2012
Individual at Onley HMP Onley Natural Published 22 Apr 2012
Individual at Elmley HMP Elmley Natural Published 22 Apr 2012
Individual at Frankland HMP Frankland Natural Published 22 Apr 2012
Individual at Parc HMP Parc Natural Published 19 Apr 2012
Individual at Liverpool HMP Liverpool Natural Published 14 Apr 2012
Individual at Winchester HMP Winchester Natural Published 12 Apr 2012
Individual at Risley HMP Risley Natural Published 7 Apr 2012
Individual at Birmingham HMP Birmingham Self-inflicted Published 4 Apr 2012
Individual at Lincoln HMP Lincoln Self-inflicted Published 3 Apr 2012
Individual at Pentonville HMP Pentonville Self-inflicted Published 30 Mar 2012
Individual at Liverpool HMP Liverpool Natural Published 30 Mar 2012
Individual at Maidstone HMP Maidstone Natural Published 21 Mar 2012
Individual at Swaleside HMP Swaleside Self-inflicted Published 20 Mar 2012
Individual at Northumberland HMP Northumberland Self-inflicted Published 14 Mar 2012
Individual at Wandsworth HMP Wandsworth Natural Published 12 Mar 2012
Individual at Wakefield HMP Wakefield Natural Published 12 Mar 2012