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 Hewell HMP Hewell Self-inflicted Published 6 Jan 2012
Individual at Holloway HMP Holloway Natural Published 5 Jan 2012
Individual at Frankland HMP Frankland Self-inflicted Published 5 Jan 2012
Individual at Wormwood Scrubs HMP Wormwood Scrubs Self-inflicted Published 3 Jan 2012
Individual at Norwich HMP Norwich Self-inflicted Published 2 Jan 2012
Individual at Isle of Wight HMP Isle of Wight Natural Published 1 Jan 2012
Individual at Wharflane House Wharflane House Self-inflicted Published 31 Dec 2011
Individual at Maidstone HMP Maidstone Natural Published 28 Dec 2011
Individual at Elmley HMP Elmley Natural Published 27 Dec 2011
Individual at Woodhill HMP Woodhill Self-inflicted Published 27 Dec 2011
Individual at Bedford HMP Bedford Self-inflicted Published 24 Dec 2011
Individual at Manchester HMP Manchester Other Published 24 Dec 2011
Individual at Northumberland HMP Northumberland Natural Published 23 Dec 2011
Individual at Isle of Wight HMP Isle of Wight Natural Published 23 Dec 2011
Individual at Hewell HMP Hewell Natural Published 20 Dec 2011
Individual at Norwich HMP Norwich Natural Published 18 Dec 2011
Individual at Glen Parva HMP Glen Parva Self-inflicted Published 13 Dec 2011
Individual at Merseybank Merseybank Natural Published 12 Dec 2011
Individual at Holme House HMP Holme House Natural Published 11 Dec 2011
Individual at Liverpool HMP Liverpool Self-inflicted Published 11 Dec 2011
Individual at Birmingham HMP Birmingham Natural Published 9 Dec 2011
Individual at Birmingham HMP Birmingham Natural Published 6 Dec 2011
Individual at Harmondsworth IRC Harmondsworth Natural Published 6 Dec 2011
Individual at Full Sutton HMP Full Sutton Natural Published 6 Dec 2011
Individual at High Down HMP High Down Natural Published 3 Dec 2011
Individual at Bristol HMP Bristol Natural Published 29 Nov 2011
Individual at Norwich HMP Norwich Natural Published 26 Nov 2011
Individual at Littlehey HMP Littlehey Natural Published 24 Nov 2011
Individual at Glen Parva HMP Glen Parva Self-inflicted Published 19 Nov 2011
Individual at Forest Bank HMP Forest Bank Natural Published 16 Nov 2011
Individual at Wakefield HMP Wakefield Natural Published 16 Nov 2011
Individual at Hewell HMP Hewell Natural Published 15 Nov 2011
Individual at Parc HMP Parc Natural Published 13 Nov 2011
Individual at Elmley HMP Elmley Natural Published 9 Nov 2011
Individual at Hewell HMP Hewell Natural Published 9 Nov 2011
Individual at Swaleside HMP Swaleside Natural Published 9 Nov 2011
Individual at Leeds HMP Leeds Natural Published 7 Nov 2011
Individual at Aylesbury HMP Aylesbury Self-inflicted Published 5 Nov 2011
Individual at Pentonville HMP Pentonville Natural Published 5 Nov 2011
Individual at Birmingham HMP Birmingham Natural Published 5 Nov 2011
Individual at Bristol HMP Bristol Self-inflicted Published 4 Nov 2011
Individual at Holme House HMP Holme House Self-inflicted Published 3 Nov 2011
Individual at Channings Wood HMP Channings Wood Natural Published 30 Oct 2011
Individual at Highpoint HMP Highpoint Natural Published 29 Oct 2011
Individual at Liverpool HMP Liverpool Natural Published 29 Oct 2011
Individual at Hewell HMP Hewell Natural Published 23 Oct 2011
Individual at Hewell HMP Hewell Natural Published 21 Oct 2011
Individual at Bullingdon HMP Bullingdon Self-inflicted Published 15 Oct 2011
Individual at Full Sutton HMP Full Sutton Natural Published 11 Oct 2011
Individual at Isle of Wight HMP Isle of Wight Natural Published 10 Oct 2011