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 Brixton HMP Brixton Natural Published 7 Oct 2011
Individual at Wayland HMP Wayland Natural Published 4 Oct 2011
Individual at Bowling Green Bowling Green Other Published 1 Oct 2011
Individual at Frankland HMP Frankland Homicide Published 1 Oct 2011
Individual at Manchester HMP Manchester Natural Published 30 Sep 2011
Individual at High Down HMP High Down Natural Published 29 Sep 2011
Individual at Bullingdon HMP Bullingdon Natural Published 28 Sep 2011
Individual at Winchester HMP Winchester Self-inflicted Published 26 Sep 2011
Individual at Brigstocke Road Brigstocke Road Natural Published 25 Sep 2011
Individual at Felmores Felmores Natural Published 24 Sep 2011
Individual at Shepton Mallet HMP Shepton Mallet Natural Published 13 Sep 2011
Individual at New Hall HMP New Hall Natural Published 12 Sep 2011
Individual at Peterborough HMP Peterborough Natural Published 10 Sep 2011
Individual at Channings Wood HMP Channings Wood Natural Published 9 Sep 2011
Individual at Full Sutton HMP Full Sutton Natural Published 8 Sep 2011
Individual at Durham HMP Durham Other Published 8 Sep 2011
Individual at Wandsworth HMP Wandsworth Natural Published 8 Sep 2011
Individual at Durham HMP Durham Natural Published 8 Sep 2011
Individual at Isle of Wight HMP Isle of Wight Natural Published 6 Sep 2011
Individual at Dorchester HMP Dorchester Natural Published 6 Sep 2011
Individual at Swaleside HMP Swaleside Natural Published 3 Sep 2011
Individual at Norwich HMP Norwich Self-inflicted Published 28 Aug 2011
Individual at Manchester HMP Manchester Natural Published 27 Aug 2011
Individual at Preston HMP Preston Self-inflicted Published 26 Aug 2011
Individual at Bristol HMP Bristol Self-inflicted Published 23 Aug 2011
Individual at Doncaster HMP Doncaster Self-inflicted Published 22 Aug 2011
Individual at Gloucester HMP Gloucester Self-inflicted Published 20 Aug 2011
Individual at Gartree HMP Gartree Natural Published 20 Aug 2011
Individual at Cardiff HMP Cardiff Natural Published 20 Aug 2011
Individual at Manchester HMP Manchester Natural Published 18 Aug 2011
Individual at Wakefield HMP Wakefield Natural Published 13 Aug 2011
Individual at Wymott HMP Wymott Natural Published 11 Aug 2011
Individual at Guys Marsh HMP Guys Marsh Natural Published 10 Aug 2011
Individual at High Down HMP High Down Natural Published 4 Aug 2011
Individual at Birmingham HMP Birmingham Natural Published 4 Aug 2011
Individual at Manchester HMP Manchester Natural Published 3 Aug 2011
Individual at Campsfield House IRC Campsfield House Self-inflicted Published 2 Aug 2011
Individual at Exeter HMP Exeter Self-inflicted Published 2 Aug 2011
Individual at Colnbrook IRC Colnbrook Natural Published 31 Jul 2011
Individual at Glogan House Glogan House Natural Published 31 Jul 2011
Individual at Ealing Ealing Self-inflicted Published 30 Jul 2011
Individual at Stocken HMP Stocken Natural Published 28 Jul 2011
Individual at Wandsworth HMP Wandsworth Natural Published 28 Jul 2011
Individual at Hewell HMP Hewell Other Published 27 Jul 2011
Individual at Leeds HMP Leeds Self-inflicted Published 27 Jul 2011
Individual at Stafford HMP Stafford Natural Published 26 Jul 2011
Individual at Bure HMP Bure Natural Published 25 Jul 2011
Individual at Wakefield HMP Wakefield Natural Published 24 Jul 2011
Individual at Manchester HMP Manchester Self-inflicted Published 22 Jul 2011
Individual at Brigstocke Road Brigstocke Road Self-inflicted Published 19 Jul 2011