Source · Deaths in custody

PPO Fatal Incident Reports

6,470 incidents 5,745 published 1,502 recommendations 1,653 self-inflicted 3,404 natural causes

Deaths in custody investigated by the Prisons and Probation Ombudsman. 26% of deaths are self-inflicted. Source: PPO.

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Learning & thematic publications

75 cross-establishment publications

Learning Lessons Bulletins (50), thematic reviews (2), consultation responses (11), Policy into Practice (5) and annual reports (7): the systemic patterns the Ombudsman draws from many investigations.

TitleTypeDateSource
Annual Report 2025 to 2026 Annual report Jul 2026 PDF
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 21: Segregation Learning Lessons Bulletin Mar 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 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 inquiry into Rehabilitation and Resettlement Consultation response Feb 2025 PDF
PPO response to JHAC Inquiry into Prison Culture Consultation response Feb 2025 PDF
PPO response to JSC Tackling Drugs in Prison Inquiry 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
Fatal Incident Investigations Learning Lessons Bulletin Issue 17: Post-release death investigations Learning Lessons Bulletin Jan 2023 PDF
Investigating deaths after release from prison – a pilot evaluation 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

Incidents

183 records
Name Establishment Cause Status Date of death Recs
Brian Fletcher HMP Hewell Natural Published 5
Michael Dawson HMP Lindholme Natural Published 4
Peter Brook HMP Leeds Natural Published 1
Ann Browning HMP Send Natural Published 1
David Marsh HMP Lincoln Natural Published 2
Mark Waterman HMP Swansea Natural Published 2
Peter Williams HMP Littlehey Natural Published 2
Fay Newman HMP/YOI Downview Natural Published 2
David Morris HMP Frankland Natural Published 3
Peter Magloire HMP Wormwood Scrubs Self-inflicted Published 3
Andrew Clark HMP Norwich Natural Published 2
George Haldenby HMP The Verne Natural Published 3
Brian James HMP Elmley Natural Published 1
Adam Diesa-Green HMP Lowdham Grange Other Published 1
Daniel Brown HMP/YOI High Down Natural Published 3
Kenneth Cox HMP Norwich Natural Published 2
Dean Collins HMP Birmingham Natural Published 2
Kenneth Kesans HMP Usk Natural Published 2
Kevin Golby HMP Five Wells Unascertained Published 1
Uziel Mendoza-Sillerico HMP Lowdham Grange Natural Published 10
Thomas Ruggiero HMP Swaleside Self-inflicted Published 5
Simon Ludlow HMP The Mount Other Published 2
Jake O’Brien HMP Forest Bank Self-inflicted Published 12
Surendra Patel HMP Hewell Natural Published 4
Andrew Neal HMP Wayland Self-inflicted Published 5
Philip Eldridge HMP The Verne Natural Published 1
Colin Storey HMP Northumberland Self-inflicted Published 3
Lee Martin HMP Winchester Natural Published 2
John McGovern HMP The Verne Natural Published 3
Stephen McDermott HMP Isle of Wight Natural Published 1
Taylor Atkinson HMP/YOI Eastwood Park Self-inflicted Published 6
Henry Benoi-Davies HMP Nottingham Natural Published 5
Daniel Bates HMP Northumberland Other Published 2
Michael Quinn HMP Berwyn Natural Published 6
Keith Saunders HMP Peterborough Natural Published 2
Benjamin Harrison HMP Rochester Other Published 5
Nigel Malt HMP Gartree Natural Published 29 Apr 2025 1
Peter Long HMP Oakwood Natural Published 10 Mar 2025 1
Glen Candler HMP Wakefield Natural Published 6 Mar 2025 1
Christopher Tatton HMP Rye Hill Natural Published 28 Feb 2025 1
Raymond Connor HMP Whatton Natural Published 22 Feb 2025 2
Timothy Frank HMP Ranby Natural Published 10 Feb 2025 2
Christopher Walton HMP Ranby Natural Published 6 Feb 2025 7
Lorna Carter HMP/YOI Styal Natural Published 27 Jan 2025 1
Brian Kemp HMP Fosse Way Natural Published 26 Jan 2025 3
Alan Hughes HMP Risley Natural Published 6 Jan 2025 2
Brian Hayes HMP/YOI High Down Natural Published 1 Jan 2025 1
Carl Forrester HMP Exeter Natural Published 13 Nov 2024 2
John Corran Isle of Man Natural Published 12 Nov 2024 1
John Freer HMP Northumberland Natural Published 29 Oct 2024 1