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.

Clear

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

159 records
Name Establishment Cause Status Date of death Recs
Arron Hamer HMP Buckley Hall Self-inflicted Published 4
Steven Ison Bowling Green Approved Premises Self-inflicted Published 3
Peter Magloire HMP Wormwood Scrubs Self-inflicted Published 3
Waleed Ali HMP Wandsworth Self-inflicted Published 1
Simon Follos HMP Stoke Heath Self-inflicted Published 3
Georgie Smith HMP Bristol Self-inflicted Published 3
Daniel Brown HMP/YOI High Down Natural Published 3
Wayne Domeney HMP Isle of Wight Natural Published 1
Hallum Elgood HMP Norwich Self-inflicted Published 2
Thomas Ruggiero HMP Swaleside Self-inflicted Published 5
Aaron Taylor HMP Garth Natural Published 1
Jake O’Brien HMP Forest Bank Self-inflicted Published 12
Patryk Jalocha HMP Manchester Self-inflicted Published 2
Alexander Rodgers HMP Wymott Self-inflicted Published 2
Paul Smyth HMP Altcourse Self-inflicted Published 4
Peter Campbell HMP Pentonville Other Published 2
Mesut Olgun HMP Hewell Self-inflicted Published 1
Simon Dunn HMP Garth Self-inflicted Published 4
Nathan Byrnes HMP Liverpool Self-inflicted Published 2
Steve McBride HMP Warren Hill Self-inflicted Published 1
Andrew Neal HMP Wayland Self-inflicted Published 5
Nezam Ghalate HMP Manchester Self-inflicted Published 3
Ben Foley HMP Exeter Self-inflicted Published 1
Luke Ashcroft HMP Lincoln Self-inflicted Published 3
Imran Khan HMP Isle of Wight Self-inflicted Published 10
Frazer Williams HMP Guys Marsh Self-inflicted Published 9
Rickie Poon HMP Pentonville Self-inflicted Published 2
Taylor Atkinson HMP/YOI Eastwood Park Self-inflicted Published 6
Michael Marsh HMP Exeter Self-inflicted Published 6
Richard Glenn HMP Lincoln Self-inflicted Published 1
Mark Bradley HMP Stafford Self-inflicted Published 2
Paul Coughlin HMP Bristol Self-inflicted Published 1
Michael Tate HMP Gartree Natural Published 6 Feb 2025 2
Christopher Walton HMP Ranby Natural Published 6 Feb 2025 7
Nickolas Fretwell HMP Elmley Self-inflicted Published 16 Oct 2024 1
Stuart Greener HMP Nottingham Natural Published 16 Oct 2024 1
Harold Day HMP Five Wells Natural Published 25 Sep 2024 2
Nigel Feckey HMP Fosse Way Self-inflicted Published 23 Sep 2024 3
Phillip Sheridan HMP Full Sutton Natural Published 21 Jul 2024 2
Craig Topham HMP Nottingham Other Published 28 Jun 2024 1
Scott Howley HMP Wealstun Self-inflicted Published 6 Mar 2024 1
Ashley Ferrie HMP Fosse Way Self-inflicted Published 13 Feb 2024 3
Kyle Tyler HMP/YOI High Down Other Published 8 Feb 2024 1
Sean Higgins HMP Rochester Self-inflicted Published 7 Feb 2024 6
Kevin Kane HMP Grendon Self-inflicted Published 29 Jan 2024 3
Patryk Gladysz HMP Wandsworth Self-inflicted Published 19 Jan 2024 3
Nathan Shepherd Ascot House Approved Premises Self-inflicted Published 16 Jan 2024 3
Melvin Grant HMP Bedford Self-inflicted Published 21 Nov 2023 3
Simon Faherty HMP Elmley Self-inflicted Published 20 Nov 2023 4
Paul Roberts HMP Preston Self-inflicted Published 14 Nov 2023 1