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

76 records
Name Establishment Cause Status Date of death Recs
Michael Dawson HMP Lindholme Natural Published 4
Samuel Omar HMP Stafford Natural Published 3
Fay Newman HMP/YOI Downview Natural Published 2
James Bell HMP Forest Bank Self-inflicted Published 2
Christopher Roberts HMP Isle of Wight Natural Published 2
Christopher Stephens HMP Guys Marsh Other Published 2
John Richards HMP Aylesbury Other Published 2
Graham Stridgeon HMP Wymott Natural Published 2
Daniel Brown HMP/YOI High Down Natural Published 3
Alan Whelan HMP Leeds Self-inflicted Published 1
Peter Hopkins HMP/YOI Doncaster Natural Published 4
Lee Jackson HMP Bristol Self-inflicted Published 2
Jake O’Brien HMP Forest Bank Self-inflicted Published 12
Malcolm James HMP/YOI Parc Natural Published 2
Nathan Byrnes HMP Liverpool Self-inflicted Published 2
David Smith HMP Whatton Natural Published 2
Imran Khan HMP Isle of Wight Self-inflicted Published 10
Frazer Williams HMP Guys Marsh Self-inflicted Published 9
Michael Marsh HMP Exeter Self-inflicted Published 6
Henry Benoi-Davies HMP Nottingham Natural Published 5
David Ogden HMP Forest Bank Self-inflicted Published 2
Christopher Walton HMP Ranby Natural Published 6 Feb 2025 7
Alexander Corbett Fleming House Approved Premises Self-inflicted Published 23 Aug 2024 4
Eric Stringer HMP Wormwood Scrubs Natural Published 23 Aug 2024 4
Gavin Wheale HMP Birmingham Other Published 8 Aug 2024 1
Ming Jiang HMP Swaleside Natural Published 21 Jul 2024 4
Tony King HMP Swaleside Natural Published 18 Jun 2024 2
Eric Pyle HMP Littlehey Natural Published 28 May 2024 1
Lewis Brown HMP Birmingham Self-inflicted Published 27 May 2024 3
Edward Lomas HMP Pentonville Self-inflicted Published 22 May 2024 4
Stephen Jones HMP Peterborough Natural Published 5 May 2024 3
Edward Hands HMP Bedford Other Published 16 Feb 2024 4
Stuart Berry HMP Chelmsford Self-inflicted Published 1 Feb 2024 3
John Leadbitter HMP Hull Natural Published 31 Jan 2024 3
Lawrence Johnson HMP Frankland Natural Published 13 Jan 2024 3
Simon Faherty HMP Elmley Self-inflicted Published 20 Nov 2023 4
Lucas Kidd HMP Ranby Other Published 19 Oct 2023 2
James Wood HMP Hull Natural Published 4 Sep 2023 1
Rajwinder Singh HMP Wandsworth Self-inflicted Published 25 Jun 2023 6
Joseph Louis HMP Wormwood Scrubs Natural Published 26 Apr 2023 4
Pearce, Luke HMP Swinfen Hall Self-inflicted Published 6 Apr 2023 1
Frank Ospina Colnbrook Immigration Removal Centre Self-inflicted Published 26 Mar 2023 4
Andrew Hadwin HMP Durham Natural Published 2 Feb 2023 4
Lawrence Dugbazah HMP Littlehey Natural Published 6 Jan 2023 3
Oliver Davies HMP Hewell Self-inflicted Published 31 Dec 2022 3
Aaron Harte HMP Peterborough Other Published 3 Nov 2022 4
Pearson, John HMP Holme House Natural Published 24 Oct 2022 2
Rebecca Parkinson HMP/YOI Styal Other Published 31 Jul 2022 2
Max Marchant HMP The Mount Other Published 25 Jul 2022 13
Tyrone Beresford HMP The Mount Other Published 14 Jul 2022 7