Source · Deaths in custody

PPO Fatal Incident Reports

6,395 incidents 5,660 published 1,165 recommendations 1,632 self-inflicted 3,362 natural causes

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

Clear

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 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 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 2023-24 Annual report Jul 2024 PDF
Annual report 2022-23 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

53 records
Name Establishment Cause Status Date of death Recs
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
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
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
Wayne Bayley HMP Pentonville Other Published 17 May 2022 7
Jeremie Simmons HMP Wakefield Self-inflicted Published 4 May 2022 6
Mehrban Hussain HMP Wormwood Scrubs Natural Published 1 Apr 2022 5
William Roalfe HMP Channings Wood Natural Published 20 Nov 2021 9
Azroy Dawes-Clarke HMP Elmley Self-inflicted Published 10 Nov 2021 8
Ashley Wood HMP Exeter Self-inflicted Published 9 Sep 2021 9
Matthew Braben HMP Wormwood Scrubs Self-inflicted Published 16 Aug 2021 5
Anne-Marie Roberts HMP/YOI Eastwood Park Natural Published 24 Jul 2021 6
Keith Williams HMP Dovegate Self-inflicted Published 12 Jul 2021 14
Daniel Beckford HMP Wandsworth Self-inflicted Published 23 Jun 2021 6
Eral Morgan HMP Oakwood Other Published 17 Feb 2021 3
Christopher Parker HMP Holme House Self-inflicted Published 12 Nov 2020 4
Terence Devereux HMP Channings Wood Self-inflicted Published 24 May 2020 5
Timothy Smith HMP Risley Self-inflicted Published 20 May 2020 3
Ryan Nash HMP Bedford Self-inflicted Published 30 Apr 2020 10
Peter Tauroza HMP Wandsworth Self-inflicted Published 6 Mar 2020 8
Keith Turner HMP Humber Self-inflicted Published 9 Jan 2020 11
Liridon Saliuka HMP Belmarsh Self-inflicted Published 2 Jan 2020 15
David Bassett HMP Swansea Self-inflicted Published 1 Dec 2019 4
Brandon Johnson HMP Wandsworth Other Published 12 Sep 2019 5
Daniel Short Glogan House Approved Premises Other Published 14 Aug 2019 8
Paul David Horrocks HMP Thorn Cross Other Published 30 Jun 2019 7
Christine McDonald HMP/YOI Styal Self-inflicted Published 3 Mar 2019 9