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.

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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

59 records
Name Establishment Cause Status Date of death Recs
Lewis Brown HMP Birmingham Self-inflicted Published 27 May 2024 3
Brian Burrows HMP Leeds Self-inflicted Published 15 May 2024 3
Sean Higgins HMP Rochester Self-inflicted Published 7 Feb 2024 6
Patryk Gladysz HMP Wandsworth Self-inflicted Published 19 Jan 2024 3
Melvin Grant HMP Bedford Self-inflicted Published 21 Nov 2023 3
Davey Price HMP Forest Bank Self-inflicted Published 27 Oct 2023 3
Piotr Zmijewski HMP Maidstone Self-inflicted Published 9 Sep 2023 3
Davina Canning HMP Hewell Self-inflicted Published 29 Jul 2023 3
Lee Kenyon HMP Altcourse Self-inflicted Published 24 Jun 2023 2
Steven Hart HMP Bedford Self-inflicted Published 29 Mar 2023 4
Rolandas Karbauskas HMP Lowdham Grange Self-inflicted Published 25 Mar 2023 6
Glen Adrian HMP Durham Self-inflicted Published 8 Mar 2023 3
Haydar Jefferies HMP Coldingley Self-inflicted Published 5 Mar 2023 2
Christopher Corkill Isle of Man Self-inflicted Published 24 Feb 2023 15
Reece Godward HMP Leeds Self-inflicted Published 23 Feb 2023 2
Mohammed Eumda HMP Chelmsford Self-inflicted Published 30 Jan 2023 2
Milad Fathy HMP Leeds Self-inflicted Published 29 Jan 2023 1
Lawrence Dugbazah HMP Littlehey Natural Published 6 Jan 2023 3
Akash Akeel HMP Leeds Self-inflicted Published 31 Dec 2022 2
Thomas Goldring HMP Winchester Self-inflicted Published 29 Dec 2022 4
Benjamin Donnelly HMP Cardiff Self-inflicted Published 20 Dec 2022 1
Mark Mason HMP Durham Self-inflicted Published 8 Dec 2022 2
Shaine Tester HMP Gartree Self-inflicted Published 1 Nov 2022 2
Kevin McDonnel HMP Nottingham Self-inflicted Published 29 Sep 2022 2
Anthony O’Connell HMP Swaleside Self-inflicted Published 18 Sep 2022 9
Shane Davies HMP Cardiff Self-inflicted Published 28 Aug 2022 1
Sion Evans HMP/YOI Parc Self-inflicted Published 12 Aug 2022 5
Max Marchant HMP The Mount Other Published 25 Jul 2022 13
Kayleigh Melhuish HMP/YOI Eastwood Park Self-inflicted Published 7 Jul 2022 8
Marc Skelly HMP Lindholme Self-inflicted Published 22 Jun 2022 4
Jeremie Simmons HMP Wakefield Self-inflicted Published 4 May 2022 6
Angela Thompson HMP/YOI Styal Self-inflicted Published 11 Apr 2022 3
James Bailey HMP The Mount Self-inflicted Published 1 Mar 2022 6
Craig Steadman HMP Winchester Self-inflicted Published 27 Feb 2022 5
William Roalfe HMP Channings Wood Natural Published 20 Nov 2021 9
Ashley Wood HMP Exeter Self-inflicted Published 9 Sep 2021 9
David Mears HMP Channings Wood Natural Published 17 Aug 2021 6
Keith Williams HMP Dovegate Self-inflicted Published 12 Jul 2021 14
Akhtar Hussain HMP Manchester Self-inflicted Published 8 Jul 2021 12
Piotr Marszalek HMP Wandsworth Self-inflicted Published 8 Jun 2021 8
James Kiteley HMP Sudbury Other Published 5 Jun 2021 3
Lukasz Lukasik HMP Hull Self-inflicted Published 27 May 2021 6
Sebastião Lucas HMP Wandsworth Self-inflicted Published 12 May 2021 6
Jason McQuoid HMP Risley Self-inflicted Published 2 Mar 2021 5
Przemyslaw Wozniak HMP Wandsworth Self-inflicted Published 17 Feb 2021 8
Deejay Blampey HMP Exeter Self-inflicted Published 2 Feb 2021 7
Decland Mooney HMP Cardiff Natural Published 6 Dec 2020 3
Michael Lavin HMP Altcourse Natural Published 12 Nov 2020 6
Carl Kent HMP Dartmoor Self-inflicted Published 21 May 2020 4
Ryan Nash HMP Bedford Self-inflicted Published 30 Apr 2020 10