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
Brian Lomas HMP Birmingham Natural Published 2 May 2025 1
Roy Anderson HMP Ranby Natural Published 10 Mar 2025 2
Darren Stapleton HMP Peterborough Natural Published 4 Feb 2025 1
Alex Davies HMP/YOI Styal Self-inflicted Published 24 Dec 2024 2
Brian Acott HMP Lewes Natural Published 17 Sep 2024 2
Eric Stringer HMP Wormwood Scrubs Natural Published 23 Aug 2024 4
Christopher Ash HMP Birmingham Natural Published 26 Jun 2024 1
Lewis Brown HMP Birmingham Self-inflicted Published 27 May 2024 3
Rakeem Malik HMP Long Lartin Natural Published 20 May 2024 1
Ashley Ferrie HMP Fosse Way Self-inflicted Published 13 Feb 2024 3
Sean Higgins HMP Rochester Self-inflicted Published 7 Feb 2024 6
Brian Field HMP Full Sutton Natural Published 4 Feb 2024 1
Daniel Fielding HMP Liverpool Self-inflicted Published 19 Jan 2024 6
Matthew Osborne HMP Lowdham Grange Self-inflicted Published 25 Nov 2023 1
John Kenny HMP/YOI Parc Natural Published 21 Oct 2023 1
Ricky Crosher HMP Lowdham Grange Self-inflicted Published 11 Oct 2023 3
Darren Barker HMP Peterborough Natural Published 12 Sep 2023 2
Raymond Cartwright HMP Risley Natural Published 6 Aug 2023 2
John Rombach HMP Stafford Natural Published 17 Jul 2023 2
Damon Hardman HMP Lewes Self-inflicted Published 8 Jun 2023 3
Rolandas Karbauskas HMP Lowdham Grange Self-inflicted Published 25 Mar 2023 6
Michael Tucker HMP Wayland Self-inflicted Published 22 Mar 2023 2
Ryan Harding HMP/YOI Parc Other Published 8 Jan 2023 3
Thomas Goldring HMP Winchester Self-inflicted Published 29 Dec 2022 4
Matthew Xavier HMP Highpoint Natural Published 16 Dec 2022 2
Anthony O’Connell HMP Swaleside Self-inflicted Published 18 Sep 2022 9
Sebastian Mularz HMP Hull Natural Published 17 Aug 2022 6
Kayleigh Melhuish HMP/YOI Eastwood Park Self-inflicted Published 7 Jul 2022 8
Guiseppe Tabone HMP Lewes Other Published 28 Jun 2022 5
Andrew Evans HMP Lewes Other Published 28 Jun 2022 5
Lee Scott HMP Humber Self-inflicted Published 14 Jun 2022 4
Wayne Bayley HMP Pentonville Other Published 17 May 2022 7
James Bailey HMP The Mount Self-inflicted Published 1 Mar 2022 6
Azroy Dawes-Clarke HMP Elmley Self-inflicted Published 10 Nov 2021 8
Ashley Wood HMP Exeter Self-inflicted Published 9 Sep 2021 9
Daniel Ayers HMP Winchester Self-inflicted Published 25 Jul 2021 14
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
George Petrou HMP Pentonville Self-inflicted Published 1 Mar 2021 7
Eral Morgan HMP Oakwood Other Published 17 Feb 2021 3
David Reid HMP Rye Hill Natural Published 11 Jan 2021 5
Decland Mooney HMP Cardiff Natural Published 6 Dec 2020 3
Robert Frith HMP Berwyn Self-inflicted Published 14 Nov 2020 8
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
Matthew Singh HMP Berwyn Other Published 23 Nov 2019 4
Malacai Samson HMP Pentonville Self-inflicted Published 23 Aug 2019 7