Source · Deaths in custody

PPO Fatal Incident Reports

6,563 incidents 5,801 published 1,698 recommendations 1,676 self-inflicted 3,427 natural causes

Deaths in custody investigated by the Prisons and Probation Ombudsman. Among the incidents indexed here, 26% are recorded as self-inflicted. Source: PPO.

Theme: emergency_response · Remove

Incidents

126 records

John Warry

HMP StaffordDate of death 25 September 2022

Natural causesInvestigation: Report published10 recommendations indexed

PPO entry published 12 December 2025

Dale Samm

HMP The MountDate of death 25 September 2022

Self-inflictedInvestigation: Report published2 recommendations indexed

PPO entry published 11 September 2024

Terrance Dass

HMP LittleheyDate of death 20 September 2022

Natural causesInvestigation: Report published1 recommendation indexed

PPO entry published 24 September 2024

Anthony O’Connell

HMP SwalesideDate of death 18 September 2022

Self-inflictedInvestigation: Report published9 recommendations indexed

PPO entry published 8 July 2024

Thomas Oleisky

HMP WealstunDate of death 11 September 2022

Self-inflictedInvestigation: Report published5 recommendations indexed

PPO entry published 25 July 2025

Steven Haldane

HMP StaffordDate of death 29 August 2022

Natural causesInvestigation: Report published2 recommendations indexed

PPO entry published 27 June 2025

Sebastian Mularz

HMP HullDate of death 17 August 2022

Natural causesInvestigation: Report published6 recommendations indexed

PPO entry published 21 July 2025

John Reid

HMP WinchesterDate of death 10 August 2022

Natural causesInvestigation: Report published5 recommendations indexed

PPO entry published 19 December 2024

Max Marchant

HMP The MountDate of death 25 July 2022

Other non-naturalInvestigation: Report published13 recommendations indexed

PPO entry published 19 March 2025

Tyrone Beresford

HMP The MountDate of death 14 July 2022

Other non-naturalInvestigation: Report published7 recommendations indexed

PPO entry published 25 November 2024

Kayleigh Melhuish

HMP/YOI Eastwood ParkDate of death 7 July 2022

Self-inflictedInvestigation: Report published8 recommendations indexed

PPO entry published 28 October 2024

Lee Scott

HMP HumberDate of death 14 June 2022

Self-inflictedInvestigation: Report published4 recommendations indexed

PPO entry published 20 June 2025

Armstrong, Karl

MerseybankDate of death 23 May 2022

Other non-naturalInvestigation: Report published3 recommendations indexed

PPO entry published 26 March 2024

Isaac Ayeni

HMP AylesburyDate of death 16 May 2022

Other non-naturalInvestigation: Report published2 recommendations indexed

PPO entry published 1 August 2025

Thomas Simmons

HMP HumberDate of death 20 April 2022

Natural causesInvestigation: Report published3 recommendations indexed

PPO entry published 6 December 2024

James Bailey

HMP The MountDate of death 1 March 2022

Self-inflictedInvestigation: Report published6 recommendations indexed

PPO entry published 8 July 2024

Craig Steadman

HMP WinchesterDate of death 27 February 2022

Self-inflictedInvestigation: Report published5 recommendations indexed

PPO entry published 16 July 2025

Michael Grimes

HMP Isle of WightDate of death 26 February 2022

Natural causesInvestigation: Report published1 recommendation indexed

PPO entry published 4 September 2025

Pisani, Jonathan

HMP Forest BankDate of death 19 January 2022

Other non-naturalInvestigation: Report published1 recommendation indexed

PPO entry published 26 March 2024

John O’Driscoll

HMP CardiffDate of death 29 December 2021

Self-inflictedInvestigation: Report published2 recommendations indexed

PPO entry published 6 December 2024

Ian Davies

HMP BristolDate of death 6 December 2021

Self-inflictedInvestigation: Report published7 recommendations indexed

PPO entry published 11 July 2025

Liam Turner

HMP ManchesterDate of death 6 December 2021

Other non-naturalInvestigation: Report published2 recommendations indexed

PPO entry published 8 July 2024

Diana Grant

HMP BronzefieldDate of death 20 November 2021

Self-inflictedInvestigation: Report published6 recommendations indexed

PPO entry published 14 July 2025

William Roalfe

HMP Channings WoodDate of death 20 November 2021

Natural causesInvestigation: Report published9 recommendations indexed

PPO entry published 11 September 2024

Doherty, James

HMP Wormwood ScrubsDate of death 18 November 2021

Self-inflictedInvestigation: Report published8 recommendations indexed

PPO entry published 23 April 2024

Azroy Dawes-Clarke

HMP ElmleyDate of death 10 November 2021

Self-inflictedInvestigation: Report published8 recommendations indexed

PPO entry published 16 July 2025

Paul Gobell

HMP WhattonDate of death 6 November 2021

Self-inflictedInvestigation: Report published3 recommendations indexed

PPO entry published 6 December 2024

Ryan Harris

HMP CardiffDate of death 1 October 2021

Self-inflictedInvestigation: Report published3 recommendations indexed

PPO entry published 8 July 2024

Matthew Braben

HMP Wormwood ScrubsDate of death 16 August 2021

Self-inflictedInvestigation: Report published5 recommendations indexed

PPO entry published 7 March 2025

Daniel Ayers

HMP WinchesterDate of death 25 July 2021

Self-inflictedInvestigation: Report published14 recommendations indexed

PPO entry published 25 July 2025

Anne-Marie Roberts

HMP/YOI Eastwood ParkDate of death 24 July 2021

Natural causesInvestigation: Report published6 recommendations indexed

PPO entry published 18 July 2025

Akhtar Hussain

HMP ManchesterDate of death 8 July 2021

Self-inflictedInvestigation: Report published12 recommendations indexed

PPO entry published 27 November 2024

Daniel Beckford

HMP WandsworthDate of death 23 June 2021

Self-inflictedInvestigation: Report published6 recommendations indexed

PPO entry published 16 August 2024

Shahrooz Ghassemian

HMP WandsworthDate of death 21 June 2021

Self-inflictedInvestigation: Report published10 recommendations indexed

PPO entry published 3 October 2024

Piotr Marszalek

HMP WandsworthDate of death 8 June 2021

Self-inflictedInvestigation: Report published8 recommendations indexed

PPO entry published 16 August 2024

James Kiteley

HMP SudburyDate of death 5 June 2021

Other non-naturalInvestigation: Report published3 recommendations indexed

PPO entry published 19 July 2024

Jake Swords

HMP PeterboroughDate of death 2 June 2021

Other non-naturalInvestigation: Report published2 recommendations indexed

PPO entry published 31 October 2024

Lukasz Lukasik

HMP HullDate of death 27 May 2021

Self-inflictedInvestigation: Report published6 recommendations indexed

PPO entry published 18 July 2025

Sebastião Lucas

HMP WandsworthDate of death 12 May 2021

Self-inflictedInvestigation: Report published6 recommendations indexed

PPO entry published 6 January 2026

Godfrey Muzhuzha

HMP The MountDate of death 3 May 2021

Natural causesInvestigation: Report published4 recommendations indexed

PPO entry published 16 August 2024

Flanagan, Ryan

HMP ChelmsfordDate of death 23 March 2021

Natural causesInvestigation: Report published4 recommendations indexed

PPO entry published 2 May 2024

Rimantas Zalalis

HMP ThamesideDate of death 22 March 2021

Other non-naturalInvestigation: Report published4 recommendations indexed

PPO entry published 26 July 2024

Jason McQuoid

HMP RisleyDate of death 2 March 2021

Self-inflictedInvestigation: Report published5 recommendations indexed

PPO entry published 21 March 2025

Przemyslaw Wozniak

HMP WandsworthDate of death 17 February 2021

Self-inflictedInvestigation: Report published8 recommendations indexed

PPO entry published 11 September 2024

Clive Pinder

HMP RisleyDate of death 17 February 2021

Natural causesInvestigation: Report published5 recommendations indexed

PPO entry published 26 July 2024

Deejay Blampey

HMP ExeterDate of death 2 February 2021

Self-inflictedInvestigation: Report published7 recommendations indexed

PPO entry published 16 August 2024

Christopher Parker

HMP Holme HouseDate of death 12 November 2020

Self-inflictedInvestigation: Report published4 recommendations indexed

PPO entry published 8 August 2025

Michael Lavin

HMP AltcourseDate of death 12 November 2020

Natural causesInvestigation: Report published6 recommendations indexed

PPO entry published 9 May 2025

Baltrunas, Karolis

HMP The MountDate of death 27 August 2020

Self-inflictedInvestigation: Report published7 recommendations indexed

PPO entry published 19 April 2024

Charnley, Bradley

HMP RisleyDate of death 13 August 2020

Self-inflictedInvestigation: Report published4 recommendations indexed

PPO entry published 2 May 2024

Top recommendation themes

healthcare (299) safeguarding (238) emergency_response (158) record_keeping (140) communication (130) policy (125) mental_health (115) safety (106) training (91) medication (80)

Learning & thematic publications

112 cross-establishment publications

Learning Lessons Bulletins (50), thematic reviews (2), consultation responses (11), Policy into Practice (5), annual reports (7) and FOI responses from the Ombudsman's disclosure log (37): the systemic patterns the Ombudsman draws from many investigations.

Title	Type	Date	Source
The number of complaints received by the PPO from 1 January 2023 onwards by people held in immigration removal centres and in short-term holding facilities	FOI response	Jul 2026	PDF
Annual Report 2025 to 2026	Annual report	Jul 2026	PDF
To provide information on prisons in the United Kingdom with forty or more self-inflicted deaths in the last ten years, alongside their total	FOI response	Jul 2026	PDF
The three English prisons with the highest number of self-inflicted deaths between 2016 to 2026 (excluding HMP Leeds), with annual breakdowns	FOI response	Jul 2026	PDF
The total number of prison deaths that occurred while the individual was located in a segregation unit per calendar from 2021 to 2025	FOI response	Jul 2026	PDF
The number of drug-related deaths in prisons in England and Wales from 2010 to 2025	FOI response	Jul 2026	PDF
A breakdown of the epilepsy deaths in Welsh prisons from the PPO’s Learning Lessons Bulletin on epilepsy deaths	FOI response	Jul 2026	PDF
The number of people held in prison, either serving a sentence or on remand, who have died by suicide between 2016 to 2026, broken down by each prison in Yorkshire	FOI response	Jul 2026	PDF
PPO response to JSC Inquiry into Children and Young Adults in the Secure Estate	Consultation response	Jun 2026	PDF
The number of upheld complaints made to the Prisons and Probation Ombudsman (PPO) about accommodation from 2024 to 2025.	FOI response	Apr 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
HMP Elmley prisoner deaths by year from 2010 to 2025	FOI response	Feb 2026	PDF
Complaints to the PPO about inadequate access to sanitary products since 2020	FOI response	Feb 2026	PDF
The number of health-related deaths in prison	FOI response	Feb 2026	PDF
How many complaints did IPCI receive from prisoners during 2024?	FOI response	Feb 2026	PDF
How many complaints has the PPO received regarding lost property by HMP Peterborough	FOI response	Feb 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
The number of deaths linked to drug taking in prisons in England and Wales between 2020 to 2024	FOI response	Jun 2025	PDF
How many prisoner deaths has the PPO been notified of each year, or started investigating, where there is a suspicion the death was drug-related?	FOI response	Jun 2025	PDF
The number of prisoners who died where no care plan was in place as found in PPO fatal incident investigations (1 February 2023 to 16 September 2023)	FOI response	Jun 2025	PDF
Provide a list of deaths by suicide in English prisons since 2022	FOI response	Jun 2025	PDF
The PPO response time for all cases in last three and current financial year	FOI response	Jun 2025	PDF
The number of self-inflicted deaths recorded in prisons from 2019 to 2024	FOI response	Jun 2025	PDF
The number of individuals in prisons, young offender institutions and approved premises in England and Wales and/or within 14 days of being released from prison were at the time of their deaths subject to an IPP	FOI response	Jun 2025	PDF
To confirm when the Prisons and Probation Ombudsman’s (PPO) Yarl’s Wood special investigation report was completed	FOI response	Jun 2025	PDF
To provide the total number of Prevention of Future Deaths (PFDs or Regulation 28 letters)	FOI response	Jun 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