Home / Sources / PPO Fatal Incident Reports
Index live
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

Top recommendation themes

healthcare (200) safeguarding (163) emergency_response (126) record_keeping (103) policy (88) communication (88) mental_health (72) safety (69) training (63) medication (51)

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

85 records
Name Establishment Cause Status Date of death Recs
Ricardo Cotteral HMP Sudbury Homicide Published 24 Apr 2022 5
Mehrban Hussain HMP Wormwood Scrubs Natural Published 1 Apr 2022 5
James Bailey HMP The Mount Self-inflicted Published 1 Mar 2022 6
Craig Steadman HMP Winchester Self-inflicted Published 27 Feb 2022 5
Andrew Hill HMP Holme House Self-inflicted Published 3 Feb 2022 2
Edward Teague HMP Humber Natural Published 22 Jan 2022 1
John O’Driscoll HMP Cardiff Self-inflicted Published 29 Dec 2021 2
Dylan Davies HMP Cardiff Other Published 28 Dec 2021 1
David Wise HMP Wandsworth Other Published 15 Dec 2021 2
William Roalfe HMP Channings Wood Natural Published 20 Nov 2021 9
Maqsood Asif HMP Stafford Natural Published 18 Nov 2021 5
David Mears HMP Channings Wood Natural Published 17 Aug 2021 6
Daniel Ayers HMP Winchester Self-inflicted Published 25 Jul 2021 14
Keith Williams HMP Dovegate Self-inflicted Published 12 Jul 2021 14
Daniel Beckford HMP Wandsworth Self-inflicted Published 23 Jun 2021 6
Shahrooz Ghassemian HMP Wandsworth Self-inflicted Published 21 Jun 2021 10
Khyber Nasim HMP Pentonville Self-inflicted Published 17 Jun 2021 3
Sebastião Lucas HMP Wandsworth Self-inflicted Published 12 May 2021 6
Peter Coulthard HMP Whatton Natural Published 23 Mar 2021 4
Jason McQuoid HMP Risley Self-inflicted Published 2 Mar 2021 5
Eral Morgan HMP Oakwood Other Published 17 Feb 2021 3
Clive Pinder HMP Risley Natural Published 17 Feb 2021 5
Joshua Esberger HMP Hull Self-inflicted 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
Marek Witulski HMP Peterborough Self-inflicted Published 9 Jul 2020 5
Sean Huntroyd HMP Winchester Natural Published 7 May 2020 2
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
Thomas Moffett HMP Preston Natural Published 6 Aug 2019 5
Christine McDonald HMP/YOI Styal Self-inflicted Published 3 Mar 2019 9
Salim Sakaria HMP Risley Natural Published 14 Dec 2018 3
Jonathan McCarthy HMP Onley Natural Published 12 Aug 2018 2
Aaron Nunes HMP/YOI Parc Natural Published 21 Feb 2016 25