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.
Top recommendation themes
Learning & thematic publications
| Title | Type | Date | Source |
|---|---|---|---|
| PPO response to JSC Inquiry into Children and Young Adults in the Secure Estate | Consultation response | Jun 2026 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 21: Segregation | Learning Lessons Bulletin | Mar 2026 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 22: Self-inflicted deaths in reception prisons | Learning Lessons Bulletin | Mar 2026 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 20: Epilepsy | Learning Lessons Bulletin | Nov 2025 | |
| Annual Report 2024 to 2025 | Annual report | Jul 2025 | |
| Policy into Practice: Handling of prisoners’ property | Policy into Practice | Mar 2025 | |
| Policy into Practice: Handling of property complaints | Policy into Practice | Mar 2025 | |
| Complaints Investigations Learning Lessons Bulletin Issue 11: Property complaints | Learning Lessons Bulletin | Mar 2025 | |
| PPO response to JSC Tackling Drugs in Prison Inquiry | Consultation response | Feb 2025 | |
| PPO response to JHAC Inquiry into Prison Culture | Consultation response | Feb 2025 | |
| PPO response to JSC inquiry into Rehabilitation and Resettlement | Consultation response | Feb 2025 | |
| Policy into Practice: Emergency Response | Policy into Practice | Jan 2025 | |
| PPO response to the Independent Sentencing Review 2024/25 call for evidence | Consultation response | Jan 2025 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 19: Post-release death investigations 2 | Learning Lessons Bulletin | Jul 2024 | |
| Annual Report 2023-24 | Annual report | Jul 2024 | |
| Annual report 2022-23 | Annual report | Jul 2024 | |
| Policy into practice: Use of force | Policy into Practice | Feb 2024 | |
| PPO response to the inquiry into prison population and capacity | Consultation response | Nov 2023 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 18: Self-inflicted deaths of IPP prisoners | Learning Lessons Bulletin | Sep 2023 | |
| Investigating deaths after release from prison – a pilot evaluation | Learning Lessons Bulletin | Jan 2023 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 17: Post-release death investigations | Learning Lessons Bulletin | Jan 2023 | |
| PPO response to the inquiry into the Prison Operational Workforce | Consultation response | Jan 2023 | |
| Annual Report 2021-22 | Annual report | Oct 2022 | |
| Policy into Practice: Use of restraints on escort | Policy into Practice | Sep 2022 | |
| PPO Response to the Inquiry into IPP sentences | Consultation response | Jan 2022 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 16: Second wave COVID-19 related deaths | Learning Lessons Bulletin | Dec 2021 | |
| Annual Report 2020-21 | Annual report | Sep 2021 | |
| PPO responses to the Inquiry into Women in Prison | Consultation response | Aug 2021 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 15: COVID-19 PPO fatal incident investigations | Learning Lessons Bulletin | Feb 2021 | |
| Complaints Investigations Learning Lessons Bulletin Issue 10: COVID-19 PPO Complaints | Learning Lessons Bulletin | Dec 2020 |
Incidents
| Name | Establishment | Cause | Status | Date of death | Recs |
|---|---|---|---|---|---|
| Kevin McDonnel | HMP Nottingham | Self-inflicted | Published | 29 Sep 2022 | 2 |
| Dale Samm | HMP The Mount | Self-inflicted | Published | 25 Sep 2022 | 2 |
| Anthony O’Connell | HMP Swaleside | Self-inflicted | Published | 18 Sep 2022 | 9 |
| Thomas Oleisky | HMP Wealstun | Self-inflicted | Published | 11 Sep 2022 | 5 |
| Sebastian Mularz | HMP Hull | Natural | Published | 17 Aug 2022 | 6 |
| Sion Evans | HMP/YOI Parc | Self-inflicted | Published | 12 Aug 2022 | 5 |
| Max Marchant | HMP The Mount | Other | Published | 25 Jul 2022 | 13 |
| Tyrone Beresford | HMP The Mount | Other | Published | 14 Jul 2022 | 7 |
| Kayleigh Melhuish | HMP/YOI Eastwood Park | Self-inflicted | Published | 7 Jul 2022 | 8 |
| Marc Skelly | HMP Lindholme | Self-inflicted | Published | 22 Jun 2022 | 4 |
| Ricardo Cotteral | HMP Sudbury | Homicide | Published | 24 Apr 2022 | 5 |
| Lewis Petryszyn | HMP/YOI Parc | Other | Published | 15 Apr 2022 | 4 |
| 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 |
| Andrew Hill | HMP Holme House | Self-inflicted | Published | 3 Feb 2022 | 2 |
| Alaa Ghanem | HMP Exeter | Other | Published | 14 Jan 2022 | 1 |
| Ian Davies | HMP Bristol | Self-inflicted | Published | 6 Dec 2021 | 7 |
| Diana Grant | HMP Bronzefield | Self-inflicted | Published | 20 Nov 2021 | 6 |
| William Roalfe | HMP Channings Wood | Natural | Published | 20 Nov 2021 | 9 |
| Azroy Dawes-Clarke | HMP Elmley | Self-inflicted | Published | 10 Nov 2021 | 8 |
| Ryan Harris | HMP Cardiff | Self-inflicted | Published | 1 Oct 2021 | 3 |
| Ashley Wood | HMP Exeter | Self-inflicted | Published | 9 Sep 2021 | 9 |
| Matthew Braben | HMP Wormwood Scrubs | Self-inflicted | Published | 16 Aug 2021 | 5 |
| Daniel Ayers | HMP Winchester | Self-inflicted | Published | 25 Jul 2021 | 14 |
| Anne-Marie Roberts | HMP/YOI Eastwood Park | Natural | Published | 24 Jul 2021 | 6 |
| Keith Williams | HMP Dovegate | Self-inflicted | Published | 12 Jul 2021 | 14 |
| Akhtar Hussain | HMP Manchester | Self-inflicted | Published | 8 Jul 2021 | 12 |
| 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 |
| Piotr Marszalek | HMP Wandsworth | Self-inflicted | Published | 8 Jun 2021 | 8 |
| James Kiteley | HMP Sudbury | Other | Published | 5 Jun 2021 | 3 |
| Jake Swords | HMP Peterborough | Other | Published | 2 Jun 2021 | 2 |
| Robert Stephens | HMP The Verne | Natural | Published | 28 May 2021 | 5 |
| Lukasz Lukasik | HMP Hull | Self-inflicted | Published | 27 May 2021 | 6 |
| Sebastião Lucas | HMP Wandsworth | Self-inflicted | Published | 12 May 2021 | 6 |
| Peter Coulthard | HMP Whatton | Natural | Published | 23 Mar 2021 | 4 |
| Carl Sheldon | Wharflane House Approved Premises | Other | Published | 8 Mar 2021 | 3 |
| Jason McQuoid | HMP Risley | Self-inflicted | Published | 2 Mar 2021 | 5 |
| George Petrou | HMP Pentonville | Self-inflicted | Published | 1 Mar 2021 | 7 |
| Przemyslaw Wozniak | HMP Wandsworth | Self-inflicted | Published | 17 Feb 2021 | 8 |
| Deejay Blampey | HMP Exeter | Self-inflicted | Published | 2 Feb 2021 | 7 |
| Joshua Esberger | HMP Hull | Self-inflicted | Published | 11 Jan 2021 | 5 |
| Robert Frith | HMP Berwyn | Self-inflicted | Published | 14 Nov 2020 | 8 |
| Christopher Parker | HMP Holme House | Self-inflicted | Published | 12 Nov 2020 | 4 |
| Michael Lavin | HMP Altcourse | Natural | Published | 12 Nov 2020 | 6 |
| Dean Briant | HMP Littlehey | Self-inflicted | Published | 18 Jul 2020 | 2 |
| Marek Witulski | HMP Peterborough | Self-inflicted | Published | 9 Jul 2020 | 5 |
| Terence Devereux | HMP Channings Wood | Self-inflicted | Published | 24 May 2020 | 5 |