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: safeguarding · Remove

Incidents

178 records

Sean Higgins

HMP RochesterDate of death 7 February 2024

Self-inflictedInvestigation: Report published6 recommendations indexed

PPO entry published 7 March 2025

Kevin Kane

HMP GrendonDate of death 29 January 2024

Self-inflictedInvestigation: Report published3 recommendations indexed

PPO entry published 8 August 2025

Patryk Gladysz

HMP WandsworthDate of death 19 January 2024

Self-inflictedInvestigation: Report published3 recommendations indexed

PPO entry published 1 August 2025

Nathan Shepherd

Ascot House Approved PremisesDate of death 16 January 2024

Self-inflictedInvestigation: Report published3 recommendations indexed

PPO entry published 4 April 2025

Melvin Grant

HMP BedfordDate of death 21 November 2023

Self-inflictedInvestigation: Report published3 recommendations indexed

PPO entry published 28 October 2025

Simon Faherty

HMP ElmleyDate of death 20 November 2023

Self-inflictedInvestigation: Report published4 recommendations indexed

PPO entry published 4 April 2025

Paul Roberts

HMP PrestonDate of death 14 November 2023

Self-inflictedInvestigation: Report published1 recommendation indexed

PPO entry published 25 October 2024

Davey Price

HMP Forest BankDate of death 27 October 2023

Self-inflictedInvestigation: Report published3 recommendations indexed

PPO entry published 1 November 2024

Karl Quincey

HMP WakefieldDate of death 21 October 2023

Self-inflictedInvestigation: Report published2 recommendations indexed

PPO entry published 19 December 2025

Andrew Hague

HMP WealstunDate of death 15 October 2023

Other non-naturalInvestigation: Report published2 recommendations indexed

PPO entry published 16 July 2025

Muxsin Awjama

HMP NottinghamDate of death 5 October 2023

Self-inflictedInvestigation: Report published2 recommendations indexed

PPO entry published 31 October 2024

Piotr Zmijewski

HMP MaidstoneDate of death 9 September 2023

Self-inflictedInvestigation: Report published3 recommendations indexed

PPO entry published 17 April 2025

Andrew Winspear

HMP HullDate of death 8 August 2023

Self-inflictedInvestigation: Report published1 recommendation indexed

PPO entry published 15 May 2025

Davina Canning

HMP HewellDate of death 29 July 2023

Self-inflictedInvestigation: Report published3 recommendations indexed

PPO entry published 25 April 2025

John Rombach

HMP StaffordDate of death 17 July 2023

Natural causesInvestigation: Report published2 recommendations indexed

PPO entry published 9 May 2025

Mark Beresford

HMP RanbyDate of death 7 July 2023

Self-inflictedInvestigation: Report published1 recommendation indexed

PPO entry published 25 October 2024

Rajwinder Singh

HMP WandsworthDate of death 25 June 2023

Self-inflictedInvestigation: Report published6 recommendations indexed

PPO entry published 8 August 2025

Filmon Brhane

HMP MaidstoneDate of death 12 June 2023

Self-inflictedInvestigation: Report published8 recommendations indexed

PPO entry published 19 September 2025

Damon Hardman

HMP LewesDate of death 8 June 2023

Self-inflictedInvestigation: Report published3 recommendations indexed

PPO entry published 21 July 2025

Lee Gorst

HMP ManchesterDate of death 25 April 2023

Self-inflictedInvestigation: Report published1 recommendation indexed

PPO entry published 24 October 2025

Kevin Smith

HMP/YOI DoncasterDate of death 22 April 2023

Self-inflictedInvestigation: Report published2 recommendations indexed

PPO entry published 24 June 2025

Steven Hart

HMP BedfordDate of death 29 March 2023

Self-inflictedInvestigation: Report published4 recommendations indexed

PPO entry published 18 July 2025

Frank Ospina

Colnbrook Immigration Removal CentreDate of death 26 March 2023

Self-inflictedInvestigation: Report published4 recommendations indexed

PPO entry published 15 October 2024

Rolandas Karbauskas

HMP Lowdham GrangeDate of death 25 March 2023

Self-inflictedInvestigation: Report published6 recommendations indexed

PPO entry published 7 February 2025

Keith Gadd

HMP BristolDate of death 9 March 2023

Self-inflictedInvestigation: Report published2 recommendations indexed

PPO entry published 20 August 2025

Christopher Beddall

HMP DovegateDate of death 26 February 2023

Self-inflictedInvestigation: Report published1 recommendation indexed

PPO entry published 9 July 2025

Karl Reavy

HMP LiverpoolDate of death 15 February 2023

Other non-naturalInvestigation: Report published1 recommendation indexed

PPO entry published 18 July 2025

Fallon Adams

HMP PeterboroughDate of death 9 February 2023

Other non-naturalInvestigation: Report published1 recommendation indexed

PPO entry published 5 December 2025

Roy King

HMP LittleheyDate of death 30 January 2023

Self-inflictedInvestigation: Report published5 recommendations indexed

PPO entry published 11 April 2025

Mohammed Eumda

HMP ChelmsfordDate of death 30 January 2023

Self-inflictedInvestigation: Report published2 recommendations indexed

PPO entry published 25 October 2024

Colin Ryan

HMP BristolDate of death 29 January 2023

Self-inflictedInvestigation: Report published1 recommendation indexed

PPO entry published 3 October 2025

Weighman, Daniel

HMP ChelmsfordDate of death 6 January 2023

Self-inflictedInvestigation: Report published3 recommendations indexed

PPO entry published 2 May 2024

Oliver Davies

HMP HewellDate of death 31 December 2022

Self-inflictedInvestigation: Report published3 recommendations indexed

PPO entry published 6 November 2024

Thomas Goldring

HMP WinchesterDate of death 29 December 2022

Self-inflictedInvestigation: Report published4 recommendations indexed

PPO entry published 19 December 2025

Uddin, Mohammed Sayeef

HMP HighpointDate of death 28 December 2022

Self-inflictedInvestigation: Report published4 recommendations indexed

PPO entry published 21 May 2024

Matthew Xavier

HMP HighpointDate of death 16 December 2022

Natural causesInvestigation: Report published2 recommendations indexed

PPO entry published 30 August 2024

Jonusas, Ricardas

HMP SwalesideDate of death 16 December 2022

Self-inflictedInvestigation: Report published2 recommendations indexed

PPO entry published 22 April 2024

Ben Hyland

HMP LeedsDate of death 11 December 2022

Self-inflictedInvestigation: Report published1 recommendation indexed

PPO entry published 8 July 2024

Anderson, Craig

Isle of Man PrisonDate of death 25 November 2022

Self-inflictedInvestigation: Report published15 recommendations indexed

PPO entry published 29 April 2024

Ian Kettles

HMP BristolDate of death 11 November 2022

Self-inflictedInvestigation: Report published4 recommendations indexed

PPO entry published 7 February 2025

Ahmed Alshbli

HMP DurhamDate of death 10 November 2022

Self-inflictedInvestigation: Report published2 recommendations indexed

PPO entry published 20 February 2025

Russell Irvine

HMP DurhamDate of death 7 November 2022

Self-inflictedInvestigation: Report published5 recommendations indexed

PPO entry published 8 July 2024

Tyrone Richards

HMP ManchesterDate of death 25 October 2022

Self-inflictedInvestigation: Report published1 recommendation indexed

PPO entry published 1 May 2025

Kevin McDonnel

HMP NottinghamDate of death 29 September 2022

Self-inflictedInvestigation: Report published2 recommendations indexed

PPO entry published 26 July 2024

Dale Samm

HMP The MountDate of death 25 September 2022

Self-inflictedInvestigation: Report published2 recommendations indexed

PPO entry published 11 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

Sebastian Mularz

HMP HullDate of death 17 August 2022

Natural causesInvestigation: Report published6 recommendations indexed

PPO entry published 21 July 2025

Sion Evans

HMP/YOI ParcDate of death 12 August 2022

Self-inflictedInvestigation: Report published5 recommendations indexed

PPO entry published 21 February 2025

Max Marchant

HMP The MountDate of death 25 July 2022

Other non-naturalInvestigation: Report published13 recommendations indexed

PPO entry published 19 March 2025

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