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 |
|---|---|---|---|---|---|
| William Roalfe | HMP Channings Wood | Natural | Published | 20 Nov 2021 | 9 |
| Maqsood Asif | HMP Stafford | Natural | Published | 18 Nov 2021 | 5 |
| Ann-Marie Pyle | HMP/YOI Drake Hall | Natural | Published | 30 Sep 2021 | 1 |
| Ashley Wood | HMP Exeter | Self-inflicted | Published | 9 Sep 2021 | 9 |
| David Mears | HMP Channings Wood | Natural | Published | 17 Aug 2021 | 6 |
| Matthew Braben | HMP Wormwood Scrubs | Self-inflicted | Published | 16 Aug 2021 | 5 |
| 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 |
| Khyber Nasim | HMP Pentonville | Self-inflicted | Published | 17 Jun 2021 | 3 |
| Piotr Marszalek | HMP Wandsworth | Self-inflicted | Published | 8 Jun 2021 | 8 |
| Robert Stephens | HMP The Verne | Natural | Published | 28 May 2021 | 5 |
| Lukasz Lukasik | HMP Hull | Self-inflicted | Published | 27 May 2021 | 6 |
| Godfrey Muzhuzha | HMP The Mount | Natural | Published | 3 May 2021 | 4 |
| Peter Coulthard | HMP Whatton | Natural | Published | 23 Mar 2021 | 4 |
| Rimantas Zalalis | HMP Thameside | Other | Published | 22 Mar 2021 | 4 |
| George Petrou | HMP Pentonville | Self-inflicted | Published | 1 Mar 2021 | 7 |
| Clive Pinder | HMP Risley | Natural | Published | 17 Feb 2021 | 5 |
| Deejay Blampey | HMP Exeter | Self-inflicted | Published | 2 Feb 2021 | 7 |
| David Reid | HMP Rye Hill | Natural | Published | 11 Jan 2021 | 5 |
| Joshua Esberger | HMP Hull | Self-inflicted | Published | 11 Jan 2021 | 5 |
| Michael Lavin | HMP Altcourse | Natural | Published | 12 Nov 2020 | 6 |
| James Drury | HMP Exeter | Natural | Published | 23 Jun 2020 | 1 |
| Terence Devereux | HMP Channings Wood | Self-inflicted | Published | 24 May 2020 | 5 |
| Ronnie Gaunt | HMP Risley | Natural | Published | 15 Apr 2020 | 1 |
| Alex John | HMP Pentonville | Natural | Published | 13 Jan 2020 | 2 |
| Liridon Saliuka | HMP Belmarsh | Self-inflicted | Published | 2 Jan 2020 | 15 |
| Gary Bell | HMP Holme House | Self-inflicted | Published | 28 Dec 2019 | 4 |
| Saria Hart | HMP/YOI Foston Hall | Self-inflicted | Published | 12 Oct 2019 | 5 |
| Jason Birch | HMP Whitemoor | Self-inflicted | Published | 26 Sep 2019 | 5 |
| Malacai Samson | HMP Pentonville | Self-inflicted | Published | 23 Aug 2019 | 7 |
| Frederick Heard | HMP/YOI Parc | Natural | Published | 9 Aug 2019 | 4 |
| Thomas Moffett | HMP Preston | Natural | Published | 6 Aug 2019 | 5 |
| Paul David Horrocks | HMP Thorn Cross | Other | Published | 30 Jun 2019 | 7 |
| Christine McDonald | HMP/YOI Styal | Self-inflicted | Published | 3 Mar 2019 | 9 |
| Peter Howard | HMP Littlehey | Natural | Published | 15 Jun 2018 | 2 |
| Taras Nykolyn | HMP Woodhill | Homicide | Published | 5 Jun 2018 | 7 |
| Kevin Delahunty | HMP Risley | Self-inflicted | Published | 29 Mar 2018 | 8 |
| Nicola Birchall | HMP/YOI Styal | Other | Published | 4 Feb 2018 | 4 |
| Aaron Nunes | HMP/YOI Parc | Natural | Published | 21 Feb 2016 | 25 |
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