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.

Incidents

115 records

Peter Coulthard

HMP WhattonDate of death 23 March 2021

Natural causesInvestigation: Report published4 recommendations indexed

PPO entry published 6 December 2024

George Petrou

HMP PentonvilleDate of death 1 March 2021

Self-inflictedInvestigation: Report published7 recommendations indexed

PPO entry published 8 November 2024

Marek Witulski

HMP PeterboroughDate of death 9 July 2020

Self-inflictedInvestigation: Report published5 recommendations indexed

PPO entry published 17 October 2025

Carl Kent

HMP DartmoorDate of death 21 May 2020

Self-inflictedInvestigation: Report published4 recommendations indexed

PPO entry published 18 July 2025

Ryan Nash

HMP BedfordDate of death 30 April 2020

Self-inflictedInvestigation: Report published10 recommendations indexed

PPO entry published 22 August 2024

Alex John

HMP PentonvilleDate of death 13 January 2020

Natural causesInvestigation: Report published2 recommendations indexed

PPO entry published 17 July 2025

Alan Johnston

HMP LiverpoolDate of death 27 November 2019

Self-inflictedInvestigation: Report published5 recommendations indexed

PPO entry published 12 September 2024

Jason Birch

HMP WhitemoorDate of death 26 September 2019

Self-inflictedInvestigation: Report published5 recommendations indexed

PPO entry published 8 November 2024

Daniel Short

Glogan House Approved PremisesDate of death 14 August 2019

Other non-naturalInvestigation: Report published8 recommendations indexed

PPO entry published 12 December 2025

Frederick Heard

HMP/YOI ParcDate of death 9 August 2019

Natural causesInvestigation: Report published4 recommendations indexed

PPO entry published 29 April 2025

Davide Parra

HMP ErlestokeDate of death 5 August 2019

Self-inflictedInvestigation: Report published4 recommendations indexed

PPO entry published 22 May 2025

Salim Sakaria

HMP RisleyDate of death 14 December 2018

Natural causesInvestigation: Report published3 recommendations indexed

PPO entry published 13 December 2024

James Thomas

HMP RisleyDate of death 20 August 2017

Other non-naturalInvestigation: Report published2 recommendations indexed

PPO entry published 25 September 2024

Adams, Yasmin

HMP Foston HallDate of death 13 November 2016

Self-inflictedInvestigation: Report published6 recommendations indexed

PPO entry published 24 April 2024

Aaron Nunes

HMP/YOI ParcDate of death 21 February 2016

Natural causesInvestigation: Report published25 recommendations indexed

PPO entry published 27 August 2024

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.

TitleTypeDateSource
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