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 |
|---|---|---|---|---|---|
| Heather, Darren | HMP Bure | Natural | Published | 26 Jul 2022 | — |
| Doyle, Eamonn | HMP Rye Hill | Natural | Published | 25 Jul 2022 | — |
| Max Marchant | HMP The Mount | Other | Published | 25 Jul 2022 | 13 |
| Individual at Rye Hill | HMP Rye Hill | Natural | Published | 24 Jul 2022 | — |
| Lightbourne, Terrance | HMP Preston | Natural | Published | 24 Jul 2022 | — |
| Individual at Altcourse | HMP Altcourse | Natural | Published | 23 Jul 2022 | — |
| Lawton, Michael | Stoke Heath Post-release | Natural | Published | 22 Jul 2022 | — |
| Neil McKenna | HMP Littlehey | Natural | Published | 19 Jul 2022 | 2 |
| Emlyn Francis | HMP Dovegate | Natural | Published | 18 Jul 2022 | 3 |
| Mitchell, Richard | The Mount Post-release | Other | Published | 17 Jul 2022 | — |
| Malcolm Bennett | HMP Bullingdon | Self-inflicted | Published | 16 Jul 2022 | — |
| Cannon, Wayne | HMP Bullingdon | Natural | Published | 15 Jul 2022 | — |
| Tyrone Beresford | HMP The Mount | Other | Published | 14 Jul 2022 | 7 |
| Individual at Holme House | HMP Holme House | Natural | Published | 14 Jul 2022 | — |
| Tottem, Michael | HMP Highpoint | Natural | Published | 13 Jul 2022 | — |
| Waterworth, Peter | HMP Leyhill | Natural | Published | 13 Jul 2022 | — |
| Jackson, Andrew | Lincoln Post-release | Self-inflicted | Published | 13 Jul 2022 | — |
| Leon Cadman | HMP Peterborough | Natural | Published | 12 Jul 2022 | 4 |
| Shehu Balogun | HMP Liverpool | Other | Published | 12 Jul 2022 | 1 |
| Peterson, Felix | HMP Berwyn | Natural | Published | 11 Jul 2022 | — |
| Nathaniel Humphreys | HMP Littlehey | Self-inflicted | Published | 11 Jul 2022 | 2 |
| Rushton, Henry | HMP Doncaster | Natural | Published | 8 Jul 2022 | — |
| Individual at Swaleside | HMP Swaleside | Natural | Published | 7 Jul 2022 | — |
| Kayleigh Melhuish | HMP/YOI Eastwood Park | Self-inflicted | Published | 7 Jul 2022 | 8 |
| Parkinson, Lee | Leeds Post-release | Self-inflicted | Published | 6 Jul 2022 | — |
| Williams, Patrick | HMP Leyhill | Natural | Published | 6 Jul 2022 | — |
| Beattie, Richard | HMP Rye Hill | Natural | Published | 4 Jul 2022 | — |
| Joseph Gornall | HMP Humber | Other | Published | 3 Jul 2022 | — |
| Howe, Alex | Ashley House Post-release | Other | Published | 3 Jul 2022 | — |
| Individual at Durham | HMP Durham | Natural | Published | 3 Jul 2022 | — |
| Eileen McDonagh | HMP/YOI Styal | Self-inflicted | Published | 2 Jul 2022 | 2 |
| Kabiri, Vahid | HMP Doncaster | Self-inflicted | Published | 1 Jul 2022 | — |
| Waddingham, Paul | HMP Moorland Closed | Natural | Published | 28 Jun 2022 | — |
| Guiseppe Tabone | HMP Lewes | Other | Published | 28 Jun 2022 | 5 |
| Andrew Evans | HMP Lewes | Other | Published | 28 Jun 2022 | 5 |
| Individual at Whatton | HMP Whatton | Natural | Published | 27 Jun 2022 | — |
| Steven McGuire | HMP Humber | Other | Published | 26 Jun 2022 | — |
| Clifton, Lee | Lindholme Post-release | Other | Published | 25 Jun 2022 | — |
| Browne, Raibeart | HMP Gartree | Natural | Published | 25 Jun 2022 | — |
| Denning, Christopher | HMP Bedford | Natural | Published | 24 Jun 2022 | — |
| Huggins, Philip | HMP Frankland | Natural | Published | 23 Jun 2022 | — |
| Individual at Low Newton Post-release | Low Newton Post-release | Other | Published | 22 Jun 2022 | — |
| Marc Skelly | HMP Lindholme | Self-inflicted | Published | 22 Jun 2022 | 4 |
| Smith, Lee | HMP Hewell | Self-inflicted | Published | 20 Jun 2022 | — |
| Newman, Christopher | HMP The Mount | Natural | Published | 20 Jun 2022 | — |
| Individual at Gartree | HMP Gartree | Natural | Published | 20 Jun 2022 | — |
| Phillips, George | Elmley Post-release | Other | Published | 20 Jun 2022 | — |
| Wilson, John | HMP Forest Bank | Natural | Published | 17 Jun 2022 | — |
| Individual at Altcourse | HMP Altcourse | Natural | Published | 17 Jun 2022 | — |
| Roberts, Michael | HMP Nottingham | Other | Published | 16 Jun 2022 | — |