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: healthcare · Remove

Incidents

204 records

Esson, Stuart

HMP RochesterDate of death 12 February 2022

Self-inflictedInvestigation: Report published9 recommendations indexed

PPO entry published 10 April 2024

John Creevy

HMP GarthDate of death 25 January 2022

Natural causesInvestigation: Report published2 recommendations indexed

PPO entry published 9 June 2025

Christopher Reed

HMP Isle of WightDate of death 24 January 2022

Natural causesInvestigation: Report published4 recommendations indexed

PPO entry published 24 October 2025

Musse, Hamdi

Bullingdon Post-releaseDate of death 13 January 2022

Natural causesInvestigation: Report published8 recommendations indexed

PPO entry published 1 May 2024

Ian Davies

HMP BristolDate of death 6 December 2021

Self-inflictedInvestigation: Report published7 recommendations indexed

PPO entry published 11 July 2025

Diana Grant

HMP BronzefieldDate of death 20 November 2021

Self-inflictedInvestigation: Report published6 recommendations indexed

PPO entry published 14 July 2025

William Roalfe

HMP Channings WoodDate of death 20 November 2021

Natural causesInvestigation: Report published9 recommendations indexed

PPO entry published 11 September 2024

Maqsood Asif

HMP StaffordDate of death 18 November 2021

Natural causesInvestigation: Report published5 recommendations indexed

PPO entry published 19 June 2025

Doherty, James

HMP Wormwood ScrubsDate of death 18 November 2021

Self-inflictedInvestigation: Report published8 recommendations indexed

PPO entry published 23 April 2024

Ann-Marie Pyle

HMP/YOI Drake HallDate of death 30 September 2021

Natural causesInvestigation: Report published1 recommendation indexed

PPO entry published 21 March 2025

Ashley Wood

HMP ExeterDate of death 9 September 2021

Self-inflictedInvestigation: Report published9 recommendations indexed

PPO entry published 19 June 2025

David Mears

HMP Channings WoodDate of death 17 August 2021

Natural causesInvestigation: Report published6 recommendations indexed

PPO entry published 4 July 2025

Matthew Braben

HMP Wormwood ScrubsDate of death 16 August 2021

Self-inflictedInvestigation: Report published5 recommendations indexed

PPO entry published 7 March 2025

Daniel Ayers

HMP WinchesterDate of death 25 July 2021

Self-inflictedInvestigation: Report published14 recommendations indexed

PPO entry published 25 July 2025

Keith Williams

HMP DovegateDate of death 12 July 2021

Self-inflictedInvestigation: Report published14 recommendations indexed

PPO entry published 20 September 2024

Akhtar Hussain

HMP ManchesterDate of death 8 July 2021

Self-inflictedInvestigation: Report published12 recommendations indexed

PPO entry published 27 November 2024

Khyber Nasim

HMP PentonvilleDate of death 17 June 2021

Self-inflictedInvestigation: Report published3 recommendations indexed

PPO entry published 12 July 2024

Piotr Marszalek

HMP WandsworthDate of death 8 June 2021

Self-inflictedInvestigation: Report published8 recommendations indexed

PPO entry published 16 August 2024

Robert Stephens

HMP The VerneDate of death 28 May 2021

Natural causesInvestigation: Report published5 recommendations indexed

PPO entry published 11 July 2025

Lukasz Lukasik

HMP HullDate of death 27 May 2021

Self-inflictedInvestigation: Report published6 recommendations indexed

PPO entry published 18 July 2025

Godfrey Muzhuzha

HMP The MountDate of death 3 May 2021

Natural causesInvestigation: Report published4 recommendations indexed

PPO entry published 16 August 2024

Coysh, Edward

HMP WymottDate of death 26 April 2021

Natural causesInvestigation: Report published8 recommendations indexed

PPO entry published 21 May 2024

Peter Coulthard

HMP WhattonDate of death 23 March 2021

Natural causesInvestigation: Report published4 recommendations indexed

PPO entry published 6 December 2024

Rimantas Zalalis

HMP ThamesideDate of death 22 March 2021

Other non-naturalInvestigation: Report published4 recommendations indexed

PPO entry published 26 July 2024

Tate, Jamie

HMP ManchesterDate of death 14 March 2021

Other non-naturalInvestigation: Report published3 recommendations indexed

PPO entry published 24 May 2024

George Petrou

HMP PentonvilleDate of death 1 March 2021

Self-inflictedInvestigation: Report published7 recommendations indexed

PPO entry published 8 November 2024

Clive Pinder

HMP RisleyDate of death 17 February 2021

Natural causesInvestigation: Report published5 recommendations indexed

PPO entry published 26 July 2024

Tuckwell, Peter

HMP OakwoodDate of death 13 February 2021

Natural causesInvestigation: Report published3 recommendations indexed

PPO entry published 4 April 2024

Deejay Blampey

HMP ExeterDate of death 2 February 2021

Self-inflictedInvestigation: Report published7 recommendations indexed

PPO entry published 16 August 2024

David Reid

HMP Rye HillDate of death 11 January 2021

Natural causesInvestigation: Report published5 recommendations indexed

PPO entry published 24 March 2025

Joshua Esberger

HMP HullDate of death 11 January 2021

Self-inflictedInvestigation: Report published5 recommendations indexed

PPO entry published 12 July 2024

Michael Lavin

HMP AltcourseDate of death 12 November 2020

Natural causesInvestigation: Report published6 recommendations indexed

PPO entry published 9 May 2025

Marcus Drury

HMP ExeterDate of death 23 June 2020

Natural causesInvestigation: Report published1 recommendation indexed

PPO entry published 27 September 2024

Terence Devereux

HMP Channings WoodDate of death 24 May 2020

Self-inflictedInvestigation: Report published5 recommendations indexed

PPO entry published 19 June 2025

Ronnie Gaunt

HMP RisleyDate of death 15 April 2020

Natural causesInvestigation: Report published1 recommendation indexed

PPO entry published 27 September 2024

Coath, Andy

HMP PentonvilleDate of death 23 February 2020

Self-inflictedInvestigation: Report published3 recommendations indexed

PPO entry published 4 April 2024

Alex John

HMP PentonvilleDate of death 13 January 2020

Natural causesInvestigation: Report published2 recommendations indexed

PPO entry published 17 July 2025

Liridon Saliuka

HMP BelmarshDate of death 2 January 2020

Self-inflictedInvestigation: Report published15 recommendations indexed

PPO entry published 19 December 2025

Gary Bell

HMP Holme HouseDate of death 28 December 2019

Self-inflictedInvestigation: Report published4 recommendations indexed

PPO entry published 25 October 2024

Perry, Jared

HMP ParcDate of death 3 November 2019

Self-inflictedInvestigation: Report published7 recommendations indexed

PPO entry published 23 April 2024

Saria Hart

HMP/YOI Foston HallDate of death 12 October 2019

Self-inflictedInvestigation: Report published5 recommendations indexed

PPO entry published 11 October 2024

Jason Birch

HMP WhitemoorDate of death 26 September 2019

Self-inflictedInvestigation: Report published5 recommendations indexed

PPO entry published 8 November 2024

Malacai Samson

HMP PentonvilleDate of death 23 August 2019

Self-inflictedInvestigation: Report published7 recommendations indexed

PPO entry published 22 July 2024

Frederick Heard

HMP/YOI ParcDate of death 9 August 2019

Natural causesInvestigation: Report published4 recommendations indexed

PPO entry published 29 April 2025

Thomas Moffett

HMP PrestonDate of death 6 August 2019

Natural causesInvestigation: Report published5 recommendations indexed

PPO entry published 25 April 2025

Paul David Horrocks

HMP Thorn CrossDate of death 30 June 2019

Other non-naturalInvestigation: Report published7 recommendations indexed

PPO entry published 8 November 2024

Christine McDonald

HMP/YOI StyalDate of death 3 March 2019

Self-inflictedInvestigation: Report published9 recommendations indexed

PPO entry published 14 August 2024

Finlayson, Finlay

HMP LewesDate of death 25 January 2019

Natural causesInvestigation: Report published4 recommendations indexed

PPO entry published 12 April 2024

West, Russell

HMP Forest BankDate of death 8 July 2018

Natural causesInvestigation: Report published2 recommendations indexed

PPO entry published 25 April 2024

Peter Howard

HMP LittleheyDate of death 15 June 2018

Natural causesInvestigation: Report published2 recommendations indexed

PPO entry published 16 July 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