Source · Deaths in custody

PPO Fatal Incident Reports

6,470 incidents 5,745 published 1,502 recommendations 1,653 self-inflicted 3,404 natural causes

Deaths in custody investigated by the Prisons and Probation Ombudsman. 26% of deaths are self-inflicted. Source: PPO.

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Learning & thematic publications

75 cross-establishment publications

Learning Lessons Bulletins (50), thematic reviews (2), consultation responses (11), Policy into Practice (5) and annual reports (7): the systemic patterns the Ombudsman draws from many investigations.

TitleTypeDateSource
Annual Report 2025 to 2026 Annual report Jul 2026 PDF
PPO response to JSC Inquiry into Children and Young Adults in the Secure Estate  Consultation response Jun 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
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
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
Complaints Investigations Learning Lessons Bulletin Issue 11: Property complaints Learning Lessons Bulletin Mar 2025 PDF
PPO response to JSC inquiry into Rehabilitation and Resettlement Consultation response Feb 2025 PDF
PPO response to JHAC Inquiry into Prison Culture Consultation response Feb 2025 PDF
PPO response to JSC Tackling Drugs in Prison Inquiry Consultation response Feb 2025 PDF
Policy into Practice: Emergency Response Policy into Practice Jan 2025 PDF
PPO response to the Independent Sentencing Review 2024/25 call for evidence Consultation response Jan 2025 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 19: Post-release death investigations 2 Learning Lessons Bulletin Jul 2024 PDF
Annual report 2022-23 Annual report Jul 2024 PDF
Annual Report 2023-24 Annual report Jul 2024 PDF
Policy into practice: Use of force Policy into Practice Feb 2024 PDF
PPO response to the inquiry into prison population and capacity Consultation response Nov 2023 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 18: Self-inflicted deaths of IPP prisoners Learning Lessons Bulletin Sep 2023 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 17: Post-release death investigations Learning Lessons Bulletin Jan 2023 PDF
Investigating deaths after release from prison – a pilot evaluation Learning Lessons Bulletin Jan 2023 PDF
PPO response to the inquiry into the Prison Operational Workforce Consultation response Jan 2023 PDF
Annual Report 2021-22 Annual report Oct 2022 PDF
Policy into Practice: Use of restraints on escort Policy into Practice Sep 2022 PDF
PPO Response to the Inquiry into IPP sentences Consultation response Jan 2022 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 16: Second wave COVID-19 related deaths Learning Lessons Bulletin Dec 2021 PDF
Annual Report 2020-21 Annual report Sep 2021 PDF
PPO responses to the Inquiry into Women in Prison Consultation response Aug 2021 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 15: COVID-19 PPO fatal incident investigations Learning Lessons Bulletin Feb 2021 PDF

Incidents

111 records
Name Establishment Cause Status Date of death Recs
Sean Williams Natural Published 3
Arron Hamer HMP Buckley Hall Self-inflicted Published 4
Patryk Jalocha HMP Manchester Self-inflicted Published 2
Malcolm MacDougal HMP Full Sutton Other Published 3
Brian Holland HMP Liverpool Natural Published 1
Paul Deville HMP Manchester Natural Published 2
Charles Stevens HMP Swaleside Other Published 2
John Phillips HMP Dartmoor Self-inflicted Published 2
Taylor Atkinson HMP/YOI Eastwood Park Self-inflicted Published 6
Michael Marsh HMP Exeter Self-inflicted Published 6
Mark Bradley HMP Stafford Self-inflicted Published 2
Michael Quinn HMP Berwyn Natural Published 6
Clare Dupree HMP/YOI Eastwood Park Other Published 2
Christopher Walton HMP Ranby Natural Published 6 Feb 2025 7
Stephen Blackwell HMP Oakwood Natural Published 18 Jan 2025 1
Ming Jiang HMP Swaleside Natural Published 21 Jul 2024 4
Peter Honnor HMP Wandsworth Natural Published 27 Jun 2024 4
David Baxter HMP Wealstun Natural Published 26 May 2024 5
David Maggs HMP/YOI Parc Natural Published 7 May 2024 1
Rana Khan HMP Wandsworth Natural Published 5 Apr 2024 4
Stephen Smith HMP Liverpool Natural Published 24 Mar 2024 2
Kevin Noel HMP Leyhill Natural Published 18 Jan 2024 2
John Kelk HMP Wakefield Natural Published 30 Dec 2023 2
Jamie Funnell HMP Lewes Other Published 16 Dec 2023 3
Melvin Grant HMP Bedford Self-inflicted Published 21 Nov 2023 3
Simon Faherty HMP Elmley Self-inflicted Published 20 Nov 2023 4
Josh Tarrant HMP Elmley Other Published 1 Nov 2023 2
Steven Lee HMP Preston Natural Published 19 Oct 2023 2
Davina Canning HMP Hewell Self-inflicted Published 29 Jul 2023 3
Rajwinder Singh HMP Wandsworth Self-inflicted Published 25 Jun 2023 6
Glody Muyeki HMP Aylesbury Other Published 15 May 2023 2
Malcolm Vickery HMP/YOI Parc Natural Published 11 Mar 2023 1
Anthony Binfield HMP Lowdham Grange Self-inflicted Published 6 Mar 2023 4
Christopher Corkill Isle of Man Self-inflicted Published 24 Feb 2023 15
Andrew Hadwin HMP Durham Natural Published 2 Feb 2023 4
Roy King HMP Littlehey Self-inflicted Published 30 Jan 2023 5
Ian Deavall HMP Forest Bank Natural Published 24 Jan 2023 3
Ian Wadsworth Elm Bank Approved Premises Other Published 21 Jan 2023 2
Ross Appleby HMP/YOI Parc Other Published 18 Jan 2023 1
Paul Paget HMP Swaleside Natural Published 17 Jan 2023 3
Mark Mason HMP Durham Self-inflicted Published 8 Dec 2022 2
Curtis Cadman HMP Lincoln Natural Published 21 Nov 2022 2
Aaron Harte HMP Peterborough Other Published 3 Nov 2022 4
John Warry HMP Stafford Natural Published 25 Sep 2022 10
Dale Samm HMP The Mount Self-inflicted Published 25 Sep 2022 2
Terrance Dass HMP Littlehey Natural Published 20 Sep 2022 1
Anthony O’Connell HMP Swaleside Self-inflicted Published 18 Sep 2022 9
Thomas Oleisky HMP Wealstun Self-inflicted Published 11 Sep 2022 5
Steven Haldane HMP Stafford Natural Published 29 Aug 2022 2
Sebastian Mularz HMP Hull Natural Published 17 Aug 2022 6