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.
Top recommendation themes
Learning & thematic publications
| Title | Type | Date | Source |
|---|---|---|---|
| Annual Report 2025 to 2026 | Annual report | Jul 2026 | |
| 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 inquiry into Rehabilitation and Resettlement | Consultation response | Feb 2025 | |
| PPO response to JHAC Inquiry into Prison Culture | Consultation response | Feb 2025 | |
| PPO response to JSC Tackling Drugs in Prison Inquiry | 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 2022-23 | Annual report | Jul 2024 | |
| Annual Report 2023-24 | 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 | |
| Fatal Incident Investigations Learning Lessons Bulletin Issue 17: Post-release death investigations | Learning Lessons Bulletin | Jan 2023 | |
| Investigating deaths after release from prison – a pilot evaluation | 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 |
Incidents
| Name | Establishment | Cause | Status | Date of death | Recs |
|---|---|---|---|---|---|
| Brian Fletcher | HMP Hewell | Natural | Published | — | 5 |
| Michael Dawson | HMP Lindholme | Natural | Published | — | 4 |
| Peter Brook | HMP Leeds | Natural | Published | — | 1 |
| Ann Browning | HMP Send | Natural | Published | — | 1 |
| David Marsh | HMP Lincoln | Natural | Published | — | 2 |
| Mark Waterman | HMP Swansea | Natural | Published | — | 2 |
| Peter Williams | HMP Littlehey | Natural | Published | — | 2 |
| Fay Newman | HMP/YOI Downview | Natural | Published | — | 2 |
| David Morris | HMP Frankland | Natural | Published | — | 3 |
| Peter Magloire | HMP Wormwood Scrubs | Self-inflicted | Published | — | 3 |
| Andrew Clark | HMP Norwich | Natural | Published | — | 2 |
| George Haldenby | HMP The Verne | Natural | Published | — | 3 |
| Brian James | HMP Elmley | Natural | Published | — | 1 |
| Adam Diesa-Green | HMP Lowdham Grange | Other | Published | — | 1 |
| Daniel Brown | HMP/YOI High Down | Natural | Published | — | 3 |
| Kenneth Cox | HMP Norwich | Natural | Published | — | 2 |
| Dean Collins | HMP Birmingham | Natural | Published | — | 2 |
| Kenneth Kesans | HMP Usk | Natural | Published | — | 2 |
| Kevin Golby | HMP Five Wells | Unascertained | Published | — | 1 |
| Uziel Mendoza-Sillerico | HMP Lowdham Grange | Natural | Published | — | 10 |
| Thomas Ruggiero | HMP Swaleside | Self-inflicted | Published | — | 5 |
| Simon Ludlow | HMP The Mount | Other | Published | — | 2 |
| Jake O’Brien | HMP Forest Bank | Self-inflicted | Published | — | 12 |
| Surendra Patel | HMP Hewell | Natural | Published | — | 4 |
| Andrew Neal | HMP Wayland | Self-inflicted | Published | — | 5 |
| Philip Eldridge | HMP The Verne | Natural | Published | — | 1 |
| Colin Storey | HMP Northumberland | Self-inflicted | Published | — | 3 |
| Lee Martin | HMP Winchester | Natural | Published | — | 2 |
| John McGovern | HMP The Verne | Natural | Published | — | 3 |
| Stephen McDermott | HMP Isle of Wight | Natural | Published | — | 1 |
| Taylor Atkinson | HMP/YOI Eastwood Park | Self-inflicted | Published | — | 6 |
| Henry Benoi-Davies | HMP Nottingham | Natural | Published | — | 5 |
| Daniel Bates | HMP Northumberland | Other | Published | — | 2 |
| Michael Quinn | HMP Berwyn | Natural | Published | — | 6 |
| Keith Saunders | HMP Peterborough | Natural | Published | — | 2 |
| Benjamin Harrison | HMP Rochester | Other | Published | — | 5 |
| Nigel Malt | HMP Gartree | Natural | Published | 29 Apr 2025 | 1 |
| Peter Long | HMP Oakwood | Natural | Published | 10 Mar 2025 | 1 |
| Glen Candler | HMP Wakefield | Natural | Published | 6 Mar 2025 | 1 |
| Christopher Tatton | HMP Rye Hill | Natural | Published | 28 Feb 2025 | 1 |
| Raymond Connor | HMP Whatton | Natural | Published | 22 Feb 2025 | 2 |
| Timothy Frank | HMP Ranby | Natural | Published | 10 Feb 2025 | 2 |
| Christopher Walton | HMP Ranby | Natural | Published | 6 Feb 2025 | 7 |
| Lorna Carter | HMP/YOI Styal | Natural | Published | 27 Jan 2025 | 1 |
| Brian Kemp | HMP Fosse Way | Natural | Published | 26 Jan 2025 | 3 |
| Alan Hughes | HMP Risley | Natural | Published | 6 Jan 2025 | 2 |
| Brian Hayes | HMP/YOI High Down | Natural | Published | 1 Jan 2025 | 1 |
| Carl Forrester | HMP Exeter | Natural | Published | 13 Nov 2024 | 2 |
| John Corran | Isle of Man | Natural | Published | 12 Nov 2024 | 1 |
| John Freer | HMP Northumberland | Natural | Published | 29 Oct 2024 | 1 |
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