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.

Clear

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

104 records
Name Establishment Cause Status Date of death Recs
John Chapman HMP Gartree Natural Published 2
Alexander Muzyczka HMP Leeds Self-inflicted Published 2
Mohammed Shabir HMP Leeds Natural Published 1
Steven Ison Bowling Green Approved Premises Self-inflicted Published 3
Christopher Roberts HMP Isle of Wight Natural Published 2
Christopher Stephens HMP Guys Marsh Other Published 2
Graham Stridgeon HMP Wymott Natural Published 2
Peter Hopkins HMP/YOI Doncaster Natural Published 4
Colin Storr HMP Durham Self-inflicted Published 4
Uziel Mendoza-Sillerico HMP Lowdham Grange Natural Published 10
Thomas Ruggiero HMP Swaleside Self-inflicted Published 5
Lee Jackson HMP Bristol Self-inflicted Published 2
Kien Vuong HMP Leeds Self-inflicted Published 4
Nezam Ghalate HMP Manchester Self-inflicted Published 3
John Phillips HMP Dartmoor Self-inflicted Published 2
Luke Ashcroft HMP Lincoln Self-inflicted Published 3
Imran Khan HMP Isle of Wight Self-inflicted Published 10
Michael Marsh HMP Exeter Self-inflicted Published 6
Henry Benoi-Davies HMP Nottingham Natural Published 5
Michael Pugh HMP Swaleside Self-inflicted Published 29 Jun 2024 3
Raymond Moyle HMP Hull Natural Published 20 Jun 2024 2
David Baxter HMP Wealstun Natural Published 26 May 2024 5
Edward Lomas HMP Pentonville Self-inflicted Published 22 May 2024 4
Brian Burrows HMP Leeds Self-inflicted Published 15 May 2024 3
Graham Daggett HMP Lincoln Natural Published 3 Apr 2024 1
Taklus Hussain HMP Littlehey Natural Published 8 Mar 2024 2
Edward Hands HMP Bedford Other Published 16 Feb 2024 4
Kevin Kane HMP Grendon Self-inflicted Published 29 Jan 2024 3
Daniel Fielding HMP Liverpool Self-inflicted Published 19 Jan 2024 6
Nathan Shepherd Ascot House Approved Premises Self-inflicted Published 16 Jan 2024 3
Lawrence Johnson HMP Frankland Natural Published 13 Jan 2024 3
Darren Boamah HMP Wormwood Scrubs Natural Published 3 Jan 2024 2
John Rigby HMP Wymott Natural Published 17 Dec 2023 4
Christopher Baptiste HMP Swaleside Other Published 31 Oct 2023 4
Lucas Kidd HMP Ranby Other Published 19 Oct 2023 2
Ricky Crosher HMP Lowdham Grange Self-inflicted Published 11 Oct 2023 3
Giles Harvey HMP Dovegate Self-inflicted Published 9 Oct 2023 1
Piotr Zmijewski HMP Maidstone Self-inflicted Published 9 Sep 2023 3
Amer Fareed HMP/YOI High Down Other Published 8 Aug 2023 1
Raymond Cartwright HMP Risley Natural Published 6 Aug 2023 2
Liam Darby HMP Erlestoke Other Published 21 Jul 2023 1
Anthony Kwan HMP Channings Wood Natural Published 8 Jul 2023 3
Mark Conway HMP Isle of Wight Natural Published 25 Jun 2023 4
Rajwinder Singh HMP Wandsworth Self-inflicted Published 25 Jun 2023 6
Filmon Brhane HMP Maidstone Self-inflicted Published 12 Jun 2023 8
Amy Cross HMP/YOI Eastwood Park Other Published 10 Jun 2023 2
Joseph Louis HMP Wormwood Scrubs Natural Published 26 Apr 2023 4
Rolandas Karbauskas HMP Lowdham Grange Self-inflicted Published 25 Mar 2023 6
Glen Adrian HMP Durham Self-inflicted Published 8 Mar 2023 3
Anthony Binfield HMP Lowdham Grange Self-inflicted Published 6 Mar 2023 4