State Custody related deaths

PFD Category
Reports: 348 Areas: 57 Earliest: Aug 2013 Latest: 19 Feb 2026

74% response rate (above 62% average). 74% of classified responses show concrete action taken. Reports rose 40% from 25 (2023) to 35 (2024).

Response Status
Responded 256 No Response 3 Historic 73 Pending 7
AI Classification
Action Taken 74%
Action Planned 16%
Noted 11%
Disputed 0%
Based on 19 classified responses
Reports by Quarter
PFD Reports
348 results
Rajwinder Singh
Response Pending
2026-0100 19 Feb 2026 Inner West London
HMP Wandsworth NHS England Oxleas
Concerns summary HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and offers no training in risk formulation.
Edward Hands
Response Pending
2026-0097 17 Feb 2026 Bedfordshire and Luton
Northamptonshire Healthcare Foundation … HMP Bedford Ministry of Justice
Concerns summary Confusion and differing policies between prison and healthcare staff regarding prisoners under the influence led to inadequate observation, failed recognition of clinical deterioration, and delayed medical assessment.
Josh Tarrant (1)
Response Pending
2026-0075 9 Feb 2026 Mid Kent & Medway
NHS England
Concerns summary Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Josh Tarrant (2)
Response Pending
2026-0076 9 Feb 2026 Mid Kent & Medway
Prisons Probation and Reducing Reoffending
Concerns summary Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Josh Tarrant (3)
Response Pending
2026-0077 9 Feb 2026 Mid Kent & Medway
HMP Elmley
Concerns summary Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Gareth Chumber-Kelly
Response Pending
2026-0073 9 Feb 2026 North London
HMPPS Serco HMP Pentonville +1 more
Concerns summary Inefficient prison reception processes lead to lost critical prisoner information, and suicide/self-harm training for staff was suspended despite high rates of suicidal ideation and ligature deaths.
Emmett Morrison
Response Pending
2026-0071 6 Feb 2026 Worcestershire
Prison Probation and Reducing Offending
Concerns summary HMP Long Lartin suffered from a continued influx of illicit drugs. There were also systemic failures in the ACCT process, with no support actions recorded for a prisoner with a history of self-harm.
Anthony Binfield
All Responded
2025-0080 17 Dec 2025 Nottingham City and Nottinghamshire
HMP Lowdham Grange
Concerns summary A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm risk, persists despite repeated policy reminders and staff unawareness.
Sundeep Ghuman
Partially Responded
2025-0625 15 Dec 2025 London Inner South
Ministry of Justice HMP Belmarsh
Concerns summary Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead of 'high risk,' reflecting a significant training and operational failure.
Action taken summary HMP Belmarsh has withdrawn its S1 system and both Belmarsh and HMP High Down are now fully compliant with national CSRA policy. Naloxone is now available across residential units with trained staff, a
Oliver Mulangala
Partially Responded
2025-0610 8 Dec 2025 Surrey
HMP High Down HMPPS Ministry of Justice
Concerns summary The pervasive availability of illicit drugs, particularly new psychoactive substances, and mobile phones in HMP High Down leads to widespread misuse, coercion, and severe safety concerns.
Action taken summary HMPPS is investing over £40m in physical security measures across 34 prisons in 2025/2026, including anti-drone technology, and all adult male closed prisons are equipped with X-ray body scanners. The
Stuart Berry
Partially Responded
2026-0015 1 Dec 2025 Essex
HMPPS MoJ Essex Partnership University NHS Founda…
Concerns summary Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, inadequate observations, and accessible ligature points, contributed to the death.
Action taken summary HMPPS has developed interim upskilling sessions on self-harm and suicide risks for prison officers, and the Safety Support Skills training module is under national review. Four ligature-resistant cell
Aminata Coulibaly
All Responded
2025-0596 26 Nov 2025 Essex
Chief Constable of Essex Police
Concerns summary Police failed to share critical self-harm information with mental health services and contact handlers inadequately recorded severe welfare concerns, hindering appropriate assessment and response.
Action taken summary Essex Police has implemented new training on victim care and information sharing, established a new communication framework with EPUT, and introduced new guidance and a Quality Assurance team in Conta
Diana Grant
Partially Responded
2025-0594 24 Nov 2025 Surrey
[REDACTED] The Secretary of State for t… NHS England [REDACTED] CEO
Concerns summary Critically ill mental health patients needing secure admission, especially if dangerous, face unavoidable prolonged detention in prison due to restricted unit capacity, where their needs cannot be fully met, posing a risk of death.
Action taken summary NHS England has established Single Points of Contact (SPoCs) across all 15 Secure Provider Collaboratives to streamline mental health bed admissions from prisons, and these SPoCs are implementing robu
Steven Ruddick
All Responded
2025-0591 18 Nov 2025 County Durham and Darlington
REDACTED
Concerns summary Procedural differences in observing detained persons during toilet visits between police and GeoAmey custody created an opportunity for prohibited items to be hidden. The subsequent search was also potentially inadequate.
Matthew Singh Prevention of future deaths report
Partially Responded
2025-0567 5 Nov 2025 North Wales (East and Central)
Ministry of Justice c/o Government Lega… HMP Berwyn London +1 more
Concerns summary High availability and use of illicit psychoactive substances persist at HMP Berwyn, posing significant risks to prisoner health and contributing to future deaths.
Action taken summary HMPPS has implemented physical security enhancements, including anti-drone measures and window improvements, and invested over £40 million this financial year. They have also established Incentivised
Steven Davidson
All Responded
2025-0536 21 Oct 2025 Essex
HCRG Care Group
Concerns summary Healthcare staff at HMP Chelmsford lack proficiency in navigating System One records to find critical past self-harm information, or are unaware of its importance during prisoner health assessments, indicating training deficiencies.
Action taken summary HCRG has amended its training provision to include mandatory structured SystmOne training for all new staff during induction and refresher training for existing staff. They are also embedding this tra
Declan Carr
All Responded
2025-0541 20 Oct 2025 East Riding of Yorkshire and City of Kingston Upon Hull
NHS England
Concerns summary Inadequate national policy for sharing information on psycho-social support for substance misuse during prisoner transfers risks continuity of care and future deaths.
Action taken summary NHS England confirmed that a national pathway for transferring non-clinical healthcare information, including psycho-social support, between prisons was implemented on 24 November 2025. They also cond
Scott Berry
All Responded
2026-0038 20 Oct 2025 City of Kingston Upon Hull and the County of the East Riding of Yorkshire
HM Prison & Probation Service
Concerns summary Imprisonment for Public Protection (IPP) prisoners face profound hopelessness and mental health suffering due to indefinite detention and lack of access to parole reviews or rehabilitative programs, increasing suicide risk.
Action taken summary HM Prison and Probation Service has implemented multiple changes to policy and practice for IPP prisoners, including revisions to release on temporary licence and offender management processes. They h
Jamie Funnell
All Responded
2025-0508 13 Oct 2025 East Sussex
Practice Plus Group
Concerns summary An expired alcohol dependence policy, chaotic emergency care with faulty equipment and incorrect CPR, and insufficient training evidence demonstrate a cavalier attitude to patient safety.
Action taken summary Practice Plus Group has implemented bimonthly dip tests for emergency response bags, delivered comprehensive training, and implemented a new guidance document. They also confirm that the alcohol depen
Richard Hunt
Partially Responded
2025-0498 8 Oct 2025 Rutland and North Leicestershire
Crown Premises Fire & Safety Inspectora… His Majesty’s Prison & Probation Service Governor HMP Stocken
Concerns summary Deliberate tampering with prison fire alarm systems, disabling their buzzers, led to undetected fires, a systemic issue worsened by the absence of central oversight for wing office fault reporting.
Steven Hart
Partially Responded
2025-0487 24 Sep 2025 Bedfordshire and Luton
CEO of HMPPS [REDACTED] Governor [REDACTED] HM Chief Inspector of Prisons [REDACTED]
Concerns summary Systemic failings included an unmonitored ligature point in a 'safer cell,' inadequate communication of mental state risks during handovers, and observations not being carried out to standard, contributing to the death.
Martin Collins
Partially Responded
2025-0497 17 Sep 2025 Suffolk
Minister of State for Prisons Probation and Reducing Reoffending
Concerns summary The prison telephone system lacks automated monitoring for unusual call volumes and there's no system for manual oversight, leading to missed opportunities to identify risk triggers and prevent suicide.
Action taken summary HM Prison and Probation Service confirms initial discussions are underway with BT to explore the technical feasibility of implementing automated monitoring of prisoner call volumes, with this work to
Masood Hamid
All Responded
2025-0434 20 Aug 2025 Manchester North
Chief Executive North West Ambulance Se… Chief Executive Oldham Borough Council Chief Constable Greater Manchester Poli… +1 more
Concerns summary There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective investigation into the death, hindering learning and future prevention.
Lewis Petryszyn
Partially Responded
2025-0394 31 Jul 2025 South Wales Central
G4S Cwn Taf Morgannwg University Health Boa…
Concerns summary Policies lack specified timeframes for intervention and support for prisoners at risk of substance misuse, leading to delayed care and intervention from the Dyfodol service.
Azroy Dawes-Clarke
Partially Responded
2025-0388 29 Jul 2025 Kent and Medway
Department of Health and Social Care Ministry of Justice
Concerns summary Communication during a medical emergency in prison was confused, with no clear command structure established between prison staff, healthcare, and paramedics, indicating an ongoing risk for future critical events.