State Custody related deaths
PFD Category
Reports: 357
Areas: 57
Earliest: Aug 2013
Latest: 8 Apr 2026
74% response rate (above 63% average). 58% of classified responses show concrete action taken. Reports rose 40% from 25 (2023) to 35 (2024).
PFD Reports
357 resultsRickie Poon
Response Pending
2026-0194
Inner North London
HM Prison Pentonville
Practice Plus Group
Concerns summary (AI summary)
Failures in the ACCT process at HMP Pentonville, including poor management and implementation, insufficient accountability, and gaps in training, contributed to the death. Additionally, the report raises concerns about a nurse performing futile CPR on the deceased, highlighting the need for proper resuscitation training.
Jonathan Thornton
Response Pending
2026-0200
8 Apr 2026
Nottingham and Nottinghamshire
HMP Nottingham
Ministry of Justice
Northampton Healthcare NHS Foundation T…
+2 more
Concerns summary (AI summary)
Information sharing barriers between the Community Forensic Team and prison healthcare, as well as between prison healthcare and operational prison staff, were identified as concerns. The limited and broad categorisation of alerts on NOMIS/DPS was also raised as an issue.
Mark Smith
Response Pending
2026-0205
7 Apr 2026
Inner South London
1. Chief Executive Officer, Practice Pl…
Chief Executive Officer, Practice Plus …
2. Chief Executive Lewisham and Greenwi…
+3 more
Concerns summary (AI summary)
The report identifies concerns about the potential for incorrect medication dosages to be prescribed or administered, the risk of patients being discharged back to prison from QEH without an MDT meeting, and healthcare staff being unable to access a prisoner's cell at night.
Thomas Ruggiero
No Identified Response
2026-0172
24 Mar 2026
Ian Potter
HMP Swaleside
Concerns summary (AI summary)
Key issues include a vulnerable cell bell system that can be silenced externally, staff failing to complete critical ACCT documentation, and confusion regarding emergency 'Code Blue' protocols.
Thomas Ruggiero
No Identified Response
2026-0171
24 Mar 2026
Ian Potter
Oxlease NHS Foundation Trust
Concerns summary (AI summary)
Healthcare team, particularly mental health staff, inconsistently attended ACCT reviews, leaving vulnerable prisoners without adequate safety netting and protective measures.
Thomas Ruggiero
No Identified Response
2026-0170
24 Mar 2026
Ian Potter
Department for Prison, Probation and Re…
Concerns summary (AI summary)
Widespread reliance on inexperienced, probationary prison officers across the prison estate leads to poor communication, lack of control, and increased risk of deaths in custody.
Ronald Meikle
No Identified Response
2026-0168
24 Mar 2026
Milton Keynes
Central & North West London NHS Foundat…
Chief Inspector of Prisons
HMPPS
+3 more
Concerns summary (AI summary)
Key concerns include widespread availability of illicit drugs, inconsistent response to intoxication, fragmented information sharing, blocked observation panels, and inadequate support for vulnerable prisoners.
Luke Ashcroft
No Identified Response
2026-0159
20 Mar 2026
Lincolnshire
HMP Lincoln
Ministry of Justice
Concerns summary (AI summary)
Corded telephones in CSU cells pose a clear self-harm risk when suspended, and unreliable provision of telephone access prevents prisoners in crisis from reaching support services.
Clare Dupree
No Identified Response
2026-0181
18 Mar 2026
Avon
Director General Operations
Ministry of Justice
Concerns summary (AI summary)
In-cell automatic fire detection is still to be fully implemented at Eastwood Park prison and across a number of prisons in the wider prison estate; the current use of domestic smoke detectors only mitigates the risks from an in-cell fire.
Rajwinder Singh
No Identified Response
2026-0100
19 Feb 2026
Inner West London
HMP Wandsworth
NHS England
Oxleas
Concerns summary (AI 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
All Responded
2026-0097
17 Feb 2026
Bedfordshire and Luton
HMP Bedford
Ministry of Justice
Northamptonshire Healthcare Foundation …
Concerns summary (AI 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.
Noted
(AI summary)
• A common, local protocol for managing those suspected to be under the influence of illicit substances (UTI) at HMP Bedford has been agreed and implemented with the Prison Governor and Head of Safety.
• The protocol clearly articulates the roles, responsibilities, and expectations of both healthcare and prison staff in the identification, assessment, and management of those suspected to be UTI.
• The protocol makes it clear when prison staff should escalate to healthcare staff and states that healthcare staff are responsible for taking the lead on • HMP Bedford and NHFT carried out a joint review of the UTI policies and protocols in place, resulting in the removal of any previous conflicting guidance and implementation of a single UTI protocol.
• The updated protocol has been issued to all prison and healthcare staff through structured briefings, written notices, daily meeting updates, and daily checks.
• A newly appointed substance misuse lead carries out daily assurance and visits all suspected UTI cases, ensuring consistency between operational and healthcare colleagues and consistent adherence to the UTI protocol.
Gareth Chumber-Kelly
Partially Responded
2026-0073
9 Feb 2026
North London
HMP Pentonville
HMPPS
Ministry for Justice
+1 more
Concerns summary (AI 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.
Noted
(AI summary)
• HMP Pentonville has introduced a digital induction passport to consolidate key risk information from paper records into a secure electronic format.
• The prison has appointed a Head of Early Days with specific responsibility for the reception function, who is leading a comprehensive review of reception procedures.
• The group safety team conducts regular early days exercises, which replicate a prisoner’s arrival and induction experience.
Josh Tarrant (3)
All Responded
2026-0077
9 Feb 2026
Mid Kent & Medway
HMP Elmley
Concerns summary (AI summary)
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Action Planned
(AI summary)
HMPPS is consulting with clinical experts to develop and issue new written guidance for staff on recognising signs of Acute Behavioural Disturbance (ABD). This guidance aims to ensure officers identify potential medical emergencies and escalate concerns appropriately, in line with updated NHS England Use of Force frameworks.
Josh Tarrant (2)
No Identified Response
2026-0076
9 Feb 2026
Mid Kent & Medway
Probation and Reducing Reoffending, Min…
Prisons, Probation and Reducing Reoffen…
Concerns summary (AI 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 (1)
All Responded
2026-0075
9 Feb 2026
Mid Kent & Medway
NHS England
Concerns summary (AI summary)
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
1 response
from NHS England
Emmett Morrison
All Responded
2026-0071
6 Feb 2026
Worcestershire
Prison, Probation and Reducing Offending
Probation and Reducing Offending, Minis…
Concerns summary (AI 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.
Action Planned
(AI summary)
• HMPPS is investing over £40 million in physical security measures across 34 prisons in the 2025/26 financial year.
• This includes £10 million on anti-drone measures such as window replacements, external window grilles and specialist netting across 15 priority prisons, including HMP Long Lartin.
• The Crime in Prisons Taskforce has been established to work closely with police and the CPS to improve the prosecution of those conveying contraband.
Anthony Binfield
All Responded
2025-0080
17 Dec 2025
Nottingham City and Nottinghamshire
HMP Lowdham Grange
Concerns summary (AI 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.
Action Taken
(AI summary)
HMPPS has reinforced the importance of clear observation panels at HMP Lowdham Grange through staff briefings, Governor's orders, and video messages to prisoners. Prisoners blocking panels may face sanctions and a new local PFD meeting has been established.
Sundeep Ghuman
Partially Responded
2025-0625
15 Dec 2025
London Inner South
HMP Belmarsh
Ministry of Justice
Concerns summary (AI 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
(AI summary)
HMP Belmarsh has withdrawn the S1 system for cell sharing risk assessment and reviewed all prisoners under the previous system, updated their risk level to be in line with national policy. HMPPS is updating the CSRA policy and naloxone is now available across all residential units.
Oliver Mulangala
Partially Responded
2025-0610
8 Dec 2025
Surrey
HMP High Down
HMPPS
Ministry of Justice
+1 more
Concerns summary (AI 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
(AI summary)
HM Prison and Probation Service is investing over £40m in physical security measures across 34 prisons, including £10m on anti-drone measures, and equipping all adult male closed prisons with X-ray body scanners. They also work with the Office for National Statistics (ONS) on a 2023 publication which was produced by matching deaths data with data from Coroner’s reports.
Stuart Berry
Partially Responded
2026-0015
1 Dec 2025
Essex
Essex Partnership University NHS Founda…
HCRG
HMPPS
+1 more
Concerns summary (AI 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 Planned
(AI summary)
HMPPS is reviewing national prison officer training, developing interim upskilling sessions on recognising risks and triggers, and considering upgrading Victorian-style windows to anti-ligature designs. They are concluding a project to convert 50 cells across 13 locations to a fully ligature‑resistant standard. HCRG is retraining reception nurses, introducing an Early Days in Custody (EDiC) Nurse role, improving identification and escalation of urgent mental health referrals, and reviewing the Mental Health Operational Standard Operating Procedures and referral processes.
Aminata Coulibaly
All Responded
2025-0596
26 Nov 2025
Essex
Chief Constable of Essex Police
Concerns summary (AI 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
(AI summary)
Essex Police has implemented several measures, including mandatory reflective practice, updated training for contact handlers, improved hate crime investigation supervision, and a mental health triage team that shares information with EPUT and develops Mental Health Risk Management Briefings.
Diana Grant
All Responded
2025-0594
24 Nov 2025
Surrey
[REDACTED] CEO, NHS England
[REDACTED] The Secretary of State for t…
Concerns summary (AI 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
(AI summary)
NHS England is mapping arrangements for emergency admissions to adult forensic beds across Adult Secure Provider Collaboratives, developing a new national service specification for Access Assessment Services, and has created a database of Access Assessment Services across England. NHS England's South East Health and Justice team has commissioned healthcare provision at HMP Bronzefield, and a Standard Operating Procedure has been issued to reception and healthcare staff; NHS England is also mapping emergency admission arrangements across Adult Secure Provider Collaboratives.
Steven Ruddick
Partially Responded
2025-0591
18 Nov 2025
County Durham and Darlington
GeoAmey
HM Prison Service
Concerns summary (AI 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.
Noted
(AI summary)
HMPPS acknowledges the coroner's concerns regarding differences in operational practice between police custody and HMPPS PECS, particularly regarding toilet visits and searching. They state that current HMPPS policies are grounded in safety, proportionality, legality, and respect for decency and dignity and no changes to policy or PECS operating procedures are proposed.
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…
Governor, HMP Berwyn
Concerns summary (AI 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
(AI summary)
HMPPS is investing over £40 million in physical security enhancements across 34 prisons to deter drone use, has implemented Incentivised Substance Free Living Units in 85 prisons, and appointed 17 Group Drug and Alcohol Leads. They have also introduced the Adult Health, Care and Wellbeing Core Capabilities Framework and are redesigning Foundation Training for new prison officers to include mandatory modules on drug and alcohol misuse.
Steven Davidson
All Responded
2025-0536
21 Oct 2025
Essex
HCRG Care Group
Concerns summary (AI 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
(AI summary)
HCRG Care Group has amended its training provision so that all new staff receive structured SystmOne training as part of their induction and will provide refresher training to existing staff within three months. The Performance and Quality teams are embedding SystmOne training into existing governance and supervision processes.