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).

Response Status
Responded 263 No Response 11 Historic 80 Pending 2
AI Classification
Action Taken 58%
Action Planned 27%
Noted 14%
Disputed 0%
Based on 401 classified responses
Reports by Quarter
Clear
PFD Reports
80 results
Michael Berry
Historic (No Identified Response)
2018-0157 22 May 2018 Bedfordshire & Luton
HM Prison Bedford
Concerns summary (AI summary) A "reduced risk" healthcare cell contained a clear ligature point, an inwardly opening window, indicating a design flaw that could be easily avoided.
Michalla Sweeting
Historic (No Identified Response)
2018-0165 21 May 2018 Avon
Bristol Community Health
Concerns summary (AI summary) Concerns were raised about inadequate handover procedures for detox patients, including nurses' record review responsibilities and the timing of observations relative to medication administration.
Sidonio Teixeira
Historic (No Identified Response)
2017-0366 12 Dec 2017 Worcestershire
HMP Long Lartin
Concerns summary (AI summary) The adequacy of prison intelligence processes, including reporting and analysis, was questioned. A critical internal report on these issues was not shared with relevant staff, indicating a failure to learn lessons.
Christopher Talbot
Historic (No Identified Response)
2017-0427 29 Nov 2017 Preston and West Lancashire
HMP Preston HM Probation and Prison Service Ministry of Justice
Concerns summary (AI summary) An untrained supervising officer relied solely on shadowing, a senior officer lacked a breathing guard for resuscitation, and staff were not informed of previous unnatural death causes, reducing vigilance.
Robert Richards
Historic (No Identified Response)
2017-0406 20 Nov 2017 London Inner (West)
HMP Wandsworth St George’s Hospital
Concerns summary (AI summary) HMP Wandsworth suffered from pervasive bullying due to inadequate staff, poor communication, insufficient training, and inappropriate cell allocation. Critical issues also included inadequate medical training and supply restocking.
Vilhelmas Borkertas
Historic (No Identified Response)
2017-0342 31 Oct 2017 London Inner (North)
HMP Pentonville
Concerns summary (AI summary) A bisexual prisoner was improperly celled with a homophobic cellmate despite clear risk assessment information, raising concerns about placing inmates with conflicting profiles.
Levi Cronin
Historic (No Identified Response)
2017-0287 6 Oct 2017 Suffolk
HMP Highpoint HM Prison and Probation Service NHS England
Concerns summary (AI summary) Concerns arose over inadequate information sharing between healthcare and prison staff, particularly regarding historical risk data. Poor recording of observable changes on prison wings also hindered effective dynamic risk assessments.
Daniel Dunkley
Historic (No Identified Response)
2017-0147 2 May 2017 Milton Keynes
HMP Woddhill
Concerns summary (AI summary) The report notes that three referrals were made for Mr Dunkley to undergo a full mental health assessment before his death.
Arthur Morley
Historic (No Identified Response)
2017-0106 4 Apr 2017 Buckinghamshire
HMP Grendon
Concerns summary (AI summary) The report indicated concerns but did not provide specific details on what matters gave rise to them, making it impossible to identify key safety issues.
Ondrej Suha
Historic (No Identified Response)
2017-0098 30 Mar 2017 Staffordshire (South)
National Offender Management Service
Concerns summary (AI summary) Prison officers lacked specific training for night shifts and basic resuscitation, hindering their ability to respond effectively to emergencies.
Valdas Jasiunas
Historic (No Identified Response)
2017-0062 8 Mar 2017 London (East)
Metropolitan Police
Concerns summary (AI summary) Custody risk assessments inadequately screen for alcohol dependency, and the computer system's design leads to frequent errors, further complicated by a lack of multi-language support for safety information.
Mark Lilliott
Historic (No Identified Response)
2016-0453 16 Dec 2016 Liverpool and Wirral
HMP Liverpool
Concerns summary (AI summary) Delays in accessing a radio-equipped senior officer for emergency assistance within the prison, exacerbated by noise on the wing, could critically impede swift responses in future emergencies.
Simon Turvey
Historic (No Identified Response)
2016-0480 13 Dec 2016 Milton Keynes
National Offender Management Service Prison and Probation Ombudsman
Concerns summary (AI summary) The prison failed to inform family members how to report welfare concerns, potentially leading to missed suicide risk factors for detainees.
Michelle Barnes
Historic (No Identified Response)
24 Oct 2016 County Durham and Darlington
NOMS, Prison Service, Equality Rights a…
Concerns summary (AI summary) Prison officers failed to initiate an ACCT process for a highly distressed prisoner, opting for a vague "offer support" note without a clear action plan, despite significant emotional risk.
Calam Atour
Historic (No Identified Response)
2016-0461 12 Oct 2016 Wiltshire and Swindon
National Offender Management Service
Concerns summary (AI summary) Chronic understaffing in the prison system compromises officer safety and prisoner welfare. The method for determining staffing levels also fails to account for the specific risks posed by the inmate population type.
Peter Lawrence
Historic (No Identified Response)
2016-0314 30 Aug 2016 Cambridgeshire and Peterborough
National Offender Management Service
Concerns summary (AI summary) The initial screening process for new prisoners lacked a robust method to identify and comprehensively record less obvious risk factors, particularly with limited background information.
Stephen St Clair
Historic (No Identified Response)
2016-wp25358 12 Aug 2016 Isle of Wight
Ministry of Justice National Offender Management Service
Concerns summary (AI summary) Prison guidance for suicide risk factors is inadequate, omitting irrational behaviour as a key indicator of psychosis, which led to insufficient monitoring and care for a prisoner at risk.
Thomas Jordan
Historic (No Identified Response)
10 Aug 2016 West Yorkshire (East)
Her Majesty's Prison, Leeds The Leeds Teaching Hospitals NHS Trust
Concerns summary (AI summary) Communication failures between the hospital and prison healthcare resulted in continued administration of a discontinued drug, as discharge information was not promptly reviewed by prison staff.
Olawale Adelusi
Historic (No Identified Response)
22 Jul 2016 London (West)
METROPOLITAN POLICE SERVICE
Concerns summary (AI summary) There was no effective system to transmit critical information regarding a detained person's self-harm risk and mental health, as detailed observations of distress were not included in formal handover documents.
John Betteridge
Historic (No Identified Response)
2016-0238 30 Jun 2016 County Durham and Darlington
G4S National Offender Management Service NHS England +1 more
Concerns summary (AI summary) Prison healthcare staff and a GP lacked or had insufficient ACCT training, resulting in non-adherence to mandatory ACCT procedures and indicating a clear, ongoing training need.
Beverley Devanney
Historic (No Identified Response)
2016-0485 24 Jun 2016 West Yorkshire (West)
West Yorkshire Police
Concerns summary (AI summary) Police officers lacked formal training for handling complex situations like Miss Devanney's, raising concerns about appropriate responses in similar future circumstances.
Steven Trudgill
Historic (No Identified Response)
2016-0210 6 Jun 2016 Suffolk
Ministry of Justice
Concerns summary (AI summary) HM Prison Service lacked standardised treatment programs for fire setters with complex mental health issues, and a suggested therapeutic community option for the deceased was not implemented.
Adetokunbo Ajakaiye
Historic (No Identified Response)
2016-0209 27 May 2016 South Yorkshire (East)
Ministry of Justice NHS England
Concerns summary (AI summary) Prison healthcare staff lacked essential knowledge and practical experience regarding malaria and tropical diseases, posing a significant risk in an era of increased foreign travel.
Sheldon Woodford
Historic (No Identified Response)
2016-0189 16 May 2016 Hampshire Central
HMP Winchester
Concerns summary (AI summary) Key safety documents (SASH) are not universally identifiable during reception, and officers receive insufficient training in ACCT processes for managing at-risk individuals.
Shalane Blackwood
Historic (No Identified Response)
2016-0179 3 May 2016 Nottinghamshire
HMP Nottingham National Offender Management Service NHS England +1 more
Concerns summary (AI summary) The prison lacks adequate provision for complex health needs, has insufficient staff for prisoner regimes, faces rife NPS use, and has unclear decision-making tools and staff awareness for physical symptoms alongside mental health issues.