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
Lee Curran
Historic (No Identified Response)
2014-0079 25 Feb 2014 Manchester (West)
Department of Health and Social Care HMP-YOI Forrest Bank Ministry of Justice +2 more
Concerns summary (AI summary) PPO recommendations for high cholesterol and loss of consciousness protocols were not fully implemented, with NICE guidelines ignored by doctors. Additionally, prison staff lacked training in accurate medical note-taking, leading to incorrect entries.
Amy Friar
Historic (No Identified Response)
2014-0051 3 Feb 2014 Surrey
Ministry of Justice
Concerns summary (AI summary) The absence of universal emergency codes across the prison estate creates confusion for transferring staff, risking delays in emergency response.
Damion Anthony Andre Martin
Historic (No Identified Response)
2013-0280 30 Oct 2013 Liverpool
NOMS HMP Liverpool Rights and Responsibilities Group
Concerns summary (AI summary) Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, and cell observation was compromised by restricted views and missed checks.
Jordan Buckton
Historic (No Identified Response)
2013-0187 14 Aug 2013 Dorset
Dorset Healthcare University NHS Founda… National Offender Management Service
Concerns summary (AI summary) Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate follow-up after prescribing anti-depressants and a mental health course was discontinued due to staff shortages.
Ronald Sherlock
Historic (No Identified Response)
2013-0181 9 Aug 2013 Norfolk
Serco
Concerns summary (AI summary) Older prisoners lacked appropriate access to speech and language therapists to assess and manage swallowing difficulties, including recommendations for diet and fluid intake.