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
11 resultsThomas 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.
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.
Matthew Braben
No Identified Response CC
2024-0423
1 Aug 2024
West London
His Majesty’s Prison and Probation Serv…
Ministry of Justice
Concerns summary (AI summary)
Inadequate recognition of childbirth as a mental health risk factor, poor ACCT process and staff training, and prolonged cell confinement due to gym instructor shortages significantly harmed prisoner mental health.
Yuri Hatton
No Identified Response CC
2024-0608
11 Jun 2024
Inner West London
HMPPS
HMP Wandsworth
Concerns summary (AI summary)
Many prison OSGs lacked official training, first aid training records were insufficient, and crucial prison-specific training for recognising unconsciousness had not been implemented.
Daniel Beckford
No Identified Response CC
2024-0607
11 Jun 2024
Inner West London
HMPPS
HMP Wandsworth
Concerns summary (AI summary)
Prison officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council UK guidance.