Source · Prevention of Future Deaths

John Philips

Ref: 2026-0289 Date: 22 Jun 2026 Coroner: Nicholas Lane Area: Devon, Plymouth and Torbay 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe SystmOne electronic patient record system can deactivate a patient's active record when a previous organisation accesses it, removing current care plans and risking unsafe clinical care. A national technological solution is preferable.

Date 22 Jun 2026

56-day deadline 16 Oct 2026 est. estimated from the Judiciary.uk publication date

Responses identified 1 of 1

Coroner's concerns

AI summary

The SystmOne electronic patient record system can deactivate a patient's active record when a previous organisation accesses it, removing current care plans and risking unsafe clinical care. A national technological solution is preferable.

View full coroner's concerns

The MATTER OF CONCERN is as follows: The national SystmOne electronic patient record operates in an unsafe way because it appears to allow a patient’s record to be accessed (which might be for a necessary administrative reason) by a member of staff in an organisation previously involved in the patient’s care, which seems to have the automatic effect of deactivating the patient’s active record in an organisation currently involved in the patient’s care (and associated appointments, tasks, treatment plans etc), without this being obvious to anyone – this leads to the removal of important and current tasks, referrals and appointments for the patient whilst they are being cared for by the current organisation and will likely result in unsafe clinical care being provided by NHS Trusts. The inquest heard evidence (from clinicians involved in providing healthcare within prisons) that this functionality of SystmOne is acknowledged and that, accordingly, steps are being taken by the healthcare provider (Oxleas NHS Foundation Trust) to mitigate against the risks of this happening and to try and ensure that when the problem arises, it is identified and that there is consideration of whether clinical care and treatment plans have been affected. However, it appears that, given SystmOne is used nationally by numerous healthcare providers, a technological solution to prevent this issue from occurring (or identifying clearly that it has occurred for those using the system) would be preferable and improve patient safety.

This issue was identified by the clinical review that formed part of the PPO investigation into Mr Phillips’ death. The clinical review made the following recommendation to NHS England:
– NHS England to consider the system wide SystmOne administrative risk highlighted in this case and to take any action deemed appropriate to safeguard and mitigate the future risk of reoccurrence.

It is not clear whether any action has been taken following this recommendation – those giving evidence at the inquest who were familiar with using SystmOne were not aware that any changes had been made to its functionality in respect of this issue.

Responses

1 respondent

NHS England

NHS / Health Body

Letter dated 20 Jul 2026 PDF

AI-classified response stance Disputed

AI-generated response summary

• NHS England stated it would share the findings of its review with regional commissioning teams, the Welsh Health Board, and HMP Parc. • It indicated it would highlight to healthcare staff the importance of not re-registering patients who are no longer residents when accessing their records. • The findings and learning from this case will be shared with NHS England’s Health and Justice Delivery Oversight Group.

View full response

Dear Mr Lane, Re: Regulation 28 Report to Prevent Future Deaths – John Edward Brynmor Phillips who died on 29th October 2022.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 22nd June 2026 concerning the death of John Edward Brynmor Phillips on 29th October
2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Mr Phillip’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Mr Phillip’s care have been listened to and reflected upon.

Your Report raised concern that the national SystmOne electronic patient record (used in the prison service) operates in an unsafe way, owing to the ability for records to be activated/deactivated at different organisations at any time, with little or no safeguards, which is likely leading to unsafe clinical practice.

By way of providing some background information, the electronic patient record used for people in prison in England is known as Health and Justice Information System (HJIS) and currently uses SystmOne (by TPP). There is an established process for transferring a prisoner’s healthcare record to the receiving prison’s healthcare organisation when prisoners transfer between prisons.

During this inquest there was concern that the SystmOne electronic patient record allows for healthcare professionals previously involved with a patients care to access their records and that this automatically deactivates the patient’s active record in the organisation currently involved in their care. NHS England’s National Health and Justice Team have reviewed this case. This review identified that a member of staff at HMP Parc did access Mr Phillips’ notes after he had transferred to HMP Dartmoor, and during this access, they manually registered Mr Phillips back to HMP Parc despite the fact that he was residing at HMP Dartmoor. This was reflected in the information that was in the task section of SystmOne. SystmOne did not automatically register Mr Phillips' record when it was retrieved in HMP Parc's SystmOne. Following this, a member of staff at HMP Dartmoor, believing that Mr Phillips had been transferred back to HMP Parc, actioned the outgoing transfer task, which then removed Mr Phillips from the HMP Dartmoor Mental Health Triage waiting list.

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

20th July 2026

Once a patient has transferred between prisons and their SystmOne record is accessed for purposes such as updating, it does not automatically pull the patient and records back to the previous site when they are accessed. A request to re-register the patients record is required for this. If the re-register request is made, the deduction or deactivation of the record at the “new” prison then takes place. This appears to be what happened in this case and was human error, not an automatic process. We therefore do not believe that the events in this tragic case were due to a systemic issue within SystmOne.

To further reassure you, this does not impact on clinical care and treatment plans. Once the request to correct the re-registration is made, the patient’s records remain as they were and are unaffected by this movement of their clinical record.

In order to ensure that all healthcare providers are aware of this investigation and any learning, we will be sharing the findings with the NHS England Regional Health and Justice Commissioning Teams, the Welsh Health Board and HMP Parc. We will highlight to them that when accessing the records of a patient who has left a prison, healthcare staff are mindful of the movement of records and not requesting the re- registering of the patient that is no longer a resident in that prison.

In addition, the findings, information and any learning from this case will be shared with NHS England’s Health and Justice Delivery Oversight Group (HJDOG). The HJDOG is the senior leadership forum, which holds responsibility for the oversight of delivery and continuous improvement in Health and Justice commissioned services, through both national and regional teams. All health and justice related Reports to Prevent Future Deaths are shared with HJDOG members, and assurance is sought from regions where learning and action is identified.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Mr Phillips, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Report sections

Investigation and inquest

On 7 November 2022 an investigation was commenced into the death of John Edward Brynmor Phillips. The investigation concluded at the end of the inquest hearing on 18 June 2026 at Exeter Coroner’s Court, heard by HM Area Coroner Nicholas Lane together with a jury. Section 2 of the Record of Inquest (which recorded the medical cause of Mr Phillips’s death) was determined by the jury as: 1a) ligature suspension Section 3 of the Record of Inquest (which set out how, when and where Mr Phillips came by his death) was determined by the jury as: ‘Mr Phillips was found unconscious in his cell (B3-12 at HMP Dartmoor) on the morning of 29th October 2022. Mr Phillips had deliberately used a ligature to end his own life as evidence by the suicide note that he had left. Resuscitation was attempted by prison officers and medical staff, and was continued by the ambulance service until he was pronounced deceased at 9.39am in his cell. There was a delay of approximately 2.5 months in John Phillips undergoing a mental health assessment at HMP Dartmoor – this delay came about because once John Phillips had been transferred to HMP Dartmoor from a different prison his prison medical records were activated by the healthcare team at this other prison
– with the unintended consequence of deactivating the medical records at HMP Dartmoor, leading to the cancellation of a referral that had been tasked to the mental health team at HMP Dartmoor – however, this delay did not materially contribute to John Phillips’ death.’ Section 4 of the Record of Inquest (which set out conclusions in respect of Mr Phillips’ death) was determined by the jury, in narrative form, as: ‘Over the course of his time at HMP Dartmoor Mr Phillips intermittently but frequently suffered repeated low moods, paranoia and anxiety, particularly relating to his long term status as an IPP and EPP prisoner. This led to his intentional use of a ligature to end his life by suicide.’

Circumstances of the death

Mr Phillips was 37 years old at the time of his death. He had spent a significant amount of his adult life as a serving prisoner, including receiving an IPP sentence. Having been recalled to prison in 2020 (and then sentenced to an additional term of imprisonment in November 2021 for further offending) he was transferred (at his request) to HMP Dartmoor in July 2022.

Mr Phillips had a history of low mood, anxiety and paranoia – he reported that he had considered taking his own life on a number of occasions and had made one significant attempt. Although Mr Phillips did not obviously suffer from overt poor mental health to those who were involved in his care and management at HMP Dartmoor, he had requested, at his reception health assessment in July 2022, to be referred to the prison mental health team for assistance. This referral was made immediately. The inquest heard evidence that the referral to the mental health team was cancelled, or ‘deactivated’, on Mr Phillips’ SystmOne records, and that this likely came about owing to a member of staff at HMP Parc, the establishment from where Mr Phillips had been transferred, carrying out an ‘uploading’ exercise relating to Mr Phillips’ SystmOne records – this uploading exercise was apparently a well-known feature of how SystemOne needed to be operated (in the prison setting at least). The inquest heard evidence that in consequence of the uploading of Mr Phillips’ SystmOne records at HMP Parc, his current SystmOne records at HMP Dartmoor became deactivated, with associated current tasks (including the referral to the mental health team) being cancelled. It appears that no member of the healthcare staff at HMP Dartmoor realised that this deactivation of the records had taken place – they were swiftly reactivated (by a similar uploading process taking place at HMP Dartmoor) but the previous tasks remained cancelled. Over two months later, Mr Phillips enquired about why he had not yet been seen by the mental health team, as he had initially been referred. This led to a swift triage and an assessment of Mr Phillips by a mental health nurse. Mr Phillips was commenced on anti-depressant medication and placed on a waiting list for psychological therapy, to try and address his symptoms of low mood and anxiety. This 2.5 month delay in Mr Phillips undergoing a mental health assessment and treatment commencing were directly owing to the SystmOne records deactivation incident.

On 29 October 2022 Mr Phillips was found to be unconscious in his cell, having used a ligature to take his own life. The jury determined that Mr Phillips died by suicide – the delay in Mr Phillips being assessed by the mental health team was recorded by the jury in their determinations, although it was noted that this did not materially contribute to his death.

Action should be taken

In my opinion, unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe that your organisation has the power to take such action.

Copies sent to

2) Oxleas NHS Foundation Trust (IP)4) Practice Plus Group (IP)5) HMPPS / GLD (IP)6) PPOfor the attention of the PPO Ombudsman who is the author of the PPO report and to the author of the PPO clinical review (IP)

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Shared signals

Report details

Reference: 2026-0289
Date of report: 22 June 2026
Coroner: Nicholas Lane
Coroner area: Devon, Plymouth and Torbay

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 16 Oct 2026 (estimated from the Judiciary.uk publication date).

Sent to

NHS England

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.