Anthony Philips

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Anthony Philips,
a prisoner at HMP Risley,
on 3 October 2025
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2026
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
1. The Prisons and Probation Ombudsman aims to make a significant contribution to
safer, fairer custody and community supervision. One of the most important ways in
which we work towards that aim is by carrying out independent investigations into
deaths, due to any cause, of prisoners, young people in detention, residents of
approved premises and detainees in immigration centres.
2. If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate,
our recommendations should be focused, evidenced and viable. This is especially
the case if there is evidence of systemic failure.
3. In July 2025, Mr Anthony Philips was sentenced to twelve weeks imprisonment for
harassment and breaching his Sexual Harm Prevention Order and taken to HMP
Durham. He died of congestive heart failure on 3 October, at HMP Risley, having
transferred there in August. This was caused by ischaemic heart disease due to
coronary artery atheroma (a build-up of fatty plaque inside the arteries that supply
blood to the heart) and left ventricular hypertrophy (thickening of the heart muscle
wall). He was 62 years old. We offer our condolences to Mr Philips’ family and
friends.
4. The Ombudsman’s office wrote to Mr Philips’ next of kin to explain the investigation
and to ask if they had any matters they wanted us to consider. They did not
respond.
5. NHS England commissioned an independent clinical reviewer to review Mr Philips’
clinical care at Risley. The clinical reviewer’s report is attached as Annex 1.
6. The clinical reviewer concluded that the clinical care Mr Philips received at Risley
was of a good standard and equivalent to that which he could have expected to
receive in the community. She found that Mr Philips’ healthcare needs were
appropriately managed with referrals undertaken when necessary. The clinical
reviewer made no recommendations.
7. The PPO investigator investigated the non-clinical issues relating to Mr Philips’
care.
8. We did not find any non-clinical issues of sufficient concern to make a
recommendation, but we bring the issues below to the attention of the Governor
and Head of Healthcare.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Governor to note
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Roll checks
10. To complete roll checks, HMPPS’ policy requires staff to obtain a clear view of the
prisoner’s face, wake them if necessary and confirm signs of life. On 3 October, an
operational support grade (OSG) recorded no concerns during the morning roll
check at 6.30am. When an officer unlocked Mr Philips’ cell at 8.00am, they found
him showing clear signs of rigor mortis (stiffening of the body that typically develops
between two and four hours after death). No CCTV footage was available to
corroborate the timing or completion of the morning roll checks.
11. We have not been able to interview the OSG who completed the check as she has
been on sick leave since Mr Philips’ death. However, we have not identified issues
with inadequate roll checks in our recent investigations following deaths at Risley.
We therefore bring this potential issue to the Governor’s attention who will want to
assure herself that roll checks are taking place in line with policy.
Head of Healthcare to note
Availability of defibrillators
12. At the time of Mr Philips’ death, there were no defibrillators stored on the residential
units. Although healthcare staff obtained a defibrillator in a timely manner, the
absence of this equipment on the unit could delay critical intervention in a medical
emergency. We bring this to the Head of Healthcare’s attention.
Inquest
13. At the inquest held on 1 June 2026, the Coroner concluded that Mr Philips died
from natural causes.
Adrian Usher
Prisons and Probation Ombudsman May 2026
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE