John Phillips

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Independent investigation into
the death of Mr John Phillips,
A report by the Prisons and Probation Ombudsman
a prisoner at HMP Dartmoor,
on 29 October 2022
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
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© Crown copyright, 2026
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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.
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.
Mr John Phillips died on 29 October 2022 after being found hanged in his cell at HMP
Dartmoor. He was 37 years old. I offer my condolences to Mr Phillips’ family and friends.
There were two self-inflicted deaths at HMP Dartmoor in the three years leading up to the
death of Mr Phillips.
The clinical reviewer found that the clinical care provided to Mr Phillips was not equivalent
to that which he could have expected to receive in the community based on the delay in
his mental health assessment.
I found that the non-clinical care provided to Mr Phillips was generally of a good standard.
There were no clear signs that Mr Phillips was in crisis in the period leading up to his
death, which came as a shock to those around him.
I am also concerned that the current HMPPS emergency response policy is not fit for
purpose and have made a recommendation to the Director General.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman May 2024
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
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 11
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Summary
Events
1. In 2006, Mr John Phillips received an Imprisonment for Public Protection (IPP)
sentence for robbery with a four year minimum tariff. Following the expiry of his
tariff, Mr Phillips was released by the Parole Board on three occasions between
2015 and 2019 but was recalled for further offences and threatening his ex-partner.
His next review by the Parole Board was due in 2025.
2. On 22 July 2022, Mr Phillips transferred to HMP Dartmoor. He consistently denied
having any thoughts of suicide or self-harm while there. Staff identified that Mr
Phillips was experiencing anxiety and paranoia and referred him to the mental
health team. However, due to an administrative error, he was not assessed by the
team until October, after which he was referred for therapeutic groups and
prescribed antidepressants.
3. Both prisoners and staff said that they had no concerns about Mr Phillips and that
he seemed his usual self when he was locked up the day before his death. His last
telephone calls to his family did not indicate any significant distress.
4. On 29 October around 8.45am, prisoners looked into Mr Phillips’ cell and realised
that he was sat in his chair with bedding tied around his neck and to the window
bars. They alerted staff who responded, cut the ligature and tried to resuscitate Mr
Phillips. Paramedics attended and took over Mr Phillips’ treatment. They confirmed
that he had died at 9.10am. Police found a note in Mr Phillips’ cell indicating his
intention to take his own life.
Findings
5. During Mr Phillips’ time at Dartmoor, he consistently denied having any thoughts of
suicide or self-harm and both staff and prisoners did not observe any obvious signs
he was in crisis. His death was a shock to those who knew him. Mr Phillips had
been serving an IPP sentence since 2006 and had spent the vast majority of his
time in prison since then. It is clear from the note that Mr Phillips left that the
amount of time he had spent in prison had deeply affected him, such that he could
no longer see a future. However, we have concluded that he hid his distress and it
was reasonable that staff did not identify an imminent risk of suicide.
6. The clinical reviewer concluded that Mr Phillips’ healthcare was not equivalent to
that he could have expected to receive in the community based on the delay in his
assessment by the mental health team and provision of healthcare reviews and
medication. This was partly due to Mr Phillips’ medical record being incorrectly
transferred to another prison.
7. We are concerned that the current HMPPS emergency response policy is not fit for
purpose and causes an unnecessary delay in ambulances being despatched. We
make a recommendation to the Director General of HMPPS in this regard.
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Recommendation
• The Director General of HMPPS must review the current emergency response
policy to eliminate the conflict between calling an ambulance immediately and
providing the 999 operator details about the nature of the emergency.
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The Investigation Process
8. We were notified of Mr Phillips’ death on 31 October 2022. The investigator issued
notices to staff and prisoners at HMP Dartmoor informing them of the investigation
and asking anyone with relevant information to contact her. Several prisoners
responded.
9. The investigator obtained copies of relevant extracts from Mr Phillips’ prison and
medical records. There is no CCTV on the wing where Mr Phillips died. Dartmoor
lost the body worn camera footage of the emergency response during a system
update before they had been able to save a copy for the investigation.
10. NHS England (NHSE) commissioned a clinical reviewer to review Mr Phillips’
clinical care at the prison. The investigator and clinical reviewer interviewed five
members of staff and three prisoners at HMP Dartmoor in February 2023.
11. We informed HM Coroner for Exeter and Greater Devon of the investigation. The
results of the post-mortem examination were not available at the time of writing. We
have sent the Coroner a copy of this report.
12. The Ombudsman’s family liaison officer contacted Mr Phillips’ mother to explain the
investigation and to ask if she had any matters she wanted us to consider. She
asked how Mr Phillips had been able to take his own life, which we have addressed
in this report, based on the evidence available to us.
13. Mr Phillips’ mother received a copy of the draft report. She did not make any
comments.
14. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out one factual inaccuracy and this report has been amended
accordingly. NHSE also pointed out a factual inaccuracy in the clinical review which
a recommendation was based on. We have therefore removed this
recommendation.
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Background Information
HMP Dartmoor
15. HMP Dartmoor is a training prison holding up to 689 adult male prisoners. Primary
healthcare services are provided by Practice Plus Group (PPG) and mental health
services by Devon Partnership NHS Trust.
HM Inspectorate of Prisons (HMIP)
16. The most recent HMIP inspection was a short scrutiny visit in September 2020. The
visit took place while the prison was subject to COVID-19 restrictions. Inspectors
found that relationships between prisoners and staff were generally good. The key
work scheme had been suspended at the time due to COVID-19 restrictions. The
prison was also subject to a closure notice at the time which was cancelled in
December 2021.
Independent Monitoring Board
17. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to September 2022, the IMB noted
that, following the decision to stay open, the essential investment then needed in
Dartmoor did not take place. They found that there were staff shortages in several
areas, with high numbers of staff required to escort prisoners during hospital stays
due to an older prison population. Prisoners were often locked up for 23 hours a
day. There was reduced access to activities and education, daily communications,
showers and association. The IMB concluded that prisoners’ experience at
Dartmoor was unacceptable though they noted that it had begun to improve
towards the end of the reporting year.
Previous deaths at HMP Dartmoor
18. Since October 2019, Mr Phillips was the twelfth prisoner to die at Dartmoor. Nine of
these previous deaths were due to natural causes and two were self-inflicted. Four
prisoners have died of natural causes since Mr Phillips. None of our investigations
into these previous deaths raised issues relevant to this investigation.
Imprisonment for Public Protection (IPP)
19. IPP sentences are indeterminate, which means that when the minimum tariff has
expired, individuals are required to demonstrate to the Parole Board that their risk
has reduced enough to be managed in the community. IPP sentences were
introduced in 2005 and abolished in 2012, but the abolition did not apply
retrospectively to those who had already received the sentence.
20. In September 2023, the PPO published a learning lessons bulletin on the self-
inflicted deaths of IPP prisoners. This was due to an increase in self-inflicted deaths
among IPP prisoners in 2022. We concluded that more needed to be done by
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HMPPS to ensure that the high levels of deaths did not continue. We noted that an
IPP sentence should be considered as a potential risk factor for suicide and self-
harm. IPP prisoners can often struggle with their uncertain status leading to feelings
of hopelessness and frustration. We found that this can cause a lack of
engagement with the parole process and sentence planning and create a lack of
trust in the system.
Assessment, Care in Custody and Teamwork (ACCT)
21. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner. After an
initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner.
22. As part of the process, a care plan (a plan of care, support and intervention) is put
in place. The ACCT plan should not be closed until all the actions of the care plan
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
which accompanies the prisoner as they move around the prison. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011.
Key worker scheme
23. The key worker scheme was introduced in the men’s prison estate in 2018. It
provides prisoners with an allocated officer that they can meet regularly to discuss
how they are and any day-to-day issues they would like to address. Improving
safety is a key aim of the scheme. All adult male prisoners should have around 45
minutes of key work each week, including a meaningful conversation with their
allocated officer.
24. In 2023/24, due to exceptional staffing and capacity pressures in parts of the estate,
some prisons are delivering adapted versions of the key work scheme while they
work towards full implementation. Any adaptations, and steps being taken to
increase delivery, should be set out in the prison’s overarching Regime Progression
Plan which is agreed locally by Prison Group Directors and Executive Directors and
updated in line with resource availability.
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Key Events
Background
25. On 24 March 2006, Mr Phillips received an Imprisonment for Public Protection (IPP)
sentence, with a minimum tariff of four years imprisonment. In 2015, Mr Phillips was
released for the first time. He was recalled to custody two years later. In January
2019, Mr Phillips was released again but was recalled three weeks later. In
December 2019, Mr Phillips was released for the third time. In July 2020, probation
staff recalled him due to allegedly threatening his ex-partner. During this last period
on release he also committed further offences of robbery and handling stolen
goods. He was taken to HMP Swansea.
26. On 23 July 2020, Mr Phillips transferred to HMP Parc. He said he had no thoughts
of suicide or self-harm. During his time at Parc, Mr Phillips engaged with his key
workers, was employed as a barber and did not raise any significant issues. He
hoped to be transferred to a category D open prison as part of his sentence
progression.
27. On 26 November 2021, Mr Phillips was given an 87 month extended sentence for
offences of robbery and handling stolen goods. May 2025 was listed as the earliest
point at which the Parole Board would consider release.
HMP Dartmoor
28. On 22 July 2022, Mr Phillips transferred to HMP Dartmoor. During his reception
healthscreen with a nurse, he said that he had no problem with being at Dartmoor
and had been there before. He said that he had no thoughts of suicide or self-harm.
Mr Phillips’ reception healthscreen noted that he had newly diagnosed type II
diabetes, a history of substance misuse, had detoxed from methadone (an opiate
substitute) at Parc and suffered from anxiety and paranoia. Staff referred him to the
mental health team. This was a routine referral and meant that Mr Phillips should
have been seen within five working days. He was prescribed metformin (for
diabetes) and cetirizine (an antihistamine).
29. On 23 July, a chaplain from the chaplaincy department spoke to Mr Phillips. He told
her that he was happy to be back at Dartmoor and she noted that he seemed
cheerful. He said that he did not expect to receive any visits but would keep in
contact with his friends and family via the telephone and was happy with this.
30. On 24 July, Mr Phillips had a secondary healthscreen with a nurse. He said that he
would like to see the mental health team and the nurse told Mr Phillips that he had
already been referred.
31. On 25 July, a member of staff at Parc re-registered Mr Phillips at HMP Parc. It was
not possible to establish why, as the person who did so no longer worked at the
prison. However, when this happened, Mr Phillips’ records transferred to Parc and
his appointments and referrals at Dartmoor were automatically cancelled by the
system, without staff at Dartmoor being notified. On 26 July, Mr Phillips’ record was
transferred back to Dartmoor but his previous appointments and referrals were not
reactivated.
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32. On 27 July, Mr Phillips had an induction meeting with the substance misuse service.
He said that he would like to be prescribed methadone again (he had successfully
withdrawn from methadone around two months earlier). He was advised to apply to
the substance misuse clinical lead prescriber. Mr Phillips said he did not want to
engage with the substance misuse service and did nothing more to pursue a
methadone prescription.
33. On 26 September, the Prison Offender Manager (POM) met Mr Phillips. He said
that he was well and felt settled at Dartmoor. He said he would like to be employed
to use his time productively. They spoke about Mr Phillips’ offending history and Mr
Phillips said that he was slowly accepting that he would not be eligible for
consideration for release until 2025. He said that he was still motivated to address
his offending behaviour. Mr Phillips also said that he was finding it hard to cope
after his methadone prescription had been stopped at Parc. The POM noted that he
would contact the substance misuse and mental health teams.
34. On 29 September, the POM emailed the mental health team to say that he had
spoken with Mr Phillips who said he had applied to see them. Mr Phillips had said
that his mental health was relatively stable at present but he wanted to see if any
support was available as a preventative measure. There is no evidence that this
email was actioned by the mental health team.
35. The POM also emailed substance misuse services. He wrote that Mr Phillips had
told him that he wanted to see someone from the team about being prescribed
methadone as he felt it had been withdrawn without justification at Parc and was
impacting his physical and mental health.
36. On 5 October, the POM emailed the mental health team again, asking when Mr
Phillips was going to be assessed. As a result of this email, on 10 October, a nurse
assessed Mr Phillips. He said he had no suicidal thoughts but was low in mood. He
rated his mood four out of ten but said he had been down to one out of ten in the
last week. He said that he struggled with motivation and spent much time standing
on the landings or watching television and felt anxious and paranoid.
37. Mr Phillips told the nurse that he had attempted suicide in the past, most recently in
2018 when he had taken a heroin overdose. He said that he had had thoughts of
suicide since then, mainly when he was paranoid. Mr Phillips said that he had no
current thoughts of suicide or self-harm. The nurse sent the GP an electronic task
requesting that they consider prescribing Mr Phillips antidepressants and review
him in four to six weeks. He also noted that Mr Phillips should be discussed in the
multidisciplinary team meeting, and he would recommend two group courses for
anxiety and emotional management. The nurse documented that he did not assess
Mr Phillips needed suicide and self-harm prevention procedures (known as ACCT)
support at the time.
38. Mr Phillips called his father at 3.05pm. They had a general conversation and Mr
Phillips asked his father to research potential changes to IPP sentences as he had
heard that prisoners on IPP sentences were going to be resentenced and he hoped
that this was true.
39. On 11 October, an officer introduced himself to Mr Phillips as his key worker. He
had recently been allocated to him. He noted that Mr Phillips was a quiet prisoner
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who had been in contact with his POM and discussed his progression. Mr Phillips
said that he was waiting for a psychological assessment and also needed to
undertake mental health courses, though he was unsure what these were. He was
due to start education on 18 October. Mr Phillips said that he had no issues that he
wanted to raise with him. The officer told the investigator that Mr Phillips socialised
well with other prisoners on the wing. He said that he never had any concerns that
Mr Phillips was a risk to himself.
40. On 13 October, a substance misuse worker assessed Mr Phillips. He said he
wanted to be prescribed methadone. He encouraged Mr Phillips to use alternative
coping strategies such as attending a relapse prevention group. Mr Phillips said he
had no current thoughts of suicide or self-harm.
41. On 18 October, Mr Phillips did not attend the relapse prevention group. The mental
health multi-disciplinary team discussed Mr Phillips and added him to the waiting list
to attend therapy groups. At the time, the waiting list for these groups was around
five months although it is unclear whether Mr Phillips was told this because there is
no record of contact. On 21 October, a prison GP prescribed Mr Phillips sertraline
(an antidepressant) which he started taking two days later.
42. On 23 October, Mr Phillips saw a nurse due to a medical issue. They gave him
advice and topical treatment. The next day, he received treatment in hospital for the
condition. On return to prison, he was prescribed antibiotics as directed by the
hospital.
43. On 26 October, Mr Phillips called his father. They had a general conversation and
spoke about what had happened at the hospital. On 28 October at 3.10pm, Mr
Phillips telephoned his father again, who asked if the antibiotics had worked, to
which Mr Phillips replied that there had been no change and he would see a GP
when he had finished the course. His father asked how Mr Phillips’ job in the
servery was going and Mr Phillips replied that it was okay and they got extra time
out of their cell though the pay was bad. Mr Phillips said he would call his parents in
a couple of days and he loved them both. Mr Phillips did not attend a substance
misuse group session that day.
44. Prisoner A told the investigator that he was friends with Mr Phillips, and they drank
coffee together most mornings. He said that Mr Phillips seemed happy and he
never had any concerns that he was a risk to himself. Mr Phillips went to his cell just
before they were locked up that evening and asked for some coffee and sugar. He
said that it was normal for them to share things. He said that Mr Phillips seemed his
usual self, was laughing and they shared some banter. He had no concerns about
his safety. Prisoner B was also good friends with Mr Phillips. He said that Mr Phillips
had also come to his cell before they were locked up and asked for some tea bags
and sugar. He said that he seemed his “normal self”.
45. An Operational Support Grade (OSG) checked prisoners were in their cells on the
wing around 8.00pm that evening. She could not remember specifically checking Mr
Phillips but said that there must have been nothing exceptional during the check as
she would have reported it if there was.
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Events of 29 October
46. On 29 October between 5.20am and 5.50am, the OSG checked all the prisoners on
the wing. She estimated that she would have checked Mr Phillips’ landing at around
5.40am. Again she could not specifically remember checking Mr Phillips but knows
that she did and there was nothing which gave her cause for concern.
47. Around 8.30am, staff unlocked three prisoners. They were unlocked before other
prisoners as they were employed on the wing. Five minutes later, Prisoner A
wondered why Mr Phillips had not been unlocked as he had a job on the servery.
An officer told the investigator that only cleaners were unlocked before the other
prisoners, which is why Mr Phillips had not been unlocked.
48. Prisoner A went to Mr Phillips’ cell and looked through his observation panel. He
said there was limited light but Mr Phillips was sat in his chair and looked as if he
was asleep. He asked Prisoner B to look through the flap, and he also thought that
Mr Phillips was asleep. At 8.45am, Prisoner A thought something was not right and
returned to Mr Phillips’ cell with Prisoner C. They looked through the observation
panel, turned the night light on and realised there was a strip of material attaching
Mr Phillips to the window bars. The prisoners shouted for an officer, who was
nearby, to check Mr Phillips.
49. The officer went straight to the cell and looked through the observation panel. He
thought Mr Phillips looked slumped in his chair so he opened his cell door. He then
realised that Mr Phillips was suspended by a ligature made from a bed sheet
attached to the window bars. He shouted a code blue and ran down the wing stairs
to alert staff. (Code blue is an emergency code indicating that a prisoner is not
breathing or is having difficulty breathing.)
50. A Supervising Officer (SO) was in the wing office when he heard the officer’s shout.
He ran towards the officer, who said there was a code blue, which the SO radioed.
Control room staff requested an ambulance immediately. The SO and officer
accidentally went to the wrong landing. Two other officers had already reached Mr
Phillips’ cell in response to the call. They went straight in, supported Mr Phillips’
body and cut the material. They then removed the ligature from his neck, checked
for signs of life and began chest compressions. Healthcare staff arrived at the cell
soon after and assessed Mr Phillips. They inserted an airway and administered
oxygen. At 9.10am, paramedics arrived at the wing. At 9.39am, the paramedics
confirmed that Mr Phillips had died.
51. Police found a note in Mr Phillips’ cell after he died. He apologised for his
behaviour, stated that he could not go on and regretted how he had lived his life
and the amount of time he had spent in prison. Mr Phillips wrote that he had no life
or future. He apologised to the person who found him.
Contact with Mr Phillips’ family
52. On 29 October, the Deputy Governor travelled to Mr Phillips’ mother’s address to
break the news of his death, but found she no longer lived there. Through speaking
to a neighbour, Mr Phillips’ aunt, he obtained Mr Phillips’ mother’s address nearby.
At 1.00pm, he arrived at the address and told Mr Phillips’ mother that he had died.
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He offered his condolences. Mr Phillips’ mother fetched Mr Phillips’ father from
another address nearby and he spoke to both of them together.
53. Mr Phillips’ mother lived over three hours away from Dartmoor, which took the
Deputy Governor away from the establishment for some time. There was a
shortage of available family liaison officers (FLOs) at Dartmoor which meant longer
term support for the family would be difficult.
54. On 1 November, staff at Dartmoor asked staff at HMP Channings Wood if they
could assist with the family liaison. An officer at Channings Wood was allocated as
the FLO for Mr Phillips’ family. On 2 November, she was given Mr Phillips’ mother’s
contact details. As she knew Mr Phillips’ mother had already been informed of her
son’s death, she waited until she had received more information from Dartmoor
before phoning her. On 5 November and 6 November, she tried to ring Mr Phillips’
mother several times but could not get through. On 7 November, the Head of Safety
wrote to Mr Phillips’ mother explaining that staff had been unable to get through to
her on the telephone. She asked that Mr Phillips’ mother contact the family liaison
officer and gave her their contact details.
55. On 8 November, the family liaison officer spoke to Mr Phillips’ mother and offered
her condolences. She offered her a contribution to funeral expenses in line with
HMPPS’ policy. She remained in contact with Mr Phillips’ family.
Support for prisoners and staff
56. After Mr Phillips’ death, the Head of Offender Management debriefed the staff
involved in the emergency response to ensure they had the opportunity to discuss
any issues arising, and to offer support. The staff care team also offered support.
57. The prison posted notices informing other prisoners of Mr Phillips’ death, and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Phillips’ death.
Post-mortem report
58. The post-mortem report was not available at the time of writing. However, the
coroner recorded the preliminary cause of death as hanging.
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Findings
Assessment and management of risk
59. Prison Service Instruction (PSI) 64/2011, Safer Custody, lists risk factors and
potential triggers for suicide and self-harm. It says all staff should be alert to the
increased risk of self-harm or suicide posed by prisoners with these risk factors and
should act appropriately to address any concerns. Any prisoner identified as at risk
of suicide and self-harm must be managed under ACCT procedures. PSI 64/2011
also states that any information that becomes available which may affect a
prisoner’s risk of harm to self must be recorded and shared, to inform proper
decision making.
60. Mr Phillips had been at Dartmoor for about three months when he took his own life.
During that time he had consistently denied having any thoughts of suicide or self-
harm. Staff did not identify any signs that he was a risk to himself. His friends on the
wing shared this view and said that he seemed his usual self just before he was last
locked in his cell. We listened to the calls Mr Phillips made to family in the period
before his death and none of these conversations suggested he was in crisis.
61. Mr Phillips had spent the vast majority of his time in prison since 2006, whilst
serving an IPP sentence. He had been released by the Parole Board on a few
occasions, but was recalled due to suspected threatening behaviour towards his ex-
partner and committing further offences. Mr Phillips received a further prison
sentence and was not eligible for release until 2025. Although Mr Phillips appeared
to be engaged with his sentence progression at his recent meeting with his POM, it
is clear from the note that he left in his cell that the amount of time he had spent in
prison had deeply affected him and he no longer felt there was a point to continuing
with his life. Mr Phillips spoke to his dad on 10 October about possible changes to
IPP sentences but did not appear to be in immediate distress.
62. Overall, the investigator and clinical reviewer found that Mr Phillips’ outward
presentation did not indicate any significant risks to himself. We know that suicidal
ideation is often a private process. Even had staff recognised Mr Phillips’ IPP
sentence as a risk factor for suicide, we conclude that staff could not reasonably
have foreseen an imminent risk of suicide in the days leading to his death.
Welfare checks
63. At Dartmoor, there is no expectation that staff check prisoners when they start their
shift in the morning. This is in accordance with Dartmoor’s Local Security Strategy.
However, in Mr Phillips’ case, this meant that there was a long period during which
he was not checked. A prison governor told the investigator that Dartmoor was
going to introduce a routine check when day staff started their shift as an extra
precaution for prisoner safety and security, we therefore do not make a
recommendation.
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Family Liaison
64. When Mr Phillips died, there were no family liaison officers (FLOs) available to
appoint and the Deputy Governor travelled to Mr Phillips’ family home to deliver the
news and offer support. This was good practice to cover a gap in provision.
Neighbouring HMP Channings Wood provided a trained FLO who followed up the
initial visit and provided ongoing support.
65. The Head of Safety told the investigator that Dartmoor had since trained three
FLOs, and another was hoping to be trained soon. We therefore do not make a
recommendation.
Clinical care
66. Overall, the clinical reviewer concluded that Mr Phillips’ healthcare was not
equivalent to that he could have expected to receive in the community.
Mental health
67. Mr Phillips was struggling with low mood so the GP at Dartmoor prescribed
antidepressants and put him on the waiting list for therapeutic groups. The clinical
reviewer concluded that this approach was comparable to community services.
68. In June 2022, Mr Phillips asked to see the mental health team. A referral was made
but due to Parc, his previous prison, transferring his records this referral was
automatically cancelled by the system. Since Mr Phillips’ death, Dartmoor have
made changes to the administrative process to identify if prisoners have been
incorrectly recorded as transferring to another prison. The clinical reviewer is
satisfied that this has been appropriately addressed but is concerned how Parc
incorrectly registered him back there. They have made a recommendation to Parc
to investigate why this occurred which the Head of Healthcare will want to address.
69. In September, Mr Phillips’ POM emailed the mental health team twice to request an
assessment after he had spoken to Mr Phillips. The first email was not actioned.
The Mental Health Team Manager was unable to check why, as the mental health
team had been taken over by a different Trust since then, so they no longer had
access to the old email account.
70. The second email resulted in Mr Phillips being assessed by the team. The clinical
reviewer noted that the delay in Mr Phillips being assessed was a missed
opportunity for the team to engage with Mr Phillips, for him to understand what
support was available at Dartmoor and to address his mental ill-health. However,
the reviewer concluded that the omission was unlikely to have contributed to Mr
Phillips’ overall wellbeing as when he was eventually assessed he said he was low
in mood but his mental health was generally stable.
71. Mr Phillips was prescribed antidepressants on 23 October but the clinical reviewer
notes that no review was booked with the GP. This should have taken place one to
two weeks after he started antidepressants, in accordance with national guidelines.
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Contact with emergency services
72. PSI 03/2013, Medical emergency response codes, instructs that staff radio a code
blue when a prisoner is in chest pain, having difficulty breathing, unconscious,
choking, having a fit, having a severe allergic reaction or having a stroke. Control
room staff must then immediately call an ambulance and “await updates from the
scene”. Staff with the prisoner must provide relevant information about the condition
of the prisoner to control room staff so that they can pass is on to the ambulance
service. 999 operators require certain information in order to despatch and prioritise
emergency ambulances, including the location of the emergency, and whether the
patient is breathing.
73. We listened to the recording of the 999 call staff in the control room made when
they received the code blue emergency alert. The information given to the operator
was confused and failed to pass on basic information about the nature of the
emergency. It took two minutes for the operator to establish that staff were calling
from Dartmoor and Mr Phillips was not breathing (and therefore for the ambulance
to be despatched), and four minutes for them to be transferred to the wing when
they were given full details of what had happened.
74. We have not reviewed any evidence that suggests this impacted on the outcome for
Mr Phillips. However, we have investigated a number of deaths, particularly self-
inflicted deaths, where the instructions in PSI 13/2013 are not compatible with the
efficient despatching of ambulances by 999 operators. We make the following
recommendation:
The Director General of HMPPS must review the current emergency response
policy to eliminate the conflict between calling an ambulance immediately and
providing the 999 operator details about the nature of the emergency.
Governor to note
Key work
75. Mr Phillips had only one key work session in the three months he spent at
Dartmoor. This was with his key worker on 11 October. The key worker explained
that Mr Phillips was allocated to him briefly as he was then temporarily promoted.
76. The Head of Re-offending said that since Covid-19, Dartmoor had been struggling
to successfully reinstate the key work model in full. He said that some officers did
not deliver key work for months due to poor wing management. In January 2023,
out of 600 prisoners who should have been receiving one session a week, 278 key
work sessions took place in. In February 2023, 48 key work sessions took place.
77. The Head of Re-offending said that at the time Mr Phillips was at Dartmoor, key
work was being allocated on a daily basis, dependant on staffing resource and
other pressures. He said that staffing levels were reasonable but Dartmoor’s ageing
population meant officers were frequently redeployed for hospital escorts, creating
staff shortages on the wings. If prisoners were in crisis, they would be prioritised for
key work. In August 2023, we asked him for an update. He said that key work
delivery was still being impacted by resourcing pressures, which the regional Prison
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Group Director (PGD) was aware of but had little power to support while officers
were being sent on detached duty to establishments experiencing other staffing
pressures. Both the PGD and the Head of Re-offending acknowledged the need for
increased key work at Dartmoor, to ensure meaningful contact for prisoners.
78. It is difficult to measure the impact on Mr Phillips. During his time at Dartmoor, Mr
Phillips engaged with various members of staff including his POM and chaplaincy.
He also had regular contact with his family and had friends on the wing. Mr Phillips
showed no obvious signs of distress or isolation. Our recent learning bulletin on IPP
sentenced prisoners identified that they should be prioritised for key work. This is
something the Governor will wish to consider.
79. We found no clear plan in place to improve key work delivery at Dartmoor by the
Governor and PGD, despite the clear benefits for prisoners. Specifically, we found
no plan to address the impact of staff redeployment to other prisons and the impact
of the ageing population on resources. We do not make a recommendation but
suggest the Governor and PGD consider this in light of the National Regime Model.
Inquest
80. The inquest into Mr Phillips’ death ended on 15 June 2026 and concluded that Mr
Phillips died as a result of suicide.
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