Lindsay Phair

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Independent investigation into
the death of Mr Lindsay Phair
a prisoner at HMP Whatton,
on 18 November 2024
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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OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2026
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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. On 26 May 2021, Mr Lindsay Phair was sentenced to 15 years in prison for rape.
He died from disseminated oesophageal poorly differentiated adenocarcinoma,
which was contributed by ischaemic heart disease on 18 November 2024, while a
prisoner at HMP Whatton. He was 64 years old. We offer our condolences to Mr
Phair’s family and friends.
4. The Ombudsman’s office wrote to Mr Phair’s next of kin to explain the investigation
and to ask if they had any matters they wanted us to consider. They had no
questions but asked for a copy of our report.
5. NHS England commissioned an independent clinical reviewer, to review Mr Phair’s
clinical care at HMP Whatton.
6. The clinical reviewer concluded that the clinical care Mr Phair received at Whatton
was of a high standard and at least equivalent to that which he could have expected
to receive in the community. He found that Mr Phair’s symptoms were well
managed, however found that healthcare missed opportunities to implement care
plans to manage Mr Phair’s falls. The clinical reviewer made four recommendations
not related to Mr Phair’s death that the Head of Healthcare will want to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Phair’s care.
8. We did not find any non-clinical issues of concern. We make no recommendations.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
Practice Plus Group pointed out some factual inaccuracies in the clinical review,
which has been amended accordingly.
10. In an inquest held on 23 January 2025, the Coroner concluded that Mr Phair died of
natural causes.
Adrian Usher December 2025
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
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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