Michael Phillips

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Michael Phillips
on 18 November 2022,
following his release from
HMP Stoke Heath
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, 2024
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Summary
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. Since 6 September 2021, the PPO has been investigating post-release deaths that
occur within 14 days of the person’s release from prison.
3. 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.
4. Mr Michael Phillips died of a ruptured spleen on 18 November 2022, the day after
his release from HMP Stoke Heath. He was 55 years old. I offer my condolences to
those who knew him.
5. Mr Phillips was found unresponsive in the street in the early hours of 18 November.
He had suffered a cardiac arrest. He was taken to hospital and during attempts to
resuscitate him, his spleen ruptured. Hospital doctors agreed that the internal
bleeding was too severe to treat and stopped resuscitation attempts. Toxicology
tests showed that Mr Phillips had taken psychoactive substances (PS).
6. Mr Phillips was released homeless. However, we found that his community offender
manager had prepared for his release by promptly completing accommodation
referrals to local authorities and homelessness charities. The provision of suitable
accommodation for people leaving prison is an issue that extends beyond the remit
of Stoke Heath or local probation services, and the local authority may want to be
aware of the issues raised in this case.
7. We make no recommendations.
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The Investigation Process
8. HMPPS notified us of Mr Phillips’ death on 25 November 2022.
9. The PPO investigator obtained copies of relevant extracts from Mr Phillips’ prison
and probation records.
10. We informed HM Coroner for Stoke-on-Trent and North Staffordshire of our
investigation. They gave us the results of the post-mortem examination. We have
sent the Coroner a copy of this report.
11. The Ombudsman’s family liaison officer contacted Mr Phillips’ sister to explain the
investigation and to ask if she had any matters she wanted us to consider. She had
no questions but asked for a copy of our report.
12. Mr Phillip’s sister received a copy of the draft report. She did not make any
comments.
13. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Stoke Heath
14. HMP Stoke Heath is a category C prison and young offenders institution which
holds up to 782 men who have been convicted and sentenced. There is also a
small open category D unit attached to the prison aimed to help those close to the
end of their sentence resettle back into the community. It is managed by HMPPS.
HM Inspectorate of Prisons
15. The most recent inspection of Stoke Heath was in 2019. Inspectors reported an
improvement in the prison’s approach to substance misuse. There was a
designated drug treatment unit which provided a positive, recovery-focused
environment for prisoners with positive outcomes. There were appropriate
throughcare arrangements to facilitate treatment continuation for prisoners on
release. Harm reduction information included naloxone training to treat overdose in
the community and there were good links with community drug services and
residential rehabilitation centres.
Probation Service
16. The Probation Service works with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, as well as prepare reports to advise the Parole Board and
have links with local partnerships to whom, where appropriate, they refer people for
resettlement services. Post-release, the Probation Service supervises people
throughout their licence period and post-sentence supervision.
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Key Events
17. On 16 August 2022, Mr Michael Phillips was convicted of having a bladed article in
a public place and was sentenced to eight months in prison. He was moved to HMP
Stoke Heath on 26 August.
Accommodation
18. On 10 October, Mr Phillips’ community offender manager (COM) made a referral to
the Community Rehabilitation Services to help find Mr Phillips local accommodation
for his release (as he was due to be homeless). The same day, she made a referral
to the Lyme Trust, a local housing charity. The Lyme Trust completed a telephone
assessment with Mr Phillips to assess his suitability for their housing.
19. On 17 October, the COM completed a Duty To Refer application to Stoke-on-Trent
Council. (Certain public authorities must notify local authorities that a person who
has engaged with them might be homeless or at risk of homelessness.) The
application was accepted but not progressed before Mr Phillips was released.
20. On 4 November, the Lyme Trust told the COM that Mr Phillips was unsuitable for
their housing due to his history of violent offending.
21. On 17 November, Lifehouse (a local homeless charity) contacted the COM to tell
her that they would be able to help Mr Phillips with temporary accommodation.
Unfortunately, they had no beds available on the day of his release from prison.
Lifehouse told the COM that Mr Phillips would need to wait for a bed to become
available before they could offer him temporary housing.
Substance misuse support
22. On 30 August 2022, after a referral was submitted to the prison Substance Misuse
Team (SMT), a substance misuse worker saw Mr Phillips for an initial assessment.
Mr Phillips told the SMT worker about his long history of drug use. As Mr Phillips
only had ten weeks left in prison, the worker was unable to put him on any
substance misuse courses. She did however give him some workbooks to
complete, and they talked about the risks of drug taking in prison.
23. On 27 October, the SMT worker saw Mr Phillips for a pre-release review. The SMT
worker told Mr Phillips about the risks of taking drugs in the community. She
explained that his tolerance levels would have dropped whilst in prison and that he
was therefore at an increased risk of overdosing and dying. They discussed ways to
minimise this risk if Mr Phillips did decide to use drugs, such as taking smaller
amounts and not taking them alone. The SMT worker told Mr Phillips about
naloxone (a medication used to reverse the fatal effects of opiate (heroin)
overdose). Mr Phillips told the SMT worker that he did not use heroin, but would be
happy to be trained in how to use naloxone prior to his release from prison. The
SMT worker asked Mr Phillips if he would like any help from substance misuse
services in the community. Mr Phillips said he did not want help from them and so
the SMT worker closed the case.
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24. On 1 November, Mr Phillips completed the naloxone training.
Release from Stoke Heath
25. On 17 November, Mr Phillips was released from Stoke Heath with a supply of
naloxone.
26. He attended his induction appointment at Stoke Probation Office. As Mr Phillips was
homeless, the COM told him to go to the Macari Centre (a local homelessness
charity). The COM also told Mr Phillips to make a homeless application to the
council and provided him with a telephone number for Rough Sleepers (a local
organisation that helps house homeless people).
Circumstances of Mr Phillips’ death
27. In the early hours of 18 November, Mr Phillips was found unresponsive by the
police in the streets of Stoke-on-Trent in wet and cold conditions. The police started
chest compressions whilst they waited for the ambulance to arrive. Paramedics said
that Mr Phillips had gone into hypothermic cardiac arrest (a drop in core body
temperature that results in cardiac arrest). They took Mr Philips to Royal Stoke
Hospital where chest compressions were continued using an automated machine.
Whilst the doctors were trying to save his life, Mr Philips’ spleen ruptured, and he
started to bleed internally. Doctors agreed that the internal bleeding was too severe
to treat, and he was pronounced deceased at approximately 12.55pm.
28. On 25 November 2022, the police informed HMPPS that Mr Phillips had died.
Cause of death
29. No post-mortem examination was carried out. A hospital doctor provided Mr Phillips’
cause of death as a ruptured spleen caused by automatic cardiac massage induced
trauma (chest/abdominal injuries as a result of vigorous chest compressions) and
hypothermic cardiac arrest.
30. The toxicology report stated that Mr Phillips had MDPHP (a psychoactive
substance, also known as ‘monkey dust’) in his system at the time of his death. The
toxicology report noted that adverse effects associated with the use of MDPHP
include unconsciousness, seizures and cardiac arrest.
31. The Coroner advised us that he would determine the cause of death at inquest.
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Findings
32. Homelessness on release from prison is a significant and complex challenge. While
prison and probation staff can submit referrals to local authorities and charities,
there are occasions when beds are not available, or the individual does not meet
the eligibility criteria for housing. This means that these individuals are released
homeless and are expected to report to the local authority on the day of their
release in the hope of receiving emergency housing. If an individual is homeless, it
can increase the likelihood that they will commit further crimes or seek shelter and
support in harmful places.
33. Mr Phillips was released from prison without any suitable accommodation. Although
his COM was able to find him accommodation with a local homeless charity, they
did not have any beds available on the day of his release, so he was released
homeless.
34. We consider that Mr Phillip’s COM suitably prepared for his release by promptly
completing accommodation referrals to the local authorities and homeless charities.
She also provided Mr Phillips with the phone number of a local homelessness
charity and directed him to the local council on the day of his release.
35. The provision of suitable accommodation for people leaving prison is an issue that
extends beyond the remit of Stoke Heath or local probation services. However, as a
result of having no accommodation available, Mr Phillips was left to face attempting
to survive a night in the open air with nothing but his clothing to protect him from
near freezing temperatures. We are sure that the Local Authority will want to be
aware that he did not succeed in that attempt.
Adrian Usher
Prisons and Probation Ombudsman September 2023
Inquest
The inquest, held on 21 October 2024, concluded that Mr Phillips died by misadventure.
The medical cause of death was recorded as fentanyl and MDPHP toxicity with
hypothermia.
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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
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