Philip Warne

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Philip Warne,
a prisoner at HMP The Verne,
on 24 March 2023
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, 2024
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
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. 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. Mr Philip Warne died of lung cancer on 24 March 2023 at HMP The Verne. He was
75 years old. We offer our condolences to Mr Warne’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Warne received at The
Verne was of a reasonable standard and was at least equivalent to that which he
could have expected to receive in the community.
5. We found no non-clinical issues of concern. We make no recommendations.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
6. HMPPS notified us of Mr Warne’s death on 24 March 2023.
7. NHS England commissioned an independent clinical reviewer to review Mr Warne’s
clinical care at The Verne.
8. The PPO investigator investigated the non-clinical issues relating to Mr Warne’s
care.
9. The PPO family liaison officer wrote to Mr Warne’s next of kin, his daughter, to
explain the investigation and to ask if she had any matters she wanted us to
consider. She asked about the clinical care Mr Warne had received at The Verne
and why he was discharged from hospital on 30 December and moved to a new
wing. These issues have been addressed in our report and the clinical review. She
also had questions about various prison procedures which we have addressed in a
separate letter.
10. Mr Warne’s daughter received a copy of the initial report. She did not make any
comments.
11. The initial report was shared with HMPPS. They did not find any factual
inaccuracies.
Previous deaths at HMP The Verne
12. Mr Warne was the eighteenth prisoner to die at The Verne since March 2020. Of
the previous deaths, 15 were from natural causes, one was self-inflicted and one is
awaiting classification.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
13. On 5 January 2018, Mr Philip Warne was sentenced to 14 years imprisonment for
sexual offences. He was moved to HMP The Verne on 11 March 2022.
14. Mr Warne had several health conditions including heart disease, high blood
pressure and type 2 diabetes.
15. During July and August, Mr Warne saw healthcare staff at The Verne several times
about pain in his chest and upper arm. Healthcare staff checked for heart issues,
but the test results were normal. They initially diagnosed muscular pain and
prescribed pain relief. However, when the pain was no better after a month, they
referred Mr Warne for an X-ray of his chest and shoulder.
16. On 30 September, following an X-ray and CT scan, a respiratory consultant told Mr
Warne that he had lung cancer, and that he needed further scans and a biopsy to
determine his exact diagnosis.
17. On 3 November, Mr Warne had a lung biopsy and a week later, a respiratory
consultant told Mr Warne that he had squamous cell carcinoma of the lung, and that
he needed to have more tests before they could decide on a treatment plan for him.
18. On 16 November, Mr Warne saw an oncologist who told him that he could start
radiotherapy and chemotherapy in approximately three weeks’ time.
19. On 19 December, Mr Warne had his first round of radiotherapy treatment.
20. On 26 December, a nurse saw Mr Warne in his cell after he told wing staff that he
felt unwell. The nurse took his observations which showed he urgently needed
medical attention for possible sepsis (a life-threatening reaction to an infection).
Prison staff took Mr Warne to the Accident and Emergency (A&E) department at
Dorset County Hospital where he was diagnosed with influenza and pneumonia
(infection of the lungs). Over the next few days, Mr Warne remained in hospital and
was treated with oxygen and antibiotics.
21. After an improvement in his health, on 30 December, the hospital discharged Mr
Warne back to The Verne. As Mr Warne was too weak to use stairs, he was moved
to a wing which had ground floor accommodation.
22. The next day, a nurse saw Mr Warne in his cell. The nurse was concerned that Mr
Warne was looking increasingly unwell and was struggling to breathe. A senior
paramedic at The Verne attended the cell and took clinical observations. The
paramedic was concerned about Mr Warne’s presentation, so he rang the hospital
respiratory team for advice. They said that Mr Warne should be taken back to A&E
to be assessed. He was admitted the same day and remained there for the next
week.
23. On 9 January 2023, Mr Warne was moved to Weymouth Hospital for rehabilitation
and physiotherapy so that he could be independent and mobile on his return to The
Verne.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
24. On 12 January, Mr Warne had an appointment with his oncologist. The oncologist
said that Mr Warne was now too weak to have chemotherapy, however, he would
be able to finish his radiotherapy treatment. The oncologist said that this would be
palliative radiotherapy (to manage the symptoms of, but not cure, his cancer).
25. On 24 January, after an improvement in his mobility, Mr Warne was discharged
from Weymouth Hospital and moved back to The Verne.
26. On 9 February, Mr Warne completed his radiotherapy treatment.
27. On 1 March, Mr Warne had an appointment with his oncologist at Dorset County
Hospital. The oncologist told Mr Warne that he was too unwell to cope with any
further treatment, but that the palliative radiotherapy should manage his symptoms
and pain for a while. She was unable to give an exact prognosis.
28. Over the next few weeks, Mr Warne remained at The Verne where healthcare staff
monitored him and gave regular pain relief.
29. On 16 March, Mr Warne said he did not with anyone to resuscitate him if his heart
or breathing stopped and signed an order to that effect.
30. On the morning of 24 March, a nurse was helping Mr Warne in his cell when she
noticed that he had turned pale and was unable to speak properly. The nurse took
his observations which showed that his heart rate was high and that his oxygen
levels had dropped, so she called a code blue (a medical emergency code used
when a prisoner is unconscious or having breathing difficulties). Several nurses and
a GP attended the cell and agreed that Mr Warne was in the last stages of his life.
As Mr Warne did not wish to be resuscitated, the nurses did not start chest
compressions, and Mr Warne died at approximately 10.46am.
Post-mortem report
31. The post-mortem report concluded that Mr Warne died of bilateral
bronchopneumonia (infection in the lungs) caused by advanced lung cancer.
Ischaemic heart disease was also listed as a contributory factor.
Adrian Usher
Prisons and Probation Ombudsman October 2023
Inquest
The inquest, held on 9 September 2024, concluded that Mr Warne died from natural
causes.
4 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