Phillip Chell

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Phillip Chell,
a prisoner at HMP Oakwood,
on 28 June 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
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OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
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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. Mr Phillip Chell died of pulmonary haemorrhage (bleeding into the lung) on 28 June
2023, at HMP Oakwood. He was 43 years old. We offer our condolences to Mr
Chell’s family and friends.
4. The PPO family liaison officer wrote to Mr Chell’s parents to explain the
investigation and to ask if they had any matters they wanted us to consider. They
were concerned that Mr Chell was not prescribed painkillers for an existing elbow
injury and was not seen by a doctor when he first started to cough up blood. These
issues have been addressed in the clinical review.
5. NHS England commissioned an independent clinical reviewer to review Mr Chell’s
clinical care at HMP Oakwood. The clinical reviewer concluded that the clinical care
Mr Chell received at Oakwood was of a good standard and equivalent to that which
he could have expected to receive in the community. She made one
recommendation not connected to Mr Chell’s death, which the Head of Healthcare
will wish to address.
6. The PPO investigator investigated the non-clinical issues relating to Mr Chell’s care.
We did not find any non-clinical issues of concern. We make no recommendations.
7. We shared our initial report with HMPPS. They found no factual inaccuracies.
8. We sent Mr Chell’s parents a copy of the initial report. They raised a number of
issues that do not impact on the factual accuracy of this report and have been
addressed through separate correspondence.
Adrian Usher December 2023
Prisons and Probation Ombudsman
Inquest
The inquest, held on 12 June 2025, concluded that Mr Chell died from natural causes.
Prisons and Probation Ombudsman 1
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