Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0289, written 22 Jun 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jun 2026 |
|---|---|
| Reference | 2026-0289 |
| Deceased | John Philips |
| Coroner | Nicholas Lane |
| Coroner area | Devon, Plymouth and Torbay |
| Organisation named | Oxleas NHS Foundation Trust · Devon Partnership NHS Trust |
| Source | judiciary.uk record |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
COUNTY OF DEVON, PLYMOUTH AND TORBAY
CORONER AREA
REPORT TO PREVENT FUTURE DEATHS
REGULATION 28
CORONERS (INVESTIGATION) REGULATIONS 2013
JOHN EDWARD BRYNMOR PHILLIPS
HM AREA CORONER
NICHOLAS LANE
1.
CORONER
I am Nicholas Lane – HM Area Coroner for County of Devon, Plymouth and Torbay.
2.
DATE OF REPORT
22 June 2026.
3.
CORONER’S LEGAL POWERS
I make this report under Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28
and 29 of the Coroners (Investigations) Regulations 2013.
4.
THIS REPORT IS BEING SENT TO:
1) Chief Executive Officer
- NHS England
You are under a duty to respond to this report within 56 days of the date of this report – 17 August 2026.
I may extend the required date for response, if an application (with reasons) is made by you.
5.
YOUR RESPONSE
Your response must contain details of action taken or proposed to be taken, setting out the timetable for
action. Otherwise, you must explain why no action is proposed.
I have a duty to send a copy of your response to the Chief Coroner.
In accordance with the Chief Coroner’s PFD Publication Policy (2026), you should send any representations
that you wish to make regarding publication of your response. These representations should be made at
the same time as the response is provided. I will pass any representations received to the Chief Coroner
for their determination.
Please note any links to webpages included in the response will not be checked for sensitive information
prior to publication, as the information is already online.
The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s
webpage – Non-responses to Prevention of Future Deaths (PFD) reports – Courts and Tribunals Judiciary.
6.
OVERVIEW
I am concerned that the national SystmOne electronic patient record operates in an unsafe way, owing to
the ability for records to be activated/deactivated at different organisations at any time, with little or no
safeguards, which is likely leading to unsafe clinical practice.
7.
ACTION SHOULD BE TAKEN
In my opinion, unless action is taken to address the above concerns then there is a significant risk of future
deaths and I believe that your organisation has the power to take such action.
8.
INVESTIGATION and INQUEST
On 7 November 2022 an investigation was commenced into the death of John Edward Brynmor Phillips.
The investigation concluded at the end of the inquest hearing on 18 June 2026 at Exeter Coroner’s Court,
heard by HM Area Coroner Nicholas Lane together with a jury.
Section 2 of the Record of Inquest (which recorded the medical cause of Mr Phillips’s death) was
determined by the jury as:
1a) ligature suspension
Section 3 of the Record of Inquest (which set out how, when and where Mr Phillips came by his death) was
determined by the jury as:
‘Mr Phillips was found unconscious in his cell (B3-12 at HMP Dartmoor) on the morning of 29th October
2022. Mr Phillips had deliberately used a ligature to end his own life as evidence by the suicide note that
he had left. Resuscitation was attempted by prison officers and medical staff, and was continued by the
ambulance service until he was pronounced deceased at 9.39am in his cell.
There was a delay of approximately 2.5 months in John Phillips undergoing a mental health assessment at
HMP Dartmoor - this delay came about because once John Phillips had been transferred to HMP Dartmoor
from a different prison his prison medical records were activated by the healthcare team at this other prison
- with the unintended consequence of deactivating the medical records at HMP Dartmoor, leading to the
cancellation of a referral that had been tasked to the mental health team at HMP Dartmoor - however, this
delay did not materially contribute to John Phillips' death.’
Section 4 of the Record of Inquest (which set out conclusions in respect of Mr Phillips’ death) was
determined by the jury, in narrative form, as:
‘Over the course of his time at HMP Dartmoor Mr Phillips intermittently but frequently suffered repeated
low moods, paranoia and anxiety, particularly relating to his long term status as an IPP and EPP prisoner.
This led to his intentional use of a ligature to end his life by suicide.’
9.
CIRCUMSTANCES OF DEATH
Mr Phillips was 37 years old at the time of his death. He had spent a significant amount of his adult life as
a serving prisoner, including receiving an IPP sentence. Having been recalled to prison in 2020 (and then
sentenced to an additional term of imprisonment in November 2021 for further offending) he was
transferred (at his request) to HMP Dartmoor in July 2022.
Mr Phillips had a history of low mood, anxiety and paranoia – he reported that he had considered taking
his own life on a number of occasions and had made one significant attempt. Although Mr Phillips did not
obviously suffer from overt poor mental health to those who were involved in his care and management
at HMP Dartmoor, he had requested, at his reception health assessment in July 2022, to be referred to the
prison mental health team for assistance. This referral was made immediately.
The inquest heard evidence that the referral to the mental health team was cancelled, or ‘deactivated’, on
Mr Phillips’ SystmOne records, and that this likely came about owing to a member of staff at HMP Parc,
the establishment from where Mr Phillips had been transferred, carrying out an ‘uploading’ exercise
relating to Mr Phillips’ SystmOne records – this uploading exercise was apparently a well-known feature
of how SystemOne needed to be operated (in the prison setting at least). The inquest heard evidence that
in consequence of the uploading of Mr Phillips’ SystmOne records at HMP Parc, his current SystmOne
records at HMP Dartmoor became deactivated, with associated current tasks (including the referral to the
mental health team) being cancelled.
It appears that no member of the healthcare staff at HMP Dartmoor realised that this deactivation of the
records had taken place – they were swiftly reactivated (by a similar uploading process taking place at HMP
Dartmoor) but the previous tasks remained cancelled. Over two months later, Mr Phillips enquired about
why he had not yet been seen by the mental health team, as he had initially been referred. This led to a
swift triage and an assessment of Mr Phillips by a mental health nurse. Mr Phillips was commenced on
anti-depressant medication and placed on a waiting list for psychological therapy, to try and address his
symptoms of low mood and anxiety. This 2.5 month delay in Mr Phillips undergoing a mental health
assessment and treatment commencing were directly owing to the SystmOne records deactivation
incident.
On 29 October 2022 Mr Phillips was found to be unconscious in his cell, having used a ligature to take his
own life. The jury determined that Mr Phillips died by suicide – the delay in Mr Phillips being assessed by
the mental health team was recorded by the jury in their determinations, although it was noted that this
did not materially contribute to his death.
10.
DETAIL OF CONCERNS
During the course of the investigation and inquest I obtained and heard evidence giving rise to a concern.
In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it
is my statutory duty to report to you.
The MATTER OF CONCERN is as follows:
The national SystmOne electronic patient record operates in an unsafe way because it appears to allow a
patient’s record to be accessed (which might be for a necessary administrative reason) by a member of
staff in an organisation previously involved in the patient’s care, which seems to have the automatic effect
of deactivating the patient’s active record in an organisation currently involved in the patient’s care (and
associated appointments, tasks, treatment plans etc), without this being obvious to anyone – this leads to
the removal of important and current tasks, referrals and appointments for the patient whilst they are
being cared for by the current organisation and will likely result in unsafe clinical care being provided by
NHS Trusts.
The inquest heard evidence (from clinicians involved in providing healthcare within prisons) that this
functionality of SystmOne is acknowledged and that, accordingly, steps are being taken by the healthcare
provider (Oxleas NHS Foundation Trust) to mitigate against the risks of this happening and to try and
ensure that when the problem arises, it is identified and that there is consideration of whether clinical care
and treatment plans have been affected.
However, it appears that, given SystmOne is used nationally by numerous healthcare providers, a
technological solution to prevent this issue from occurring (or identifying clearly that it has occurred for
those using the system) would be preferable and improve patient safety.
This issue was identified by the clinical review that formed part of the PPO investigation into Mr Phillips’
death. The clinical review made the following recommendation to NHS England:
- NHS England to consider the system wide SystmOne administrative risk highlighted in this case and
to take any action deemed appropriate to safeguard and mitigate the future risk of reoccurrence.
It is not clear whether any action has been taken following this recommendation – those giving evidence
at the inquest who were familiar with using SystmOne were not aware that any changes had been made
to its functionality in respect of this issue.
11.
COPIES AND PUBLICATION OF THIS REPORT
I have a duty to send a copy of my report to every Interested Person (IP) who in my opinion should receive
it.
I also may send a copy of the report to any other person who I believe may find it useful or of interest.
I confirm I have sent the report to:
1) Mr Phillips’ family (IP).
2) Oxleas NHS Foundation Trust (IP).
3) Devon Partnership NHS Trust (IP).
4) Practice Plus Group (IP).
5) HMPPS / GLD (IP).
6) PPO – for the attention of the PPO Ombudsman who is the author of the PPO report and to the
author of the PPO clinical review (IP).
I also have a duty to send a copy of the report to the Chief Coroner.
You may make representations to me, the coroner, about the publication of the contents of this report in
line with the Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief
Coroner alongside the report. Please refer to Section 5 above for additional information relating to the
publication of reports and responses.
12.
Date: 22 June 2026
Signature:
Nicholas Lane
HM Area Coroner
County of Devon, Plymouth and Torbay
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Mr Nicholas Lane
HM Area Coroner for
Devon, Plymouth and Torba
County Hall
Topsham Road
Exeter
EX2 4QD
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
20th July 2026
Dear Mr Lane,
Re: Regulation 28 Report to Prevent Future Deaths – John Edward Brynmor
Phillips who died on 29th October 2022.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 22nd
June 2026 concerning the death of John Edward Brynmor Phillips on 29th October
2022. In advance of responding to the specific concerns raised in your Report, I would
like to express my deep condolences to Mr Phillip’s family and loved ones. NHS
England is keen to assure the family and yourself that the concerns raised about Mr
Phillip’s care have been listened to and reflected upon.
Your Report raised concern that the national SystmOne electronic patient record (used
in the prison service) operates in an unsafe way, owing to the ability for records to be
activated/deactivated at different organisations at any time, with little or no safeguards,
which is likely leading to unsafe clinical practice.
By way of providing some background information, the electronic patient record used
for people in prison in England is known as Health and Justice Information System
(HJIS) and currently uses SystmOne (by TPP). There is an established process for
transferring a prisoner’s healthcare record to the receiving prison’s healthcare
organisation when prisoners transfer between prisons.
During this inquest there was concern that the SystmOne electronic patient record
allows for healthcare professionals previously involved with a patients care to access
their records and that this automatically deactivates the patient’s active record in the
organisation currently involved in their care. NHS England’s National Health and
Justice Team have reviewed this case. This review identified that a member of staff at
HMP Parc did access Mr Phillips’ notes after he had transferred to HMP Dartmoor,
and during this access, they manually registered Mr Phillips back to HMP Parc despite
the fact that he was residing at HMP Dartmoor. This was reflected in the information
that was in the task section of SystmOne. SystmOne did not automatically register Mr
Phillips' record when it was retrieved in HMP Parc's SystmOne. Following this, a
member of staff at HMP Dartmoor, believing that Mr Phillips had been transferred back
to HMP Parc, actioned the outgoing transfer task, which then removed Mr Phillips from
the HMP Dartmoor Mental Health Triage waiting list.
Once a patient has transferred between prisons and their SystmOne record is
accessed for purposes such as updating, it does not automatically pull the patient and
records back to the previous site when they are accessed. A request to re-register the
patients record is required for this. If the re-register request is made, the deduction or
deactivation of the record at the “new” prison then takes place. This appears to be
what happened in this case and was human error, not an automatic process. We
therefore do not believe that the events in this tragic case were due to a systemic issue
within SystmOne.
To further reassure you, this does not impact on clinical care and treatment plans.
Once the request to correct the re-registration is made, the patient’s records remain
as they were and are unaffected by this movement of their clinical record.
In order to ensure that all healthcare providers are aware of this investigation and any
learning, we will be sharing the findings with the NHS England Regional Health and
Justice Commissioning Teams, the Welsh Health Board and HMP Parc. We will
highlight to them that when accessing the records of a patient who has left a prison,
healthcare staff are mindful of the movement of records and not requesting the re-
registering of the patient that is no longer a resident in that prison.
In addition, the findings, information and any learning from this case will be shared
with NHS England’s Health and Justice Delivery Oversight Group (HJDOG). The
HJDOG is the senior leadership forum, which holds responsibility for the oversight of
delivery and continuous improvement in Health and Justice commissioned services,
through both national and regional teams. All health and justice related Reports to
Prevent Future Deaths are shared with HJDOG members, and assurance is sought
from regions where learning and action is identified.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of Mr
Phillips, are shared across the NHS at both a national and regional level and helps us
to pay close attention to any emerging trends that may require further review and
action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
NHS England
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