John Philips

DATE OF REPORT 22 June 2026.

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.

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

1. 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.’