Phillip Sheridan

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Independent investigation into
the death of Mr Phillip Sheridan,
a prisoner at HMP Full Sutton,
on 21 July 2024
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, 2025
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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. 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 Sheridan died of acute myocardial infarction (heart attack) caused by
ischaemic heart disease (reduced blood flow to the heart) and severe coronary
atheroma (fatty material builds up on the walls of the arteries which reduces blood
flow). Diabetes mellites (disease that causes high blood sugar levels) and
cerebrovascular disease (condition that affects the blood flow to the brain)
contributed to but did not cause Mr Sheridan’s death. Mr Sheridan was 70 years old
when he died on 21 July 2024, while a prisoner at HMP Full Sutton. We offer our
condolences to Mr Sheridan’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Sheridan received at Full
Sutton was equivalent to that which he could have expected to receive in the
community. The clinical reviewer made a recommendation about engaging with
prisoners who refuse medical treatment and documenting these interactions. She
also made a recommendation not related to Mr Sheridan’s death which the Head of
Healthcare will wish to consider.
5. Mr Sheridan told staff that he wanted to die and harm himself. Staff responded
promptly and appropriately by beginning suicide and self-harm prevention
procedures (known as ACCT). However, staff could not complete ACCT checks
adequately due to a cabinet obstructing their view. The day after Mr Sheridan’s
death, the prison removed these cabinets from cells in healthcare for prisoners
subject to ACCT checks. When staff found Mr Sheridan unresponsive, signs of rigor
mortis were present, indicating that the previous ACCT checks had not fulfilled their
objective of ensuring Mr Sheridan was alive and well.
6. There was a delay in radioing an emergency code when an officer found Mr
Sheridan in his cell. However, this was minimal and did not affect the outcome for
Mr Sheridan who had been dead for some time.
Recommendations
• The Head of Healthcare and the Regional Manager for PPG should be assured
that there is a refusal of care pathway in place which supports practitioners
caring for patients who refuse treatment to a point of their self-neglect.
• The Governor should ensure that staff adequately assess a prisoner’s welfare
when doing ACCT checks.
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The Investigation Process
7. HMPPS notified us of Mr Phillip Sheridan’s death on 22 July 2024.
8. NHS England commissioned an independent clinical reviewer to review Mr
Sheridan’s clinical care at HMP Full Sutton.
9. The PPO investigator investigated the non-clinical issues relating to Mr Sheridan’s
care.
10. She obtained and reviewed copies of relevant extracts from Mr Sheridan’s prison
and medical records.
11. The investigator and clinical reviewer interviewed four members of staff and a
prisoner at Full Sutton on 12 September. They interviewed four more members of
staff via MS Teams on 3 October. The investigator also contacted Safer Custody
members of staff for further information on internal prison processes.
12. The Ombudsman’s office wrote to Mr Sheridan’s next of kin to explain the
investigation and to ask if she had any matters she wanted us to consider. They did
not respond.
13. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies and their action plan is annexed to this
report.
Previous deaths at HMP Full Sutton
14. Mr Sheridan was the ninth prisoner to die at Full Sutton since 21 July 2021. Of the
previous deaths, seven were from natural causes, and one was self-inflicted. Since
Mr Sheridan’s death and up to the end of October 2024, two prisoners have died of
natural causes and one due to unknown causes. There are no similarities between
the findings in our investigation into Mr Sheridan’s death and these previous
investigations.
Assessment, Care in Custody and Teamwork
15. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner. After an
initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner.
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Key Events
16. On 18 June 1987, Mr Phillip Sheridan was sentenced to life imprisonment for
attempted rape, robbery and other offences. His tariff (the minimum amount of time
he would spend in prison) was twelve years. Having spent time in several prisons,
Mr Sheridan transferred to HMP Full Sutton in November 2011.
17. Mr Sheridan had been diagnosed with several health conditions during his time in
prison: diabetes, asthma, a stroke, mobility issues, acute schizophrenia and
paranoia associated with personality disorder. He was also incontinent in the last
year prior to his death. Mr Sheridan often did not engage with treatment for his
conditions. In particular, he had a long history of refusing insulin for managing his
diabetes. Medical professionals believed that Mr Sheridan had the mental capacity
to refuse treatment.
18. On 29 April 2020, Mr Sheridan said he did not want to be resuscitated if his heart or
breathing stopped and signed an order to that effect (DNACPR - Do Not Attempt
Cardiopulmonary Resuscitation). This document was valid at the time of death, but
had not been reviewed since Mr Sheridan first signed it as it should have been.
19. On 8 August 2022, a GP assessed Mr Sheridan and noted he was moderately frail
and no longer able to live an independent life. The GP also noted that Mr Sheridan
was able to understand information and make decisions about his care.
20. On 5 June 2023, paramedics tried to convince Mr Sheridan to go to hospital to
investigate a possible stroke, but he refused. A GP noted that he had the mental
capacity to make this decision. Later that day, he agreed to go to hospital but
discharged himself the following day. On 8 June, another GP reviewed Mr Sheridan
and assessed that he had mental capacity to refuse treatment. He remained in the
healthcare unit until 24 August.
21. Mr Sheridan’s incontinence issues became worse during his last year. A prisoner
said that often when Mr Sheridan’s bed was changed, the linen was not disposed of
appropriately in waste bags. He also said that Mr Sheridan did not have a buddy (a
prisoner who supports another with their practical needs) once he was no longer
allowed to be Mr Sheridan’s buddy due to a risk assessment. However, we found
that staff tried their best to find buddies for Mr Sheridan. When that was not
possible, staff supported him within their capacity.
22. On 8 July 2024, Mr Sheridan complained about chest pain. Prison officers took him
to the healthcare unit in a wheelchair. Mr Sheridan refused to stay in healthcare for
assessment as he wanted to return to his cell to vape. Healthcare staff continued to
monitor Mr Sheridan regularly and they had no acute concerns.
23. On 15 and 16 July, Mr Sheridan refused to take his insulin. On 16 July, when staff
asked him why, he said he had had enough in this life and wanted to die. A
Custodial Manager (CM) started prison suicide and self-harm monitoring, known as
ACCT. He set Mr Sheridan’s observations as ‘sessionally’ (this meant one
observation in the morning, afternoon, evening and overnight).
24. On 17 July, a supervising officer chaired an ACCT review, with the Head of
Healthcare and a healthcare officer also present. Mr Sheridan said he wanted to die
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and refused to take his medication. He was hostile towards staff, which was
common, and refused to elaborate on why he did not want to be treated. He also
said he would stab himself in the stomach with tweezers. Staff removed the
tweezers and pens from his cell. Staff present increased his ACCT observations to
hourly.
25. On 18 July, Mr Sheridan’s condition declined, he looked paler and frailer than usual,
and a nurse assessed that he needed to go to hospital. However, Mr Sheridan
refused to go.
26. On 19 July, Mr Sheridan accepted being transferred to the healthcare unit within the
prison, but only agreed to receive support from healthcare for his incontinence
issues. He continued to refuse treatment for his diabetes.
27. On 20 July, a nurse changed Mr Sheridan’s incontinence pad and made him a
drink. Mr Sheridan continued to refuse other treatment.
Events overnight 20 - 21 July
28. There is no CCTV in the healthcare unit so the following account is taken from
documentation. Overnight from 20 July to 21 July, an officer checked Mr Sheridan
every hour, even though he was under the impression the checks only had to be
conducted once overnight (sessionally), as this was noted on top of the page where
he was recording the times of the observations. He was worried that Mr Sheridan
might fall out of bed, so he checked Mr Sheridan at 7.30pm, 8.30pm, 9.00pm,
10.00pm, 11.00pm, 12.30am, 1.30am, 2.30am, 3.30am, 4.30am, 5.30am and
6.00am to check that he had not fallen. He noted that Mr Sheridan was asleep all
night, but that it was difficult to see him because Mr Sheridan’s chest did not move
a lot as he was breathing and there was also a cabinet partially obstructing the
view.
29. On 21 July at 7.00am, another officer checked Mr Sheridan. In interview, he told us
that he could not see Mr Sheridan’s face because a cabinet had obstructed his
view, but he could see Mr Sheridan’s chest going up and down and was satisfied
that he was alive.
30. At 8.15am, an officer checked Mr Sheridan and thought he was asleep. The officer
believed it would be cruel to wake Mr Sheridan in his poor health condition so early
in the morning to confirm, especially as this was typical behaviour from Mr
Sheridan.
31. A few minutes after 9.00am, an officer went to give Mr Sheridan his breakfast. In
interview, the officer said that he did not respond when she called. When she
entered the cell, she saw that Mr Sheridan’s eyes were open and she could not see
any signs he was breathing.
32. The officer was not carrying a radio, so she left the cell to ask for support from
healthcare staff, who were in an office upstairs. On her way up, she spoke to
another officer and asked him to lock a prisoner in the exercise yard (he was a
difficult prisoner and she was concerned he would interfere with the emergency
response) and told the officer that she thought Mr Sheridan was dead. This officer
had a radio but did not use it at this point.
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33. The officer continued upstairs and told a nurse that Mr Sheridan was not breathing.
The two officers then went into Mr Sheridan’s cell while the nurse radioed a code
blue at 9.10am. Control room staff immediately requested an ambulance. In
interview, the officer was not sure how long it took from the moment she saw Mr
Sheridan to the code blue being called, but she referred to only stopping briefly to
ask for the door to be closed.
34. Several members of staff went to Mr Sheridan’s cell to assist. The nurse
remembered he had a DNACPR in place, and a member of staff located it from an
office upstairs. The nurse assessed Mr Sheridan and noted that signs of rigor mortis
were present. Staff did not try to resuscitate Mr Sheridan, both because there were
unequivocal signs of death and in accordance with his wishes.
35. Initially the ambulance was given the highest priority. However, once prison staff
updated the 999 handler that Mr Sheridan had no signs of life and a DNACPR was
in place they lowered the priority of the call. Paramedics attended and confirmed Mr
Sheridan’s death at 10.30am.
Post-mortem report
36. The post-mortem report concluded that Mr Sheridan died of acute myocardial
infarction caused by ischaemic heart disease and severe coronary atheroma.
Diabetes mellitus and cerebrovascular disease were also listed as contributory
factors.
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Findings
Clinical care
37. The clinical reviewer concluded that Mr Sheridan’s healthcare was equivalent to
that he could have expected to receive in the community. She noted that healthcare
staff repeatedly told Mr Sheridan about the dangers of not taking insulin and other
medication. She concluded that he was aware of the potentially life-threatening
consequences. Appropriate care planning was in place for the management of Mr
Sheridan’s long-term conditions and he was regularly reviewed by healthcare staff.
The clinical reviewer concluded that while Mr Sheridan’s behaviour was sometimes
challenging, healthcare staff treated him with respect and compassion.
38. The clinical reviewer was satisfied that there was sufficient evidence that Mr
Sheridan had capacity to refuse treatment. However, she noted that there should be
a more robust process to have ongoing discussions about consent and record that
the patient understands the consequences of not being treated. We endorse the
clinical reviewer’s recommendation that:
The Head of Healthcare and the Regional Manager for PPG should be assured
that there is a refusal of care pathway in place which supports practitioners
caring for patients who refuse treatment to a point of their self-neglect.
Head of Healthcare to note
39. On 29 April 2020, Mr Sheridan said he did not want anyone to resuscitate him if his
heart or breathing stopped and signed an order to that effect (DNACPR). This
document was valid at the time of death, but it had not been reviewed annually as it
should have been. The clinical reviewer made a recommendation about this which
the Head of Healthcare will wish to address.
40. Mr Sheridan’s incontinence issues became worse during his last year. The clinical
reviewer recommended that soiled bedsheets are dealt with appropriately which the
Head of Healthcare will consider.
Management of Mr Sheridan’s risk to himself
41. Staff opened an ACCT on 16 July, when Mr Sheridan said he no longer wanted to
take insulin because he wanted to die. Initially staff set his observations at
sessionally. During an ACCT review the following day, Mr Sheridan also said he
would self-harm, so staff increased his observations to hourly. Staff acted
appropriately in opening an ACCT and continued to encourage Mr Sheridan to take
his insulin and explained the dangers if he did not. The only review that took place
had a SO, nurse and healthcare officer present and staff completed an appropriate
care plan for Mr Sheridan.
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ACCT checks
42. The officer checking Mr Sheridan overnight from 20 July to 21 July believed he only
needed to check him once but still checked on Mr Sheridan hourly as he was
concerned he might fall out of bed. These ACCT checks were done at predictable
intervals but since the officer did not believe they were ACCT checks this was
understandable. However, after this they continued to be completed on the hour. At
the top of the page where staff recorded the ACCT checks, someone had
incorrectly written “sessional”. We have not been able to find out who wrote this.
Staff should check the frequency of ACCT checks from the ACCT plan section. We
highlight these issues to the Governor.
43. Staff also told us that there was a cabinet partially obstructing the view of Mr
Sheridan, so they were not able to see his whole body, and importantly, could not
see his head. After Mr Sheridan’s death, the prison identified this as an issue and
removed cabinets from healthcare cells holding prisoners on an ACCT. We
welcome this decision and encourage the Governor to consider removing the
cabinets from all healthcare cells, so staff can easily see these prisoners with
healthcare concerns and carry out adequate welfare checks.
44. Day staff took over Mr Sheridan’s ACCT checks at 7.00am. The officer who did this
check said that he could see Mr Sheridan’s chest going up and down. The officer
doing the next check said that he thought Mr Sheridan was asleep. When staff
discovered Mr Sheridan unresponsive, shortly after 9.00am, he had signs of rigor
mortis. It is not possible to determine exactly how long it takes for rigor mortis to set
in but Mr Sheridan had most likely been dead for a few hours. This suggests the
checks done most recently that morning were insufficient to ensure Mr Sheridan
was alive and well. We recommend that:
The Governor should ensure that staff adequately assess a prisoner’s welfare
when doing ACCT checks.
Governor to note
45. Prison Service Instruction (PSI) 03/2013, Medical Emergency Response Codes,
states that when staff find a prisoner unresponsive, they should immediately alert
the control room using a medical emergency code to ensure a timely, appropriate,
and effective response to medical emergencies. The control room should then
automatically call an ambulance.
46. The officer was not carrying a radio when she went into Mr Sheridan’s cell on 21
July. In interview, she said that there are two radios for officers on the unit. The
Head of Safer Custody said that there are not enough radios for all staff to have
one. He also explained that even if there were, it would not be feasible to use so
many radios as it would overload the network, making raising alarms difficult and
confusing. He also said that, in the healthcare unit, healthcare staff carry radios and
that officers are expected to share two radios between them, one upstairs and one
downstairs.
47. The other officer could have radioed a code blue as soon as the officer told him that
Mr Sheridan was unresponsive. However, he was focused on locking another
prisoner away and getting to Mr Sheridan’s cell. The delay in calling a code blue
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was minimal and made no difference to Mr Sheridan in the circumstances. We
therefore make no recommendation but bring the matter to the Governor’s attention.
Adrian Usher
Prisons and Probation Ombudsman February 2025
Inquest
The inquest hearing was held on 4 September 2025. The Coroner concluded that Mr
Sheridan died of natural causes.
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