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Investigation and inquest
On 22nd September 2022, I commenced an investigation into the death of Martin Samuel WILLIS, aged 55 years. The investigation concluded at the end of the inquest with a jury on the 13th to 17th day of November 2023. The conclusion of the inquest was Mr Willis died from hanging and the narrative conclusion was that: “Mr Martin Willis took his own life, in part because the risk of him doing so was not reported, communicated and the precautions in place were insufficient to prevent him doing so whilst the balance of his mind was disturbed”.
Circumstances of the death
Mr Willis was a serving prisoner at HMP Stoke Heath when at 8:37 am on the 15th September 2022 he was found hanging in his cell. He was on the suicide and self-harm prevention scheme (ACCT).
Coroner’s concerns
1. The ACCT procedure was not properly implemented, complied with or supervised. A scheduled observation at 8 am did not take place and a false entry was entered at 7:30 am and later deleted. The last correct entry was at 7 am with earlier omissions.
2. The prison service has taken action to address the issues relating to the ACCT procedure and will be kept under review.
3. Overriding issues remain as to whether or not the late Mr Willis was on the correct levels of observation up to constant watch and whether he should have been transferred to an psychiatric grounds for treatment at another prison establishment with a hospital wing.
4. Whilst the prison service and the mental health providers have reviewed the circumstances of Mr Willis’s death, I am concerned that there should be a collective and not individual response to ensure that all lessons can be learned. I therefore recommend that there be an inter-agency review between the prison service and mental health services as to the mental health care provided to the late Mr Willis including the evidence at the inquest and the jury’s findings. In so doing, I do not purport to suggest what the outcome of the review should be.
Information checked against the published report and official responses