Martin Willis

Coroner's concerns

AI summary

The ACCT procedure was not properly implemented or supervised, including false entries and omissions. Concerns remain regarding correct observation levels and the need for an inter-agency review of mental health care provided in prison.

View full 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 out on 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.

Responses

3 respondents

North Staffordshire Combined Healthcare NHS / Health Body

22 Mar 2024 PDF

Action Planned

The trust states that the coroner's concerns have informed the development of a Health in Justice Suicide Prevention Plan, including a multi-agency Suicide Prevention Forum, and will share the results of an inter-agency review with staff and partners. Completion is expected by September 2024. (AI summary)

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Dear Mr Ellery

Regulation 28 Report – Prevent Future Deaths – Martin Samuel Willis

I am writing in response to your correspondence dated 19th December 2023 regarding the regulation 28 of the Coroners (Investigations) Regulations 2013 following the inquest regarding the death of Martin Samuel WILLIS which concluded on the 17th November 2023.

At the time of Mr Willis’ death the Mental Health Services in HMP YOI Stoke Heath were provided by the North Staffordshire Combined Healthcare NHS Trust and Substance Misuse Services were provided by Forward Trust, however from 1st November 2023 Mental Health Services have been provided by the Midlands Partnership University NHS Foundation Trust. The services are delivered by the Health in Justice Team within the Trust. The Shropshire Community Health NHS Trust continue to provide the Prison Healthcare services within HMP YOI Stoke Heath.

Colleagues from HMP YOI Stoke Heath, the Midlands Partnership University NHS Foundation Trust, Shropshire Community Health NHS Trust and the North Staffordshire Combined Healthcare NHS Trust met on 29th January 2024 to conduct an inter-agency review as directed in the Regulation 28 correspondence.

The MATTERS OF CONCERN described in the Regulation 28 correspondence have informed the development of the Health in Justice Suicide Prevention Plan including the development of a multi- agency Suicide Prevention Forum for the Midlands Partnership University NHS Foundation Trust Health in Justice Services and partners as is referenced in the response/s below.

Chief Executive Officer Trust Headquarters Lawton House Bellringer Road Trentham ST4 8HH

for discrimination, harassment or personal abuse The agreed actions from our inter-agency review in response to the MATTERS OF CONCERN outlined in your correspondence are as follows:

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.

Action 1. HMMPS YOI Stoke Heath, the Shropshire Community NHS Trust and the Midlands Partnership University NHS Foundation Trust have reviewed the ACCT processes and procedures and have communicated regarding this directly, as outlined in the HMMPS response to you dated 28th February 2024. The multi-agency review received assurances from HMP YOI Stoke Heath that the new processes are being kept under review.

Action 2. All Midlands Partnership University NHS Foundation Trust staff working in HMP YOI Stoke Heath are required to complete the Trust’s mandatory suicide prevention training and the ACCT training provided by HMP YOI Stoke Heath. As part of the Suicide Prevention plan for Health in Justice Services the Midlands Partnership University NHS Foundation Trust will continue to seek opportunities for joint / shared training initiatives regarding best practice regarding suicide prevention in His Majesty’s Prison Services in line with the national strategies referenced above and in support of a personalised / person centred multi-agency approach to suicide prevention in Health in Justice Services. Completion timescale September 2024.

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 out on psychiatric grounds for treatment at another prison establishment with a hospital wing Action 3. In addition to the above actions the Midlands Partnership University NHS Foundation Trust will request a review of the NHS England procedures and processes regarding the referral of and transfer to patients to prison establishments with a hospital wing to ensure clarity of criteria for admission and referral and escalation and appeal processes taking into consideration some perceived challenges in terms of criteria and escalation highlighted during the inter-agency review. Completion timescale September 2024.

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.

for discrimination, harassment or personal abuse Action 4. The interagency review was conducted on 29th January 2024 as referenced above. The required actions / next steps of the inter-agency review and subsequent progress will be shared with staff and partners via the Midlands Partnership University NHS Foundation Trust Multi-Agency Health in Justice Suicide Prevention Forum which will support delivery of the Health in Justice Suicide Prevention Plan and facilitate continued shared learning across partner agencies. Completion timescale September 2024.

I hope the above information meets with your approval and satisfaction and that the actions outlined suitably address your MATTERS OF CONCERN. I would also like to express my condolences to the family for their loss of Mr Willis.

Please do not hesitate to contact me if you require any further information.

Midlands Partnership University NHS / Health Body

22 Mar 2024 PDF

Action Planned

Following an inter-agency review, the trust is implementing actions including refresher training, improving the ACCT procedure, updating risk assessment documentation, and reviewing procedures for transferring prisoners to establishments with hospital wings. Various completion timescales are provided, ranging to September 2024. (AI summary)

View full response

Dear Mr Ellery,

Regulation 28 Report to prevent future deaths regarding the death of Mr Martin Samuel Willis

I am writing in response to your Regulation 28 Report dated 19th December 2023 following the inquest into the death of Martin Samuel Willis which concluded on the 17th November 2023.

At the time of Mr Willis’ death the Mental Health Services in HMP YOI Stoke Heath were provided by the North Staffordshire Combined Healthcare NHS Trust and Substance Misuse Services were provided by Forward Trust. From October 2023 these services have been provided by the Midlands Partnership University NHS Foundation Trust.

Colleagues from HMP YOI Stoke Heath, Midlands Partnership University NHS Foundation Trust, Shropshire Community Health NHS Trust and North Staffordshire Combined Healthcare NHS Trust met on 29th January 2024, to undertake an inter-agency review as directed in the Regulation 28 Report.

In addition to the matters of concern highlighted in your report, the inter-agency review considered the concerns found by the members of the jury recorded on the Record of Inquest documentation. Our inter-agency review noted that the Safety in Custody Statistics, England and Wales: Deaths in Prison Custody to September 2023 reported an increase of 24% on Prison suicides in the previous reporting period and it was reflected that this increase is likely indicative of the pressures felt upon His Majesty’s Prison Services currently across the country.

The agreed actions from our inter-agency review in response to the MATTERS OF CONCERN outlined in your correspondence are as follows:

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. Mr J P Ellery H M Coroner for Shropshire, Telford & Wrekin Shirehall, Abbey Foregate Shrewsbury Shropshire SY2 6ND Trust Headquarters St George's Hospital Corporation Street Stafford ST16 3SR

Together we are making life better for our communities

Action 1. HMP YOI Stoke Heath have reviewed the ACCT processes and procedures following Mr Willis’ death. The multi-agency review received written information from HMP YOI Stoke Heath confirming the new processes that are in place and that these are being kept under review.

2. The prison service has taken action to address the issues relating to the ACCT procedure and will be kept under review.

Action 2. All Midlands Partnership University NHS Foundation Trust staff working in HMP YOI Stoke Heath are required to complete suicide prevention training and also the ACCT training provided by HMP YOI Stoke Heath. Completion timescale July 2024.

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 out on psychiatric grounds for treatment at another prison establishment with a hospital wing

Action 3. In addition to the above actions the Midlands Partnership University NHS Foundation Trust have commenced discussions with NHS England regarding a review of their Standard Operating Procedure concerning the referral of and transfer of prisoners to prison establishments with a hospital wing which was an agreed outcome of the inter-agency review. Completion timescale September 2024.

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.

Action 4. The interagency review was conducted on 29th January 2024, as part of our on-going service delivery commitments we will conduct on-going meetings with the Shropshire Community Health NHS Trust and HMP YOI Stoke Heath.

Together we are making life better for our communities I hope the above information meets with your approval and satisfaction and that the actions outline suitably address your outlined matters of concern.

Please do not hesitate to contact me if you require any further information.

HM Prison and Probation Service Central Government

PDF

Action Taken

HMPPS will present an operational briefing to staff on responsibility for ACCT checks. They have updated Case Co-ordinator processes, and are sharing QA with managers, and meeting with partner agencies to relay responsibilities. (AI summary)

View full response

Dear Mr Ellery, RE: MARTIN WILLIS INQUEST I write with reference to the above and would like to thank you for the opportunity to address your findings and in doing so a strategy has been put in place going forward. ACCT CHECKS: Clear direction must be given as to who is responsible for completing the ACCT checks. Stating everyone is responsible makes no one responsible and this is not sufficient. ACTION TO BE TAKEN: I will be presenting an Operational Briefing on 21st December to all staff, taking into consideration the Governors Order GO 01/2023 which reads as follows: The purpose of this Governors Orders is to make you aware that it is the responsibility of the Cleaning Officer to ensure that ACCT observations and conversations are conducted and recorded in the ACCT document between the hours of 0745 - 1715. Between the hours of 1745 – 1915 an Officer will be detailed on the Night Orderly Officers detail sheet. When the wing is in patrol state it is the responsibility of the Patrol Officer to check on all ACCTS. It is the responsibility of all staff to check the detail sheet outside the Communication Room to ensure compliance with this order. In the segregation unit the responsibility will be allocated to the regimes officer. The Senior Officer will check and sign the ACCT document on a daily basis and will also ensure that the last 24 hours have been recorded accurately and correctly, any

irregularities will be raised to the member of staff who recorded the entry and also to their line Manager. It is not the responsibility for the Senior Officer or Custodial Managers to allocate ACCT checks. Please ensure that it is only your own observations and interactions that you record as it is part your legal responsibility to the prisoners in our care. I cannot stress the importance of completing these checks and recording accurately in the ACCT document all observations and conversations. If you have any concerns around this instruction, you should speak to the Safer Custody Team or your Custodial Manager. This Governors Order will also be incorporated into all ACCT V6 training which is delivered to all staff by our Regional Safety Team and inhouse trainers.
2. OBSERVATIONS NEED TO BE CLEAR/CONCISE: Observations recorded were not clear as there was no distinction from day to night and when and how regular an observation needs to take place. Stating 5 x Obs per day is too vague and gives no clear direction. ACTION TO BE TAKEN:  Prior to all reviews the Case Co-Ordinator will ensure that all relevant documents have been completed and that all observations are clear and precise for example 5x observations per day every 2 hours or 3 x observations during the day every 3 hours.  The Supervising Officer will check daily to ensure that the previous 24 hours have been recorded accurately and any discrepancies challenged accordingly.
3. ALL PARTS OF THE ACCT DOCUMENT SHOULD BE COMPLETED: There were significant areas not completed throughout the document by all such as the Case Manager, ACCT Assessor, Supervising Officer, and the Wing Staff. ACTION TO BE TAKEN:  Awareness Training has been prepared for the ACCT v6 which will be delivered by 3 suitably qualified staff during our next four Training Shutdown Days, 11th December 2023, 8th January, 12th February and 11th March 2024.  A good practise guide will also be issued to assist all Case Co-Ordinators.
4. QUALITY ASSURANCE (QA): Assurance was not shared with relevant managers to ensure errors picked up from the first 72 hours. ACTION TO BE TAKEN:  Safer Custody and Senior Leadership Team (SLT) will ensure all QA is shared with relevant managers, and a confirmation email that the errors have been rectified will be saved as evidence.

 The Daily Report Log for the Governing Governor and the Management Team will include a QA briefing.  Supervising Officers will ensure the daily checks are completed and staff challenged accordingly.  Psychology Team will provide supervision to all Case Co-Ordinators on reviews.  A Good Practise Meeting will be organised and held by the Safer Custody Team inclusive of all Case Co-Ordinators, Mental Health Teams and external providers to share and discuss complex case reviews and good practises.
5. ALL REVIEWS MUST BE MULTI AGENCY: Reviews did involve other agencies, but participants were not aware that they were there to make collaborative decisions on observations and action plans moving forward. All discussions should be recorded in full, and each person should sign as an agreement that they are happy with agreed actions. ACTION TO BE TAKEN: I will be meeting with all Partner Agencies and relaying their responsibilities. Awareness Training for all Partner Agencies staff has been organised.
6. CONSTANT WATCH: Constant Watch should have been considered. ACTION TO BE TAKEN:  Removal of any ligature material suggests that the prisoner is an immediate threat to themselves and therefore constant supervision will be considered.  Case Co-ordinators have been reminded that if a constant watch is discussed and deemed not appropriate then this should be recorded with an acceptable reason. I sincerely hope that my strategy going forward has alleviated any of the concerns raised by your findings.

Report sections

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).

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