Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2024-0171, written 19 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Dec 2023 |
|---|---|
| Reference | 2024-0171 |
| Deceased | Martin Willis |
| Coroner | John Ellery |
| Coroner area | Shropshire, Telford and Wrekin |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
1 2 3 4 5 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Rt Hon Edward Argar MP Minister of State for Prisons, Parole and Probation 2. 3. – Chief Executive (Interim) North Staffordshire Combined Healthcare NHS Trust – Chief Executive Midlands Partnership NHS Foundation Trust (if appropriate) CORONER I am Mr John Penhale Ellery, Senior Coroner, for the coroner area of Shropshire, Telford & Wrekin. 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. 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 During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN 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. 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. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation/s have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days (plus 14 for the forthcoming Christmas and New Year period) of the date of this report, namely by 27th February 2024. I, the coroner, may extend the period. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Leigh Day Solicitors Shropshire Community Health NHS Trust Browne Jacobson Clyde & Co LLP Prisons and Probation Ombudsman's Office Government Legal Department I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Mr John Penhale Ellery Senior Coroner Shropshire, Telford & Wrekin 19th December 2023 6 7 8 9
3 responses 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 J P Ellery
Senior Coroner
HM Coroners Service
Shirehall
Abbey Foregate
Shrewsbury
SY2 6ND
Dear Mr Ellery,
Her Majesty’s Prison and Probation Service
Mark Greenhaf
Governing Governor
HMP & YOI Stoke Heath
Warrant Road
Market Drayton
Shropshire
TF9 2JL
Phone:
05th December 2023
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.
Yours sincerely,
Governor
Enc: Governors Order
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 22 March 2024 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. 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. Yours sincerely, Chief Nurse and Director of Quality & Professional Leadership cc The Rt Hon Edward Argar MP Minister of State for Prisons, Parole and Probation Together we are making life better for our communities
Date: 22nd March 2024
Mr J P Ellery
Senior Coroner
Shropshire, Telford and Wrekin Area
HM Coroner’s Service
The Shirehall
Abbey Foregate
Shrewsbury
Shropshire
SY2 6ND
Chief Executive Officer
Trust Headquarters
Lawton House
Bellringer Road
Trentham
ST4 8HH
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.
www.combined.nhs.uk
Follow us on Twitter: @CombinedNHS
Follow us on Facebook: www.facebook.com/NorthStaffsCombined
We are a diverse and inclusive Trust and there is no place in our organisation
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.
www.combined.nhs.uk
Follow us on Twitter: @CombinedNHS
Follow us on Facebook: www.facebook.com/NorthStaffsCombined
We are a diverse and inclusive Trust and there is no place in our organisation
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.
Yours sincerely
Chief Executive Officer
North Staffordshire Combined Healthcare NHS Trust
CC’d
The Rt Hon Edward Argar MP Minister of State for Prisons, Parole and Probation
– Chief Executive Midlands Partnership NHS Foundation Trust (if appropriate)
www.combined.nhs.uk
Follow us on Twitter: @CombinedNHS
Follow us on Facebook: www.facebook.com/NorthStaffsCombined
We are a diverse and inclusive Trust and there is no place in our organisation
for discrimination, harassment or personal abuse
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