Shropshire Star

Prisoner had asked to be moved for specialist health care before he died, inquest hears

A prisoner found dead in his cell at a Shropshire prison had asked to be moved to a jail with specialist health care available because of his mental health, the inquest into his death has heard.

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Stoke Heath Prison

Martin Samuel Willis, 55, was pronounced dead at Stoke Heath Prison, near Market Drayton, on the morning of September 15 last year.

At the inquest into his death at Shrewsbury Coroner's Court on Wednesday(15) , independent consultant forensic psychiatrist Professor Inti Quarshi, (corr) giving evidence as an expert witness, said he believed that Mr Willis should have been constantly observed by staff and referred to a mental health centre because of his mental health deterioration from September 11 when he barricaded his cell and had made a ligature from a shoelace.

The jury heard the statement of mental health nurse, Kerry Davani, and her many appointments with Mr Willis at the prison between July and September 2022.

During that time Mr Willis, who suffered from psychosis and hypertension, reported hearing voices and not sleeping well. He was on anti-psychotic medication for his condition.

In August he asked to be moved to 24-hour care at Dovegate Prison, saying the voices wanted to harm him and were telling him to kill himself.

Staff at Stoke Heath were also made aware that someone had overheard an inmate telling Mr Willis to bring him his "stuff" or "you know what will happen".

But he denied this had happened and said he was not being bullied or giving his medication to anyone else. He also denied being stressed about possibly being given parole in October, she said.

When Kerry Davani saw Mr Willis on September 9 he appeared dishevelled and was responding to unseen stimuli throughout the meeting, she said.

She recommended close observation of him half hourly at night and hourly in the day.

Psychiatrist Dr James Appleford, who worked two days a week at Stoke Heath, said that when he examined Mr Willis in August there had been a degree of deterioration from when he had seen him in the past.

There were questions raised about whether he was taking his medication properly or whether he was diverting some of it, he said.

Dr Appleford said he felt Mr Willis's condition at the time should be managed at Stoke Heath because he was engaged with mental health services.

Had he been made aware that Mr Willis had been found with a ligature made from a shoelace on September 11 he would have increased the times he was observed and considered a transfer out of Stoke Heath to either Dovegate or the NHS medium secure unit at Heartlands, he said.

Senior coroner for Shropshire and Telford and Wrekin, John Ellery, was told it could take two to three weeks for a transfer to take place.

Miss Laura Profumo, lawyer for Mr Willis's family, asked that, with his mental health deterioration, why Mr Willis was not transferred. She said that there were red flag indications of mental health relapse included hearing voices of people wanting to kill him or telling him to kill himself. She asked why there hadn't been an earlier referral for a transfer to a health care unit.

The inquest continues.

* Whatever you're going through, Samaritans are here – day or night, 365 days a year. You can call them for free on 116 123, email them at, or visit to find your nearest branch.

* Samaritans also say sometimes writing down your thoughts and feelings can help you understand them better.

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