Inadequate precautions taken to prevent prisoner from taking his own life

An inquest into the death of Martin Samuel Willis, 55, an inmate at the prison near Market Drayton, heard that he himself had asked to be moved to somewhere where there was 24-hour health care.

At the end of the hearing at Shrewsbury Coroners Court on Friday the jury concluded that Mr Willis took his own life, whilst the balance of his mind was disturbed and in part because the risk of him doing so was not reported/communicated. The jury said precautions were insufficient to prevent him doing so.

The medical cause of death was hanging.

Prison officers found Mr Willis in his cell at around 8.38am on September 15. An ambulance was called and he was given CPR, but he was pronounced dead shortly afterwards.

The week-long inquest was told the 55-year-old, who had a psychotic illness, had been in and out of jail since his 20s. His cell was on F-Wing, a specialised area of the prison for people with drug addiction issues.

In its written conclusion the jury said insufficient protection was given to him in light of the rapid decline in his symptoms.

"There was inadequate levels of supervision and allocation of responsibility of staff on the wing, due to no supervising officer or custodial manager.

"There were failings in identifying and communicating the risk of self-harm based on his behaviour decline such as a request for more observations, a cell change, Mr Willis being found with a ligature and barracading his door.

"He made requests for a referral to a medical until and observations but neither of these requests were acted on."

The inquest was told that after Mr Willis reported hearing voices telling him to kill himself, prison officials launched an Assessment Care in Custody Teamwork (ACCT) case for him - a protocol to try to keep inmates safe who are at risk of self-harm or suicide.

But the jury said that there were several failings of the procedure including: the severity of Mr Willis' situation not noted sufficiently; A lack of attendance by multi-disciplinary staff at review meetings; risks triggers and protective factors not completed; sources of support incomplete; review notes not shared or signed by all attendees; specific observation times not adhered to.

The hearing was told that, as part of Mr Willis's ACCT programme, he was supposed to be checked on once every half hour during the night and once every hour during the day. However, his log showed that many intervals were longer than they should have been. Indeed, the day he died, Mr Willis was checked on at 7am, and then not again until he was found in his cell.

Selina Fyffe, who was head of safer custody at the prison at the time told the jury: "On this occasion, we let him down," referring to the lack of checks on Mr Willis.

A "portrait" of Mr Willis, written by his sister Paula, was read to the jury to paint a picture of his life.

They had grown up in the Stoke-on-Trent area.

"He was my little brother," she said. "We were the youngest two of five siblings. We were inseparable. Our dad was an alcoholic and abusive towards our mum. Occasionally, he would be violent towards Martin."

She said Mr Willis suffered from anxiety early on in his life

Despite his struggles, Mr Willis was always "a joker", she said and his death left her "heartbroken".

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