Records altered after prison suicide

Records of welfare checks on an inmate who committed suicide at a Shropshire prison were altered by staff after his death, an investigation has found.

A report by the Prisons and Probation Ombudsman into the death of Martin Willis, aged 55, at Stoke Heath prison on the morning of September 15, 2022, found that suicide and self harm prevention procedures “were not well managed”, and records of observation checks on Mr Willis, intended to be carried out hourly, had been amended.

At an inquest held earlier this year the coroner was told that Mr Willis, who had been diagnosed with schizophrenia in 2017, had asked to be placed under 24-hour supervision in the days prior to his death, after complaining of hearing voices.

He had been under enhanced supervision measures following an incident four days prior to his death when, on September 11, he was found with a ligature which he told staff was intended as a “cry for help”.

However, the ombudsman report stated that checks on Mr Willis which were required by the enhanced procedures, known as ACCT, were not always carried out.

“On the morning Mr Willis died he should have been checked at least hourly, but he was not,” the report said.

“ACCT procedures were not well managed. The pages within the ACCT document were not accurately completed, supervisor daily checks were not adequate, and observations did not always take place at the correct intervals.”

The report also noted that alterations made to Mr Willis’ records led to three members of staff being issued with formal warnings, although all three were subsequently allowed to return to their duties.

“After Mr Willis had been discovered, an entry was made on his ACCT document recording that he had been checked, as he should have been, before he was discovered. This entry was then crossed out,” the report said.

“The Governor initiated a disciplinary investigation and suspended three members of staff.

“All three members of staff were allowed to return to duty once the investigation was completed.”

The report noted that despite these serious issues, Mr Willis had received “comprehensive support from the mental health team” and noted that the standard of clinical care that he received while at the prison was of a good standard.

A statement from the Ministry of Justice said that support for the most vulnerable prisoners was being prioritised at Stoke Heath following the death of Mr Willis.

“Our thoughts remain with Mr Willis’s family and friends,” said a spokesperson.

“Since this incident, HMP Stoke Heath has improved its safety procedures and provided training to staff on how best to support vulnerable prisoners.”