Source · Prevention of Future Deaths

Melissa Mathieson

Ref: 2025-0367 Date: 21 Jul 2025 Coroner: M. E. Voisin Area: Avon Responses identified: 1 / 1 View PDF

The care home provided misleading information on supervision levels and lacked formal induction periods, regular reviews for residents, and comprehensive updates to support plans and risk assessments.

Date 21 Jul 2025
56-day deadline 15 Sep 2025
Responses identified 1 of 1
Care Home Health related deaths

Coroner's concerns

AI summary
The care home provided misleading information on supervision levels and lacked formal induction periods, regular reviews for residents, and comprehensive updates to support plans and risk assessments.
View full coroner's concerns
(1) the offer of placement and the level of supervision i.e. 1:1 was misleading, there was no clarification for example, 24hrs cover, 8hrs cover during the day only, or when carrying out activities or when outside the home only. (2) there was no formal induction period set for residents with formal weekly reviews (3) there was no formal review of the support plan and risk assessment especially during the induction period.

Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com

Responses

1 respondent
Alexandra Home Other
23 Jul 2025 PDF
Action Taken

Alexandra Homes has updated their Report on Action Taken to Prevent Future Deaths, building on a previous report. Actions include introducing a new resident observation record, revising the client referral form, and implementing a compatibility profile and impact assessment. (AI summary)

View full response
Dear Ms Voisin Re: Regulation 28 Report – Death of Melissa Louise Mathieson Alexandra Homes (Bristol) Ltd – Response to Prevent Future Deaths I write further to your Regulation 28 Report. As the Responsible Individual for Alexandra Homes (Bristol) Ltd, I wish to express our continued condolences and reiterate our commitment to ensuring the safety and wellbeing of all individuals in our care. In response to your request that action be taken to prevent future deaths, please find enclosed our updated Report on Action Taken to Prevent Future Deaths, dated 23rd July
2025. This document builds on the report submitted to you on 14th July 2025. For completeness and clarity, the concerns raised in your report have been directly addressed, with updates and new actions highlighted in red throughout. To assist your review, I have also enclosed the following supporting documents:  Memo to Staff – Introduction of the New Resident, 6-Week Observation & Review Record, including: Associated Guidance for completion.  Client Referral Form – Revised to improve the quality and depth of pre-admission information.  Compatibility Profile & Impact Assessment – A new framework to assess the risks and appropriateness of potential admissions in the context of existing residents.  New Resident – 6 Week Observation & Review Form – This new form is designed to provide a structured and consistent approach to monitoring each new resident during their initial six weeks in our care These documents reflect the serious and sustained efforts made to strengthen our processes, enhance risk management, and improve professional practice across our service.

I would be grateful if you could confirm whether the actions outlined satisfy the requirements of your Regulation 28 report, or whether any further clarification or steps are required. Thank you for your attention to this matter and for your ongoing role in safeguarding the welfare of vulnerable individuals.

Report sections

Investigation and inquest
On 7th January 2015 I commenced an investigation into the death of Melissa Louise Mathieson. The investigation concluded at the end of the inquest on 18th July 2025. The medical cause of death was: 1a) Severe hypoxic ischaemic brain injury associated with an out-of-hospital cardiac arrest with features highly suggestive of neck compression The conclusion of the inquest was a short form with a narrative which read as follows: “Melissa died as a result of unlawful killing caused by both the act of strangulation and also due to the acts and omissions by the home entrusted with her care. The home failed Melissa in numerous ways: the resident who went on to strangle her should not have been placed in the same facility as Melissa, at all, based on his known risks. The decision was wrongly made to place him in the same facility with an ineffective care plan and risk assessment, with staff that were not trained on his level of risk, and managers who failed to act when concerns were highlighted by staff and Melissa. In addition, the placing authority knowing this residents risks should not have agreed the care plan and package being offered, furthermore they also failed to act when concerns were raised. With this resident’s known risks he should not have been offered a placement at the home and the catalogue of failures resulting in his placement with no effective risk assessment in place resulted in the death of Melissa. “

Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com
Circumstances of the death
Melissa was autistic, suffered with ADHD and had a diagnosis of Asperger’s, she was 18yrs old and was vulnerable. She became a resident of Alexandra Homes in August 2014 along with another resident, called , who went on to murder her on 12th October 2014. had undergone an assessment with a consultant child and adolescent psychiatrist, , who formed the opinion that he presented with a significantly high risk of future violence towards others, his violence also includes sexually harmful behaviour towards others including strangulation, the frequency and imminence of violence is also high, she said, that he should be supervised at all times. had said that he wanted to kill somebody and have sex with their dead body. was moving from a school where he had been supervised 24 hours a day on a 2:1 basis during the day and 1.5:1 at night. When at Alexandra Homes his care plan stated 1:1 but was not 24hrs a day and was not 1:1 care at all, in that at night there were 16 residents to 1 support staff and during the day he was allocated a support worker to do activities, but he could wonder around the home on his own unsupervised. Support workers, staff and Melissa raised concerns about ’s behaviour generally and specifically that Melissa was frightened of him. On 12th October at about 11.40pm, and Melissa had already gone to their bedrooms, Jason was unsupervised, when staff heard a loud bang. One of them said …” I ran up the stairs and opened the fire door, Melissa was on her back, her legs were slightly skew whiff. Her head was slightly to one side facing the stairs, I could see one eye which was open and there was a cut above it, I could see marks around her neck which were very red. She was fully clothed and she appeared dead…” Melissa was taken to the local hospital but died a few days later from her injuries.
Inquest conclusion
“Melissa died as a result of unlawful killing caused by both the act of strangulation and also due to the acts and omissions by the home entrusted with her care. The home failed Melissa in numerous ways: the resident who went on to strangle her should not have been placed in the same facility as Melissa, at all, based on his known risks. The decision was wrongly made to place him in the same facility with an ineffective care plan and risk assessment, with staff that were not trained on his level of risk, and managers who failed to act when concerns were highlighted by staff and Melissa. In addition, the placing authority knowing this residents risks should not have agreed the care plan and package being offered, furthermore they also failed to act when concerns were raised. With this resident’s known risks he should not have been offered a placement at the home and the catalogue of failures resulting in his placement with no effective risk assessment in place resulted in the death of Melissa. “

Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com

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Report details

Reference
2025-0367
Date of report
21 July 2025
Coroner
M. E. Voisin
Coroner area
Avon

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 15 Sep 2025.

Sent to

Alexandra Homes Ltd

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