Individual at Victoria House

Investigation into the circumstances surrounding the
death of a man
at an Approved Premises in the Humberside Probation
Area in February 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2008
This is the report of an investigation into the circumstances surrounding the death of
a man on 12 February 2008 at an Approved Premises, Scunthorpe. The man
collapsed and was discovered approximately ten minutes later by another resident,
outside the main entrance to the building. Attempts were made to resuscitate him
before paramedics arrived. The man was pronounced dead at the hospital. He had
suffered an acute heart attack. The man was 42 years old.
The loss of any family member is distressing and I offer my sincere condolences to
the man’s family and friends.
The investigation was undertaken by one of my colleagues. We would like to thank
the manager of the Approved Premises and her staff for their cooperation, and for
gathering all relevant documentation and ensuring it was made available.
The man had been released on a nine month conditional licence from HMP
Lindholme on 1 February. He lived at Victoria House for just 11 days. The man’s
family had a history of heart problems and high cholesterol, unbeknown to staff at
Victoria House until after he died. The man was not taking any prescribed
medication before his custodial sentence, during and post release from prison. On
arrival at the hostel, he registered with a local GP surgery but did not make an
appointment.
The man’s heart attack is typical of someone his age and with his lifestyle. Heart
attacks remain the most common cause of death amongst men over 40 years old
and occur when the blood supply to part of the heart is interrupted by a blockage to
the coronary artery. The man’s symptoms of apparent sudden chest pain on the day
he died were also characteristic of a heart condition. Unusually, his heart attack was
captured on Close Circuit Television, albeit obscurely. The staff response to the
man’s collapse was also captured, more intelligibly.
At the time of writing, there have been 67 deaths of residents in Approved Premises
since I took over responsibility for investigations in 2004. This was the first death in
custody at Victoria House for four years, and my investigation has revealed how,
despite the lengthy period without a death under their supervision, staff at Victoria
House acted professionally in their response. Following the man’s death, the
approved premises manager identified where one improvement could be made to
internal instructions covering emergencies. This concerns the compilation of a grab
sheet to act as staff guidance in emergencies. I agree with her judgement.
In short, this is an investigation that reflects well upon staff at Victoria House and the
Yorkshire and Humberside Probation Area. It gives me pleasure to issue this report
without any recommendations.
Jane Webb
Deputy Prisons and Probation Ombudsman August 2008
2
CONTENTS
Summary 4
The Investigation Process 5
Victoria House Approved Premises 6
Key Findings 9
Issues 14
3
SUMMARY
The man was sentenced to 18 months imprisonment on 9 October 2007, following a
period on remand. He served four months at HMP Hull and, latterly, HMP Lindholme
before being released on licence.
The man’s licence conditions dictated he reside at Victoria House. He arrived on 1
February 2008 with his licence enforcement plan. The man’s nine month licence,
due to expire on 11 November was explained to him in full both before he was
released from prison and once again at the Approved Premises. He had some
difficulty understanding and accepting part of his licence conditions but worked well
with his offender manager in the short time that he was a resident. During his
induction with an appointed key worker, the man said he had no physical or mental
health problems.
On 12 February, the man had an arranged meeting with his offender manager and a
trainee probation officer to discuss his action plan for the future. Later that day, the
man apparently asked other residents if they had any indigestion tablets. None of
the residents could help him. At about 3.00pm, he spoke to his sister and
complained that he had been experiencing chest pains. The man’s sister advised
him to tell the staff at the hostel. They also arranged to meet at around 4.00pm that
day, after his meeting with the offender manager.
It is not known precisely when but at sometime around 3.00pm, the man spoke to his
sister and the Deputy Manager of the hostel. The man told his sister that he had
chest pains. According to the Deputy Manager, he told her that he had heartburn.
The man asked for some tablets but was told by the Deputy Manager that if he
needed over the counter medication, he should go to the local chemist and purchase
his own.
At 3.20pm, the man went outside with a cup of tea. He sat down on one of the
chairs, obscured from the CCTV camera that filmed the front door entrance.
Approximately 15 minutes later, the man collapsed. At the same time, his offender
manager arrived early for their planned meeting, due to start at 3.45pm. The man
lay for around thirteen minutes before he was found by another resident.
The man’s offender manager was the first member of staff to raise the alarm and the
hostel’s Assistant Warden responded, followed by other members of staff. Life
support was given while an ambulance was called. Paramedics arrived within four
minutes and took over the resuscitation procedures.
Around 15 minutes later, the man was taken to hospital. His sister arrived at the
hostel to find out where he was and had seen an ambulance enter the premises from
where she was parked. The Hostel Manager explained what had happened, and
told the man’s sister which hospital he had been taken to. The man’s sister
mentioned that there was a history of high cholesterol in the family.
The manager telephoned the hospital’s Accident and Emergency Department at
around 5.10pm, and was told that the man was pronounced dead shortly after his
arrival.
4
THE INVESTIGATION PROCESS
1. The investigation was opened by one of my investigators, on 14 February 2008.
My investigator requested all relevant documentation and, following receipt of
the man’s files, began to identify the key issues and the staff who interacted
with him during his brief time at Victoria House. My investigator interviewed the
manager of the Approved Premises on 3 March. My investigator also asked for
further documentation during her visit and received the remainder of the man’s
documentation in due course.
2. The Coroner was informed of the Ombudsman’s investigation. In return, the
Coroner’s Officer contacted my investigator to confirm that there would not be
an inquest into the man’s death. My investigator asked for a copy of the post
mortem report and I am grateful to the Coroner’s Officer for sharing this
information so speedily. The post mortem report concluded that the man’s
cause of death was acute myocardial infarction and dilated cardiomyopathy.
The Coroner will receive a copy of this report.
3. One of my Family Liaison Officers contacted the man’s next of kin shortly after
the investigation was opened. The family liaison officer explained her role and
that of my office and provided information about the investigation process. My
investigator also offered the man’s family the opportunity to raise any issues or
concerns. The man’s sister expressed concern that the man did not feel well
on the day he died. She asked for further information about the man’s chest
pains on the day he died, which he told her about over the telephone. She
advised him to tell a member of staff. The man said that he had already told
staff and was told to go to the local pharmacy to buy his own medication, but he
did not have any money. His sister asked who the man spoke to and whether
the action by staff was appropriate.
4. Following sight of the draft report, the man’s sister highlighted one factual
inaccuracy relating to the meeting that she arranged with the man. I have
made the necessary amendment in the appropriate section of this report. The
draft was also sent to Humberside Area Probation Service.
5
VICTORIA HOUSE APPROVED PREMISES
10. The purpose of Approved Premises (formerly known as probation and bail
hostels) is to provide an enhanced level of residential supervision in the
community, alongside a supportive and structured environment. Such
premises are approved by the Secretary of State (Justice Secretary) under
Section 9 of the Criminal Justice and Court Services Act 2000. Approved
Premises do not function to imprison offenders in the community. Residents
have to comply with their individual licence or bail conditions, curfews, and the
‘house rules’ of premises but essentially, they are free to come and go from
the building(s).
11. Victoria House is one of 101 Approved Premises in England and Wales and
one of 13 premises in the Yorkshire and Humberside Probation Area. It has a
total of 20 beds (one emergency bed), and normally accommodates 19
residents. It is staffed 24 hours a day by probation employees whose role is
to provide support and ensure that the rules and licence or bail conditions are
complied with. Victoria House operates a curfew from11.00pm to 6.00am. It
also operates a 24 hour CCTV facility which covers all communal areas inside
the hostel, the main office area and the front door entrance to the building.
13. On arrival, all residents are offered a tour of the premises and the opportunity
to register with a local GP surgery. Victoria House has an arrangement with
the surgery to enable all new residents without a GP of their own to register
during their stay. Appointments can be made within 24 hours of arrival.
Victoria House also has an arrangement with the GP surgery and local
pharmacy to facilitate the delivery of medication to the premises. All
prescription medication must be handed in to the staff in the front office,
where each item is logged and stored safely. Residents can request their
medication at any time up to 11.00pm. They are also permitted to place a
request for medication during the night.
14. Information about relevant rules, procedures and expectations whilst a
resident at Victoria House is also given during induction and residents are
allocated both a key worker (Assistant Warden or the Probation Service
Officer) and a link/support worker. Regular key work sessions then take place
which gives residents the opportunity to discuss any issues or difficulties in
more depth. Within five working days, a three way meeting is arranged
between a new resident, the key worker and the offender manager. The
resident’s action plan (setting out the courses to be taken and issues to be
addressed as part of a rehabilitation programme) is discussed. Three way
meetings then take place every four weeks.
15. The day­to­day routine at Victoria House is relaxed, although residents do
have to surrender their keys on weekdays between the hours of 9.00am –
11.30am to allow for all communal areas to be cleaned. Key work sessions
run during the day, and some residents have to attend offender management
meetings or groupwork appointments with external staff in the probation
service area. Other residents occupy their time in employment or attend
counselling and other life skills sessions in the local probation offices.
6
16. Victoria House keeps basic first aid equipment in the main office, which
includes resuscitation face masks. All staff are fully trained in first aid and the
four day training they complete is comprehensive. Refresher courses are also
available every two years (on a rota system). Staff and visitors are also
required to carry personal alarms with them at all times.
17. Her Majesty’s Inspectorate of Probation (HMIP) last inspected the Yorkshire
and Humberside Probation Area in July 2005. The area was inspected under
the Effective Supervision Inspection Programme which did not include
Approved Premises. Under HMIP’s current programme, Approved Premises
are inspected and Yorkshire and Humberside is due for inspection later this
year.
18. In a recent joint inspection of Approved Premises, ‘Probation hostels: Control,
Help and Change?’ (published in March 2008), Her Majesty’s Chief Inspectors
of Probation, Prison and Constabulary visited a number of Approved
Premises and concluded that, overall, the control function of hostels was
being delivered. Inspectors found that both ‘Help’ and ‘Change’ functions
required some improvement, however, many examples of good practice in
these areas had also been evident.
7
KEY FINDINGS
26. The man was sentenced to 18 months imprisonment on 9 October 2007. As
he had already spent just over five months on remand, he became eligible for
release on conditional licence on 1 February 2008. Arrangements were
made, as part of his pre­release from Lindholme, for himto take up residency
at Victoria House Approved Premises.
27. The man was subject to an exclusion zone as part of his licence conditions.
This was explained to him along with the other conditions of his release. The
man appeared happy with the conditions in the main, but regularly questioned
whether this would hinder his chances of securing employment in the
transport industry.
28. The man arrived at Victoria House during the afternoon of 1 February. He
brought with him some personal belongings but no prison record of being on
medication. He was inducted by a Probation Support Officer (PSO) who
became his key worker. The man said that he had no health problems but
agreed to register with the local GP surgery. He was allocated a room on the
first floor. After a tour of the building and an explanation of the hostel rules,
he settled in well.
29. Later that day, the man attended his first ‘three way’ appointment with his
Offender Manager, and his key worker. They discussed his licence conditions
again. The man expressed some unhappiness about one of the conditions
but confirmed that he understood what was expected of himand signed the
licence. An initial action plan was completed with the man’s full engagement.
This set out how his risk and rehabilitation would be managed in order to
prepare himfor a return to the community. In agreement with the offender
manager, the man would focus on securing accommodation and employment
as part of his resettlement programme.
30. For the next two days, the man was checked on by staff and appeared to be
doing well. He stayed close to the hostel and spoke to one of his brothers
about the prospect of helping him at work as an initial step towards re­
employment. The man agreed to speak to the offender manager about it
before going out with his brother. He also made enquiries with the Benefits
Agency about making a claim for Job Seeker’s Allowance. His progress was
recorded on the Probation Area’s database.
31. On 5 February, the man met with the offender manager and her co­worker, a
trainee probation officer. They discussed his accommodation and the
prospect of the man going to live with one of his sisters. The man could not
provide a full address but explained that he was due to meet up with his sister
later in the week and would obtain it then. The offender manager provided
him with a copy of a map showing the areas where the man was prohibited
from going. He expressed some concern over his licence conditions again,
and said that he felt they may hinder his chances of re­employment and
resettlement. The man’s next appointment was scheduled for 12 February at
3.45pm.
8
32. The man met his key worker the next morning for his first session. Reflecting
on the meeting, the key worker recorded that the man had got used to the
hostel and was getting on well with staff and residents. His sister had offered
him accommodation and he was continuing to focus on getting a job with his
previous employer. The key worker mentioned that the man’s licence
conditions may have implications but that the man was discussing the issue
with the offender manager.
33. On 7 February, the man spent the day with his sister. When he returned to
the hostel that evening, he told one of the Assistant Wardens and duty officer
that night, that he had an infection in his left eye and had been to see the local
GP. The man then went to the Accident and Emergency Department at the
local hospital and was prescribed eye drops to treat the infection.
34. Four days later, on 11 February, another Assistant Warden made a note in
the man’s log that his left eye was still causing him problems. Seeing that the
man’s eye was red, this assistant warden asked him if he wanted to make an
appointment with the doctor. The man declined and said that he preferred to
go to hospital and had not seen a doctor for approximately 19 years. He kept
his eye drops (Maxitrol, 5ml) in his room in agreement with hostel staff.
Tuesday 12 February
35. At some point during the morning, another resident helped the man apply his
eye drops. The man then watched television in the lounge and seemed fine
according to the residents who saw him. During the early part of the
afternoon, the man began to complain of indigestion and asked if anyone had
any indigestion tablets. None of the residents he asked could help him. At
approximately 2.50pm, the man spoke to his sister on the telephone and
arranged to meet her after his planned three­way meeting with the offender
manager and the trainee probation officer. The man told his sister that he had
pains in his chest. His sister advised him to speak to a member of staff. He
said that he already had and was told to buy his own medication.
36. According to the approved premises manager’s chronology of events, shortly
after 3.00pm, the man knocked on the main office door and asked the Deputy
Manager if she had any indigestion tablets. The deputy manager explained
that she did not, and advised him to walk down to the chemist to purchase his
own. The deputy manager later confirmed to the approved premises manager
that the man did not tell her he was having chest pains and did not show signs
of being ill. The approved premises manager’s statement of her interview with
my investigator, said that the man described heartburn to the deputy
manager.
37. At around 3.14pm, CCTV footage of the upstairs corridor showed the man
walking towards the staircase. He then disappeared down the stairs and
reappeared on camera in the kitchen. He made a hot drink, and from the
footage viewed, he did not present as noticeably in pain or distress. The man
then left the kitchen and made his way to the front door. At approximately
9
3.20pm, the camera filming the inside of the main office showed the man’s
silhouette through the window in the main office door as he left the building. It
was not clear from the footage whether the man could open the front door or
needed to be let out by staff in the main office. My investigator later
confirmed that the man let himself out.
38. The man went outside to drink his tea while he waited for the offender
manager to arrive. One of the CCTV cameras is positioned to look directly at
the front door to the hostel. It is positioned high up, on the outside wall of the
entrance to the building, and therefore, looks down at the front door at an
angle much higher than eye level. From the camera position, the man could
clearly be seen walking around in the front garden. At 3.27pm, he sat down
on one of the chairs that had been placed along the front of the building by the
residents who smoked. Unfortunately, this was a blind spot for the camera.
He went ‘off screen’ for approximately five minutes.
39. The next image of the man was at 3.32pm. Two minutes later, he sat back
down and again went off screen. The offender manager arrived for their
planned three­way meeting at 3.36pm, a few minutes early. As she followed
the path and turned left to face the front door of the hostel, the offender
manager looked left, through the window to the main office and pressed the
buzzer to alert staff that she had arrived. The man’s key worker let the
offender manager in. She made her way to the main office, signed in and
collected her personal alarm.
40. At roughly the same time, the man presumably slumped in the chair. It is not
clear from the CCTV footage exactly what happened, given that he was
mostly obscured from the camera. What is clear is that the man dropped his
mug of tea, which could be seen rolling down the path, and his right leg (the
only visible part of his body) kicked out to the side of him slightly. The man’s
right foot remained in camera view for approximately two and a half minutes.
In the main office, the man’s key worker and the offender manager could be
seen talking and looking at the four CCTV screens sporadically. The offender
manager continued to wait for the man and her colleague, the trainee
probation officer, unaware that the man was outside.
41. At 3.39pm, the man fell from his seat and collapsed on the pavement. His
head came partly into camera view on the bottom right hand side of the
screen. Neither the man’s key worker or the offender manager noticed.
About four minutes later, at 3.43pm, the trainee probation officer arrived at the
front door of the hostel. As the offender manager had done moments earlier,
the trainee probation officer stayed on the path, turned left towards the front
door, and then looked left into the main office window to alert staff that she
had arrived. The trainee probation officer was buzzed in and made her way to
the main office. The trainee probation officer did not see the man’s head to
the right of the main entrance door.
42. The key worker left both the offender manager and trainee probation officer in
the main office to tell the man that they had arrived. He could not find him.
According to the approved premises manager’s chronology of events, the key
10
worker first checked the man’s room, and then looked in the two residents
lounges on the ground floor before knocking on other resident’s doors. At
around the same time, the Assistant Warden on duty, was about to finish her
afternoon break and made her way outside through the main office, to the fire
escape to have a cigarette. This assistant warden was joined outside by her
colleague, a support worker at the hostel, who had come in early for his shift.
43. At 3.50pm, another resident, made his way outside to have a cigarette. He
used the front door entrance. The CCTV footage showed the resodent open
the front door and walk outside from one camera angle. He could also be
seen walking past the main office window to go outside from another camera
angle. The resident looked to his left as he stepped outside the door, and
saw the man lying on the floor. He bent down, saw that the man was
motionless and went back inside. The resident knocked on the main office
door, and when the offender manager opened it, the resident told her that the
man had collapsed. They went outside. On seeing the man lying on the floor,
the offender manager pressed her personal alarm to alert other staff that there
was an emergency.
44. The assistant warden on duty was the first member of staff to respond to the
alarm. She was closely followed by several other members of staff, including
the approved premises manager and deputy manager. At 3.51pm, the
assistant warden was seen on camera bending down to check the man. At
the same time, the key worker went back to the main office and telephoned
for an ambulance.
45. The approved premises manager told my investigator that, on realising that
the man was motionless, the assistant warden asked her to get a
resuscitation pack which included a protective face shield. It is clear from the
CCTV footage that the approved premises manager walked back into the
office for a resuscitation pack at 3.52pm. The deputy manager took a pillow
out to the assistant warden, who then placed it under the man’s head for
support. The approved premises manager closely followed and handed the
assistant warden the pack. At approximately 3.53pm, the assistant warden
began to administer mouth to mouth and chest compressions.
46. The approved premises manager stayed outside while the assistant warden
gave the man CPR. At 3.55pm, paramedics arrived and took over his life
support. Between them, the key worker, deputy manager and approved
premises manager gave paramedics further information about the man. The
approved premises manager wrote in her chronology of events that this
included details about his next of kin (named as the man’s brother), his date
of birth and the medication he was using. A member of staff, believed to be
the support worker, obtained the man’s eye drops from his room and handed
them to paramedics. The man was placed on a stretcher and left Victoria
House for the local hospital at 4.10pm. The approved premises manager and
assistant warden returned to the office at 4.11pm with the used equipment.
47. Shortly after the man left for the hospital, staff gathered in the main office and
watched what appeared to be a recording of the CCTV footage covering the
11
time of his collapse. The approved premises manager told my investigator
that the deputy manager telephoned the relevant agencies and Area Chief
Officer for Humberside Probation and began her own log of what happened.
The approved premises manager filled in a green accident report formand
held a debrief session with assistant warden and the key worker. All other
staff on duty were offered support and were reminded of the counselling
service.
48. By coincidence, the man’s sister had been parked relatively near the hostel
and was waiting for the man when he collapsed in the front garden. She had
rung his mobile phone a few times between 4.05pm and 4.30pm to see where
he was. At around 4.30pm, she went to Victoria House to look for him. The
approved premises manager took the man’s sister into the interview room,
explained that the man had collapsed, and that he was taken to hospital by
ambulance. The man’s sister said that she had seen the ambulance drive by
from where she was parked and had hoped it was not for her brother. She
also told the approved premises manager that the man had complained to her
that he was having chest pains. The approved premises manager said that
she was not aware that he was having pains, and that unfortunately, he had
not disclosed this to her staff. The approved premises manager later told my
investigator that, at the time of speaking to the man’s sister, she was unaware
that the man had asked other residents for indigestion tablets a few hours
before he collapsed.
49. The man’s sister left her contact details with the approved premises manager
before making her way to hospital. At approximately 5.10pm, the approved
premises manager telephoned the hospital and was told that the man had
died. The approved premises manager explained that his sister was on her
way and was his next of kin contact. The man’s sister’s details were given to
hospital staff. Shortly after, at about 6.00pm, the approved premises manager
and the deputy manager gathered residents in the lounge and told them that
the man had died. The resident that found the man was specifically asked if
he was okay and the appropriate care and support services were offered.
Other residents not present at the time, were told as and when they arrived
back at the hostel.
50. Later that evening, the Assistant Chief Officer for Approved Premises, arrived
at Victoria House. He offered support to the staff and was further briefed on
what had happened. The remaining staff on duty were also offered support
by the Assistant Chief Officer for Offender Management in the area.
51. The approved premises manager made arrangements with the man’s sister to
collect his personal belongings. The staff at Victoria House sent a card of
condolence to the man’s family but did not attend the funeral.
12
ISSUES
52. The man came to Victoria House as part of his release on licence from
Lindholme. Little was known about him on arrival, and during the short time
he spent there, the man preferred to keep himself to himself. He complied
with his licence conditions and was looking to regain employment in the
fishing delivery industry. The man’s wish to live with his sister was also being
explored as part of his ‘moving on’ action plan, and would have been a
positive step toward re­integrating into the community.
53. I mention in my introduction to this report that the man’s family had a history
of heart problems and high cholesterol, but staff at Victoria House did not
know this until after he died. In a previous investigation at another approved
premises, I reported that rapid responses to cardiac arrest significantly
increases the likelihood of someone surviving a heart attack. When the heart
stops, the absence of oxygenated blood can cause irreparable brain damage
in a few minutes, and death invariably occurs within ten minutes. Crucial to
that investigation, and the main focus of my investigation into the man’s
death, has been in how staff responded to his collapse. I have also
concentrated on the effectiveness of CCTV, the monitoring of residents’
behaviour and the concern raised by the man’s family. I deal with the issues
raised by my investigation below.
The man’s complaint of chest pain and request for non­prescribed medication
54. During the early stages of my investigation, the man’s sister told the approved
premises manager and my FLO that he had complained of chest pains on the
afternoon of his death. The man’s sister advised him to let staff know about
his symptoms and was surprised to learn of the response the man got, which
was to medicate himself. There was some discrepancy over exactly when the
man told the deputy manager that he was in pain and what type of pain he
experienced. The deputy manager told the approved premises manager that
the man did not tell her that he was experiencing chest pain, but that he had
heartburn. The approved premises manager’s chronology of events said that
this happened just after 3.00pm. The man’s sister said that when she spoke
to himat 2.50pm, he said that he had already told a member of staff he had
chest pain. I have not been able to confirm the precise time that the man
knocked on the office door, nor the type of pain the man described. From the
CCTV footage, the man did not present as in distress while he made a hot
drink at 3.14pm and took it outside a few minutes later. The deputy manager
also told the approved premises manager that he did not show signs of being
ill when they spoke. The man had no known medical problems and did not
come to hostel with medication from prison. As a resident, but effectively in
the community, the man could come and go as he pleased save for his two
licence conditions. I cannot level any criticism at the deputy manager for
responding in the way that she did to the symptoms the man described.
13
The man’s collapse and the staff’s response
55. The man lay collapsed outside the main building for approximately 14 minutes
before a resident discovered him. When the assistant warden arrived at the
man’s side at 3.51pm, there was a further two minute delay before she
commenced CPR. My investigator viewed the footage of the man’s collapse
several times during the investigation process. In addition, she consulted the
Head of Probation and Diversity for my office, who also viewed the footage
from the camera in the main office, and the camera pointing at the front door
entrance to Victoria House. My investigator also followed the route to the
front door entrance that both the offender manager and trainee probation
officer took when they arrived for their three­way meeting with the man that
day. This investigation has considered two questions. Firstly, whether staff
could have reasonably discovered the man any earlier, and secondly, whether
attempts to commence CPR should have started as soon as he was found. I
deal with these questions in turn below.
CCTV and monitoring
56. Under Humberside Approved Premises Controlled Exit and Entry Policy, staff
are required to make residents aware of the ‘T card system’, which in Victoria
House, is located by the front door. The system simply asks residents to
move a card to let staff know whether they are in or out. By ‘in or out’ the
policy is aimed at residents who intend on leaving the building. Residents
who go outside but remain in the grounds are not subject to this requirement.
The man was one of those residents.
57. With regard to CCTV monitoring, the approved premises manager confirmed
when interviewed that there is at least one person based in the main office 24
hours per day. The main office has four CCTV screens positioned opposite
the main desk. The local policy and procedure covering monitoring and
surveillance expect staff to be aware of the importance of being vigilant in
observing the CCTV cameras. However, it is not the sole responsibility of one
person to monitor the screens all the time. Nor is it mandatory for hostel
managers to dedicate members of staff solely to monitoring duties.
58. The recent Joint Inspection of Approved Premises (mentioned on page 8 of
this report), commented on the differing approaches to monitoring residents
using CCTV. From the sample of Approved Premises they visited, inspectors
concluded that some hostels operate a policy similar to Victoria House, whilst
others do not. The rationale hostel managers gave for not dedicating a
member of staff to constant CCTV monitoring was that this freed up staff to
spend more time working with residents.
59. Highlighting the inherent problem with monitoring, the approved premises
manager told my investigator:
“…the second you do something else and take your eyes off the
screen, something could happen”.
14
The key worker that staffed the office on the afternoon of 12 February, did not
see the man go outside. Nor was he expected to know where the man was.
Footage of the man walking around outside was clear. However, for much of
his time outside, the man sat in a blind spot and the subsequent image of him,
once he collapsed, was barely noticeable in the bottom right hand corner of
the screen.
60. In one of my previous reports where a resident died in comparable
circumstances, I maintained that it would be unreasonable to level any
criticism at staff for failing to notice such an image. Given that there are four
CCTV screens showing simultaneous pictures, and that the key worker was
not able to watch all of the screens all of the time, it is not surprising that the
obscured image of the man went unnoticed. My investigator had the benefit
of hindsight in viewing the footage. The key worker did not. Since my
investigation, residents have been prohibited from sitting in the blind spot.
61. At the precise moment that the man dropped his mug of tea, the offender
manager arrived but did not notice himto her right. The key worker booked
the offender manager in and took his eyes off the screen to give her a
personal alarm. Closer inspection of the route the key worker took, confirmed
to my investigator that it was difficult to see how she could have noticed the
man. The offender manager looked to her left to get the attention of the key
worker. There would have been no reason for her to look right on her
approach to the front door. In addition, the front door has a large wooden
frame around it which slightly obscures the right hand corner from an eye
level position. As the trainee probation officer followed exactly the same path
when she arrived, it seemed perfectly natural for both visitors to look left,
press the buzzer, and enter without noticing the man.
Staff response to the man’s collapse
62. The CCTV footage clearly shows the assistant warden respond to the alarm
first. When she got to the man, the assistant warden made him comfortable
but did not commence CPR until the approved premises manager handed her
a resuscitation pack. The Assistant Warden holds a full first aid certificate,
valid for three years. All first aid trained staff are required to carry a mouth
shield and other resuscitation aids at all times. Section E, paragraph 17 of
Probation Circular 35/2006 stipulates that:
“In addition, Probation Areas/Voluntary Management Committees (sic) should
ensure that staff considering whether to commence CPR (Cardiopulmonary
Resuscitation), should follow advice in their training, and that where mouth
guards and other resuscitation aids are issued, they are of a type with non­
return valves and are carried on the person of staff at all times.”
63. That said, in a telephone conversation with my investigator on 27 June, the
assistant warden explained that at break times, she is required to hand in her
keys, pager and first aid pack. This is presumably for security reasons as
AssistantWardens are permitted to leave the premises during break times.
15
As the assistant warden was on her break when the man was found, she had
to ask for the equipment before administering CPR.
64. The administration of CPR is a stressful and tiring experience for staff, and
the man had been lying outside for approximately 14 minutes before being
found. I do not believe that the delay in obtaining a face mask for the
assistant warden would have changed the outcome for the man. Nor do I feel
that it is reasonable to level any criticism at the assistant warden for waiting
until she was better equipped to begin life support. That said, the
expectations of immediate first aid support have been revised since the
assistant warden qualified. I highlight the significant change in the next
section.
First aid training
65. A Probation Circular entitled ‘Preventing Deaths of Approved Premises
Residents’ (PC35/2006) was issued to all senior managers in each probation
area in September 2006 (implementation date October 2006). It provides
advice about reducing the incidence of deaths and self harm amongst
residents and draws on the lessons learnt from my reports into deaths of
residents in Approved Premises. Among the common themes my previous
investigations have highlighted, is the importance of appropriate and up to
date first aid skills.
66. When interviewed by my investigator, the approved premises manager
confirmed that all her staff had to complete full first aid training (four day
course) and that a rota system was in place for the delivery of refresher
courses every two years. As I mention above, all Assistant Wardens hold
First Aid at Work certificates (FAW) which remain the only legally recognised
first aid qualification. The certificate is valid for three years and the assistant
warden told my investigator that she was scheduled to attend her refresher
course in the weeks that followed the man’s death.
67. Under the revised guidelines for resuscitation, published by The Resuscitation
Council (UK) in 2006, first aid trained staff are no longer expected to
administer breaths automatically. Newly trained staff and staff attending
refresher course are now instructed to check the airway, commence 30 chest
compressions immediately, and if necessary, administer two breaths at the
end of this cycle. The previous guidelines made breaths more compulsory,
and recommended two breaths to 30 chest compressions. It is likely that the
assistant warden was first aid trained under the old guidelines and would
automatically administer breaths. The refresher course will familiarise all staff
at Victoria House with the new guidelines.
Contingency Plans following a death at an Approved Premises
68. The approved premises manager conducted a debriefing session with the
assistant warden and key worker and used the CCTV footage to compile a log
of events. The approved premises manager captured their involvement
effectively in the chronology of events that she passed to my investigator.
16
The approved premises manager did not ask staff to make personal
statements. During a visit to Victoria House on 3 March, my investigator
discussed the benefits of personal statements with the approved premises
manager. The benefits of statements are two fold. An account of personal
involvement helps staff to identify what went right and on occasion, what went
wrong. Personal statements also capture what happened as soon as or very
shortly after it happened, and are often a reliable source of information.
Probation Circular 40/2004 advises at Annex C that if a death has occurred:
“All members of staff are advised to make their own personal notes of the
sequence and timing of events for future reference if required”
Regionally, paragraph 8.6 of Humberside Probation Area’s procedures and
practice further strengthens this advice. It says that:
“All actions taken must be recorded on the case record and hostel log. Each
member of staff on duty should make notes of exactly what happened as soon
as practically possible and, if interviewed by the police and/or Ombudsman’s
representative, they should keep a copy of the statement that they give.”
The approved premises manager agreed to incorporate statements into the
hostel’s existing contingency plans for accidents and emergencies. Her
action brings Victoria House in line with national and regional guidelines on
preventing deaths in approved premises. I make no formal recommendation.
70. In general, my investigator found that staff at Victoria House followed good
contingency plans and that the approved premises manager and her deputy
manager, had reflected a great deal on how well they had responded to the
man’s heart attack. During her informal interview, the approved premises
manager also explained that she was considering the introduction of a grab
sheet which would serve to document the essential requirements for an
effective emergency response. The grab sheet would be an at­a­glance
document, and would further improve her staff’s efficiency and effectiveness
in dealing with emergencies. I would like to congratulate the approved
premises manager for her learning the lessons approach to the man’s death,
and for her foresight in wishing to introduce her own guidance to staff at the
hostel.
17