Individual at Augustus House

Investigation into the circumstances surrounding the
death of a resident at an Approved Premises in the
Warwickshire Probation Area, on 14 November 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2009
This is the report of an investigation into the death of a man. He was a resident at
Kenilworth Road Approved Premises in Leamington Spa when he died after an
accidental drugs overdose on 14 November 2007. He had been at the hostel for a
month, and two days before his death had been sentenced to a community order
with a residency order to stay at the Approved Premises for six months. He had told
hostel staff that he saw this as an opportunity to turn his life around. However, whilst
visiting a friend in his home town, he took heroin and collapsed. The friend called an
ambulance but the paramedics were unable to resuscitate him. He was 28 years
old. I extend my sympathy to his friends and family and those who worked with him.
In spite of the man’s untimely death, many of the lessons that emerged from the
investigation were positive. He was assisted by many people and the support that
he was given was impressive. A number of agencies worked with him to make sure
that he transferred seamlessly from prison to an Approved Premises. He was told
on more than one occasion about the dangers associated with the reduced tolerance
to drugs which is common after a period of abstinence. Sadly, despite the best
efforts of many members of staff, and a range of specialist services, the lure of drugs
was too strong for the man to resist.
The investigation was carried out by one of my investigators. I am grateful to the
Chief Officer of Warwickshire Probation Area and her staff for their assistance during
the investigation. I apologise for the length of time it has taken to issue this report
and for any additional distress which has been caused.
I have commended the care and support that the man received and am pleased to
say that no recommendations are necessary.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2009
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CONTENTS
Summary 4
The investigation process 5
Kenilworth Road Approved Premises 7
Key findings 9
Issues 15
3
SUMMARY
The man was born on 22 January 1979 and died on 14 November 2007. He began
using drugs at the age of 18 and moved on to heroin two years later. Until February
2007, he was in full time employment. However he was then made redundant and
shortly thereafter lost his flat. He turned to crime to fund his drug use.
In July 2007, the man appeared in court charged with theft. He pleaded guilty and
was released on bail for pre-sentence reports to be prepared. One of his bail
conditions was to reside at an Approved Premises in Nuneaton and for a bail
assessment to be carried out. However, the Approved Premises was close to his
home town and the man continued to associate with friends who used drugs.
His use of drugs contravened the Approved Premises rules and staff began
proceedings in respect of this breach of his bail conditions. The man then
absconded. He voluntarily reported to the police five weeks later and was remanded
into custody at HMP Blakenhurst. Whilst in prison he completed a detoxification
programme and worked with the drugs team to prepare for his release.
On 16 October 2007, the man appeared in court and was released on bail on
condition that he reside at the Kenilworth Road Approved Premises in Leamington
Spa. This hostel is further away from his home town and probation staff hoped that it
would assist the man to remain drug-free. He settled well into the regime, attending
sessions with his keyworker and attending education classes. However, he
frequently used alcohol and tested positive for heroin on two occasions.
The man returned to court on 12 November and was sentenced to a 12 month
community order with a six-month residency order to live at Kenilworth Road. He
told his keyworker that he was “ecstatic” at the sentence as it “was a chance to turn
his life around”.
Two days later, he left the Approved Premises, telling staff he was attending a
hospital appointment. It is not known if he did so, but what is clear is he returned to
his home town and visited his grandmother. He then went to a friend’s flat where he
injected heroin. He collapsed and his friend called an ambulance before trying to
resuscitate him. Sadly, neither he nor the paramedics were successful.
Police informed the family of the man’s death and also notified the Approved
Premises staff. Staff informed the residents and offered them support. Senior
managers attended Kenilworth Road to support both staff and residents.
4
THE INVESTIGATION PROCESS
1. The man died on 14 November 2007 and staff informed my office the following
day. My investigator opened the investigation four days later when she visited
Kenilworth Road Approved Premises. She met the manager as well as other
hostel staff, and was shown round the premises. Staff also provided a copy of
the man’s records.
2. The investigator returned to the Approved Premises on 23 November to interview
a member of staff and the resident with whom the man had shared a room. In
January 2008, she interviewed the drugs worker who worked with him at HMP
Blakenhurst and the probation officer who prepared the reports for court. I regret
that workload pressures have delayed the writing and issuing of this report.
3. One of my family liaison officers wrote to the man’s family to ask if they had any
matters they wanted my investigation to address. The family did not wish to raise
any issues.
4. The inquest was held on 22 February 2008 when HM Coroner for Warwickshire’s
verdict was death due to misuse of drugs.
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5. KENILWORTH ROAD APPROVED PREMISES
6. Approved Premises (formerly known as probation and bail hostels) are approved
by the Secretary of State to accommodate sentenced offenders and those
directed to live there by the courts as a condition of bail. Their purpose is to
provide an enhanced level of residential supervision in the community, as well as
a supportive and structured environment. They operate on each day of the year
with 24-hour staff cover.
7. The Warwickshire Area of the National Probation Service has two Approved
Premises. McIntyre House is in Nuneaton and mainly serves the north of the
county while Kenilworth Road is in Leamington Spa.
8. Kenilworth Road is a large and imposing building in a residential street. It has
accommodation for up to 19 men and extensive public rooms on the ground floor.
Kenilworth Road has ten members of staff. The manager is also the Area
Manager for Approved Premises in the Warwickshire area, with responsibility for
the other hostel too. There is a full time administrator, five assistant wardens and
two night waking permanent staff. There is also a pool of relief staff who cover
periods of sickness, annual leave, and training. In addition, a cleaner and a cook
are employed.
9. The manager and deputy manager are qualified Probation Officers. The
Assistant Wardens and night waking staff are not professionally qualified, but
they all have had a formal induction into the Approved Premises. When
appropriate, they have linked into Probation Service Officer modular training, but
there is no specific training programme for Approved Premises staff. Staff have
attended a suicide awareness course and training events on raising awareness
about mental health issues. They also have had the opportunity to attend joint
Prison Service training events. All Approved Premises permanent staff have a
minimum of the basic first aid training.
10. The Approved Premises has an admissions policy based on assessment of risk.
In recent years, the resident profile has changed significantly with prolific lower
risk offenders being superseded by individuals convicted of more serious violent
or dangerous offences. The hostel now takes fewer people coming straight from
court. The majority of residents are required to stay at the Approved Premises as
conditions of a court order or of a licence on release from prison.
11. Each resident is allocated a keyworker soon after his arrival and this member of
staff acts as their primary point of contact for dealing with practical issues.
Regular keywork sessions give residents the opportunity to discuss their
difficulties in depth. Although these sessions are not governed by a set agenda,
issues such as benefits, health and accommodation are routinely discussed.
12. Residents are required to pay rent and abide by the rules and regulations of the
Approved Premises, including observing a strict overnight curfew between
11.00pm and 6.00am. When residents are subject to statutory supervision,
pertinent information is shared regularly with field probation officers who act as
case managers.
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13. The Approved Premises has a Closed Circuit Television (CCTV) system to
maintain the security of the premises and help ensure the safety of residents and
staff.
14. A previous death at Kenilworth Road occurred 15 months before the death of the
man. The cause of death was also a drugs overdose. However, the
circumstances surrounding the two deaths are different in all other respects.
7
KEY FINDINGS
15. On 4 July 2007, the man was arrested on suspicion of theft and appeared in
court. A week later, he met with a probation officer at Nuneaton Justice Centre,
who was preparing a pre-sentence report (PSR) for the court. At this meeting,
the man said that he had committed the theft in order to obtain money for drugs.
At interview, the probation officer told my investigator that the man had said that
he was “rubbish at crime” as he always got caught.
16. On 19 July, the man had a second meeting with the probation officer in which he
told her that he had also been charged with burglary. He told the probation
officer that he had been feeling low over the past few months and that his life had
spiralled out of control. However, he said that he had never self-harmed or
attempted to end his life. He said that he had used drugs from the age of 18,
starting with cannabis, then acid (LSD), speed (amphetamines) and ecstasy. He
said that he started to use heroin at 20 years of age, firstly smoking and then
injecting it.
17. The probation officer told my investigator that the man had been homeless when
she met him, and her first step was to find him a place that had a stable
environment in which he could settle. She decided to look for a bed in an
Approved Premises where he could undergo a bail assessment. This is usually a
four week period where somebody who has pleaded guilty to an offence in court
is assessed for their suitability for a community order. If they do not have a
permanent residence or a suitable address, the Approved Premises staff decide if
they are suitable for a six month condition of residence whilst completing their
community order. The aim is then to move the resident on to stable
accommodation after the six month period.
18. The probation officer explained that in these four weeks the intention was that the
man would be assessed by the community drug team or the criminal justice drug
team staff as to his suitability for a Drug Rehabilitation Requirement (DRR) as
part of a community order. She told my investigator that she thought this was “a
brilliant idea” as the man would have a base, somewhere to sleep and regular
meals. She told my investigator that managers at McIntyre House Approved
Premises in Nuneaton had agreed to give him a bed.
19. On 3 August 2007, the man moved into McIntyre House for a four week period of
bail assessment which was due to finish on 21 August. The probation officer
visited him at McIntyre House. When asked how he seemed at that point, she
told my investigator:
“… He was doing really well and had settled in … at the point that I met
him he was homeless. So it was good to see that he was there at the
hostel. He appeared to be doing really well … he was clean, he had a
room and he was being fed. And I think he was quite happy there
because he was able to settle. I think he was seeing the drug
community team at that point and it was all well and good … I went in
with the purpose of seeing him to just say keep up the good work … ”
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20. However, on 10 August, the man was given a formal warning after staff found
drug paraphernalia in his room. Three days later, an entry in the computerised
record system said that a detective constable from the man’s home town had
come to the hostel to tell staff that the man might have been going back there
during the day. He felt this might be detrimental to his efforts to stay drug-free.
He asked staff to communicate this to the man and wanted to make it clear that
he had brought this up in the interests of the man’s welfare. The staff later
discussed the officer’s concerns with the man and he admitted he had visited his
home town a couple of times. Later that day, he was prescribed methadone and
told staff he was feeling more positive.
21. Five days later, the man had an appointment to meet the probation officer at the
Justice Centre. However, he read “appointment at the JC” as being at the Job
Centre and went there instead. Staff accepted that it was a genuine mistake and
rescheduled the meeting.
22. The following week, staff again found drug paraphernalia in the man’s room.
Managers withdrew his bed space and started breach of bail proceedings. He
then absconded from McIntyre House.
23. On 1 October, the man telephoned the probation officer who persuaded him to
surrender himself to the police at the Justice Centre. She worked in the same
building and so went to see the warrant officer to arrange the time that the man
could come in and be processed. He handed himself in to the police the
following day, appeared in court and was remanded in custody to HMP
Blakenhurst. His next court appearance was set for 16 October.
24. On 10 October, a Counselling, Assessment, Referral, Advice and Throughcare
(CARATs) worker at Blakenhurst went to see the man to go through his Drug
Intervention Record (DIR) (the initial assessment) with him. (CARATs workers
can run programmes, offer counselling, support and referral to rehabilitation
centres to prisoners and on release.) The drugs worker told my investigator that
in the DIR, the man said that he had never attempted self-harm or suffered
previous overdoses but disclosed that accommodation was an issue. He told her
that for two weeks prior to coming into custody he had been prescribed a
standard methadone maintenance programme with Nuneaton Community Drug
Team. She added that, as the man had been on the run for two months, he
would not have had any legal methadone in that period. She said that he had
also disclosed that before he came to Nuneaton he had been using two to three
bags of heroin a day, injecting the drug into his arms and his feet. In prison, the
healthcare staff put him on a methadone detoxification programme.
25. The same day, the probation officer visited the man at Blakenhurst. She told my
investigator that he looked fine and he told her that he had not used heroin for six
weeks at that point. She said that she had no evidence of this but that he
certainly looked “reasonable” and did not appear to be suffering from withdrawal
symptoms. She discussed with him the possibility of going to Kenilworth Road
Approved Premises for bail assessment. The probation officer explained to my
investigator that it was at this point she realised the problem with McIntyre
House. The hostel was within easy reach of the man’s home area where he
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26. Two days later, the drugs worker had another one-to-one session with the man
when they discussed drug awareness. She told my investigator that in this
session they looked at the drugs the man had been using and the affect they had
on his body. She also drew up a release plan for him that included an
appointment for him on 16 October at 2.30pm with Nuneaton Drug Team. This
was to ensure that, if he was released from court, he would have somewhere to
go and get some support. She said that every release plan contains an
assessment of the prisoner’s drug awareness and his harm minimisation:
“ … That is basically looking at his tolerance levels, looking at if he is
an injector how to minimise the harm he’s doing to himself, i.e. don’t
share any equipment, go and get clean needles from the needles
exchange, make sure you are with somebody … when you use, smoke
if you can, don’t inject … ”
27. My investigator asked her if she had spoken to the man about the dangers of
using needles, about reduced tolerance and about taking drugs in the presence
of someone else. In response, she replied that the topics included steps to take
when someone has taken an overdose such as calling an ambulance. The
discussion also dealt with common myths such as walking the person around and
slapping their face. Other areas covered were how quickly tolerance levels drop
and the relative benefits of smoking rather than injecting heroin.
28. On 16 October, the man was bailed by Nuneaton Magistrates Court to Kenilworth
Road Approved Premises. On arrival, he underwent an induction which was
carried out by an assistant warden. She discussed the rules and regulations with
the man, and he signed a copy of the rules to say that he understood what was
expected of him. During the induction, the assistant warden gave him a leaflet for
residents who used drugs. It explained the Approved Premises’ rules and
procedures about drugs and drugs paraphernalia. It also warned of the dangers
of reduced tolerance.
29. The assistant warden said that the man had been put on a curfew under his bail
conditions which involved him being in the Approved Premises from 8.00pm to
8.00am. This was specifically because his offending had happened in the
evening. The man fully complied with the additional curfew requirements. My
investigator asked her how he seemed and how he handled the induction
process. She said that he had appeared very positive and motivated and, as the
induction process was very similar to that of McIntyre House, he had coped with it
very well. He was also tested for drugs and alcohol and proved negative for
opiates and crack/cocaine.
30. The man settled quickly into the Approved Premises regime and was assessed
as being very compliant and a well mannered resident. At Kenilworth Road, he
shared a room with another resident. The resident told my investigator that he
and the man got on well together, although, as he is a quiet person, they did not
10
31. When asked how the man got on with other residents and staff at the Approved
Premises, the resident said:
“Well I’ve never heard any bad reports about him, everybody seems to
like him … he was friendly and everybody used to get on with him …
he seemed quieter on some days … but he wouldn’t say anything
about what it was … he was fairly open about himself generally
speaking, apart from his private life and I didn’t really want to know that
anyway so he was fairly open in his attitude and everything.”
32. Whilst at Kenilworth Road, the man attended regular keywork sessions with his
allocated key worker. When asked by my investigator what these sessions
involved, the key worker replied:
“Keywork sessions take place normally within the first three days…I
normally do them when management has gone home because then we
have a room to interview on our own without any interruptions. They
normally last about an hour depending on the needs and it’s normally
motivational work to get them through their bail assessment. So it’s
trying to find out which areas of the man’s life needs assistance and
help with. That’s what the bail assessment is about and then me
liaising with different agencies ... obviously he had drug issues so I’m
not qualified to do that so I then contact services that could enable
him.”
33. The key worker told my investigator that her first session with the man involved a
general discussion about his background and how he began using drugs. She
said that he mentioned alcohol initially and then drugs as the main issue. He was
trying to convince staff that this time he was going to succeed in staying opiate
free and was not going to “mess up like he did at McIntyre House”. She told my
investigator that he sounded genuine when he said this. He was always polite to
staff and other residents, displaying a good sense of humour.
34. The man’s basic literacy skills were also assessed at these keywork sessions.
The key worker told my investigator that the man’s education was not to the
standard it should have been. She said that his initial assessment showed that,
although he was able to get through life, he wanted to improve his education.
She therefore put him forward for education classes.
35. He fully complied with regular testing for alcohol and illicit drugs. Although his
alcohol tests were positive, he was always within the legal limit. The key worker
told my investigator that one day the man had told her that he had been drinking
in the park with the local alcoholics. She then said that, at first, he did extremely
well as all of his drug tests produced negative results.
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36. However, on 2 November the man tested positive for opiates (although negative
for cocaine). The key worker said that she had been on duty that day and the
man had been out all day. When he returned, she decided to inspect his
appearance closely and noticed that he had pin pupils and was scratching, both
of which she thought were signs of opiate use. She called him into the office to
give him a drug test, which proved to be positive. When asked if she had
questioned him about why he had started using again, she replied:
“… He said it’s because he’s out of his comfort zone, which is
Nuneaton area, his home town, and over here he wasn’t familiar with
the local users … but this one day he went to sign on at the Job
Centre, runs into an ex-resident’s sister who was a known user and
they got talking … and she invited him back to hers and she was the
one that gave it to him … ”
37. The key worker then wrote the bail assessment report on the man and discussed
it with him. Her recommendation was that he was suitable to be a resident at the
Approved Premises if the court agreed that part of a community sentence was a
“condition of residence”. That report was then sent to the probation officer to
include in her report to the court.
38. However, on 8 November, the man had another positive drugs test and he
admitted to the key worker that he had injected heroin. As a result of this second
lapse, managers decided to amend the recommendation to one that asked the
court for a two week adjournment. This was in order to fully test his motivation to
remain drug-free and to ensure that he had access to appropriate prescribed
medication. The key worker told my investigator that this was not a refusal, but it
was to enable the man to be prescribed the correct medication given that he was
again using heroin.
39. When the man appeared at Nuneaton Magistrates Court on Monday 12
November this amended report was not shown and the court acted on the advice
in the original report. He was sentenced to a 12-month community order that
included a six month residence order at Kenilworth Road.
40. Staff at Kenilworth Road Approved Premises assumed that the recommendation
for an adjournment with the same bail conditions had been granted, and therefore
alerted the on call manager and local police that he was in breach of bail as he
had not returned to the Approved Premises by 8.00pm. He returned to the
Approved Premises at 8.55pm and explained that he had had problems with the
trains. Staff accepted his explanation. He also showed staff a reporting
instruction form issued by probation staff at the court. This confirmed the
sentence details and told him to report to the deputy manager of the hostel, at
5.30pm.
41. The key worker told my investigator that she had been on duty when the man
came back from court and she tested him for drugs. He was negative for both
opiates and crack cocaine but he had been drinking. She said that he was
“ecstatic” with his sentence and told her that he saw this as a chance to turn his
life around.
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42. However, the resident said that the man seemed a bit agitated the following day,
finding it difficult to settle to anything. Nevertheless, he did not say or do
anything to cause the resident to be concerned about him. On Wednesday, 14
November, the man left the Approved Premises at 10.35am saying he was
attending a hospital appointment. He told the resident that after that he was
going to see someone, but did not say who.
43. The man did not return to the hostel and it is not known if he attended the
hospital. At 8.45pm, Warwickshire Police informed staff that he had died in a
friend’s flat in his home town. The evidence suggested that he had taken an
accidental drug overdose. Their enquiries later revealed that the man had gone
to visit his grandmother. He then spent time in a friend’s home. During the
afternoon, the friend left to buy provisions. On his return, he found the man
collapsed on the floor with a syringe beside him. The friend called an ambulance
and began cardio pulmonary resuscitation. Sadly, the paramedics were unable
to resuscitate the man and he was certified dead.
44. The staff and residents who had known the man were extremely shocked by his
death. Senior managers arrived at Kenilworth Road to support them. The key
worker told my investigator that staff were given a long debrief session and she
had all the support she needed. The resident said that he too was offered
support, as were all residents. Managers sent a letter of condolence to the family
and spoke to the man’s father by telephone. The probation officer learned the
news the following morning. She and a colleague later attended the man’s
funeral.
13
ISSUES
Drug treatment
45. The probation officer identified the man’s needs and organised a place in an
Approved Premises on two separate occasions. She visited him at McIntyre
House and in prison. The Approved Premises staff also worked to meet the
man’s needs and referred him to other agencies where necessary. When it was
clear that he was using drugs again, staff adapted the plans to meet these
additional needs. The prison drugs worker ensured that the man knew of the
dangers of injecting heroin and reduced tolerance after a period of being drug-
free. The key worker also stressed these dangers.
46. The man received help and advice from a number of sources that was focussed
on helping him to stop using drugs. Too often in my reports, I have to highlight
lack of communication between agencies. However, the care the man received
was seamless and I am pleased to commend those staff who worked so well
together to ensure he received the opportunity and support to break free of drugs.
Conclusion
47. For most of his adult life the man was able to finance his drug use through his
earnings. However, being made redundant started a downward spiral into
homelessness and crime. In all his dealings with staff in the criminal justice
system, he said that he wanted to stop using drugs and put his life back on track.
However, the probation officer who wrote the pre-sentence report assessed him
as being at an early stage of the recovery process. This was borne out by his
reverting to drugs while at Kenilworth Road.
48. The man was a friendly and engaging person, and police, probation and drugs
professionals all worked very closely with him. In spite of this, and despite his
best intentions, he continued to use drugs. Sadly, on 16 November 2007, he
took a quantity of drugs that led, apparently unintentionally, to his untimely death.
14
ANNEXES
1. Documents considered during the investigation
Probation records
Pre-sentence reports
Prison drugs team records
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