Individual at Wenger House

Investigation into the circumstances surrounding the
death of a man, who was a resident at an Approved
Premises managed by the Probation Service,
on 20 September 2007
Report by the Prisons and Probation Ombudsman for
England and Wales
March 2008
This is the report of an investigation into the death of a man, who was a
resident at an Approved Premises managed by the Probation Service. He
died from natural causes on 20 September 2007. He was 74 years old.
I would like to add my personal condolences to those already expressed to
the man’s family on behalf of this office by one of my Family Liaison Officers.
This investigation was undertaken by one of my investigators. I am grateful
for the assistance he received from staff at the Approved Premises. In
particular I would like to thank the Manager of the Approved Premises for his
kind cooperation. It is evident that Approved Premises is both run and
managed by caring and professional members of staff.
The man was taken by ambulance to a local hospital on 16 September and it
was here that he died during the morning four days later. All loss of life is
sad, but the man’s passing raises no issues of wider concern.
This version of my report, published on my website, has been amended to
remove the names of the man who died and those of staff and prisoners
involved in my investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman March
2008
CONTENTS
Summary 3
The investigation process 4
The Approved Premises 5
Key Events 7
Conclusion 11
SUMMARY
The man was born in 1933. He was 74 years old when he died on 20
September 2007 at a local hospital. The man died from natural causes as a
consequence of an upper gastrointestinal haemorrhage (bleed from his
stomach).
The man had been sentenced to two years imprisonment at Stafford Crown
Court on 26 June 2006. He was initially held at HMP Birmingham and HMP
Stafford before he transferred to HMP Wymott on 18 October 2006. During
his first reception health screen at Birmingham, it was noted that the man was
a smoker who had diabetes, asthma and mobility problems. It was also
recorded that the man had previously undergone surgery on his prostate and,
as a consequence, encountered problems with incontinence.
The man was released on licence from Wymott on 22 May 2007, after serving
11 months of his sentence. As part of his licence conditions the man was
required to reside at an Approved Premises managed by the Probation
Service.
On 6 September 2007, the man phoned the duty office at the Approved
Premises from his room. He told staff that he felt giddy and had chest pains.
Staff immediately called for an ambulance and then went to the man’s room.
He was taken to hospital. Whilst the man was in hospital, staff from the
Approved Premises kept in contact with him on a daily basis. When the man
was discharged from hospital on 13 September, he returned to the Approved
Premises.
During the morning of 16 September, the man went to a car boot sale. On his
return to the Approved Premises, he complained of having pains in his chest
and was again admitted to hospital. The Approved Premises maintained
contact with both the man and hospital staff.
Four days later, the man passed away in the hospital.
THE INVESTIGATION PROCESS
1. The investigation was opened on 9 August 2007 when my investigator
issued notices announcing the investigation to staff and to residents.
The notices included an invitation to those who wished to submit
information relating to the man’s death to make themselves known to my
investigator. In the event, nobody came forward. My investigator also
studied all relevant probation and prison records relating to the man.
These included his main prison record, medical records, hostel records,
supervision plan and licence. My investigator visited the Approved
Premises on 16 October and 8 November and discussed aspects of the
man’s treatment with staff at the hostel.
2. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of my investigation and to request a copy of the Post
Mortem report. Upon completion, this report will be sent to the Coroner
to assist him in his enquiries into the man’s death.
3. One of my Family Liaison Officers contacted the man’s family. This
gave them the opportunity to discuss the purpose of the investigation
and to raise any concerns or questions that they would like explored and
addressed. The family did not wish to raise any specific concerns
relating to the care the man received whilst under the supervision of the
Approved Premises. I hope that this report helps the family better
understand the events leading up to the man’s death.
THE APPROVED PREMISES
4. The Approved Premises, formally known as a Probation and Bail Hostel,
opened in 1976. The purpose of an Approved Premises is to provide an
enhanced level of residential supervision in the community, providing a
supportive and structured environment for offenders.
5. The hostel contains accommodation for 26 male residents, who are
subject to bail, licence or a community sentence. Places are
predominantly offered to individuals who are registered with the multi-
agency public protection unit. The building has 24 single bedrooms and
one double. One of the single rooms has been adapted as a bed-sit
facility.
6. The hostel is managed by a Senior Probation Officer (SPO) who has
overall responsibility for its running. He is assisted by a Deputy
Manager who is responsible for the day-to-day management of
residents. The frontline team is made up of Key Workers (Probation
Service Officers) covering between them evening and weekend shifts,
as well as Night Care Workers.
7. The admission policy at the Approved Premises is based on an
assessment of risk. In recent years the residents’ profile has changed
significantly, with prolific lower risk offenders superseded by those
convicted of more serious violent or dangerous offences. These
offenders are assessed as posing a risk of re-offending or harm to the
public and, at any given time, the Approved Premises manages a
number of ‘high risk’ offenders. The majority of residents are required to
stay as a condition of a court order or prison licence.
8. Multi-Agency Public Protection Arrangements (MAPPA) support the
assessment and management of the most serious sexual and violent
offenders. The aim of MAPPA is to ensure that a risk management plan
is drawn up for the most serious offenders which benefits from the
information, skills and resources provided by the individual agencies,
including the police, co-ordinated through MAPPA.
9. Whilst at the Approved Premises, residents are required to abide by the
rules and regulations. These include a strict overnight curfew between
11:00pm and 6:00am. During the day residents are free to go out
unaccompanied, and are not required to tell staff where they are going.
Breakfast and an evening meal are provided to all residents. There is
also the opportunity for residents to move into self-catering
accommodation using the bed-sit facility. The Approved Premises has a
comprehensive system of closed circuit television. This monitors
movements in and out of the building, as well as other strategic points.
10. Upon arrival at the Approved Premises residents receive a full induction
and are made as welcome as possible. During the induction process
they are told about the local house rules and their required behaviour.
Details of next of kin, personal information and medical information are
also recorded. A Probation Service Officer was the man’s Key Worker
and he acted as a conduit between the man and his Offender Manager.
11. Residents are required to maintain regular contact with the Deputy
Manager, Key Worker and their Offender Manager. They all work to the
Approved Premises Risk Management and Supervision Plan which is
drawn up by the Deputy Manager and the Offender Manager using
eOASys (electronic offender assessment system) as a directive. The
main emphasis of these contacts is to explore the cause of the residents’
offending behaviour in a structured way and to develop skills to avoid re-
offending. The staff and resident meetings are supplemented by the
residents’ inclusion in accredited programmes of work, for example, sex
offending programmes. The process is further assisted, in most cases,
by in-house group work programmes which are mainly aimed at offering
learning opportunities to assist the residents in acquiring new life skills.
KEY EVENTS
12. On 26 June 2006, the man was sentenced at Stafford Crown Court to
two years imprisonment for indecent assault. He arrived at HMP
Wymott on 18 October after previously being held at HMP Birmingham
and HMP Stafford. The man’s medical history consisted of diabetes,
asthma and mobility problems. It was also noted that the man had
previously undergone surgery on his prostate. A range of medication
was prescribed for the man to treat his various conditions.
13. On 22 May 2007, the man was released from custody on licence. As
part of his licence conditions he was required to reside at the Approved
Premises. A letter summarising the man’s medical history was prepared
by medical staff at Wymott before he was released, and was forwarded
to the Approved Premises. An appointment was made by the Approved
Premises with their local General Practitioner (GP) surgery and the man
registered there on 23 May. He walked with the aid of a stick and had
been given a ground floor room at the hostel due to his lack of mobility.
14. When interviewed for this investigation, the man’s Key Worker recalled
that they had their first meeting on 27 May 2007. At their initial meeting,
the Key Worker checked how the man felt about being at the Approved
Premises and how he was settling in. This was an opportunity for the
man to express any concerns he had about his situation. The Key
Worker also explained his role, the man’s responsibilities, and the
expectations of the Probation Service whilst he was a resident at the
Approved Premises.
15. The Key Worker recalled that there had been occasions when the man’s
behaviour had caused concern and where he had acted inappropriately.
The Key Worker said that he ensured that any inappropriate behaviour
was discussed with the man and dealt with. The Key Worker felt that the
man had very little realisation of where he was and that he was in denial
concerning the seriousness of his offences. When issues were raised
with the man he had a habit of breaking into song or whistling to
disengage from events.
16. The Key Worker said that he felt comfortable about talking to the man
although the man’s behaviour led to him being given direct instructions
about how to deal with other residents and to treat others with respect.
There were no further incidents of inappropriate behaviour at the
Approved Premises after the man had been given a warning by the Key
Worker of the implications of any recurrence.
17. After the man was warned about his behaviour, he had a spell of buying
his own food and eating it in his room but staff were then able to
encourage him to eat with other residents. The Key Worker also
recalled that the man experienced some problems with incontinence but
the Approved Premises asked for an Incontinence Nurse to come in to
assist him. The Key Worker added that, although the man had mobility
problems, he was able to drive and had been very proud when he
purchased a car.
18. On 6 September 2007, the Key Worker was on duty with another
member of staff. At around 7:30pm, the man rang the duty office at the
Approved Premises from his room and told staff that he had pains in his
chest. They immediately called for an ambulance and then went to the
man’s room. While the staff were waiting for the ambulance they talked
to the man, asking him what he had eaten and where he had been
during the day.
19. The man was then taken by ambulance to the Accident and Emergency
Department (A&E) at the local hospital. After the man left for hospital,
the Key Worker informed a Police Inspector from the Public Protection
Unit. The Police Inspector visited the man in A&E and liaised with
medical staff to ensure that they were made aware of possible risks.
The man was later admitted to a ward and the Approved Premises then
kept in daily contact with the hospital. The man was diagnosed as
having experienced a bleed from his stomach (gastrointestinal bleed).
An endoscopy was performed. (An endoscopy is a test that looks inside
the body. The endoscope is a long flexible tube that can be swallowed.
It has a camera and light inside it.) Two ulcers were found in the man’s
stomach.
20. The Manager of the Approved Premises confirmed that whilst the man
was in hospital he kept in contact with his brother. The man also
continued to update his brother about his condition whilst he was in
hospital.
21. When interviewed a former resident of the Approved Premises, told my
investigator that the man was a pleasant person who was very sociable
and had a very good sense of humour. The former resident said that the
man never argued with other residents and they could not help liking
him.
22. My investigator asked the former resident about the man’s health. He
replied that, although the man could not walk very far, he was able to get
around the hostel. He said that, due to his mobility problems, if the man
walked into town he would get a taxi back. He added that the man
bought a car which the former resident’s friend did a bit of work on.
When asked about the man’s admissions to hospital, he recalled that
when the man went into hospital for the first time the man told him that
he had stomach ulcers.
23. On 13 September, the man was discharged from hospital and returned
to the Approved Premises. The former resident accompanied the man
in the taxi back to the hostel. The Key Worker recalled that the man was
very pleased to be back at the Approved Premises and bought cakes for
all the staff.
24. On his return from hospital the man had been given additional
medication. When asked how the man’s medication was administered
to him, the Key Worker said that medication for all the residents is kept
in the duty office in a locked cabinet. Residents have 24 hour access to
the medication via a hatch in the duty office. The Approved Premises
expects residents to take their medication at the correct intervals but, if
someone is absent minded, staff will remind him. My investigator was
able to see how this process was administered and was able to view the
man’s medication record.
25. On 14 September, the man attended a meeting with the Key Worker.
The man claimed that he felt much better. The Key Worker noted that
he appeared quite unwell and a little confused about his medication, but
otherwise he was fine.
26. On 16 September, the former resident and the man went to a car boot
sale. After they returned to the Approved Premises, the former resident
went to visit relatives. Around 12.10pm, the man phoned the duty office
and asked for an ambulance to be called as he felt unwell and had chest
pains. Staff immediately called for an ambulance. The man was again
taken to hospital and the Approved Premises then kept in daily contact
with the hospital. Staff at the Approved Premises did not contact the
man’s family when he was taken to hospital. They assumed that the
man would keep his family informed, as he had done previously.
27. When the former resident returned in the evening, he discovered that the
man had been admitted to hospital. He went to visit the man in the
hospital and saw him again on 17 and 18 September. The man also
phoned him and asked him to run a few errands. The man asked the
hospital to treat the former resident as his next of kin and to keep him
informed of any developments. He confirmed that no other residents
visited the man.
28. Around midnight on 19 September, the former resident received a call
from the hospital. He was told that the man was very ill and was not
expected to last the night. He informed hostel staff about this and they
immediately contacted the hospital. The hospital confirmed that the man
was very poorly and advised the hostel to phone throughout the night for
updates on his condition.
29. At 1:30am on 20 September, the hospital contacted the Approved
Premises and informed staff that the man had been moved to intensive
care. The former resident went to the hospital the following morning and
was told that the man’s ulcers were bleeding and there were clots on his
lungs. Medical staff also informed him that the treatments for the two
conditions were in conflict and that the ulcers had worsened. The man
was taken into theatre on a number of occasions but nothing could be
done for him. The man was made to feel as comfortable as possible
and the former resident remained with him.
30. Later that morning at around 11:30am, the Key Worker contacted the
hospital. He was told that the man was very poorly and that the hospital
had experienced problems contacting his family. The Key Worker asked
if he could assist with contacting the man’s family but was told that it was
now too late. The call was then cut off. The Key Worker immediately
phoned back and was told that the man had died. The Key Worker
logged what had happened before notifying the man’s Offender Manager
of his death. The Key Worker then contacted the man’s family. He
explained his role and what had happened and also offered his
condolences. Staff also immediately informed the other residents.
31. Arrangements were later made for the man’s belongings to be given to
his family. Staff from the hostel also attended his funeral.
32. The post mortem report records the man’s death as being due to natural
causes, as a consequence of upper gastrointestinal haemorrhage (bleed
from his stomach) caused by perforation of gastric adenocarinoma
(perforated ulcer). An inquest into the man’s death will not take place
as there were no suspicious circumstances surrounding his death.
CONCLUSION
33. The man moved to the Approved Premises in May 2007 and died of
natural causes in September 2007 in the local hospital.
34. I would like to commend the actions taken by staff when the man was
taken ill. On both occasions staff at the Approved Premises summoned
an ambulance immediately so that the man could receive appropriate
treatment in hospital. The decision to allocate the man a room on the
ground floor at the Approved Premises was also good practice. Indeed,
I think that the Approved Premises treated the man with sensitivity and
professionalism. The Chief Officer of the local Probation Area will wish
to share that conclusion with the staff of the Approved Premises.
35. I make no recommendations arising from this investigation.