Individual at Ozanam House

Investigation into the circumstances surrounding the
death of a resident in an Approved Premises managed
by the Probation Service
Report by the Prisons and Probation Ombudsman for
England and Wales
October 2007
The man who is the subject of this investigation was found dead on 11 March
2007. The cause of the man’s death appears to have been from a drug
overdose. The man had been a resident at approved premises. He was 25
years old.
The loss of any family member is deeply distressing and I would like to extend
my condolences to the man’s family and friends for their loss. I know that he
will be sadly missed.
The aim of my investigation was to discover whether the level of care
provided by staff at the approved premises and the probation area was
appropriate, and whether any lessons could be learnt to help prevent a similar
death in future.
Two investigators carried out the investigation into the man’s death on my
behalf. I am grateful for the assistance they received from staff at the
approved premises. In particular I would like to thank the Manager and
Deputy Manager for making the necessary facilities and information available
to my investigators. It is evident that these approved premises are run and
managed by caring and professional members of staff.
The man went missing from the approved premises just over two weeks after
he had been released from HMP Lincoln. Although he had a history of drug
abuse before he arrived at the approved premises, during the first few days at
the hostel he appeared to progress well. However, several days after his
arrival the man appeared to be under the influence of an unknown substance.
On 9 March, the man failed to return to the hostel, having been found drinking
alcohol in his room the previous evening. He was found dead, locally, that
weekend.
The man had an established history of drug abuse and in all probability was
well acquainted with the effects and consequences of their use. My
investigation concludes that little could have been done to prevent him from
dying in the circumstances that he did. However, I make three
recommendations.
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.
Emma Bradley
Deputy Prisons and Probation Ombudsman October
2007
CONTENTS
Summary 4
The Investigation Process 5
Approved Premises 6
Key Findings 8
Issues 12
Recommendations 14
SUMMARY
The man who is the subject of this investigation was released from Lincoln
Crown Court on 23 February 2007, and arrived at the approved premises late
that afternoon. On his arrival, the man was given an induction by a member
of staff at the hostel. The project support worker explained the house rules
and regulations and the man signed a compact agreeing to these.
During his first few days at the approved premises the man appeared settled,
helping out in the kitchen and mixing well with other residents. Within days of
his arrival he met with his offender manager (probation officer) and key
worker. During these first few days staff reported that the man appeared to
be progressing well and that he had apparently not been tempted by drugs.
On 28 February, the man met with his offender manager attending with a
friend with whom he had offended in the past. That evening staff at the
approved premises reported that the man, “… seemed to be very hyper …”
The following morning, 1 March, the man failed to attend an appointment as
part of his drug rehabilitation requirement. In the afternoon he made an
unplanned visit to his offender manager. The man told his offender manager
that he had had his travel pass confiscated. During the meeting, the offender
manager told the man that he had been issued with a warning for failing to
attend his drug rehabilitation appointment that morning. A new appointment
to attend was made for the following Monday.
On 5 March, the man attended his drug rehabilitation appointment as planned,
but failed to provide a urine sample for staff. The man met with his offender
manager as planned in the afternoon. The offender manager recorded that
the man was under the influence of what appeared to be heroin. Over the
following days the man met with both his key worker and offender manager.
The man tested positive to a drug test at the approved premises on 7 March.
The following day, 8 March, he attended a drug rehabilitation appointment
under what was described as the possible influence of an illegal substance.
That evening the man returned to the hostel, apparently under the influence of
something. Later that night, the man and another resident were found to be
drinking alcohol in the man’s room.
On the morning of Friday 9 March, the man’s key worker had planned to
speak with him about the events of the previous evening. However, the man
left the hostel at about 9.00am before his key worker was able to do so. The
man failed to return to the hostel that evening or the following day. Staff at
the approved premises were informed of the man’s death at around lunchtime
on Sunday 11 March.
THE INVESTIGATION PROCESS
1. The investigation into the man’s death was completed by two of my
investigators. They visited the approved premises and were shown the
man’s room, as well as other areas of the hostel. My investigators met
with the manager at the approved premises and explained the
investigation procedure to the manager and they talked about the man’s
time at the hostel.
2. My investigators returned to the approved premises on 23 April 2007, in
order to conduct interviews with staff and a number of residents who had
known the man. I know that for some this was difficult, coming so soon
after his death. My investigators were given full access to records and
documentation relating to the man as well as full access to information
about the approved premises.
3. One of my Family Liaison Officers contacted the man’s mother. She
explained my role and the investigation process. On 1 May 2007, my
family liaison officer and one of my investigators met with the man’s
parents at their home in North Shields.
4. During the visit the man’s parents raised a number of issues, some of
which my family liaison officer and investigator were able to address
during their meeting. The man’s mother asked why her son had been
located in a hostel so far away from her home. She felt that it was a long
journey for him to make home visits on a regular basis. The probation
area has four approved premises, and the hostel at which the man was
resident was one of those located closest to his mother’s home. The man
was given a free travel pass so that he could visit his family and travel
around. The man’s mother asked if he had any solicitors representing him
and I understand that these details have now been provided. The man’s
mother also enquired as to whether or not the probation service had done
anything to support the man on his release from prison and this is
addressed in my report.
5. During their meeting the man’s parents expressed their gratitude for the
sensitivity and kindness showed by staff at the approved premises. They
also spoke highly of their contact with the Police, who they said also acted
sensitively.
THE APPROVED PREMISES
6. The man who died was resident at approved premises, formerly known as
a probation and bail hostel. The purpose of approved premises is to
provide an enhanced level of residential supervision in the community,
providing a supportive and structured living environment.
7. The approved premises at which the man was a resident is located near a
city centre. The hostel is managed by a senior probation officer, 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 three key workers, one of whom works part
time. There are also ten support workers covering between them evening
and weekend shifts, as well as three night care workers.
8. The admissions 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. The majority of
residents are required to stay as a condition of a court order or prison
licence.
9. Each resident is allocated a key worker. This member of staff acts as their
primary point of contact during their stay and assists residents in sorting
out practical issues. Regular key work sessions also give residents the
opportunity to discuss their difficulties in depth. Although the sessions are
not governed by a set agenda, issues such as benefits, health and future
accommodation are routinely discussed. Residents at the approved
premises are all registered with a local general practitioner.
10. Whilst at the approved premises, residents are required to pay rent and
abide by the rules and regulations. This includes observing a strict
overnight curfew between 11.00pm and 7.00am. During the day residents
are free to go out unaccompanied, they are not required to tell staff where
they are going. Breakfast and dinner is provided to all residents. The
hostel has a comprehensive system of closed circuit television. This
monitors movement in and out of the building, as well as other strategic
points.
11. The approved premises has an established routine for inducting all new
residents. The induction is carried out by the member of staff who is on
duty at the time a new resident arrives. During the process residents are
told about the local house rules and their expected behaviour. The hostel
has a strict policy on alcohol and drug use. The possession and or use of
alcohol or drugs is strictly forbidden, in either the hostel or its grounds.
The one exception is prescription medication. On arrival, all new residents
are told of the rules regarding the use of illegal and prescription drugs.
Part of the induction includes telling those prisoners recently released from
prison that they may have a reduced tolerance to illicit substances.
12. Staff at the approved premises routinely test those residents suspected of
drug abuse. Oral swabs are taken from individuals when there is
reasonable suspicion that there has been drug or alcohol abuse. Room
searches are carried out on a regular basis. Although staff are not
permitted to search an individual, they are able to search their property.
13. In April 2005, new legislation came into force in England and Wales
allowing the courts to impose community orders and to specify the
activities that on offender must undertake. These activities can include
drug treatment, mental health treatment, residence at a specific address,
supervision by the Probation Service, curfew between certain hours of the
day and unpaid work. The man was subject to a suspended sentence with
a supervision order. Three requirements were identified, two years of
supervision, drug rehabilitation and a 24 month residence order. A review
of the man’s status was to have taken place at Crown Court on 23 March
2007.
14. The man’s drug rehabilitation requirements required him to participate in
regular drug testing and treatment, at a local drug coordination agency.
The expectation for those given drug rehabilitation requirements is that
they might continue to abuse drugs upon their release and during their
residence at approved premises. However, the aim of the programme is
to manage the addictive behaviour and give individuals the opportunity to
access detoxification programmes.
15. The supervision element of the man’s order required him to report to his
offender manager. The man was required to report up to four times a
week. During supervision, offenders are expected to analyse their criminal
and anti-social behaviour in a structured manner, and develop skills to
avoid re-offending.
16. Offenders who fail to keep scheduled appointments, or who commit new
offences, can be breached and returned to court. The first stage of the
breach process is that the offender is issued with a warning if they are
unable to provide evidence that they had a legitimate reason for not
attending. If no evidence is provided, the warning stays on file. Two
unacceptable absences in a year mean that they are returned to court.
The court has the power to re-sentence the offender or add new conditions
to the order.
KEY FINDINGS
17. On 26 January 2007, the man who is the subject of this investigation was
arrested for stealing from a local shop. He told his probation officer that
the thefts were to fund his drug habit. This placed the man in breach of a
suspended sentence supervision order imposed on 2 October 2006, at
Crown Court and he was remanded at HMP Lincoln on 29 January 2007 to
await sentence. During his subsequent court appearance, a number of
other charges were taken into consideration.
18. On 23 February, the man was given a 24 month suspended sentence
order with supervision and Drug Rehabilitation Requirement (DRR) and an
additional residence requirement. At approximately 5.00pm that
afternoon, the man arrived at the approved premises. He arrived with no
documentation or personal possessions. The man had previously resided
at the approved premises for about a week in August 2006. His stay at
that time was problematic, he broke hostel rules and appeared to be under
the influence of an unknown substance on a number of occasions.
19. On his arrival the man was given an induction by a project support worker.
He described the man as being, “a little bit bewildered by the speed of
events.” He explained to the man the rules and expectations, as well as
the local policy on drugs. However, there is no evidence to suggest that
issues of drug tolerance were discussed. (During the induction process
staff at the approved premises are provided with an induction prompt
sheet. The prompt highlights a number of issues that must be covered
during the induction process. One of these relates to the issues
surrounding drug tolerance.) In addition to listening to the verbal induction
from the project support manager, the man signed a compact agreeing to
these rules and expectations. The man was not asked to take a drugs test
at the time of his induction or at any time over the following days.
20. During the first few days of his stay at the hostel, the man appeared
settled. He helped out in the kitchen and mixed well with a number of the
other residents.
21. On Monday 26 February, the man met with his offender manager and
another person who was responsible for his drug rehabilitation
programme. The man told them that he had remained drug free since
going into prison.
22. The following day, the man met with his offender manager a second time.
The man said he continued not to have any drug problems and that he had
met with his key worker at the hostel.
23. The man had a second meeting with his key worker on the morning of
Wednesday 28 February. She reported that he seemed to be doing well
and that he had not been tempted by drugs. The key worker said that he
was involved with cooking and cleaning duties and had been in contact
with his family. She said she made the man aware that he was not to
enter the rooms of any other residents.
24. That afternoon the man met with his offender manager. This was earlier
than had been planned as he had been given an appointment to attend the
benefits office at 2.30pm. The man attended the probation office with a
friend with whom he had offended in the past. The man spent that
evening in the approved premises. Staff recorded that he:
“…seemed to be very hyper when seen pacing around a lot at supper
time, went to room again after supper.”
25. On 1 March, the man failed to turn up for his first drug rehabilitation
appointment. When he learnt of his non attendance his offender manager
said, “… I didn’t expect him to miss it. I thought he was very motivated…”
That afternoon, the man made an unplanned visit to his offender
manager’s office. He told his offender manager that he had had his travel
pass confiscated by travel inspectors. The man had apparently been
gloating about his friend having been caught without a valid ticket and had
become abusive towards staff. The offender manager explained to the
man that he had been issued with a warning for missing his drug
rehabilitation appointment. The offender manager told the man that he
was to attend for his drug rehabilitation appointment the following Monday
morning and was to visit him in the afternoon.
26. Little is known of the man’s movements during the day on Friday 2 March.
However, that evening he spent some time on the hostel telephone. A
project support worker at the hostel recorded:
“Later at around 10.30pm the man appeared to be drunk. He was
swaying, finding it difficult to coordinate himself and was falling asleep
when sat down. This could also be because he had taken
something. As the man appeared fine when he returned to the hostel
earlier in the evening and did not leave the hostel again. It would appear
that whatever affected him had been consumed within the hostel.”
The project support worker said that the man did not appear to smell of
alcohol.
27. On 3 March, the man left the hostel in the morning, returning at about
6.30pm. The project support worker said that, “…he appeared in a similar
disorientated state as the previous evening.” On Sunday 4 March, the
man went out in the morning, returning to the approved premises after
lunch. That evening he told the project support worker that his father was
ill and did not have long to live.
28. The man attended for a drug rehabilitation appointment on 5 March as
instructed, however, he was unable to provide a urine sample for drug
testing. That afternoon, the man went to meet with his offender manager
as planned. The offender manager said they discussed the man’s general
behaviour and his aggressiveness, discussing strategies to help avoid
conflict. The offender manager recorded in the man’s notes that he was:
“…heavily under the influence of what appeared to be heroin at the
time so I am unsure how much of the conversation registered.”
The offender manager said that the man admitted to him during their
meeting that he had “started dabbling a bit.” That evening, the man
remained in the hostel, staff reporting that he was fine.
29. The man’s key worker met with him on Tuesday 6 March. They discussed
his general disruptive behaviour and the key worker issued him with a
warning letter. She said that the man told her that he had not been under
the influence of anything whilst at the approved premises, although he
occasionally smoked cannabis. The man expressed concern about his
father’s health.
30. The following day, the man met with his offender manager as arranged.
The offender manager recorded that although the man looked okay he
suspected that he was possibly under the influence of something.
However, the man denied this. That evening the man was drug tested by
staff at the hostel and he tested positive for opiates. Whilst being tested
the man told staff that he had taken a number of painkillers for toothache,
which he said his mother had given him.
31. The next day, the man attended another drug rehabilitation appointment
and was further drug tested. It was recorded that he attended under the
influence of a substance. Probation staff discussed the possibility of the
man accessing a structured day care programme. An initial assessment
appointment was requested.
32. That evening, the man was seen to come and go from the approved
premises on several occasions. Another project support worker recorded
that:
“…at supper time [the man] appeared to be under the influence of
something possibly drugs, no smell of alcohol. He was falling all
over the place, slurred speech.”
33. Later that evening, the same project support manager found another
resident drinking alcohol in the man’s room, something that is forbidden.
The man told staff that the lager had nothing to do with him. He was told
by staff that the rule breaking would be dealt with by his key worker the
following day.
34. The project support worker who found the other man drinking in his room
said that that night the man expressed concerned that he might be asked
to leave, because alcohol was found in his room. He said that the man
asked him three or four times that night if, as a consequence of breaking
hostel rules, he would be made homeless. The project support worker
said:
“The man kept coming down asking if he would be put out of the hostel
and be made homeless and we just said no. The chances are you’ll
just get a hostel warning…”
The project support worker said that several times he tried to explain to the
man that he would not be made homeless, but would probably just get a
warning. He said:
“…I don’t think he [the man] was taking on board what I was saying
because I don’t even think he was actually hearing what I was saying
most of the time because he really, just wasn’t there.”
35. CCTV footage shows that the following morning the man left his room at
8.45am. At 8.46am he entered the kitchen made some breakfast and
chatted with other residents before returning to his room, but not entering
it, at 8.57am. The man returned to the dining room at 8.59am, before
leaving the hostel at 9.02am. The man left the hostel before he had been
spoken to by his key worker, who was going to speak to him about the
alcohol being found in his room the previous evening. That morning the
man failed to attend a prearranged meeting with his offender manager and
he failed to return to the hostel that evening. At 11.20pm staff at the
approved premises informed the police of his absence.
36. The following day the man again failed to return to the hostel. At 8.45am,
the police contacted staff at the approved premises requesting details of
the man’s next of kin. At 12.10pm, police informed staff that the man had
been found dead locally.
Post Mortem Report
37. A post mortem was conducted. The pathologist concluded that: “…death
from trauma has, as far as it is ever possible to do, been ruled out”. The
pathologist reported that toxicology had shown the presence of morphine,
codeine and diazepam as well as cannabis. He concluded that it
appeared as if the man had died, “…as a result of the combined effects of
morphine and diazepam”.
ISSUES
Induction process
38. Probation Circular 35/2006 – Preventing Deaths of Approved Premises
Residents, highlights that the causes of resident’s deaths at hostels is
often due to reduced drug tolerance upon release from prison. It says:
“Where this topic is not already covered at the induction interview,
Approved Premises should ensure that advice and guidance is
given to all residents on reduced drug tolerance following release
from custody. It is good practice for this to be included in a leaflet for
residents, which could include contact details for drugs advice
agencies.”
It is not apparent that the man was informed of the issues surrounding
reduced drug tolerance, or that he was provided with written information
advising him of the heightened risk during his induction at the approved
premises.
39. The prompt, used by staff during the induction process, highlights the need
for issues of drug tolerance to be discussed during a resident’s induction.
However, I believe that the layout of the form is such that there is not
sufficient emphasis placed on the important issue of drug tolerance.
40. Although released after the man’s death, Probation Circular 23/2007
(Reducing the Risk of Drug Related Deaths), provides additional
clarification and information with regard to the action required by offender
managers to reduce the risk of drug related deaths. It also provides
guidance relevant to Approved Premises, which includes:
“Providing the offender with leaflets and other written information and
ensuring that they understand them. Some approved premises staff
have reported that completing the risk assessment on the induction
form with offenders is an effective way to engage them in discussion
around the risk of overdose. This discussion is backed up by giving
the offender a leaflet.”
The manager should review the induction process at the approved
premises to ensure that an auditable discussion, regarding issues of
drug tolerance, is completed during the induction process.
The manager, in partnership with other approved premises managers
from the probation area, should review the provision of materials
available to residents with regard to drug tolerance issues, to ensure
compliance with Probation Circular 23/2007.
Drug Testing
41. Probation Circular 05/2006 (Approved Premises: Drug Testing of
Residents) says:
“Testing known drug users on arrival or when they are suspected of
renewed drug use is a targeted and prudent use of resources. Hostels
which are not currently testing on this basis are asked to put this
provision in place.”
At the time of the man’s death, although written and approved, the policy
document providing guidance as to the circumstances in which residents
should be tested for drugs had not been published by the approved
premises and the area probation service. This is to be regretted.
However, I have subsequently had sight of the hostel’s Substance Misuse
Strategy and confirmation of its publication.
42. Staff who had come into contact with the man told my investigators that
they were aware that residents coming to the hostel under a DRR or drug
related offence should be tested upon arrival at the hostel or as soon as
possible. However, the man was not tested and staff were unable to
provide a reason as to why this had not been done.
The manager should remind all staff at the approved premises of the
policy on testing residents who are suspected of drug abuse or have
a history of drug use.
43. I should add that given the man’s appearance and interaction with staff,
and the deterioration in his behaviour during his time at the hostel, it is
most probable that had the man been tested on his arrival from court, he
would have tested negative. As a consequence I believe that the failure to
test the man at this point had no bearing upon his death or indeed on the
standard of care provided to him by both the probation service and staff at
the approved premises.
RECOMMENDATIONS
The manager should review the induction process at the approved
premises to ensure that an auditable discussion, regarding issues of
drug tolerance, is completed during the induction process.
Accepted
The manager, in partnership with other approved premises managers
from the probation area, should review the provision of materials
available to residents with regard to drug tolerance issues, to ensure
compliance with Probation Circular 23/2007.
Accepted
The manager should remind all staff at the approved premises of the
policy on testing residents who are suspected of drug abuse or have a
history of drug use.
Accepted