Individual at Staitheford House

Investigation into the circumstances surrounding the
death of a male resident at an approved premises in
Staffordshire Probation Area, in January 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2007
This is the report of an investigation into the circumstances of the death in
January 2007 of a man, who was a resident of an approved premises. The
cause of his death was a drug overdose. He was 28 years old, and had a
long history of misusing drugs.
I would like to extend my condolences to the man’s family and friends for their
loss.
Two of my colleagues conducted this investigation. I am grateful for the
assistance they received from staff of the Staffordshire Probation Area and
from the Chase Prolific Offender Management Unit.
The man had been released on licence from HMP Erlestoke to the approved
premises in Stafford. During his two week stay, he was observed by staff on a
number of occasions as being under the influence of illicit substances.
Despite this being a breach of hostel rules, staff did not take any early formal
action against him. On what was to be his last day at the approved premises,
the man left the premises and went out in the morning. The decision to recall
him to prison had already been taken before he failed to return by the hostel’s
curfew time. The next morning, the police reported that he had been found
dead in a property in Stafford.
I judge that the approved premises is managed by committed staff, and
largely in accordance with approved premises standards. I also commend the
work of the Chase team. However, I note that the man was far more
compliant with them than he was with the hostel. Had his breaches of the
approved premises rules been dealt with more robustly, it is possible that his
death would not have occurred as it did. I believe there are lessons here not
just for the hostel itself and for Staffordshire Probation Area but for the
Probation Service as a whole.
I have made seven recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman September 2007
2
CONTENTS
Summary 4
Conduct of the investigation 5
Background 6
Key findings 10
Issues raised in the investigation 24
Conclusion 27
Recommendations 28
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SUMMARY
The man at the centre of this report was convicted on 6 July 2004 for offences
of burglary, possession of a class A drug and handling stolen goods. When
he was arrested he was already on licence for a previous offence, with 50
days remaining before its expiry. He was given a custodial sentence of four
years and 50 days, which he initially served at HMP Stafford, moving on to
HMP Featherstone and then HMP Erlestoke. The man had a number of
previous convictions and was identified as a prolific offender. His history of
substance misuse was a significant factor in his offending behaviour.
Whilst serving his sentence, the man tried to remain drug free and attended
courses run by the Prison Service. His probation officers, who were part of
the Chase Prolific Offender Project (CPOP) team, had regular contact with
him whilst he was in custody. The man told them that it was his intention not
to return to drug use when he was released from prison.
The man was granted release on parole from 29 December 2006 and had a
number of conditions attached to his licence, one of which was to reside at an
approved premises in Stafford. Another condition was to participate on the
CPOP to address his offending behaviour and remain drug free.
The man was released on the Friday before a Bank Holiday weekend. He
went to the CPOP office, met his probation officer and was drug tested with a
negative result. He then went to the approved premises, but left quickly
afterwards, saying that he wanted to visit his family. He did not complete his
induction to the approved premises. Staff saw little of the man for the first
three days of his stay. When they did, there were no concerns apart from his
anxiety to go out.
Staff then began to notice a change in the man’s behaviour and he looked as
if he was under the influence of substances but did not smell of alcohol. He
produced a positive drugs test at a CPOP appointment. He continually broke
his licence and hostel rules, despite it being brought to his attention, and was
thought to be under the influence of substances on no fewer than eight
occasions.
On 11 January 2007, the man was unaware that the decision had been made
to recall him to prison and hostel staff prepared to ask the police to collect him
on his return. However, he failed to return that night before the curfew time of
11.00pm and the police were notified. Early the following morning, the police
contacted the approved premises to inform them that the man had been found
dead. It was suspected that he had overdosed on drugs. He was 28 years
old.
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CONDUCT OF THE INVESTIGATION
1. The investigation was conducted by one of my senior investigating
officers, and one of my assistant ombudsmen. I am grateful for the
assistance they received from the Staffordshire Probation Area,
especially from the deputy manager and staff at the approved premises,
and from the Chase Prolific Offender Project (CPOP). Although those
interviewed were coming to terms with the man’s death, they made
facilities available and participated fully in the investigation.
2. My investigators visited Staffordshire Probation Headquarters, the
approved premises and the CPOP office. They studied records and
interviews were conducted with staff at the approved premises and
CPOP. Transcripts of the interviews are attached as annexes to this
report.
3. One of my Family Liaison Officers contacted the man’s family and
explained the investigation process to them. They were invited to raise
any concerns or questions they might have for the investigation to
consider. The man’s sister asked whether he was subject to any kind of
drug testing whilst a resident at the approved premises. I hope that my
report answers any further questions that the family may have.
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BACKGROUND
Counselling Assessment Referral Advice and Throughcare (CARATs)
4. CARATs teams assess prisoners identified as having a drug problem.
CARATs workers give basic information about drugs and their effects,
and offer counselling and group work to prisoners who want to reduce
their use. They also refer prisoners to drug treatment rehabilitation
programmes.
Prison Addressing Substance Related Offending (PASRO)
5. PASRO is a prison based programme to address drug related offending.
It has been adapted from a community programme known as ASRO.
The man undertook a PASRO programme whilst in custody.
6. Drug programmes vary widely, with some run by outside drug workers,
others by prison officers, and some by a mixture of both. The duration of
programmes also varies, some lasting a few weeks and others up to 18
months. The prisoner will be expected to give up using drugs while on
the programme. Many such programmes are located on voluntary
testing wings where prisoners are regularly tested for drugs.
The approved premises
7. Approved premises, formerly known as Probation and Bail Hostels, are
approved by the Secretary of State within Section 9 of the Criminal
Justice and Court Services Act 2000. They provide accommodation for
people granted bail in criminal proceedings and also supervision and
rehabilitation for those convicted of offences. Hostels provide a
supportive, structured environment in the community for high risk and
difficult to manage offenders. The purpose of the period of residence is
to ensure that the individuals concerned are subject to close oversight in
the community. Their supervision within the approved premises is
governed by the National Offender Management Service’s (NOMS’s)
Standards for the Supervision of Offenders. NOMS produces Probation
Circulars which set standards for the work of staff in probation areas,
including those working in approved premises.
8. Approved premises are a resource for managing high risk of harm
offenders who have either been released from prison on licence or bailed
from court. When a prisoner is released on licence, they are still a
serving a sentence but can live in the community instead of in prison.
Conditions are attached to each licence and breach means that recall to
prison can be considered. Recall is normally proposed by the probation
officer, and involves an application being made to the Home Office (now
Ministry of Justice).
9. The approved premises in Stafford is a large Victorian detached house
on the edge of Stafford. It was originally the headquarters of
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Staffordshire Probation Service and opened as a bail hostel on 10
August 1981.
10. From November 2004, the approved premises was run by the deputy
manager, a senior probation officer. The deputy manager was the acting
manager until the manager was appointed in November 2006. The
manager has other part-time duties for the probation area and the deputy
manager remains in charge of the day to day running of the premises.
11. The approved premises has three probation service officers (PSOs)
working in the hostel, one of whom was seconded to another post in
November 2006. There are six contracted night supervisors, two sharing
a full-time position. There is also a week-end supervisor who works 12
hour shifts each Saturday and Sunday. There are at least six members
of relief staff who can be called upon to cover shifts when staff are sick
or on leave.
12. The hostel has accommodation for 12 residents in five bedrooms. Two
rooms are shared by three residents and three rooms by two residents.
Until June 2006, it also had two cluster houses which accommodated six
residents. At present, the hostel is re-organising the staff sleep-in room
and adjoining office space to accommodate up to three more residents.
13. Like most approved premises, referrals for a place are made by the field
probation officer. There is a close working relationship with the CPOP
team whose probation officers have ultimate responsibility for managing
offenders.
14. Every resident should complete their induction on the day of arrival.
Residents are given instructions to travel immediately to the approved
premises to arrive by 8.00pm at the latest. This allows receiving staff to
assess any difficulties or concerns and show newcomers around. The
induction also ensures that residents know the rules. Attendance at key
worker sessions is part of the residents’ contract and failure to attend can
be considered a breach of hostel rules.
15. Breakfast and dinner are provided each day. A doctor is available locally
and there are also links with a number of community organisations.
Unless a resident is subject to individual curfew arrangements imposed
by a court, they must be on the premises between the hours of 11.00pm
and 6.00am.
16. Resident have keys to their rooms, which they hand into the office when
they go out and collect on return. They are not allowed to bring friends
into the hostel without prior permission.
17. Room searches are not routinely undertaken unless staff have particular
suspicions about a resident. For hygiene and health and safety
purposes, room checks must be carried out at least once a week and
undertaken by two members of staff. All concerns must be recorded in
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the house log and the resident’s personal file. Issues must be shared
with the resident by the key worker and the discussion recorded.
18. Like all approved premises, there are rules regarding alcohol and drugs.
The possession or use of alcohol, solvents and controlled substances is
not allowed either in the approved premises or within the grounds.
Medication which is prescribed to an individual must be notified to staff
and stored securely in the main office.
19. A minimum of two curfew checks must be carried out daily in the core
building of the approved premises, usually at 11.00pm and 6.00am. All
curfew requirements are monitored by staff. Additional curfew checks
imposed on specific residents are also carried out by staff where
necessary. In addition, all communal areas, including bathrooms,
showers and toilets, must be checked regularly and these checks
recorded in the house log. This process is to confirm the well being of
each resident.
20. Night duty is normally supervised by two night supervisors. At least one
of the night staff will be first aid trained. They are given a handover by
the day staff when they begin their shift. They keep order and look after
residents’ welfare, issue medication and patrol the premises overnight.
Any issues that occur during the night are recorded in the house log.
The approved premises also has a number of CCTV cameras installed in
communal areas of the hostel which are monitored by staff from the main
office.
21. The approved premises runs a weekly life skills group work session and
morning diary planning meetings. It encourages residents to access
services within the community and offers basic skills assessment and
tuition at the local probation office.
22. Minor infringements of approved premises’ rules are dealt with by
informal caution which should be recorded. Serious or repeated
misbehaviour results in firmer action which should be initiated by the
management of the hostel, initially using written cautions. Cautions are
used in approved premises to differentiate between National Standards
warnings which might be issued by probation officers. Failure to improve
behaviour can result in withdrawal of the bed and recall to prison.
23. Information about residents is recorded in their individual file and in the
house log book.
Chase Prolific Offender Project (CPOP)
24. The CPOP team works with people identified by the Crime and Disorder
Reduction Partnership as prolific offenders. The Prolific and Priority
Offender panel meets every month to identity such offenders in the area.
It is a multi agency panel which uses a scoring matrix to determine
whether the person meets the criteria to be designated as a prolific or
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priority offender. Those identified must have been sentenced to 12
months or more imprisonment or a community order. Currently 30
offenders are supervised.
25. CPOP is jointly managed by police and probation and aims to interrupt
any future offending and increase offender rehabilitation through police
and probation information exchange and police surveillance. CPOP has
a good relationship with the approved premises in this case, whose staff
can contact CPOP any time in an emergency.
26. There are links with key partner agencies, such as medical staff,
substance misuse counsellors and employment workers, to give a
holistic service and support to the offender. CPOP has its own medical
staff, including a doctor to co-ordinate medical treatment and drug
interventions. They provide intensive support as seamlessly as possible
and, as many clients are in and out of prison, they often engage with
prison healthcare.
27. The CPOP team will interview a prisoner whilst in prison, and an
appointment is made to see them on the first day of their release. This is
seen as an important part of the support for released prisoners to help
address their offending behaviour.
28. As most prisoners are released on a Friday, CPOP both try to arrange a
suitable time on the first day of release and provide weekend services.
Case Recording and Management System (CRAMS)
29. CRAMS is the probation service’s case recording system. It
electronically records contact with offenders supervised by the probation
service. Probation officers within the prison and outside in the
community, including staff in approved premises, use the same system.
When a concern is raised, the database can be accessed for further
information.
30. The log book is a manual case recording system used in approved
premises when any incidents occur. It is used in conjunction with
CRAMS and records any information that needs to be passed on to all
members of staff.
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31. KEY FINDINGS
Prior to the man’s release from prison
32. On 6 July 2004, the man was convicted of possession of a class A drug
and handling stolen goods. He had been identified as a prolific offender
and was under the supervision of Chase Prolific Offender Project
(CPOP). He was already on licence for a previous offence, and had 50
days remaining before it expired.
33. The man’s probation officer at the time, prepared a pre-sentence report
before he was sentenced. He identified him as someone whose criminal
activities were both related to and funded his personal drug problems.
The man had been breached by CPOP during his previous period on
licence.
34. The man was no stranger to the criminal justice system and his probation
officer felt that it was unlikely that he would escape a custodial sentence.
He had made genuine attempts in the past to change his habits but with
no success. His probation officer felt that CPOP should continue to over
see the man whilst he was in custody. To facilitate the plan, they would
recommend his transfer to HMP Featherstone, a prison with which they
had working links. The man would be encouraged to remain on a drug
free wing and participate in drug counselling. He would also complete a
series of offending behaviour programmes in custody and on release.
CPOP would arrange a planned structured release from prison, and the
man would be subject to stringent supervision requirements including
drug testing, monitoring and support to secure training and employment.
35. The man at the centre of this report began his sentence at HMP Stafford,
and thereafter was transferred to four other prisons. He successfully
completed PASRO and was involved with CARAT workers. He was also
part of the drug testing regime and seemed positive about remaining
drug free and not re-offending.
36. A parole assessment was prepared in December 2005 by a second
probation officer, who was also member of the CPOP team. This
probation officer told my investigators that he had met and corresponded
with the man on several occasions regarding his supervision and parole.
During this period, the man was granted category D status and was
subsequently transferred to HMP Leyhill, an open prison. However, he
lost his open prisoner status because of resumed drug taking. The man
was subject to disciplinary action which resulted in his transfer to HMP
Gloucester on 27 October 2005, followed by a transfer to HMP Erlestoke
on 15 November.
37. As a result, the man moved prison three times shortly before his
intended release. The second probation officer initially arranged for the
deputy manager of the approved premises in Stafford, and himself to
visit the man at Leyhill. However, he told them he had been transferred
10
to Gloucester and the appointment was cancelled. A third probation
officer, who jointly managed the man with the second probation officer,
arranged another date for him to be interviewed. Because the man was
moved quickly from Gloucester to Erlestoke, CPOP were not able to
meet him until 20 December 2005.
38. In the second probation officer’s report for the man’s parole application,
he wrote that the risk of re-offending could most effectively be reduced if
the factors underlying his offending were addressed as part of an
intensive, structured community supervision period. This would be close
supervision with a minimum of four contacts every week. The man
would also have the option to participate in a substance misuse
programme in the community, Offender Substance Abuse Programme
Treatment (OSAP).
39. Another condition of parole was that the man would be expected to live
at the approved premises in Stafford. This would provide secure and
stable accommodation, allow him to be monitored, and support his re-
integration back into the community. Residence would include a drug
abstinence requirement (DAR) to confirm his drug free lifestyle, as his
previous offending had shown that he committed offences very quickly
when he returned to drugtaking. The man confirmed that he would be
willing to work with CPOP on release and abide by the conditions
imposed upon him. A further condition was that CPOP would work with
him to monitor his behaviour, with regular liaison with hostel staff and
regular drug tests.
40. The first hearing of the Parole Board was in early January 2006 and the
man’s application was refused. His appeal also failed and the Board
raised concerns about statutory supervision and his history of substance
misuse including drug use whilst in prison.
41. The man was later granted parole and was eligible for release on licence
from 29 December 2006. In preparation, he was visited at Erlestoke on
20 December 2006 by the third probation officer and a nurse, both of
whom worked for CPOP. They discussed any medical intervention he
might need on release to support his intention to remain drug free. The
man said he did not need any intervention and that he had been drug
free for some time. He was receiving medication for stress, and said he
only took drugs whilst in prison.
42. This was the first time the nurse had met the man and she told my
investigators he presented himself well. He admitted to using heroin
whilst in prison, but said it was intermittent and his way of getting through
his sentence. He had been drug free until his transfer to Gloucester and
was adamant that on release this would not be a problem. The nurse
said she and the probation officer spent about two and a half hours with
the man. They discussed his emotions and the practicalities of being
released. The man was very rational and appeared to understand what
was being said to him by the nurse. He was offered all the appropriate
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medication regimes, including a detoxification programme. He declined
any support but was happy to engage with CPOP and be tested for drug
use.
43. In relation to the condition of residence at the approved premises, the
man told the nurse that he was concerned about the number of rules in
place. This would be his first time staying in a hostel and he was not
happy about sharing a room, not having a television and the hostel
curfew times. However, he understood that staying in an approved
premises was better than being homeless. The nurse felt that, because
of the length of time he had been in custody, he had forgotten how
different life could be outside of prison.
The man’s release from prison
44. The man was released from HMP Erlestoke on 29 December 2006 and
went to CPOP as instructed by his licence conditions. He was
interviewed by his second probation officer, who also telephoned the
approved premise to inform them that the man had arrived safely at
CPOP. He said that there were no problems and, when they had
finished interviewing him, the man would make his way to the hostel for
his induction.
45. The probation officer told my investigators that he had seen the man a
number of times whilst he was in prison. They had discussed many
issues about what was required upon release. He said the man was
apprehensive about being released, but openly discussed issues,
especially access to drugs. He had also completed a PASRO course
whilst in custody and was well aware of the pitfalls of misusing drugs.
46. The man’s licence had a requirement to be drug tested, known as drug
absence requirement (DAR). He was DAR screened by CPOP staff and
produced a negative test result for Class A drugs. This was a positive
start and demonstrated that he had not recently used drugs in prison.
The probation officer said the man gave him the impression that he
would not return to using drugs.
47. An appointment had already been arranged for the man to see the
medical practitioner. The doctor told my investigators that he was very
involved with CPOP offenders, and specifically wanted to see the man
on his first day out of prison to check how he was. The doctor had
known the man for some time because of the man’s previous
involvement with CPOP. The doctor was also the chief police surgeon
for Staffordshire Police and had come across the man in police custody
on a number of occasions. The doctor felt that the man did not have a
particularly easy relationship with staff and he was always quite resistant
to CPOP.
48. The probation officer telephoned the doctor to tell him the man had
arrived. The doctor was not in the office, but was en route by car to
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Stafford Police Station where CPOP are based. He said he would arrive
shortly and told the probation officer how long the journey would take.
After waiting for a short period to see the doctor, the man decided he
could wait no longer. He left the building before the doctor arrived,
saying that he felt confident that he did not need any medical support
and told the probation officer that he intended to visit his family before
going to the approved premises.
49. The doctor discussed the man with his probation officer and considered
whether it would be appropriate and safe for him to see him on his own
over the weekend at the hostel. It was eventually decided that this was
not a viable option and, as probation had already interviewed the man
and he had produced a negative DAR test, the doctor decided to make
an appointment the following Tuesday (Monday being New Year’s Day).
As the doctor was well known and had a good relationship with the
approved premises, he was confident that staff would contact him at any
time should an emergency arise.
50. The probation officer telephoned the approved premises to inform them
that he had given permission for the man to visit his family en route to
the hostel. The man was instructed to ensure that he arrived at least
between 8.00pm and 9.00pm so that his hostel induction could be
carried out.
51. The man arrived at the approved premises in Stafford around 5.00pm.
He was met by the duty probation service officer (PSO). The PSO was
in the dining room and sat next to the man, and he did not interact with
any of the other residents. The man ate half his dinner very quickly, and
said he wanted to leave immediately so he could visit his sister who lived
nearby.
52. The PSO told my investigators she was unable to engage in any real
conversation with the man, who was in a hyperactive and excitable
mood. Throughout their limited conversation, he was anxious to leave
the premises. The PSO said that he raised no issues or concerns with
her that evening. She agreed that the man would complete his induction
on his return from his sister. However, before he left she managed to tell
him about some of his induction, got him to sign the hostel rules and
show him his room. She also reminded the man that he had a job centre
appointment on Tuesday 2 January. She provided details about
registering with the local doctor, and he said that he was not prescribed
any medication (although this was not checked with the prison).
53. The first of the night supervisors came on duty around 7.00pm. She told
my investigators that she had reviewed the man’s records before he
returned at 10.55pm. She introduced herself to him and said he was in a
good mood and talked mainly about his family. Throughout the night,
hostel checks were carried out by the night staff. There were no issues
reported, all residents were accounted for, and were quiet and settled.
13
54. Another PSO was assigned as the man’s key worker. When the key
worker arrived on duty on the morning of Thursday 30 December, the
man had already gone out. The night staff said that they had been
unable to complete his induction, because he had arrived back at the
hostel late the previous night. The man’s key worker told my
investigators that it was important for him to complete the man’s
induction, and intended to try to do so when they met later in the day.
55. The man returned to the hostel at 5.20pm, and his key worker introduced
himself and explained his role as a key worker. He said the man’s mood
was agitated and he was annoyed about being at the hostel. He was
impatient, hard to communicate with and wanted to go out as soon as he
could. The man told his key worker that he had a friend waiting outside
to give him a lift and would not be able to complete his induction. He
then left the premises again and his key worker said that he passed the
task onto the night duty staff. My investigators found no evidence to
suggest the induction was ever completed.
56. Later that evening another member of the night supervisor’s team was
on duty. He already knew the man from their local area. At around
12.25am, during a routine hostel check, he saw the man and another
resident in the pool room. There were no problems with the man and he
made no entries in the log.
57. At around 10.00am on Sunday 31 December, the man carried out the
cleaning tasks assigned to him as part of a resident’s responsibilities,
and did so without any fuss. One of the hostel weekend supervisors said
the man was in a good mood, socialising with other residents and
showing them pictures of his family. Afterwards, he left the hostel to go
out, saying he would be back at tea time and would complete his
induction then.
58. The man returned later at around 6.30pm and spoke to staff to request a
room change because his room mate snored. He was told that he would
need to speak to the deputy manager when she returned from leave on 2
January. He also said he would continue his induction in about ten
minutes time. However, the man did not go back to the office for over an
hour until 8.05pm. Then he said that he had to go out for about ten
minutes, but would be back to finish his induction. He eventually
returned an hour and a half later.
59. During the night, the normal hostel checks were carried out and no
concerns were raised.
60. It is not known what time the man went out on Monday morning (New
Year’s Day), but he telephoned at around 4.15pm to ask if his evening
meal could be saved because he did not expect to return in time. He
was told that this was not possible. When he returned later that evening,
the man spoke to the night staff to complain of difficulty sleeping
because of his room mate’s snoring. He was allowed to sleep
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temporarily in another room, but was told he would still need to see the
deputy manager on her return to duty. No issues were reported
throughout the night.
61. Around 9.15am on Tuesday 2 January, the man was reminded to
register with the hostel local doctor. Later that morning, he attended
CPOP and was DAR screened. The test result was negative and there
was no cause for concern. The CPOP doctor told my investigators that,
although the man was usually resistant to advice, on this day they had a
reasonably good conversation. He seemed to accept the positive
reinforcement that CPOP were giving. The negative drug test showed
that he was doing well, even though he admitted that he had got drunk
the previous Saturday and snorted cocaine. He also talked about having
trouble sleeping and the doctor explained that cocaine use could cause
sleeping problems. He agreed to provide sleeping medication for the
man for Tuesday and Wednesday night.
62. The doctor also discussed the pressures of being released, and offered
reassurance as the man said he did not feel fantastic about it. The
doctor talked about prescribing Naltraxone to help with his rehabilitation.
(Naltraxone is an opiate blocker, used for drug users to decrease the
temptation to use drugs.) The man did not agree to the suggestion but
did not dismiss the treatment for the future.
63. The man returned to the hostel around 5.20pm, and met his key worker.
He said the man appeared to be under the influence of substances and
was unsteady on his feet. When he sat down to eat his dinner, his face
kept falling into his food. The key worker asked the man if he was okay
and whether he had taken any drugs. The man denied taking any
substances and said he was just tired. He could not hold a conversation
for any length of time. He said three times that he had had a drink, but
later denied it. Throughout the short conversation, the man’s face
continued to fall into his food and so his key worker told him to get some
rest. His key worker noted the log book accordingly, saying that the
man’s behaviour should be monitored for alcohol and drug taking.
64. The deputy manager saw the man for the first time that evening at
around 5.30pm. He was in the dining room and she introduced herself to
him. She said he looked quite drowsy and she believed he was under
the influence of a substance. The man said that he had not taken drugs
and he only had a few drinks. The deputy manager left the hostel for the
day shortly afterwards. A second PSO member of staff, also saw the
man and he too believed he was under the influence of a substance.
The PSO noted in the house log book that he should have a drug test the
following day.
65. Despite agreeing with his key worker that he needed to rest, the man left
the hostel with two other residents after eating his tea. They all arrived
back at 6.45pm, but within five minutes the man went out again . When
he returned later that night, staff noticed that he again appeared under
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the influence of substances. His eyes were red and he was falling
asleep. He managed to tell staff that he had lost his bike and a giro.
66. At 12.20am, the man came down to the office and reported that he had
lost his mobile phone in the hostel. Around 20 minutes later, staff logged
that he appeared to have sobered up a little and now said that he had
found his phone. Staff reported no concerns for the remainder of the
night.
67. The following morning (Wednesday, 3 January), the man attended
CPOP for a scheduled appointment. He met the counsellor, as well as
both his CPOP probation officers, for a motivational class aimed to help
him comply with his licence conditions.
68. On the morning of Thursday 4 January, the man’s key worker returned to
work after being off duty over the weekend and Bank Holiday. As he did
not see the man in the hostel, he left a note for him arranging a key work
meeting for the following day.
69. Later that afternoon around 2.00pm, the man attended another
scheduled appointment at CPOP with the nurse. She told my
investigators that he was under the influence of alcohol. He was not
drunk but his speech was slurred at times. Despite this, he presented
himself appropriately and he communicated well during the session. The
man said he needed to drink because he could not relax at the hostel,
was not sleeping well, did not like sharing a room and just did not like
being there. The nurse said she believed he had mentioned this to staff.
The man said he was looking for alternative accommodation and had
been to the Housing Office to collect some forms.
70. The man’s appointment with the nurse lasted around thirty minutes. He
understood the purpose of the CPOP programme, and how it could help
and support him. The nurse felt that he did not fully appreciate how his
presentation could have an effect. For example, he did not see any
problem about smelling of alcohol and did not consider that he had an
alcohol problem. He admitted he had taken a small amount of cocaine
and heroin on New Year’s Eve but said he had not taken any since. The
nurse told us that he was undecided about treatment options, and made
no commitment. His main concern seemed to be that, if he had an
alternative place to live, everything would be fine and he raised no other
concerns with her.
71. The man returned to the hostel around 8.45pm. The second night
supervisor told the investigators that, when the man collected his key, he
appeared to be under the influence of some substance but did not smell
of alcohol. He described him as just about able to stand up and keep his
eyes open. The man did not appear to be in any distress or in need of
any urgent medical attention. The night supervisor confronted the man
about his behaviour and said it would be recorded. Whilst doing this, he
16
handed him the note telling him about his key work meeting with his key
worker the next day.
72. On Friday 5 January, the man was again reminded by staff that he had a
key work meeting at 5.00pm. He also met the deputy manager for a
general chat about his welfare. The man said he was not taking drugs,
but had been taking unprescribed diazepam he had bought off the
streets. He said he had been drinking and was struggling to deal with
some problems, but had discussed them with CPOP.
73. The deputy manager told the investigators that the man was aware of the
risks from reduced drug tolerance levels and he had said he was
determined not to relapse. They discussed his resettlement plans and
he said he was settling in to life at the hostel. He said that he now had a
girlfriend. She was quite different to previous friends in his life, and he
wanted to spend more time with her. He requested an overnight pass
but the deputy manager said that this was not possible as overnight
passes were only given in exceptional circumstances.
74. The man later arrived at CPOP. He was DAR screened and again
produced a negative test result. Later that afternoon, he failed to turn up
to his key work meeting with his key worker and had not arrived back at
the hostel by 8.30pm. His key worker told the investigators that he was
now aware of all the entries in the contact log and on CRAMS about the
man’s behaviour, and it was important that he spoke with him as soon as
possible. He said that failure to attend key work meetings could warrant
a warning, but he thought it should be given by his probation officer as it
would carry more authority than if given by hostel staff. As the approved
premises had a good working relationship with CPOP, this information
was passed on to them as well as to the hostel deputy manager.
75. The weekend supervisor began her weekend shift at around 8.00am on
Saturday 6 January and spoke with the man soon afterwards. It was a
week since she had last seen him. She described him as a totally
different person from what she remembered. At her first encounter, he
had been bright and outgoing. In contrast, he was now sleepy,
incoherent, and appeared to be under the influence of substances as he
could hardly keep his eyes open.
76. During their conversation, the man spoke to the weekend supervisor
about his need for an overnight pass in a couple of weeks because he
had a girlfriend and wanted to spend time with her. The weekend
supervisor said that he would need to speak to his key worker about it.
The man also asked for a travel warrant to allow him to visit his girlfriend
the following day (Sunday) and was advised to speak to the deputy
manager.
77. The man left the hostel for the day, returning at 6.05pm accompanied by
someone known to the weekend supervisor as a heroin user. A second
weekend supervisor, who was on duty, came out of the office and asked
17
the man’s companion to wait outside for him. The man briefly came
inside and they left together five minutes later. He returned just before
the hostel curfew time of 11.00pm, a long time after the first weekend
supervisor’s duty ended at 8.00pm.
78. At 12.05am, night staff saw the man in the pool room and noted in the
log book that he again was under the influence of some substance but
did not smell of alcohol. There is no evidence to suggest that he was
checked in his room by staff overnight.
79. The following morning, the weekend supervisor came on duty at 8.00am.
Around 8.50am, it was clear that the man’s behaviour was causing
concern. He was able to carry out his cleaning job, but could not keep
his eyes open. The weekend supervisor did not challenge him about his
behaviour, as again he was eager to leave the premises. He said he had
got some money from his father and intended to use it to travel to see his
girlfriend.
80. Later that afternoon, the man telephoned the hostel requesting
permission to extend the hostel curfew time of 11.00pm. He was told
that this was not possible and it would be considered as a breach of the
hostel curfew times if he did not return. He arrived back around 10.30pm
and asked if there were any hostels in the Worcestershire area as he
wanted to be near his girlfriend. Again staff noted in the log that the man
had returned appearing to be under the influence of a substance.
81. On Monday 8 January, the man attended another scheduled meeting at
CPOP and met the doctor at around 11.45am. A urine test was
conducted and he tested positive for opiates, benzodiazepine and
cocaine. Initially, he denied taking drugs but, after speaking with his third
probation officer, he admitted taking drugs the previous day. He also
admitted to drinking a couple of cans of alcohol that morning. The doctor
assessed that he was under the influence of a substance. The
appointment was terminated and another offered the following day. Staff
at the approved premises were told that the man admitted taking heroin
and a key work meeting was arranged for 11.00am on Wednesday 10
January.
82. During the doctor’s conversation with the man, the doctor was concerned
because he [the man] said he intended to register with another doctor in
the area because he wanted more medication. The doctor explained
that he was reluctant to prescribe any medication in addition to the
sleeping tablets because he admitted taking unprescribed drugs. The
doctor was concerned that more medication, mixed with unknown illegal
drugs, could be dangerous. He said he was so concerned that he faxed
a letter to the local doctor explaining that the man was under the
supervision of CPOP. He also included the man’s screening results so
they were aware of his present condition.
18
83. The man returned to the approved premises later that night at 10.48pm.
The night supervisors recorded on CRAMS that he was again heavily
under the influence of a substance. When he was at the office no
alcohol could be smelt, but whilst talking he seemed to fall asleep.
Around 12.30am, the man appeared downstairs wearing only his
underwear. He was advised by the night staff not to walk about partially
dressed and returned to his room.
84. On the morning of Tuesday 9 January, the man’s key worker reminded
him that he had appointments with CPOP and the key work meeting the
following day. He also advised the man to contact the Department of
Work and Pensions regarding his community care grant and he was
allowed to use the office telephone to do so. The man went out at
around 9.50am. His key worker contacted CPOP later to provide an
update, and was told that the man had not yet turned up for his
appointment.
85. The man failed to attend the appointment with CPOP. He eventually
arrived at 12.55pm, so missing his DAR testing. The third probation
officer said that the man made a couple of confused telephone calls to
CPOP that morning enquiring about the time of his appointment, but
gave no reasonable explanation for why he was late. He appeared to be
under the influence of a substance and the probation officer assessed he
would not be fit to see the doctor. As all DAR tests are at a specific time,
he was given an official warning for missing it.
86. Later that afternoon, the deputy manager contacted the man’s second
probation officer to discuss the concerns about the man’s substance
misuse. They agreed that his behaviour warranted a verbal warning. As
CPOP were unable to work with him that day, they agreed that he would
be seen the following morning when the verbal warning would be given.
The warning would also say that, if the man did not engage with the
support and treatment offered, his bed would be withdrawn at the
approved premises and he would be recalled to prison.
87. Later that night, the man returned to the approved premises at about
10.45pm when the two night supervisors were on night duty. As usual,
he came to the office to collect his key. They noticed once more that he
seemed to be under the influence of some substance but did not smell of
alcohol. The second night supervisor raised the subject with the man
and reminded him of the hostel rules. The man and another resident
waited downstairs for a while then made their way to their rooms
upstairs. Later, the same night supervisor saw on the CCTV that the
man had taken a carton of milk from the residents’ kitchen. As the milk
was for all residents to use throughout the night, he went to retrieve it.
The man handed over the milk and said goodnight to the night supervisor
as he left the room.
88. Approximately an hour later, the man returned to the office and the night
staff reminded him of his appointments for the following day. They
19
described him however as looking worse than he had done an hour
earlier. There were black marks around his nose which the second night
supervisor brought to his attention. He wiped them away before leaving
the office.
89. The next morning (Wednesday, 10 January), the man’s key worker and
the night supervisor both reminded him several times about his
appointments for the day. He was due to see the deputy manager at
8.30am, had a key work meeting at 9.00am, and an appointment with
CPOP at 3.00pm.
90. The man went to the appointment with the deputy manager. She told my
investigators he seemed very distracted. He told her this was because
his girlfriend was waiting for him outside. He confirmed that he was
aware of all his appointments for the day. The deputy manager gave
permission to reschedule the appointment with his key worker to the
following day at 9.00am.
91. During the meeting, the deputy manager discussed the man’s behaviour
and the observations that he had been under the influence of
substances. He denied this saying it had been alcohol, despite the
deputy manager saying that staff smelt no alcohol. She told him there
was evidence that he had been smoking substances in the hostel, and
raised the blackness around his nose seen by night staff. He denied
smoking drugs in the hostel, but admitted he had had a relapse while
saying he did not think that drug misuse was a problem for him. The
deputy manager emphasised that, until the man was in treatment, they
could not address any other issues, and she talked about the importance
of him attending the CPOP meeting later that day without being under
the influence of any substances. He was given a verbal warning
regarding drug misuse during curfew hours on 9 January.
92. The deputy manager told the investigators that the man fully understood
he would be asked to leave the hostel if there was a further breach of
hostel rules. Shortly afterwards, she had a long telephone conversation
with the second probation officer. They came to the conclusion that the
man would be allowed one more night to prove himself but, should his
behaviour again fall short of what was expected, his bed would be
withdrawn. The probation officer said that when the man arrived at
CPOP later that day, they would try to complete some motivational work
with him.
93. The man arrived on time for his appointment with CPOP and was not
evidently drunk or drugged. He completed his session with the
counsellors but his engagement with the therapist was limited. He was
apparently distracted by thoughts of wanting to transfer from the
approved premises to Worcester to be near his girlfriend.
94. The man went back to the hostel at around 10.45pm and staff there felt
he appeared vague. He collected his giro cheque of £109 but staff
20
decided not to give him the letter from the deputy manager (which
confirmed the verbal warning), determining to hand it over in the
morning.
95. At 7.25am the next morning (Thursday, 11 January), the man’s key
worker reminded him that he had a key work meeting at 9.00am and
handed him the letter from the deputy manager. The man went out an
hour later at 8.25am. The deputy manager told staff that she intended to
contact the second probation officer to update him on the man’s recent
behaviour and drug taking.
96. The second PSO member of staff whilst on his way into town at about
8.50am saw the man banging on the door of the Post Office. The PSO
recorded in the log book that the man had not recognised him at first
when he greeted him. The PSO confronted him about his behaviour and
the man then said he thought he looked familiar. The man failed to
return to the hostel for his key work meeting at 9.00am.
97. The deputy manager reviewed all the information about the man’s
behaviour and her concerns grew. He had returned to the hostel on a
number of occasions under the influence of substances, and was
believed to have used drugs on the premises. She spoke with the
second probation officer again about the man continually breaking hostel
and licence rules. They decided that his bed should be withdrawn and
he should be recalled to prison. The probation officer discussed the plan
with the medical staff at CPOP. They were to work as normal and not be
influenced by the recall decision as the process could be lengthy. He
then started to process the man’s recall by preparing and sending the
required documentation to the Home Office section that deals with recall.
98. The man went early to his scheduled appointment with the CPOP nurse.
Again, he appeared to be under the influence but did not smell of
alcohol. He denied taking drugs or alcohol that day, but admitted taking
a small amount of heroin every couple of days. The nurse had a good
conversation with him and they again discussed a detoxification
programme. The man was not very receptive to the idea and denied
daily usage of drugs. He mentioned he had a girlfriend with no offending
or drug use history, and said he was going to ask his father for money to
rent a flat. The nurse said the man was fixed on finding somewhere to
live, and did not understand that he had to reside at the approved
premises as a condition of his licence.
99. The nurse conducted an Altrix test on the man (Altrix is a mouth swab
and is carried out by taking the tissue from the inside of the mouth and
testing it for drugs). The specimen was sent for testing and returned
after the man’s death showing a positive result for cocaine. The nurse
made another appointment to see him on Saturday 13 January and
asked him to attend without being under the influence of drugs or
alcohol. At the end of the appointment, the man said that he might go on
to the programme that the nurse had discussed with him.
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100. The man’s emergency recall was approved around 4.00pm and the
approved premises staff and the police were informed. Staff collected
his personal belongings from his room. On the man’s return to the
hostel, staff would be required to contact the police who would
immediately collect him and return him to prison.
101. The man had failed to return by the curfew time of 11.00pm, and night
staff informed the deputy manager and the police that he was absent.
The following morning, the police contacted the approved premises to
report that the man had been found the previous night in a property in
Stafford. He had apparently overdosed. The police asked for the man’s
next of kin details so they could inform them that morning.
After notification of the man’s death
102. The deputy manager followed the contingency plans in respect of a
death of a resident at an Approved Premises, and informed the residents
and all the necessary agencies including CPOP. Later that afternoon,
the man’s father contacted the hostel and visited later that day to collect
his son’s belongings. Staff passed on their verbal condolences to the
man’s family. Staff on duty at the time were informed and CRAMS was
updated.
103. The man’s third probation officer expressed his sadness at the man’s
death. He told my investigators that the man had been offered intensive
support from the hostel and CPOP. They had liaised and used
information about his behaviour to try and engage with him and offer
medical interventions to help reduce the risk of returning to drugs.
Although it was recorded that the man presented early signs of drug use,
CPOP gave him the opportunity to try to conform to the conditions of his
licence. Unfortunately, the man continued to take drugs.
104. The deputy manager said that a staff briefing meeting did not take place
and instead, she and the hostel manager spoke with staff individually as
soon as they could. This took a period of time to complete because of
the differing shift and annual leave patterns to which staff worked.
105. Support was offered to staff by the hostel manager and deputy manager
and they were encouraged to talk about any issues. The Chief Officer
and Area Probation Manager also visited to speak with staff. A note was
left in the log book for all staff who were not on duty at the time to see
when they returned to duty.
106. Around two weeks later, at the monthly staff meeting, the man’s death
was one of the issues discussed. The hostel manager also attended
and, together with the deputy manager, answered any queries from staff.
The deputy manager said that it was difficult to have all staff at meetings,
and some staff did not attend.
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Post Mortem
107. The post mortem report concludes that the cause of the man’s death was
a mixed drug overdose.
23
ISSUES RAISED IN THE INVESTIGATION
The man’s behaviour
108. The approved premises staff were fully aware of the man’s licence
conditions, primarily abstention from drugs. However, from soon after
his arrival at the hostel the behaviour he displayed was not what was
required of him. He was initially very hyperactive, and rarely spent any
time at the premises - so much so that it was impossible to conduct a
thorough induction. He therefore almost immediately fell foul of the
hostel rule of having a proper induction.
Induction into an approved premises is a fundamental part of a
resident’s resettlement. Staff at the approved premises should
ensure that it is delivered in a timely and effective manner and
certainly within 24 hours of arriving.
109. Staff did not confirm with the prison whether the man was prescribed any
medication on release. My investigators confirmed that he was not on
any medication but, given his licence conditions, this is important
information that should have been confirmed.
Prior to a resident’s arrival at the hostel, staff should contact prison
healthcare to establish whether they will be released with any
medication.
Breach of hostel rules
110. On the man’s third day as a resident at the approved premises, he
appeared to be under the influence of substances. He was observed on
no fewer than eight occasions as being under the influence at the hostel
and at his CPOP appointments. It was only on the eighth occasion that
he was warned about the consequences.
111. The man also missed a number of important key worker appointments
even though he was being given reminders by staff. In spite of his
behaviour, staff at the hostel and CPOP continued to try to engage with
him to encourage him to adhere to his licence conditions and address his
substance misuse. They had very limited effect.
112. There were a number of occasions that the man broke hostel rules by his
behaviour and was not challenged by staff (although it was recorded in
CRAMS and the house log book). I do not criticise staff for not taking
immediate action as they have to decide how effective any intervention
will be, and whether there are any personal safety risks involved.
However, if a resident breaks hostel or licence rules, staff are permitted
to issue cautions which must be recorded. None was given to the man
by the day shift PSOs, or by night, evening or weekend staff, at the time
or after they witnessed any breach of hostel rules. When he eventually
received a warning, it was in the latter stages of his stay at the hostel
24
and the warning was given by the deputy manager. At this late stage, it
appears to have been non-productive.
113. For whatever reason, the staff interviewed for the investigation were
reluctant to give verbal or written warnings. I believe that such
responsibilities are a fundamental part of their role and the running of an
effective hostel.
114. I do not know whether the man would have acted differently if he had
been warned about his behaviour at an earlier stage. However, delaying
the warnings increased the risk to him and to others.
The management of the approved premises should remind staff of
the enforcement procedures to be used for residents who breach
hostel rules, and provide the necessary training.
115. Despite the known health risks associated with being under the influence
of drugs, there was no evidence to suggest that the man was checked
during the night, given that he was observed as appearing under the
influence of substances on several evenings in the hostel. I am not sure
of the practicalities of conducting night time room checks, but believe it to
be a good health and safety practice for an individual who may pose a
health risk.
The management of the approved premises should review the
health and safety checks procedure during the night period for
residents who are suspected of breaching hostel rules in regard to
alcohol and drugs.
Room Searches
116. No room searches were carried out during the man’s entire stay. This
was despite suspicions of him taking drugs both in and outside of the
premises. My investigators found that little use was made of random
room searches. Staff entered residents’ rooms during the day mainly for
health and safety purposes.
117. The use of random room searches would improve the security within the
hostel, as well as discouraging residents from breaking hostel rules.
118. I am also aware that other approved premises routinely conducting bag
searches when residents return to their premises. I do not know how
feasible this would be for this approved premises to implement, but it
might have helped reduce the type of behaviour displayed by the man.
The management of the approved premises should review its room
search policy to include the use of random searches. Staff should
be encouraged to take a more robust approach should they have
suspicions of a resident taking illicit substances.
25
Management of the approved premises
119. The manager at the approved premises has two other roles in
Staffordshire Probation Area. But the position was in fact vacant for
some time before the current incumbent took up the role. My
investigators judged the deputy manger to be competent in her role as
deputy manager. However, the demands of her role mean that she also
often attends meetings off site. I believe consideration should be given
to making the job of manager a full time position.
The Staffordshire Probation Area should consider making the
manager’s post at the approved premises a full-time position.
Policy for dealing with deaths
120. Although hostel staff were aware of the Probation Circular on Deaths in
Approved Premises, the approved premises had no local procedures to
deal with a death of a resident occurring outside the premises. In this
particular circumstance, a briefing meeting should have been held
immediately after staff learnt of the man’s death so they had the
opportunity to review any emerging issues. In addition, a letter of
condolence should have been sent to the man’s family.
Management at the approved premises should consider introducing
a local policy relating to the deaths of residents.
Chase Prolific Offender Programme
121. My investigators were impressed at the work and commitment of the
CPOP staff in dealing with prolific offenders, especially the medical team.
There was a good relationship with the hostel and residents were
monitored well.
26
CONCLUSION
122. There is no doubt that the man was offered considerable support prior to
leaving prison, and upon release, to help him tackle his misuse of drugs.
He had regular interaction with staff at both the hostel and CPOP, and
was well aware that taking illegal substances would breach his licence
conditions. Unfortunately, he appears to have returned very quickly to
his old way of life and was not ready to accept any of the interventions.
123. Staff became concerned about him very soon after he came to live at the
hostel. The man was questioned about his behaviour on many
occasions, but he was not warned about breaking hostel rules. Had his
apparent drug taking been tackled more robustly, it is possible that his
death would not have occurred as it did.
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RECOMMENDATIONS
1. Induction into an approved premises is a fundamental part of a
resident’s resettlement. Staff at the approved premises should
ensure that it is delivered in a timely and effective manner and
certainly within 24 hours of arriving.
2. Prior to a resident’s arrival at the hostel, staff should contact prison
healthcare to establish whether they will be released with any
medication.
3. The management of the approved premises should remind staff of
the enforcement procedures to be used for residents who breach
hostel rules, and provide the necessary training.
4. The management of the approved premises should review the
health and safety checks procedure during the night period for
residents who are suspected of breaching hostel rules in regard to
alcohol and drugs.
5. The management of the approved premises should review its room
search policy to include the use of random searches. Staff should
be encouraged to take a more robust approach should they have
suspicions of a resident taking illicit substances.
6. The Staffordshire Probation Area should consider making the
manager’s post at the approved premises a full-time position.
7. Management at the approved premises should consider introducing
a local policy relating to the deaths of residents.
28