Individual at Wilton Place

Investigation into the circumstances surrounding the
death of a resident at an Approved Premises in the Greater
Manchester Probation Area in November 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
July 2007
This is a report into the death of a resident at an Approved Premises in the Greater
Manchester Probation Area in November 2006. The man was 71 years old. He
appears to have died from natural causes.
The man had been found in his bedroom during the morning curfew check. He was
assessed by the member of staff who found him as being beyond resuscitation. An
ambulance was called to the hostel and arrived within minutes. The paramedics
confirmed that he could not be revived.
The man who died had lived at the hostel since 19 October 2005 as a condition of
his release from custody. He suffered from a number of chronic health problems,
and over the course of 12 months, was admitted to hospital on no fewer than seven
occasions. Concerted efforts were made by both the manager of the hostel and his
supervising probation officer to arrange more suitable accommodation.
Unfortunately, these efforts proved unsuccessful and he died a week after being
discharged from hospital for the last time.
This investigation has been undertaken by one of my investigators. I would like to
thank the Senior Probation Officer in charge of the hostel and her staff for their co-
operation and active participation. Oldham Primary Care Trust (PCT) carried out a
clinical review into the man’s care and I thank the clinical reviewer for his
comprehensive account.
One of my Family Liaison Officers contacted the man’s wife to inform her of my
investigation and to offer her the opportunity to raise any concerns. I add my
condolences to those already expressed by my Family Liaison Officer, and hope this
report answers any questions the family may have about the circumstances
surrounding the man’s death.
I make two recommendations in this report. One relates to how hostel staff should
be consulted by medical staff when decisions to discharge residents from hospital
are taken. The other challenges the National Offender Management Service
(NOMS) to consider how it can better meet the needs of an increasingly frail hostel
population. The clinical review has made five further recommendations, which I
endorse.
In my view, the man’s medical and social care needs could not be fully met at the
hostel. Approved Premises have a very specific function, namely to protect the
public through monitoring of residents’ behaviour. They are not set up to deal with
people struggling with chronic ill health. Yet if the current trend for longer prison
sentences continues, there will be many more elderly former prisoners like the man
who is the subject of this report housed in Approved Premises and presenting with
complex health needs. The implications of this are far-reaching, and extend far
beyond those hostels making up the Approved Premises estate.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2007
2
CONTENTS
Summary 4
The Investigation Process 5
The Approved Premises 6
Key Findings 8
Issues 15
Recommendations 20
3
SUMMARY
The man who died appeared at Manchester Crown Court in April 2003 and was
sentenced to five years’ imprisonment for a number of serious offences. The Court
of Appeal subsequently reduced his sentence to four years. He was released on
licence from HMP Risley on 19 October 2005, when he became a resident at the
hostel in the Greater Manchester Probation Area.
The following day, he was admitted to hospital after becoming short of breath whilst
on a social outing with his wife. He was kept in overnight and was discharged back
to the hostel on 21 October.
On 20 March 2006, the man was found collapsed in his room suffering from chest
pains and breathlessness. An ambulance was called and he was taken to hospital
where he was diagnosed as having suffered a stroke. He was discharged to the
hostel the next day. Three days after being discharged, he suffered a heart attack
and was again taken to hospital. He was admitted and remained an inpatient for a
week before being discharged.
During the early hours of 2 April, the man was found on the floor of his room by
hostel staff. The emergency services were called and he was admitted to hospital
where he remained for two days.
Less than two weeks later, he was admitted again to the Royal Oldham Hospital
after suffering kidney failure. On this occasion, he was admitted for over a month,
during which time he was assessed by medical and social care professionals. He
was deemed to be fit to live independently and was discharged to the Approved
Premises on 19 May.
On 5 July, the man was admitted to hospital once more, this time after suffering a
coughing fit. He stayed there for five days before being discharged to the hostel, five
days later. The next day, he was observed clutching at his chest and struggling for
breath. An ambulance was called and he was taken to hospital where it was
diagnosed that he was suffering from anaemia. He remained at the hospital until 18
July.
On 19 October, the man who is the subject of this report was taken to the Royal
Oldham Hospital after vomiting and feeling dizzy and breathless. He was admitted
as an inpatient and stayed at the hospital until 26 October.
At 5.00am on 3 November, hostel staff heard the man coughing in his bedroom.
They asked if he was ‘alright’ and he said that he was. At 7.55am, he did not
respond to the daily wake up call. Staff found him lying sideways across his bed with
the TV remote control in his hand. His eyes were wide open and he was
unresponsive to verbal stimuli. The staff believed he was dead because blood had
started to pool in the pressure points under his skin. They therefore did not
commence emergency life support. An ambulance was called and the paramedics
confirmed that the man had died.
4
THE INVESTIGATION PROCESS
1. My investigator considered the man’s probation records, including those held by
the hostel, before formally opening the investigation on 29 January 2007.
2. Prior to my investigator arriving at the Approved Premises, notices were issued
to staff and residents announcing the investigation and inviting anyone who had
information relevant to the man’s death to make themself known to the
investigator. Nobody came forward, although six members of staff, including the
man’s supervising probation officer, were interviewed by prior arrangement.
3. One of my Family Liaison Officers contacted the man’s wife to offer her the
opportunity to participate in the investigation process. She expressed concern
that her husband had been allocated to a bedroom unsuited to his needs
following a lengthy hospital admission in April and May 2006. She wanted to
know why her husband was told he would only be at the hostel for four months
when in fact he stayed there for more than a year. She also expressed concerns
about whether the hostel was able to meet the man’s health needs – she thought
he should have been moved elsewhere. Finally, she was unhappy that she only
learned of the man’s death when she arrived at the hostel three hours after he
had been found. I hope this report addresses these concerns and answers any
other questions she or any other family members may have about the
circumstances surrounding the man’s death.
4. Having spoken to hostel staff and considered the hostel and probation records,
my investigator became concerned about how the man’s health was managed.
It is unusual for my investigators to ask for clinical review when a resident dies in
Approved Premises. However, my investigator was sufficiently concerned about
the circumstances of the man’s death that he asked Oldham PCT to look into the
care he was given. I am most grateful to the PCT for agreeing to undertake a
review. It has proved to be invaluable to the investigation.
5. My investigator also contacted Her Majesty’s Coroner to inform him of the nature
and scope of the 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.
5
THE APPROVED PREMISES
9. The Secretary of State approves Approved Premises (formerly known as
probation and bail hostels) within section 9 of the Criminal Justice and Court
Services Act 2000. Their purpose is to provide an enhanced level of residential
supervision in the community, as well as a supportive and structured
environment. They operate on each day of the year with 24-hour staff cover.
10. The Approved Premises where the man died is a 27-bed hostel for men, located
in north Manchester. It is the only one of the seven Approved Premises in the
Greater Manchester Probation Area that has disabled access. It is managed by
a Senior Probation Officer who has overall responsibility for the running of the
hostel. There is also a deputy manager who is responsible for the day-to-day
management of residents and for making decisions about enforcement. The
‘frontline’ team is made up of ten permanent members of staff, comprising four
residential service officers, five residential service workers and an administrator.
The services of relief staff are also drawn upon to cover staff sickness, training
and annual leave. Staff are trained in risk management and emergency first aid,
but are not trained to do nursing tasks.
11. The hostel has an admissions policy based on assessment of risk. In recent
years, the resident profile has changed significantly with prolific lower risk
offenders being superseded by individuals convicted of more serious violent or
dangerous offences. The hostel now takes fewer people coming straight from
court, and the majority of residents are required to stay at the Approved
Premises as a condition of a court order or prison licence.
12. Each resident is allocated to a keyworker soon after his or her arrival, and this
member of staff acts as their primary point of contact for sorting out practical
issues. Regular keywork sessions give residents the opportunity to discuss their
difficulties in depth. Although these sessions are not governed by a set agenda,
issues such as benefits, health and move-on accommodation are routinely
discussed. The man had two keyworkers over the course of his stay at the
hostel.
13. The hostel has close links with local health services, and all residents are
registered with a General Practitioner who is located two doors away. A service
level agreement between the hostel and surgery ensures that residents have
open access to medical services every morning. Prescribed medications are
stored in a locked cupboard to which only staff have access. There are set
medication times throughout the day and the onus is on residents to present
themselves to the staff at the right times.
14. Residents are required to pay rent and abide by the rules and regulations of the
hostel, including observing a strict overnight curfew between 11.00pm and
6.00am. When residents are subject to statutory supervision, pertinent
information is shared regularly with field probation officers who act as case
managers.
6
Release on Licence
15. All prisoners sentenced to more than 12 months imprisonment are released on
licence, which means they are supervised by the Probation Service until the
licence expiry date. In general terms, the expiry date falls threequarters of the
way through a released prisoner’s sentence. There are standard conditions for
all licences, which include:
• keeping in touch with the probation officer in accordance with any instructions
that may be given
• residing at an address approved by the supervising officer
• only undertaking approved work
• not travelling outside the United Kingdom
• being well behaved, not committing any offence and not doing anything that
could undermine the purposes of supervision, which are to protect the public,
prevent re-offending and help successful resettlement into the community.
Further conditions can be added by the Secretary of State if they are deemed
necessary to manage a person’s risk.
Multi-Agency Public Protection Arrangements (MAPPA)
16. The MAPPA is a formal partnership between police, probation, prisons and other
statutory and non-statutory agencies that assesses and manages offenders in
order to minimise the risk of serious harm they may pose to the public. There
are four core functions:
• identification of offenders with the potential to commit serious violent and sexual
offences
• sharing relevant information between agencies
• assessing the risk of serious harm
• managing that risk.
Offenders who come within the MAPPA remit are classified according to the
nature of the risk and its management. The higher the risk, the higher the level
at which they are managed. Level one offenders are managed by one agency,
usually the police or probation service. Level two offenders are managed jointly
by all the MAPPA agencies, and level three offenders are managed by the Multi-
Agency Public Protection Panel (MAPPP) made up of senior managers from the
MAPPA agencies.
7
KEY FINDINGS
17. The man who is the subject of this report was sentenced to five years
imprisonment by Manchester Crown Court in April 2003 for a number of serious
offences. He lodged an appeal and his sentence was subsequently reduced to
four years in October 2003. He spent the majority of his time in custody at HMP
Risley, where he had a lot of contact with healthcare as a result of his complex
health needs. His diabetes was monitored as an on-going concern and he was
also treated for chest pains and breathlessness.
18. On 26 July 2005, the man’s case manager submitted a referral to Greater
Manchester Probation Area’s Approved Premises Central Admissions
Department. The referral form consists of 17 sections which need to be
completed with relevant information about potential hostel residents. Section 11,
headed Health and Special Needs, states that potential residents must be fit to
function at a probation hostel. It qualifies this by saying that they need to be
mobile and able to care for themself. It further says that they must not to be in
need of nursing care. In section 11, the case manager has written that the man
had a ‘previous heart bypass operation’ and currently suffered from ‘kidney
problems linked to heart and artery problems’. It was also noted that the man
‘has previously resided in a hostel before following release from custody’.
19. According to the documentation, the man’s referral was received at the
Approved Premises Central Admissions Department on 3 August. He was
provisionally accepted for a place at the Approved Premises on 7 October, and a
bed was made available for him for 19 October onwards.
20. Due to the nature of his offences, the man’s case was managed in accordance
with the local Multi-Agency Public Protection Arrangements (MAPPA). One of
the conditions inserted into his licence under the direction of the MAPPA was
that he reside at an Approved Premise upon his release. The others were:
• To not seek to approach or communicate with the victims.
• To not enter a specified area in Manchester.
These conditions were enforceable for the duration of the man’s licence, from
the day of his release until 18 February 2007.
21. On 19 October, the man was released from Risley. He was met at the prison by
his wife and his supervising probation officer. The supervising officer told my
investigator that the man was released with a significant amount of prescribed
medication by the prison. The supervising officer drove the man and his wife to
the Approved Premises and remained at the hostel until the man had been
shown round and formally inducted. The induction was completed by a member
of hostel staff. Due to his health needs, the man was allocated to a disabled
room on the ground floor. All of his prescribed medication was taken from him
and locked in the medication cabinet, with the exception of his insulin.
22. The following day, the man who later died left the hostel accompanied by his
wife. During the outing, he became short of breath and was taken to the
8
Accident and Emergency Department of Oldham General Hospital. He was
admitted as an in-patient and kept in overnight. The hospital established that the
exercise had aggravated the man’s angina. He was discharged from the
hospital and returned to the hostel later in the day.
23. On 30 December, the man attended an outpatient appointment at Manchester
Royal Infirmary to undergo a heart scan. He also saw a vascular surgeon, as it
was known that he suffered from ischaemia (reduced blood supply to the heart).
A follow-up appointment with the surgeon took place on 31 January 2006 when it
was decided that he needed to be admitted to hospital for surgery.
24. During the course of his keywork session on 20 February, the man said that his
poor health continued to pose problems. He disclosed that he was awaiting an
appointment for a cataract operation, but had been told that this could only be
arranged after a vascular operation had taken place. He told his keyworker that
the vascular operation was necessary to relieve the pressure in his arteries.
25. On 13 March, the man was admitted to Manchester Royal Infirmary to undergo
vascular surgery. The operation would appear to have been a success and he
was discharged from hospital on 17 March. Upon his return to the hostel around
2.30pm, he told a member of staff that he was feeling well.
26. Three days later, during the morning of 20 March, the man was found collapsed
in his room, suffering from chest pains and breathlessness. An ambulance was
called and he was taken to the Royal Oldham Hospital. The diagnosis was that
he had suffered from a mild stroke. He was discharged to the Approved
Premises the next day.
27. At around 12.30pm on 24 March, the man was again found collapsed in his
room. An ambulance was called and he was again admitted to the Royal
Oldham Hospital. On this occasion, the diagnosis was that he had suffered a
heart attack. He remained at the hospital as an inpatient until 30 March when he
once more returned to the hostel.
28. Around 4.25am on 2 April, a Residential Service Worker (RSW) heard the man
shouting “hello” from his bedroom. When the RSW entered the room he found
the man on the floor with blood coming from his mouth. The RSW examined him
and ascertained that the blood was the result of a cut tongue. The RSW told my
investigator that the man was both conscious and lucid at this point. He kept
trying to get up, but the RSW was concerned about the unintentional damage
this might cause so put him in the recovery position and told him to stay there.
However, the man started coughing so the RSW assisted by manoeuvring him
into an upright position. He then called an ambulance which arrived minutes
later. The man was removed by the paramedics and taken to the Royal Oldham
Hospital where he was once again admitted as an inpatient. On this occasion,
his collapse was attributed to dehydration caused by his diuretic medication. He
was kept at the hospital for two days before being discharged to the hostel on
the afternoon of 4 April.
9
29. The following day, 5 April, the hostel manager and the man’s supervising officer
discussed the hostel’s ability to meet his health needs. The hostel manager said
that hostel staff are not trained to deliver nursing-type care and questioned
whether the hostel was meeting its ‘duty of care’ as defined in law. The hostel
manager expressed a view that the man’s quality of life might be improved if he
was allowed to return home to live with his wife. She also said that, in her
opinion, the man’s care needs were now more important that the potential risk of
harm he posed to others.
30. As responsibility for managing the man fell to the MAPPA, the supervising
probation officer alone could not give him permission to move home. An
emergency Level Two MAPPA meeting was therefore arranged for 6 April.
According to the supervising officer’s record of the meeting, the consensus of
the MAPPA was that the option of the man returning home was not one to
consider at that time because of unresolved victim issues and media scrutiny.
Instead, the supervising officer and hostel manager were given the task of
finding the man a placement at a nursing home.
31. The man who died was again admitted as an inpatient to the Royal Oldham
Hospital on 16 April. It is not recorded in his probation records what happened
prior to his admission, although the hospital records obtained by the clinical
reviewer cite renal failure (kidney failure) as the reason.
32. Three days later, the hostel manager telephoned the hospital and explained that
the man was managed by the MAPPA and that it had given her responsibility for
finding him a placement at a nursing home. A social worker at the hospital
subsequently arranged for a needs assessment to be carried out by Manchester
Social Services. This took place on 20 April.
33. On 21 April, the man’s bed at the hostel was formally withdrawn by Greater
Manchester Probation Area. The logic behind this decision, made jointly by the
hostel manager and senior management, was that it would force either the
hospital or social services to accept responsibility for the man’s care, as the
hostel manager did not believe he could be adequately looked after by hostel
staff.
34. Later in the day, the hostel manager and the man’s supervising officer visited the
man at the Royal Oldham Hospital. During the visit, the hostel manager and
supervising officer told the man that they did not think his health needs were
being met at the Approved Premises. They encouraged him to think about living
in a residential care home where the staff would be better able to care for him.
The man disclosed that he had some fears about the standard of care he was
receiving at the hostel and, at the end of the meeting, accepted that a care home
was probably the best option. I commend the hostel manager and supervising
officer for jointly visiting the man in hospital and engaging with him in this way. It
was very good practice.
35. On 24 April, the supervising officer was telephoned by Manchester Social
Services who said that the man was ineligible for assistance because he was
living in Oldham. The supervising officer explained that he was a not a
10
permanent resident and that the man’s home address was actually in
Manchester. Contact was subsequently made with Oldham Social Services who
said that the man was not eligible to receive help from them as he was only a
temporary resident and that his permanent address was in Manchester.
36. The man’s supervising officer visited the man in hospital again on 28 April. The
supervising officer later recorded that he was up and about but not yet well
enough to be discharged. He also noted that the man appeared to have
accepted the need to go into a care home. The supervising officer visited him
again at the hospital on 5 May to see how he was doing.
37. The supervising officer received an e-mail from Manchester Social Services on 9
May. They now accepted that the man was their responsibility as his residence
in Oldham was only temporary.
38. However, on 12 May, the supervising officer was told by Manchester Social
Services that the man did not meet their criteria for assistance. The needs
assessment carried out on 20 April showed that the man needed support with
some household chores and personal care, but he did not fall into the ‘critical’ or
‘substantial’ categories of need. He was deemed to be able to climb stairs
without assistance and to bathe and dress himself unaided. The supervising
officer contacted a senior manager within Greater Manchester Probation Area
and told them that a hostel place needed to be found urgently as the hospital
was preparing to discharge the man. The supervising officer mentioned that the
disabled room at the Approved Premises was now occupied.
39. The man’s referral was accepted by the Approved Premises Central Admissions
Department on 15 May on the understanding that he would be a temporary
resident. In the absence of more suitable accommodation, he was once again
allocated to the Approved Premises he was resident in previously.
40. The man was discharged from hospital on 19 May. He arrived at the hostel
around 1.00pm, when he was reminded of the hostel rules and his licence
conditions. As the disabled room was occupied by another resident, he was
allocated to a room on the first floor. This can only be reached via the stairs. He
was moved to a room on the ground floor a few days later, but it was not one
with disabled access.
41. The next six weeks were relatively uneventful. The man saw his doctor five
times for routine appointments, and he attended an outpatient appointment with
the vascular surgeon at Manchester Royal Infirmary on 12 June. His health was
regularly discussed with his new keyworker, who recorded on more than one
occasion that he reported feeling unwell as a result of the hot weather. The
keyworker helped the man develop strategies for coping with the heat, such as
staying indoors during the hottest part of the day.
42. During the evening of 5 July, the man suffered a coughing fit. An ambulance
was called and he was taken to the Royal Oldham Hospital where he was
admitted as an inpatient. After a period of assessment, he was discharged to
the hostel on 10 July.
11
43. The following day, the man who is the subject of this report was observed
clutching at his chest and struggling for breath. An ambulance was immediately
called and he was again taken and admitted to the Royal Oldham Hospital.
Tests carried out at the hospital revealed that he suffered from anaemia (a
deficiency of red blood cells). This condition means that there is less oxygen in
the body, which in turn leads to episodes of acute breathlessness. The man was
given a blood transfusion to treat the condition.
44. During the morning of 18 July, the man was visited in hospital by the hostel
manager and a probation officer who was temporarily covering for the man’s
supervising officer. The hostel manager and the probation officer told him that
they had identified a residential home in Manchester which they thought met his
health and care needs. After being told that it was not a home for the elderly (as
he had previously thought), the man signed the documentation needed to make
a referral, although it was noted that he had reservations about leaving the
hostel. The paperwork was sent to the home later that day. The man was
discharged from the hospital around 3.00pm and arrived back at the hostel a
short time later.
45. On 3 August, the man was taken to the residential home by his keyworker. The
purpose of the visit was so that he could view the property and make an
informed decision about whether he wanted to go there or not. After being
shown round, the man said that he would be willing to move as long as his wife
was happy for him to do so.
46. A week later, on 9 August, the home wrote to the man saying that they would not
be offering him a place. The letter said that he did not want to live there and, if
he did become a resident, he would not stay there after his licence expired in
February 2007.
47. Between August and mid-October, the man’s health was relatively stable. He
saw his GP on nine occasions for scheduled appointments, and he attended four
outpatient appointments at the Royal Oldham Hospital and Manchester Diabetes
Centre respectively. On 22 September, he was taken to the Accident and
Emergency Department after suffering from severe cramps in his legs. The
problem was diagnosed as intermittent claudication, a condition common to
those who suffer from ischaemia, and he was returned to the hostel without
being admitted. Throughout this period, the man’s supervising officer and the
hostel manager continued to make efforts to find him accommodation more
suited to his needs.
48. On 11 October, the man told his keyworker he was unwell. He described feeling
dizzy, and other residents told the keyworker that they had seen him almost fall
over. The keyworker advised the man to sit down. An emergency GP
appointment was made, and the man attended with his wife. Hostel staff
subsequently received a telephone call from the doctor telling them not to issue
the man with two of his medications for the next two days as his blood pressure
was low. Hostel staff asked the doctor to send confirmation of this instruction in
writing.
12
49. At 9.20pm on 19 October, the man came to the general office and told the RSW
that he was feeling dizzy and breathless. He also disclosed that he had vomited
20 minutes previously. The RSW called an ambulance which arrived at 9.25pm.
The man was taken to the Royal Oldham Hospital and admitted as an inpatient.
50. He remained an inpatient for eight days. His ill health was attributed to anaemia
and a myocardial infarction (heart attack). The man was discharged to the
hostel on 26 October, with outpatient appointments at the hospital lined up for
the coming weeks.
51. On 31 October, the man attended Moss Side probation office for a prearranged
supervision session with his case manager. His health problems were
discussed at length and the supervising officer subsequently recorded that he
did not look like “a picture of health at all”. The man and his supervising officer
also talked about life at the hostel. The man who later died said that he felt very
settled and reported feeling happy with his situation. The supervising officer
wrote in his case records that, the man “has clearly benefited from the high
quality support and supervision the staff [at the hostel] have provided.”
52. At 9.50pm on 2 November, an RSW started her waking night shift. Shortly
afterwards, a resident approached her and told her that there was excrement on
the floor in the kitchen area. She went to room 18, the man’s bedroom, and
asked him if he had had an accident. Initially he denied it, but then admitted that
he had soiled himself. After checking that he was okay, the RSW provided the
man with some cleaning materials to clear up the mess, which he did.
53. At 11.00pm, the RSW commenced the night time curfew check. She told my
investigator that she remembered the man sitting in the conservatory area near
his bedroom and asking him if he was okay. He said he felt tired, before making
himself a hot drink and going to bed.
54. As the man was known to be vulnerable and his health problematic, he was
checked throughout the night by hostel staff. My investigator has been unable to
confirm the exact date when the hostel brought in this measure, although it is an
example of good practice. At 1.00am and 3.00am, the man was observed to be
asleep. At 5.00am, the RSW heard him coughing and asked him if he was
alright. He replied in the positive and was therefore left alone.
55. Around 7.50am, a Residential Service Officer (RSO) started her shift. At the
same time, the RSW commenced the morning wake-up call of residents. As the
man’s room was in the annex building, she did not reach it until 7.55am. She
knocked on the door and told him it was time to get up. He did not answer, so
she knocked again. There was no response, so she opened the door. Upon
entering the room, she saw the man lying flat on the bed breadthways. His feet
and hands were dangling off the side. She noticed that he had the remote
control to his TV in his right hand and his eyes were wide open, staring at the
ceiling. The RSW shouted the man’s name a couple of times, but again
received no response. She saw that the tips of his ears were red and that blood
had started to pool on the underside of his arms and bottom of his hands. From
13
experience, she knew that this signifies that a person is dead and therefore did
not check for a pulse.
56. The RSW then left the man’s room and locked the door. She went to the
general office and told her colleague that she thought the man had died. They
returned to his room together and went in. The RSO saw that the man was not
breathing and quickly returned to the office to phone for an ambulance. The
ambulance operator advised the RSO to commence Cardio Pulmonary
Resuscitation (CPR), but upon returning to the man’s room she and the RSW
agreed that to do so would be futile – more blood was pooling around the
pressure points of the back of his head, his arms and underside of his hands.
57. The ambulance arrived at the Approved Premises within five or six minutes. The
paramedics quickly established that the man was beyond resuscitation and rigor
mortis had started to set in. Emergency life support was therefore not started.
58. Over the next few hours, police officers arrived at the hostel to arrange the
removal of the man’s body. In the midst of these formalities, the RSO, the RSW
and the rest of the staff team spoke to the other residents to make sure they
were okay. Similarly, the RSO and RSW were spoken to by colleagues and
management. They both told my investigator that they felt supported.
59. Later in the morning, the man’s wife arrived at the hostel, expecting to see her
husband as usual. She was told by hostel staff that he had sadly passed away
earlier that morning. By this point, the RSO had been out to purchase some
flowers which were placed in the man’s room out of respect.
14
ISSUES
Clinical
60. The clinical review carried out by the PCT offers a detailed account of the man’s
medical history and a critical analysis of his treatment and care. It describes a
long history of vascular problems and diabetes dating back at least 15 years,
during which time he suffered a number of heart attacks. In 2006 alone, he
experienced a myocardial infarction (heart attack), was diagnosed with anaemia
and underwent surgery on his arteries. The man had a “poor medical history”.
61. At the request of my investigator, the clinical reviewer examined the nursing and
social care assessment completed by Manchester Social Services in April and
May 2006. As detailed above, this assessment concluded that the man did not
meet the criteria for residential / nursing home care. This ultimately led to him
being returned to the Approved Premises where staff felt unable to cope with his
health problems. In the clinical reviewer’s professional opinion, the assessment
carried out by Manchester Social Services is comprehensive and detailed. It
incorporates the views of the patient, family and hospital staff and also
acknowledges the concerns of hostel staff about their ability to care for the man.
The assessment clearly states that the man was able to negotiate stairs and
independently maintain his personal hygiene, whilst noting that he did not
experience problems with his bowel or bladder. The only issue raised related to
the man’s blood sugar levels, which it said needed to be monitored by external
parties if he was not capable of doing it himself.
62. The clinical reviewer’s view is that Manchester Social Services’ assessment of
the man’s needs is valid, as was the decision not to categorise him as being in
‘critical’ need. He concludes that, “there is no evidence that his needs could not
be met [at the Approved Premises]” and points out that “a number of individuals
with similar or worse problems can be managed in their own homes with the
appropriate support package being in place.”
63. However, the clinical reviewer acknowledges that the concerns and worries of
hostel staff were not addressed by the hospital or Manchester Social Services.
He highlights that the hostel was not involved in any discussions concerning the
management of the man’s health needs and at no point were hostel staff told
what was expected of them. This probably explains why a number of hostel staff
told my investigator that they felt isolated and ill-equipped to deal with the man.
64. I therefore fully endorse the clinical reviewer’s recommendation that, “staff from
the bail hostel should be involved in case conferences where the future medical
care of residents is discussed.”
Approved Premises staff should be involved in case conferences where
the future medical care of residents is discussed.
Greater Manchester Probation Area has accepted this recommendation and the
Senior Probation Officers in charge of Manchester’s seven Approved Premises
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have been informed of the need to involve hostel staff in medical case
conferences.
65. The clinical review also makes five other recommendations, two of which relate
to how the Prison Service passes on information and records to community
health services. I fully endorse these. Two more relate to the practices of GP
and associated services and therefore fall outside of my remit. The final
recommendation concerns how prescribed medication is stored and dispensed
in Approved Premises. I am aware that this matter is currently being reviewed at
a national level by the National Offender Management Service (NOMS)
The Prison Service should undertake a full medical, nursing and social
needs assessment prior to discharge to Approved Premises when there
are complex medical problems. A full package of support would therefore
be in place that met the person’s needs.
All individuals should be fully registered with a local General Practitioner if
they are expected to be resident at an Approved Premises for more than
three months. The GP would then have access to the medical records
prior to the prison sentence.
A copy or full summary of the prison medical records should be forwarded
to the new General Practitioner at discharge from prison
The community matron, or equivalent, should be involved in the discharge
and aftercare when there have been multiple admissions over a short
period of time.
Approved Premises should review the storage and dispensing of
medication and consider the use of seven day dispensing packs.
In its response to the draft version of this report, Greater Manchester Probation
Area said the Approved Premises division has already looked at the issue of
dispensing medication. As the use of seven day dispensing packs depends on
the willingness of the local pharmacy to provide this service and the current
provision is inconsistent, alternative arrangements are being explored.
The appropriateness of the man’s placement at the hostel
66. From March 2006 onwards, the man’s health deteriorated significantly. In the
four weeks between 20 March and 16 April alone, he was admitted to hospital
four times, experiencing chest pains, breathlessness, acute dehydration and
kidney failure.
67. Numerous members of hostel staff, including the Senior Probation Officer, told
my investigator they did not feel equipped to deal with the man’s complex health
problems. Certainly they are not trained to do so, and it is therefore not
surprising that they described feeling ‘out of their depth’. The hostel manager
said she did not think the man should have been at the Approved Premises after
this time.
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68. I fully acknowledge the clinical reviewer’s point that people with health problems
similar to the man’s are routinely cared for in their own homes. The inference is
that the hostel should have been able to meet his personal needs. However, an
Approved Premises is fundamentally different to a person’s home. Whereas a
family member might be prepared to help a loved one with their personal care
and hygiene needs, the same relationship does not exist between hostel staff
and residents. In addition, Approved Premises are currently not resourced to
deliver personal care to residents.
69. There is little doubt that the man’s quality of life was only maintained because of
the goodwill of hostel staff and the unwavering dedication of his wife who visited
him every day. The clinical reviewer has identified that the man could have
received input from community nursing services. I would go one step further and
say that he should have received community nursing services or been placed in
a residential care home. I was pleased to learn that the hostel manager and the
man’s supervising officer continued to pursue this option even after Manchester
Social Services had declined responsibility.
70. The man’s case poses serious questions about whether Approved Premises are
able to meet the needs of ageing and ailing residents. If the current trend for
longer prison sentences continues, it is almost inevitable that the resident profile
will continue to change, with younger, healthier bailees being replaced by older
released prisoners, some with chronic illnesses. NOMS needs to consider how
the changing resident profile is affecting and will affect Approved Premises on
the frontline.
The National Offender Management Service (NOMS) should conduct a
review of the Approved Premises estate to assess its ability to meet the
needs of frail, elderly residents. Local initiatives suggestive of good
practice should be shared across the estate.
I am pleased to report that Greater Manchester Probation Area has expressed a
willingness to contribute to any national review.
Mr man’s location after being discharged from hospital
71. After the man was discharged from the Royal Oldham Hospital on 19 May 2006,
he was allocated a bedroom on the first floor. He remained there for a couple of
days, before being given a room on the ground floor, albeit not one with disabled
access. His wife has expressed concerns about this and asked why her
husband was not given the disabled room he had occupied prior to his hospital
admission on 16 April.
72. My investigator has discovered that, during the course of his hospital admission,
the man’s residency at the hostel was terminated by Greater Manchester
Probation Area. The reason given for this was that it was hoped it would force
Social Services to take responsibility for his care. After his residency was
terminated, the disabled room was allocated to a new resident who suffered from
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emphysema. When the man returned to the hostel in May, the disabled room
was still occupied. He was therefore allocated to the room on the first floor.
73. The hostel manager told my investigator that the man was allocated to this room
partly on the basis of the Social Services needs assessment which clearly stated
that he was able to climb stairs unaided. When a room on the ground floor
became available, he was moved there straightaway.
74. Given that medical professionals said that, in their opinion, the man was able to
get around without assistance, allocating him a room on the first floor was
entirely reasonable. Similarly, in situations where there are competing demands
on resources (as I understand it, there is only one disabled room in the seven
hostels run by Greater Manchester Probation Area), managers have to make
difficult decisions based on need on a daily basis. The decision to allocate the
disabled room to an elderly man suffering from emphysema rather than to the
man who is the subject of this report is not therefore one that I criticise.
The length of the man’s stay at the Approved Premises
75. Prior to being released from Risley, the man was apparently told that he could
expect to be at the hostel for four months. His wife told my Family Liaison
Officer that both she and her husband were concerned when he was still at the
hostel over a year later. She asked my investigator to look into the matter.
76. My investigator was unable to establish who told the man that he could expect to
be at the hostel for four months. However, it is not uncommon for prisoners to
be given this sort of information whilst in custody. Four months is also not an
unrealistic timescale to expect to be at an Approved Premises after being
released from custody.
77. As detailed above, released prisoners have to reside at an address approved by
the supervising probation officer for the duration of their licence. In practice, this
means that the supervising officer can compel a released prisoner to live at an
Approved Premises for the whole licence period if they feel it is justified.
78. The man’s licence commenced on 19 October and expired on 18 February 2007.
The supervising officer was therefore fully entitled to compel him to stay at the
hostel until February 2007. For this reason alone, it would be wrong to criticise
probation for prolonging the man’s residency. However, there is clear evidence
in this case that the supervising officer and hostel manager made concerted
efforts to find the man alternative accommodation at a relatively early stage.
These efforts continued even after Manchester Social Services refused to fund a
place at a residential or nursing home and the care home rejected the man’s
application.
79. Given that there is also evidence that the MAPPA considered the option of the
man returning home and rejected it on public protection grounds, I cannot see
anything that the probation service could have done differently to shorten his
stay.
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Informing the man’s next of kin of his death
80. The man’s wife was extremely unhappy that she only learned of her husband’s
death when she arrived at the hostel around 11.00am, some three hours after he
had been found in his room. As she visited the man almost every day he was at
the hostel, she was disappointed that the staff did not telephone her at home
before she left around 10.20am.
81. My investigator raised this issue with the hostel manager, who would have been
responsible for contacting the man’s next of kin or delegating the task to
somebody else. The hostel manager said that, when the police arrived at the
hostel, they made a point of telling her not to telephone the next of kin. They
said that they would take care of it by sending an officer to her home to break
the news face-to-face. Unfortunately, the officer arrived at the house after
10.20am by which time she was already on her way to the hostel.
82. When family members and loved ones are to be informed of the death of a
prisoner or hostel resident, it is always my preference that they are told face-to-
face rather than over the phone. In prisons, it is now normal for a senior
member of staff and a trained Family Liaison Officer to carry out this task,
geographical considerations allowing. However, in Approved Premises, this may
simply not be practical – most hostels have only two or three members of
frontline staff on at any time and they are often responsible for managing
upwards of 20 residents. (I leave to one side a separate argument that the
Probation Area as a whole should take on this responsibility.) In this instance,
given that the Greater Manchester Police specifically told the hostel manager not
to telephone the man’s wife, it would be very unfair of me to criticise the hostel
for not doing so. Nevertheless, I understand and share her concern that she
only learned of her husband’s death when she arrived for her daily visit at the
hostel.
Conclusion
83. Overall, despite the very difficult issues raised by this case, I judge that the
support and care offered to the man following his release from prison reflect very
well upon the hostel staff, their managers, his supervising officer and Greater
Manchester Probation Area as a whole.
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RECOMMENDATIONS
To the National Offender Management Service
1. Approved Premises staff should be involved in case conferences where
the future medical care of residents is discussed.
2. The National Offender Management Service (NOMS) should conduct a
review of the Approved Premises estate to assess its ability to meet the
needs of frail, elderly residents. Local initiatives suggestive of good
practice should be shared across the estate.
3. Approved Premises should review the storage and dispensing of
medication and consider the use of seven day dispensing packs.
To the Prison Service
4. The Prison Service should undertake a full medical, nursing and social
needs assessment prior to discharge to Approved Premises when there are
complex medical problems. A full package of support would therefore be in
place that met the person’s needs.
5. A copy or full summary of the prison medical records should be forwarded
to the new General Practitioner at discharge from prison.
To the Primary Care Trust
6. All individuals should be fully registered with a local General Practitioner if
they are expected to be resident at an Approved Premises for more than
three months. The GP would then have access to the medical records prior
to the prison sentence.
7. The community matron, or equivalent, should be involved in the discharge
and aftercare when there have been multiple admissions over a short
period of time.
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