Individual at Peterborough

Investigation into the circumstances surrounding the
death of a man
at Peterborough Probation and Bail Hostel, in
Cambridgeshire Probation Area,
in September 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
May 2007
This is the report of an investigation into the death of a man who died in a bedroom
at Peterborough Probation and Bail Hostel whilst on bail. It appears that he died
after drinking alcohol and taking heroin.
Many of my investigations into the deaths of people who die from using drugs reveal
a long history of drug use. This was not the case with the man. Although he had a
history of alcohol abuse, he had successfully overcome an addiction to
amphetamines. However, in the hostel he was mixing with other residents who used
Class A drugs and could readily obtain them. The man had many hours to fill each
day and was grieving for his father, who had died very recently. The drugs were
supplied by another resident, who was about to be reported to the Police. Whether
an earlier report would have restricted the man’s supply, and saved his life, cannot
be known. Ultimately, he alone decided to use the heroin, and hostel staff should
not be critical of their slightly delayed report.
I offer my sincere sympathy and condolences to the man's family and friends for their
loss, especially so soon after the death of the man’s father.
My office investigates the deaths of all prisoners in custody and residents in
Approved Premises. In this case the investigation was carried out by one of my
investigators. I am grateful to the Assistant Chief Officer and the manager of the
hostel for their assistance during the investigation.
I make no recommendations, and am pleased to commend hostel staff for their
prompt response, and the Probation area for providing first aid training and
equipment.
Emma Bradley
Deputy Prisons and Probation Ombudsman May 2007
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CONTENTS
Summary 4
The Investigation Process 5
Peterborough Probation and Bail Hostel 6
Key Findings 8
Issues 12
Recommendations 15
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SUMMARY
The man was born in December 1956 and died in September 2006, at the age of 49.
He had a history of alcohol abuse and had criminal convictions spanning four
decades.
On 13 May 2006, the man was charged with a number of offences. After a short
time on bail, he was remanded into custody at HMP Norwich. He was bailed again
on 4 August, with the conditions that he made no contact with the witnesses in the
case, resided at the Peterborough Probation and Bail Hostel, did not enter Norfolk
and did not drink alcohol.
The man settled into the hostel routine well, and fully participated in the activities,
including an Open Day and sport competition. A warning letter was issued after he
talked about a new resident’s offences, and he took it to heart. The man told staff
that he was surprised how relaxed the atmosphere was in the hostel.
In September, the conditions of the man’s bail were altered to allow him to visit his
father in hospital in Norfolk. Sadly, his father died, and staff and residents noted how
badly affected the man was by his loss. Again his bail was amended to allow him to
attend the funeral, and spend the nights of 19 and 20 September at his mother’s
home.
The following week staff were informed that the man was apparently using cannabis
and that his next door neighbour was supplying drugs to residents. The neighbour’s
room was searched, but nothing was found. The deputy manager told staff to
monitor the situation and carry out more room searches if necessary.
On 29 September, staff received new information about the neighbour and searched
his room again. No drugs or drugs paraphernalia were found, but there were alcohol
containers in the bin. As this was against the hostel rules, the procedure to breach
him was started. In the meantime, the neighbour, the man and a third resident
walked to the local shop to buy some cider. After drinking the cider, the man
accepted his neighbour’s suggestion that they should buy some drugs. They
returned to the neighbour’s room and smoked the heroin they had bought.
The Probation Service Officer (PSO) on duty that day was alerted by the sound of
the smoke alarm. He went to the room where he found the man slumped against the
wall. He had no pulse and was not breathing, so the PSO attempted cardio
pulmonary resuscitation, until the arrival of the paramedics. Sadly, in spite of all their
efforts, the man was pronounced dead. The police notified his family, and the
assistant chief probation officer contacted them to offer support and assistance. At a
later date, he arranged for the family to visit the hostel.
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THE INVESTIGATION PROCESS
1. My office was notified of the man’s death on Monday 2 October. The investigator
opened the investigation on Thursday 5 October, when she visited Peterborough
Probation and Bail Hostel. She met the Assistant Chief Officer for
Cambridgeshire Probation Area, responsible for the approved premises and the
hostel manager. The investigator was shown round the approved premises, and
saw the man’s room and the neighbouring room where he died. She was also
given copies of all documents relating to the man. In the afternoon, she met the
detective sergeant of Cambridgeshire Constabulary who was leading the police
investigation and agreed to conduct the separate investigations concurrently.
The police investigation concluded that the man’s death was not caused by a
third party.
2. On 28 November, my investigator returned to the hostel and interviewed two
members of staff and spoke briefly to a third.
3. One of my Family Liaison Officers contacted the man’s family to ask if they had
any concerns to be included in the investigation. They said that they had no
concerns about his stay at the hostel, and praised the staff for their care and
concern.
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PETERBOROUGH PROBATION AND BAIL HOSTEL
4. Peterborough Probation and Bail Hostel is on the edge of a well established
housing estate, and is the only hostel in the Cambridgeshire Probation area. It is
a single storey building whose design was copied from an old people’s home,
and it provides accommodation for 29 male residents. Most bedrooms are single
rooms along two corridors, named Nene and Cavell. An office has been set
aside for the use of the local police when working in the neighbourhood, which
ensures that they have a high profile in the hostel.
5. The hostel’s occupancy rate is always above 90% and is usually 100%. Most of
the residents live there as a requirement of their licence, but recently there has
been an increase in the number of residents on bail.
6. The manager is a senior probation officer and the deputy is a probation officer.
There are five full time probation service officers (PSOs) who each supervise a
shift and engage in key work with residents. There are four full time and one part
time approved premises supervisors, who work under the supervision of the
PSOs.
7. Staff carry key fobs, which give quick access to all the rooms, alarm fobs to alert
colleagues that they need assistance, and first aid equipment pouches.
8. The approved premises operates a curfew from 11:00pm until 6:00am. Staff
carry out checks to ensure that all residents are in their own rooms between
those times, and a closed circuit television (CCTV) system monitors movement in
the hostel 24 hours a day. Random drug tests are carried out and all residents
know that they can be tested at any time. Staff also search residents’ rooms if
they suspect that they have brought drugs or alcohol into the premises.
9. At the induction meeting, each new resident is given a copy of the hostel rules,
which are explained. The resident then signs to say that he agrees to observe
the rules and keeps a copy. The rules cover the behaviour expected of the men
and are aimed at providing a safe and calm atmosphere in the hostel. The
possession and use of unprescribed drugs and drugs paraphernalia in the hostel
is banned, as is alcohol.
10. Residents who break the rules are given warnings, depending on the seriousness
of the breach. A written warning may be issued, followed by a final warning
letter. If a resident does not heed the warnings, their place in the hostel may be
withdrawn. If a breach of the rules is serious enough, staff may issue a final
warning letter rather than going through all the stages of the warning process. If
a resident is found with drugs or drug paraphernalia, depending on the
circumstances, a final warning letter may be issued or the person’s licence
breached immediately.
11. The hostel staff have developed good links with the community. The approved
premises advisory committee provides a forum where people from the local
community can raise issues of concern. The head teacher of the local school
and a general practitioner who serves the neighbourhood sit on the board, as do
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local residents’ representatives. In the summer of 2006, the approved premises
held an open day and hosted people from the surrounding area. Photographs of
the day were prominently displayed on a notice board when my investigator
visited. The residents of the approved premises publish a newsletter and
participate in a residents’ forum.
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KEY FINDINGS
12. On 13 May 2006, the man was arrested and charged with a number of offences.
He appeared in court on 15 May, and was given bail with the requirement that he
live at his parents’ address. However, a week later, he was remanded into
custody at HMP Norwich. The records do not show why his bail was withdrawn.
On 4 August, he was again granted bail subject to the conditions that he made no
contact with the witnesses in the case, resided at the hostel, did not enter Norfolk
and did not drink alcohol. During his stay at the hostel, the man settled in well
and his likeable character made him popular with the residents. He was said to
be good at supporting and encouraging those with problems. He also played an
active role in the Open Day that was held whilst he was a resident.
13. The man arrived at Peterborough Probation and Bail Hostel at 7:15pm on 4
August 2006. He had his induction that evening, which included being shown
round the hostel and introduced to staff and residents. The hostel rules were
explained to him, and he signed a copy which was placed on his file. He was
allocated Room 14, which is one of three rooms in an L shape at the end of a
corridor. The residents of the other two rooms (13 and 15) were also on bail.
14. Over the next few days the man appeared to settle in well. However on 7
August, a warning letter was issued to him because he broke one of the hostel
rules. He had recognised a new resident as having been in HMP Norwich and
had discussed the new arrival with other residents. His key worker explained to
the man that this was not allowed, as talking about other residents’ offences did
not promote a calm atmosphere. The man apologised, and added that he was
pleasantly surprised at the very relaxed atmosphere and how well the residents
got on with each other.
15. After this shaky start, the man was careful to behave in a way that contributed to
the relaxed atmosphere. He often sat outside at one of the picnic tables, taking
part in lively conversations. Over the next few weeks, the man and the new
resident became friends and the other resident was greatly upset at the man’s
death.
16. When the man arrived at the hostel he had told staff that his father was seriously
ill. One of the conditions of his bail was that he must not enter Norfolk, except for
court appearances or appointments with his solicitor and probation staff. The
condition was altered to allow him to visit his father in hospital. In the middle of
September, his father died. His bail conditions were again altered to allow him to
spend the nights of 19 and 20 September at his mother’s house, and attend the
funeral. Several members of staff told my investigator that his father’s death hit
the man very hard, and they noticed that he kept himself to himself more and
grieved for his father.
17. A week later, a resident told staff that the men in rooms 13, 14 and 15 were using
drugs in the hostel. The resident said that the resident from room 15 was
supplying drugs to other residents, and the man who died was smoking cannabis.
As a result of the information the deputy manager of the hostel told staff to search
Room 15. However, nothing was found and the deputy manager emailed staff to
8
advise them to keep a close eye on the situation and carry out further room
searches if necessary.
18. According to the deputy manager, the man’s records showed that he had a
problem with alcohol, but this was the first indication that he was currently using
drugs. When the man arrived at the hostel, he told staff that he had used
amphetamines ten years earlier, and had been dependant for about ten years.
19. On 29 September, the resident in room 13 talked to the man at breakfast. After
breakfast, the resident from room 13 told his key worker that the resident in room
15 was offering drugs to other residents. The key worker, who was the duty
PSO, and another member of staff searched room 15 for drugs and drug
paraphernalia. They did not find any drugs but they did find empty alcohol
containers in the bin, which was a breach of the hostel rules.
20. Shortly before 9.00am, the deputy manager arrived for work and saw the man
sitting alone outside, having a cup of tea and a cigarette. The deputy manager
said good morning to the man, who replied. The deputy manager said that the
man appeared to be deep in thought, and that since his father’s death, he had
been more reserved and less cheerful, which was how he looked that morning.
The deputy manager was the acting manager of the hostel as the manager was
on annual leave. The PSO consulted the deputy manager about the alcohol
bottles in the room of the man’s neighbour, and as it was not the first time he had
broken the rules, they decided to breach him. This meant that the PSO would
complete the necessary forms explaining how the man’s neighbour had broken
the conditions of his bail. He would then inform the police who would come and
remove the neighbour from the hostel. The PSO completed the paperwork
before going for lunch.
21. At about 11.30am, the man walked to the shops with his neighbour and the
resident from room 13 and bought some cider. The man’s neighbour asked him if
he wanted to buy some drugs. The man agreed and the neighbour contacted a
woman, who joined them briefly and had a discussion with the man. The woman
left, after arranging to meet the man and his neighbour later. The three men sat
on a park bench and drank the cider. The resident from room 13 later told the
PSO that the man had also been drinking vodka, but he did not repeat this when
he spoke to the police. At that point, the resident from room 13 returned to the
hostel, intending to pass on the latest information, but unfortunately, the PSO
was at lunch.
22. By about 12.30pm, the man and his neighbour had returned to the hostel and
gone to the neighbour’s room. Sometime between then and 1:00pm, the resident
from room 13 knocked on the neighbour’s door and asked what was happening.
The man shouted through the door, “We’re doing some gear (the colloquial term
for heroin). Come back later on.” The resident from room 13 returned to his
room without passing on this information to staff.
23. After lunch, the three staff on duty were very busy as, amongst other things, two
new residents arrived. The PSO did not realise that the neighbour had come
back from the shops, and did not telephone the police about breaching him.
9
Instead, as he worked, The PSO looked out for the neighbour as he intended to
call him into the office and tell him what was going to happen.
24. At about 3.00pm, the PSO heard the smoke alarm make a few quiet bleeps, as if
it was about to ring fully. Although the alarm did not sound fully, the PSO saw
from the control panel that it had been triggered in Room 15. The PSO went to
the room, knocked briefly on the door and then used his key fob to enter the
room. He immediately saw that the room was full of dense, acrid smoke, which
was not from cigarettes.
25. The man’s neighbour got up from the bed, looking very disorientated. The man
was lying slumped on the bed, and the PSO realised that something was wrong.
(he has been qualified in first aid for a number of years and his latest refresher
training was earlier in 2006.) He checked the man’s pulse but could not find one,
and there was no sign of breathing. The PSO briefly asked the neighbour what
they had taken, but he denied they had taken anything.
26. The PSO was carrying the cordless telephone from the office, and dialled 999 but
his call was not connected. (He later realised that he had not dialled 9 for an
outside line before dialling 999.) Rather than try again, he used the alarm fob on
his belt to alert his colleague that he needed assistance.
I commend the issue of the alarm fob to all staff as an example of good
practice. It allows a member of staff to summon assistance in an instant
and his or her location can immediately be seen from the alarm board.
27. The PSO laid the man on the floor and began cardio-pulmonary resuscitation
(CPR). CPR is the process of giving mouth to mouth resuscitation, interspersed
with chest compressions, in an attempt to get the person breathing again. The
PSO did not have a face mask to hand and so had to improvise one to put over
the man’s mouth and nose. He tore a piece of a plastic shopping bag to make a
hole in the middle, through which he breathed into the man. Unfortunately, while
the PSO was breathing into the man, some fluid passed through the mask.
Despite this, he carried on with CPR, demonstrating a high level of care and
dedication.
28. The other member of staff ran to the room, and the PSO told him to call an
ambulance. The other member of staff then returned to the office and called an
ambulance, before going back to the room to allow the operator to talk to the
PSO. The operator gave some advice, but the PSO was already carrying out
CPR to the operator’s satisfaction. The other member of staff then went to the
main door of the hostel to wait for the paramedics’ arrival. Meanwhile, one of the
office staff alerted the deputy manager to the emergency and he also went to
room 15. The PSO asked him to fetch the first aid kit which contained a face
mask with a tube to insert into the patient’s throat. The PSO attempted to fit the
tube into the man’s throat, but without success and so he continued the CPR.
29. The paramedics arrived and were shown to room 15. They took over
administering CPR and continued to try to resuscitate the man. The ambulance
went round the back of the hostel to outside the fire door next to the man’s room.
10
Unfortunately, the paramedics could not revive the man. They told the deputy
manager that the man had died, and added that the PSO had done everything
possible to save him.
30. The deputy manager implemented the procedures for responding to a death in
the hostel. He notified the police and telephoned the senior probation manager
on call that day. The residents who were in the hostel were aware that
something was wrong, but were sensitive and kept away from all the activity. The
other member of staff gathered them in the lounge and broke the news of the
man’s death. He also told them of the support that was available as they came to
terms with his death. A senior manager and the Assistant Chief Officer
responsible for the hostel arrived and worked with the staff for the rest of the day.
They also gave support to the staff, particularly the three most closely involved.
The Assistant Chief Officer stayed until he had spoken to all the staff as they left
as well as the new staff coming on duty that night. He returned on Saturday and
Sunday to speak to the staff who were on duty on those days.
31. The police informed the man’s family of his death and the Assistant Chief Officer
spoke to members of his family over the weekend. In the following weeks, he
acted as the point of contact for the man’s family. The following week, a debrief
meeting was held for all the staff involved in the attempt to resuscitate the man.
Each member of staff had the opportunity to discuss what happened and how
they felt about it. At the meeting, the PSO told staff how much support he had
received from the residents when he returned to duty after the weekend. Each
resident who saw him asked how he was and praised him for his actions. He
asked that the manager thank the residents for their consideration at the next
residents’ meeting.
32. The Assistant Chief Officer and the manager agreed that, if the family gave
permission, a representative from the hostel would attend the man’s funeral. The
PSO told my investigator that he would have liked to have represented the hostel.
However, by the time the hostel staff learned of the funeral, it had already taken
place. The Assistant Chief Officer and the manager later arranged for family
members to visit the hostel to see the man’s room, which had been kept out of
use until they visited. They also meet staff and residents. The family met the
PSO, who was very moved when they spoke to him about the man when he was
young. The man’s sister later told my family liaison officer that she greatly
appreciated the manager’s kindness and sensitivity to the family.
33. At their next meeting, the residents proposed to name a sports trophy as a
memorial to the man, and this was agreed after consultation with the family. The
residents also wrote contributions to an ‘in memoriam’ page in the next edition of
the hostel newsletter.
11
ISSUES
First aid provision
34. The PSO has been a fully trained first aider for a number of years. When he
discovered the man, he was immediately able to assess the situation and begin
CPR. He summoned help to call an ambulance and obtain the first aid kit. His
administration of CPR was focussed and determined, even when there was the
transfer of fluid into his mouth. The paramedics said that the PSO had done
everything that was possible to save the man.
The PSO should be commended for his attempt to resuscitate the man.
35. Hostel managers had previously decided not to include masks in the first aid
equipment pouches carried by staff, and so the PSO did not have one when he
began to administer CPR. He improvised with a plastic bag, which did not
prevent the transfer of fluids.
36. Instead masks were contained within first aid kits. The masks had a tube
designed to go partially down the throat, but the PSO could not fit it into the
man’s mouth and throat. The PSO thought that the difficulty could have been
because the man had several front teeth missing. The other masks in the hostel
were subsequently checked, and found to be working properly. In addition, more
first aid boxes are to be provided in the bedroom corridors.
37. Probation Circular 35/2006 reminds managers that the requirement is that all
supervisory staff must be trained, as a minimum, in basic first aid. Managers
have decided that first aid training will be a priority during the current year, and
propose to arrange two courses which would mean that eight of the staff team
would be qualified. Managers may wish to advise staff attending the courses to
pay particular attention to the fitting and use of face masks.
Drugs in the hostel
38. Three of the hostel rules refer to the possession and use of drugs and alcohol.
They ban the possession and use of drugs, drug paraphernalia, alcohol and
alcohol containers and make residents responsible for any of these items found
in a room that they are using. Staff are expected to be vigilant for signs that
residents may be using drugs in the hostel. They are also aware of former
residents who live locally and prevent them from loitering in the hostel grounds in
case they are supplying drugs. The staff also liaise closely with the residents’
offender managers (probation officers) and drug workers from the local drug
treatment agencies. There are, therefore, aware of residents who use drugs
and/or alcohol.
39. Random drug tests are carried out when staff suspect that a resident is using
drugs. Both urine tests and swab tests are used, although urine tests are more
common as they test for a wider range of drugs. Staff are aware of the ways that
residents may try to cheat during a test and work hard to ensure that they stay
12
one step ahead of the residents. Residents have told staff that the possibility of
being tested acts as an incentive in deciding not to take drugs.
40. However, staff are aware that some residents use drugs and may supply them to
others. Room searches are carried out when staff suspect a particular resident
and they look for paraphernalia as well as drugs. The public areas in the hostel
are also regularly searched, particularly the toilets which have many places to
secrete drugs. The relationships between staff and residents are sometimes
strong enough for residents to inform them of others who are using or supplying
drugs.
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41. GOOD PRACTICE
The PSO should be commended for his attempt to resuscitate the man.
I commend the issue of the alarm fob to all staff as an example of good
practice. It allows a member of staff to summon assistance in an instant
and his or her location can immediately be seen from the alarm board.
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ANNEXES
1. Documents considered during the investigation
Probation hostel file
Family liaison log from the Assistant Chief Officer
Post Mortem and toxicology report
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