Individual at Southwell House

CIRCUMSTANCES SURROUNDING THE DEATH OF A MAN AT A HOSTEL IN THE
NOTTINGHAMSHIRE PROBATION AREA ON 5 FEBRUARY 2006
REPORT BY THE PRISONS AND PROBATION OMBUDSMAN FOR
ENGLAND AND WALES
AUGUST 2006
This is the report of an investigation into the death of a man, who died aged 36 in his
bedroom at a hostel in the Nottinghamshire Probation Area on 5 February 2006
(hereafter referred to as ‘Hostel B’). He died six weeks after his release from prison on
licence. The post mortem and toxicology reports indicate that the cause of death was a
drug overdose consistent with a fatal intake of heroin.
I would like to offer my sincere condolences to this man’s family and friends on their
loss. I know that the staff and residents at this hostel and at his first hostel (hereafter
referred to as ‘Hostel A’) share those sentiments.
The aim of my investigation was to discover whether the level of care provided by the
Approved Premises was appropriate, and whether any lessons could be learnt to help
prevent a similar death in the future. An investigator from my office carried out the
investigation. I am grateful for the co-operation she received from all at Hostel B and
from the Manager of Hostel A and from the man’s Probation Officer.
This report raises issues regarding the monitoring of the use of medication, especially
by offenders with a history of drug abuse. This has significant implications for public
protection. I am also concerned by the delays in informing the man’s family of his
death. I make four recommendations and highlight three examples of good practice.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN August 2006
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Contents
Summary 4
The investigation process 5
The man himself 6
Approved Premises 7
Hostel A 7
Hostel B 7
Events leading to the man’s death 9
Events after the man’s death 13
Issues considered during the investigation 14
Conclusions 16
Recommendations and Good Practice 17
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Summary
1. The man at the centre of this report was born in 1969. He was 36 years old
when he died in his bedroom at Hostel B on 5 February 2006. Post mortem
and toxicology reports indicate that the cause of death was an overdose of
heroin.
2. He had previously served three short prison sentences. His last sentence had
been the longest. He had been convicted on 11 December 2003 and on 16
January 2004 was sentenced to 30 months imprisonment. He was initially held
in HMP Nottingham then transferred to HMP Ranby on 10 February 2005. He
was released on licence from Ranby on 10 March 2005.
3. On 16 July 2005, the man was recalled to prison for breaching his licence
conditions. On 23 December 2005, he was re-released from Nottingham
prison. One of the conditions was to reside at Hostel A in the Nottinghamshire
Probation Area; another was to address his substance misuse. He also
attended a clinic for those with drug and alcohol problems. He regularly
attended this clinic for support, drug tests and his naltrexone prescription which
was part of a detoxification programme.
4. Hostel A has a strict policy that no drugs may by be used by residents.
However, the man tested positive for heroin on several occasions and this was
the main reason for his move to Hostel B on 26 January 2006. This is a drugs
managed site which works with residents in an effort to stop misusing drugs.
5. Hostel B is in the Radford area of Nottingham. The man was familiar with this
area and this was where he had committed some of his offences. He therefore
felt vulnerable, and it was later agreed that he would transfer back to Hostel A.
6. Whilst a resident at Hostel B, the man reportedly kept himself to himself, either
staying in his room or being away from the hostel. He had more social
interaction while at Hostel A. Reports from both hostels describe him as being
a friendly, polite and helpful man.
7. The night before he died, the man returned to the hostel just before curfew.
He looked slightly ‘blotchy’ and staff suspected he might have been drinking.
However, he was coherent and did not present any problems.
8. On the morning of Sunday 5 February 2006, during curfew checks, staff found
the man in his room. He was ‘slumped’ over his bed and unresponsive. An
ambulance was called immediately. Both members of staff on duty were first
aid trained and began putting the man into the recovery position. Whilst
moving him, the paramedics arrived. As soon as they reached the room, the
paramedics realised the man had passed away and pronounced him dead at
7.59am.
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The Investigation Process
9. My investigator visited Hostel B on three occasions. She interviewed several
members of staff as well as the Senior Officer at Hostel A and the man’s
supervising Probation Officer. She also visited HMP Nottingham to gather
information from his prison records.
10. Information was sought from the clinic he attended in Nottingham. The
coroner’s office and police were also consulted.
11. The terms of reference for the investigation and notices to staff and residents
were issued. The investigator was given unrestricted access to the man’s
records and to the Approved Premises.
12. One of my Family Liaison Officers spoke to the man’s mother to ask if she
wanted to raise any concerns about her son’s care whilst in the Approved
Premises. The following matters were raised:
• She would like information about what happened to her son between
leaving prison and his death;
• She was upset about her son’s clothing being laundered prior to her
collecting them, as she understood from a letter received from the Area
Deputy Director that nothing in his room would be touched;
• She wonders why, when her son was found at 7.35am, she was not
informed of his death until 3.45pm.
13. A draft of this report was sent to the man’s family and Nottingham Probation
Service to enable them to make any comments. The family has not requested
any comments to be included in the final report. Nottingham Probation
Service’s response to recommendations is included in the recommendation
section.
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The man himself
14. He was born in 1969 and raised in Cheshire, and was aged 36 when he died.
15. Reports of interviews with the man describe him previously living with friends in
an environment where he was vulnerable to peer pressure and which involved
drugs and crime. He apparently travelled abroad to escape from this. When he
returned to England, he settled for a time in the South West where he formed a
relationship and had a daughter. The relationship had ended and his ex-
partner and daughter moved abroad.
16. The man had worked for building companies as a plasterer and installing
double glazing. His last job had been in the South West, selling magazines.
The job ended a few years ago and he had been both unemployed and
homeless since that time.
17. During this period, he became involved with a homelessness charity that
helped him apply to a charity-run local detoxification unit in Nottingham. The
man arrived here in November 2002. Whilst there he became very ill and was
admitted to hospital for treatment for endocarditis, an infection of the heart
valves. His condition was exacerbated by drug use and he subsequently spent
several periods in hospital for treatment for this and for septicaemia.
18. The man had been a habitual drug user since he was 21 years old. His main
drug was heroin, used intravenously. He also misused cocaine and alcohol.
19. Housing was again a problem for the man upon his re-release from prison.
However, as a condition of his licence, he was required to reside at Hostel A for
the remaining six months of his sentence. During this time, his future housing
needs were to be addressed. Prior to his death, several housing applications
had been made to relevant agencies.
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Approved Premises
20. Approved Premises were formally known as Probation and Bail Hostels. They
are approved by the Secretary of State within section 9 of the Criminal Justice
Act 2000. Approved Premises provide a supportive, structured environment in
the community for high risk and difficult to manage offenders. The
management of those accommodated in Approved Premises is governed by
the National Standards for Supervision of Offenders and the guidance
contained in the National Approved Premises Handbook.
21. The purpose of Approved Premises is to provide an enhanced level of
supervision for some of the most difficult and high-risk offenders in the
community. They are not principally an accommodation resource.
22. It is Approved Premises procedure that, in the event of a death at the premises,
the police are called. The Approved Premises staff will notify the police of next
of kin details and the police are responsible for informing the next of kin.
Hostel A
23. Hostel A is one of three Approved Premises managed by Nottinghamshire
Probation Area. It is made up by two detached houses linked by a garage. It is
set in a residential street and has a capacity for 14 residents. There are eight
bedrooms, six of which are doubles and two singles.
24. Hostel A is a catered premises, providing breakfast and one cooked meal a
day. The accommodation charge payable by residents is £22.56 per week.
25. The hostel has a strict no-drugs policy and residents are subject to drug testing.
They have a test within 24 hours of arriving at the hostel, and then as required
in consultation with their probation officer. ‘Suspicion’ testing can be carried out
if a resident is suspected to be using drugs. Residents who are illegally using
drugs risk their place at the hostel.
Hostel B
26. This hostel is another of the sites managed by Nottinghamshire Probation Area.
It is a large detached house on three floors, situated in the residential Radford
area of Nottingham, and can accommodate 18 residents. Their main focus is
on high risk offenders although they do accept offenders on bail. Residents are
subject to community penalties or prison licences. Residents must be over 18
years of age.
27. At Hostel B there is a curfew from 11:00pm to 7.30am. Staff physically check
all residents’ rooms and speak to each resident in occupancy at both these
times daily. There are also two hostel checks daily. As well as confirming the
welfare of residents, these additional checks are intended to ensure that rooms
are being used properly and that no banned items are being held in
possession.
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28. The hostel is a self-catering premises and residents have access to a kitchen.
There is one kitchen to two residents, situated on the same floor as their
bedrooms. The accommodation charge payable by residents is £5.18.
29. Closed circuit television (CCTV) has recently been installed, monitoring the
main communal areas of the hostel including the kitchens as well as the offices.
However, this was not in place whilst the man was a resident. The monitoring
screens are fitted in the Deputy Manager’s office which is not in constant use.
As a consequence, the CCTV is not continuously monitored.
30. Each new resident is given an information booklet which outlines information
about the Approved Premises and the hostel rules. Hostel B is a drugs
managed site and Illicit drugs and drugs paraphernalia are not allowed on the
premises. Staff have the authority to search a resident’s room if it is suspected
that they are breaking the hostel rules. Residents are also subject to random
drug testing.
31. Residents’ medication is securely stored within the office. It is handed to
residents by staff according to the medication instructions. Each resident has a
drug dispensing chart which a member of staff signs when the medication is
dispensed. The Approved Premises Handbook states that it remains the
residents’ responsibility to collect and take the medication. There are no official
means of monitoring and following up any missed medications.
32. Each resident has a dedicated keyworker to assist in meeting their specific
needs. Keyworkers hold regular one-to-one meetings with their residents, and
liaise with other agencies and the resident’s probation officer to monitor and
facilitate as appropriate the residents’ reintegration back into the community
and to address specific needs.
33. The staffing complement is:
• one Senior Probation Officer (Manager)
• one Deputy Manager
• one full time administration assistant
• six Approved Premises Officers (formerly Resident Social Workers)
• four waking night staff
There is a minimum requirement for two staff to be on duty at all times.
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Events leading to the man’s death
34. This man was released on licence from HMP Ranby on 10 March 2005. His
licence was revoked and he was returned to prison on 16 July. He was granted
release on licence on 23 December 2005, with the extra condition to reside at
Hostel A in Nottinghamshire for the remaining six months of his sentence.
35. He was supervised by his probation officer as part of the Prolific Offender
Programme (POP). This manages prolific offenders and offers a more intense
and structured monitoring regime. The man was required to tackle his
substance misuse, and apply for accommodation, education and skills training.
The man took this opportunity to become involved in sporting activities run by
the POP team.
36. Through the programme, the man attended the local clinic for those with drugs
and alcohol problems. He was already known to the clinic, having been in
contact with them previously. He attended on 23 December 2005 (the day of
his release) when it was arranged that he would receive a naltrexone (blocker)
prescription to help him stop his drug use. On the way to the appointment, he
disclosed to staff that he had used illegal drugs two days prior to his release
from prison. Because his drug test was positive, he was prevented from
commencing the naltrexone medication and was asked to return at a later date.
The POP team then gave him a lift to Hostel A.
37. The man returned to the clinic on 3 January 2006. His drug test was negative
and he was offered the naltrexone prescription. Because he had a history of
kidney problems, he received a reduced dose of 25mgs of naltrexone daily,
rather than 50mgs, and was to continue to have liver function tests. The man
was informed about the effects of naltrexone and was warned about the risks of
overdose.
38. The man soon settled into the regime of Hostel A and was described as
pleasant, courteous and helpful both to staff and other residents.
Unfortunately, despite the detoxification programme, he still used illicit drugs on
several occasions. He was warned that to remain at Hostel A he needed to
produce negative drug tests or he would lose his place.
39. The manager of Hostel A (a Senior Probation Officer) and the man’s Probation
Officer thought that the man was meeting the objectives set for him, and so
were not keen to have to revoke his licence if he lost his place at Hostel A.
However, towards the end of January, a space was needed at Hostel A for
another offender. After much consideration, the man was selected to move out.
He was continuing to use drugs, which was against the hostel rules, but was
thought to be progressing well enough to be able to adjust to the move.
40. The man arrived at Hostel B at approximately 9.15pm on 26 January 2006. It is
not clear why it was so late in the day, however he had attended POP activities
during the day and was still within his curfew. Due to the late hour, the man
did not undergo a full induction. However, he did sign the hostel rules. It was
noted when he arrived that he smelled of alcohol. It was decided that staff
would raise this matter at his induction the following day. The man did not take
his naltrexone on 26 January.
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41. On 27 January, the man went out of the hostel and failed to attend the induction
meeting. He returned later, apologised and was given a slip to remind him to
attend an appointment at 4.00pm that afternoon. He failed to attend this
appointment and again did not take his naltrexone.
42. For the rest of that day and the next, the man had minimal contact with the
staff. On 30 June, he was questioned about not attending his induction
appointments and attended later that day. The man was not used to the self-
catering practice at Hostel B and was concerned that he did not have enough
money for food. Hostel staff were able to offer some food and also gave him a
letter so that he could get a food parcel from the Salvation Army.
43. The man then left the hostel and returned at 11.20pm which is past the curfew
of 11.00pm. He was issued with a verbal warning and his probation officer was
informed.
44. On 31 January, the man’s probation officer received a call from the clinic for
those with drug and alcohol problems. They believed that the man was not
taking his naltrexone prescription and did not want to prescribe more as they
did not believe he was cooperating with the treatment plan. At the time he was
in possession of a two week supply. It was agreed that this would be discussed
the following day with the man at a scheduled three way meeting at the hostel
between himself, his probation officer and a member of staff from Hostel B.
45. At the meeting on 1 February, the man discussed how he was finding the
change of hostels quite stressful. He was used to having a meal cooked at
Hostel A and did not know anyone at Hostel B. He was advised to try and mix
with the other residents to help him adjust. His housing issues were discussed
and he was told he had an appointment with one agency the following week.
There is no mention of the naltrexone prescription in the notes of the meeting.
However, his probation officer is sure it would have been discussed, but had
not been minuted. That evening, when being given appointments, the man
became confused about what he had to do. It was agreed that he would attend
the office first thing in the morning to sort his appointments out. He then failed
to attend the office the following morning.
46. The man returned to the hostel late that evening. Whilst speaking with the
staff, he mentioned that he had arranged to go on a kayaking trip with Traffic
Street (Community Services Probation team), which is part of the Prolific
Offender Programme. He took his naltrexone that night, which was the second
and last time he took it whilst at Hostel B, the other occasion being on 28
January.
47. The man also told staff that he felt more vulnerable at Hostel B than at Hostel
A. It appears he was concerned about being in the area where he had
committed some of his offences and had associates. He had not interacted as
much with the residents at Hostel B and felt isolated. He was also struggling
with the self-catering aspect of the hostel. The man’s probation officer was
worried that he was not yet ready for such independence.
48. On 3 February, a place had become available at Hostel A and the manager of
this hostel contacted the man’s probation officer. In consultation with the
managers at Hostel B, it was agreed that it would be beneficial for the man to
return to Hostel A. The fact that he was still not drug free was discussed and it
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was agreed that he needed to provide a negative drug test by the following
week to keep the place. The man himself was out on the kayaking trip, but his
probation officer was able to contact him to inform him of the move and explain
the importance of a negative drug test. The man was happy about the planned
move back to his original hostel.
49. The Deputy Manager at Hostel B waited in until approximately 6.30pm on 3
February so that he could take the man to Hostel A. However, he had not yet
returned since leaving in the morning for the kayaking trip. The Deputy
Manager liaised with the Hostel A Manager to say that they would pay for a taxi
or that he would take the man on Monday 6 February.
50. The man returned late that evening and said he would wait until Monday to
move. This may have been because he was waiting for his Giro cheque to
arrive at Hostel B the next day.
51. On Saturday 4 February the man was visited by two other men. Visitors are not
allowed into the premises until 10.00am, so he sat outside with them until this
time when they all entered the premises together. Approved Premises staff
have the authority to ban visitors when appropriate. The staff were concerned
about the visitors’ motives, and told the man to be careful and let them know if
there were any problems, or else to remain inside the hostel. However, at
approximately 11.30am, the man received his Giro and all three men left.
52. Two Approved Premises Officers were on duty that evening for the ‘sleepover’
shift. The male officer’s shift had begun at 5.00pm and the female officer’s at
10.00pm. The man returned that evening at approximately 10.50pm and rang
the bell to be let in. Staff looked out to see who was there and saw him
speaking to a woman before coming inside. He did not walk past the office, so
the male officer went to see where he was. The man had gone straight into the
toilets by the front door, and the male officer checked to see if he was alright.
The man confirmed that he was and said he would be out shortly.
53. The two officers then began the 11.00pm curfew check of the premises. They
returned to the office at approximately 11.20pm, and the male officer went to
see if the man was still in the toilets; he was leaving as the male officer arrived.
The male officer thought that he looked ‘blotchy’ and he wondered if he had
been drinking, although there was no smell of alcohol. He asked the man again
if he was okay, and he replied that he was.
54. The man asked if the kitchens were locked and was informed that they were, as
they are locked at curfew check each night. The man took a bottle of milk from
a carrier bag and asked if he could put it in his fridge. The male officer walked
up the stairs to the kitchen with him. The man then poured himself a cup of
milk. There was a discussion between them about the woman the man had
been talking to outside. The man said that he had just met her and gave no
more details. He said goodnight and went to his room.
55. The two officers discussed the man when the male officer returned. The male
officer felt that the man might have been drinking, but as he was coherent, and
appeared fine, the staff were not concerned. The female officer asked whether
he was unsteady on his feet, but the male officer said he had walked up to his
room without any problems. If the CCTV had been in place at the time, there
11
would have been a record of the man’s movements throughout the building
during the night.
56. At 7.30am the following morning, 5 February, the two officers began their
curfew check of all the hostel residents. They reached the man’s room at
approximately 7.35am. When they opened the door, they noticed that he was
‘slumped’ over his bed and was naked from the waist up.
57. The male officer called to the man to try and wake him. When this had no
effect, he shook his shoulder. Again there was no response. The female
officer ran downstairs to call an ambulance while the male officer, who has a
first aid qualification, checked for a pulse. He could not find a pulse, and so
attempted to put the man into the recovery position. The male officer struggled
to move the man because of a back problem, and so ran downstairs to ask the
female officer to help him and also to fetch a resuscitation mask.
58. The ambulance services were still on the telephone and they asked if anyone
was first aid trained. The female officer handed the telephone to the male
officer, and the call was transferred to a cordless handset and both members of
staff returned upstairs.
59. The ambulance services advised the two officers to begin cardio pulmonary
resuscitation (CPR). As they moved the man into the appropriate position, the
paramedics arrived at the hostel and were taken directly to his room. When the
paramedics saw the man, it was clear to them that there was nothing they could
do and he was pronounced dead at 7.59am.
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Events after the man’s death
60. The police attended Hostel B shortly after the paramedics contacted them.
They initially treated the call as a ‘suspicious death’, which meant that
statements were taken, records sought and contact was made with the
coroner’s office. In the man’s room, the police found some foil and liquid,
suspected to be lime juice, an unused syringe in his jacket and an empty bottle
of white cider under his pillow. Before leaving the hostel, the police sealed the
room so that it could not be entered without their permission.
61. The police officers who attended the hostel also took responsibility for notifying
the man’s family of his death. The sergeant in charge of the case states that
steps were taken around lunchtime, but he could not provide specific
information about the time. As the family lived outside the Nottingham area, the
information had to be passed to another police force. Unfortunately, it appears
that the information was initially sent to the wrong police force. Records show
that the information was first sent by fax to Merseyside police. Merseyside
police telephoned Nottingham police that the address was not in their area, and
they believed it should be dealt with by Manchester police. The call from
Merseyside was recorded at Nottingham at 2.53pm. The man’s family were
eventually informed of his death at 3.45pm.
62. A post mortem examination was carried out on 7 February. The cause of death
was recorded as a drug overdose. The toxicology report comments that blood
and urine results were consistent with a recent and fatal intake of heroin.
Cocaine was also found but the toxicology report concludes that this was less
likely to have been associated with significant acute toxicity. There is no
suggestion that the man’s previous health problems were associated with his
death.
63. The man’s bedroom remained sealed whilst the police carried out their
inquiries. His family were informed that it was sealed in a letter from the
probation area’s Deputy Director of Interventions. They were told that, once the
room was released, they would be able to visit it. Once the room was released
by the police, hostel staff cleared the room and washed all the man’s clothing.
They informed his mother and she was considerably distressed as she had
wanted to see his room as he left it. She also wanted to pack his possessions
herself, which she had believed she would be able to do.
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Issues considered during the investigation
Positive drugs test on release from prison
64. The man was released from prison at short notice. He had reportedly taken
illegal drugs the day before leaving prison to ‘celebrate’ his release. He was
not aware that the Approved Premises he was going to be released to was drug
free, and informed his probation officer that he would not have taken the drugs
if he had been aware of the hostel rules. The concern remains, however, that
he was able to access illegal drugs whilst in prison custody, and as a result was
unable to commence the detoxification programme on the day of his release.
Change of hostels
65. The man was initially required to reside at Hostel A, and spent five weeks there
before moving to Hostel B. He was moved due to a space being needed for
another offender. Whilst there were concerns about moving the man, it was
thought that he was making sufficient progress to be able to cope with the
move. There was also the issue that he was producing positive drug tests and
Hostel A was a drug free hostel.
66. It soon became clear that the man was not coping well at Hostel B and felt
more vulnerable to peer pressure because he had associates in the area.
When a place became available again at Hostel A, just after a week later, it was
agreed that he could return. It was stressed that he needed to abstain from
illegal drug use to maintain the place. Sadly, the man passed away before he
could return to Hostel A.
Residents’ medication
67. The man was prescribed naltrexone, but did not regularly collect it. He had
been warned of the risks of taking naltrexone and continuing to use illegal
drugs. Whilst at Hostel B he only took naltrexone twice and continued to use
illegal drugs. Staff at the clinic for those with drug and alcohol problems were
aware from their drug tests that the man was not taking naltrexone, and
informed his probation officer who in turn notified hostel staff.
68. I am concerned that hostel staff were not more proactive about monitoring the
man’s use of medication and reminding him of the importance of doing so. It
was a condition of his licence that he address his drug use and, by failing to
take the naltrexone, he was in danger of breaching that condition. I am also
surprised that staff are not required to routinely monitor residents’ collection
and taking of medication, and to report any lapses to their supervising officer.
Informing the man’s family of his death
69. The family was understandably concerned that there was a delay in being
informed of his death. When there is a death in Approved Premises, it is the
responsibility of the police to inform the next of kin. In this case, the same
police officers who were to investigate the death were also responsible for
informing the family. They initially treated the death as suspicious and
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therefore spent most of the morning taking statements, liaising with paramedics
and the coroner’s office. These delays were then compounded by confusion
about the correct police force who would inform the man’s family. I have said in
other reports that I believe that the Probation Service itself should take
responsibility for informing next of kin of the deaths of residents of Approved
Premises. This case further underlines why I believe the Probation Service
should follow the example of the Prison Service in this regard.
The man’s belongings and washing of his clothing
70. The family believed that they would be able to see the man’s room at Hostel B
as he left it and to pack his belongings themselves. They were distressed
when they were informed that the man’s clothing had been washed.
71. My investigator has read the letter to the family, and we understand how the
misunderstanding arose. In fact, staff at Hostel B acted according to probation
policy on dealing with such unfortunate circumstances but they are sorry that
their actions caused distress to the man’s family and have taken heed of their
concerns. The Nottinghamshire Probation Area has already decided that, in
the event of similar events in the future, the next of kin will be consulted about
how they would like to any belongings to be dealt with. Although this will offer
scant comfort to this man’s family, I commend the action that Nottinghamshire
has now taken.
CCTV
72. CCTV was installed at Hostel B shortly after the man’s death as part of a
scheduled national implementation. Whilst any recorded information of this
man’s movements in the hostel, specifically on the evening of 4 February might
have been useful, I am concerned that the CCTV monitors are in the Deputy
Manager’s office which is only used during the main working hours Monday –
Friday. In my view, the Approved Premises Officers’ office, which is in use
throughout the waking hours until at least curfew checks at 11.00pm seven
days a week, would be a more suitable place for the monitors to be installed.
Staff would then be able to monitor the screens more frequently throughout the
day and night, and when they had specific concerns.
15
Conclusions
73. The man was a resident at Hostel B from 26 January 2006, having moved there
from Hostel A where he had lived for the previous month. He moved hostels
primarily due to testing positive for heroin, but also because a space was
needed for another offender.
74. The man did not settle particularly well in Hostel B and felt vulnerable in the
area. He also felt isolated and seemed to be struggling with independence.
When a space became available again at Hostel A, it was agreed it would be in
his interests to return but that he would need to remain drug free. He was due
to return on Monday 6 February.
75. The man was a known drug user. Despite appearing motivated to stop his drug
habit, he clearly struggled to remain drug free. He had also not been taking his
naltrexone medication. Whilst it remains the resident’s own responsibility to
take his/her medication, there should be more monitoring by Approved
Premises staff and questions posed to residents if they are regularly not taking
medication as prescribed. In this case the prescription was part of the
treatment to help address the man’s drug use, which was part of his licence
conditions. There was accordingly a public protection aspect to his use of
medication.
76. During the licence period, the man engaged well with his probation officer and
the services provided by the Prolific Offender Programme and the clinic for
those with drug and alcohol problems. Despite his continued drug use, it would
appear that he was making better progress than he had on his earlier release in
March 2005.
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Recommendations
Nottinghamshire Probation Area
1. The Chief Officer should draw this report to the attention of the Governor
of HMP Nottingham and make him aware that the man produced a
positive drugs test the day he was released from the prison.
Nottingham Probation Service have responded as follows: a letter has been
sent to the Governor of HMP Nottingham to make him aware of the positive
drugs test that the man produced on the day of his release. It has been
suggested that a review of release procedures may be considered.
2. The Chief Officer should ensure there is more regular monitoring of
residents’ use of their medication and that appropriate steps are taken
when they are not doing so.
Nottingham Probation Service have responded as follows: staff are required to
follow the procedure for medication as outlined in the AP Handbook. The AP
staff have undergone a team development day designed to address issues
including the procedures relating to medication and guidelines have been
reissued. Further to this, new keyworking guidelines have been issued as
has a new recording system to quality assure the work done by staff.
3. The CCTV monitors should be located where they can be seen frequently
and regularly by staff.
Nottingham Probation Service have responded as follows: CCTV installation
had begun prior to the man’s death and the AP Manager had taken advice
from the contractor in terms of placing them. It was decided not to place them in
the Duty room as the monitors would have to be above the windows, leading to
possible neck injuries due to the strain of looking up constantly, and staff would
have to stand on steps to reach and operate them and they would be facing the
door that residents use to speak to staff. Therefore residents would quickly
come to know where the monitors did not operate and there may be issues of
confidentiality.
We are liaising with the NPD (National Probation Directorate) to try to overcome
these problems. We will continue to pursue a better outcome if possible.
4. The Chief Officer should draw the family’s concerns about delays
notifying them of their son’s death to the attention of the Chief Constable
of Nottinghamshire.
Nottingham Probation Service have responded as follows: the Chief Constable
of Nottinghamshire has been contacted to raise concerns surrounding the
delayed notification of the man’s death to his family. The NPD have recently
considered the subject of family liaison and will be shortly issuing revised
guidance on deaths in Approved Premises which suggests that probation areas
may wish to consider appointing a named individual to each Approved
Premises, as the point of contact with bereaved families. The role could
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encompass giving information to families after the initial notification of the death
by the police, arranging for the family to visit the Approved Premises and
organising the return of property to the family.
Nottinghamshire Police have, as a result of the above, investigated this. In
their view, because it was initially treated it as a suspicious death, a balance
was struck between the management of a potential crime scene, enquiries to
ensure the correct and proper identity of the deceased, and collecting sufficient
information to properly and respectfully brief the family.
Good Practice
5. I am pleased to note that, since this investigation began, hostel staff now carry
a telephone on all hostel checks.
6. I am also pleased to note that comments made by the man’s family regarding
the removal and handling of personal possessions have been accepted and,
should any such unfortunate events recur in the future, families will be
consulted about this sensitive process.
7. Staff at Hostel A planted a rose bush in their garden in memory of the man.
This was a gesture that I believe was appreciated by his family.
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