Individual at Ashley House

Circumstances surrounding the death of a man
In June 2005, when he was resident at
an Independent Approved Premises used by the Probation Service and
managed by a Management Committee.
Report by the Prisons and Probation Ombudsman for England and Wales
January 2006
This is the report of an investigation into the death of a man who died in June
2005. He had been a resident of an Approved Premises for ten weeks prior to
his death. He was on conditional bail. The man died apparently by his own
hand.
The purpose of my investigation was to discover whether the level of care
provided for the man at the Approved Premises was sufficient, and whether
there are any lessons that can be learned to help prevent a similar tragedy in
the future.
During his time at the Approved Premises the man became known as a
sociable man, popular with residents and staff alike. The man was due to
attend court on the day after his death, but he had given no indication that he
was unduly anxious about the forthcoming hearing. Members of staff at the
premises who had worked closely with the man were shocked and distressed
by his death. They were concerned that he must have been suffering inner
turmoil that had not been apparent to them.
Members of staff in Approved Premises are responsible for the management of
numbers of high risk offenders on a daily basis. I am satisfied that staff at this
premises exercise their responsibility in a caring and supportive manner. I am
also satisfied that the hostel is managed in a professional way, and operates in
accordance with Approved Premises guidelines. I have found no evidence to
suggest that the man had given any indication of intent to take his life, nor that
his actions could have been easily predicted or prevented. However, I make
one recommendation where the opportunity for improvement may exist.
The man was close to his mother, who visited weekly during her son’s stay at
the premises. I have no doubt that his death in such shocking circumstances
affected her deeply and I offer the man’s family and friends my sincere
condolences on their loss.
STEPHEN SHAW CBE
PRISON AND PROBATION OMBUDSMAN JANUARY 2006
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Contents Page
Introduction 3
Summary 4
Investigation Methodology 5
The Approved Premises 6
The man 8
Events leading to the man’s death 9
Consideration and Conclusions 13
Recommendations 15
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Summary
1. The man appeared at a
Magistrates’ Court on 15 April 2005, charged with serious offences, said to
have taken place many years previously. He was remanded on bail to be
tried at the Crown Court, but he was unable to return home. A condition for
him to reside at Approved Premises was therefore imposed. The man was
admitted to the Approved Premises later the same day.
2. The man was described as a sociable man, popular with staff and residents
at the premises. He conformed to requirements and caused no problems.
He was considered to be an ‘ideal resident’ and, although he was known to
be concerned about his forthcoming court appearance, he gave no
indication that he was depressed. He met his mother each weekend and
she told the police that she saw nothing to suggest he had considered self-
harm.
3. The man was due to return to the Crown Court in June for a Plea and
Directions hearing. On the day before the hearing, when he had been
resident at the Approved Premises for some ten weeks, the man left the
house shortly before the curfew hour, ostensibly to post a letter. He was
spoken to by three residents on their way back to the house and he
seemed to be in good spirits, assuring them he would return in time for
curfew. When he failed to do so, the police were informed that he had
breached his bail.
4. At approximately 1:20am on the day of the man’s death, police officers
called at the house to inform staff that the man’s body had been found at a
block of flats situated behind the Approved Premises. It was thought that
he had hanged himself.
5. The man had no history of depression or mental health problems and there
were no signs of any such problems during his period of residence at the
Approved Premises. All the indications were that he was settled and
coping well in the circumstances in which he found himself.
6. Key work sessions took place regularly as required. With the exception of
one occasion in May when the man was worried about the possibility of
people trying to discover his whereabouts, the investigation found no
indication of other problems, apart from the forthcoming court appearance.
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Investigation Methodology
7. A senior investigator from this office conducted the investigation. I am
grateful for the assistance that the investigator received from the manager,
staff and residents at the Approved Premises. I am conscious that the
investigation placed an extra burden upon the manager and her staff who
were trying to come to terms with the man’s death. Nevertheless, they
made facilities readily available and participated fully in the inquiry.
8. Notices were distributed within the Approved Premises, notifying staff and
residents of the investigation. The investigator conducted formal interviews
with the operation manager, three assistant managers, one of whom was
the man’s key worker, and with two residents. The investigator also
examined documents provided by the premises.
9. Her Majesty’s Coroner was contacted to inform him of the nature and scope
of my investigation and to request a copy of the Post Mortem report. Upon
completion, this report will be sent to the man’s mother, to the Probation
Area and the National Probation Directorate, and to the Coroner to assist in
his enquiries into the man’s death.
10. One of my family liaison officers contacted the man’s mother. She spoke
positively about the attention she received from the Manager of the
Approved Premises at the time of her son’s death.
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The Approved Premises
11. Approved Premises were formerly known as Probation and Bail Hostels
and are approved by the Secretary of State within Section 9 of the Criminal
Justice and Court Services Act 2000. Their purpose is to provide
accommodation for persons granted bail in criminal proceedings, and in
connection with the supervision and rehabilitation of persons convicted of
offences. Approved Premises can provide a supportive, structured
environment in the community for high risk and difficult to manage
offenders. The management of offenders accommodated in Approved
Premises is governed by the National Standards for the Supervision of
Offenders and the guidance contained in the National Approved Premises
Handbook.
12. The house is one of four Approved Premises in the Probation Area. It is an
independent, voluntary Approved Premises, managed by a Management
Committee, and provides specialist services for offenders with drug
dependency problems. The premises can accommodate 22 residents, 16
men in the main building and six women in separate cluster
accommodation. The house accepts offenders on bail and subject to either
community penalties or prison licences. Residents must be between the
ages of 18 and 65, but any type of offender will be considered depending
upon the level of assessed risk and the dynamics of the resident group at
any particular point in time.
13. Until about a decade ago, Approved Premises offered accommodation for
offenders who had nowhere else to go, but in recent years the resident
profile has changed. Nowadays, Approved Premises cater largely for
dangerous or serious offenders who are assessed as posing a high risk of
re-offending or harm to the public. The purpose of the house is to provide
an enhanced level of supervision for offenders in the community. Each
resident is subject to curfew restrictions, usually from 11:00pm to 6:00am
for those not working, although other curfew hours may be enforced if either
court orders or licences stipulate.
14. In addition to treatment programmes for drug abusers, the house provides a
programme for all residents to ensure their time is used gainfully.
Residents are required to attend a weekly Life Skills Group, together with
other regular educational activity groups. The house is staffed by a
manager, an operational manager, seconded by the Probation Area,
assistant managers and night supervisors. At least two members of staff
are on duty at any time. Night cover is provided by a night supervisor who
on waking duty throughout the night, and an assistant manager who sleeps
on the premises. CCTV cameras provide oversight of communal rooms
and corridor areas throughout the day and night.
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15. Each resident is allocated an assistant manager as key worker. Key
workers are responsible for monitoring the behaviour of their residents, and
for providing advice and encouragement. Residents are expected to meet
weekly with their key workers. The meetings are recorded and any areas of
particular concern are noted. Close links are maintained between key
workers and case managers, although those on bail are not convicted and
consequently are unlikely to have allocated case managers outside of the
premises. The focus of key work sessions is also different for those on bail
as it is not possible to address offending behaviour. Instead, key workers
provide practical advice and address any emotional issues that may arise.
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The man
16. The man was 54 years of age when he died, and had been resident at the
Approved Premises for almost ten weeks. He was born in the West
Midlands, the only child in a family that moved when he started his
secondary education. After leaving school, the man had various jobs
before becoming a taxi driver. He remained unmarried but left the family
home when he was able to purchase his own property. After spending
holidays in Jersey, he decided to move there permanently and bought a
newsagent’s on the island.
17. The man’s parents visited him regularly until his father died, after which he
maintained frequent contact with his mother. During his stay at the
Approved Premises, the man indicated that his business had been
successful and that he had developed a wide circle of friends. He said that
he had sold most of the business, but retained a newspaper delivery round.
18. In April 2005, the man was arrested as he arrived in England to visit his
mother. He was charged with several serious offences, alleged to have
occurred almost 30 years ago. The man had no previous convictions and
had not been in contact with the criminal justice system before his arrest.
He told his mother about the nature of the charges against him and said he
was innocent. He said he intended to deny the offences when he appeared
in court.
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Events leading to the man’s death
19. The man was referred to the Approved Premises on 15 April by a member
of staff from the Probation Area who works at the Magistrates’ Court. A
comprehensive referral form was completed. The man was said to have no
previous convictions, no problems with alcohol or drugs, no history of
depression or self harm and no difficulty in coping. As an un-convicted
person, referred from Court, there was no OASys (Offender Assessment
System) assessment, but it is clear from the application form that the man
was not considered to pose a high risk, either to his self or others.
20. The man was accepted for residency and, on the same day, he was
granted bail with a condition to reside at the Approved Premises. Further
conditions were that he should not contact witnesses and not go to a
particular area without prior appointments with his solicitor. He was to
appear at Crown Court on 22 April for a preliminary hearing. As the man
was a man of previous good character, the Approved Premises was his first
experience of hostel life.
21. Upon arrival at the hostel, the man was taken through the induction
procedure during which the rules were explained to him. The result of a
routine drug test was negative and the man said he had never used non-
prescription drugs. He was placed in a double room, as it is the regular
practice at the house for new residents to be allocated shared rooms until
staff are satisfied that they are coping well.
22. Each resident of the house is allocated a key worker who is required to
meet formally with his or her residents on a weekly basis. What takes place
at those sessions depends upon the status of the resident, as it is not
possible to focus on offending behaviour with residents who are un-
convicted. The man met with his key worker the day after his arrival. They
discussed the hostel regime and expectations. The various house activities
and groups were explained to him and the man agreed to participate in as
many activities as required.
23. Thereafter, key work sessions took place weekly and there is no indication
in the session notes that the man was depressed or unhappy, above what
might be expected from one who was facing trial on serious charges and
was unfamiliar with the criminal justice system. The man made a claim for
benefit in order to pay the required rent and he was actively seeking work.
He appeared to settle well and the hostel log indicates that, although he
seemed a quiet man, he was soon mixing with other residents. On 22 April,
he appeared at Crown Court and was remanded again to June for a Plea
and Directions hearing. Having quickly settled into the regime, on 7 May
the man was moved to a single room overlooking the front of the house.
He remained there until his death.
24. Those members of staff and residents who were interviewed by the
investigator described the man as a quiet man who had no mood swings.
His key worker said that, in the weeks they worked together, he did not see
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the man angry or upset. The key worker described the man as level
headed and well organised, but also light hearted and quick to smile. He
also said that he found the man’s calmness and equanimity refreshingly
unusual in a hostel resident. The key worker told the investigator that the
photograph taken of the man when he arrived at the hostel showing a ‘half-
smile’ on his mouth and in his eyes, “summed him up well”. The key worker
said the man was always affable.
25. The man attended morning meetings and groups, regularly contributed in
appropriate ways, and always did what was required of him. It was said
that he spent much of his free time with crosswords and other puzzles,
engaging with other residents, yet remaining slightly aloof. All drug tests
were negative and routine searches of his room produced no results. In
May, the man had a problem with his foot and was prescribed Diclofenac,
an anti-inflammatory pain killing drug. On 15 June, he told a member of
staff that he had sickness and diarrhoea, and a telephone call was made to
NHS Direct. The man was advised to drink water and call again if his
symptoms persisted. He did not report the problem again and otherwise,
he remained healthy. The man was described as polite and compliant, in
many ways a model resident.
26. At the beginning of May, the man told his key worker that he had lost his
rented rooms and was soon to dispose of his newspaper delivery business.
However, neither staff members nor other residents had any sense of the
man being unduly troubled, apart from one occasion when he expressed
anxiety over people trying to discover where he was living. He was
concerned as an unknown person had called on his mother late at night.
An assistant manager reassured him about confidentiality policies and the
subject was not raised again.
27. The man had no known contact with anyone outside the house except his
mother whom he met each weekend. He was not seen to have any
particular friends and he received no letters. A resident who was
befriended by the man, and clearly felt close to him, described him as a
jovial person who did not take many things seriously. She said he was a
kind, caring man, whom she had come to see as something of a father
figure. She told the investigator that she had only seen the man “down” on
a few occasions, in particular after he had been in consultation with his
solicitor. He told her he was worried about the Plea and Directions hearing,
but she tried to reassure him as she knew he would not be sentenced on
that day.
28. On a Saturday in June, the man met his mother as usual. In her statement
to police, she said she had found nothing unusual in her son’s demeanour
or behaviour. The man then spoke to his mother on the telephone a few
days later and seemed to be in good spirits. On the Thursday before he
died, the man spent some time with another resident who gave him £2 for
cigarettes. She said it was unusual for the man to have no money, but she
was aware that he often lent money to other residents and she thought
perhaps he had not been repaid. The resident told the investigator that she
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had seen nothing unusual in the man. On the rare occasions that he was
less than cheerful, he would “stick his head in a magazine and smoke a lot”
but the resident did not notice such behaviour on that day.
29. The man attended the morning meeting on 23 June, and was later seen in
the common room by an assistant manager who said there was nothing
unusual in his behaviour. With hindsight, the assistant manager recalled
that the man was smoking hand rolled cigarettes rather than his usual
ready made brand, but she said that she would not have found this
significant even if she had noticed at the time.
30. Around 7.00pm on 23 June, the man participated in a planned meeting with
his key worker. The key worker told the investigator that the man seemed
no different, and he did not see signs of anything untoward. He knew that
the man was due to attend court the following morning but said he did not
appear unduly worried about this. The key worker said it was a pleasant
evening and he and the man sat on the patio, talking in the sun. When the
session came to an end, the key worker returned to the house while the
man remained on the patio for a time. Later that evening, he played pool
with another resident.
31. CCTV photographs taken on the night of his death indicate that the man left
the premises at about 10:45 pm. He was carrying a holdall in one hand and
what appears to be a letter in the other. As he descended the stairs, he
glanced around him as if to ensure no-one was about. The man was not
seen leaving the hostel, but three residents who had been for a walk and
were on their way back spoke to him in the street. One resident told the
investigator that they were surprised to see the man in the street as it was
close to curfew time.
32. The resident said he asked the man, jokingly, if he was escaping. Without
stopping, the man replied that he was going to post a letter and carried on
walking. The resident told the investigator that the man’s response seemed
to be “jovial”. Another resident said something to the man about hurrying
back for curfew, but none of the three men was concerned at the time. The
resident told the investigator that he discerned nothing different about the
man’s demeanour or behaviour, either when they met at dinner or later in
the street, and he found the manner of the man’s death surprising.
33. At 11:00 pm, the night supervisor and the assistant manager on duty
carried out the required curfew check by visiting each room to ensure that
all residents were in. The man’s room was empty. The night supervisor
conducted a thorough check of the premises, but the man was missing.
The assistant manager was surprised at his absence as he had been a
‘model resident’. At approximately 11:30 pm, the assistant manager
checked the CCTV footage and saw that the man had left the house at
10:43 pm. The man’s absence at curfew placed him in breach of his bail
conditions and the assistant manager immediately completed the
paperwork necessary to breach him, as was required, and notified the
police of the breach by telephone.
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34. At 1:20 am, two police officers called at the hostel and informed the night
supervising officer that a body, thought to be that of the man, had been
discovered outside a block of flats close to the rear of the house. There
had been scaffolding around the block for some time and the man had
apparently hanged himself. The post mortem examination subsequently
confirmed that this was the cause of death. The visiting police officers
found a length of new rope in the man’s room.
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Consideration and Conclusions
35. It was the role of this investigation to consider if the risk of self harm had
been properly assessed and managed, and whether the level of care
provided for the man, during the time he spent at the house, was adequate.
In doing so, I also considered whether the hostel procedures were
commensurate with the requirements for all such hostels as defined in the
Approved Premises Handbook and familiar to staff. It was clear that the
premises provide a structured environment for residents who present a high
level of risk. The members of staff interviewed were confident about their
roles and procedures to be followed. Staff members were also caring and
concerned to do their best for all residents.
36. The investigation found that there are procedures in place for the recording
of day to day events of note in the hostel log and, additionally, for any
specific issues of concern to be recorded in individual's files. The members
of staff were familiar with these procedures. It was a matter of pride to
them that records were made quickly after events occurred while they were
clear in the mind. There was evidence in the detail of the daily 'hand overs'
that members of staff are supportive of their colleagues, and work well as a
team, so that there is continuity of care. It appeared that residents' issues
are dealt with sensitively regardless of which staff members are on duty.
37. The investigation found every indication that the man was popular with the
residents and staff at the house, and did all he could to be helpful. Apart
from one or two health problems of short duration, he was healthy and had
no difficulties with drink or drugs. The man had no history of depression or
mental health problems and there were no signs of any such problems
during his period of residence. All the indications were that he was settled,
was coping well at the house, and appeared content.
38. Key work sessions took place regularly as required and were appropriately
recorded. The man’s key worker discussed practical issues and assisted
him with areas of concern. The notes indicate that, on 24 May, the man
was worried about the possibility of people trying to discover his
whereabouts but he seemed reassured after speaking with the key worker.
The investigation found no indication of other problems, apart from the
forthcoming court appearance. The man was facing serious charges and
the possibility of a lengthy period in custody if convicted.
39. The man had told his key worker that he expected to be at the house for
some time, as he understood his court dates would be in August and
beyond. With hindsight, it could be suggested that the man intended his
behaviour to demonstrate all was well with him, thus enabling him to avoid
closer scrutiny. However, staff at the house did not have the benefit of
hindsight and, at the time, there were no signs that he intended to harm
himself. Although we cannot be certain, the acquisition of a rope that was,
apparently, cut to size may indicate that the man developed such intent and
planned his actions in advance.
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40. The man was referred to the Approved Premises by the court duty officer,
and a referral assessment completed on 15 April gave no indication of a
risk of self-harm. However, the assessment was not as detailed as it would
have been if the man had been referred for residence following a prison
sentence, or post conviction, when an OASys assessment including a risk
management plan would have been completed. OASys is a system, used
by both the Prison and Probation Services, for identifying and quantifying
risk. The system can identify the risk of self-harm but it is, essentially,
geared towards assessing the risk of harm to the public and the risk of re-
offending.
41. I understand that the assessment of those released on bail pre-conviction
presents a unique challenge, and in the man’s case, given the lack of
indicators, it is unlikely that OASys would have identified any risk of self-
harm. Nevertheless, I question the practice of forgoing a system of
thorough risk assessment in use throughout the Prison and Probation
Services.
I recommend that the Probation Area reviews its procedures for
assessing the risk posed by those on bail to themselves and others,
and considers whether they can be improved
42. That said the investigator formed the view that members of staff work hard
to ensure that residents are treated as individuals, with care and
consideration. She was satisfied that the overall quality of care provided by
the Approved Premises to the man was good. There was no evidence to
indicate that the man’s sad death could have been prevented by changes in
either management procedures or policy.
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Local Recommendation:
I recommend that the Probation Area reviews its procedures for assessing
the risk posed by those on bail to themselves and others, and considers
whether they can be improved.
(Since this report was produced in draft form, it has been confirmed that the
Probation Area accepts the recommendation and is currently undertaking a
review of its procedures.)
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