Individual at Linden Bank

Investigation into the circumstances surrounding the death of
a man on 30 April 2005 while a resident at an Approved
Premises under the management of the Probation Service
Report by the Prisons and Probation Ombudsman for England
and Wales
October 2005
This is the report of an investigation into the death of a man on 30 April 2005,
while a resident at an Approved Premises. The man was on bail, charged
with offences of theft. The purpose of my investigation was to establish the
circumstances and events surrounding the man’s death, including the quality
of care provided by the Probation Service.
The investigation was led by a senior investigator. I am grateful for all the
assistance that the investigation team received from the Manager of the
Approved Premises and his staff.
A key objective of all my investigations is to make sure that the bereaved
family has the opportunity to raise any concerns and contribute to my
inquiries. In this case the investigation team spoke to the man’s mother on
the telephone. I am most grateful to her for having this conversation at what
must have been a very difficult and distressing time.
I offer sincere condolences to the man’s family and friends in their sad
loss.
The man who is the subject of the report was found hanging in a wooded area
some miles from the Approved Premises. There is some evidence of recent
opiate use. This report concludes with three recommendations and two
observations.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN OCTOBER 2005
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CONTENTS Page
SUMMARY 4
CONDUCT OF THE INVESTIGATION 5
BACKGROUND INFORMATION:
The man 6
The Approved Premises 7 - 8
THE MAN’S TIME AT THE APPROVED PREMISES 9 - 12
CONSIDERATIONS AND CONCLUSIONS 13 - 14
RECOMMENDATIONS 15
OBSERVATIONS 16
RESPONSE FROM NATIONAL PROBATION 16
DIRECTORATE
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SUMMARY
The man Harrison was 36 years old when he died. He had a history of drug
abuse and of offending to fund his habit. He had previous convictions,
between 1985 and 2004, for theft and drug offences. He was arrested for
theft on 25 April 2005 and on 26 April, he was bailed to reside at the Approved
Premises. The conditions of his bail were to co-operate with the Community
Drugs Team, including testing, and to abide by the hostel rules and
regulations. His next court appearance was scheduled for 13 May 2005. The
man arrived at the hostel around 10pm on 26 April. He received a full
induction on 27 April. On 29 April, he told the Deputy Manager that he had
injected heroin after his court appearance but before arriving at the hostel on
26 April. He also said that on 28 April he had taken a prescription drug, which
suppresses withdrawal symptoms, as well as cannabis and heroin. He
warned that he would be withdrawing over the weekend. He told a member of
staff at the hostel that he wanted help to try to break the circle of drug abuse
and offending behaviour and said that he had, on occasion, remained drug
free for periods of time.
The man was allocated a key worker and his supervision plan was discussed
with him. Arrangements were made for him to see a member of the
Community Drugs Team (CDT) on 4 May, and a doctor on 9 May. The man
left the hostel on 29 April at around 6pm and he was seen by two hostel
residents at the local train station around that time. He did not return to the
hostel before the 11pm curfew. The man was then in breach of his bail
conditions and police were advised by the hostel.
The man was found at around 9am on 30 April by two members of the public.
They saw the man hanging from a tree in a wooded area not far from the
hostel. The Police and Ambulance Service quickly arrived on the scene.
Paramedics confirmed that the man had been dead for some time so made no
attempt at resuscitation. The man’s body was transported to hospital. During
his short time at the Approved Premises from 26 to 29 April, the man had not
given staff any indication that he was intending to take his own life.
Members of staff at the premises try to ensure that residents are treated as
individuals with due care and consideration. I am content that the overall
quality of care provided by the hostel to the man was good. I have found no
evidence to indicate that this man’s sad death could have been prevented by
changes in either management procedures or policy but I have made three
recommendations.
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CONDUCT OF THE INVESTIGATION
During the course of initial inquiries, the investigation team were shown
around the Approved Premises. They reviewed all the relevant
documentation and established a chronology of events. Notices were issued
to staff and residents telling them of the investigation and offering them the
opportunity of contributing. There were no responses to these notices.
One of my Family Liaison Officers contacted the man’s family and offered
them the opportunity to meet with her and the senior investigator to discuss
the purpose of the investigation and to raise any concerns or questions that
they would like explored and addressed. The family liaison officer
subsequently spoke to the man’s mother on the telephone.
Six members of staff were interviewed during the course of the investigation.
They were all offered the opportunity of being accompanied by a work
colleague or Trade Union official. The investigation team also spoke to a
resident at the hostel.
The investigation team contacted Her Majesty’s Coroner to tell him of the
nature and scope of the investigation.
The investigation team had telephone conversations with the Police Constable
responsible for investigating the man’s death on behalf of the police. The
police were advised of the scope of the Ombudsman’s investigation and the
Police Constable provided copies of police statements taken as part of their
investigation. She also provided a copy of the Post Mortem report. The
police were offered the co-operation of the Ombudsman’s investigation and to
share any information which might be relevant to their inquiry. Transcripts of
the interviews undertaken by the investigation team were sent to the police.
The Post Mortem report of 4 May 2005 recorded the cause of death as
hanging with evidence of recent morphine and/or heroin use and intake of
ethanol. The toxicology report concluded, ‘as in all cases involving opiate
drugs, the toxicological significance of these concentrations will depend upon
the degree of tolerance possessed by the deceased. However, the additional
presence of ethanol may have exacerbated any toxic effects but it is not
possible to determine any specific resultant effects of these drugs in relation
to the deceased’s state of mind.’
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BACKGROUND INFORMATION
The man
The man was born in January 1969, and was 36 years old when he died. He
had been of no fixed abode for over six years, when he had been staying with
various friends and associates. He had a history of long term abuse of illegal
substances, particularly heroin, which he had smoked and injected. This had
led to health complications when he was admitted to hospital for a short time
as he had thrombosis in his leg as a result of which he took aspirin on a daily
basis.
The man had a history of offending to support his drug habit. He had been
convicted of various offences between 1985 and 2004, mainly theft and drug
offences and had spent periods in prison custody between 2000 and 2004.
Records from Altcourse Prison relating to his last period in custody do not
indicate that there were any concerns that he was suicidal or likely to self
harm. The man was arrested for theft on 25 April 2005 and was subsequently
bailed to reside at the Approved Premises. Hostel staff describe him as quiet,
intelligent and polite, and say that he settled well into the hostel.
The man’s parents told the police that he was shy when he was a child, until
he was nine or ten years old. They said that he left home at about 17 years
old, but he remained welcomed by his family. He lived with a partner, and had
a son, but the relationship subsequently broke up. It seems that by then the
man had developed a drug habit, and was committing criminal offences to
fund it. His family did not consider that, at any time, he was deeply unhappy
or depressed.
The Approved Premises
The Approved Premises accepts all categories of offenders. It is a 22 bed
unit, and has been designated all-male accommodation since April 2005.
Residents are over 18 and the majority are on licences or statutory orders.
College tutors attend the hostel 2 ½ days a week to teach subjects such as
basic life skills and literacy. A Community Drugs Team (CDT) nurse attends
once a week. Every resident is allocated a key worker who helps with issues
such as accommodation needs and benefits claims. A minimum of two
members of staff (supervisors) are on duty in the hostel at any time. During
the day, there is the manager or deputy manager and usually three or four
other supervising staff on duty. On night duty, there are a minimum of two
members of staff, an assistant warden and a night supervisor. The assistant
warden is the duty officer in charge of the hostel and stays awake until
midnight. The night supervisor then takes over active supervision of the
hostel and stays awake until 7am. The night supervisor can call for assistance
from the sleeping assistant warden during this time if necessary. At 7am the
assistant warden joins the night supervisor until the day staff arrive at 9am.
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Overall, the hostel employs four assistant wardens, three residential support
workers, three waking night staff, a part time administrator, a full time deputy
manager, a part time deputy manager and a manager.
The investigation team was advised that all staff have had First Aid training
this year and all undertook Health and Safety training as part of their induction
programme. Training in the Prevention and diffusion of violence took place
this year.
There was a suicide risk-management awayday around the beginning of 2004
to draw up local policies for the management of suicide risk. A risk concern
process was introduced at the premises as a result of the awayday. This is a
process to follow if staff are concerned about a resident being at risk of self
harm or suicide. A Form (A), ‘Risk of self harm or suicide’ should be raised by
the member of staff with details of their concerns. A Form RC1 should then
be completed by the member of staff and passed to a manager for
consideration of further action to be taken. Not all staff interviewed were clear
about this process. It will be redesigned this year to be more like the new
Prison Service suicide prevention arrangements, the ACCT system,
(Assessment, Care in Custody and Teamwork). The National Probation
Directorate is looking to incorporate a common approach to suicide prevention
across the North West region and this will be a modified ACCT system.
The Approved Premises used to have access to a Community Psychiatric
Nurse (CPN), who completed psychiatric assessments on site. This service
has been withdrawn over the last 12 months. Currently residents who require
a psychiatric assessment are referred to the CPN via a GP, which can take
months to organise.
The hostel log records significant incidents that have happened in the hostel,
and which other staff members need to be aware of.
Residents are allocated a room on arrival. Rooms are single occupancy apart
from one double room that is used for twin occupancy if required. Residents
have a key to their own rooms. They are expected to be in the hostel by
11pm and in their rooms between 12am and 7am, unless they have an early
curfew which is 7pm. Residents leave their room key with a member of staff
when they go out of the hostel. A cold breakfast is provided to residents and
they receive a cooked evening meal.
The hostel has a comprehensive drugs policy. Residents are expected to co-
operate with the Community Drugs Team (CDT). The CDT nurse visits the
hostel once a week. Any resident who needs methadone or any other
substitute drug provision requires a CDT referral. The CDT nurse decides
what medication is needed and is responsible for prescribing that medication.
The waiting list to see a CDT nurse outside the hostel is three or four months.
Usually, hostel residents are seen by a CDT nurse within a week of referral. If
a resident has immediate drug issues they can be referred to a GP. However,
it is difficult to get an appointment to see a GP outside of hostel visiting hours
(once a week) and the GP will not necessarily prescribe what the resident
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wants. It is the role of the CDT nurse to prescribe medication in respect of
drug issues.
The premises has a policy that no illegal drugs are to be taken on the
premises. If residents are caught in possession of illegal drugs then they are
in breach of their conditions. If residents are on a licence or a Court Order
rather than on bail, then the decision about recall or return to Court is taken by
the case manager. Their bed at the hostel is withdrawn immediately. The
only exception to this might be if the resident is in possession of a class ‘C’
drug only, and if there is evidence of a significant reduction in their use of
class ‘A’ drugs.
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THE MAN’S TIME AT THE APPROVED PREMISES
On 25 April, the man was arrested for theft from a supermarket of items worth
about £80 and on 26 April, was bailed to reside at the Approved Premises.
The Bail Referral Form noted that he came across as an intelligent young man
who had struggled with a long-term problem with heroin. The man told the
probation officer who referred him to the Approved Premises that he had not
used heroin this year and that he was trying to maintain a drug free life. The
man said that he had committed the offence as he was short of money. The
opinion of the probation officer was that the man did not come across as a
person who was still using drugs. The man’s court case was adjourned until
13 May 2005 for a pre-sentence report to be completed. He was hoping that
the Court would eventually impose a Community Supervision Order on him as
he felt that he needed this kind of support. The Bail Referral Form was faxed
to the premises at 3.10pm on 26 April. The conditions of his bail were to co-
operate with the Community Drugs Team, including testing, and to abide by
the hostel rules
26 April
The man telephoned the Approved Premises at 9.10pm on 26 April to tell
them that he was on his way but he did not expect to arrive there until after
10pm. The formal induction for residents at the premises is undertaken by a
residential support worker, between 2pm and 10pm during the week and
between 10am and 10pm on a Saturday. Induction is normally undertaken on
the day a resident arrives. As the man arrived after 10pm on 26 April, there
was no residential support worker available to undertake his induction until the
following day. When the man arrived at the hostel, he was seen by an
Assistant Warden, who was the Duty Officer throughout the night until the next
morning. The Assistant Warden showed the man around the premises and
briefly explained the hostel rules and regulations to him. The man signed a
copy of the rules and regulations to confirm that he understood them. The
Assistant Warden said that he did not have any concerns about the man’s
wellbeing when he arrived at the hostel. He said that the man was quiet when
he arrived, but this was not surprising as it was late and he was probably tired.
The Assistant Warden said that the man was not showing any signs of
disquiet, agitation or that he needed medication. He said that he would have
spoken to the man at length if he had any concerns about him.
There is a keyworker note written by the Assistant Warden, ‘Arrived late
evening, rules and regs only done. Settled in reasonably well.’
27 April
The man’s full induction was undertaken on 27 April by a residential support
worker. The support worker completed the standard induction paperwork for
the man, that is: medication consent form (signed), resident’s checklist, official
agent’s form (signed), ethnicity form, dietary needs form, notice of weekly
meetings with Deputy Manager (signed), data protection information leaflet
(signed), notice about personal property (signed), and details of next of kin.
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An induction checklist should be completed by the residential support worker
following the induction process. There was no checklist available for the man.
The support worker could not explain why, and could not recall whether the
checklist had definitely been completed.
The support worker did not have any concerns about the man in relation to
self harm or suicide. He was, however, not entirely clear about the ‘risk
concern’ process as detailed earlier.
A note in the hostel log book at 9.15pm, written by the support worker, says,
‘The man is having difficulty without the gear’. There is also a keyworker note
written by the support worker, saying, ‘Fine, not mixing too much. Full
induction done today. Went out early evening.’
28 April
On 28 April, the Approved Premises had a telephone call from British
Transport Police (BTP) around 10am, to say that they had arrested the man
for travelling on a train without paying his fare. There is a note in the hostel
log book, written by an assistant warden at the premises, saying, ‘phonecall
from BTP, they have picked up (the man)who has travelled on the train
without paying. They wanted to check if we had sent him’. The man told the
police that he was going to claim benefits as the hostel had told him to. The
Assistant Warden who had taken the message told the police that the hostel
would issue a resident with a travel permit if they had to travel to claim
benefits.
It is not clear what action the police took after this incident, but the man
returned to the hostel before the 11pm curfew. If the police had charged him
then the man would have been in breach of his bail conditions.
A keyworker note, written by the Assistant warden, says, ‘phonecall from BTP,
they had picked him up for ‘dodging’ fares. Out all day.’ She also said in
interview that she was aware that the man was suffering from drug withdrawal
and he appeared pale and shaky.
29 April
On 29 April, at around 10.30am the Assistant Warden on duty, said that he
saw the man in the pool room area talking to other residents. He said that the
man appeared relaxed and unconcerned.
The Deputy Manager, had an appointment to see the man at 11am. The
purpose of the interview was to undertake a risk assessment, appoint a key
worker and produce a supervision plan regarding drug treatment. The
interview lasted from 11am to 11.45am. The Deputy Manager said that the
man appeared ‘normal’ during the interview, and that his mood was fine, but
physically he looked slightly flushed in the face. She said that he told her that
he had injected heroin on 26 April when he came out of court and before he
arrived at the hostel. She raised with the man the comments included on the
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Bail Referral Form that said that he was no longer using heroin. The man
explained to her that he had not told the court the truth, as he did not want
them to think that he was a constant drug user.
The man told her that on 28 April he had taken a quantity of DF118 tablets
(Dihydrocodiene, a prescription drug which suppresses withdrawal symptoms
although it also has other uses), had smoked a cannabis cigarette and had
injected some heroin. He named an area which was his usual area for
obtaining drugs and he had bail conditions to keep away from another area
due to his shoplifting offences. However, the man said that as he would be
withdrawing over the weekend he might be tempted to offend to obtain drugs
to combat this. He said that he would walk to his usual area for obtaining
drugs to get drugs if necessary, which is quite a distance, and that he saw his
shoplifting as a career. The Deputy Manager thought that he was honest
about what drugs he had recently used as there were no obvious signs of
withdrawal. She said that physically the man’s face was slightly flushed but
his speech was fluent and he was clean and well presented.
The Deputy Manager explained to my investigator that the man responded
well to suggestions about the plans that would be put in place to help him.
She said that he came across as an intelligent man. However, he was
negative about the vicious circle of his drug use and offending behaviour. He
told the Deputy Manager that he consistently returned to drug use. He had an
appointment to see the CDT worker the following Wednesday, 4 May. He did
not ask to see a doctor at this stage but an appointment was arranged for him
to see a doctor on 9 May which was the next time the doctor was due at the
hostel, because of the bank holiday on 2 May. The man did not have any
medication with him. He told the Deputy Manager that he was taking aspirin
for thrombosis in his leg. No action was taken to discover whether the man
had or indeed needed a prescription for DF118 tablets.
The man was last on a Community Supervision Order between September
2002 and March 2003. He told the Deputy Manager that he had found
supervision useful but he had been disappointed in the past that this had not
been on his terms and had not been what he wanted. She said that the man
agreed that he was negative in his attitude but he did appear motivated and
willing to co-operate with the support being offered. The Deputy Manager
said that she asked the man directly about issues of self harm and suicide.
His response was that he had never harmed himself and he saw suicide as
‘an easy way out’ so would not contemplate the thought. The man told the
Deputy Manager that he had suffered from depression in the past but had not
received any medical treatment. She said that the man engaged well with her
during the interview and was very articulate. There was nothing in his
demeanour that gave her concern that he was at risk of ending his life. The
Deputy Manager said that, in fact, he was making plans for the future, that he
had made a benefit claim and was discussing his pending meeting for his pre-
sentence report.
The same Assistant Warden who had seen the man earlier that day said that
later that afternoon he spoke at length to him and two other residents. He
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said that the man was friendly, talkative, confident and articulate and told him
about his qualification to teach literacy skills and his experience of teaching
English to young offenders. This Assistant Warden said that the man gave
him the impression that he was happy to be a resident at the Approved
Premises and had settled in very quickly because he knew some of the
residents. The Assistant Warden said that the man did complain of boredom
but he felt that this was done in a light-hearted way and he did not give any
indication that he had thoughts of self harm or suicide.
At around 4.20pm the Residential Support worker said that the man told him
that he was expecting a telephone call from his family but it had not come.
The man told him that he was going to make a telephone call, presumably to
his family, to see what was happening. The man went out, presumably to
make the telephone call, and CCTV shows him leaving the premises at
4.20pm and returning at 4.55pm. The support worker said that the man’s
body language was negative when he returned to the hostel. The man said
that he had not been able to get in touch with anybody on the telephone and
was muttering about being the ‘black sheep’. The support worker said that the
man did not engage with him or make any eye contact with him. CCTV shows
him leaving the hostel again at 6pm. A resident of the Approved Premises
saw the man at a local train station, possibly that evening. He said that he
asked the man whether he was going back to the hostel. The man said that
he did not know, and it depended on where he ended up. The resident said
that the man did not appear to have any worries.
At approximately 9pm, as a result of another resident asking about the man’s
whereabouts, the Assistant Warden became aware that the man was not in
the hostel. The man did not return for curfew at 11pm and the Assistant
Warden initiated the hostel’s breach of bail procedures. That is, he
telephoned the police and faxed the required breach of bail documents to
them: bail sheet, breach statement, and the rules and regulations document
signed by the resident.
There is a keyworker note written by the Assistant Warden, ‘The man seemed
quite happy but at 9ish he went out and didn’t return, breached. It seems he
told a resident that he didn’t know if he would stay.’
30 April
Around 9am on 30 April, two members of the public saw the man hanging
from a tree in a wooded area around seven miles from the Approved
Premises. The Police and Ambulance Service arrived on the scene within 10
minutes. Paramedics confirmed that the man had been dead for some time
so made no attempt at resuscitation. The man’s body was transported to the
hospital. The police investigation concluded that there were no suspicious
circumstances surrounding the man’s death.
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CONSIDERATIONS AND CONCLUSIONS
The man was bailed to reside at the Approved Premises and he arrived there
on 26 April. He had a troubled history of drug abuse and offending to fund
this habit. He indicated to staff that he was going to try to break this pattern,
with their support. The man was scheduled to see a CDT worker and a GP
the following week. He was only in the hostel for four days, 26 to 29 April, and
staff describe him as quiet, articulate and well mannered.
Members of staff at the premises try hard to ensure that residents are treated
as individuals with care and consideration. I am satisfied that the overall
quality of care provided by the hostel to the man was good. There was no
evidence to indicate that this man’s sad death could have been prevented by
changes in either management procedures or policy. Staff who spoke to the
man say that he did not show any signs of being troubled and certainly did not
give any indication that he intended to self harm or take his own life. The
toxicology report records that the man had recently taken morphine and/or
heroin and ethanol before he died. The report cannot determine, however,
what effect this would have had on his state of mind.
There is a ‘risk concern process’ in place for staff to follow if they have any
concerns about a resident intending to self harm or commit suicide. The man
did not indicate to any member of staff that he was at risk. However, not all
staff at the Approved Premises were clear about how this process worked.
Recommendation:
A training needs analysis should be carried out to cover training in
suicide awareness, risk assessment and prevention.
The man indicated to a number of staff that he was withdrawing from long
term use of drugs. He told the Deputy Manager that he had taken some
medication (DF118 tablets) during the week to help with the withdrawal
symptoms. The man also said that he was taking aspirin to deal with
thrombosis in the leg which was a result of his drug use. He did not have any
medication when he arrived at the hostel.
I have two concerns about what happened to the man at the hostel. First, my
view is that the hostel should have enquired further into the question of the
prescription drugs he was taking, and whether these had been legitimately
obtained and required renewing.
Second, it seems to me that on 29 April the man was asking for help in
withdrawing from drugs. Without that help, he was liable to re-offend.
Although I take the view that the hostel did all it could in making the man an
appointment to see the CDT nurse the following week, it seems to me that
more flexible and coordinated arrangements ought to be available to provide
immediate help to those withdrawing from drugs.
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Recommendation:
I recommend that the local probation area considers implementing more
co-ordinated and flexible arrangements for giving immediate support,
where necessary, to hostel residents who are suffering from drug
withdrawal.
The man had a full induction on the 27 April 2004, which was undertaken by a
residential support worker. All the induction documents were completed with
and signed by the man. However, the induction checklist which should be
completed by the residential support worker after the induction cannot be
located.
Recommendation:
I am concerned that relevant paperwork appears either not to have been
completed or to have gone missing. I recommend that the manager of
the Approved Premises reviews the administrative system to ensure it is
working efficiently.
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RECOMMENDATIONS:
Recommendation:
A training needs analysis should be carried out to cover training in
suicide awareness, risk assessment and prevention.
Recommendation:
I recommend that the local probation area considers implementing more
co-ordinated and flexible arrangements for giving immediate support,
where necessary, to hostel residents who are suffering from drug
withdrawal.
Recommendation:
I am concerned that relevant paperwork appears either not to have been
completed or to have gone missing. I recommend that the manager of
the Approved Premises reviews the administrative system to ensure it is
working efficiently.
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OBSERVATIONS:
I welcome the fact that the local Probation Area is considering engaging a full
time CPN to work with the Approved Premises in the area. I hope that this
can be organised as quickly as possible.
I am concerned about the absence of a standardised risk assessment when
hostel residents are asked to share a double room. I have written separately
on this matter to the National Probation Directorate.
RESPONSE FROM NATIONAL PROBATION DIRECTORATE:
National Probation Directorate have accepted the three recommendations and
the local Probation Area are pursuing an action plan in response.
In response to the observation in the report and subsequent letter from
Stephen Shaw, expressing concerns about the absence of a standardised risk
assessment when residents are asked to share a room. National Probation
Directorate have considered these concerns and agree in principle that a risk
assessment should be conducted in such circumstances. They have agreed
to look into this further and issue appropriate guidance.
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