Individual at Chorlton

Investigation into the circumstances surrounding the death
of a man on 22 April 2005
at an Approved Premises under the
management of the Greater Manchester Probation Area
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2005
This is the report of an investigation into the circumstances of the death on 22
April 2005 of a man whose probable cause of death was a drug overdose. It
was well known that he had a long term history of misusing drugs.
The man was released from HMP Holme House to the Approved Premises.
The prison and Greater Manchester Probation Service had worked together
with him to make plans for his return to the community. His arrival at the
approved premises went smoothly, and he was welcomed by one of the
Assistant Managers who gave him a comprehensive induction. He went out
of the hostel soon afterwards but sadly died later that evening.
Since 1 April 2004, my office has been responsible for investigating all deaths
of approved premises residents, including those due to natural causes.
The Assistant Ombudsman conducted this investigation with the assistance of
an investigator from my department.
A clinical review into the man’s healthcare needs was conducted on behalf of
Central Manchester Primary Care Trust. I am grateful for the clinical
reviewer’s assistance, especially as it is not customary for such reviews to be
undertaken following deaths in approved premises.
I would like to extend my condolences to the man’s family and friends for their
loss. They have expressed disappointment with the services offered to him
on release, which they consider were not adequate for him to overcome his
heroin addiction within the community. However, along with the investigation
team and the clinical reviewer, I have been struck by the extent of the multi­
disciplinary resources and planning that went into his release. I do not believe
that there were any deficiencies. My sympathies are therefore also with those
responsible for his resettlement planning. They too are disappointed that he
did not achieve all that they had hoped.
Stephen Shaw
Prisons and Probation Ombudsman July 2005
2
Contents
Page
Summary 4
Background 5
The man 5
The approved premises 5
Conduct of the Investigation 7
Key findings 8
Prior to 22 April 8
22 April and afterwards 10
Conclusion 12
Good Practice 12
3
Summary
1 Between the age of 18 and his death, the man had been convicted of
many offences and been sentenced on 23 occasions, including nine
periods in custody. He also received financial and community penalties,
on some occasions breaching their conditions and being sentenced again.
By the definition of the police, courts and probation service of Greater
Manchester, he was identified as a prolific offender and thus the intensive
multi­disciplinary resources of the Operation Rhodes prolific offender
project were made available to him. Operation Rhodes is the project
which works in the borough where his home town is situated. Its members
include probation, police and nursing staff who work together to try to help
offenders deal with their drug use and so reduce their offending.
Offenders who have served sentences longer than 12 months are eligible.
They have four appointments with their supervisors each week, including a
weekend home visit and fast tracked medical appointments.
2 On 27 May 2004, the man was convicted of robbery from a shop and
sentenced in September to 15 months imprisonment which he served at
HMP Manchester. He was referred to the prison’s Counselling,
Assessment, Referral, Advice and Throughcare (CARATS) team and plans
were made for his release on licence on 19 November to another
Approved Premises. He breached the conditions of the licence which was
revoked seven days later and he was recalled to prison.
3 The man’s recall to prison took place on 26 November. He was located
initially in Manchester, but was transferred to HMP Holme House on 2
March 2005. The prison records include a number of adjudications and
one positive drug test. Again the CARATS team worked with him, and
again the probation area arranged accommodation in one of their hostels
and supervision by Operation Rhodes.
4 He was released from Holme House on 22 April, with a condition of
residence at an approved premises. He made his own way from the
prison to the probation office in Oldham, from where he was taken by
probation staff to the approved premises, arriving at about 4:00pm. He
was welcomed by the Assistant Manager on duty, and made himself a
drink before the induction interview was carried out. He then left the
building, saying that he was going to see his children. Later that evening,
the police contacted Chorlton Hostel to enquire about residents as a body
had been found nearby. It was later identified as that of the resident of the
approved premises. His death was the result of using excessive amounts
of heroin.
4
Background
The man
5 He was born 5 April 1974 in Oldham and was 32 years old when he
died. He had had a long term relationship, but regrettably the
relationship failed though he did keep in contact with his twin sons. His
next of kin was recorded as his elderly grandmother, and his sister has
also been attending to his affairs.
6 His criminal record dates back to April 1992 and, by the time of his
death, he had 23 convictions mostly for acquisitive crimes committed to
finance his drug misuse. He served many custodial sentences and had
also had an earlier admission to another hostel in Greater Manchester.
The approved premises
7 Approved Premises, formerly known as Probation and Bail Hostels, are
approved by the Secretary of State within Section 9 of the Criminal
Justice and Court Services Act 2000. They provide accommodation for
people granted bail in criminal proceedings and also supervision and
rehabilitation for people convicted of offences. Hostels can provide a
supportive, structured environment in the community for high risk and
difficult to manage offenders. The purpose of the period of residence is
to ensure that the individuals concerned are subject to close oversight
in the community. Their supervision within the approved premises is
governed by the National Probation Service’s Standards for the
Supervision of Offenders.
8 Referrals to the approved premises are evaluated by a Central
Admissions unit and the senior probation officer there decides whether
or not a place can be offered. There is no contact between the staff at
the hostel and a prospective resident until the day that they arrive, and
all contact is by their home probation officer who retains responsibility
for supervision during the period of residence.
9 The approved premises is one of seven in Greater Manchester. The
probation area has a specialist senior manager over all the approved
premises, with managers and other staff for each hostel. At the time of
the man’s death, the manager of this approved premises was also the
manager of another located on the other side of the area. That
arrangement changed shortly after the death but was not related to it.
There is a deputy manager, and four assistant managers, one of whom
was on duty on the day that the man arrived and later died.
10 The approved premises is situated in a pair of large houses, and in a
large, well maintained garden. It provides accommodation for 27 male
residents. The houses have been adapted in order to meet the
requirements of residents and staff, and were about to be extensively
refurbished. Some residents have single rooms, and others who have
5
just arrived share double rooms. In the domestic areas of the house
there are several lounges, television, dining area, laundry and tea and
coffee making facilities. Breakfast and dinner are provided each day.
A doctor is available locally. The hostel has links with a number of
community organisations including a local college that provides a
computer­training course and a basic skills assessment programme.
At night time a night supervisor is on duty and awake all night, with an
assistant manager who goes to bed.
11 Unless subject to specific curfew arrangements imposed by a Court, all
residents must be on the premises between the hours of 11:00pm and
7:00am. No alcohol or non­prescribed drugs are allowed on the
premises and the possession and taking of prescribed medicines must
be carried out in accordance with premises' policy.
12 The approved premises has a well established routine for inducting
new residents which is carried out by whichever assistant manager is
on duty at the time. It is good practice that a guidance document has
been developed for staff to use which ensures that they provide a
consistent induction for all residents. The document reminds staff to
inform new residents about the rules regarding the use of drugs, but it
does not give any advice about the risks, especially to residents who
have just been released from prison who may have reduced tolerance
levels. The induction follows a script and usually consists of two
interviews, which are completed by signing the resident’s contract
which is comprehensive and written in Plain English. The contract
includes the requirement that residents:
Don’t use alcohol and/ or other substances to a level
that stops you taking part in hostel routines and has
a bad effect on you, other residents and staff.
Alcohol, illegal drugs, gases, solvents and drug using
items are not allowed in the hostel or its grounds.
6
Conduct of the Investigation
13 The investigation was opened by one investigator and then handed
over to two investigators from the PPO department. They studied all
the records from Holme House, including those for the healthcare and
drug advice teams. They also studied the records from the Probation
Area, including those from the approved premises. Interviews were
conducted with hostel staff, the Operation Rhodes team and the
Burglary and Drug Reduction Co­ordinator from the Crime and Disorder
Partnership.
14 It is not usual practice for clinical reviews to be requested following
deaths in Approved Premises. However, in this case the investigators
identified questions about the medical aspects of the man’s
resettlement plan and so commissioned a review which was carried out
by the North West Regional Prison Health Development team.
7
Key findings
Prior to 22 April
15 The sentence which the man was serving at the time of his death was
imposed on 9 September 2004. On 18 December 2003, he had
committed a robbery from a shop and had been convicted of the
offence on 27 May 2004. A report was prepared by a Probation
Officer, which described his long standing history of drug use which
resulted in the breakdown of his relationship and long term offending to
fund his habit. He did not have a fixed address and, although he was
in contact with his sister and grandmother, neither could offer him
anywhere to live. The report recommended a Community
Rehabilitation Order with conditions of residence at an approved
premises and supervision by Operation Rhodes. He was remanded for
assessment for the recommendation but breached the conditions.
16 The man was sentenced to 15 months imprisonment and was located
at Manchester prison. The First Reception health screen referred him
to the prison’s detoxification wing. On 4 November he tested positive
in a Mandatory Drug Test for opiates. He was released on licence two
weeks later on 19 November with the condition that he live at another
Approved Premises.
17 The man did not conform to the conditions of the licence and it was
revoked on 22 November because:
(i) he failed to wait at the prison for collection by probation
staff
(ii) he refused an opiate blocker because he said he had
taken illegal drugs
(iii) he failed to notify the address for a weekend home visit
(iv) he failed to attend the Drugs Service on 22 November.
18 He was recalled to prison the same day and again located in
Manchester. On 8 December, he agreed to transfer to HMP Risley but,
when he arrived there, he refused to get off the bus and was returned
to Manchester. On 19 December, the man was placed on Stage 1 of
the prison’s anti bullying procedure as he had assaulted another
prisoner, and this remained open until 15 January 2005.
19 The following month on 5 January 2005, the man was escorted
between two places. The Prisoner Escort Report (PER) for the journey
refers to the prison’s suicide and self harm monitoring procedure, the
F2052SH form, having been open during an earlier sentence between
19 and 22 December 2003. This in turn refers to an earlier F2052SH in
1998, which was closed after the man stated at a review meeting that it
had been opened by the escort company following what he described
as a silly comment he had made to the police. Another F2052SH was
opened between 30 June and 5 July 2004 when he was at HMP Forest
Bank and complained about threats from other prisoners. There were
8
no other references to risks of suicide or self harm. This history was
confirmed at the request of the Central Admissions unit, before his
place at the approved premises was approved.
20 On 19 January, the man was found in possession of opiates and a
mandatory drug test on 26 January gave a positive result for opiates.
He was placed on a prison disciplinary charge which was proved, and
18 days were added to his sentence. Another drug test on 29 January
was negative.
21 On 8 February, the man was placed on another disciplinary report for
using threatening, abusive or insulting words or behaviour. He was
sentenced to five days confined in his cell, which was suspended for
three months. He was placed on the prison’s basic regime from 20
February, which meant that he had fewer privileges and less time to
associate with other prisoners. He was transferred to Holme House on
2 March; having been found fit for transfer by healthcare staff, and his
involvement with their CARATS team began soon after his arrival.
22 A Probation Service Officer (PSO) from Operation Rhodes was
allocated to provide day to day support for the man and liaise with other
team members. She visited him at Holme House on 7 April and,
because he was to receive the support offered by Operation Rhodes,
she was accompanied by another team member who was a police
officer. They were joined by a member of the CARATS team. In
interview with the investigation team, the PSO described the meeting
with the man as very productive, and said that she thought he was
determined to make a success of his release. At the meeting, the man
was informed of the rules of the approved premises and the
implications of breaching them. It was agreed that he would be
prescribed naltrexone prior to and after his release. This is a legal drug
which is prescribed to someone who is drug free and has the effect of
blocking any effect from taking opiates. The prescription would usually
begin about ten days prior to release.
23 Holme House ran Job Weeks and the man attended on weeks
beginning 11 and 18 April. He prepared a curriculum vitae in which he
said that he had completed basic training in the Army in 1995.
24 He was due to attend the prison’s healthcare on 15 April to give a urine
sample, but failed to attend and it was reported that he had used
subutex on the wing the previous day. On 21 April, the day before he
was due to be released, the CARATS worker informed the PSO that
naltrexone was not administered as he had used subutex whilst in the
prison. The man was refused permission to return to visit Holme
House following release because there was evidence from security
intelligence that he had been involved with illicit drugs or that he might
have smuggled drugs or other articles into the prison. This condition
was imposed as a result of security reports in January concerning drug
9
use, abuse of telephone calls, concealed items in letters, using other
prisoner’s telephone PIN numbers and having drugs in his property.
22 April 2005 and afterwards
25 The man left Holme House on 22 April and his licence included the
conditions that he had to:
(i) report to the Probation Office
(ii) participate in Operation Rhodes
(iii) live at the approved premises.
He was given a two day supply of amitriptyline, which is an anti­
depressant. He was also given a travel warrant to Manchester, and
discharge grant of £46 plus a cheque for £50 for the weekly rent.
26 At about 2:00pm, the man arrived at Hyde Probation Office as
requested and met the PSO and a different policeman who was also a
member of the Operation Rhodes team. They told him the times for his
supervision appointments, gave him a diary to record the
appointments, and a bus pass. They then drove him across
Manchester to the approved premises.
27 The man arrived at the hostel between 3:30pm and 4:00pm, and was
greeted by the assistant manager (AM) on duty at the time. The
assistant manager invited the man to make himself a drink and left him
for about half an hour, checking on him once in that time. Because the
man had been in another approved premises previously, the assistant
manager realised that he would be familiar with the rules and so
suggested that both induction interviews were combined. The man
agreed to this suggestion. The AM read the rules and contract to him,
and said that he gave additional explanations to make sure that he
understood. The man told him that he had not used drugs prior to
being released, had come out clean and intended to stay clean. The
AM told the investigation team that, although it was not part of the
standard induction, he was aware of notices to residents which referred
to impure heroin in the neighbourhood. He decided to draw them to the
man’s attention. This was good practice on the AM’s behalf. The man
then signed the contract and the entire induction checklist was
completed, the interview ending just before 5:00pm. The man told the
AM that he would stay for the evening meal, but quickly changed his
mind and went out.
28 When he was interviewed by the investigators, the AM described the
man as a happy, bubbly and positive person. He had asked him
whether he had any thought of harming himself and been told that he
did not. The man said that the anti­depressants he had brought with
him were to help him sleep, and he was intending to ask the doctor to
help him reduce the dose. He handed the cheque and medication in
before leaving the approved premises at about 5:00pm.
10
29 At 9:30pm a man, later identified as the resident of the approved
premises, was found dead outside a house around the corner from the
hostel.
30 The AM remained on duty at the approved premises all evening. At
11:00pm he carried out the curfew check and discovered that the only
resident who was missing was the man who had arrived that afternoon.
The AM said that he got the man’s file out of the cabinet, as he
intended to consult the duty senior probation officer. By coincidence
the duty senior probation officer was the manager or senior probation
officer (SPO) for the approved premises. Before he had chance to
make the call, the police telephoned the approved premises to enquire
whether any residents were missing. The AM informed the police
officer that the man was missing, and then telephoned the SPO to tell
him.
31 In the early hours of the morning of 23 April, the police visited the
approved premises to confirm the death, and they took responsibility
for informing the man’s family. He had named his grandmother as his
next of kin, and so the police went to the sheltered housing where she
lived. The warden advised the police that she was elderly and in poor
health. The hostel located the contact details for the man’s sister and
she was informed.
32 The AM was asked by the police to identify the man, but declined on
the advice of the SPO as it would have meant leaving one member of
staff alone in the building which would not have been acceptable.
33 The man’s family went to the hostel at about 2:00pm on 23 April, to ask
for more information about his death and to collect his belongings. At
the time his belongings had not been checked by staff, and could have
been required by the police, and so the request was refused.
34 On Monday 25 April, the deputy manager, confirmed with the police
that the property could be released and he examined it before taking it
to the man’s family. The SPO discussed the visit with him before he
went and satisfied himself that appropriate safeguards were in place.
35 In the course of the week after the man’s death, senior managers from
the probation area contacted the SPO by telephone, and visited the
approved premises to ask about the welfare of hostel staff and offer
their support. The SPO also spoke individually to the staff on duty on
the night that the man died. Most of the staff interviewed considered
that these arrangements more than met their needs. However the
deputy manager commented that, on previous similar occasions, staff
received individual letters from senior managers, rather than all offers
of support coming via line managers. It is suggested that, in future,
staff receive an individual letter, giving confidential access to support
and that letters are sent to all staff regardless of whether they knew the
deceased.
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Conclusion
36 The clinical review commends the CARATS staff at both Manchester
and Holme House prisons for their active role in attempting to help the
man. It also comments that the man himself participated in their
programmes, making the majority of referrals himself. The review goes
on to include a number of recommendations to healthcare staff at
Holme House, which I endorse. The recommendations are set out in
full in the review.
37 It is my view that the staff of Operation Rhodes also established full
and detailed release plans for the man. They made effective use of the
considerable resources of the multi­disciplinary project. However, it is
not apparent that they were aware of all of his conduct at Holme House
and they were certainly unaware that he had been prescribed anti­
depressants.
37 The investigation team were impressed with the staff at the approved
premises who dealt sympathetically, skilfully and professionally with the
man when he was alive, and then fully implemented the necessary in
response to his death. The AM was the senior member of staff on duty
at the time. He had considerable experience of working in hostels but
had only been in his current position since December 2004. His
induction did not include training on dealing with deaths in approved
premises, but he knew where the relevant procedures were located
and was able to put them into place. It would be good practice if future
induction programmes for new staff included such information, together
with consideration of the emotional aspects of the role.
Good Practice
38 It is suggested that the Chief Officer of Greater Manchester Probation
Area commend the Assistant Manager at the approved premises, for
his comprehensive and sensitive induction interview. He followed the
checklist for induction interviews, and provided additional information
about impure drugs circulating in the neighbourhood.
12