Individual at Trent House

Circumstances surrounding the death of a resident during January 2005
at a Probation Service Approved Premises.
Report by the Prisons and Probation Ombudsman for England and
Wales
April 2005
CONTENTS Page No
FOREWORD 3
SUMMARY 4
PART ONE:
Background information –
The resident 5
The Approved Premises 6
PART TWO
Events leading up to the man’s death –
The resident’s time at the Approved Premises 8
The night of the resident’s death 10
PART THREE
Consideration & Conclusions 14
Recommendations 17
2
FOREWORD
This is a report into the death of a man who died from an apparent overdose
of non-prescription drugs in January 2005. He was subject to supervision on
licence following a term of imprisonment, and resident in an Approved
Premises.
The man had used drugs for many years and was clearly aware of the
dangers associated with such use. He had expressed no desire to change his
lifestyle until a short time before his death when he acknowledged the need to
address his dependency issues, and began working to do so.
The purpose of the investigation was to establish the circumstances and
events surrounding the man’s death, and to consider whether the quality of
supervision and care provided to him by the Probation Service was adequate
and appropriate.
Two investigators from my office carried out the investigation. My thanks go
to the Manager and Deputy Manager of the Approved Premises for facilitating
the work. I am also grateful for the co-operation received from the Probation
Area and, in particular, from the staff and residents of the Approved Premises.
The man was 39 years of age, the father of two daughters, although he was
separated from their mother and prohibited from contact with them. His
parents had maintained regular contact with him during his residence in the
Approved premises and believe that more could have been done to assist
their son, whose death was devastating for them. The man’s father spoke with
one of the investigators on the telephone and provided a written response at
the draft report stage. I hope this report will answer some, if not all of their
questions and I offer the man’s parents and their family my sincere
condolences.
The Investigators carried out formal interviews with the Manager of the
premises, with the man’s key worker, with two workers who were on duty on
the night he died, with two other residents, with a drugs worker from the
Criminal Justice Intervention Team, and with his supervising probation officer.
The interviews were not recorded but the investigating officers' notes have
been agreed and signed by interviewees.
The investigators also obtained information from the man’s probation file and
examined a number of documents provided by the Probation Area.
The report is organised as follows. Part 1 provides some personal details
about the man and background information about the Approved Premises.
Part 2 considers, as far as it is possible to do so, the circumstances leading to
the man’s death. My conclusions and recommendations are presented in Part
3.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2005
SUMMARY
The man was released from prison in November 2004 on licence, having
served a sentence of two years' imprisonment for an offence of assault. The
conditions of his licence precluded him from returning to his home area and,
although he retained the support of his parents, he was required to reside at
the Approved Premises.
The man had been a drug user for more than 20 years and, during his prison
sentence, had expressed no desire to change his lifestyle.
He was not happy at the Approved Premises, where he remained aloof from
other residents, spending most of his time in his room alone. However, the
man presented no apparent management problems. He fulfilled the
conditions of his licence and was open with his supervising officer,
acknowledging that he was using drugs from time to time. The man accepted
a referral to a drug worker and appeared to adopt a positive attitude,
expressing his wish to become drug free.
Towards the end of his stay at the Approved Premises, there were marked
changes when the man became more sociable with other residents and less
unhappy about being in Approved Premises. On the evening before his death
he went out with friends before spending time in the common room with other
residents, one of whom suggested that the man asked him to acquire drugs.
Later that night, members of staff on duty were informed by the same resident
that the man was unwell and it was likely that he had taken heroin. Members
of staff found the man to be sleeping heavily but, apparently, breathing
normally. He was checked at regular intervals during the next hour until it
became apparent that his condition had deteriorated. The emergency
services were called immediately and made strenuous efforts to revive the
man but were unable to do so. He was found to be dead on arrival at the
hospital.
I conclude that, despite his previous history, before 13 January 2005, the man
had given the Probation Area no reason to suppose that he was likely to
ingest dangerous quantities of drugs. Nor can I identify any changes in
procedures that might have helped directly to prevent his death.
Nevertheless, when an Approved Premises' resident dies, there are almost
always lessons to be learned, and I have identified areas where systems
could be improved. I have made six recommendations that can be found in
Part 3, section 2.
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PART ONE
Background Information
The Resident
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1. The resident was 39 years of age when he died. Probation records
indicate that he had misused drugs since the age of 15 and had
experimented with various illicit substances during the ensuing years.
Despite this, he worked regularly in the building trade and was not a
heavily convicted man.
2. The man lived with his partner, the mother of his children, for ten years
before the relationship ended some four years ago. It was said that he
found the break up of the relationship difficult to bear and increased his
use of heroin and amphetamines to block out his problems. In 2001
he was conditionally discharged for assaulting his partner and in 2002,
after another assault, he was sentenced to four months imprisonment
together with the imposition of a restraining order.
3. Although his use of drugs was the cause of many of the man’s
difficulties, it also exacerbated his frustration over his limited contact
with his daughters. A series of incidents during a few days in
December 2002 resulted in a sentence of two years imprisonment for
breaching the restraining order and for assault occasioning actual
bodily harm on his ex-partner. At that time the man told a probation
officer, who was preparing a report for the court, that he was spending
up to £50 daily on amphetamines and £10 on heroin.
4. It was the man’s wish to return to his home area upon his release but,
as a consequence of the proximity of the proposed address to his ex-
partner, the risk was considered too high to manage and he was
required to live in Approved Premises. When he was first released
from prison in May 2004, the man reported to his supervising officer as
required. However, he failed to arrive at the Approved Premises and
his licence was revoked. The man was returned to prison where he
remained until November 2004. He was unable to provide an address
considered suitable for release and he was, again, required to live in
Approved Premises. Upon his release from prison, the man went to
stay at the Approved Premises where he remained until his death.
5. During his time at the hostel the man presented no management
problems. A full analysis completed a few days after his arrival, under
the Offender Assessment System (OASys) indicated no risk of suicide
or self harm but noted that he had previously breached hostel rules.
Although the man was said to have 'kept himself to himself' and spent
most of his time in his room, his parents visited him regularly and often
took him out for meals. A few days before his death, members of staff
noted that the man was spending more time out of his room,
associating with other residents. Generally, he appeared to have
adopted a more positive attitude.
The Approved Premises
6. Approved Premises, formerly known as Probation & Bail Hostels, are
approved by the Secretary of State within Section 9 of the Criminal
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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 supervision of offenders accommodated in Approved
Premises is governed by the National Standards for the Supervision of
Offenders.
7. The house is one of the Approved Premises managed by the Probation
Area. It provides nineteen beds, some of which are for women. The
Approved Premises accepts offenders from the age of 18 upwards,
many of whom are considered to pose a high risk of re-offending or of
harm to the public. Residents are advised not to discuss the nature of
their offences with other residents, and staff are not allowed to discuss
a resident's past with any other resident.
8. The Approved Premises has a Manager who is a Senior Probation
Officer, a Deputy Manager, an administrative assistant, a referrals
worker and a handy person. There are six residential social workers
(RSWs), two are on duty every day. There are also Night Waking
Workers (NWWs) who, as the title implies, work only at night together
with the Night Sleeping Worker (NSW), a member of staff who sleeps
in and may be called upon if necessary. Each resident has a key
worker and there are additional services available as follows:
Drugs workers from the Criminal Justice Intervention Team (CJIT), on
Tuesdays and Thursdays.
Educational services on Mondays to Thursdays.
An Employment and Training worker, on Wednesday afternoons.
9. Records are kept on duty sheets, in the premises day book and on
residents' personal history sheets, where significant events and
progress (or lack of it) are recorded. An electronic system (ICR) could
be accessed by all probation staff in the Area so that a member of staff
may record any information considered relevant. In practice, the
electronic system is mostly used by supervising officers in the field,
known as case managers. Significant information is shared at monthly
meetings between the resident, the key worker and the supervising
officer. Case managers are aware that they may telephone at any time
to speak with Approved Premises' staff as necessary and staff on the
premises would expect to liaise with the case manager if problems
arose over a resident.
10. Staff shifts change three times daily, at 8.00 am, 1.00 pm, and at 5.00
pm. At 10.00 pm, when the NWW arrives for duty, the RSW who
arrived at 5.00 pm continues as the sleeping worker and the RSW who
arrived at 1.00 pm goes off duty. Succeeding staff are expected to
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familiarise themselves with the day's events by speaking with the
preceding shift and reading the message book. NWWs are required to
check the premises at 11.00 pm when all residents are expected to be
in, and at 11.30 pm when residents should be in their own rooms.
NWWs are expected to knock on each door and open any if there are
indications of any untoward behaviour.
PART TWO
Events leading up to the man’s death –
The man’s time at the Approved Premises
11. The man was admitted to the premises in November 2004, and went
through an induction procedure in which the rules and expectations of
the premises were explained to him. He readily acknowledged that he
had regularly used drugs in the past but said he did not consider his
lifestyle problematic and had no wish to change it. He was reminded
that illicit drugs were not allowed on the premises and told that help
could be made available if he changed his mind at any time.
12. The hostel log indicates that very little was seen of the man around the
premises. There are entries noting, 'X in his room', 'Spent the whole
evening in his room', and 'When X returned to the hostel he went to his
room, had no contact with anyone not even staff except on curfew and
closedown checks.' His key worker told the investigators that the man
said he had been told that the place was full of 'bad 'uns' with whom he
had no wish to associate. She said he had been very withdrawn and
had little contact with anyone.
13. The key worker was allocated the man’s case almost two weeks after
he arrived at the house and immediately initiated a formal key work
session with him, after which she met and talked with him informally on
several occasions. No record was kept of these informal meetings.
The key worker told the investigator that, as all seemed well with the
man, there was no apparent focus for further formal meetings.
14. The records of the man’s meetings with his supervising officer also
indicate that his initial attitude towards the Approved Premises was far
from positive. He continued to dispute that a condition of residence
was necessary for risk management, as he believed he was unlikely to
offend against his ex-partner again. The man was particularly unhappy
about the curfew restrictions, expressing the desire to go out at night
with friends. At various times he told the key worker and the
supervising officer that he 'hated' living at the house and the records
indicate their efforts to encourage him to become more settled.
15. On 30 November 2004, The man told his supervising officer that he
had contemplated breaching his licence in order to leave the approved
Premises by being recalled to prison. He was dissuaded when he was
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told that he could seek alternative accommodation in his home area,
outside the exclusion zone. On 1 December, during the man’s meeting
with his supervising officer at the Probation Office, he indicated that he
had used heroin twice and amphetamine once since his release.
However, the session was more positive when the man told the
supervising officer that, for the first time in 28 years, he felt that he
wanted to stop using drugs completely and was beginning to
understand that help could be made available to him. He was referred
to a drug worker from CJIT who worked in partnership with the
probation office providing a service for offenders who reported there.
16. The drug worker explained to the investigators that her usual
procedure would be to complete a feedback form for the supervising
officer after each session with an offender. However, she did not do so
for this man as she and the supervising officer would talk after each
session to discuss progress and plan future work. The supervising
officer's records confirm that such discussions took place but there is
no complete record of the work undertaken.
I recommend that the probation area develops a protocol with the CJIT
team for the formal sharing and recording of information.
17. The drug worker recalled that she had seen the man on five or six
occasions and had discussed with him various strategies for remaining
drug free. She did not undertake any drug testing as he was,
apparently, being open about his drug use. At that time, no drug
testing equipment was available at the Approved Premises although it
has, since, been provided. The Manager told the investigator that one
member of staff has been trained in the use of the equipment and
another is about to be trained. It is now possible for random drug tests
to confirm if residents are drug free.
18. The man and the drug worker had identified the risk he would run if he
mixed with other drug users, and he cited this as one reason why he
had had kept himself separate from other residents at the Approved
Premises. His key worker also noted the man’s concerns about
whether he might meet drug dealers in the area around the house and
he had been careful about where he went outside.
19. An entry in the record of contact log for 15 December indicates that the
man continued to question the need to live in Approved Premises. He
said he hated the curfew arrangement that prevented him from going
'out clubbing' with his friends. He told the case manager that he would
do something 'stupid' to escape the hostel and, when questioned about
what he meant, the man said he might overdose on heroin to get
moved. The case manager told the investigators that, from his
knowledge of the man , he did not believe this to be a real threat. The
man had tried many other ways of reminding the case manager that he
was not happy at the Approved Premises and the officer believed this
to be a further manipulative ploy. Nevertheless, the officer knew that
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the man had been spending long periods alone in his room and alerted
the hostel duty worker to record that his attitudes and moods should be
monitored.
20. On 23 December, the man told his supervising officer that his smoking
of heroin had increased and blamed this on the hostel environment.
However, on 30 December, the man reported that he had not used
drugs since Christmas Eve. The record of contact notes that he
recognised he had been drifting into regular drug use again. Both the
supervising officer and the drug worker reinforced how well the man
had done to focus on remaining drug free over the Christmas period.
The supervising officer noted that the drug worker had arranged for
liver function and blood tests to be carried out the following day and for
a prescription to be available on 7 January 2005.
21. At his meeting with the case manager, on 6 January, the man admitted
that he had used amphetamine and alcohol over the past week. He
said that he wanted to go drinking with his friends on his 40th birthday -
the next day - and was angry that the officer continued to refuse to
grant an extension of the curfew. The record of contact describes him
as being angry and intimidating but not depressed. The man again
threatened to breach his licence to escape the restrictions upon him
but acknowledged that any breach would result in a return to prison.
22. As arranged by the CJIT worker, the man attended a local clinic on 7
January and was prescribed naltrexone, an opiate blocker drug. He
handed in his medication to staff at the Approved Premises, as
required, and the medication record shows that one 50mg tablet was
dispensed on Saturday 8 January. However, later that day, a rash
appeared on the man’s chest and he reported difficulty in breathing.
The clinic was consulted and suggested that he could be allergic to the
naltrexone. He was advised to stop taking the medication and to seek
further advice from the doctor after the weekend. The investigators
were unable to clarify whether the man did so, although the CJIT
worker confirmed that when she spoke with him on 10 January she
explained that people may have adverse reactions to the medication
and reiterated the advice that he should to stop taking it.
23. When the key worker spoke with the man about his medication on
Tuesday 11 January, he said he was reluctant to leave the hostel and
return to the clinic as he feared that local drug dealers could target him.
She therefore arranged for him to see a different drug worker who was
due to visit the premises later in the day. The hostel log indicates that
the drug worker believed the man to be 'struggling' as his efforts to
remain drug free were hampered by his adverse reaction to the
naltrexone. The worker decided to investigate the possibility of an
acupuncture course for him. The CJIT worker expressed some
surprise to the investigators that hostel staff had decided to involve a
second drug worker with the man, particularly as there had been no
consultation with her. She explained that, although the aims of various
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drug workers are almost certainly the same, different styles of working
could cause confusion.
24. On the day before he died, the man kept appointments with the case
manager and with the CJIT worker. Both separately noted a
considerable difference in him. He told the case manager that he had
been out to celebrate his birthday but had managed to return to the
Approved Premises within the curfew time, albeit under the influence of
alcohol. He also said that he was beginning to like the house and was
starting to mix with other residents. The case manager noted this as, 'a
major breakthrough'. The man told the CJIT worker that he had used
'a bit of amphetamine and a bit of heroin' two days earlier but it had
done nothing for him and he was not going to bother again. She
described him to the investigators as being 'completely different',
positive and in a confident mood. He told her that he felt 'really happy'.
The night of the man’s death
25. The NWW told the investigators that he arrived on duty around 9.30 pm
on the night of the man’s death and went directly to the residents'
common room. He was surprised to see the man there for the first time
and, from the man’s tone of voice and demeanour, the NWW thought
he had probably been drinking. The NWW said that another resident,
Mr A, approached him and said that the man had asked him to go out
to obtain drugs. The NWW described a 'fatherly chat' with Mr A in
which he was told clearly not to procure drugs for the man. The
resident agreed that he would not do so and said that he was 'not daft'.
Around 9.40 pm the NWW went to the office to tell his colleague of
what had happened and as he did so, Mr A left the premises.
26. Another resident, Mr B, told the investigators that he had been talking
with the man in the common room that evening and found him to be in
good spirits. He said that the man had been out for a drink with friends
and was talking about his future in positive terms. The man told Mr B
that he was looking forward to leaving the hostel and getting himself off
drugs. Mr B described a 'normal, general sort of conversation' and
thought that the man left the common room around 9.45 pm to go to his
room.
27. The NWW said he watched for Mr A’s return to the house around 10.40
pm, and questioned him about procuring drugs. Mr A categorically
denied that he had obtained drugs, either for himself or anyone else.
He was adamant that nothing would be found on him if he was
searched, but the NWW noted that he was well aware that hostel
workers have no powers to search residents, and are not allowed to do
so. Mr A went upstairs but the NWW was unable to say whether or not
he went directly to his own room.
28. A third resident, Mr C, told the investigators that, on his return to the
house earlier in the evening, the man had tried to persuade him to get
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drugs. Mr C described it as 'hassling' but refused. Mr C said that Mr A
knocked on his door between 10.45 pm and 11.00 pm asking the
resident to accompany him to another room as he (Mr A) thought
someone had overdosed. The resident observed that Mr A was
agitated and perspiring and the resident said he thought that Mr A
might have taken 'something'. The resident said that he had previously
used illicit drugs and did not want to become involved. However, he
said that, against his better judgement he went with Mr A to the man’s
room where he saw the man lying crossways across the bed.
29. Mr C described moving the man round, to place him in a more
comfortable position. He said Mr A told him that he had bought two
bags of heroin for the man but did not say how much had been taken
by whom. The resident thought that Mr A seemed panicky, trying to
decide whether to inform staff about the man. However, having
satisfied himself that the man was alive and breathing well, Mr C
returned to his room, taking no further action. The investigators were
unable to corroborate Mr C’s information and, unfortunately, Mr A failed
to return to the Approved Premises later in January. Consequently, it
was not possible for the investigators to interview him or for him to
answer the allegations against him. The other resident also failed to
return to the Approved Premises in February.
30. The residential social worker who was on duty as the night sleeping
officer that night, told the investigators that she and her colleague, the
NWW, started their curfew check at 11.00 pm. They checked the
rooms of those residents who were not in the common room, to ensure
that they were on the premises. She said she saw Mr A and Mr C
talking together but she did not address them. After checking other
rooms, she saw Mr A in his room, seeming flustered. When she asked
him if all was well, Mr A told her he thought there might be something
wrong with the man and she went directly to the man’s room where she
met the NWW around 11.00 pm.
31. The NWW said that, when he opened the room door, he saw the man
asleep, lying on his side with his head facing towards the bed, snoring.
The NWW believed that the man had been drinking earlier in the
evening and, mindful of what Mr A had said, he knew there was a
possibility that the man had also taken drugs. He turned the man’s
head to the side and ensured that his airway was clear. The NWW told
the investigators that he and his colleague took those precautionary
measures although he was not overly concerned as the man appeared
to be sleeping naturally. He explained that he had previous experience
of finding people asleep when he knew they had taken drugs. He
would keep a regular watch on them until he was sure that all was well.
He said it had been his experience that people would wake after a few
hours.
32. The NWW said that he left the light on in the man’s room and visited
the room again four times during the next hour. He said that on the
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first three occasions there was no cause for concern, the man was
breathing heavily and snoring. However, on the fourth visit, the man
had stopped snoring and the NWW noticed a residue that he took to be
either mucus or vomit around the man’s mouth. He said he tried to find
a pulse or sign of breathing but could not, although the man was warm.
He banged on his colleague's door and went downstairs as quickly as
he could to call the emergency services.
33. The NWW was joined by his colleague, who switched the call to the
mobile phone, before both workers returned to the man’s room. There
they followed instructions from the emergency services to place the
man on his back although they were not able to get him onto the floor.
The NWW returned to the office for the face guard to give mouth to
mouth resuscitation, as instructed over the telephone. As he did so,
the paramedics arrived. Although the paramedics worked for some
time to resuscitate the man before taking him to Queen's Medical
Centre, he was declared dead on arrival.
PART THREE
Consideration & Conclusions
34. It was my role to consider whether the level of care provided for the
man at the Approved Premises was adequate. In doing so, I also
considered whether the hostel procedures were clear to staff and
commensurate with the requirements for all Approved Premises as
defined in the Approved Premises Handbook. I conclude that, before
the night of his death, the probation Area had no reason to suspect that
the man might have, or had in fact, ingested dangerous quantities of
drugs. Nor have I identified changes in its procedures that might have
helped directly to prevent his death.
35. It is apparent that, from the outset, the man was a reluctant resident at
the Approved Premises, withdrawn and unwilling to participate in the
daily routine of the house beyond what was specifically required of him.
His avoidance of contact with residents and staff presented no
management problems and the man was not a focus for concern.
Consequently, there was little of note to report to the supervising
officer. Nevertheless, communication between those who have
specific roles to play in the supervision of offenders is crucial for the
identification and management of problem issues and, in this man’s
case the level of communication appears to have been less than
satisfactory.
36. Although the man kept appointments with his supervising officer and
met with his key worker in the Approved Premises, there was only one
key work session during approximately 8 weeks residence and there
appears to have been little meaningful contact between the workers. In
a telephone conversation on 1 December, the supervising officer
suggested to the key worker that the man’s use of alcohol should be
12
monitored but there was no further indication of work to be undertaken
by the key worker. During the eight weeks that the man spent at the
Approved Premises no three way meeting took place and there was no
regular sharing of information between the supervising officer and the
key worker.
37. The key worker was, therefore, unaware of all the occasions when the
man had 'lapsed' into drug use and knew nothing of his contact with the
CJIT worker at the probation office. It is a matter of speculation
whether the key worker would have learned of these issues had she
met with the man more regularly or whether she could have done more
for the man had she been kept better informed. However, it is unlikely
that she would have referred him to the hostel drug worker had she
known of CJIT's involvement.
I recommend that the Probation Area reminds staff about the required
level of formal contact between Key workers and residents.
I recommend that the Probation Area reminds staff about the required
level of communication between case managers and key workers in
Approved Premises.
(Since the completion of this investigation, this recommendation has been
addressed as the new version of National Standards, published in March
2005, places a requirement on all probation staff to ensure that relevant
information is properly communicated.)
38. The Night Waking Worker's previous experience was in the Prison
Service and he was very clear about his role in supervising residents
and dealing with difficulties. He also had previous experience of
monitoring those sleeping off the effects of drug taking and, in his
words, 'they usually wake after a few hours.' He was aware of the
problems that may be caused by the use of alcohol and opiates
together and it was a fine judgement as to whether medical assistance
should be sought. The man’s condition did not appear to be life
threatening and, on the basis of his previous knowledge and
experience, the NWW decided not to call a doctor.
39. It may be that, in similar circumstances, other staff would have acted
differently but I do not consider the NWW's decision was unreasonable,
given that he continued to check the man’s condition at regular
intervals and observed no deterioration. However, the NWW accepted
that he did not record the checks that he made, in the hostel log, and
said that this was an oversight. The Night Sleeping Worker was
present at the checks before she retired to bed but, thereafter, the
NWW was alone. I have no reason to doubt the NWW's word but,
without any records, there is necessarily no corroboration of his
evidence.
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I recommend that the National Probation Directorate reminds staff
working in Approved Premises of the need for vigilant recording of
significant issues and actions, to protect themselves and residents.
(This recommendation is also addressed by the new National Standards that
require Approved Premises staff to 'maintain a daily house record of any
significant events that happen within approved premises' and cross reference
them to individual offender records where appropriate.)
40. The NPD has confirmed that there is no national requirement for
Approved Premises staff to carry mobile telephones. However, given
that one was available, the investigators were surprised that the NWW
had neither the telephone nor the face guard with him when he
discovered the man in difficulties. The investigators were told that the
waking staff member usually carries the mobile telephone but, on the
night of the man’s death, the battery had run low and it was 'on charge'.
41. The man’s room was on the first floor and, without the mobile
telephone, the NWW could not summon the emergency services until
he had returned downstairs to the office where the main telephone is
situated, thus costing time. When the emergency services instructed
the workers to commence mouth to mouth resuscitation, pending their
arrival, further time was spent retrieving the face guard from the office.
The Night Waking Worker believed there was virtually no loss of time
by not having the equipment with him, and there is no evidence to
suggest that a speedier response would have prevented the man’s
death. However, there may be occasions when the loss of time,
however brief, could mean the difference between life and death for
others.
42. Following a previous investigation into the death of a hostel resident in
another Probation Area, I recommended that a reminder be issued to
all areas of the requirement for Approved Premises' staff to carry radios
with them when they are available. I make a similar recommendation
about the use of other equipment.
I recommend that the National Probation Directorate issues a reminder to
all Probation Areas about the protocols for carrying and use of mobile
telephones and other essential emergency equipment in Approved
Premises.
(At the draft report stage, the NPD explained that staff in Approved Premises
are required to carry personal alarms and, as part of the implementation of the
recommendations of a security survey, new alarms will be supplied. I note that
these will have a direct call button to the approved Premises alarm system and
directly to the police, although not to other emergency services.)
43. Probation Circular 40/2004 required all Probation Areas to devise by
October 2004 a strategic plan to reduce incidents of sudden death in
Approved Premises. This Probation Area has fulfilled the requirement
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and the plan is available in Approved Premises. However, the
Manager of the house told the investigators that, although he was
familiar with the contents of the strategy, he could not guarantee that
all his staff knew of its contents as its existence was relatively new.
NPA is to be applauded for allocating resources to the production of
such a comprehensive plan. However, this will not be cost effective if
staff in Approved Premises are not familiar with the document. The
plan states:
'Hard copies [of the plan] will be given to each member of the core staff
and to staff dealing with referrals.'
I recommend that NPA takes steps to ensure that all staff working in
Approved Premises have access to a copy of the strategic plan and are
familiar with its contents.
Recommendations
National recommendations:
I recommend that the National Probation Directorate reminds staff
working in Approved Premises of the need for vigilant recording of
significant issues and actions, to protect themselves and residents.
I recommend that the National Probation Directorate issues a reminder
to all Probation Areas about the protocols for carrying and use of mobile
telephones and other essential emergency equipment in Approved
Premises.
I recommend that NPA takes steps to ensure that all staff working in
Approved Premises have access to a copy of the strategic plan and are
familiar with its contents.
Area Recommendations:
I recommend that the Probation Area develops a protocol with the CJIT
team for the formal sharing and recording of information.
I recommend that the Probation Area reminds staff about the required
level of formal contact between Key workers and residents.
I recommend that the Probation Area reminds staff about the required
level of contact and communication between case managers and key
workers in Approved premises.
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