Individual at Elliott House

Circumstances surrounding the death of
a resident in Probation Service Approved Premises
in September 2004
Report by the Prisons and Probation Ombudsman for England and
Wales
February 2005
FOREWORD by STEPHEN SHAW, CBE
This is the report of an investigation into the circumstances of the death of an
Approved Premises resident who died on 23 September 2004, from multiple
injuries received when he was struck by a bus.
Since 1 April 2004, my office has been responsible for investigating all deaths
of Approved Premises residents, including those that occur off the premises.
A senior member of my staff, Mrs Morris, conducted the investigation with the
assistance of the Manager and Deputy Manager of the Approved Premises.
Although no formal statements were taken, I am grateful for the assistance
and co-operation that Mrs Morris received from staff at the Approved
Premises. A letter was sent to the resident's parents offering them contact but
they did not respond and my office has had no contact with them.
A Consultant Forensic Psychiatrist provided confirmation of the resident's
condition and treatment.
The loss of their son in such tragic circumstances must have been a great
shock to the parents of the deceased man and I extend my condolences to
them.
February 2005
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Summary
The resident was a young man of 29 years and was his parents' only child. He
appeared at Magistrates' Court in July 2003 charged with several offences of
assault in which the victims were his mother and a police officer who came to
arrest him at his parents' house. It was said that the offences were directly
related to the deceased man's mental illness that had manifested itself for
some 4 or 5 years but was unrecognised and untreated at that time. It has
also been suggested that he had been drinking alcohol to excess and that this
exacerbated the aggressive aspect of his personality.
In relation to the court proceedings, the man underwent psychiatric
assessment. There was general agreement that he was suffering a mental
illness and a suggestion that it could be schizophrenia but there was no
agreed diagnosis. He was granted conditional bail at the Approved Premises
and subsequently sentenced to a 3 years' Community Rehabilitation Order
with conditions of psychiatric treatment and to reside where directed. The
supervising officer considered the Approved Premises to be the most
appropriate placement for the man at that time. He settled well and presented
no management problems. The man remained at the Approved Premises until
his death and had come to look upon it as his home.
On Thursday 23 September the man left the Approved Premises for his
regular weekly shopping trip to the City Centre. Members of staff on duty at
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the premises were surprised when he failed to return, as this had not
happened previously, and the police were informed of his absence. It was not
until the following day that the Approved Premises discovered that the man
had been killed when, running to catch a bus, he was struck by another bus
travelling in the opposite direction
The Investigation found that a high level of care was given to the man by the
members of staff at the Approved Premises, who are experienced in the
supervision of residents suffering mental ill health. Staff and residents alike
were distressed by the unexpected manner of the man's death and paid their
respects to him and to his family when several of them attended his funeral.
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The Deceased man
1. During his stay at the Approved Premises the man was seen by a
number of mental health professionals. All agreed that he suffered
from a mental illness although the exact diagnosis was unclear. It was
originally thought that he suffered with schizophrenia but, later, it was
suggested that he experienced psychotic incidents. His mental health
was reasonably maintained but his condition manifested itself in a
persistent and unshakeable belief that people in his past had poisoned
him. In particular, he believed that a noxious substance had been
placed in his drink some years previously and that his eyes and his
body had been contaminated. The man often reported 'black things'
floating in his eyes and had been examined by an opthalmic consultant
who could find no organic reason for such visions.
2. Although the man was preoccupied by his beliefs, that made him
extremely depressed at times, he was able to function well on a day to
day basis. He lived with his parents all his life and had no experience
of independent living but his personal hygene was good, he could
travel around safely and manage his finances well. Staff at the
Approved Premises described him as polite, grateful for their help and
a pleasant addition to the residents' group. My colleague was told that
the man was "a nice lad with not much experience of the Criminal
Justice System."
3. The man was treated with a combination of anti-psychotic and anti-
depressant medications. He was prescribed:
Fluoxetine 40mg in the morning
Choropheniramine 4 mg x 2 daily
Quetiapine 200mg in the morning and 400mg at night.
His medication was kept in a locked cupboard at the Approved
Premises and dispensed to him by staff as required by paragraphs 5.7
and 5.8 of the Approved Premises Handbook. The man fulfilled the
conditions of the Rehabilitation Order by accepting the psychiatric
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treatment offered. He had begun to work with a psychologist, as it had
become clear that medication alone was not addressing his delusions.
4. The man's illness had made it very difficult for his parents to deal with
him and, although they would often talk on the telephone, it was,
understandably, some time after the offences before they felt able to
see him. He missed his parents and was keen to renew his
relationship with them. Prior to his demise, monthly visits had been
established and the relationships between parents and son were being
rebuilt. It had been decided that family support should be re-
established before plans for move on accommodation were
considered.
The Approved Premises
5. In its publicity material, the Approved Probation Premises for male
offenders describes itself as providing accommodation for mentally ill
offenders although it is not recognised as a national specialist resource
by the National Probation Directorate. It does, however, benefit from a
long-standing partnership with the local Forensic Psychiatry Clinic and
is visited several times weekly by a forensic psychiatrist with members
of his team. The house has 20 single rooms, two lounges, a games'
room, kitchen, dining room and residents' laundry. The Manager is a
Senior Probation Officer with a Probation Officer as Deputy Manager.
There are waking night care staff and day staff are experienced
Probation Service Officers.
Events leading to the resident's death
6. During his time at the Approved Premises it became common practice
for the man to go out and about into the City Centre during the daytime.
It was also his habit to shop in the late afternoon or early evening each
Thursday. My colleague was told that the man would often clean his
ears vigorously with cotton wool buds that, from time to time, could not
be extracted without a visit to the local Accident and Emergency
department. This had occurred about a week before his death and his
ear had become badly infected. Since then the man had insisted on
keeping cotton wool in his ears and his hearing had been somewhat
affected.
7. On 23 September the man had been in and out of the hostel with other
residents during the day. He returned around 15.30 and was last seen
by members of staff on duty when he went out again, alone, a little
later. The man did not return by curfew time and staff members were
surprised and worried as this was unlike him. Telephone calls were
made to the local police and hospital but there was no news of him that
night. The following morning he was reported to the police as having
failed to return to the premises as required.
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8. Later that morning, the local radio station broadcast details of a man,
who had been knocked down by a bus and had not yet been identified.
A description was given of the clothes the man was wearing, including
a football shirt, and of a tattoo. A member of the Approved Premises
staff heard the broadcast and was able to alert police to the possibility
that the man was the missing resident. This was confirmed later in the
day when the man's fingerprints were identified.
Consideration and conclusions
9. The man was vulnerable by virtue of his mental ill-health but no more
vulnerable than many other residents of the Approved Premises.
Those who reside in Approved Premises are bound by certain
restrictions but their status is very different from those who are held in
custody. Although in the care of the state, residents are entitled to
come and go as they please within the confines of the Approved
Premises rules and the requirements of their supervision. The man
participated in offence focussed key work sessions, took his medication
regularly, fulfilled the terms of the condition of treatment in his
Rehabilitation Order and appeared to be making progress. He was
used to travelling the few miles to and from the city centre, he was
familiar with the area and there was no reason for hostel staff to
suspect that he would be unsafe.
10. Despite the depression that occurred from time to time, the man had
not expressed any desire to harm himself. In the days preceding the
accident there had been no additional concerns about his condition and
the psychologist commented that his mood appeared to be improving.
Contact with the mental health professionals and with the Approved
Premises staff disclosed nothing to suggest that the man was feeling
low and his death appears to have been a tragic accident that affected
all those who had known him at the Approved Premises.
11. My colleague was left in no doubt that the Approved Premises provided
a supportive environment for the man, within which psychiatric services
were available. The investigation found that staff cared for the man
well and took appropriate action over his unexpected absence. Indeed,
had the member of staff been less vigilant or less familiar with the
man's appearance, it could have been some time before his parents
knew of his death.
STEPHEN SHAW
OMBUDSMAN FEBRUARY 2005
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