Individual at Westbourne House

Circumstances surrounding the death of a man, on 3
August 2004, at an Approved Premises under the
management of the Probation Service.
Report by the Prisons and Probation Ombudsman for
England and Wales
April 2005
CONTENTS Page No
INTRODUCTION 3
SUMMARY 4
CONDUCT OF THE INVESTIGATION 6
PART ONE:
Background Information ­
Section 1 – The man 7
Section 2 – The Approved Premises 8
PART TWO
Events leading up to the mans death ­
Section 1 – The man's time at the Approved Premises 9
Section 2 – What occurred on 3 August 2004 10
PART THREE
Consideration and conclusions 11
Recommendations 12
2
INTRODUCTION
This is a report of my investigation into the death, apparently from natural
causes, of a man. He was a resident of an Approved Premises, on life licence
following his conviction and life sentence for murder in 1967.
The purpose of my investigation was to establish the circumstances and
events surrounding his death, including the quality of care provided by the
Probation Service. I also wanted to find out whether there were any lessons
to be learned about operational methods, policy, practice or management
arrangements that might help prevent such occurrences in the future.
A member of staff from my office carried out the investigation with the co­
operation of the Probation Area. I am grateful for all the assistance that my
Investigator received from the Manager and members of staff at the Approved
Premises.
A key part of the investigation was to make sure that the family had the
opportunity to raise any concerns they had about his death. My investigator
was able to speak to the brother in law, on the telephone. I am most grateful
to himfor having this conversation at what must have been a very difficult and
distressing time for both himself and his wife (the man’s sister).
The man’s sister wrote a letter to the Coroner about her brother’s eldest son.
She said that, on attempting to contact him, it was found that he had in fact
sadly died with his own son five years previously in a car accident.
I offer the man’s sister and her family my sincere condolences. It does seem,
however, that the last few months of the man’s life at the hostel were tranquil,
and that he was well respected. I hope that this provides some comfort.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN
3
SUMMARY
The man died of a heart attack at the Approved Premises on 3 August 2004.
During his stay at the premises he was perceived as a quiet and resourceful
man, and was well respected by other residents. He abided by the hostel
rules.
He did not present with any serious medical complaints either at North Sea
Camp prison or at the Approved Premises. He visited his GP only once while
at the hostel, on 3 March 2004, complaining of a chesty cough for which he
was treated.
The night hostel assistant at the hostel recalled that, when the man was
checked at 11pm curfew on the night of 2 August, he was in good spirits.
Sadly, when he was next checked, at around 6am on 3 August, he had
passed away.
My investigation has identified two areas where procedures for dealing with
fatal incidents could be improved. My recommendations can be found in Part
3.
4
CONDUCT OF THE INVESTIGATION
My Investigator conducted formal interviews with two members of the hostel
staff. The interviews were not tape­recorded but the Investigating Officer’s
notes have been agreed, and signed by the interviewees.
Another member of probation staff, the man’s Probation Officer, met with the
investigator and a note of the meeting was agreed.
The Investigator also examined a variety of documents readily provided by the
Probation Area. She spoke on the telephone to the man’s GP who provided
details of treatment he had provided to him which he confirmed in writing in a
letter to the Coroner.
A clinical review of the healthcare provided to the man while at North Sea
Camp prison and at the Approved Premsises was arranged by the Director of
Nursing/Clinical Governance, Primary Care Trust (PCT). The review was
undertaken by a doctor, GP Clinical Governance lead for the PCT. The
review concluded that there was no indication of sudden death from any
particular existing illness but did not fully assess the medical care received by
the man.
An inquest, with a jury, was held on 4 October 2004 and delivered a verdict of
death from natural causes (myocardial infarction).
5
PART ONE
Background information
Section 1 – The man
The man was born in Glasgow on 21 May 1939. He was 65 years of age
when he died on 3 August 2004 at the Approved Premises. He had been
twice married, but it seems that both relationships ended in divorce. He had
five sons and three daughters, aged between 49 and 24 years. He had a
history of heavy alcohol consumption.
On 10 September 1967, he was convicted of murder and sentenced to life
imprisonment. On 6 April 1979 he was first released on life licence, but he
was recalled on 15 February 1980 following concerns about his potential for
violence. On 26 November 1982 he was again released on life licence, but on
12 June 1995 the licence was revoked for a second time following various
incidents concerning alcohol and potential violence. He did not return to
prison, and remained unlawfully at large until January 2001, when he was
rearrested, and admitted to HMP Pentonville. He remained there until 18
February 2002, when he was transferred to HMP North Sea Camp.
During 2003 he spent five periods of temporary home leave at the Approved
Premises. This is usual for someone who has spent a considerable length of
time in prison. These stays went well, and on 9 February 2004 he was
released from North Sea Camp prison on life licence, with a condition of
residence at the Approved Premises.
The man’s key worker at the hostel, his probation officer and the hostel
manager, all described him as being very resourceful and having a positive
influence on other residents through sharing the benefits of his life
experience. He was perceived as a quiet resident, respected by the other
occupants and abided by hostel rules. He did not present any management
problems. His probation officer was, at the time of the man’s death, trying to
arrange suitable accommodation for him to move into from the hostel. The
man was looking forward to being settled in his own accommodation outside
the hostel. Suitable accommodation was in fact identified shortly after his
death.
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Section 2 – The Approved Premises
Probation 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. Their purpose is to provide
accommodation for people granted bail in criminal proceedings and in
connection with the supervision and rehabilitation of people convicted of
offences. Hostels 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.
Approved Premises operate on each day of the year with 24 hour staff cover
on a rota basis. The hostel is a large house on a busy road. The hostel has
41 places and is managed by a senior probation officer. There is a deputy
manager and a team of nine staff members, responsible for the daily
management of residents.
The premises accommodates two categories of residents: those on life
licence (such as the man) and those granted bail in criminal proceedings.
The accommodation comprises a mixture of single bedrooms and six self­
contained flats, for which residents are required to pay rent. The self­
contained flats each house two residents with separate bedrooms and shared
kitchen and bathroom facilities.
All residents must be in the hostel between the hours of 11.00pm and 6.00am
the next morning unless a court has imposed an alternative curfew.
Night cover at the hostel is provided by two night hostel assistants. An
assistant manager, who sleeps on the premises, is on duty throughout the
night.
A Basic Skills tutor attends the hostel one day a week, and a Community
Psychiatric Nurse (CPN) attends one morning a week. The hostel has links
with an organization which helps residents to find employment. It works with
partners as part of the Criminal Justice Intervention Programme, which aims
to provide individual tailored solutions for drug misusing offenders with the
aim of getting them out of crime and into treatment.
Residents are allocated key workers who are expected to meet with them
regularly, to identify any issues of concern on a day to day basis and to assist
where possible. There is also an expectation that information will be shared
regularly with probation officers in the field, who are responsible for case
management.
7
PART TWO
Events leading to the man’s death
Section 1 – The man’s time at the Approved Premises
On 9 February 2004, the man arrived at the Approved Premises and received
a full induction. This included the provision of health and safety information,
expectations of behaviour and details of the hostel rules. He was required,
like most residents, to be present at the hostel between the hours of 11.00pm
and 6.00am the next morning.
The man was allocated a key worker and a probation officer, with whom he
kept in regular contact.
He gave the hostel details of his eldest son, as his next of kin, and also details
of his sister. He told his key worker that he was not in touch with his family,
although on 27 February 2004 he said that he missed his children and might
contact them at a later stage. On 29 July 2004 the man’s key worker noted
that one of the man’s sons had come to visit him but he was not at the hostel.
The note says that the man said that he did not want contact with this son
anyway as he was taking drugs. The hostel manager thought that he might
have met one of his sons shortly before 3 August, although this cannot be
confirmed by hostel staff or by the official visitors signing in book at the
premises.
Hostel records indicate that the man appeared settled and was coping very
well. On 18 May 2004, he moved to one of the self­contained flats.
During the man’s time at North Sea camp prison, the only ailment he reported
was hemorrhoids, for which he had medication.
The man continued to report few health problems while at the Approved
Premises. The notes of his key worker describe his health as follows:
18 February 2004: Health ‘No problems apart from haemorrhoids.’
27 February 2004: Health ‘Has a problem with ears which have swollen
up. Doctors appointment requested for this afternoon.’
On 3 March 2004 the man visited the hostel GP, with whom he registered
temporarily for three months. This is not unusual with hostel residents as they
do not reside permanently at the hostel. While at the surgery, the man
completed a medical history form, which did not indicate any adverse medical
problems. The doctor treated him for a chesty cough and an infected cyst on
his chest wall, prescribing cough medicine and cream.
The notes of the man’s key worker continue to show no major concerns about
his health:
8
18 April 2004: Health ‘No problem apart from chest, throat a bit
blocked. He will take the bike to use it for exercising.’
1 May 2004: Health: ‘No problems. Had diarrhoea because he ate
seafood but he is better now.’
5 June 2004: Health ‘No problems. He told me that he still drinks but
can control it very well.’
29 July 2004: Health ‘No problems with his health. He told me that the
only problem was occasional colds with the change of temperature in
the winter. Otherwise he said that he was enjoying the sun and going
for walks in the park. He still drinks the occasional beer in the pub with
his friends but comes straight back to the hostel.’
The night hostel assistant recalled that he had distributed some medication to
the man but he could not recall the date or the details of the medication or
what ailments he was suffering from. The hostel no longer had any record of
any medication.
While at the hostel, as part of his supervision plan, the man was referred to
Crossroads, an alcohol counselling organisation, for counselling about alcohol
abuse. There is a record of sessions he attended on 17 March 2004, 31
March 2004 and 28 April 2004. He was also required to fill in an alcohol
monitoring sheet. There were no serious concerns about his alcohol
consumption during this period, or any incidents of violence.
Section Two – What occurred on 3 August 2004
On 2 August 2004 the man was checked at the 11pmcurfew and the night
hostel assistant recalled that he was in good spirits. Shortly after 6am the
next morning, the night hostel assistant went to the man’s room at Flat C to
conduct a routine morning curfew check. The man was not in his room so the
night hostel assistant began a room search. He eventually found him in the
bathroom, lying on the floor, slumped against the door. He formed the opinion
that he was dead. He then called the man’s flatmate who declined to enter
the bathroom. He immediately called the night security guard and then went
quickly to phone the Assistant Manager on night duty, at around 6:21. He told
the Assistant Manager to come downstairs as there had been an incident. The
Assistant Manager arrived downstairs and made his way with the night hostel
assistant to Flat C. He entered the flat and made his way upstairs to the
bathroom. He could only open the door by about two feet as the man was
lying on the bathroom floor, with his body against the door. At about 6:32 he
called an ambulance. When the paramedics arrived, they confirmed that the
man was dead, and called his GP. At 7:20am two police officers arrived and
examined the scene, and were subsequently joined by their sergeant. It is not
clear which member of staff contacted the police. The man’s GP, arrived at
around 8:07am. Shortly after 8:10 he confirmed his death. The police officers
left around 8:40.
The Assistant Manager completed an Incident Report after the incident.
9
The night hostel assistant, who was first on the scene, said in interview that
he did not know of any formal procedures to follow after a death in an
Approved Premises. He did not complete an incident report but made notes.
The Hostel Manager told my Investigator that deaths and other incidents are
dealt with by staff at the level of Assistant Manager and above. These staff
are aware of Probation Circular 40/2004 (Strategy for preventing sudden
deaths in Approved Premises – Annex C­ What to do in the event of an
incident of significant self­harm or a fatality), but other staff would not
necessarily be aware of the circular.
The police notified the man’s next of kin of his death. There is no clear
direction in Probation Circular 40/2004 Annex C about whether the hostel
should be in contact with the next of kin. This is an issue that has been
carefully considered in the Prison Service and would benefit from new thinking
in a Probation or NOMS context.
.
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PART THREE
Consideration and conclusions
It is my role to consider the adequacy of care provided for this man at the
Approved Premises. In doing so, I have also considered whether hostel
procedures were clear to staff and in line with the requirements for all such
hostels as defined in the Approved Premises Handbook.
The handbook requires residents to be registered with a GP. The Approved
Premises complied with this requirement by identifying a GP who was willing
to take all the residents of the hostel. It appears that this man received
appropriate care from the GP.
Members of staff at the Approved Premises work 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 him was
good. There was no evidence to indicate that his sad death could have been
prevented by changes in either management procedures or policy.
That said, the Night Hostel Assistant was first on the scene after the incident
on 3 August 2004 but he was not aware of any formal procedures for dealing
with such an incident. It was not appropriate to try and involve a resident in
the incident, and the Assistant Manager should have been alerted
immediately to the nature and location of the incident. This would have made
no difference in this man’s case, but the consequences in other
circumstances could have been more serious.
I recommend that the Approved Premises ensure all staff are aware of
Probation Circular 40/2004 (Strategy for Preventing Sudden Deaths in
Approved Premises). This will ensure they are better prepared to deal
with such incidents.
I am also concerned that the Approved Premises was not able to produce
records of what medication had been issued to this man.
I recommend that the Approved Premises review arrangements for
keeping records of medication it issues.
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RECOMMENDATIONS:
Local:
I recommend that the Approved Premises ensure all staff are aware of
Probation Circular 40/2004 (Strategy for Preventing Sudden Deaths in
Approved Premises), in particular Annex C. This will ensure they are
better prepared to deal with such incidents.
Local:
I recommend that the Approved Premises review arrangements for
keeping records of medication it issues.
STEPHEN SHAW
PRISONS AND PROBATION OMBUDSMAN
April 2005
12