Individual at Wilton Place

CIRCUMSTANCES SURROUNDING THE DEATH OF
A MAN IN HOSPITAL IN AUGUST 2004; WHILST RESIDENT
IN AN APPROVED PREMISES IN THE
GREATER MANCHESTER AREA
Report by the Prisons and Probation Ombudsman for England and
Wales
January 2005
This is the report of an investigation into the circumstances of the death of a
man who was resident in an Approved Premises under the management of
the Greater Manchester Probation Area. The man died in hospital in August
2004. The cause of death was bronchopneumonia but he had also been
suffering with chronic lymphocytic leukaemia for some time.
Since 1 April 2004, my office has been responsible for investigating all deaths
of Approved Premises residents, including those due to natural causes. A
senior member of my staff conducted the investigation with the assistance of
the Manager of the Approved Premises. Although no formal statements were
taken, I am grateful for the assistance and co-operation that my investigator
received from staff. A letter was sent to the man’s current partner offering her
contact but she did not respond.
Confirmation of the man’s condition and treatment was provided by his
Consultant Haematologist.
Although some of the information contained in this report does not show the
man in a positive light, offending behaviour is only one facet of an individual’s
personality and I have no doubt that those who knew him well saw a different
side of him. I extend my condolences to his family for their loss.
STEPHEN SHAW, CBE
JANUARY 2005
Contents
Summary
Events leading to the man’s death
Considerations and conclusions
Area recommendation
Summary
The man was a man of 62 years who was released from HMP Risley on his
non-parole date in November 2003, following a prison sentence of four years.
There was an extended licence period to March 2005.
As he could not return to live with his partner, he was accommodated in a
ground floor room at the Approved Premises where it was known that he had
been suffering from leukaemia. He settled well and presented no
management problem but there were several short hospital admissions when
he suffered back pain due to arthritis.
On 1 August 2004, he was admitted to hospital with chest pain and was
diagnosed as suffering a chest infection and spine deterioration due to
osteoporosis. He was prescribed antibiotics and his condition improved for a
time. However, he developed another chest infection and died in hospital on
24 August 2004. The cause of death was bronchopneumonia, contributed by
chronic pulmonary disease and chronic lymphocytic leukaemia.
The Investigation raised no issues about the level of care afforded him by staff
at the Approved Premises who are increasingly required to deal with the
management of high risk offenders. Staff and residents alike were distressed
by his death, albeit not entirely unexpected. There was, however, one
domestic issue highlighted by the National Probation Directorate that the
investigation has attempted to explore.
The report makes two recommendations.
Events leading to the man’s death
1. The man settled well at the Approved Premises and presented no
management problems. He was allocated a key worker who worked
with him on offending behaviour issues as well as more practical
matters concerning move-on accommodation and benefit entitlement.
He also maintained regular contact with his partner who remained
supportive towards him.
2. On 2 May 2004, he complained of chest pains and difficulty in
breathing. Hostel staff immediately called the emergency services and
he was taken to hospital where he was admitted via the Accident and
Emergency department, suffering with a fever and chest infection. He
was treated with antibiotics and found to be suffering from chronic
obstructive pulmonary disease, probably aggravated by his having
been a heavy smoker for many years.
3. During his time in hospital, his rent continued to be paid and his room
was kept available. He was discharged on 23 May and returned to the
Approved Premises. He complied with the hostel regime and worked
with his key worker as required. There were no concerns about him,
other than his continuing poor health. He was admitted to hospital
again on 10 June with an episode of pneumonia. He underwent
various tests but no abnormlity was found in his lungs and he was
discharged back to the Approved Premises on 2 July.
4. His final admission to hospital was on 1 August 2004 after he had
suffered severe back and chest pain. He was treated for another chest
infection and an x-ray showed a crush fracture of two vertebrae caused
by osteoporosis. There was an initial improvement in his condition.
When his key worker visited him on 11 August, he expressed the hope
that he would be discharged by that weekend. He was planning for his
future and talked of having been approved for mobility allowance.
5. Unfortunately, the improvement did not continue. The consultant
indicated that the leukaemia would predispose him to frequent chest
infections and he developed another. On 21 August, he was
transferred to an acute ward but, despite intensive treatment, his
condition could not be stabilised and he died on 24 August. Staff at the
Approved Premises were informed of his death, that morning, by the
man’s partner.
Consideration and conclusions
6. It is right that the death of one who is in the care of the state should be
fully investigated and proper attention paid to any issues raised. This
man’s death affected those who had known him at the Approved
Premises and this investigation found that staff cared for him well and
took appropriate action to deal with his episodes of illness quickly and
effectively. There is no doubt that the ethos and environment of the
Approved Premises is supportive for residents and staff alike and I
have no recommendations to make in this respect.
7. There is, however, one area to be considered. When the National
Probation Directorate was notified of his death, surprise was expressed
that, having spent more than three weeks in hospital, he was still
registered as a resident of the Approved Premises. Chapter 6.42 of
the Approved Premises Handbook, 'Stay in Hospital' states,
'If the resident is likely to return to the Approved Premises and the
residential requirement remains in force, the managing body should
continue to reserve a place for the first five days. In exceptional
circumstances the managing body could consider reserving a place in
the Approved Premises for a longer period.'
12. Although the Approved Premises Manager did not seem aware of this
instruction, she explained that there were exceptional circumstances
and that the decision to keep the man’s room available for him was
based on several considerations. He had nowhere else to go and it
was crucial that his level of risk continued to be properly managed. His
rent was paid throughout each period of in-patient treatment and there
was no financial loss to the premises.
13. It was clearly in the man’s best interests to return to a consistent,
friendly environment after each period of in-patient treatment. I have
no doubt that the level of care afforded to him by staff at the Approved
Premises was of a high standard and I find that the manager took the
most responsible course of action. I agree with her decision. However
the investigation has revealed a lack in staff awareness of the
Approved Premises Handbook and the guidance contained therein.
Area Recommendation
I recommend that the National Probation Directorate issues guidance to
all Probation Areas about the need for Managers of Approved Premises
to familiarise themselves and their staff with the Approved Premises
Handbook.