Individual at Bridge House

Circumstances surrounding the death of a resident in Probation Service
Approved Premises in July 2004
Report by the Prisons and Probation Ombudsman for England and
Wales
February 2005
CONTENTS Page No.
FOREWORD 3
INVESTIGATION PROCEDURES 3
SUMMARY 5
PART ONE:
Background Information -
Section 1 – The deceased person 7
Section 2 - The Approved Premises 11
PART TWO:
Events leading up to the resident’s death 13
PART THREE:
Consideration and conclusions 18
Recommendations 24
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FOREWORD
This is a report into the death of a man who died from an apparent overdose
of non-prescription drugs in July 2004. He was on life licence, resident in
Approved Premises under the management of the Probation Service. 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.
Mrs Marian Morris and Ms Louisa Watkins from my office carried out the
investigation with the assistance of, an Assistant Chief Officer (ACO). My
thanks go to the ACO for facilitating the investigation, for providing procedural
advice and for conducting a number of interviews. I am also grateful for the
co-operation received from the Probation Area and from the staff of the
Approved Premises.
The resident had spent many years away from his family but his death was no
less painful for them. I offer the family my sincere condolences. I am
especially grateful to them for agreeing to meet with my colleagues and for
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welcoming them into their home. The information provided by the family was
invaluable to the investigation. The man’s parents wanted the answers to
specific questions about their son's care and I have attempted to answer
those questions in this report.
The man made choices about his own life and was clearly aware of the
dangers associated with drug use. However, aspects of his supervision by
the Probation Area while on life licence were frankly extraordinary, paying little
heed to the risks to him personally or to society at large.
Investigation Procedures
The Investigators conducted formal interviews with the Manager and
Operational Manager of the Approved Premises, with the man’s Key Worker,
with a previous Key Worker, another resident, a Probation Officer and a
Senior Probation Officer all of whom were involved in supervising the man.
The interviews were not recorded but the Investigating Officers' notes have
been agreed and signed by interviewees.
The Investigators obtained information from a voluntary organization who
worked closely with the man and from a Treatment Manager at a Drug
Project. They also examined a variety of documents readily provided by the
Probation Area and by the Drug Project.
The report is organised as follows. Part 1 provides some personal details
about the man and information about the Approved Premises and its cluster
house. Part 2 considers, as far as it is possible to do so, the circumstances
surrounding the man’s death. My conclusions and recommendations are
presented in Part 3.
The Investigation uncovered discrepancies between the Approved Premises
records and those of the supervising officer. Many questions arising from
those discrepancies remain unanswered and aspects of the man’s
supervision left much to be desired, characterised by lack of communication
and assessment. I draw several areas of poor practice to the attention of the
Probation Area although I do not find that they contributed directly to the
man’s death. However, the failure of probation staff to identify the extent of
his drug use and to take appropriate action was crucial.
STEPHEN SHAW, CBE
PRISONS AND PROBATION OMBUDSMAN February 2005
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SUMMARY
The man was released from a prison sentence in February 2003 on licence
after serving 12 years of a life sentence for an offence of manslaughter by
virtue of diminished responsibility. His family supported him throughout his
sentence and his parents were happy for him to stay at their home on release.
However, his offence had been committed in his parents' home area and a
condition in his licence prevented him from returning there without the
permission of his supervising officer. A further licence condition required him
to reside initially at the Approved Premises and, thereafter, where directed by
his supervising officer. The man remained at the Approved Premises until he
was involved in a motor cycle accident and admitted to hospital with serious
injuries.
It was known that he would have limited mobility for some time after his
discharge from hospital and his parents asked if he could stay with them until
he was fully recovered. However, because of the proximity of their address to
that of his victim, permission was refused. When he was discharged, the man
moved to a house under the management of the Approved Premises, where a
ground floor room was converted for his use. He shared the premises with
one other resident and was put in touch with a volunteer from a local
organization who visited him weekly. There was a nightly telephone call from
the Approved Premises and his allocated key worker was required to visit
weekly.
In February 2004, a local police officer reported his suspicions that the man
might be using drugs and he was tested. The test proved positive for cocaine
and opiates and, when challenged, the man admitted cocaine use to his
supervising officer. The supervising officer discussed the situation with the
Lifer Unit and, as a consequence, the Assistant Chief Officer issued a formal
warning to the man. Thereafter, weekly urine tests were negative for cocaine
and positive for opiates. However, scant attention was paid to the possible
indications of heroin use as it was assumed that this was accounted for by the
man’s opiate based medication for pain relief.
The man agreed to participate in a programme run by the a Drug Project and
attended three times weekly from March to the end of May. During this time
he shared information with the Drug Project staff about the extent of his
ongoing use of and dependence upon heroin. He was worried that he might
be recalled to prison if his supervising officer discovered the extent of his drug
use. He had referred himself to the Drug Project, refused permission for
information to be shared and, consequently, no information was disclosed to
the Probation Service. Perhaps more significantly, none was requested.
In June, the man was allowed to visit his parents and they noticed a change in
his looks, demeanour and behaviour. His visit ended with a family argument
during which he was abusive to his mother. He returned to the Approved
premises house on 28 June. Although the family was worried, they believed
that the visit would not have been allowed if the Probation Service had any
concerns about the man. On his return the man reported to his supervising
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officer on 29 June. The contact notes recorded that all seemed well and that
he talked about the possibility of finding accommodation, near his brother, but
outside the exclusion zone. This was the last time that he was seen by
anyone from the Probation Area.
On the evening of 5 July, the man watched the television with his fellow
resident who said that he seemed 'fine'. The next morning, as the fellow
resident left the house, he heard the man breathing heavily in his room but
decided not to disturb him. When he returned some time later, he made the
man tea and took it to his room where the door was ajar. There he found the
man kneeling by the side of the bed, unconscious, with a syringe close by.
The emergency services were called and, upon their arrival, the man was
pronounced dead.
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The circumstances and events surrounding the death of the Approved
premises’ resident.
PART ONE
Background Information
Section One – The resident
1. The resident was a man of 51 years, born and bred in the county
where his family has a thriving business in which he worked for a time
after leaving school. He married at the age of 20 and went abroad with
his wife where their son was born and they made a good life for
themselves. However, he returned to this country some three years
later because of political unrest where they were living. After his
return, the man became involved in illicit drug taking. His marriage
foundered and he was divorced in 1981. Subsequently, he had little
contact with his son.
2. Prison and Probation records indicate that the man had a long history
of multi drug use. He was heavily dependent upon drugs and
committed offences of dishonesty to finance his dependency. In 1990,
when he had been depressed over the breakdown of a relationship, he
was charged with murder after he stabbed a local man who was well
known to him and to his family. Records indicate that he had taken
LSD, amphetamines and methadone. The victim was stabbed when
he attempted to prevent the man from robbing his shop.
3. In 1991, the man was sentenced to life imprisonment for manslaughter
on the basis of diminished responsibility while under the influence of
drugs. He said that he had wanted money for enough drugs to kill
himself. Records indicate that during the early part of his sentence he
was withdrawn and depressed. In 1995, on the anniversary of the
offence, he made a serious attempt to end his life when he could not
5
come to terms with what he had done. However, his recovery led to a
change in his behaviour.
4. Thereafter, he engaged in constructive work on his offending and
related issues. The man also undertook a number of courses to
improve his education and managed to wean himself off the anti-
depressant drugs that he had been taking for some time. He was
variously described as hard working, pleasant and co-operative.
5. He attended meetings of Narcotics Anonymous and, according to
prison records, managed to become drug free. Perhaps most
significantly, he demonstrated genuine remorse for his crime and was
able to appreciate its effects upon the victim's family. When he was
being considered for release on licence, the man appeared to
understand and accept that he should not live in proximity to the
victim's family.
6. Before his release, the man spent a number of home leaves at an
Approved Premises in the Probation Area. In February 2003, he was
released, with a condition of residence after spending more than 12
years in custody. The Home Circumstances Report, prepared some
months earlier, suggested that monitoring of his drug and alcohol use
should be the focus of his supervision as such use could indicate
increasing risk. It was made a condition in his licence that,
"He shall comply with any reasonable requirements imposed by his
supervising officer for the purpose of addressing his drug and alcohol
intake."
Another condition of his licence was that,
"He shall not enter the areas identified on an exclusion zone map
without the permission of his supervising officer."
7. The man was very positive during his first weeks at the Approved
premises, giving himself challenging objectives. He gained full time
employment and no concerns were expressed. In the Offender
Assessment System (OASys) form completed by his key worker, in
March 2003, he identified his contact with his family as being very
important to him but said that he had severed all contact with previous
acquaintances. The assessment also noted the previous suicide
attempt and identified depression and return to previous lifestyle as
possible triggers that needed to be closely monitored. The man was
assessed as posing a low risk of harm to the public but medium risk of
reconviction.
8. In March 2003, the man injured his leg in a motor cycle accident and
was admitted to hospital for three days. He was discharged with
medication and it was, again, noted in hostel records that he should be
watched carefully for signs of depression, as he was suffering
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considerable pain. He was off work for some six weeks, during which
time the house log showed him as being on home leave at his parents'
address for two weeks. His parents confirmed that their son was with
them at home during this time. On his return to the Approved
Premises, it was clear that his mood was low and he was bored.
Subsequently, another resident alleged that the man had used drugs in
the house. His room was searched but there was no evidence of drug
use and he was warned of the possible consequences if it was found
that he was using drugs. My investigators uncovered no evidence of
any further monitoring at that time.
9. During the next six months there were several occasions when his key
worker expressed and recorded his reservations about the man’s
choice of friends and particular concern that he could be led into drug
use by a woman friend who was thought to be using heroin. The key
worker warned the man of the dangers and shared his concerns with
the supervising officer. Nevertheless, there was no evidence that the
man had used drugs and, once he was fit enough to return to work, he
had a more positive attitude. Hostel records indicate that there were
further periods of home leave approved in April, May and for five days
at the beginning of September although these visits were not recorded
by the supervising officer.
10. At the end of September 2003, the man was involved in a second,
more serious, motor cycle accident. He was admitted to hospital with a
broken ankle, broken pelvis, broken arm, broken kneecap and head
injury and the prognosis was that he would have limited mobility for
some time after his discharge. During October 2003, when he was
recovering from his injuries, there was considerable discussion about
where he would stay when discharged. His room at the Approved
Premises could only be held for five days and, in any event, would not
be suitable for someone who was incapacitated by injury.
11. The man’s parents indicated their willingness to nurse him at home
with the assistance of their daughter-in-law but the supervising officer's
line manager deemed that there were insufficient grounds to seek a
variation of the licence conditions. The Investigators were of the
opinion that such a variation was, in fact, unnecessary as the wording
of the licence condition, "…without permission of his supervising
officer", empowered the officer to make the decision.
12. My colleagues were surprised at the apparent inconsistency in allowing
the man to return to his parents’ address, within the exclusion zone, in
March, April, May and September 2003, when, a few weeks later,
permission was refused. Although the man then had a more serious
injury, there had been no indication of heightened risk and no other
change in his circumstances. My colleagues found references in hostel
records that conflicted with those of the supervising officer, who denied
having given permission for those periods of leave. There was a
further anomaly in that the Approved Premises contact sheets record
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the man as being "in at curfew" nightly during the time in June 2004
when his parents said he was at home with them.
These inconsistencies cannot be directly linked to the man’s death, and
I make no recommendation. However, they highlight areas of poor
practice that I urge the Probation Area to scrutinise further.
13. In November 2003, after the man’s father had complained to the Chief
Officer and to his Member of Parliament about the refusal to allow his
son home, the victim liaison officer was consulted. She said that the
victim's widow was still badly affected and expressed her view that the
family would be distressed if the man returned to the area. However,
she did not consult the family as, unless there was likely to be a firm
decision to allow the man to return she did not wish to upset the family
by discussing the issue.
14. On the same day the Lifer Unit was consulted and the case-worker
supported the view that,
"we should try all available avenues before considering a return to [the
home area]."
15. The cluster house, with a ground floor kitchen and bathroom, was
deemed to be the only premises suitable for the man’s limited mobility
and arrangements were made to convert a ground floor living room into
a bedroom for him. His family and my colleagues were surprised to
discover that the house is in an area notorious for drug use, close to a
cafe where drug dealing is carried on openly. The Probation Area
acknowledged that the location was far from perfect and the house has
now been closed. Nevertheless, it seemed far from an ideal placement
for someone, recently released from a lengthy prison sentence, whose
index offence was directly drug related and who was known to have
had difficulty in controlling his use of illegal drugs.
Background Information
Section Two – The Approved Premises
16. Approved Premises, formerly known as Probation & 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 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.
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17. The Probation Area has four Approved Premises. The premises in
question can accommodate 12 residents in the main premises and
could take eight more in two cluster houses, one of which was a three
bedroom terraced house, close to Premises A and approximately two
and a half miles – a 20 minute drive - away from Premises B. The
cluster house was, originally, managed by Premises A but was
subsequently 'attached' to Premises B as, otherwise, with only 12
beds, Premises B would not have been viable and could have been at
risk of closing.
18. Cluster houses originally came into being as move-on accommodation
but in recent years they have become part of the Approved Premises
Estate and subject to the same rules as main premises. These rules
are governed by the National Standards for the Supervision of
Offenders in the Community and by the guidance within the Approved
Premises Handbook. In the Probation Area, cluster houses are used
largely for those on licences who are assessed as needing a lower
level of supervision and who are able to manage within the local
community. Residents of both the main premises and the cluster
houses are allocated a key worker to meet with them weekly, to identify
any areas of difficulty and to manage these, on a day to day basis,
under the direction of supervising officers.
19. The Manager explained that there were various difficulties in providing
adequate oversight of residents at the cluster house, due to the
distance of the house from the main premises and staff constraints. He
said that one staff member had been visiting weekly, alone, to check
that all was well with the house. The hostel was unable to provide
double cover, but even the briefest visit involved the absence of a staff
member from the main premises for more than two hours. The
restrictions of the staff rota, and residents' availability, made it difficult
to schedule weekly key work sessions. Like those in the main
premises, residents in the cluster houses are subject to a nightly
curfew but there is insufficient staff to enable evening visits. Instead,
the curfew is managed by means of a telephone call, each night at 11
pm. Using a dedicated telephone that receives incoming calls, a
member of staff in the main premises is required to speak to each
resident individually.
PART TWO
Events leading to the resident’s death
20. On 14 November 2003, the man moved into the cluster house although
his transfer from hospital did not go as smoothly as expected. There
was no one at the house to meet him and practical issues such as the
buying and preparation of food had not been considered. His brother
visited him and expressed dismay at the lack of facilities provided, but
over the next few days arrangements were made such as the provision
of meals on wheels. The hospital had prescribed opiate-based pain
9
relief medication for the man. According to the guidance in the
Approved Premises Handbook, he would have been required to hand
this in for staff to dispense in the main premises from where he could
collect it each day. The Probation Area confirmed that this was area
practice and the guidance was, subsequently, re-issued in Probation
Circular 33/2004, 'The Handling of Medication of Residents of
Approved Premises'. However, as the man was unable to make the
journey from the cluster house to the Approved Premises, he was
allowed to keep his medication.
21. The investigation found no evidence that the man’s self-medication
was monitored. As identified in this report, his situation was unusual
and it is unlikely that every possibility can be covered by guidelines.
Nevertheless, Circular 33/2004 requires Approved Premises to have a
system in place for the collection, safe-keeping, recording and
administering of prescribed medication. Although such a system was
in place at the Approved Premises, it did not encompass the man’s
special circumstances and was absent in his case.
22. The Prison Service is developing an 'In-Possession Medication' policy
that will provide a risk-assessed system for some prisoners to self-
administer their medication, as they would do in the community. In the
draft of this report I commented that, with the development of the
National Offender Management Service (NOMS), it could be a
retrogressive step if the governance of medication in Approved
Premises were to become more restrictive than the system operating in
prisons. When the draft report was disclosed to the National Probation
Directorate (NPD), it commented that the environment in Approved
Premises differs from that in prisons and the risk and management
issues faced are different.
23. NPD believes there is a strong risk management and duty of care
rationale behind the policy of strictly controlling the security and
dispensing of medications. I agree that the issues involved in the
management of risk in the community differ from those in prisons.
Nevertheless, it is the intention of NOMS to join the work of the prison
and probation services to provide a seamless, more effective service.
It intends to do this by introducing end-to-end management of each
offender, ensuring that work in custody is built upon in the community.
If certain prisoners are to be encouraged to adopt a more reasonable
attitude by being allowed to take control of their own medication in
custody, it is appropriate that such encouragement should continue in
the community, providing the risk is properly assessed. I trust that, in
the fullness of time, NOMS may consider a joint procedure that will not
only ensure offenders' safety, but will enable those who do not pose a
risk to take responsibility for their own well being. Meantime, I hope
that the NPD will seek ways of working jointly with NOMS Health
Partnerships to ensure a seamless transition from prison to the
community for those who require medication.
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I recommend that the National Probation Directorate should review the
current procedures for dealing with residents' medication and ensure
there is a safe, secure system with which staff are familiar.
(At the draft report stage, the National Probation Directorate agreed
that the monitoring of the man’s use of medication at the cluster house
was not adequate. The NPD has said that it intends to issue further
advice to all Probation Areas and I trust they will do so in the near
future.)
24. In December 2003 the man was put in touch with a volunteer from a
local voluntary organisation who visited him weekly and continued to
offer support throughout his residency. The man subsequently shared
the premises with another resident and the two men got on well
together. The resident said that he would often cook for them both and
they would watch television together in the evenings. When the man
was more mobile, the voluntary organization obtained a bicycle for him
as he found it easier to cycle than walk. He was able to get out and he
would occasionally visit a local public house with his fellow resident.
25. Between November 2003 and February 2004 the man appeared to
make good progress although his leg was not healing well and his
mobility continued to be limited. His father visited him during
December 2003 but his request to spend Christmas with his parents
was refused, "due to licence conditions". The key worker expressed no
concerns in the notes sent regularly to the supervising officer who also
visited the man in line with the requirements of National Standards. He
continued to receive support from the voluntary organisation’s worker
who shared information with the supervising officer on a regular basis.
26. In February 2004, a Community Police Officer told the key worker that,
by chance, he had seen the man in the street, associating with known
drug dealers. The key worker reported immediately to the supervising
officer and it was decided that the man should undergo urine testing to
ascertain whether he had used illicit drugs. The test proved positive.
27. The supervising officer’s contact sheet for 26 February 2004 records:
“Result of drug test showed positive for cocaine and opiates. Positive
for opiates is of limited concern because he is also taking opiate based
pain killers following his motor cycle accident. Worker from [the
Approved Premises] will arrange to have more exhaustive tests done
on the next sample.”
Ongoing tests continued to show positive for opiates but the
Investigators found no evidence of any in-depth analysis that might
have established whether the amount was commensurate with the
man’s prescribed medication. There is no mention in the hostel
records of any further analysis of the test results.
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28. The man met with the key worker and the supervising officer and
admitted that he had used cocaine on two occasions. He accepted
that this was problematic and expressed the desire to address the
problem. It was agreed that the key worker would take him to the l
Drugs Project which he did on the same day although no formal referral
was made. The man decided to participate in a Change Programme
involving attendance three times weekly for eight weeks. The
supervising officer had a warning letter issued, as he was advised to do
by the Lifer Unit.
29. The supervising officer's report of 2 March, forwarded to the Lifer
Section of the Sentencing Policy and Penalties Unit via the ACO,
provided details of the man’s lapse and the remedial action taken. The
'Areas of Concern' section noted,
"Further evidence of drug abuse will result in immediate action."
Despite this, the evidence of continuing opiate use in weekly drug tests
prompted no further action.
30. My colleagues were given information by the Drug Project, indicating
that the man attended regularly, between 3 March and 31 May, on
Wednesdays, Thursdays and Fridays. He participated in 16 sessions
of the Change Programme followed by 10 sessions at an Action Group
with weekly goal setting meetings. He told workers at the drug project
that he was using heroin and cocaine on a daily basis spending at least
£20 daily.
31. On 2 April 2004, the man told the drug project worker that he had
reduced his heroin intake to once in two or three days and that he had
stopped using cocaine entirely. He said that he did not wish to
participate in a methadone reduction programme as this would involve
his G.P. knowing that he was using heroin. The man said he was
frightened that he would be recalled if the Probation Service discovered
his drug use. During the Investigation, the man’s parents said they had
recently discovered that his bank statements indicated he had received
in excess of £10,000 compensation since his first accident and that he
had, in fact, continued to spend in the region of £150 daily. They
spoke of his bank balance standing at around £3 at the time of his
death.
32. The man also told the drug project worker that, through his contacts, he
had obtained a supply of a drug called Subutex that, he understood,
was helpful as a heroin substitute. He sought advice about the drug's
correct use, but was told it should not be used without the proper
medical support that he was so reluctant to seek. None of the
information given by the man to the drug project was shared with either
his supervising officer or key worker because he had self-referred and
had withdrawn his permission for information to be disclosed. Given
that he was on life licence, many people would find this extraordinary.
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The Probation Area’s Hostels Manager has now taken steps to review
the learning points from the man’s death and has identified the
shortcomings in the current information sharing and confidentiality
agreement with the drug project. I was very glad to hear that steps are
already being taken to review the agreement.
I recommend that the Probation Area reviews and, if necessary, re-
negotiates its information sharing agreement with the Drug Project to
ensure that information pertaining to the management of risk can be
openly shared.
33. The Investigators were puzzled by the supervising officer's report to the
Lifer Section of the Sentencing Policy and Penalties Unit dated 28 May.
Although weekly drug tests continued to prove positive for opiates and
the drug project told the Investigators that no information was shared
with the supervising officer, the report states,
"I shall continue to monitor very carefully the man’s drug use and he
will continue to be tested for drugs on a weekly basis. The last three
tests have all been negative since he received his warning letter…I
shall continue to see the man monthly as well as receive regular
weekly reports from his attendance at the Drug Project."
It seems reasonable to expect that, if such weekly reports had been
requested, the drug project would have commented upon the man’s
refusal to allow the disclosure of information and this, in itself, would
have raised concerns. There was nothing in the record of contact to
indicate when such reports were received and the supervising officer
did not refer to them during the Investigation.
34. On 5 May 2004, the man reported to the Drug Project that he had
stabilised his heroin use but could not get beyond three days without
the drug. He remained adamant that he did not wish to involve the
medical profession due to his fears of recall, but expressed his desire
to undertake a detoxification process, if possible away from the area.
His final attendance at the Drug Project was on 29 June when he
wanted to discuss ongoing support with the worker, saying that he had
detoxified at his parents' home.
35. We cannot know for sure if the man had detoxified during his home
leave although his parents said they noticed a difference in him during
his visit between 21–28 June 2004. They described him as having lost
weight and being unable to eat. They thought that his behaviour was
more aggressive than usual and, after an evening's drinking with his
brother, there was an argument during which he was abusive towards
them. His mother found her son's behaviour both bemusing and
distressing. She said that after his return to the Probation Area he
telephoned every day asking for forgiveness.
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36. On 29 June 2004 the man reported to his supervising officer who noted
that he appeared to be happy following his visit home. He talked about
the possibility of working with his brother, in the away from the
exclusion zone. In the time up to his death, seven days later, the man
was not seen again by his supervising officer or by any member of staff
from the Approved Premises.
37. The man’s fellow resident could not say at precisely what time he left
the house on 6 July although he thought it was “mid-morning”. He said
he could hear the man breathing heavily and considered knocking to
wake him. However, he decided not to disturb the man and went to the
Approved premises to get various things needed for the house. On his
return, as he took his coat to his room, he noticed that the man’s
bedroom door was open and thought he must be up and about. He
shouted, asking if the man wanted tea. Although there was no reply,
he made the tea, knocked on the man’s open door and went in.
38. The resident described the man kneeling next to the bed, unconscious,
with a syringe beside him. The resident said that, from the man’s
position and his lack of response, he feared that something was very
wrong. An ambulance was called and the man was pronounced dead.
PART THREE
Consideration & Conclusions
39. It was my role to examine the quality of supervision and care provided
to the man as a resident in Approved Premises. In doing so, I also
considered whether any change in operational methods, policy,
practice or management arrangements could help prevent a similar
death in future.
40. The circumstances in which the man was placed at the cluster house
were very unusual and derived in a large part from the serious accident
that he had suffered. Nevertheless, the arrangements left much to be
desired. The decision to accommodate a man with such serious
injuries in a house, with one other offender, when daily contact with
staff in the main premises was by telephone only, was far from ideal.
Leaving aside its unsuitable location for offenders (especially those
with a history of drug use), amenities in the house were basic and the
Investigators were informed that it had been without hot water for a
lengthy period while repairs were negotiated with the landlord. The
Approved Premises estate in the Probation Area seems ill-equipped to
cope with disability and ill-prepared for the requirements of the
Disability Discrimination Act (DDA). I appreciate that, nationally, much
of the estate is not purpose-built and that improvements have
considerable resource implications. However, I suspect for that reason
that other areas are also unprepared.
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I recommend that the National Probation Service undertakes an audit of
Approved Premises, with a view to taking remedial action if there are not
premises in each Probation Area suitable for those with disability.
(This recommendation has already been addressed. Having seen the
report in draft, NPD has said it has undertaken DDA assessments of all
Probation Board managed Approved Premises and has commissioned
surveys of those under voluntary management. Given the difficulties of
making each site fully accessible, the approach being adopted initially
is to ensure that provision is available in each region and this is
consistent with the requirements of DDA.)
41. The distance of the cluster house from the Approved Premises caused
management problems, as reported to the National Probation
Directorate in a memorandum sent electronically by the Manager in
November 2003. Section 12 of the Approved Premises Handbook
states that daily contact should be made with each resident and that
this may be combined with curfew checks. Although the nightly
telephone call made to each resident at the cluster house fulfilled this
requirement, I question whether such a call could provide the same
safeguards as personal contact.
42. Since the man’s death, the cluster house has been closed together
with a second cluster house. A larger house, within quick walking
distance of the Approved Premises has replaced both premises. It is
anticipated that this will be much easier to manage but the Probation
Area must ensure that it can fulfil its supervisory responsibilities
towards those accommodated in Approved Premises.
I recommend that the Probation Area reviews its management of the
new Approved Premises cluster house, to consider if there are
alternative methods of managing curfew requirements, achievable
within resource constraints.
(Since reading this report in draft, the Probation Area has commented
that the new cluster house is less than five minutes walk away from the
main premises and is visited daily by members of staff, in addition to
the telephone curfew check.)
43. Communication between all those charged with the supervision of
offenders is crucial for the identification and management of problem
issues. In this man’s case, communication between the Approved
Premises and the supervising officer appears to have been neither
regular nor meaningful. Key work visits to the man at the cluster house
should have been weekly but there were four occasions when the visits
were cancelled, recorded as being for reasons of resources. I accept
that the Approved Premises had been carrying two staff vacancies for
some time. These had been covered by relief staff, who were less
experienced than permanent staff and it is understandable that the
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Assistant Manager was reluctant to leave relief staff alone.
Nevertheless, I find the lack of direct contact unacceptable.
44. The quality of recording in key work pro-formas and Individual
Programme Plans that were on file at the Approved Premises was
inadequate. The pro-formas were repetitious, stating that the man was
doing well and testing negative for cocaine, with no mention of opiates.
The Individual Programme Plans were also repetitious and, from 2
February 2004 to 28 June 2004, were not signed by the man. There
was no mention of drug issues. I am surprised that the Approved
Premises Operational Manager did not bring this to the key worker's
attention after record inspections.
45. The man’s parents commented upon the draft report in a letter to Mrs
Morris. They stated,
"All the key worker pro-formas say [our son] was fine, doing ok, they
are all very repetitive, and I can tell you that [our son] complained
constantly to us about the lack of communication and help that he had
and felt very vulnerable on release from hospital. However, he was
scared of complaining himself for fear of any backlash and let us do his
complaining for him."
46. The Approved Premises Operational Manager supervises key workers
every six weeks and file checks are undertaken at the end of each
month. However, to a large extent, the Manager must rely upon staff
members managing their own workloads and, he acknowledged, it
would be possible for three key-work visits to be missed in a short
space of time, without his knowledge, as happened in this case. With
hindsight, in the Manager’s opinion, the reasons given for three of the
four missed visits were not acceptable.
47. A supervising officer is responsible for the overall management of each
offender and it is the role of Approved Premises staff to pass on
information to the supervising officer for review, action and decision.
Written recordings of key-work sessions should be sent to the
supervising officer to provide regular information about progress or
problems but no action was taken when notes did not arrive.
48. The Investigation has raised a number of questions over the level of
supervision afforded to this man and whether there was any
meaningful consideration of his needs. In interview the supervising
officer acknowledged that, “on many occasions the Key Worker had
missed the man at his accommodation.” Given that the man was
thought to have mobility problems, I am surprised that alarm bells did
not ring and that no effort was made to ascertain why the key worker
failed to make contact. I am also surprised that no action was taken
over the lack of contact, particularly since the record of contact log
indicates that between 20 April and 7 June 2004, the man had missed
two appointments with the supervising officer. However, it was noted
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that one of these absences was deemed acceptable, as the
appointment letter was not received.
I recommend that the Probation Area reviews the procedures for
recording, monitoring, disclosing and acting upon information and
observations from key-work sessions, with a view to issuing further
guidance to key workers and Case Managers if necessary.
(Since reading the report in draft form, the Probation Area has commented
that protocols are being developed in respect of the interface between key-
workers and case managers. Various standards are being set such as the
requirement for key-work information to be place in the case record within a
time frame.)
49. In a previous report into the death of a young hostel resident from a
drug overdose, I recommended that the National Probation Directorate
(NPD) should issue further guidance about the required level of
information sharing between those who are variously involved in an
offender's supervision.
I recommend that the National Probation Directorate reviews its
information sharing protocols and issues guidance to all Areas to
ensure the effective care and management of offenders.
(Since reading the draft report, NPD has said it will address issues of
communication between supervising officers and case managers. The new
version of National Standards, currently in draft form and issued for
consultation, puts a requirement on all probation staff to ensure that relevant
information is properly communicated.)
50. Before he moved into the cluster house, responsibility for the man’s
supervision was transferred from the supervising officer to a senior
practitioner who transferred to the resettlement team, in October 2003,
on a temporary basis. He was responsible for managing around 40
cases of high-risk offenders and life licencees whilst also providing an
advisory function for other members of the team. The senior
practitioner commented that in his view, at that time, the provision for
lifers in the Area was less than satisfactory. A significant number of life
licencees were supervised by the acting Senior Probation Officer who
also had a great many other responsibilities. Many of these cases had
been transferred from other teams without OASys risk assessment,
due to a reorganisation that occurred at the same time as a move into
a new office.
51. The assessment and management of risk fulfill crucial roles in the
supervision of offenders, especially those who must work to re-
establish themselves in the community having spent long periods in
custody. A full 'OASys Two' form was completed by the man’s key
worker at the Approved Premises, in March 2003 and reviewed in June
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2003. Although, at that time, there were no current concerns about
self-harm, it was noted that the risk could increase if the man became
depressed or returned to drug use. In the review it was also noted that
the man had been keeping company with women believed to have,
"connections with drug misuse" and that he had been warned about
this. The supervising officer had also prepared an OASys risk
assessment on 3 March 2003 but accepted that there had been no
further formal reviews or screening during the ensuing 12 months.
52. In April 2004, the man’s supervision was transferred back to his original
supervising officer. When interviewed the officer stated that when the
man was seen in April, the officer thought he was, "looking good and
his state of mind was good." However, the officer also said that when
he was seen in May the officer was "shocked" as he had, "regressed,
was heavily reliant on his crutches again and had lost weight." The
officer expressed the view that a number of negative factors had
contributed to the man’s condition. Among these were his
apprehension about the possibility of a further operation, his concerns
about his father's health, and boredom as his limited literary skills
meant he mainly watched television throughout the day.
53. It was for those reasons and their possible impact upon the man’s
frame of mind that, the supervising officer said she permission was
given for a period of home leave. The officer did not mention any
concerns about possible drug use and none of the concerns expressed
in interview were reflected in the record of contact. The entry for 17
May stated,
"Saw [the man] progressing slowly after accident more mobile as he is
on crutches. Support worker is helping him considerably"
The next entry dated 7 June also indicated no problems.
54. During interview, the officer explained that while the man was being
supervised, the supervisor was acting up as a Senior Probation Officer
and holding 31 lifer cases in addition to 35 other, mainly high risk,
resettlement cases. The officer explained that lifer cases have always
been viewed as a separate category and said, "…even now fewer lifer
cases have either OASys or regular reviews. Instead, the officer said,
reports to the Lifer Unit, that were available on file, constituted case
reviews. I have commented elsewhere in this report upon the
surprising content of one such report.
55. I have no wish to impugn the integrity of any ASPA employee but there
was a clear failing in recording and communicating decisions. I readily
accept that the supervision of those released on life licence presents
unique challenges that need to be managed within limited resources.
Nevertheless, I question the practice of forgoing a system of risk
assessment in use throughout the Prison and Probation Services, and
regular review of that assessment.
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I recommend that the Probation Area reviews its handling of Life
Licences to consider if standards of assessment and supervision are
sufficient to ensure effective offender management.
(Since reading my draft report, the Probation Area has embarked upon a Life
Licence review.)
56. By far the most worrying aspect of this case was the abysmal failure of
any employee of the Probation Area to properly identify and address
the extent of this man’s drug use. Assumptions were made but not
tested and on the one occasion when further investigative action was
suggested, it was not undertaken. On 26 February, when a drug test
showed positive for cocaine and opiates, the record of contact sheet
notes that the key worker was to arrange to have, "more exhaustive
tests done on the next sample." No exhaustive tests were undertaken,
no reminders were given, no results were requested and thereafter,
although urine tests continued to indicate opiate use, this was
apparently ignored.
57. The fact that the man received compensation following his first motor
cycle accident appears to indicate that the fault was not his.
Nevertheless, when he was involved in a second, serious, motor cycle
accident within a year, speculation as to whether there was anything
more than bad luck involved might have been expected. When the
man admitted using illicit drugs, although he was introduced to a Drug
Project there was no formal referral to the organisation and, according
to the project, no formal feed-back, despite there being a condition in
the man’s licence that he should comply with his supervisor's
requirements to address his drug intake.
58. Thereafter, there seems to have been an assumption that the drug
Project’s intervention had been successful and there was no further,
meaningful, assessment of the man’s drug use by the Probation Area.
No one questioned whether the amount of medication that he was
taking should decrease as his condition improved. The Supervising
Officer assessed factors that might have contributed towards the
deterioration in the man’s condition that were observed in the short
period between April and May 2004, but, despite all the clues, the
officer did not consider his use of drugs.
I recommend that the Probation Area should conduct an in-house
inquiry to assess training and competence issues for those members of
staff responsible for the management of the man’s licence.
(The Probation Area has said it is currently seeking the assistance of an
external consultant to undertake a review of training and competence issues.)
59. All those involved in the management of offenders know how high the
risk associated with the use of class 'A' drugs can be. Although the
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man was, ultimately, responsible for his actions, the Probation Area
had a duty of care towards him. Closer supervision and assessment
from those fulfilling that responsibility could have identified the extent of
his drug use and enabled decisions to be made about how best to
ensure his safety.
60. Although this investigation leaves questions to be answered, it has
revealed a lamentable lack of communication between the Approved
Premises, the Case Manager and other agencies involved in the care
of this man. Although it will be of scant consolation to his family, I hope
that the lessons learned from his sad death will help prevent such
events occurring in the future.
STEPHEN SHAW
OMBUDSMAN
17 February 2005
RECOMMENDATIONS
National Offender Management Service Recommendation
I recommend that the National Offender Management Service should
review the policies of the prison and probation services for the handling
and dispensing of offenders' medication and give consideration to
developing a joint system.
National Recommendations
I recommend that the National Probation Service undertakes an audit of
Approved Premises, with a view to taking remedial action if there are not
premises in each Probation Area suitable for those with disability.
I recommend that the National Probation Directorate reviews its
information sharing protocols and issues guidance to all Areas to
ensure the effective care and management of offenders.
Area Recommendations
I recommend that the Probation Area reviews and, if necessary re-
negotiate its information sharing agreement with the Drug Project to
ensure that information pertaining to the management of risk can be
openly shared.
I recommend that the Probation Area reviews its management of the
new Approved Premises cluster house, to consider if there are
alternative methods of managing curfew requirements, achievable
within resource constraints.
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I recommend that the Probation Area reviews the procedures for
recording, monitoring, disclosing and acting upon information and
observations from key-work sessions, with a view to issuing further
guidance to Key Workers and Case Managers if necessary.
I recommend that the Probation Area reviews its handling of Life
Licences to consider if standards of assessment and supervision are
sufficient to ensure effective offender management.
I recommend that the Probation Area should conduct an in-house
inquiry to assess training and competence issues for those members of
staff responsible for the management of the man’s licence.
N.B. The Probation Area has confirmed that all my recommendations
have been accepted and implemented.
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