Individual at Dickson House

Circumstances surrounding the death of a resident in
Probation Services Approved Premises
in June 2004
Report by the Prisons and Probation Ombudsman for England and
Wales
October 2004
CONTENTS Page No.
FOREWORD
SUMMARY
PART ONE:
Background Information -
Section 1 - The resident
Section 2 - The Approved Premises
PART TWO:
Events leading up to the resident's death -
Section 1 - The resident's time at the Approved Premises
Section 2 - The events in June 2004
PART THREE:
Consideration and Conclusions
Recommendations
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FOREWORD
This was among the first investigations that my office has undertaken into a
death of an Approved Premises’ resident. It was occasioned by the death of a
resident at a Railway Station in June 2004.
The purpose of my investigation was to discover whether the level of care
provided for the resident by the Approved Premises was sufficient and, in
particular, whether the likely risk of self-harm had been properly assessed and
managed. My full terms of reference are attached at Annex 1.
A senior member of the Prisons and Probation Ombudsman’s Office, carried
out the investigation with the assistance of a District manager from the
Probation Area. I am grateful to the District Manager for facilitating the
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investigation, for providing policy advice and for interviewing members of staff.
I am also grateful for the co-operation that the Investigators received from the
Probation Area and, in particular, from the Manager and staff at the Approved
Premises. Very helpful comments were also received from the National
Probation Directorate and from the Probation Area when the report was sent
to them in draft.
The death of a son is a devastating experience for parents, no matter what
has gone before, and the death of their son in such shocking circumstances
was particularly distressing for the resident's parents. I am especially grateful
to them for meeting with the Investigator at what was a very emotional time for
them. Their grief over the loss of their son was evident and I offer my sincere
condolences to them and their family.
The Investigators conducted formal interviews with the Hostel Manager, a
member of the hostel staff, a Probation Officer who prepared a pre-sentence
report on the resident, and with his supervising officer. The interviews were
not recorded but the Investigators' notes have been agreed and signed by
interviewees.
The Investigators obtained information, by telephone, from a hostel resident
and they examined a variety of documents provided by the Probation Area.
The report is organised as follows. Part 1 provides some personal details
about the resident and information about the Approved Preemises. Part 2
considers, as far as it is possible to do so, the circumstances surrounding the
resident's death. My conclusions and recommendations are presented in Part
3, and two Annexes complete this report. As the reader will discover, it is a
dismal story of breakdown in communication and lack of offender
management.
STEPHEN SHAW
PRISONS AND PROBATION OMBUDSMAN OCTOBER 2004
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SUMMARY
The resident was 22 years of age when he died. He began experimenting
with drugs when he was a teenager and became a multi drug user over the
ensuing years. He appeared to understand the dangers of his lifestyle but
seemed powerless to change it, funding his drug use through acquisitive
offending.
On 14 May 2004, the resident was due to be sentenced at Crown Court for
offences of residential burglary and was facing a custodial sentence.
Following a custodial remand, he was thought to be drug free and he was
bailed for a period of residence at the Approved Premises to be assessed for
a possible community sentence.
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The process by which the resident was admitted to the hostel was confused
and chaotic. Initially, he had been found unsuitable for residence, but the
decision to refuse him a place was not conveyed to the referring officer nor to
the Court. The Approved premises was informed that he was to reside there
when he was actually on his way.
The young man arrived at the hostel during a very difficult period but settled
well and, initially, gave no cause for concern. On 11 June at Crown Court, he
was sentenced to a 12 months' Drug Treatment and Testing Order (DTTO).
Over a short time, the members of Approved Premises staff in closest contact
with the resident came to suspect that he was continuing to use drugs and he
confessed as much to those supervising him in the Drug Treatment and
Testing team. Very regrettably, the information was not shared between the
two teams and a risk management plan was not put into place.
On a morning in June 2004, after an altercation with a hostel worker over an
incorrect benefit payment, the resident left the hostel and did not return that
day. At 24:00 that night, the hostel was informed by telephone that he had
died from an apparent drug overdose at the local Railway Station earlier in the
evening.
The investigation has revealed an appalling series of breakdowns in
communication between the Court, the hostel, the drugs agency and the
DTTO team responsible for this man's supervision and treatment. While
better communication might not have prevented his death, there are
significant lessons to be learned. The Probation Area has acted promptly
following these sad events. However, I have identified areas where
communication systems could be improved and have made four
recommendations that can be found in Part 3. Section 2.
THE CIRCUMSTANCES AND EVENTS SURROUNDING THE RESIDENT'S
DEATH
PART ONE - Background Information
Section 1: The Resident
The resident was brought up within a loving family environment but despite
this, he began using drugs during his teenage years, and experimented with
whatever drugs he could obtain. His parents described how information
pamphlets, designed to educate young people about the dangers of drug use,
only made him more curious and increased his consumption. When he was
aged 14, he was excluded from school.
He funded his drug use through offending and he received his first custodial
sentence when he was aged 16, around the time he first used heroin
intravenously. Thereafter, he admitted that he used heroin, cocaine, cannabis
and at times, alcohol, on a regular basis.
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It was beyond his parents' best efforts to help the man despite sending him to
stay with his paternal grandparents, away from his home area, from time to
time. His drug use continued and his behaviour deteriorated to the extent that
everything of any value in the home had to be locked away. Finally, when the
police called at the house, with dogs, looking for drugs, his parents felt they
could no longer put their other family at risk and, consequently, their son was
asked to leave.
By the time he appeared in Court, during April 2004, charged with domestic
burglaries, the man had acquired some 30 previous convictions for offences
of dishonesty, all committed to fund his drug use. He was regarded as a
persistent offender and had changed from an ordinary young boy into
someone his family could hardly recognise.
The man was remanded in custody for the preparation of a pre-sentence
report and was interviewed by a Probation Officer in prison in May 2004. He
told the Probation Officer that he knew he needed help to overcome his habit
of drug abuse. He said that during the remand period he had detoxified and
was drug free but he worried that upon release he could return to his old
ways. The Probation Officer was impressed with the man's insight into his
drug use. The Officer thought that the man knew what he needed to do to
stop using drugs but was struggling with the fact that he could not actually do
it. It was the officer's opinion that the man needed to be away from his home
area and his drug-using friends.
The report suggested that the man should be remanded on bail for four weeks
with a condition of residence at the Approved Premises where he could be
further assessed as to his suitability for a community order and the Court
agreed. It was a further condition of his bail that he should not go to the area
where many of his drug contacts congregated.
The man was on bail at the Approved Premises from 14 May 2004 until 11
June 2004, when he was sentenced to a 12 months’ Drug Treatment and
Testing Order (DTTO). The Approved Premises Manager said that, as there
can be no condition of residence in a DTTO, it was made a requirement of the
man's treatment package that he reside at the Approved Premises. The
condition of bail excluding him from his home area no longer applied.
Section 2 - The Approved Premises
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 management of offenders
accommodated in Approved Premises is governed by the National Standards
for the Supervision of Offenders.
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The Approved Premises is one of three within the Probation Area. There are
eighteen beds in fourteen single and two shared rooms one of which, on the
ground floor, is equipped for special needs.
The premises usually operate to capacity and accepts offenders on bail and
subject to community penalties or prison licences. Residents must be over
the age of 18 but the hostel will consider any type of offender depending upon
the level of assessed risk and the dynamics of the resident group at any
particular point in time.
Over the last ten years or so, the profile of Approved Premises’ residents has
changed from low risk to high risk. Premises no longer simply offer
accommodation for those who have nowhere else to go, and the purpose of
the Approved Premises in this case is to provide an enhanced level of
supervision for some of the most difficult and high-risk offenders in the
community.
There is a curfew from 10.30pm to 10am (for those not working) but earlier
curfew hours can be accommodated if made by the court. There is a rota of
jobs for residents designed to improve their social skills. The housekeeper
checks the satisfactory completion of these each morning before residents are
allowed to leave the premises.
There is no full daytime programme of activities but there is a weekly group-
work session that residents are required to attend, together with a monthly
residents' meeting chaired by the Manager.
The staffing complement is:
Manager
Support Services Officer (contracts side, admin etc.)
5 Residential Services Officers who work a five-week shift pattern
2 night waking cover (there is one sleeping and one waking staff member
each night)
Residential Administrative Services Officer
Housekeeper/Cook
Breakfast and cooked evening meals are provided.
Probation representatives at Court make referrals for straightforward bail beds
to the two Residential Services Officers on duty. Prompt decisions are
required and the Manager is only consulted if the two Residential Services
Officers cannot agree upon the suitability of a referral. For those subject to
orders or licences, who are likely to present a higher risk, the Manager makes
decisions about suitability, after careful consideration, on the basis of
information available from a variety of sources.
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PART TWO - EVENTS LEADING UP TO THE RESIDENT'S DEATH
Section one: The resident's time at the Approved premises
The process by which the man was admitted to the hostel was chaotic. It has
not yet been possible to unravel the confusion completely but I set out below
what I think occurred.
The man was referred for a bail placement on 10 May 2004, by telephone, to
a relief member of staff who took the required details and completed a referral
form. The form noted that there were, "2 x suicide attempts - overdose last
year" but, perhaps surprisingly, stated that he was not at risk of suicide/self
harm. There was no evidence of further risk assessments undertaken during
his stay at the premises. The man was refused a place as he had several
convictions for residential burglary to fund his drug use and the Manager was
concerned about the risk of re-offending to local residents. There was no
decision noted on the referral form but on a separate 'Reasons for Refusal'
form the decision is clearly indicated in the box marked 'risk to the community
too great to be managed'.
Nevertheless, the pre-sentence report (PSR) put before the Court states at
paragraph 17, "[the hostel] is holding a bed available for [ this man] and would
require a condition of bail……".
The Manager told the Investigators that the PSR author was simply mistaken,
as beds cannot normally be reserved. The procedure is for the referrer to be
told that they should telephone on the day to check that a bed is still available.
However, the referring officer was sure that he had made no mistake about
the decision, as he was surprised that the Approved Premises had agreed to
take the resident. It would be good practice for the Court duty officer to check
with the premises that a bed is still available before bail is granted but, due to
the wording in the report, this did not happen.
Accordingly, on Friday 14 May 2004, the Approved Premises was informed by
the Court duty officer on the telephone that the resident was actually on his
way to the hostel having been bailed by the court. As he was already on his
way and there was a vacancy in a single room, the Manager took the view
that he should remain over the weekend and the position could be clarified the
following Monday. If the resident had posed a problem over the weekend, his
bail could have been withdrawn but in fact he did not.
The man arrived at what was described as a very difficult time for the
Approved Premises as there had been some adverse publicity in the local
area and members of the public had staged a demonstration outside the
premises.
Although the premises was fully occupied when the man arrived, moves were
arranged for some residents and no new referrals were taken until the
situation calmed down. Despite all the difficulties, the man settled in well over
the weekend, complied with rules and was described as being "pleasant about
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the place". He was not aware of the mix up over his referral and he was
allowed to remain.
However, when the Manager subsequently received a copy of the man's bail
form, she was surprised to learn that he had been bailed for a Drug Treatment
and Testing Order (DTTO) assessment. The PSR also stated that,
previously, the man, "had the opportunity to use the Drug Treatment and
Testing Team " but had failed to attend as required. The view of the DTTO
team was that, as the man had been unable to demonstrate motivation to
change in the community and was doing so only when in custody, he was not
yet suitable for consideration.
The Manager explained to the Investigators that the Approved Premises has
been accepting residents for DTTO assessment and subject to DTTOs for
about a year and that all such referrals should be considered by the Manager.
At the time of the man's admission the referral form had been revised but the
old form was also still in use. It has been recognised that this could, and
probably did, cause confusion. To redress the situation, a new form has been
devised for use within the Probation Area and is soon to be distributed around
the area, as the old form is removed from the system. I commend the
Probation Area for taking such prompt action to improve practice and avoid
confusion over future referrals.
The man went through the induction process when the rules and safety
regulations of the premises were explained to him. An appointment was
arranged with the local GP who prescribed Amitriptyline to help the man
sleep. The Approved Premises has an arrangement with the doctor and with
the local pharmacy that prescriptions for hostel residents are delivered directly
to the hostel. Medications are kept in a secure cabinet and dispensed to
residents by hostel staff according to the doctor's instructions. The
Investigators were satisfied that the man's medication was safely dispensed in
this way.
The resident was given an introductory letter to the Benefits Agency to claim
sickness benefit as a recovering drug user. He met his Key Worker when she
came on duty two days after he arrived. She described him as a polite young
man who impressed her as sincere and motivated. He cited his relationship
with a young woman as an underpinning motivator and the Key Worker
impressed upon him the importance of keeping to his bail conditions. The Man
seemed sincere when he explained that he would meet his girlfriend
elsewhere rather than going to his home area.
The purpose of the remand was to assess the man's suitability for a DTTO, at
the Court's request, but there was no requirement for him to seek any
treatment during the remand period. The Investigators were told that
residents on bail assessment would usually have had an initial assessment,
perhaps in custody, and would thus be known to the local DTTO team. They
would be directed towards community resources during the bail period and
supported by the Drug Management Team. This was not the case for this
man who had not been referred to the DTTO team before arriving at the
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Approved Premises, as the author of the pre-sentence report had not
considered him suitable for assessment.
At a second key work session a few days later, the man appeared to have
settled in and did not seem at all concerned by the problems of the 'mob'. He
talked about the support of his parents and the need to prove himself to them,
particularly to his father. However, given the lack of contact with the DTTO
team, the Key Worker advised him to attend one of the local drug and alcohol
advisory agencies on a voluntary basis although he was not obliged to do so.
Early in June, the man arrived back at the hostel some 20 minutes after
curfew and was clearly worried about the possibility of breach. He provided
an explanation about train times that the Key Worker was able to verify but
she was concerned about his demeanour. The Key Worker had also noticed
that the man had been spending time with other residents suspected of being
drug users and recorded her suspicion that he was using illegal drugs.
The first available appointment that the Probation Officer in the DTTO team
could give to the man for an assessment interview was on the day before his
Court appearance and 27 days after he arrived at the hostel. The man told the
officer he had been drug free for some nine weeks and demonstrated an
awareness of the steps he needed to take to remain so, such as staying away
from his home area where he would be more likely to be tempted by old
acquaintances. Despite the earlier, negative assessment by another DTTO
team, the DTTO team Probation Officer assessed him as suitable for the
Order and wrote to the Court accordingly. It is expected that an offender’s
motivation before and during the early stages of an order may not be very
high. The National Probation Directorate (NPD) has confirmed that low
motivation is not in itself a reason to find an offender unsuitable for a DTTO as
motivation can increase when the offender is engaged during the programme.
Nevertheless, with hindsight, the Probation Officer recognised that the man's
motivation may have been the avoidance of a custodial sentence rather than
a sustainable desire for a DTTO.
In Court the man was sentenced to a DTTO for twelve months. The first date
for the Court to review his progress was set for one month's time. A
programme was set up in which, in addition to keeping appointments with the
Probation Officer in the DTTO team he was to be tested on Tuesday and
Friday of each week. He was also required to attend a drug and alcohol
treatment agency sub contracted to provide contact hours and treatment for
DTTOs - three times weekly for treatment and counseling sessions.
About a week later, when his Key Worker returned to duty after a short period
of planned absence, she noticed a significant difference in the man's
behaviour and it seemed clear to her that he had used drugs. The man
admitted to cannabis use but minimised it by saying that the Order had been a
relief and he had briefly lapsed. The Key Worker arranged for a three-way
meeting with the man and his Case Manager to take place 7 days later, to
discuss and reinforce the requirements of the supervision plan.
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My investigation has revealed that practice varies from Probation Area to
Probation Area but, in line with health service policy locally, the Probation
Area does not operate a policy of complete abstinence for those subject to
DTTOs.
The expectation is that there will be a gradual move away from illegal to
prescribed drug use and that illicit drug use will reduce over time. A progress
report is presented to the Court on the review date and the Court will decide
whether to allow the Order to continue on the basis of progress made. If there
is no improvement and/or a lack of commitment, then the DTTO team may
propose that the Order should be revoked.
There is no legal requirement for an offender subject to a DTTO to be
abstinent and breach proceedings on the grounds of positive tests alone
cannot be initiated. Although breach action in itself does not automatically
lead to the termination of an order, as courts will usually take into account the
chaotic nature of drug misuse, I am surprised that there is not greater
standardisation in respect of the management of DTTOs across the country.
In my draft report I said I would be interested to know how many offenders die
drug-related deaths while subject to a DTTO. The NPD has explained that,
since April 2004, Probation Areas have been required to provide information
as to how many DTTOs are revoked due to the death of the offender,
although the cause of death is not recorded. Between April and August 2004
there were 27 cases recorded as “offender died” from a DTTO caseload of
approximately 8000.
On 16 June 2004, the man told his allocated worker at the drug agency that,
since being released from prison, he had used heroin and cannabis when he
had returned to his home area and had contact with friends there. My
investigation found no evidence that this information was relayed to the
Approved Premises.
Two days later, on 18 June when he attended at the drug agency for testing,
the man said he had used heroin intravenously the previous day, had
accidentally overdosed and been taken to hospital by ambulance. The worker
advised him about reduced tolerance to drugs after a period of abstinence but
the information was not passed on to staff at the Approved Premises. Also on
that day, the man's Key Worker described him as appearing "under the
weather" and failing to return for dinner. She did not learn of the previous
day's events until after his death when the man's mother confirmed that she
had collected him from the hospital after the overdose and returned him to the
hostel.
On 22 June 2004, when the man attended the treatment project for testing, he
was given further advice about the need to use minimum amounts of drugs if
he could not abstain completely and to use them in a safe environment.
There was no evidence that this information either was relayed to the hostel.
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My investigation identified a further significant issue over the assessment of
risk. At the PSR stage, the Probation Officer commented that the man had
taken two overdoses in recent years, "one of tablets, the other of heroin." He
did not give the source of his information but stated that the man was no
longer suicidal as, he said, "too many people would be upset if he took his
life". On that basis and using the OASys assessment tool, he assessed the
man as being at medium risk of self-harm.
The PSR author completed the OASys form electronically as he was required
to do but, at that time, the Approved Premises staff were not trained in the use
of the electronic form and were unable to access it. No paper form was sent
to the hostel. The District Manager confirmed to the Investigator that,
subsequently, one member of staff at the premises has been trained to
access and use the OASys form electronically. The Area is also working
towards getting all SPOs, administration managers and Residential Services
officers trained in the use of e-OASys and printing off the form for use in
hostels at the earliest opportunity. I am glad that a problem area has been
identified and dealt with swiftly.
I cannot say if a similar problem exists in other Probation Areas and I have no
recommendation to make. Nevertheless, I hope that the National Probation
Directorate will take whatever steps are necessary to ensure that such a
useful tool as OASys is made easily available to all those within the Probation
Service for whom it is appropriate and that they are familiar with the method of
accessing it.
Since the man's death, the Probation Area has embarked upon the production
of “Sudden Deaths” guidelines and a revision of the “Self Harm and Suicide”
policy. Although these are in draft form as yet, I commend the Area for taking
speedy action to review and improve its policies.
Section two: The events of 23 June 2004
In the morning post on 23 June 2004, the man received a giro-cheque for
£12.59 from the Benefits Agency, from which he was required to pay £6.92 to
the hostel for two days' rent and amenities. The payment was much less than
he had expected and he became somewhat agitated. The cheque was
accompanied by a letter stating that the man was not entitled to benefit after 3
June 2004 as he had not provided an ongoing sickness certificate. A member
of the hostel staff tried to calm the man and explained to him that the Agency
must be mistaken as there was a certificate on file to 24 June.
The man became very angry and verbally abusive towards the member of
staff, despite her reassurances that she would intervene with the Benefits
Agency on his behalf. The altercation ended when the man took the cheque
from her and left the house, still in an agitated state. The staff member
described him as, "storming off." For a time he was seen opposite the hostel
talking to another resident but he did not return and he was not seen alive
again at the Approved Premises.
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At 21:40 there was a telephone call from a police officer to inform staff that the
man would not be returning. No further details were given and it was not until
24:00 that the Approved Premises received information that, at the local
Railway Station, the man had been found dead from a suspected heroin
overdose.
PART THREE: CONSIDERATION AND CONCLUSIONS
It was my role to examine the level of care provided to this man during the
period of his residence at the Approved Premises and in particular, to
consider if the risk of self-harm had been properly assessed and managed. 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.
The circumstances of the man's referral and admission to the Approved
premises leave questions unanswered. My investigation has not discovered
exactly how the misunderstanding over his suitability occurred, but it could
have been avoided if the decision of the hostel had been clearly recorded and
confirmed to the referring officer in writing. Although I am satisfied that the
confusion itself did not have a direct bearing on the events of 23 June 2004, it
is my view that the interests of offenders and those working with them in
hostels would be better served if decisions about referrals are more clearly
conveyed.
I recommend to the Probation Area and to the National Probation
Directorate that all decisions concerning the admission of residents to
Approved Premises should be recorded and confirmed either
electronically or by fax to the referring office. A copy of the email or fax
should be kept in the Approved Premises’ file.
The assessment and management of risk have a crucial role to fulfill in the
supervision of offenders, the more so when members of staff are in constant
contact. It is something of an anomaly that those who may get to know most
about an offender through their regular daily contact are not usually those
responsible for the case management and authorised to make decisions.
My investigation confirmed that there are clear procedures in place at the
Approved Premises for daily events to be recorded in the hostel log and
entries were kept up to date. The daily hand over process enables colleagues
to share information and ensure that both events and their assessments of
situations are made known. I have no doubt that the staff of the Approved
Premises are dedicated, caring individuals who do their very best for the
residents in their care, within the limits of their responsibility.
However, although the Key Worker's suspicions and concerns about the
man's drug use were recorded and shared with her colleagues, they were not
shared with the DTTO team as there was no recognised procedure for doing
so. It was the Key Worker's intention to inform the DTTO officer at a joint
meeting scheduled for 28 June 2004 but by then it was too late.
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Those in the DTTO team had more than suspicions as the man had
confessed his continued drug use to them but the knowledge was not relayed
to the hostel. Consequently, although both groups of professionals working
with the man were aware that all was not well, there was a failure to
communicate, and the lack of shared knowledge prevented a joint risk
management plan from being devised and implemented. I can only speculate
as to whether the existence of such a plan could have helped prevent the
man's death although I suspect that his reliance upon heroin at that time was
considerable.
My investigation revealed that there are no national protocols for the
arrangement of DTTO teams, which have developed in response to local
need. In this area, the Probation Officer works in a multi-agency team with
Health Service professionals based in Health Service premises, sharing a
common file on each offender referred to the team. The Probation Officer
speculated that Health Service staff might have lacked understanding about
the nature of Approved Premises and, consequently, assumed that as
information is readily available to the Probation Officer in the team, it was not
necessary to inform the Approved Premises.
Whether or not that was so, the Probation Area has acted quickly to improve
the levels of communication between staff in Approved Premises and the
DTTO team. It has been agreed that the Approved Premises and the DTTO
team will operate a policy of open communication and that offenders will be
advised of this practice when they are assessed. Information about changes
of circumstance such as positive drug test results or assessment of increased
risk will be conveyed immediately by telephone and recorded. A weekly
feedback form has been devised which will be completed by both DTTO
Probation staff to the hostel and by hostel staff to the DTTO team.
Additionally, it is now expected that all individuals who are to be assessed for
a DTTO with a condition of residence at the Approved Premises will, first, be
required to undergo a four to six week period of bail assessment at the hostel,
before a DTTO is proposed to a court. This will enable issues of concern to
be addressed and a risk management / treatment plan to be implemented. I
commend the Probation Area for quickly taking steps to improve practice in
response to an identified omission. I suggest that further action should be
taken to identify and prevent similar omissions should they exist elsewhere.
I recommend that the National Probation Directorate issues guidance to
all areas about the requirements of communication systems between
Approved Premises and Case Managers, and considers carrying out an
audit of compliance within 12 months of the guidance being issued.
Drug taking is a risky activity at all times and better communication between
those responsible for this man's treatment and care might not have prevented
his death. However, this investigation has revealed a lamentable lack of
communication between the court, the hostel, the drugs agency and the
DTTO team together with an absence of purposeful offender management. If
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lessons can be learned then I hope that at least some good may emerge from
these sad events and the sorry loss of life.
I recommend that a copy of this report is tabled for consideration by the
Probation Board and that the Area sends copies to the DTTO team and
the Management Committee of the drug agency. I understand that the
Area is already implementing this recommendation, which they first saw
in draft.
I further recommend that my comments on the need for greater
standardisation in the management of DTTOs and the need for research
into drug-related deaths of those subject to the Order be drawn to the
attention of the Director General of the National Probation Service.
I am aware that the National Standard for DTTOs sets out enforcement
requirements and the NPD has said that it routinely monitors Probation Areas’
compliance with the standard. I am pleased to say that, having seen this
report in draft, the NPD has agreed to issue a reminder to all Probation Areas
about best practice to prevent drug-related deaths.
RECOMMENDATIONS:
I recommend to the Probation Area and to the National Probation
Directorate that all decisions concerning the admission of residents to
Approved Premises should be recorded and confirmed, either
electronically or by fax, to the referring officer, and a copy of the email
or fax kept in the Approved Premises' file.
I recommend that the National Probation Directorate issues guidance to
all areas about the requirements of communication systems between
Approved Premises and Case Managers, and considers carrying out an
audit of compliance within 12 months of the guidance being issued.
I recommend that a copy of this report is tabled for consideration by the
Area Probation Board and that the Area sends copies to the DTTO team
and the Management Committee of Spotlight.
I further recommend that my comments on the need for greater
standardisation in the management of DTTOs and the need for research
into drug-related deaths of those subject to the Order be drawn to the
attention of the Director General of the National Probation Service.
STEPHEN SHAW
OMBUDSMAN
October 2004
14