Individual at Victoria House

The Death of an
Approved Premises Resident
on 2 May 2004
Report by the
Prisons and Probation Ombudsman
for England and Wales
November 2004
CONTENTS
Page
Section A The Investigation 3
Section B Approved Premises 15
Section C Chronology of Events 17
Section D Appendices 18
Foreword
The sad death of an approved premises resident on 2 May 2004 has
been investigated under transitional arrangements agreed with the
National Probation Service, who appoint a senior investigating officer
to work directly to me for the purposes of the investigation. He or she
produces a draft report which I then review and amend as necessary.
In this case the senior investigating officer was an Assistant Chief
Probation Officer (ACPO) of Humberside Probation Area and I am
grateful to him for his comprehensive efforts. The remainder of the
report is his, with amendments for reasons of clarity and consistency.
The ACPO interviewed staff at the approved premises, where he also
examined records. Together with the investigator from my office, he
also visited the resident’s relatives. I know that both have offered their
condolences to his family, but I should also like to offer mine. The
family asked a number of questions and the ACPO has done his best
to answer them. The final part of the investigation was the
commissioning of a clinical review by the Director of Public Health at
North East Lincolnshire Primary Care Trust. I am most grateful to him
for his contribution.
The report makes a number of recommendations about procedures at
the approved premises, although I am satisfied that staff operated in
accordance with its policies in existence at the time of the resident’s
stay there.
Finally I wish to thank the Manager at the approved premises and her
staff for the help and cooperation received by the investigators in the
course of their work. Facilities were made available and all staff
participated fully and readily with the inquiry.
STEPHEN SHAW CBE
Prisons and Probation Ombudsman
November 2004
SECTION A
SUMMARY
1. The resident was released from HMP Ranby on 23 April 2004. A
place had been found for him in approved premises and he arrived
there in the late evening of 24 April.
2. He was last seen alive by resident D, his next door neighbour at the
approved premises. Resident D estimates he saw him enter his room
at approximately 23:30 on the evening of 1 May.
3. At approximately 09:40 on 2 May, approved premises staff went to his
room to check on his welfare. He appeared to be dead and drugs
equipment was found in the room.
4. There is evidence that the resident had obtained street heroin during
his time at the approved premises. A post­mortem examination was
conducted after his death and cocaine, heroin and cannabis were
found in his body.
5. The investigation report has been written by an ACPO from
Humberside. He finds that the approved premises staff acted
reasonably in their supervision of the resident, but he makes a
number of recommendations designed to improve procedures at the
approved premises.
INTRODUCTION
6. With effect from 1 April 2004 the Prisons and Probation Ombudsman
is required to investigate all deaths of approved premises residents in
accordance with the terms of Probation Circular 18/2004 which was
issued on 30 March 2004. The terms of reference for the investigation
are attached in full at Appendix 1. The investigation was established
to:
· investigate the circumstances and events surrounding the
resident’s death, particularly with regard to his management
by the relevant services;
· provide explanations and insight for the bereaved relatives;
and
· assist the inquest conducted by HM Coroner in achieving
fulfilment of the investigative obligation arising under Article 2
of the European Convention on Human Rights, by ensuring
as far as possible that the full facts are brought to light and
any relevant failing exposed, any commendable action or
practice identified, and any lessons from the death are
learned.
7. This report was commissioned on 12 May 2004 to report on the
circumstances of the death of an approved premises resident which
occurred on 2 May 2004. I would like to take this opportunity to offer
condolences for their sad loss to the deceased’s family and friends.
No one can have a greater interest in the outcome of this
investigation, and that of the Coroner’s inquest, than the members of
the family and it is imperative that the close family members are
involved in the investigation at an early stage of the process.
8. The investigating officers met with the resident’s mother at her home
on 7 May 2004. His brother and his partner were also present at the
meeting and their views and questions helped to shape this
investigation and report. The officers were grateful for their assistance
and cooperation at a particularly distressing and difficult time.
9. At an early stage of the investigation interviews were held with
relevant members of staff and with two of the approved premises
residents. A death in a residential establishment is a traumatic
experience for staff, particularly those more directly involved with the
discovery, and the investigating officers would like to express their
appreciation for the cooperation of those members of staff.
THE INVESTIGATION
10. When the resident’s death was discovered it was suspected that the
use of illicit drugs was involved. This was evident from the drug
related paraphernalia present in his bedroom. A copy of the toxicology
report provided for the inquest is attached at Appendix 17, which
states that illicit drugs were present in his body at the time of the post­
mortem. These were found to be cocaine, morphine (heroin) and
cannabis. Whilst the rules of the approved premises prohibit the use
of illicit drugs on the premises, residents are free to come and go as
they please between the curfew hours and routine drug testing is not
a feature for every resident as a matter of course. Similarly, room
searches are conducted at regular intervals on a random sample
basis each week and these issues are amongst those that the
investigation will seek to address to try to prevent similar deaths
happening in the future.
11. The initial questions which needed to be answered were to clarify:
· the time of death
· the apparent and actual causes of death
· whether any other person or persons were likely to have been
involved
· whether action could have been taken earlier to prevent the
death from occurring
· the policies and procedures in operation at the approved
premises at that time had been followed by staff responsible
for the resident’s supervision.
12. The events leading up to the resident’s death are recorded in the
approved premises log­book. The case file containing personal and
induction documentation was retained by the investigating officers
and arrangements made to interview staff and residents. The CCTV
tape was secured for later viewing. Copies of the relevant documents
are included within the appendices.
13. Individual interviews were conducted with staff over a number of days
immediately following the commencement of the investigation and full
copies of each of the interviews are attached at Appendix 5.
14. An invitation was posted on the residents’ notice board to provide an
opportunity for any resident to speak to the investigating officers on a
voluntary basis if they felt that they had anything to say which might
aid the investigation. Copies of two residents’ interviews are attached
at Appendix 6.
The resident’s time at HMP Ranby
15. The resident was transferred from HMP Doncaster to HMP Ranby
(near Retford in Nottinghamshire) on 13 November 2002. This was
his fourth custodial sentence; his first conviction was at age 14 and he
had a total of 20 convictions for 36 offences. These were mainly for
theft and violence related to his substance misuse.
16. Whilst at HMP Ranby the resident made a written application on 29
April 2003 to attend the drug rehabilitation programme provided at the
prison. However on 9 May 2003 it was decided that his name should
be removed from the waiting list for the course. He was taking
prescribed medication at the time and a member of the Drug
Rehabilitation Team stated that it could affect his ability to complete
the course. He had also failed three voluntary drug tests whilst at
Ranby for cannabis.
17. The Drug Rehabilitation Team response indicated that if in future he
was advised to stop taking his medication, then they would be willing
to consider a new application from him.
18. The application form required the man to answer questions about his
history of substance misuse. He replied that the drugs he had used
before were heroin, cocaine, crack, amphetamines, LSD, ecstasy,
cannabis, benzodiazepines and solvents. He stated that he took
cocaine, crack, LSD and ecstasy in binge sessions and that he used
alcohol, heroin, amphetamines and cannabis on a daily basis.
19. In response to questions about his age when he first used particular
drugs, he replied that solvents began at age 10 whereas heroin and
cocaine were relatively recent (age 30). The man wrote that he used
heroin both by smoking and injecting. He also wrote that he had not
been using any drugs while he was in jail.
20. At section 6 of the form the man stated that the prescribed medication
he was taking at the time (late April/early May 2003) was dothiepin
(for acute depression) and Sulpiride (an anti­psychotic tranquilliser).
21. The man’s prison Inmate Medical Record and Prescription and
Administration Record Chart show that he was being prescribed
Sulpiride and Amitriptyline (an anti­depressant) from his arrival at
HMP Ranby on 13 November 2002 until the Medical Officer at Ranby
stopped the Amitriptyline prescription on 2 May 2003. Dothiepin was
prescribed in place of Amitriptyline and the Sulpiride prescription
continued. The man continued to receive seven days’ supply of
Sulpiride and Dothiepin in­possession on a weekly basis until 8 April
2004.
22. On the morning of 18 October 2003 the man informed prison staff at
Ranby that he had been experiencing severe abdominal pain since
the previous evening. At 10:30 he was taken to hospital where acute
appendicitis was diagnosed. The man had his appendix removed at
the hospital before returning to Ranby on 22 October 2003.
Lincolnshire Probation Service
23. The resident was released on licence on 23 April 2004 under
supervision by the Lincolnshire Probation Service. A copy of the
licence is attached at Appendix 7. The licence period was due to
expire on 16 February 2005 unless previously revoked. Prior to his
release the requirements of the licence were explained to him and he
signed to signify his understanding and acceptance on 16 April 2004.
24. On release, he was instructed to report to the Probation Office in
Lincoln which he duly did. On reception to prison the resident was
assessed as ‘no fixed abode’ and his intended address on release
was considered unsuitable. Due to his substance misuse he was
assessed as high risk of reoffending and had previously found
approved premises accommodation beneficial due to the structures
and regimes. On Monday 26 April 2004, he contacted the Lincoln
Probation Office to enquire if his appointment with NACRO on 28 April
2004 was going ahead. This was confirmed and the approved
premises staff member on duty asked that a travel warrant be sent to
him to enable him to travel to Lincoln. During her discussion with the
approved premises staff member on 26 April 2004, a member of staff
from the Lincoln Probation Office was informed of the events since
the resident had arrived at the approved premises and she stated that
he would only be resident for six weeks. She would be setting up an
appointment for him with Addaction for drugs counselling and any
mental health requirements in the Lincoln area and would arrange
weekly contact with him.
25. Later that afternoon, just after 16:00 she rang back to the approved
premises and spoke to a staff member. She confirmed that a travel
warrant was being sent to the resident for the NACRO appointment
on 28 April 2004, and said that he would be directed to Healthy Living,
who would hopefully give him access to a community nurse. He would
also be seen by his case manager whilst in Lincoln.
The approved premises
26. A place had been allocated to the resident at approved premises and
after reporting to the Lincolnshire Probation Service on release, he
arrived at the approved premises just after 21:00 on Friday 23 April
2004. His induction into the approved premises and explanation of the
rules and procedures was carried out by a staff member immediately
on arrival. A copy of the induction record is attached at Appendix 8.
27. He was allocated room 18 on the first floor, the location of which is
indicated on the plan at Appendix 9. A Consent to Medical Records
form (Appendix 10) was signed by the resident and faxed off to the
prison on the morning of Monday, 26 April 2004. The standard referral
to a doctor at a nearby Medical Centre was signed by the resident on
Friday 23 April 2004 and faxed to the Centre on Monday morning 26
April 2004.
28. Although he became a resident at the approved premises (which is
sited in the Humberside Probation Area), responsibility for his
supervision was retained by the Lincolnshire Probation Service.
Arrangements had been made by his supervising officer for him to
receive a travel warrant to enable him to get to Lincoln on
Wednesday, 28 April 2004 to attend for a supervision session and an
appointment with NACRO at 11:30. He was also to be directed to
Healthy Living who would arrange access to a community nurse. A
record was made on the resident’s approved premises notes that he
went to Lincoln on 28 April 2004. It is likely from the evidence
provided by resident S that the deceased obtained a supply of heroin
whilst in Lincoln on that day
29. Staff had no indication of any prescribed medication which he was
taking on arrival at the approved hostel, and he failed to disclose that
he had in fact had some in his possession. The induction form has
been marked n/a against ‘check medication’. The log book entry
made by a staff member at 18:30 on Sunday 25 April 2004 recorded “I
have woken the resident because I was concerned. On awakening he
asked me if it was meal time evening, although he attended the
evening meal just over an hour ago. I asked him into the office and I
asked him if he had taken anything. He told me he had taken 1 x
Sulpiride, an antipsychotic drug usually prescribed for schizophrenia.
The resident stated that he did not realise that he had it and that he
only thought medication had to be declared if you had a lot. He told
me Sulpiride had been prescribed to him for a long time along with
Dothiepin, an antidepressant. Whilst I have only the resident’s word
for this, he states that he has been diagnosed schizophrenic for quite
some time. This is very troubling. The resident assures me he has no
other medication”.
30. An appointment was made by the approved premises staff for him to
see the doctor at the Medical Centre on Monday 26 April 2004. The
clinical review prepared by the Director of Public Health for the North
and North East Lincolnshire Primary Care Trusts states that the
resident told the doctor that he left prison on Sulpiride 200mg twice
daily and Dothiepin 75mg at night.
31. An approved premises log book entry for 27 April 2004 was made to
record that “the resident has also received his medication from the
chemist”. Prescribed medication is retained in a secure cupboard and
issued to residents as directed by the General Practitioner. A record
of medication issued is maintained for each resident and a copy of the
resident’s record is attached at Appendix 12.
32. Resident S was already at the approved premises when the deceased
arrived and they had established a friendly relationship over the first
few days. In his statement (Appendix 6) he relates that they had
previously been walking into Scunthorpe but turned back because the
deceased couldn’t make it. Resident S said that the deceased had
told him that he had arrived at the approved premises with some
amphetamines with him, but couldn’t wait “to have a pop do you know
what I mean, have a bit of heroin like”. Resident S then said that the
deceased had told him himself that he had obtained heroin when he
had gone to Lincoln for the day on Thursday, 28 April 2004.
33. In establishing the actual time of death, it was important to determine
when the resident had last been seen alive within the approved
premises. Due to staff concerns, he had initially been placed on
observation on three occasions during the night to check on his
condition. This is a routine procedure at the approved premises, and
not unusual for a new resident, particularly given the deceased’s
history of drug abuse going back over a long period of time, and that
referral information from both the releasing prison and the supervising
probation area had only been given over the telephone up to the time
of his admission.
34. The discovery of the resident’s death is recorded in the log book as
being at 09:45 on Sunday 2 May 2004. That particular weekend had
been a Bank Holiday and residents were permitted to sleep in as they
wished. It is known from the entries in the log book, and the
statements given by the members of staff on duty, that the resident
had been present in the approved premises at curfew the previous
evening, and had been in his room during the night. However, as all
other residents were down to breakfast or out of the approved
premises on the Sunday morning, it was decided to check on him to
ensure he was well. The members of staff on duty at the time were
the Assistant Warden, who had been there during the night on
sleeping­in duty, and the Support Worker who had come on duty at
09:00 to start his shift.
35. The night Support Worker on waking night duty had finished her shift
and gone off duty at 08:30 on 2 May 2004.
36. The Assistant Warden discovered the death. He had had contact with
the resident over the previous few days on returning to work after a
week off, and had been made aware of his needs and background.
Briefings and entries in relevant notes and C sheets (Resident record
of contact forms) had been made in accordance with approved
premises policies and procedures. At 09:40 the Assistant Warden
went to the resident’s room (room 18) to check up on him. In the
Assistant Warden’s statement he says “Because I hadn’t seen him
properly since the Friday and I was by the time Sunday came, Sunday
morning, I was concerned and I just wanted to go up to his room and
make sure everything was alright with him”.
37. There was no reply when the Assistant Warden knocked on his door,
so he entered the room through use of his pass key. The curtains
were closed but the visibility was good. The resident was laid on his
bed in the same position as when he had seen him at curfew at 23:00
the previous night. There was a syringe lying on the floor just
underneath the bed. The Assistant Warden then went downstairs to
get a colleague to go up to the room to check the situation. An
ambulance and the police were immediately called.
38. The room adjacent to the deceased’s, number 19, was occupied by
resident D. The rooms are both shown on the plan referred to above
at Appendix 9. Resident D had been at the approved premises since
22 April 2004. He reports having seen the decreased alive at
approximately 23:30 on the Saturday night entering his room; he
presumes returning “from the toilet or somewhere, I don’t know”. He
also reports hearing the deceased at approximately midnight
breathing really hard. He had heard him snoring before, “but nothing
like that on Saturday night, nothing at all”.
39. On admission to the approved premises, the resident had nominated
his mother as his next of kin and had given her home address which
was recorded on the file. When the police attended at the approved
premises on the morning of 2 May 2004, the resident’s mother’s name
and address were given to them in accordance with Home Office
guidance contained within Probation Circular 02/2004 issued on 6
January 2004. One of the police officers radioed through to the Louth
Police and an officer from that station then went round to see the
resident’s mother to inform her that her son had died.
Whether any other persons were likely to have been involved?
40. All residents’ rooms at the approved premises are single occupancy
and each resident has his own key. Rooms were all checked at
curfew, and in addition the deceased was subject to three checks
during the night at this stage of his stay at the approved premises.
Staff undertaking curfew and night security checks used their own
pass keys to enter the room which confirms that the door had been
locked. Entry could only have been either by a member of staff or by
the deceased opening the door to someone. The police secured the
room on their arrival at the approved premises and were satisfied that
there had been no signs of a forced entry.
41. The approved premises operates a CCTV system for security
purposes and the tape for the night of Saturday 1 May 2004 was
secured by the investigating officers. However it was subsequently
discovered that the video recording machine was faulty and the tape
was corrupted. There was insufficient picture quality to enable it to be
used to verify any of the evidence from the witness statements.
42. Although the deceased had been resident in the approved premises
for one week, he had not been observed making any close friendships
with other residents and had spent quite a lot of time alone in his
room. There was one resident at the time who could be called upon to
help verify the deceased’s movements in the hours prior to his death.
Whether any action could have been taken earlier to prevent the
death from occurring?
43. The resident had been released on licence from HMP Ranby and the
terms of his licence had been explained to him on release. The
approved premises is not a prison and the only physical restriction on
residents is the nightly curfew (normally 23:00) which is strictly
enforced. The approved premises operates to set rules which are
explained to each resident on arrival as part of the induction process.
Each resident signs to signify their agreement to comply with the
rules, and they are made aware of the implications of breaking the
rules. A copy of the licence conditions and the approved premises
rules are attached as Appendices 7 and 14 respectively.
44. The system for regular nightly checks is a local procedure for
increased supervision of offenders newly arrived at the approved
premises until it is felt that they have settled down. The records show
that these checks were carried out; the curfew check at 23:00 is
carried out for all residents by the two remaining members of staff on
duty. However during the night there is only one waking member of
staff on duty and the nightly checks are carried out singly. A recent
development announced by the National Probation Directorate is that
all approved premises should move towards double waking night
cover and consultations are being conducted at national level with the
trade unions representing approved premises staff.
45. Routine random room checks are a normal occurrence in the
approved premises regime and at some stage during the deceased’s
stay at the approved premises his room and belongings would have
been searched to ensure compliance with its rules. He was aware of
this from the induction process and chose to risk detection in the
meantime.
46. The approved premises video and surveillance equipment may have
provided valuable evidence for this investigation. Instructions have
been issued to ensure that its staff carry out a weekly check of the
recording machine and the tape quality to ensure that it is operating
properly.
47. Some approved premises have introduced random drug testing for
residents, but this facility is not currently available at this approved
premises (other than for residents who are subject to a Drug
Treatment and Testing Order where compliance is monitored away
from the approved premises). Arrangements are being made for drug
testing to be carried out in the current financial year in both of the
Humberside Probation Service’s approved premises.
48. The toxicology report and indeed the resident’s history was of a long
period where reliance had been made on the use of illicit drugs, in
addition to the medication he had been prescribed on release from
HMP Ranby. On his admission to the approved premises, full details
of his medical history had not been received there and it is imperative
that referring officers have full information available to enable a proper
assessment to be made either before or on arrival at the premises.
Clear expectations to address misuse of illicit substances would be
required of the offender, although it appears that in the resident’s
case he would not have been able to make that commitment.
CLINICAL REVIEW
49. A formal request for a full clinical review was submitted by the
Ombudsman’s Officer to the Director for Public Health, North East
Lincolnshire PCT on 14 June 2004 to assess the resident’s medical
care whilst in the approved premises.
50. A copy of the review is attached at Appendix 16.
Post­mortem report
51. A post­mortem examination of the resident’s body was carried out by
the Consultant Pathologist and a copy of his report is attached at
Appendix 17.
52. A post­mortem toxicology report was also provided from a professor
at the Royal Hallamshire Hospital who concluded that the findings
were consistent with the use of illicit heroin and cocaine, with
therapeutic range use of Dothiepin. It was the opinion of the professor
that the cause of death should be modified to aspiration of gastric
contents and drug abuse.
CONCLUSIONS
53. The resident was known to the Lincolnshire Probation Service as he
had been previously supervised by them prior to the offences which
led him to a custodial sentence which finished in HMP Ranby. He had
been allocated a bed space in the approved premises as his intended
address in Lincoln was considered to be unsuitable. The case was
retained for supervision by Lincolnshire Probation, but recent Home
Office instructions would now dictate that the case be transferred to
the Humberside Service for management from a Humberside
Probation Office (Probation Circular 52/2004 refers).
54. The resident had started his involvement with drugs and solvent
abuse from an early age and seemed unable to cope without them. It
is highly probable that he took something prior to arriving at the
approved premises and he failed to disclose to staff when asked that
he was in fact also taking prescribed medication.
55. It is clear that staff at the approved premises did not know as much
about the resident’s medical condition as they would have liked to
have done on or before his arrival, but their concerns were noted at
an early stage. Their actions were in accordance with approved
premises policies and procedures and they acted reasonably in their
supervision of him.
56. There is no clear indication of the time of death. It is clear however
that the resident was present in the approved premises at curfew time
(23:00) on the Saturday evening before being discovered on the
Sunday morning (09:45). The evidence from resident D places the
deceased on the landing outside of his bedroom at approximately
23:30 on the Saturday evening and he also reports hearing him
snoring during the night. The nightly room checks also support this
but are inconclusive as the deceased was in the same position in bed
as when the curfew check was made at 23:00. The fault on the CCTV
system cannot be used to verify this information.
RECOMMENDATIONS
57. It is recommended that the Chief Officer of the Humberside Probation
Area:
(i) arranges for approved premises staff to attend regular
information and training sessions regarding mental health
issues and medication;
(ii) reviews the procedure for additional night­time residents’
checks and provides staff with written guidance on conducting
such checks until double waking night cover is available;
(iii) ensures that the operation of the CCTV system is checked not
less than weekly;
(iv) considers the introduction of an on­site system for random
drug testing of approved premises residents as a matter of
urgency;
(v) ensures that full information is available to the Approved
Premises Manager (allocation officer) when referrals are
made to the Approved Premises from both within the
Probation Service and external agencies (e.g. Prisons) to
include medical history; and
(vi) invites the Drug Intervention Programme Manager to consider
and comment on this report.
SECTION B
APPROVED PREMISES
Legislative Provision
58. Approved Premises (previously known as approved probation and bail
hostels) are an important part of the criminal justice system. They
provide an enhanced level of residential supervision in the community
as well as a supportive and structured environment. They are
intended as a base from which residents can take full advantage of
community facilities for work, education, training, treatment and
recreation.
59. Statutory provision relating to Approved Premises is made by Section
9 of the Criminal Justice and Court Services Act 2000. Section 9(1)
gives the Secretary of State power to approve premises in which
accommodation is provided for persons granted bail in criminal
proceedings, and for, or in connection with the supervision or
rehabilitation of persons convicted of offences. Section 9(3) gives the
Secretary of State the power to make Regulations for the regulation,
management and inspection of Approved Premises. These
Regulations are The Criminal Justice and Court Services Act 2000
(Approved Premises) Regulations 2001, a copy of which is included
as Appendix A to this section of the report.
60. The Regulations place a number of duties on managing bodies, in
particular about financial control, the conduct of residents and medical
care, and the keeping and inspection of records. The Regulations also
require the adoption of admissions policies, procedures relating to
breach and house rules.
National Standards
61. As well as the Approved Premises Regulations 2001, Approved
Premises are also governed by a set of National Standards;
particularly part F of the standards. National Standards require all
probation service areas, and organisations working on their behalf, to
operate fairly and consistently with all offenders and residents in
Approved Premises, and to avoid inappropriate discrimination on
grounds of race, sex, age, disability, religion, sexual orientation or any
other improper ground.
62. A copy of part F of the National Standards is included at Appendix B
to this section of the report.
The approved premises
63. The deceased was a resident at the approved premises. The property
is situated approximately one mile north of the town centre within a
mixed residential and commercial area. The approved premises
accommodates up to 19 male residents in single occupancy
bedrooms who are subject to court orders (bailees or probation) or
post­custody licensees. It is permanently staffed with a minimum of
two members of staff on duty at any time. There is currently one
waking and one sleeping staff member on duty during the night
between the curfew hours of 23:00 and 07:00 each day, including
weekends.
64. The challenge for staff is to not only manage the risk posed by each
offender, but to work with them in conjunction with the case manager
(a designated probation officer) in a constructive and focussed
manner. The National Standards mentioned above sets out clear
guidelines on what is expected, and includes:
· as soon as practicable after arrival, every new resident is
interviewed by a member of the supervisory staff when the
house rules will be explained fully and signed by the resident
· within seven working days of each resident’s arrival, and
based on the assessment of the resident, produce a planned
programme for the expected duration of stay at the approved
premises which addresses behaviour, is congruent with any
other orders to which the resident may be subject, addresses
the management of identified risks of harm posed by the
resident and does not conflict with any reasonable
employment requirements or the resident’s religious
considerations
· ensure that residents take part in any hostel­run or other
programmes on how to avoid reoffending
· plan for the resident’s community reintegration and discharge
from the hostel; and
· contribute to any report to the Court on the resident and
include details of any serious or repeated failure to comply
with the Court order or the rules of the approved premises, as
well as achievements.
Staffing Structure – The Approved Premises
1 Deputy Approved Premises Manager, probation officer
1 Probation Services Officer
3 Assistant Wardens
4 Full­time Support Worker posts worked by 5 people, 2 doing
part­time
1 Administrative Officer
65. At any one time there is always a minimum of two members of staff
on duty. During the night between the curfew hours of 23:00 to 07:00
there is one Assistant Warden on sleeping­in duty and one Support
Worker on night waking duty. The task lists for each grade of staff
during the day and night is attached.
SECTION C
CHRONOLOGY OF EVENTS – THE RESIDENT
Date Event Comment
18.10.2002 Sentence 3 years and 3 months imprisonment at HMP
Ranby
23.04.2004 Released on To report to the Resettlement Team,
licence to Lincolnshire Probation Service.
16.02.2005
23.04.2004 The approved Arrived at approximately 21.12 and inducted
premises
2.05.2004 Found in bed at the At approximately 09:45 his room was
approved premises checked and police and ambulance were
called
2.05.2004 Ambulance crew Arrived at 10:00 and confirmed death
2.05.2004 Doctor attended Certified death at 10:55
2.05.2004 Police attended Arrived at 10:05 and took possession of room
18
Contacted the Lincolnshire Police for
notification of next of kin
SECTION D
APPENDICES
Terms of reference for the investigation 1.
Letter to staff about the investigation 2.
Letter of invitation to residents to contribute
to the investigation 3.
Letter about the interview process 4.
Interviews with members of staff 5.
13 May 2004
12 May 2004
13 May 2004
20 May 2004
20 May 2004
Interviews with residents 6.
12 May 2004
13 May 2004
Copy of Licence 7.
Copy of the approved premises Induction record 8.
Plan of the approved premises showing location of room 189.
The resident’s Consent to Medical Records form 10.
Registration with the Medical Centre 11.
Record of received medication 12.
Record of Contact – ‘Part C’ 13.
Approved Premises Rules 14.
The approved premises – Drug regulations 15.
Clinical Review 16.
Post­mortem report 17
Approved Premises Regulations 2001 18
Part F of National Standards. 19