Individual at Bridge House

Circumstances surrounding the death a resident in May 2004, at a
Probation Service Approved Premises.
Report by the Prisons and Probation Ombudsman for England and
Wales
September 2004
CONTENTS Page No
FOREWORD
SUMMARY
PART ONE:
Background Information -
Section 1 –The man
Section 2 –The Approved Premises
PART TWO
Events leading up to the man’s death-
Section 1 – The man’s time at the Approved
Premises
Section 2 – The night of the death
PART THREE
Consideration and conclusions
Recommendations
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FOREWORD
My office undertook this investigation into the death of a young man
apparently from an overdose of non-prescription drugs. The young man was
a resident of Approved premises while he was on bail, awaiting an
assessment for a Drug Treatment and Testing Order.
The purpose of my investigation was to discover if risk of self-harm had been
properly assessed and managed, and to consider whether a sufficient level of
care had been provided to the young man by the hostel.
The investigation was carried out by a senior member of staff from my office,
with the assistance of an Assistant Chief Officer (ACO) from the Probation
Area. My thanks go to the ACO for facilitating the investigation, for providing
policy advice and for interviewing staff. I am grateful for the co-operation that
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the Investigators received from the Probation Area and, in particular, from the
Manager and members of staff at the Approved Premises.
The death of one of your children - whatever their age - is a devastating
experience for the parents. I am especially grateful to the young man’s
parents for agreeing to meet with the Investigators at what was a very
emotional time for them. They provided information about their son that was
helpful to the investigation. The parents wanted the answers to specific
questions about the hostel regime and I have attempted to answer those
questions in this report. Their deep distress at the loss of their son was
evident and I offer the family my sincere condolences.
The Investigators conducted formal interviews with the Manager and
Operational Manager of the premises, with four members of the hostel staff,
with two Probation Officers who were involved in the young man’s
assessment and with a Probation Service Officer who worked with him. The
interviews were not recorded but the Investigating Officers' notes have been
agreed, and signed by interviewees.
The Investigators obtained information, by telephone, from the young man’s
aunt, Specialist Drug Services, the Assistant Chief Officer (ACO) with
responsibility for hostels, and a Manager from the Drug Management Team.
They also examined a variety of documents readily provided by the Probation
Area.
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SUMMARY
This young man of 25 years had a history of drug use from his early teens,
despite all the best efforts of his family to help him. He was due to be
sentenced for offences of dishonesty related to his drug abuse and, in April
2004, he was remanded on bail to reside at the Approved Probation Premises
where he was to be assessed as to his suitability for a Drug Treatment and
Testing Order.
The young man had become drug free during the time he had spent
remanded in custody but he tested positive for opiates upon his arrival at the
hostel and admitted that he had used drugs on his last night in prison. He
admitted to further lapses during the 12 days he spent in the hostel but
otherwise continued to demonstrate a mature attitude and was allowed to
stay. He was considered suitable for the Order.
By early May 2004, the young man had given two negative drug tests and
was happy that the Court could be given a positive report about his progress.
Later that night there was an altercation in the hostel that prevented the Night
Supervisor giving as much attention as he might otherwise have done when
the young man sought assistance around midnight.
On the morning his death was discovered, unusually, the young man missed
the house group meeting. When a member of staff went to check on him, he
was found unconscious on his bed and it became clear that he had died.
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Although I have reached the conclusion that this young man’s death would
have been difficult to predict or prevent, I have identified areas where
management systems, communication procedures and staff induction could
be improved. I have made five recommendations.
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PART ONE
Background Information
Section one – The young man
The young man was born in 1978 and was 25 years of age when he died.
He was the youngest of his mother's six children and was part of a large,
close-knit family brought up in the area. His is a sad, but all too familiar, story
of a young man for whom the use of drugs overtook everything else in his life
despite the best efforts of his family.
The young man began to experiment with drugs during adolescence and,
although his parents took him to Scotland, away from his drug using friends,
his drug use escalated during the following years. By his early twenties he
was a regular intravenous drug user. He told probation officers that he used
heroin to mask the effects of 'coming down' after smoking crack cocaine.
He sometimes committed petty offences of dishonesty to fund his drug use
and, at Edinburgh Sheriff's Court in March 2003, after the commission of drug
and alcohol related offences, the young man was sentenced to a Community
Rehabilitation Order. He lost his place in the family home when the extent of
his drug use became known to his father and he was then, effectively,
homeless.
The young man moved back from Edinburgh in July 2003. He was largely
estranged from his family who had become exhausted by their efforts to cope
with his mood swings and character changes when he was under the
influence of drugs. Nevertheless, he maintained regular contact with an aunt,
with whose family he stayed occasionally, and, albeit to a lesser extent, with
his mother who arranged to meet him from time to time.
On several occasions the young man made up his mind to address his drug
use that was costing him around £120 a day at its height. When he was using
drugs he could not recognise the effects of his behaviour upon others but,
when he was 'clean', he acknowledged the futility of his lifestyle and the
distress it caused.
After a short period of custodial remand in January 2004, the young man
appeared at Magistrates' Court for offences of shoplifting and sentence was
deferred. During the deferment he signed on for benefit, referred himself to a
drug treatment agency and kept in regular contact with a probation officer.
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Sadly, he was unable to maintain his good intentions and committed further
shoplifting offences for which he was remanded in custody.
The Detoxification the prison confirmed that, at the young man’s request, he
was blood tested once and urine tested twice during April 2004. All of those
tests were negative. When visited by a probation officer for the preparation of
a pre-sentence report, the young man suggested that a short prison sentence
might enable him to stay drug free and could, therefore, be the best thing for
him. However, he also acknowledged that he would face the same difficulties
on release.
He was assessed as being reasonably motivated to address his drug use but,
to further test his motivation and his suitability for a Drug Treatment and
Testing Order, it was decided to request that he be remanded on bail for
assessment during a period of residence at the Approved Premises.
With this in mind, later in April, at the prison the young man was inducted into
the use of naltrexone, a drug prescribed to counteract the craving for and
effects of heroin. He was given an explanatory booklet and staff stressed to
him the dangers of taking illegal drugs with naltrexone. He was also given a
'naltrexone users card' to carry in case of accident.
The young man was released from the Magistrates Court with conditions to
reside at the Approved Premises, to abide by the financial and disciplinary
rules of the hostel, and to keep all appointments with the drug team as
directed. Upon release, he was given 7 days' supply of naltrexone.
During his short stay at the hostel the young man presented no management
problems and was perceived to be a quiet, benign presence, slightly apart
from the main group of residents although liked and respected by them. Staff
members had not been able to get to know him well but found him to be
motivated with a positive attitude.
From his input into a group work session a few days before his death, it is
evident that the young man felt positive about the future, hoping to make
amends to his family and be reconciled with them. His key worker described
him to the Investigator as one of the nicest lads he had worked with and he
was deeply saddened by the young man’s death.
Background information
Section two – 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. Hostels can
provide a supportive, structured environment in the community for high risk
and difficult to manage offenders. The supervision of offenders
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accommodated in Approved Premises is governed by the National Standards
for the Supervision of Offenders.
The Approved Premises is one of four hostels in the Probation Area. and is
very much a part of the Drug Management Strategy for offenders in that area.
There is a partnership between the Probation Area's Drug Management Team
(DMT), a Specialist Drug Service and the two hostels for drug users. A Day
Care Centre is also included in the partnership to provide therapeutic input by
means of group work sessions.
Under the terms of the protocol drawn up by the partnership agencies, the
Approved Premises is maintained as close to abstinence as possible, whilst it
is recognised that residents in the other house are often somewhat less
settled and may still use drugs from time to time. Hostel staff are not
empowered to search individuals but residents are drug tested twice weekly
and rooms can be searched. There is a protocol that residents should be
required to leave the hostel if they twice test positive. Any resident of the
Approved Premises who is not a management problem could be transferred
to the other house if such a move was thought to be in the offender's best
interest.
It was the hostel's policy to search one or two rooms, randomly, each day.
Since the young man’s death, it has been decided that further preventative
measures are necessary and any resident, whose test indicates drug use, has
his room searched daily. I commend the hostel for taking such positive action
promptly.
The hostel is a conversion of three terraced houses. There are eight single
rooms, two shared rooms and two others for use in emergency. The hostel
can take 12 residents and has been full for most of the time during the past
year. Residents can be bailed for Drug Treatment &Testing Order ( DTTO)
assessment, subject to a DTTO or subject to licence, but all would be
managed through the Drug Management Team (DMT).
Night cover is provided by a Night Supervisor, on duty throughout the night,
and an Assistant Manager, who sleeps on the premises.
In addition to the accommodation provided, each resident has a Key Worker
and there are additional services available as follows:
A Probation Service Officer from DMT runs a life skills group each
Wednesday.
Alcoholics Anonymous and Narcotics Anonymous attend on alternate Fridays.
A hepatitis nurse attends twice monthly.
Various volunteers attend - a personal trainer weekly, a counsellor once or
twice a week, a provider of basic literacy and numeracy skills, a debt manager
and floating support workers (FSWs) from the Cyrenians. FSWs are funded
through a government scheme to provide support for up to 2 years for those
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who are rehoused from being homeless. The FSWs cannot find
accommodation but they can help residents through the processes of applying
for benefits, setting up utility accounts, etc.
There are also two cluster houses (soon to be replaced by one larger house)
for move-on accommodation.
PART TWO
Events leading up to the young man’s death
Section one – The young man’s time at the Approved Premises
The young man was admitted to the Approved Premises on the day he arrived
and went through an induction procedure. A urine test carried out that day
proved positive for both cocaine and opiates and he subsequently admitted
that he had used drugs on his last night in prison.
He tested positive a second time two days later but the reading was lower and
as heroin can take up to five days to pass through the system, this was not
considered to be serious. It was noted that the results of the test were likely
to have been connected to the earlier use. However it was subsequently
discovered that the young man took heroin on a night in April and disclosed
the lapse the following day during a group work session for residents
facilitated by the DMT Probation Service Officer. Details of the group
discussions are not recorded on residents' personal files and the young man’s
disclosure was neither noted nor brought to his Key Worker's attention.
I appreciate that the knowledge that group discussions are not recorded may
encourage greater openness and honesty from hostel residents but if matters
of concern are entirely confined to the group, it is not possible to provide the
necessary advice and support.
I recommend that the hostel should take steps to establish a procedure
requiring information pertaining to risk, however it is acquired, to be
recorded and made available to relevant members of staff.
The young man attended each of the daily group work sessions and met with
his Key Worker as required. Records of those meetings indicate that he was
positive about the possibility of being sentenced to a DTTO and talked of his
plans to try for a college course or training programme if he could become
drug free.
Although the young man received support from hostel staff and from the DMT,
he was not given an appointment with the Specialist Drug Service.
His first appointment with that service was arranged for six days after his next
court appearance, provided the court made a Drug Treatment and Testing
Order on that day.
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Early in May, the young man told his Key Worker that he had used heroin the
previous weekend, and the following day he again tested positive for opiates
and cocaine. He also admitted that he had quickly stopped taking the
naltrexone provided by the prison, which would have reacted badly with
heroin and make him ill. When discussing the second lapse, the young man
said that a planned reconciliation with a family member had not worked out
and he had used drugs as a means of coping with his emotions. His case
manager recorded that, with hindsight, the young man could recognise that
there were alternatives available to him.
The hostel protocol is that residents will be asked to leave after two positive
drug tests but this is not rigidly enforced for a number of reasons. Certainly it
appears that the need to meet occupancy targets plays a part in the decision
making process but, more important, is the aim of encouraging residents to
help themselves to change their lifestyles.
There was considerable discussion between the case manager and the hostel
about whether the young man should be allowed to remain. It was decided
that, despite two (known) lapses, he presented as mature, realistic and highly
motivated. He was therefore allowed to stay and assessed as suitable for a
DTTO. A report was prepared for the forthcoming court hearing, proposing
such an order. The young man was warned that any further lapses once the
order was made could result in his place at the hostel being withdrawn and
breach proceedings being implemented.
It can only be a matter of speculation as to whether the same decision would
have been reached if it had been known that there had been a third lapse but,
by the evening before his death, the young man had provided two negative
urine tests. He was described as being very happy with the second one as he
knew the test results would stand him in good stead at court. He, jokingly,
told the Assistant Manager on duty to be sure to write down the result
correctly. His key worker spoke with him on that day and noted that he
seemed in a good mood, chatting about football and pleased with his test
results. The young man went out during the evening and returned around
2230, in good time for curfew. The Key Worker gave him a breath test that
was negative and the young man went upstairs, apparently to his room.
Events leading up to the young man’s death
The night of the death
The Key Worker, who was the sleeping member of staff on the night was
subsequently told that the young man had watched the television in another
resident's room for some time before retiring. The other resident was asked
to contact the investigation team before he left the hostel as part of a planned
move but he did not do so. A further attempt at contact was made via a letter
to his new address but there was no response. Accordingly, it has not been
possible to verify what time the young man retired to his own room.
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The Night Supervisor described the night as one of the hardest nights he had
experienced during the (almost) five years that he had worked at the
Approved Premises. He told the Investigator that there had been a situation
with two residents, one of whom was drunk, being threatening and abusive
and his attention was wholly focussed on diffusing the situation. He recalled
that the young man came downstairs around 00:30 to complain that someone
had stolen tobacco from his room and to ask what would be done about it.
Although the young man was quite composed, the Night Supervisor observed
that he appeared drowsy and thought he might have taken drugs. The Night
Supervisor told the young man that he would make a note of the loss but did
not do so as he was still trying to deal with a difficult situation that, in his
words, 'consumed' him.
At 09:00 the following morning, the Assistant Manager – the young man’s Key
Worker - resumed duty and spent some time discussing the previous night's
events with the Night Supervisor, deciding that one of the difficult residents
from the previous evening should be evicted. The young man did not appear
for breakfast but this did not surprise the Assistant Manager who said that, at
weekends, some residents prefer an extra lie-in to a bowl of cereal. He told
the Investigator that a member of staff will knock on each resident's door to
wake them but nothing is done if a resident misses breakfast unless staff
members are aware of particular concerns from the previous evening. No
such concerns had been expressed about the young man.
The young man was also missing from the morning house meeting as were
two other residents. It would usually be the Assistant Warden's responsibility
to return to the main office after the meeting, prepare warnings for those who
had missed the meeting and distribute them either by taking them to residents'
rooms or by waiting until the resident appeared.
However, on this occasion, the resident to be evicted was told that he would
have to leave. He did not take this well and refused to go quietly so that it
was necessary for the police to be called. He persisted in hanging around
outside the house, ringing the bell and creating a nuisance. Thus, it was some
time before the Key Worker had the opportunity to express surprise that the
young man had missed the group meeting for the first time. The other
member of staff went to the young man’s room, to check on him, around
11:15. When there was no reply to his knock, he opened the door and saw
the young man lying on the bed. He also noted evidence of drug
paraphenalia on the bedside cabinet. The worker had recently completed a
first aid course and, knowing that time was of the essence, he made no
attempt to resuscitate the young man but hurried downstairs to arrange for an
ambulance to be called.
He then returned to the young man’s room as speedily as he could to try
mouth to mouth resuscitation but all the signs were that he had died. His
death was pronounced by the paramedics upon their arrival.
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PART THREE
Consideration and conclusions
It was my role to consider if the risk of self harm had been properly assessed
and managed, and whether the level of care provided for the young man at
the Approved Premises was adequate. In doing so, I also considered whether
the hostel procedures were clear to staff and commensurate with the
requirements for all such hostels as defined in the Approved Premises
Handbook.
The young man was interviewed in prison in April 2004 by an experienced
officer responsible for assessing and supervising offenders subject to Drug
Treatment & Testing Orders. Before meeting the young man, the officer had
seen the OASYs assessment and the Pre Sentence Report (PSR) prepared
for the court and she found nothing to concern her in either document.
She was aware of a previous incident when the young man had overdosed
but he was vague about it, recalling only that it was accidental and he had
been in hospital for a matter of hours. She knew that he had remained drug
free in prison and he had a positive attitude.
The officer indicated to the Investigator that accidental overdosing is relatively
common amongst offenders with a history of intravenous drug use.
Therefore, during the interview she discussed safe practices with the young
man together with the risks of lapse and relapse. She particularly reminded
him that his tolerance to drugs would be reduced after a period of abstinence.
The Approved Premises Drug Management Team Protocol states that the
induction of all new residents should commence within 24 hours of their arrival
at the hostel and that the process will include an explanation of hostel rules,
an introduction to the hostel programme and a briefing on health and safety
issues with particular reference to the dangers of drug use and overdose, and
support to maintain abstinence. During the induction process residents are
required to sign a number of forms but there was no evidence in those
documents that these warnings about tolerance and overdose were repeated
to the young man.
I recommend that a form should be devised and included in the
induction pack for residents to sign, indicating that they have been
given the necessary warnings and advice.
There are clear procedures in place at the Approved Premises for daily events
of note to be recorded in the hostel log. The members of staff interviewed
were familiar with these procedures and ensured that 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.
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However, the young man’s disclosure of drug use during a group meeting was
neither recorded nor shared with his Key Worker and the Investigator found a
lack of instruction for various areas of work. Members of staff interviewed
were unclear about how some tasks should be undertaken. For instance staff
were not certain whether room doors should be opened either when waking
residents in the morning, or when carrying out a routine hostel check.
Expectations did not appear to be clarified and the Investigator could not
identify a clearly defined, structured process for the induction of new staff.
Much of what is required appears to be relayed by word of mouth from others
doing the job, which can lead to a lack of consistency.
The Investigator was subsequently informed that an induction procedure for
new staff was introduced shortly before the young man’s death but staff
members who had been in post for some time did not know of it.
I recommend that the Probation Area reviews it procedures for the
induction and instruction of all staff with a view to providing clearer
written guidelines.
My Investigation revealed that most DTTO assessments would be undertaken
during a custodial remand with the assistance of drug workers and healthcare
staff in prisons. If there is any element of doubt about the level of an
offender's commitment, then a further period of bail assessment is used as it
was in the young man’s case.
When an individual is released from prison on bail with a short supply of
naltraxone, the expectation is that the Specialist Drug Service will provide a
fast-track service to re-prescribe. My Investigator was told that the
expectation is often not fulfilled. As the medication cannot be renewed without
the Specialist Drug Service’s involvement, individuals are put at increased
risk. Although the young man had stopped using naltraxone, the lack of an
appointment with the Specialist Drug Service during the bail period deprived
him of specialised assistance.
Funding for the Specialist Drug Service is provided through the Joint
Commissioning Group of the Area Drug Strategy team and it is possible that
there is an under fund. The Service is funded to provide 93 commencements
of DTTOs during 2004/05 financial year but the Area DMT target is 141
commencements. The agreement for the Specialist Drug Service to see
those on bail is not yet ratified by a Service Level Agreement (SLA) although
the Investigator learned that a draft SLA is currently being discussed with a
view to ratifying it as soon as possible.
Although it is not for me to prescribe the agreements that the Probation
Service should reach with its partnership agencies, it seems clear that the
services purchased for the provision of drug treatment should be available to
all offenders for whom the area has a duty of care, whether or not they are
subject to DTTOs.
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I recommend that the Probation Area draws this report, and my view that
treatment providers should be funded to the level necessary to meet
national targets, to the attention of the Area Drug Strategy Team.
There is one final issue that I wish to bring to the attention of the Probation
Area. The events in the Approved Premises on the night of the young man’s
death were unforeseen and potentially explosive with two residents causing
considerable problems for the experienced Night Supervisor. I have no doubt
that he dealt with those difficulties in a thorough, professional manner but in
doing so he was unable to give his full attention to the young man.
In the job description, one role of the Night Supervisor is described as
"To alert the on-call duty Assistant Manager to any emergency situation
in accordance with the handbook."
My Investigation discovered that, in practice, Assistant Managers are rarely
woken and that the circumstances in which they should be called by Night
Supervisors are open to interpretation. The Investigator was told that the
sleeping-in person would only be woken if there was an unmanageable
situation but that such situations are likely to be defined differently, according
to the level of confidence and experience of the Night Supervisor.
I recognise that it would not be possible to define precisely what constitutes
an unmanageable situation as the competence and confidence of individuals
varies. I am concerned, however, that there may be different reasons why a
Night Supervisor would not wake a colleague even if a situation was getting
out of hand.
I recommend that the Probation Area considers whether it is necessary
to develop clearer guidelines for staff on duty in hostels overnight.
Recommendations
I recommend that the hostel should take steps to establish a procedure
requiring information pertaining to risk, however it is acquired, to be
recorded and made available to relevant members of staff.
I recommend that a form should be devised and included in the
induction pack for residents to sign, indicating that they have been
given the necessary warnings and advice.
I recommend that the Probation Area reviews it procedures for the
induction and instruction of all staff with a view to providing clearer
written guidelines.
I recommend that the Probation Area draws this report, and my view that
treatment providers should be funded to the level necessary to meet
national targets, to the attention of the Area Drug Strategy Team.
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I recommend that the Probation Area considers whether it is necessary
to develop clearer guidelines for staff on duty in hostels overnight.
STEPHEN SHAW
OMBUDSMAN
SEPTEMBER 2004
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