Individual at Brigstocke Road

Investigation into the circumstances surrounding the
death of a man during March 2010
at Brigstocke Road Approved Premises
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2010
This is the report into the circumstances surrounding the death of a man on 12
March 2010 at Brigstocke Road Approved Premises, in Bristol (Approved Premises
are residential hostels under the supervision of the probation service). He was found
in his room at 9.00am by the regimes manager, after he failed to collect his
medication. The man showed no signs of life and the emergency services were
called. The police attended at 9.15am however, the police failed to inform the
ambulance service of the emergency and paramedics did not arrive until 10.20am
when they confirmed the man had died.
A post mortem was held at the request of Her Majesty’s Coroner for Avon. The post
mortem noted that the man died of Amitriptyline toxicity and ischaemic heart disease.
He did not register any next of kin with Brigstocke Road. Despite enquiries by the
police no relatives have been traced up to the circulation of this report. I extend my
sincere condolences to the staff and residents of Brigstocke Road and those touched
by his death.
A clinical review of the man’s healthcare whilst at Brigstocke Road was
commissioned from Bristol Primary Care Trust (PCT). I am grateful to them for
carrying out that review.
The investigation was carried out by one of my investigator’s. I would like to thank
the Brigstocke Road Approved Premises regimes manager, the premises manager
and staff for their assistance with this investigation. Furthermore, I am appreciative
of the help of Avon and Somerset Probation Trust.
I make two recommendations, the first commending the staff at Brigstocke Road for
the care they afforded to the man during his time there and following his death. The
second recommendation is to the National Probation Service to develop guidance in
the event of the death of a resident without next of kin. I make one point of good
practice in relation to the professionalism of a staff member of Brigstocke Road.
This final report notes that both recommendations have been accepted by Avon and
Somerset Probation Trust and the National Offender Management Service on behalf
of the National Probation Service.
Thea Walton
Acting Deputy Prisons and Probation Ombudsman September 2010
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CONTENTS
Summary 4
The investigation process 5
Brigstocke Road Approved Premises 6
Key findings 7
Issues 11
Conclusion 14
Recommendations 15
3
SUMMARY
The man was released on licence from HMP Erlestoke in November 2009 to
Brigstocke Road Approved Premises following a conviction for Arson. He was
allocated a key worker and was supervised by Avon and Somerset Probation Trust.
He was seen by mental health services to continue this support in the community.
He was prescribed medication for depression, anxiety, abdominal disease and pain
relief. His medication was dispensed to him daily by staff at Brigstocke Road.
It was evident that he became agitated and anxious when faced with decision
making and struggled to become self sufficient with his day to day living. The man
made full use of community based activities and was a regular visitor to a day unit for
those with mental health problems. He attended church on Sundays and received
support from nuns working with this church.
The man received a warning when alcohol was found in his room, although he
denied using it on a regular and daily basis. A meeting with multi disciplinary
agencies to review his future was cancelled when it was thought he was under the
influence of alcohol. A second meeting was also cancelled for the same reason
however, a short while later, the man tested negative for alcohol on a breath test. It
was documented by Brigstocke Road staff that his demeanour, when anxious, could
be similar to that of someone under the effect of alcohol.
On the evening of 8 March 2010, the man was seen having a late supper in the
communal kitchen. He was pleasant and said he was soon going to bed. The
following morning he did not attend the office for his medication. A member of staff
went to his room and found him, on the floor, with no pulse and cold to touch. The
police and ambulance were called for and on arrival of the police into the man’s
room, it was noted that in both the police and the member of staff opinion that the
man had died. An ambulance arrived sometime later, and confirmed this. The man
did not register any next of kin at Brigstocke Road, and did not talk about family to
staff. Staff arranged a funeral service for him.
There are two recommendations, the first to commend the staff at Brigstocke Road
for their care of the man during his short time there and following his death. The
second recommendation for the National Probation Service to develop guidance in
the event of the death of a resident with out next of kin. One area of good practice
refers to the professionalism of a staff member of Brigstocke Road.
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THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened by my investigator on 17
March 2010 when she visited Brigstocke Road. There she met the regimes
manager and reviewed the man’s probation service file. My investigator
asked for copies from that file to be sent to her. Later, she visited the room
where the man had been found on 9 March.
2. Copies of the Ombudsman’s notices of investigation and terms of reference
had been sent to Brigstocke Road in advance of my investigator’s visit. Up to
the circulation of this report there has not been any response to those notices.
3. On 10 March a clinical review was commissioned from Bristol PCT. Further
enquiries were made with the PCT on 10 May and a doctor was appointed as
a clinical reviewer. On 29 April, my investigator visited Brigstocke Road and
interviewed three members of staff and the man’s offender manager.
4. The man had no next of kin registered with Brigstocke Road. A copy of this
report will be retained by my office should any family or relatives make contact
in the future.
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BRIGSTOCKE ROAD APPROVED PREMISES
5. Brigstocke Road Approved Premises in Bristol are four Victorian houses
joined together through inter communal doors. The premises have rooms for
28 adult male residents, 14 on full board accommodation and 14 places for
self catering residents. The premises take offenders, on release from prison,
who are deemed to be of high risk to the public.
6. There are seven full-time staff covering shifts between 8.00am-9.30pm and
two probation service officers working night shift. Additionally there is a
manager, regimes manager and administration support.
7. All residents register with community based doctors and their medication is
prepared by a local pharmacy. It is kept in a secure cabinet in the main office
and residents attend the office at specific times during the day to receive their
allotted dose of medication, which is stored in individual dosette boxes. (A
dosette box is clearly labelled for each day and contains the correct amount of
medication to be dispensed. All the dosette boxes are prepared by the
pharmacist prior to being delivered to Brigstocke Road.)
8. Offender Managers from the Bristol probation office visit Brigstocke Road
regularly to supervise offenders and those whose offender managers are
based outside the Bristol area.
9. Brigstocke Road has links into the community to provide activities and
opportunities for residents to progress their rehabilitation and address their
offending behaviour.
10. This is the first death I have investigated at Brigstocke Road since my office
took over this responsibility in 2004.
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KEY FINDINGS
11. The man was born in 1963 and was a single man. Very little is known about
his past personal history apart from information held in his Offender
Assessment and Systems (OASys) document which recorded he had a
difficult childhood. (An OASys document details the offender’s
custodial/probation history along with personal information and offending
behaviour.) The man did not have contact with any relatives and found it
difficult to make and retain relationships. Before being taken into custody, he
was living in the Bath area and received help from the community mental
health team for anxiety and paranoia. In 2008, the man was convicted of
arson and sentenced to 45 months imprisonment.
12. Following a remand at HMP Bristol, the man was transferred to Erlestoke. In
January 2009, a mental health nurse wrote in his medical notes that the man
was well known to the mental health service whilst he was in HMP Bristol.
The nurse noted that he felt unable to cope with decision making and when
asked to do so would panic. His prescription of anti anxiety medication which
included Amitriptyline and Citalopram would continue, in addition to regular
reviews with the mental health service. It was further noted that the man was
prescribed Omeprazole for a gastric condition and ibuprofen for pain relief.
13. The man was allocated work in the gardens at Erlestoke, a job he enjoyed
and he settled into a routine. His bi monthly reviews with the mental health
service continued until August when he spoke to a mental health nurse and
expressed anxiety over his forthcoming release and future plans. The nurse
reassured him that this would be considered by the multi-disciplinary services.
14. Two weeks later, the man told a mental health nurse he was having night
terrors and hearing voices but he had no thoughts of self harm. The nurse
spoke to a doctor and Quetiapine was prescribed. (Quetiapine is an anti
psychotic medication)
15. A counsellor met with the man at the end of August and they discussed his
concerns over his forthcoming release. He was given some exercises and
coping mechanisms to reduce his anxiety. The following day it was noted that
the man appeared to be calmer. His sessions with the counsellor and mental
health nurses continued until he was released, on licence, from Erlestoke on 4
November.
16. The man was allocated a place in Brigstocke Road Approved Premises and
arrived there the same day. He was met by a probation service officer, who
completed the paperwork for his stay. The man did not offer any details of
next of kin to be registered with Brigstoke Road.
17. The following day, the man had an assessment interview with a psychiatrist
and a mental health social worker. At the interview the man said he
experienced panic attacks, anxiety, low mood and hearing voices. However,
he had not taken any illegal medications or alcohol for two years and his
physical health had improved. It was agreed that having a structured routine
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would be beneficial for his mental and physical well being. A referral was
made for him to be seen by an assessment and intervention team. He also
registered with a doctor at a surgery close to Brigstocke Road.
18. On 26 November, an initial Multi-Agency Public Protection Arrangements
(MAPPA) meeting was held to discuss actions to ensure the man’s safety and
that of the public. (MAPPA is a multi-disciplinary panel drawn from the
probation service, police and other interested parties to monitor offenders who
are deemed to be a risk to the public.)
19. A further MAPPA meeting took place on 10 December, when it was decided
that the man was to receive full support from the community mental health
team and assistance from his key worker at Brigstocke Road. His offender
manager was based in Bath, therefore an offender manager from the Bristol
probation service took over supervision of his care whilst he was resident in
Brigstocke Road. His supervisor was subsequently replaced by in January
2010.
20. The man settled into a routine at Brigstocke Road. For the first few months
he was resident on a full board basis and took his meals at the premises.
Later, he moved into the self catering area where he cooked his own meals.
He was not totally independent and staff would assist him by allowing him to
have some meals with the full board residents.
21. As part of a structured day to day routine the man attended the Compass
Centre, a day provision funded by the National Health Service which offers
activities and resources for people with mental health conditions. The man
learnt to play the guitar and took part in art class. He attended mass on a
Sunday and was offered help by the nuns at the church. He also liked to visit
charity shops and was considering some form of voluntary work.
22. The man’s probation service officer told my investigator that whilst he was not
the man’s designated key worker, he knew him extremely well and they had
built a good working relationship. He said that the man became very anxious
when faced with decision making and was concerned over his future plans for
moving on from Brigstocke Road. The probation service officer helped the
man to keep his own diary sheet so he could plan his time and prepare for
any forthcoming meetings. He added that the man could have bad days with
low mood these did not last long and with encouragement from staff he would
soon be back in control. He attended his doctor’s appointments and reported
daily to the office for his medication.
23. A multi-disciplinary meeting was held in February to assess the man’s
progress. However, the meeting was cancelled when it became known that
he had consumed alcohol. The regimes manager told my investigator that the
man had also been found in possession of alcohol in his room. This was
against Brigstocke Road’s house rules. The man was given a warning about
possessing alcohol on the premises. The regimes manager said the man was
not a heavy drinker though he liked a drink in the evenings, and was
seemingly using alcohol when he felt under pressure.
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24. A Bristol offender manager saw the man at Brigstocke Road to supervise his
licence conditions on a regular weekly basis. The offender manager told my
investigator that the man had a lack of trust in people and found it difficult to
build relationships. Nevertheless, they had worked well together although the
offender manager felt that the man still had some way to go before he would
be ready for a move into community living.
25. In early March, a meeting was arranged with a housing provider. Before the
meeting the man asked the probation service officer if he could be present to
offer him support. The officer was unable to attend and the regimes manager
agreed to act as support for the man at that meeting. Due to a family
emergency, the regimes manager was also unable to attend. The meeting
was again postponed as it was thought that the man was under the influence
of alcohol. On return to Brigstocke Road, the man took a breath test which
proved negative for alcohol. The probation service officer told my investigator
that the man’s erratic behaviour at this meeting was more than likely due to
anxiety.
26. On 8 March, a probation service officer at the approved premises reported for
night duty at Brigstocke Road. As part of his duties he would check all the
residents were in the premises before curfew time of 11.00pm. The man was
seen by the officer and took an alcohol breath test which proved to be
negative. (Breath tests are taken randomly if there is suspicion or previous
issues of alcohol use with residents.)
27. The officer carried out a check of the premises and at around 11.10pm saw
the man in the kitchen area eating some soup. They exchanged pleasantries
and the officer carried on with his duties. The following morning the officer’s
shift finished at 8.15am and he did not see the man before he left..
28. The probation service manager and the regimes manager were on duty on the
morning of 9 March. The probation service manager was in the office handing
out medication at around 8.30am. He had not seen the man that morning,
which was unusual as he was an early riser and would come to the office for
his medication. He was also aware that the man had a meeting at 9.00am
with his offender manager and that he should be ready. When the regimes
manager came into the office the prison service manager told him that the
man had not been down for his medication and he should be checked. The
regimes manager told the probation service manager to carry on with the
residents’ medication whilst he went to see the man.
29. About 8.50am, the regimes manager went to the man’s room. He knocked on
the door and called the man’s name but got no reply. The regimes manager
unlocked the door and on entering the room saw the man lying on the floor
near his bed. There was some fluid around his face. He checked for a pulse
but could not find one. Whilst checking for a pulse the regimes manager
noted that the man was cold and there were no signs of life.
9
30. The regimes manager left the room and went immediately to his office. He
telephoned the emergency services and asked for the police and ambulance
service. The operator put him through to the police. He told them that, in his
opinion, he had found one of his residents dead. The police operator told the
regimes manager they would inform the ambulance service.
31. The regimes then went to the main office and asked the probation service
officer to come with him and to shut the medication cabinet. Both men went
to the man’s room and the probation service officer checked the man for any
signs of life, of which he said there were none. They left the room and locked
it until the arrival of the police.
32. The police arrived at Brigstocke Road around 9.15am and went to the man’s
room with the regimes manager. The police established no signs of life. The
ambulance did not arrive until 10.20am when paramedics pronounced death.
I understand the police have carried out their own enquires as to why the
ambulance service took so long to respond to the regimes manager’s
emergency call.
33. In company with the police, the regimes manager searched the man’s room.
He told my investigator that the man’s television was on and it looked as if his
bed had not been slept in. A bottle of vodka was found in his refrigerator with
a small amount missing.
34. The regimes manager made contact with his senior managers in Avon and
Somerset Probation Trust and two managers attended Brigstocke Road to
support staff. Later that morning, a meeting of residents was called in the
residents’ meeting room and they were told of the man’s death. All residents
were offered support from staff.
35. No next of kin details were recorded in either the man’s prison or probation
files. Police have also been unable to trace any relatives. The man had not
spoken to staff about any family and only offered scant information about a
previous relationship with a woman in Bath.
36. Staff at Brigstocke Road made arrangements for the man’s funeral. The
probation service officer made a framed tribute and read a poem at the
service. Floral tributes were made by the administration manager. The
funeral was attended by staff and residents at Brigstocke Road, probation
service staff and the man’s friends from a community centre. Following the
service the centre arranged a wake to which all were invited.
10
ISSUES
Clinical review
37. A review of the man’s clinical records was commissioned from Bristol PCT. A
doctor carried out that review on behalf of the PCT. A post mortem
examination was undertaken and the cause of death was noted to be
Amitriptyline toxicity and ischaemic heart disease. (A higher than therapeutic
level of Amitriptyline and coronary heart disease.) Further investigations also
recorded that the man’s liver was massively enlarged, which might be due to
alcohol misuse or active hepatitis C. The high levels of Amitriptyline were
noted to be 1.03 milligrammes per litre (levels greater than one are associated
with serious toxicity). Low levels of alcohol and diazepam were recorded. The
pathologist commented:
“However, Amitriptyline is also cardio toxic and even in modest
overdose can cause cardiac arrhythmias. This patient also had
severed coronary artery disease as noted above which would also
predispose to cardiac arrhythmia.” (Irregular heart beat)
38. A summary of the man’s medical care noted that he had no recorded history
of ischaemic heart disease in his prison or community primary care medical
records.
39. The post mortem report indicated a degree of Amitriptyline toxicity found in a
sample taken from the man contributed to his sudden death. The clinical
reviewer considered whether the prescribing was appropriate and confirmed
that the dosage of 50 milligrammes per night was well within safe limits.
(Amitriptyline is licensed to be prescribed up to 150 milligrammes per day.)
Furthermore, the man’s medication was reviewed regularly by his community
doctor during the last few months of his life. His medication was prescribed in
weekly prescription scripts, dispensed and then handed to Brigstocke Road
staff.
40. The man received his medication from staff daily and there was no indication
that he was non compliant with taking his medication. The clinical reviewer’s
conclusion is:
“There is evidence of holistic care from the primary care medical team.
The man died suddenly of Amitriptyline toxicity and ischaemic heart
disease. He was found on the morning of 9 March 2010. There is no
evidence of any factors that could have prevented this death.”
Care of the man at Brigstocke Road
41. It has been well documented that the man had mental health problems which
caused him anxiety, some paranoia and at times to be low in mood. He
regularly attended doctor’s appointments and was taking prescribed
medication to address and help his mental health. Despite the medication,
11
staff at Brigstocke Road noted, and told my investigator that he still had
periods of erratic and agitated behaviour.
42. It was found that the man had been using alcohol in February 2010, which
was against the rules of Brigstocke Road. He had received a warning for
being in possession of alcohol. The probation service officer told my
investigator that he had been upset by this and was only taking a glass of
wine in the evenings. However, following his death a bottle of vodka, was
found in his room from which a small amount had been drunk.
43. The man had settled into a routine of day to day activities within the
community close to Brigstocke Road. He attended a community centre and
enjoyed taking part in guitar lessons and art classes. He was a regular
churchgoer and received support from the nuns. His offender manager told
my investigator that meetings were taking place to assess his needs and
future plans for a move to community living.
44. The man was concerned about his future and what it held for him. At
interview, the offender manager told my investigator that in his opinion the
man still had some way to go before he could be considered for residency
away from Brigstocke Road.
45. The probation service manager spoke at great length during interview about
the support he and the staff offered to the man. He told my investigator that
the man was mostly cheerful and open to advice from staff. When his mood
did alter staff would soon become aware of this change in personality and
encouraged him to be positive.
46. I note as good practice the professionalism shown by the probation service
officer in building a positive and trustful relationship with the man
9 March 2010
47. The probation service officer knew that the man had an appointment with his
offender manager at 9.00am that morning. When he did not come down for
his medication, as was his usual routine, the probation service officer alerted
the regimes manager and he went to find him. When he discovered the man,
on the floor of his room, with no signs of life, the emergency services were
contacted.
48. The police arrived shortly after the telephone call but the ambulance service
failed to arrive until one and half hours later. I understand from the regimes
manager that the police have conducted their own enquiry as to why the
ambulance was delayed. I do not have any further information as to the
outcome of that enquiry. The regimes manager had checked the man and
found no sign of life. This was supported by the probation service officer and
later by the police. Nevertheless, the late arrival of the ambulance raises
concerns and I hope that this matter has been resolved so that any future
emergencies are dealt with appropriately and in timely fashion.
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Following the man’s death
49. The man did not offer any details of next of kin to either the prison or
probation service. Very little was known about his personal history and he did
not talk about his personal life to staff. The police were unable to trace any
next of kin.
50. The administration manager at Brigstocke Road made enquires with the local
authority and coroner’s office to ascertain the procedures for financing man’s
funeral costs. No formal instructions have been circulated to assist managers
of approved premises in the steps of dealing with the death of a resident
where there is no next of kin. I therefore make the following recommendation.
The National Probation Service should develop guidelines for approved
premises, detailing the processes and procedures for the funeral
arrangements of residents without next of kin.
51. The man’s funeral was arranged by the staff at Brigstocke Road. They went
to great lengths to ensure that he was given a respectful and dignified
ceremony. Staff duties were changed so they could attend the service and
participate fully. Residents also attended to pay their respects. Following the
funeral the man’s offender manager emailed my investigator to tell her that it
had been a well attended service. The community centre kindly provided
refreshments afterwards and a choir sang their tribute to the man.
52. Whilst it is unfortunate that no next of kin could be traced, the man’s life was
celebrated by his friends and those he trusted.
I commend the staff of Brigstocke Road for their compassion in
arranging a funeral service for the man and the overall care they
afforded him whilst he was a resident.
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CONCLUSION
53. The man had mental health problems which were documented whilst he was
in prison and subsequently when he moved to Brigstocke Road. He was
prescribed medication to help his symptoms but still had periods of agitation
and anxiety when he felt under pressure. It was recorded that he had been
warned about having alcohol in his possession and alcohol was found in his
room following his death. However staff believed he was not a heavy drinker
and used alcohol as a support mechanism when he was under stress and
faced with making decisions.
54. The clinical reviewer observes in his clinical review that the man had a history
of ischaemic heart disease and no symptoms of such disease were described
in either his prison or primary care (community) medical records. The findings
of the post mortem examination indicated that the man had high levels of
Amitriptyline in his body which contributed to his sudden death from heart
disease. It is evident that he suffered from mental health problems and it is
unclear whether the man took an overdose of Amitriptyline, which he may
have saved from his daily allocation, on the evening of 8 March.
55. I commend the staff at Brigstocke Road for the care they afforded to the man
which was followed through in arranging his funeral service. I make one
recommendation to the National Probation Service to develop guideline on
funeral arrangements for residents without next of kin. One area of good
practice refers to the professionalism of a member of Brigstocke Road.
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RECOMMENDATIONS
The Chief Executive of Avon and Somerset Probation Trust
I commend the staff of Brigstocke Road for their compassion in arranging a
funeral service for the man and the overall care they afforded him whilst he
was a resident.
Accepted
The National Probation Service
The National Probation Service should develop guidelines for approved
premises, detailing the processes and procedures for the funeral
arrangements of residents without next of kin.
Accepted
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