Individual at Norfolk Park

Investigation into the circumstances surrounding the
death of a man at an Approved Premises in the South
Yorkshire Probation Area
in April 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2009
This is the report of an investigation into the circumstances of the death of a man on
2 April 2009. He had taken a drug overdose. Although he had previously misused
drugs, he remained drug free in the four years preceding his death. He was 43
years old.
I would like to extend my condolences to the man’s family and friends for their loss.
My colleague conducted this investigation. I am grateful for the assistance he
received from staff of the local Probation Area.
The man who is the subject of this report was released on licence from HMP
Moorland into private housing in the local area, arranged by his probation officer.
Shortly afterwards, he was assaulted and it was decided to relocate him to an
Approved Premises in another area. During his three week stay at the approved
premises, he interacted well with staff and residents. On what was to be his last day
there, the man went out in the evening with two other residents to obtain drugs. He
returned that evening and was later found dead in his room.
I judge that the Approved Premises is well managed by committed staff. It was
obvious to the investigator that the managers actively engaged with community
groups to provide residents with support and drug advice. I raise two areas of
concern in my report and I am pleased that the local Probation Service and
managers at the Approved Premises have already taken remedial action to address
them. I therefore make no recommendations.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Deputy Ombudsman November 2009
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Contents
Summary 4
The Investigation Process 5
The Approved Premises 6
Key Findings 8
Issues 17
Conclusion 19
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SUMMARY
On 27 January 2006, the man who died appeared at a Crown Court charged with a
serious offence. He was found guilty and sentenced to three and a half years
imprisonment and transferred to HMP Moorland. He had previously misused drugs
which was cited as one of the underlying causes of his offending history.
The man addressed his drug problem in prison by undertaking a number of
rehabilitation courses. After his release in February 2009, he moved to a housing
association property in the local area. After living there for about three weeks, he
was attacked by a group of people from the local community. There was concern for
his safety and his probation officer immediately arranged for him to reside at another
Approved Premises.
He arrived at the approved premises (AP) on 11 March and quickly settled in. He
received a full induction from staff and was also allocated a new probation officer.
No concerns for his well being were raised. He said that he had been drug free for
four years and was looking forward to starting a new life in the local area.
Around midday on 2 April, the man left the AP to attend a meeting with his probation
officer. He returned that afternoon and AP staff found nothing untoward about his
behaviour. He went out again at around 5.00pm. Although it was not known at the
time, two other residents who left the AP around the same time, met him and went in
search of drugs.
All three residents returned to the AP later that evening. Within 20 minutes, staff
were alerted that a resident had collapsed in the laundry room. He was one of the
two men who was out with the man who died. The resident was conscious but did
not look well and could not speak. Staff suspected that his symptoms were
consistent with someone who had possibly overdosed on heroin. An ambulance was
called and the resident taken to hospital. A few hours later, the hospital confirmed
that the resident had had a bad reaction to taking drugs.
A short time after the ambulance left, staff were asked to check the man’s
whereabouts by the other resident who had also been out with him that evening.
The resident said he had knocked repeatedly on the man’s door but got no
response. Staff immediately went to his room where he was found in a slumped
position. It was suspected that he had also taken drugs. Staff found no signs of life.
Cardio pulmonary resuscitation (CPR) was carried out whilst waiting for the
emergency services. The paramedics examined him and pronounced his death.
The police opened their investigation and found drug paraphernalia in another
resident’s room.
The man’s death was the first death of a resident at the AP since the Ombudsman
became responsible for investigating deaths in custody and approved premises.
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THE INVESTIGATION PROCESS
1. The investigation was conducted by one of the Ombudsman’s senior
investigators. I am grateful for the assistance he received from the local
Probation Area, especially from the acting manager and divisional manager at
the Approved Premises. Although those interviewed were themselves coming
to terms with the man’s death, they made facilities available and participated
fully in the investigation.
2. The investigator visited the Approved Premises. It was noticeable on
information boards around the AP that residents were provided with information
relating to drug and alcohol misuse. The investigator studied the AP records,
and interviews were conducted with staff. Transcripts of the interviews are
attached as annexes to this report. One of the residents offered some
information regarding the events that occurred on the day of the man’s death.
3. When the man who died arrived at the Approved Premises, he did not provide
any next of kin details. He was not known to be in contact with any family
members. Following his death and after considerable searching, the local
Social Services department were able to trace his brother. His contact details
were confidential to Social Services and not made available to the
Ombudsman’s office. My report will however be made available to the man’s
brother at any point in the future should he wish to see it.
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THE APPROVED PREMISES
4. The purpose of an Approved Premises (AP, formerly known as bail hostels), is
to provide an enhanced level of residential supervision in the community,
alongside a supportive and structured environment, for offenders who have
been released from prison. Whilst residents have to comply with their individual
licence or bail conditions, curfews, and the AP’s rules, they are essentially free
to come and go from the building.
5. There are three APs in the area, including the Approved Premises in this report,
which are supervised by a divisional manager. In addition, each hostel has its
own manager, who deals with the day to day running.
6. The Approved Premises normally accommodates up to 32 residents, in 31
bedrooms. There are two self contained houses (known as the spierhead
properties), which are situated outside to the right of the core hostel building.
All residents start their stay in the core hostel and are monitored. As they
progress, and following successful completion of risk assessments, residents
may be offered accommodation in one of the self contained houses. This
accommodation tends to be given to residents who are employed or might be
working a night shift and have proved that they are capable of living
independently.
7. The Approved Premises is staffed 24 hours a day by probation employees
whose role is to provide support and to ensure that residents comply with the
rules of the AP and their licence or bail conditions. A curfew operates from
11.00pm to 7.00am. Residents are provided with breakfast and an evening
meal at the premises. They make their own arrangements for own lunch.
8. Information about relevant rules, procedures and expectations is given during
induction. All residents are allocated a key worker (who is one of the probation
hostel workers). Regular key work sessions take place, giving the resident the
opportunity to discuss any issues or difficulties in more depth. At least one key
worker is always on duty between 8.30am and 9.00pm, including at the
weekend.
9. Two members of staff work on the reception (hostel support workers). They
work split shifts, one working at the start of the week, the other during the latter
part. There are three members of probation night care staff who work night
shifts from 6.00pm to 9.00am. More recently, the hostel employs a contracted
member of staff for night duties from a private organisation called Craft
services. At least two members of staff are on duty during the night, one
sleeping night probation worker and one waking contracted staff. In addition to
that, the AP has contractors to carry out cleaning and catering. There is also
on-call manager available during the out of hour’s times.
10. On arrival, all residents are offered a tour of the hostel and the opportunity to
register with a local doctor’s surgery. There is an arrangement with the surgery
and local pharmacy to facilitate the delivery of medication to the premises. All
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prescription medication must be handed in to the staff at the front office, where
each item is logged and stored safely.
11. Resident meetings take place every week. The Approved Premises also has a
number of professionals who visit the hostel to provide support to residents.
They include drug and alcohol workers, employment and accommodation
specialists and mental health staff who can be contacted to attend the AP
whenever necessary. The hostel also has a good relationship with the local
doctor enabling them to work together if they have concerns about managing a
resident’s risk.
12. Room searches are carried out if staff have any suspicions that a resident has
stolen property, drug paraphernalia or alcohol in their room. There are also a
number of CCTV cameras installed in communal areas of the hostel which are
monitored by staff from the main office. Staff also carry out daily health and
safety room checks at various times throughout the day and evening.
13. Basic first aid equipment is kept in the main office, including resuscitation face
masks. There are also a number of other first aid kits located around the
hostel. The two hostel support workers are fully trained in first aid and attend a
comprehensive four day accredited course, with refreshers every two years.
Other staff are trained in basic first aid and bag and valve resuscitation
methods. Other training provided is risk assessing, health and safety, and self
harm and mental health awareness.
14. Staff have regular handover meetings at the beginning, middle and end of their
shifts to update one another on any issues which have occurred during the day
or night.
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KEY FINDINGS
15. The man who is the subject of this report committed an offence of robbery on
22 December 2005 and sentenced three and a half years in prison. He was
taken to HMP Moorland, where he went about addressing his drug misuse
problem (by completing PASRO accredited programme), which was the main
factor behind his offending behaviour.
16. He was released early from prison on 22 September 2007, on licence until 21
June 2009. He did not comply with the conditions and was recalled to
Moorland in October 2007.
17. On 16 February 2009, the man was again released on licence. He had been
homeless before coming into prison. His probation officer arranged for him to
live in the local area. The accommodation was provided by Action Housing
Property, who work in association with the Probation Service to provide
accommodation. He went to the probation office, in the local area, to see his
probation officer. (He also attended the probation office on 19 and 24
February.) The main purpose of these meetings was to ensure that he
remained well behaved and did not re-offend, issues which were at the core of
his licence.
18. When the man arrived for his next appointment at the probation office on 11
March, he told staff that he had been assaulted in the local area by a group of
people because of issues that related to his past offence. He was concerned
that if he returned home, his safety might be compromised.
19. The man’s probation officer took immediate action and arranged for him to be
transferred out of the area to an Approved Premises in a different location. Her
referral highlighted that he was being moved for his own safety and had no
issues in respect of harming himself or drug misuse problems.
20. Later that evening, the man was taken to the Approved Premises by his
probation officer. He was inducted into the AP by Mr T (a probation hostel
worker). Mr T was also the man’s key worker. At the time he arrived, Mr T had
been employed at the AP for about two months. His training consisted of
shadowing other colleagues, computer training, first aid training and attendance
on an Induction to the Probation Service day. Further training events were
planned, including an event covering mental healthcare issues.
21. At interview with the investigator, Mr T said that he inducted the man who died
into the AP by explaining all the rules and procedures. The man signed
disclaimers that he agreed to abide by the AP rules. Although he was worried
about personal belongings he had left at the previous Approved Premises, Mr T
described his mood as okay. He had no drug or alcohol difficulties or thoughts
of wanting to harm himself when he arrived and he said he believed he would
be safer in this area. Despite being asked, he provided no next of kin details.
After their discussion, Mr T showed him to his room, where he settled for the
night.
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22. Due to the man’s change of address, responsibility for supervising his licence
was transferred to the Probation Office in the local area. He would be allocated
a new probation officer from the area as soon as all his paperwork was
transferred to their office.
23. One of the conditions of staying at the AP is for residents to be randomly
screened for drugs. On 16 March, the man who died produced a negative
screen for all substances. He told staff that he smoked cannabis.
24. On 19 March, the man attended the Probation Office for the first time and was
seen by a duty probation officer. The purpose of this meeting was to introduce
him to the local area and ensure that he understood his licence conditions. The
next day, Mr H was appointed as his probation officer, and this information was
relayed to the AP.
25. At interview with the investigator, Mr H said he first met the man who died on 26
March at the probation office. They discussed his reason for leaving the
previous area and how he felt about being at Approved Premises. The man
said he had no problems with staying at the AP but his main objective was to
secure his own accommodation. He did not want to move out to the suburbs
and wanted to stay somewhere reasonably close to the city centre, so he would
be able to access the facilities within the city. Mr H said he looked well, relaxed
and pleased to be away from the previous area. He identified no issues or
problems with him at that present time. He also noted that he had been drug
free for a number of years and had successfully completed a P-ASRO course
(addressing substance related offending programme for prisoners with drug
misuse problems) in prison.
26. Mr H told the man that a three-way meeting with his AP key worker (Mr T)
would be arranged as soon as possible. The aim was to identify any difficulties
or problems he may have, assist him identify anything needed to address his
offending behaviour or his social needs and share information between Mr T,
Mr H and himself which could aid his resettlement. This meeting would also
form the basis of his key work sessions with Mr T.
27. Mr T said he had regular contact with the man throughout his stay at the AP.
He described him as a “talkative bloke” who was knowledgeable and seemed to
have an opinion on lots of different subjects. He told the investigator that he
had wanted to hold a key work session with the man as soon as possible after
he had arrived. However, because of his and Mr H’s working patterns, his first
key work session was not held until 30 March. Mr T arranged the key work
session before the three-way meeting was held because he wanted to ensure
that the man had some input from him about his AP stay and could raise any
issues about his concerns.
28. Mr H told the investigator that the three way meeting would normally take place
within 15 days of an individual’s arrival at a hostel. Through subsequent e-mail
correspondence between Mr T and himself, the meeting was arranged for 17
April.
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29. The man raised no concerns at his key work session on 30 March. Mr T’s only
concern related to the man’s association with another resident, who it was
rumoured might have been bullying him. He reassured Mr T that there was no
problem between him and the other resident. Mr T reminded him that he could
speak to any member of the AP staff if he had any problems He reassured Mr
T that his drug misuse was a thing of his past and he had no intention of
associating with others who used drugs. Mr T said that there seemed to be a
genuine effort from the man to fit in at the hostel, and the residents he generally
mixed with were not known drug users.
30. No concerns were noted about the man during his three weeks at the AP. On
the morning of 31 March, he provided a negative urine screen test for illegal
substances. This information was copied to Mr H.
Events on 2 April
31. The man left the AP at 12.25pm for a meeting at the probation office. He
arrived at around 1.00pm and met Mr H. It was a short meeting (approximately
15 minutes) and he said he was still familiarising himself with the local area. Mr
H said he would be making a housing referral on his behalf as soon as possible
given his wish to secure his own accommodation, and would update at their
next meeting. The man was happy with this, but also said he was in no rush to
leave the AP and was looking forward to making his future in the area. Mr H
thought that he displayed no signs of drug use in his mannerisms, behaviour or
speech. His next appointment would be the three-way meeting with Mr T on 17
April. Mr H had no concerns about the man, who returned to the AP at 2.10pm.
32. Later, at around 5.00pm, acting hostel manager, Ms C, signed the man out of
the AP. He said he was going for a walk. Within minutes of him leaving, Ms C
also signed out two other residents, Mr A and Mr S. Ms C told the investigator
at interview that it was not apparent at the time that the three men were going
out together. Ms C finished her shift at about 6.00pm and left the AP.
33. At interview with the investigator, Mr A said that, along with the man who died
and Mr S, he left the AP after tea time. Mr A said that he had been with him
most of the day during which the man suggested they all contribute some
money to buy a bag of heroin. Having agreed to this, they left the AP in search
of someone selling the drug. Once the heroin was purchased, the three
residents went to a nearby park. Mr A said that he was the first to inject the
drug and, after doing so, he reacted badly and felt “very funny”. Seeing this
reaction to the heroin, Mr S and the man decided they would not take any of the
drugs and returned to the AP.
34. Ms N, a night shift worker, began her shift at the AP just before 6.00pm. She
was on duty for 15 hours, nine hours paid and six hours that are “sleeping”. Ms
N is contracted to work 21 hours a week, over a three week rota. The other
member of staff on the night shift was Mr L, who works for the contracted
company, Craft. Mr L does a “waking night” shift and was due to start his duty
at 9.00pm.
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35. No concerns were raised with Ms N during the handover at the start of her shift.
She told the investigator that the man returned to the AP at around 8.30pm.
She let him in and signed him in the AP book. Signing in takes place at the
front entrance of the AP (at the front of the office), and he was handed his room
key by Ms W (Hostel Support Worker) who was also on duty. The man gave
the staff no cause for concern. Ms N said she also saw two other residents
outside the front door, Mr S and Mr A, waiting for the door to be unlocked so
they could come in. Ms N did not know that they had been out with the man,
and let them into the AP.
36. Once in the AP, Mr A told the investigator that he and the man, went to Mr S’
room. Mr A said he felt much better by this time and left Mr S’ room soon
afterwards.
37. About 20 minutes later, Ms W was watching the CCTV screen in the office
when she noticed Mr A in the laundry room trying to hold Mr S upright. She
immediately left the office and beckoned Ms N (who was down the hallway) to
go to the laundry room with her. Ms N said they entered the laundry room and
saw Mr S being held up by his shoulders by Mr A. Mr A told staff that he
believed Mr S was having a fit. From her experience and regular training on
drug misuse, Ms N said she believed Mr S looked as if he was experiencing a
bad reaction to taking drugs, possibly heroin.
38. Ms N told Mr A to place Mr S on the floor. Mr S was conscious, his colour was
“quite blue” and, although he appeared to be breathing well, Ms N was
concerned as to his well being. She kept talking to him to ensure he remained
conscious. Mr S appeared unable to respond verbally, but blinked his eyes in
acknowledgement of hearing what was being said to him.
39. In the meantime, Ms W telephoned the emergency services and an ambulance
crew arrived at the AP about 8.50pm. Ms N said that Mr S’ colour had
improved a little by this time and the ambulance crew agreed with her
assessment that Mr S’ condition “looked very much like a heroin overdose”.
40. Having obtained some personal details about Mr S from the AP office, he was
taken to the Accident and Emergency Unit at the local hospital. The two
members of staff on duty remained on duty at the AP. The ambulance crew
were asked to contact the AP with an update of Mr S’ condition as soon as
possible and transport back to the hostel would be arranged for him when he
was discharged.
41. Ms N and Ms W returned to update Mr L (who had arrived for his night shift duty
at 8.55pm) on the evening’s events and then Ms W left the AP for the evening.
42. Mr L told the investigator that he had worked at the AP for around 15 years. He
had many conversations with the man who died and found no cause for
concern. Mr L said that he was aware that another resident once complained
that the man had body odour, but did not believe he was the subject of bullying
because of this. He said the man looked after himself well and interacted with
11
other residents. Although he liked to have an occasional drink of alcohol, there
was never an issue with his behaviour because of this.
43. After the earlier events in the AP, Ms N said that for the remainder of the
evening all was normal. At about 10.35pm, she received a telephone call from
the hospital. They wanted confirmation of the evening’s events from Ms N,
which she gave them. The hospital confirmed that Mr S’ collapse was due to
heroin, although they had not needed to administer any drugs to reverse the
effects. He had been monitored and the doctors were happy for him to be
discharged from their care. Ms N told the hospital staff that she would arrange
for a taxi to collect Mr S and asked for this information to be passed on to him.
44. At 10.40pm, Mr A knocked on the office door and was greeted by Ms N. Mr A
said he had knocked several times on the man’s door, but got no reply. He
asked Ms N if he had left the premises. Ms N said she had seen him earlier,
and checked to see if his room key had been handed in to the office. It had not,
which indicated that he was still in the hostel. At this stage, Ms N said she was
not too concerned, as it was possible that he just did not want to answer his
door to Mr A. On seeing Ms N’s lack of reaction, Mr A told her that the man had
been out earlier with Mr S and himself. On hearing this, Ms N immediately took
the telephone and ran to his room to investigate. Mr A followed behind her.
45. Within seconds Ms N had unlocked the man’s room. She entered and was
immediately greeted by an “absolute horrendous smell”. He looked as if he was
kneeled over sitting slumped on the end of his bed. Ms N could see that his
back and his arm, which was to the side of him, had gone blue. Ms N told Mr A
to quickly call Mr L, who was in the kitchen, to assist her.
46. Ms N lifted the man’s head up and realised it was in a waste paper basket. A
clear liquid was coming from his mouth. From her experience of dealing with
individuals who had overdosed on drugs, Ms N said she believed Kyle had
taken heroin. She could find no pulse.
47. Mr L entered the room. Because space was limited, Mr L and Mr A lifted the
man’s body onto the bed. Ms N went to collect the first aid equipment across
the corridor, whilst at the same time calling the emergency services. In
response to a general question asked by the investigator, it was confirmed that
the AP does not possess a defibrillator machine. (A defibrillator is a machine
used to shock the victim's heart and restore the heart's normal rhythmic
patterns. When a defibrillator is used, it kicks the heart into action again,
causing it to resume sending blood throughout the body.)
48. Mr L also found no pulse when he checked for signs of life. He immediately
commenced cardio pulmonary resuscitation (CPR) at the rate of 30 chest
compressions to two breaths. He was assisted by Ms N on her return to the
room. Whilst Mr L carried out chest compressions, Ms N ensured Kyle’s airway
was clear to use the bag and valve to try and pass air into his lungs. Ms N said
she felt a little frustrated because the emergency services operator kept saying
he was having difficulty hearing her and described a crackling noise over the
telephone line. As Mr L had been carrying out CPR, Ms N decided to take over
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from him, and handed the telephone to him to resume talking to the emergency
services operator.
49. Mr L stepped outside of the man’s room hoping to get a better reception to
speak to the operator and re-confirm the address of the AP. The operator told
Mr L that he should return to the man’s room so that he could update them on
his condition. Mr L said that if he went back into the room, contact may be lost.
This would mean that as well as the emergency services being unable to
contact him, Mr L would not know when the ambulance arrived at the AP
(access was restricted by an entrance barrier). The operator told Mr L not to
worry about this and that they would get into the AP somehow.
50. Ms N continued with CPR but the man remained unresponsive. Mr L returned
to the man’s room. He passed the phone back to Ms N and relieved her from
carrying out CPR. Another resident came to the man’s room and told the staff
that an ambulance had arrived and could not get past the entrance barrier. Ms
N ran to the office to open the barrier. However, before she could do so, other
residents had already gone down the driveway and had broken the barrier to
allow the ambulance through. Ms N escorted the ambulance paramedics, who
were accompanied by the police, to the man’s room.
51. The paramedics told Mr L to continue with CPR whilst they set up their
equipment. Ms N then moved some of the furniture in the man’s room to give
the paramedics more space. With more space now available, the paramedics
placed the man on the floor and assessed his condition. Soon afterwards, they
pronounced him dead. Ms N, who had left the room to speak to the other
residents, telephoned Ms C and updated her on the events of the evening. Ms
C subsequently informed Mr P, the divisional manager and Mr J, the Assistant
Chief Officer, of the man’s death.
After the man’s death
52. The police immediately sealed the man’s room and began their enquiries. They
arranged for Mr S to be collected from the hospital as they wanted to question
him about his involvement earlier that evening.
53. Ms C and Mr P both arrived at the hostel soon afterwards and instigated the
Probation Service death in an approved premises contingency plans. This
included contacting relevant agencies to inform them of the man’s death and
arrange support for Mr L, Ms N and any of the residents. (Both staff members
told the investigator at interview that the support they received was invaluable.)
54. Recalling events of the evening, Ms N said Mr A indicated that he met Mr S at
the top of the road and they returned to the hostel together, merely because
they had walked down the road together. She had seen no indication that the
man had actually been out with Mr A or Mr S, especially as he appeared to
have returned a minute or so before the other two residents.
55. AP staff and the police viewed the CCTV footage. It showed that all three
residents had signed in the AP between 8.30pm to 8.35pm. Minutes
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afterwards, they were seen entering room 19, Mr S’ room and then going to
room 18, Mr A’s room. All three residents then proceeded to go down stairs.
The man went to his room and Mr A and Mr S went to the laundry room to
make a drink.
56. In the early hours on 3 April, the police collected Mr S from hospital and took
him back to the AP. They explained that Mr S was not being charged but was
on police bail pending further enquiries. The police were highly concerned that
Mr S had tested negative for opiates, crack and crack cocaine, although he said
that the drug he took had similar effects to heroin. Given the reaction Mr S and
the man had to the drug, the police said they were anxious to try and find the
dealer who supplied them with it.
57. At approximately 1.30am, Ms C noted in the AP records that she spoke to Mr A
who wanted to talk about the man’s death. Mr A said that he had been with him
most of the day and the man had asked him whether he wanted to contribute to
a bag of heroin later in the day. Mr A agreed, and along with Mr S, they later
went out and purchased some heroin. Mr A admitted injecting heroin in a park
soon afterwards.
58. Ms C told the investigator that it was extremely busy in the AP following the
man’s death with the police in attendance. The police found drug paraphernalia
in the laundry room and in Mr S’ room. Mr S and Mr A were arrested although
they were later released without charge.
59. Incident reports were completed by Ms C and passed to relevant probation
staff. Over the next few days the man’s death brought a sombre mood to the
AP and many residents were in need of support, especially Mr S and Mr A Who
were both upset. Ms C ensured that extra time and support was given to them
by their key workers. This was also extended to all residents who wished to
discuss any issues. Ms C referred Mr S and Mr A to community drug agencies
to offer support and guidance. Other residents who felt that they may be at risk
of drug misuse were also offered the services. The Probation Service
psychologist also spoke with Mr S and Mr A to offer support.
60. There was no direct newspaper interest in the man’s death. Once the Police
thought the substances the man had taken were contaminated they issued a
release warning users to be aware of purchasing drugs in the area of the City
the man was supposed to have done. The release urged concerned people to
contact their medical services. This information was passed on by the local
Probation Area Assistant Chief Officer (ACO) to all AP staff. Residents who
were assessed as possibly being at risk were notified and spoken to.
61. On 6 April, the ACO wrote a personal letter to all the staff involved in trying to
resuscitate the man who died which acknowledged their professionalism in
dealing with his death. The staff told the investigator that they appreciated this
acknowledgement.
62. A management discussion group, consisting of Mr Pl (the AP Divisional
Manger) and community drug and alcohol teams, was set up a few days after
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the man’s death. The subject matter was “Improving treatment links with the
Approved Premises”. Its aim was to establish any immediate learning from the
man’s death and the overdoses of the other residents and discuss their
concerns about contaminated heroin in the local area. A number of areas were
identified which could further improve support, knowledge, facilities and training
to AP staff and residents, and action has already been taken to implement
these.
Next of kin
63. When he was inducted at the AP, the man refused to name anybody as his next
of kin. After an initial search, the police were not able to ascertain any next of
kin details as it appeared that he had been in the care of the local authority from
a young age. They therefore requested the Social Services files and were able
to trace the man’s brother and tell him of his death.
Critical de-brief meeting
64. A critical incident review was held on 15 May. It was open to all members of
staff to attend. Staff feedback to the investigator showed that it was welcomed
and proved an invaluable means of identifying lessons for staff. A number of
issues and recommendations were made and including the following:
“The AP’s cordless phone should be upgraded
On induction of new residents, an e-mail should be sent to the probation
officer to set up an early three way meeting within five working days, and if not
practical, the key worker to see resident in the meantime
Staff to attend an overdose and awareness course being run by the local
Ambulance Service
Craft employees to have access to probation counselling services as it was
unsure what support was in place for their workers”
The man’s funeral
65. The man’s funeral service was arranged by the Social Services and held on
Tuesday 9 June. Ms C arranged for staff from other approved premises to
provide staff cover on the day of the funeral so that staff from the Approved
Premises could be there. All seven people who attended the funeral were from
the Approved Premises and said that the words used by the officiating minister
at the service were “profound and touching”.
Post Mortem
66. The post mortem carried out confirmed that the man’s death was a heroin
overdose. The police later informed the management at the Approved
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Premises that the Coroner had held the man’s inquest in August 2009 and the
verdict was one of “misadventure”.
Other issues
67. Although not pertinent to this investigation, Ms C identified that there was no
first aid equipment in the spearhead properties. Therefore, if an emergency
arose, staff would have to return to the main building to collect the first aid
equipment located there. Ms C said the issue was being addressed as a matter
of urgency.
68. Ms N raised her concern with the investigator about the staffing resource in the
AP. The management of APs were undergoing general changes. As a result,
from November 2008, nearly 50 percent of the Approved Premises night care
team workers were contracted to Craft. The two members of staff affected at
the Approved Premises were long-serving members of probation staff with lots
of experience. Ms N’s concern was that it was important to ensure that all
future Craft employees (normally employed to cover sick and leave periods)
had basic probation and first aid training. This matter was felt to be of the
utmost importance because during the night, the two members of staff on duty
have to rely upon one another and be able to respond to incidents effectively.
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ISSUES RAISED IN THE INVESTIGATION
69. It was very evident to the investigator that all staff at the Approved Premises
continually received relevant training on a number of subject matters which
could help support and care for the AP residents. As far as possible, this was
extended to the Craft employees. Staff were extremely knowledgeable about
self harm, drug awareness and resuscitation. This level of information and
support was also on offer to residents to assist their rehabilitation.
70. The man’s involvement with drugs came as a surprise to the AP staff. He did
not show any signs that he was taking drugs and appeared to have settled into
the AP. Staff did not detect that he had taken any drugs when he returned to
the AP on the evening of 2 April and evidence suggests that he took the drugs
later whilst in the AP. When he was discovered collapsed in his room, staff
acted swiftly to try to resuscitate him and call for help.
71. Ms C said that that since the man’s death, they had arranged for staff to attend
a further course about overdose awareness and resuscitation delivered by the
local Ambulance Service. The AP had also started working with two new drugs
agencies. In addition, the AP received regular visits from community drug
workers who were able to provide information and support to residents.
Defibrillator equipment
72. As soon as Ms N was made aware that the man might have misused drugs,
she responded immediately. Along with Mr L, CPR was carried out. The AP
does not have defibrillators on site, and staff are not trained in their use.
73. The Resuscitation Council UK reports that early defibrillation is considered an
important aid to successful resuscitation. The Ombudsman has reported in
previous investigations that many members of the public have been
appropriately trained in the use of defibrillation devices which are available in
the general community.
74. After the death of the man, Divisional Manager Mr P contacted Mr E, Head of
Approved Premises team. He was advised the AP team were considering the
costs and availability of providing defibrillators for all APs. The Head of
Interventions in South Yorkshire, Mr J, has asked the Health and Safety
Manager to undertake a full risk assessment of the deployment of defibrillators
and the recommendation of that assessment is to be considered by the South
Yorkshire Executive Management Team. I make no recommendation here but
draw this report to the attention of the Regional Offender Manager who will wish
to consider buying defibrillators for the APs in his region.
Cordless Telephone
75. The use of a cordless phone is imperative to staff within the AP and can be a
tool which promotes the health and safety of staff and residents. It is of the
utmost importance that such equipment used is effective and fit for purpose. In
this particular case, staff had difficulties relaying information to the emergency
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services. I am pleased to note that they did not let this difficulty negate their
attempts to try and resuscitate the man who died. I am also pleased that, since
the man’s death, following a review of the cordless telephones in use at the AP,
the telephones have been upgraded to improved models.
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CONCLUSION
76. There is no doubt that the man who died was offered considerable support
upon his release from prison from the AP and probation staff, to enable him to
integrate back into the community. He had been drug free for four years and
appeared motivated to continue with his abstinence.
77. During his short stay at the Approved Premises, the man’s behaviour also did
not lead staff to believe that he had started misusing drugs. On his last day at
the AP, he had gone out with two other residents and taken drugs. Whether
this was the result of peer pressure, we will never know. But given his recent
good behaviour, it seems unlikely that he intended to take drugs to end his life.
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