Individual at Lawson House

Investigation into the circumstances surrounding the
death of a man in April 2009,
whilst he was a resident at Lawson House Approved
Premises, in the Devon and Cornwall Probation Area
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2010
This is the report of an investigation into the death of a man. He had lived at Lawson
House Approved Premises in Plymouth for two months when he died on 11 April
2009 of a heroin overdose during a visit to Stafford. He was 28 years old. I extend
my sympathy to his family and friends.
The man was released from prison at the end of his parole expiry date and became
a voluntary resident at the hostel. For the next two months staff helped him manage
his health and look for more permanent accommodation. Throughout that time, the
man was very clear about what help and interventions he would and would not
accept.
The investigation was carried out by my colleagues. I am grateful to the Chief
Officer of Devon and Cornwall Probation Area and her staff for their assistance
during the investigation. Particular thanks go to the manager of Lawson House, for
the help he gave the investigator.
I am satisfied that the probation staff supported the man as far as he would allow
and I am pleased to say that no recommendations are necessary.
Jane Webb
Deputy Prisons and Probation Ombudsman February 2010
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CONTENTS
Summary 4
The investigation process 5
Lawson House 6
Key findings 7
Issues 11
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SUMMARY
The man died on 11 April 2009, aged 28 years. In January 2008, he was sentenced
to 18 months imprisonment. He had been on remand for several months and so was
released on licence on 30 April 2008. He became a resident at Lawson House in
Plymouth before being transferred to Meneghy House in Cambourne, Cornwall.
After several weeks, probation staff recommended that the man should be recalled
to prison after he had acted aggressively after a disagreement with a member of the
public, but he absconded. He was arrested on 17 July and returned to prison.
On 6 February 2009, the man was released on his parole expiry date which meant
that he was not on licence. However, because of his offences, he was considered to
be a risk to the public and was subject to monitoring procedures. Police and
probation staff arranged for the man to return as a voluntary resident at Lawson
House.
The man was very firm from the outset about what interventions he would accept.
He reluctantly accepted appointments with his offender manager (formerly known as
a probation officer) but attended only half of the scheduled meetings. Similarly, he
attended four sessions with his key worker at Lawson House before refusing to
attend any more. He completely refused to work with the Community Forensic
Team, as he thought they were too closely allied to the monitoring process. As the
man was voluntarily staying at Lawson House and voluntarily supervised by an
offender manager, staff had few options when he failed to co-operate.
In line with the policy at Lawson House, the man was regularly treated for drug and
alcohol use. Tests for drugs were all negative but his alcohol readings were higher,
close to the limit for drink driving. On one occasion, the man told his key worker that
he had taken cannabis. Another time he told staff he had taken a legal substance
with effects similar to ecstasy.
After the man walked out of an interview for housing association accommodation, he
refused to look for a place to stay locally. He told staff that he intended to move to
Stafford to share a house with a man he had met in prison. At first, he refused to
give staff the address to enable them to make enquiries. However, he eventually
provided the details and arranged to visit Stafford from 8 to 11 April.
The man was found dead in the bathroom of the Stafford address on 11 April. The
post mortem report gave as the cause of death “heroin poisoning”. His mother
informed the staff at Lawson House and they confirmed the details with the Stafford
Police. The man’s mother later visited Lawson House where she met the staff.
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THE INVESTIGATION PROCESS
1. The man died on 11 April 2009 and the Ombudsman’s office was notified four
days later. The investigator opened the investigation by letter and requested the
man’s records. She visited Lawson House on 11 August when she met the
hostel manager. She interviewed the man’s key worker, was shown round the
hostel and took away further records.
2. One of the Ombudsman’s Family Liaison Officers (FLOs) contacted the man’s
family and gave them the opportunity to raise their concerns. The family
responded to the draft report and their issues addressed.
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PROBATION APPROVED PREMISES
3. Approved premises were formally known as Probation and Bail Hostels. They
provide a supportive, structured environment in the community for high risk and
difficult to manage offenders. The management of the residents is governed by
the National Standards for Supervision of Offenders and the guidance contained
in the National Approved Premises Handbook.
4. The purpose of approved premises is to provide an enhanced level of supervision
for some of the potentially most difficult and high-risk offenders in the community.
They are not principally used as an accommodation resource.
5. Residents have curfews and reporting checks, but they are not expected to
remain in the hostel all the time and, as a result, are not supervised 24 hours a
day as they are in prison. The majority of residents are at the hostel as a
condition of their licence or bail and only a very few will be voluntary residents. In
addition to residing at the hostel, residents also have other conditions they must
adhere to e.g reporting regularly to their offender manager and not changing
address without permission. Voluntary residents are accommodated in hotels to
reduce their risk of re-offending.
Lawson House Approved Premises
6. Lawson House Approved Premises is in Plymouth, which is in the Devon and
Cornwall Probation Area. It currently has the capacity for 19 residents. The
bedrooms are a mix of single and double occupancy, with some having self-
catering facilities.
7. Each resident has a dedicated key worker who holds regular one-to-one
meetings with their residents. They also liaise with other agencies and the
resident’s offender manager to monitor and facilitate the resident’s reintegration
back into the community and to address their specific needs.
8. Lawson House is staffed 24 hours a day with a minimum requirement for two staff
to be on duty at all times. The generic curfew time when residents have to be in
the hostel at night is from 11.00pm to 6.00am, although this can be extended
when required.
9. Residents’ medication is securely stored within the office. It is handed to
residents by staff according to the medication instructions. Each resident has a
drug dispensing chart which a member of staff signs when the medication is
dispensed. The approved premises has a contract with a local doctor to whom all
residents have access. The doctor sees all new residents and holds a ‘surgery’
in the hostel every Thursday for those who need to see him.
10. Residents are expected to adhere to hostel rules. One of these is to comply with
alcohol and drug tests. They must also attend the residents’ meeting every
Thursday morning. After the meeting finishes, the doctor holds his surgery.
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KEY FINDINGS
11. In January 2008, the man was sentenced to 18 months imprisonment for a
number of offences. Because of their nature, he was monitored under Multi-
Agency Public Protection Arrangements (MAPPA), which support the
assessment and management of the most serious sexual and violent offenders.
Being in supervised accommodation was a central part of the arrangements. As
he had been in custody on remand since summer 2007, he served four months
before being eligible for release on licence.
12. The man was released on licence on 30 April 2008. It was a condition of his
licence that he should live at Lawson House Approved Premises in Plymouth. He
transferred to Meneghy House in Cambourne, Cornwall on 23 June. He told staff
there that he preferred Lawson House and asked to return to Plymouth but he
remained at Meneghy House. On 9 July 2008, after he had an argument at a
local gym, staff decided that he should be recalled to prison. However, he
absconded when the police arrived to take him into custody. He remained at
large until 17 July, when he was arrested and taken to HMP Channings Wood.
13. Having been recalled to prison, the man had to remain in custody until the end of
his sentence on 6 February 2009. This meant that he would be released without
being under the supervision of an offender manager. The MAPPA panel were
concerned that he continued to present a high risk to members of the public.
They discussed ways to reduced the risk at meetings on 13 and 29 January. As
a result, the manager of Lawson House agreed to accept the man back, but this
time as a voluntary resident. An offender manager was appointed but the
contact was also voluntary as the man was no longer on licence.
14. As agreed, when the man’s prison sentence expired on 6 February 2009, he
transferred to Lawson House. On his arrival, a member of staff interviewed him
as part of the induction process and the man signed the resident’s compact. He
also gave his medication to the staff, as required by the rules. He was prescribed
medication for depression by a local doctor and he was signed off sick from work.
His medication was:
(cid:127) citalopram, an antidepressant drug used to treat major depression
(cid:127) chlorpromazine, used to treat some types of mental illness
(cid:127) salbutamol, used to treat asthma and breathing difficulties
(cid:127) Clenil Modulate, an inhaler for asthma
(cid:127) Oxytetracycline, an antibiotic used to treat bacterial infections.
15. During the man’s second stay at Lawson House, staff had to remind him to take
his medication. When he did not collect his medication and sign the record
sheet, the next time a member of staff saw him, they would remind him to take it.
He would then go to the office to collect his missed medication.
16. A member of staff asked the man to agree to keep an appointment with a
member of the Community Forensic Team. (Community Forensic Teams provide
community mental health services for people with mental illness who pose a risk
to the public.) The man was unhappy at being asked to do this and refused to
cooperate. He was also unhappy with the person who was his offender manager
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and did not want keep the appointment arranged with her on 12 February. The
man said that he would speak to the manager of the approved premises, about
being assigned to a different offender manager.
17. One of the assistant wardens, was appointed as the man’s key worker. They met
regularly for formal meetings when they discussed his activities and agreed goals
in the major areas of his life.
18. The man’s first key working session with was on 11 February. The main issues
that they discussed were how to claim Disability Living Allowance and what
accommodation would be available when he moved out of Lawson House. The
key worker explained the process of applying to a housing association, which
offers three levels of supported accommodation to prepare residents to move into
independent housing. He wrote in his notes afterwards that the man was very
eager to begin the application process. However, the man also said that one of
his former cellmates in prison had offered him shared accommodation in Stafford.
He then refused to give any further details.
19. At the next session on 22 February, benefits and housing were again top of the
agenda. The man had been in contact with the Department of Work and
Pensions (DWP) who said that he would be given income supplement. The key
worker then explained the work of a local organisation that provided supported
housing. Again, the man appeared very keen to move into independent
accommodation. He was taking his medication regularly, although he had no
contact with the Community Forensic Team.
20. The key worker frequently tested the man for drugs and alcohol use. The man’s
alcohol level was mostly close to the legal limit for driving but on one occasion it
was well above the limit. The drugs tests were always negative. However, at the
meeting on 2 March, the man said that he had recently used cannabis. He and
the key worker then discussed why he should not do so again. The key worker
noted in the contact log, “not motivated to be abstinent from cannabis.”
21. The man told the key worker that he would receive his benefits the following day.
The key worker told him that he had to attend an interview to assess his
suitability to move into one of the housing association’s properties. Three days
later, the man attended the appointment but the interview did not go well. During
a discussion about his previous convictions, he felt that one of the association’s
staff was “interrogating” rather than interviewing him and he walked out. The key
worker liaised with the association staff and asked them to consider setting up
another interview. However, at that point, the man decided that he would move
to “the Birmingham area” to stay with a friend that he had met in prison. He again
refused to give any further details.
22. On 10 March, the man was arrested and charged with criminal damage. The
police officer who telephoned Lawson House, said that he was “very drunk”.
Staff then informed the Assistant Chief Probation Officer of this fact but, as the
man was a voluntary resident, no further action was taken.
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23. The man went to what was to be his final session with his key worker on 13
March. They discussed the overnight home visit that the man had arranged for
the following two days. They discussed the arrangements and the family birthday
celebration that he would attend. The key worker recorded in the computerised
record system that he “… strongly reinforced the need to refrain from excess
alcohol use and total abstinence from drugs”.
24. The man returned from the visit at 8.00pm on 15 March. He told the staff that he
had gone to a club the previous night and had consumed a lot of alcohol but
there had been no problems. He also said that he had bought “Mind Candy” pills
that claimed to produce effects similar to ecstasy but were legal. When staff
checked the back of the packet, the information stated that it was plant food and
one of the ingredients was Ketones (organic compounds that are used in
industry).
25. Two days later, the man told his key worker that he did not want to have any
further contact with officials involved in MAPPA arrangements. By this date, he
had missed three appointments with his offender manager and attended one.
However, he met his offender manager on 17 March. She described it in her
note of the meeting as “not the most constructive session”. The man was
adamant that he would have nothing to do with anyone involved in the MAPPA
process. He told her to cancel all his appointments and said that he would not
“do any programmes” (meaning offending behaviour programmes run by
probation staff).
26. The man went on to explain his plans for the future:
“He said that he is going to use Lawson House to save up £95 and
then he is going to move to Stafford. He states that he has a ‘mate’
there who can offer him a room in a shared house, and he is going to
get away from Plymouth and Cornwall as soon as he can.”
27. The offender manager told the man that the MAPPA arrangements would remain
in place until his risk to the public was reduced. She noted his reply as, “He
doesn’t care – he wants ‘them’ to know that any decision ’they’ make then he will
un-make.”
28. On 23 March, the key worker and offender manager discussed the man. Their
concern was where he would go when he moved out of the hostel. His plan was
to move to the Midlands but not if his address had to be checked. He also said
that he was considering staying in Plymouth as he liked the city. They decided to
stress to the man that he would soon have to leave the hostel and that his
accommodation had to be confirmed before then. Also, he needed to provide the
address in the Midlands.
29. The man asked for, and received, permission to attend another family event and
return to the hostel after the 11.00pm curfew. On 31 March, he and his key
worker discussed the arrangements, including the approximate time he would
return to the hostel. He then asked to visit Stafford from 7 to 9 April and he gave
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the address of the house he intended to visit. However, when staff checked the
address, they were told it did not exist.
30. The following day, the man attended an appointment with the offender manager.
When told that staff could not trace the address, he telephoned the man who
lived there and obtained the full address, including the postcode. The man and
another member of the probation staff started to complete the paperwork for the
move.
31. As the man could not get the train fare he wanted, he changed the dates of his
visit to Stafford to 8 to11 April. He met with the key worker on 6 April to confirm
the details of his trip. The key worker made the following entry in his notes:
“Unfortunately at this time, he is exhibiting signs of Paranoid
schizophrenia and is convinced that the people in the streets of
Plymouth are talking about him. He was instructed to maintain his
medication, to which he agreed. He was asked to minimise his alcohol
consumption, which he refused.”
32. The man again refused to have any dealings with the Community Forensic Team,
as they were part of the MAPPA process. The key worker discussed the
necessity of being careful in Stafford, especially as he did not know all the
residents of the house. The man agreed to be careful.
33. The man travelled to Stafford on 8 April as planned. During the morning, he rang
staff at Lawson House. They felt that he was in “A paranoid state”, so they
informed the offender manager. She then spoke to the man who said that he
was “having a nice day”. He told her that two women had been to the house
where he was going to stay and had asked for him. He asked her who they were,
to which she replied that she had not asked anyone to call. The man said he was
not going to worry about it but was going to “enjoy my holiday”.
34. On 11 April, the man was found dead at the house in Stafford. He was
discovered in the bathroom after other residents broke open the door. A needle
was lying nearby and the post mortem report concluded that his death was due to
“Heroin poisoning”. Police broke the news to his mother and she then informed
the hostel staff. The hostel staff passed on their condolences to the family. The
man’s mother later visited Lawson House to meet the staff and collect her son’s
possessions.
10
ISSUES
Staff contact with the man
35. Although the man was not on licence when he was released from prison on the
second occasion, he was monitored through the MAPPA process. Police and
probation staff met with him to check on his activities and to offer him help to
move into the community. He was unhappy about much of this monitoring and
did not always co-operate. He attended only half his appointments with his
offender manager. He met his key worker four times and then refused to have
any further sessions. He always rejected attempts to work with the Community
Forensic Team. When his key worker asked him to consider reducing the
amount of alcohol he was drinking, he refused. The man had to be reminded on
occasion to take his prescribed medication and had several discussions with his
key worker about the possible effects of alcohol on his medication.
36. Staff tried to help the man find accommodation to move into when he had to
leave Lawson House. At first, he accepted help with arranging an interview with
staff from a housing association. However, after he felt he was being
interrogated rather than interviewed, he walked out and refused to carry on with
the application. Instead, he planned to move to Stafford to share a house with a
man he had met in prison. One of the last conversations the man had with staff
at Lawson House concerned the need to be careful when he visited Stafford.
37. However, because the man was not on licence, staff could only persuade and
could not compel him to conform. He was very firm about how far he would co-
operate and with whom. I consider that the probation staff did all they could to
advise and support him.
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CONCLUSION
38. The man was released from prison and became a voluntary resident at Lawson
House. He was voluntarily supervised by his offender manager. However, he
made his own decisions and plans for the future. His wish to move to Stafford
illustrated this very clearly. Sadly, whilst on a visit to the house where he hoped
to settle, he was found dead on the day he was due to return to Plymouth. I am
satisfied that probation staff warned him of the risks of using illegal drugs but,
nevertheless, his death was found to be due to a heroin overdose. I believe that
his death was unexpected. I have found no evidence to suggest that it could
have been prevented and no recommendations are necessary.
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