Individual at Sycamore Lodge

Investigation into the circumstances surrounding the
death of a man at Sycamore Lodge Approved
Premises in the West Midlands Probation Area in
December 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2009
This is a report into the circumstances surrounding the death of a man. He
was a resident at Sycamore Lodge Approved Premises in the West Midlands
Probation Area and had been there for two months before he died. He was
31 years old. Although it seemed initially that he died of natural causes, the
post mortem revealed that this was not the case and his death was due to a
number of factors, including the inhaling butane.
I would like to offer my sincere condolences to the man’s family on their loss.
I must apologise for the delay in issuing this report. This was due in part to
work pressures within the Ombudsman’s office, but also because of a delay in
obtaining the clinical review which was received in this office on 26 August.
The investigation was undertaken by one of the Ombudsman’s investigators.
She and I would like to thank the manager of Sycamore Lodge and his staff
for their co-operation during this investigation. A clinical reviewer was
identified by the local Primary Care Trust to undertake a review of the man’s
clinical care whilst at Sycamore Lodge. I would like to thank him for his
helpful review.
It is clear that the man had some ongoing health problems when he arrived at
Sycamore Lodge, in particular back trouble. He took medication for the pain.
Staff were aware of this, and also his history of previously harming himself so
they decided to monitor him every four hours when he was in the building.
This is commendable. However, the standard and level of checks were less
satisfactory. I make three recommendations to the manager at Sycamore
Lodge. One relates to the standard of checks on residents, the second to first
aid and the last concerns the inclusion of information in resident’s induction
packs.
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 residents
involved in my investigation.
Jane Webb
Deputy Ombudsman October 2009
2
CONTENTS
Summary
The Investigation Process
Sycamore Lodge
Key Findings
Issues
Conclusion
Recommendations
3
SUMMARY
The man was discovered in his room at Sycamore Lodge Approved Premises
at approximately 4.40pm in December 2008. Staff were making one of their
regular four-hourly checks, because they had concerns about previous
attempts to harm himself and the distress he was suffering due to back pain.
He had arrived at Sycamore Lodge on 10 October 2008 after being released
on licence from HMP Stocken. He underwent a thorough induction and, after
a restless first night, appeared to settle in well. He adopted a routine of
regularly working at his family’s business and attending meetings with his
probation officer and key worker. He seemed to be planning for the future,
addressing his past problems and looking forward to a new start after he left
Sycamore Lodge. However, his back pain continued to get worse and the
medication he was prescribed for this did not seem to help. This appeared to
have a devastating effect on him.
On the day the man died, staff recalled seeing him in the morning at about
8.30am. At 12.30pm he was checked in his room by a member of staff, as
part of the routine four-hourly check. The staff member said she knocked on
his door but, as she received no response, used a master key to open the
door. She saw him lying on his back on the bed, but noted nothing out of the
ordinary and thought he was asleep.
The next check was at 4.30pm. The same member of staff again knocked on
his door, received no reply and let herself into the room. This time she
noticed that he appeared to have had a nosebleed. She turned on the light
and immediately thought that he had died. She did not check for signs of life,
but called for immediate assistance. The second member of staff (who did
not make any checks either) also thought that he had died and telephoned for
the police and an ambulance to attend.
I make three recommendations. They concern the level and quality of checks
carried out by staff for vulnerable residents and the need to check for signs of
life when faced with a situation like this. A third recommendation concerns
additional helpful information which could be included in the residents’
induction pack.
4
THE INVESTIGATION PROCESS
1. The investigation was conducted by a senior investigator. I am grateful
for the assistance she received from the manager and staff at
Sycamore Lodge who fully participated in this investigation.
2. The investigator first visited Sycamore Lodge on 22 December when
she collected all the available documentation and had a tour of the
premises. She returned on 6 March 2009 to conduct recorded
interviews with staff. None of the residents came forward with any
additional information regarding the man. She also interviewed the
man’s probation officer on 3 April.
3. The Assistant Director of Corporate Governance at the local Primary
Care Trust (PCT) identified a clinical reviewer to carry out a clinical
review. He was assisted by two colleagues. I am grateful to him and
his colleagues for their thorough and helpful review which was received
on 26 August.
4. One of the Ombudsman’s Family Liaison Officers (FLO) was assigned
to this case. She contacted the man’s family on 7 April 2009 to explain
the role of the Ombudsman and offer a visit from the investigator. They
did not raise any questions at the time. A copy of my report will be sent
to the family.
5
SYCAMORE LODGE
1. Approved premises (formally known as probation and bail hostels) are
approved by the Secretary of State to accommodate sentenced
offenders and those directed to live there by the courts as a condition
of bail, or following release from prison. The purpose is to provide an
enhanced level of residential supervision in the community, as well as
a supportive and structured environment.
2. Sycamore Lodge is one of 101 Approved Premises in England and
Wales and it accommodates 32 residents. The residents are either on
licence from prison or have been directed to reside at Sycamore Lodge
as part of their bail conditions.
3. There are 32 bedrooms, a communal kitchen and a television room.
During the day it is staffed by a senior probation officer (the manager),
a probation officer (deputy manager), two probation service officers
and administration staff. During the night a probation service officer
stays at Sycamore Lodge with a night officer. There is also a duty
manager on call. All staff carry personal alarms for emergency
situations.
4. Each resident is allocated a key worker soon after arrival, and this
member of staff acts as the primary contact for helping to resolve
practical issues such as accommodation. Regular key work sessions
give residents the opportunity to discuss their difficulties in depth. An
offender manager from the local probation area supervises the
resident. The key worker and the offender manager work closely
together to ensure the resident has a resettlement plan and that the
resident behaves appropriately whilst at the approved premises.
5. On arrival, the resident is interviewed by their key worker. They are
given information about rules, procedures and expectations during an
induction. Details of next of kin, personal information and medical
information are recorded and a compact is agreed setting out the
standards of behaviour expected of residents.
6. All residents are offered the opportunity to register with the local
doctor’s surgery. Sycamore Lodge has an arrangement with the
surgery to enable all new residents without a doctor of their own to
register during their stay. The relationship between the doctor and the
resident is a confidential one, and the approved premises is not
responsible for a resident’s healthcare. All medication prescribed by a
doctor must be handed in to staff, where each item is logged and
stored safely. Medication is given to residents at appropriate times and
this is noted by staff.
7. All staff at Sycamore Lodge are trained in first aid and attend a
refresher course every two years. Staff receive other training including
6
risk assessing, health and safety and self harm and mental health
awareness.
8. Staff at Sycamore Lodge have the authority to search residents’ rooms
at any time if they have cause to suspect a breach of hostel rules or
that a resident has been involved in criminal activity. Hostel rules
include the requirement to follow the hostel’s financial regulations and
for residents to pay on time for their stay there. Other rules include
giving all prescribed medication to staff and to take medication as
prescribed by the doctor, participate in the hostel programme as
instructed, including meetings and key working sessions and not to
bring onto the premises or have in possession any weapons,
dangerous items, alcohol, solvents, illegal drugs or drugs
paraphernalia.
9. Staff screen all residents when they arrive for signs that they may harm
themselves. The manager or his deputy then decide whether a resident
should be placed on monitoring arrangements and the frequency of the
monitoring, which can range from every 15 minutes to four hours. The
frequency can be adjusted and a review takes place daily. The
purpose of the monitoring is to check on the residents’ physical well-
being and to look for any changes in mood, behaviour or
circumstances. The observations are recorded in handover sheets so
that all staff are aware of the situation.
7
KEY FINDINGS
10. The man was born in February 1977 and was 31 years old when he
died. He had two brothers who he kept in contact with, along with his
mother and father. He had a partner and one child.
11. He was sentenced to six years and six months imprisonment at Crown
Court in May 2004. He was initially transferred to HMP Blakenhurst.
He then moved to HMP Ashwell in December 2005, HMP Featherstone
in 2006, HMP Dovegate, HMP Stafford and finally to HMP Stocken in
2007, where he stayed until October 2008.
12. Throughout his time in prison custody, the man experienced medical
and psychiatric problems. In 2006 he was referred by Featherstone to
be assessed by a Community Mental Health Nurse who was part of the
prison’s In-Reach Community Team. She noted that whilst at
Blakenhurst, he had been assessed by a Consultant Forensic
Psychiatrist who diagnosed “impulsive anti-social personality disorder”
(a type of personality disorder), but said that he was not suffering from
any mental illness at that time.
13. The man told the nurse that he began harming himself at around the
age of 15, and would cut his arms, hands and legs. He said this was to
relieve stress and anxiety rather than a real attempt to take his own life.
Records show that he was treated at hospital in Wolverhampton on 9
October 2006 as he had cut his chest and needed stitches. He
attended again four months later as he had lacerated his abdomen and
thumb and then swallowed the blade. There were several other
instances of self harm during his time at Featherstone, but no acts
reported after February 2007.
14. Most recently in 2008, medical records from Stocken show that the
man was known to the mental health team there and diagnosed with a
personality disorder. He was prescribed venlafaxine (an anti-
depressant) and olanzapine (an anti-psychotic) which he took every
day. This medication appeared to stabilise his mood and behaviour.
The prescription chart from Stocken shows that, from September to
October 2008, he was prescribed tramadol (a pain killer), venlafaxine,
olanzapine and diclofenac (an anti-inflammatory drug).
15. The doctor at Stocken expressed concern about the high volume of
prescriptions issued to the man for tramadol. (He was involved in a
road traffic accident in 2002, and subsequently suffered from back and
buttock pain.) The doctor noted that the dosages of tramadol had been
consistently raised in response to his demands. The doctor also noted
that the man needed a review of his back problems and, that as he was
due for release on licence shortly, he should discuss this with his
community doctor.
8
16. Before the man arrived at Sycamore Lodge, West Midlands probation
faxed an accommodation referral form to the hostel on 8 September.
This form gave details about him and his offence. It said that he would
be homeless on his release from the hostel, as the offence for which he
was convicted occurred outside his proposed release address, and
was deemed unsuitable.
17. The form also gave details of the man’s referral plan. The plan
included management of his risk to the community and his drug use,
build on support from family members, resolve his employment
difficulties and address his thinking and behaviour. It was also planned
to manage his depression with a referral to a community psychiatrist
nurse (CPN).
18. The probation form also contained a section entitled “Health Issues”.
This indicated that the man had a history of harming himself, but had
undergone counselling and felt that the risk of harming himself in the
future was minimal. He said that he suffered with seasonal depression
which worsened in winter months and would take medication at the
start of winter to help with this condition.
19. A copy of Sycamore Lodge’s rules was faxed to the man at Stocken,
which he signed on 16 September 2008. The rules included a curfew
7.00pm until 7.00am every day.
20. On 10 October, he was released on licence to reside at Sycamore
Lodge. His licence was due to expire on 16 May 2009. The licence
required that he report immediately to a probation officer at Unity
House, keep in touch with the supervising officer there, permanently
reside at Sycamore Lodge and undertake work approved by the
supervising officer.
21. An induction was given to the man on 10 October. The induction
document confirmed that he was shown around, “settled down”, had
talked about any anxieties relating to his release from prison and told
that if he experienced any difficulties he should speak to staff. He said
he felt “ok” and did not feel the need to speak to a manager at that
point.
22. The induction also included a discussion about his general health. He
told the hostel worker that he was prescribed diclofennac sodium,
olanazipine, venlafaxine and tramadol. He also said that he had a
personality disorder, anxiety, depression and a history of substance
abuse (heroin and cannabis). He said that he had a history of harming
himself by cutting and burning, and had been prescribed medication to
address this.
23. The hostel keeps a ‘Record of Contact’ which details contacts with
residents. On 11 October, it was noted that the man woke up late as
he had felt unsettled the night before. He had lunch and met his family
9
who took him shopping for clothes. He returned to Sycamore Lodge in
the early evening.
24. The next day it was noted that he had taken his medication and went
out in the afternoon. He returned to the hostel in the evening. It was
reported that he had “no issues”.
25. On 13 October, the man’s probation officer visited him at Sycamore
Lodge. She wanted to know whether he would be able to collect his
medication. He told her that he had a doctor’s appointment the next
day.
26. He went to the doctor’s appointment on 14 October and was prescribed
medication for depression. This information was e-mailed to his
probation officer.
27. The man’s key worker carried out a risk assessment on 15 October.
She assessed that his risk of harming himself was “medium” and his
risk of re-offending was “medium”. The factors which might increase
the risk were failure to comply with licence conditions or hostel rules,
depression, contact with past associates, relapse into illegal drug use,
lack of family support and boredom. A further review was scheduled
for no later than 15 January 2009.
28. The key worker agreed an action plan with him after the assessment.
This looked at ways in which any risk factors could be reduced by
addressing problems such as drug misuse and his emotional well
being. His drug risk was not seen to be an immediate problem, as he
had addressed this while attending and completing drug programmes
whilst in prison custody.
29. Given that the man had spoken about his previous attempts to harm
himself, the key worker and another member of staff decided that he
should be subject to a four-hourly watch. This meant he would be
checked at four-hourly intervals throughout the day and night.
30. The next day he had another doctor’s appointment as he required
cream for a skin complaint.
31. On 17 October, the man arranged a doctor’s appointment as he had a
pain in his hip. He asked for a three pound loan for his bus fare to
enable him to collect an £80 crisis loan. This was authorised on the
understanding that he returned the money later that day, once he had
received his crisis loan.
32. Later that day he returned to Sycamore Lodge and staff noticed that he
smelt of alcohol. He took his medication in front of staff and then
returned to his room. Later, another resident complained that the man
had been sick in the toilet on the landing, and had not cleaned up after
10
himself. Staff asked the man to clean it up, which he did. The four-
hourly observations continued.
33. Two days later, he started work in the family business. He left for work
every morning and continued taking his medication. The four-hourly
checks continued when he was in the hostel.
34. On 26 October, the man took his medication as usual in the morning,
but told staff he was in a lot of pain as his hip was hurting. He said he
had an appointment at the hospital the following day for a scan. Later
that day he told staff he had received a telephone call from his mother
to say that his aunt had passed away. He told staff he was “ok”.
35. The next day staff noticed that he was limping. He took his medication
as usual and said he was going to the hospital for an x-ray. There is
no mention of the outcome of the x-ray in the hostel’s records, although
residents are entitled to keep such information confidential. For the
next few days he continued to go to work, took his medication at the
required time and still complained about his “bad hip”. He continued to
be checked every four hours in case he was at risk of harming himself.
36. On 4 November, whilst taking his medication in the morning, the man
said he was in too much pain to go to work. He went back to bed and
staff continued to check on him. Later that day he took some
painkillers for his hip and left the hostel for most of the day.
37. Nine days later, he told staff at the hostel that he had been mugged by
two men in an alley way in West Bromwich. He said they had
threatened him with a knife. He reported the crime to police and said
that they had stolen £35 and his mobile telephone. However, he did
not stay to make a statement to the police (the police visited Sycamore
Lodge the next day to take a statement). He told staff that he would
not be going to work from the next day, as the family business was in
difficulty and the shop might have to close.
38. The man went to the doctor on 18 November. He returned to the
hostel with his medication, cocodamol (a pain killer) and venlafaxine.
39. Three days later, staff noted that he was sleeping on the floor because
of his bad back. He asked for a thinner mattress, but there is no record
of whether this was supplied or not. On 27 November he asked for a
board to be placed under his mattress and agreed to speak to the
hostel manager about it the next day. He had continued to sleep on
the floor. (It seems from the records that this issue was resolved by 6
December, when he was seen sleeping on a board.)
40. On 4 December, the man was given a verbal warning for being
disruptive and behaving unacceptably the night before, as he was
smoking in the television room. It was noted that he had been under
11
the influence of alcohol. There is nothing else of note in the hostel
records after 4 December.
41. The supervisor at Sycamore Lodge was employed at the hostel when
the man was there. She knew that he had a personality disorder, no
longer took drugs but drank alcohol, and took gabapentin (a pain killer),
venlafaxtine, olanzapine and tramadol. She confirmed that he had
been observed every four hours because of his depression and his
back pain. She came on duty at 7.30am on the morning of 14
December and recalled seeing him at around 8.30am. She said he
looked “fit and well”.
42. The supervisor carried out a check (as part of the four-hourly
observations) on the man in his room at 12.30pm. She knocked on his
door and as there was no answer, let herself in with a master key. She
said that he seemed “ok” and appeared to be sleeping on his back.
She closed the door and locked it. (During her interview for this
investigation, she confirmed that it is not practice to wake up a resident
during a check.) She did not see him until her next check at 4.30pm.
43. At 4.30pm, she returned to his room to make the next check. Again
she knocked on the door, and again had no answer. When she went
into his room she saw that he was still lying on his back in bed. She
could see something which looked like blood, coming from his nose.
She turned on the light and could see a white substance around his
mouth. She then touched his arm which felt cold. She had completed
a first aid training course the day before. She did not carry out any
checks for signs of life, as she thought he had already died. She
immediately pressed her personal alarm to summon assistance and left
the room.
44. Another member of staff was alerted to the emergency when his pager
went off. He ran upstairs and saw the supervisor standing outside the
man’s room. He asked what had happened and she said “I think he is
dead”. The member of staff went into the room. He saw that the man’s
eyes were half closed, that he had some sort of liquid in his mouth and
his nose, and was very still. The member of staff said he did not touch
him or check for any signs of life, as he could tell from experience that
he had died. He confirmed in interview that he had an up to date first
aid qualification.
45. The member of staff ran back downstairs to the office where he
telephoned for an emergency ambulance and the police. After that he
telephoned the hostel’s deputy manager who was on call that day. The
deputy manager spoke very briefly to the member of staff and said he
would come to the hostel immediately. The member of staff also called
the hostel manager and left a message for him.
46. The paramedics arrived within five minutes and the member of staff
took them straight to the man’s room. He went into the room with them
12
and saw them make some checks for signs of life, including pulse and
breathing. Within a minute they confirmed that he had died. The
member of staff then left the paramedics in the room and returned to
the office.
47. Within another five minutes the police arrived and the member of staff
took them to join the paramedics in the man’s room. They told him that
he did not need to stay as the member of staff said his colleague (the
supervisor) needed his support.
48. When the deputy manager arrived shortly afterwards he spoke to the
police and the paramedics. He then checked on the supervisor and
member of staff and the residents to see how they were feeling. He
said that both staff members were shaken, particularly the supervisor,
who he drove home. When he arrived back at the hostel the manager
had arrived.
49. The manager also spoke to the police and paramedics and also
checked on the welfare of staff and other residents. He reminded them
of the services of the Employee Assistance Programme (EAP) which
gives the opportunity for staff to speak in confidence about what had
happened. He also spoke to those residents who were in the hostel at
the time to tell them what had happened. (Those he did not see, he
spoke to the next day.) He told the residents that they could also
speak to someone at the EAP if they wished, or alternatively they could
talk to a member of staff. He also contacted his manager in the
Probation Service and the Ombudsman’s office.
50. A post mortem was conducted on 16 December by a consultant
pathologist. He was informed by the police that an empty butane gas
canister was found beside the man. (The staff at Sycamore Lodge had
not been aware of this, or reported seeing it.) The investigator was
also unaware of the presence of the canister until she received a copy
of the post mortem. The toxicology report noted that his blood and
urine specimens detected morphine-glucuronide metabolites (morphine
or heroin), olanzapine, venlafaxine, tramadol and methadone. The
concentrations of morphine-glucuronide metabolites were consistent
with previous, rather than recent, use and did not indicate recent
excessive use or an overdose prior to death.
51. The low concentrations of olanzapine and venlafaxine found in the
man’s blood were consistent with the therapeutic dosage prescribed for
depression and did not indicate that he had taken an overdose.
However, the concentrations of tramadol were consistent with relatively
recent and excessive use.
52. The consultant pathologist determined that the levels of methadone
found in the man’s blood could have been consistent with either acute
over dosage or chronic therapeutic dosage. However, the additional
presence of the high concentration of tramadol in the blood could have
13
exacerbated any toxic effects resulting from methadone use, such as
respiratory depression (decreased rate of breathing).
53. Therefore the consultant pathologist concluded that, in the absence of
any other pathological findings, fatal opiod toxicity (a fatal amount of
opiates in the body) is a possibility. The cause of death was due to
acute cardio-respiratory depression (respiratory inhibition caused by
opiates), acute over dosage of methadone and tramadol and butane
gas inhalation, multiple drugs abuse and bronchopneumonia. He
concluded that the man’s death was not due to natural causes.
54. The police told the man’s family about his death and despite enquiries
made to the police, no further information was given to staff at
Sycamore Lodge about his funeral arrangements, or any concerns the
family may have had. His property was taken from the hostel by the
police (and presumably returned to his family).
14
ISSUES
Monitoring risk of suicide and self harm
55. It is commendable that staff at Sycamore Lodge identified that the man
needed closer supervision due to his back pain, which he found almost
unbearable, and history of harming himself. A record was made of
these checks and a review of the frequency of the checks made every
day. However, although he was checked on in his room at 12.30pm on
the day he died, I am not convinced that more than a cursory check
was made. In my opinion, without a closer check, it would have been
difficult to be satisfied that he was merely sleeping. I understand that it
is not practical to waken residents during checks (especially the more
frequent ones), but I would suggest that when checks are undertaken,
a closer inspection is carried out. Without doing this, staff cannot be
certain that a resident has not harmed themselves, which negates the
purpose of the checks. Also, staff did not notice the butane gas
canister which was lying by the man and they were not aware of this
until the investigator told them. (The canister had been removed by the
police.)
When staff are checking residents, they should be unobtrusive,
but make sure that they have properly assessed the residents well
being.
Checking for signs of life
56. Neither the member of staff who found the man, nor the second
member of staff who came to help, checked for signs of life, despite
being first aid trained. Both said they thought he had clearly died, and
had been dead for some time. Although this does seem likely, I would
strongly suggest that in situations such as these it is essential that staff
make the appropriate checks to clearly assess a resident’s well being.
Staff should be reminded to carry out appropriate first aid
procedures, in particular to check for signs of life, when faced
with an emergency situation such as this.
Samaritans details
57. The manager confirmed that although details of the Samaritans were
not included in the residents’ information packs, if they had wanted to
speak to them he could have facilitated this. It would be helpful if
details, such as Samaritans contact numbers, are included in the
induction booklet for residents. I understand that residents are told that
they can speak to staff and ask for the telephone numbers if they need
to, but some residents may not feel they want to ask.
Contact details for the Samaritans and other similar organisations
should be included in the residents’ induction booklet.
15
16
CONCLUSION
58. During his short time at Sycamore Lodge, I believe that staff paid
attention to the man’s needs and the difficulties that he encountered.
Appropriate meetings and contact were made and maintained with his
probation officer and key worker. He appeared to have adjusted to
living there and was making good progress with work and plans for his
future.
59. As the man’s back condition appeared to become progressively worse,
staff tried to help, for example by providing him with a board to place
under his mattress. He took medication for his condition, and staff
were aware that he was taking this correctly.
60. Because of his back pain and because of his previous attempts to
harm himself it was decided that, while he was in the hostel, he should
be checked every four hours. This was appropriate and good practice.
However, whilst the checks were recorded appropriately and reviews
undertaken daily, the checks were apparently superficial and cursory.
Whilst understanding that it would be too intrusive to awake a resident,
a more thorough check should have been made.
61. The man was not known to have abused butane previously, and so the
circumstances of his death came as a shock to staff at Sycamore
Lodge.
17
RECOMMENDATIONS
1. When staff are checking residents, they should be unobtrusive, but
make sure that they have properly assessed the residents well being.
2. Staff should be reminded to carry out appropriate first aid procedures,
in particular to check for signs of life, when faced with an emergency
situation such as this.
3. Contact details for the Samaritans and other similar organisations
should be included in the residents’ induction booklet.
18