Individual at Town Moor

Investigation into the circumstances surrounding the
death of a man in February 2007 at Town Moor Approved
Premises in the South Yorkshire Probation Area
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2007
This is the report of an investigation into the circumstances surrounding the death of
a man. The man died aged 33 in February 2007 in Town Moor Approved Premises,
South Yorkshire. He was found dead in his bed by the hostel manager after his staff
told him that the man had not taken his medication the night before. The initial post
mortem report could find no apparent cause of death, but the results of a subsequent
toxicology examination showed the fatal use of illicit heroin.
I would like to offer my condolences to the man’s family. He was a young man with a
past troubled by drug and alcohol abuse. He had begun to address these problems
before he died, and hostel staff and drug intervention programme workers were
pleased with his attitude and progress. In the two weeks he resided at Town Moor,
he had also enjoyed seeing his family and working on a church allotment.
The investigation was led by one of my investigators. One of my Family Liaison
Officers contacted the man’s family to explain the investigation process and to ask
whether they had any specific questions about the circumstances of his death.
I am grateful to the manager, staff and residents of Town Moor for their co-operation
with this investigation. I am also grateful for the assistance of a seconded probation
officer from HMP Doncaster, and to the man’s home probation officer and the two
drug intervention workers who worked with him on his release from prison.
The Probation Service in South Yorkshire emerges well from this investigation.
I have made a single recommendation and the text of my report draws attention to an
example of good practice.
This version of my report, published on my website, has been amended to remove
the name of the man who died and those of staff and residents involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2007
2
CONTENTS
Summary
The investigation process
Town Moor Approved Premises
The events leading up to the man’s death
- From 20 March 2005 to 7 February 2007
- From 8 February to 22 February 2007
- The response to The man’s death
What staff and residents said
Issues considered during the investigation
Conclusion and recommendation
3
SUMMARY
The man was 33 years old when he died. His life was troubled by addictions to
alcohol and drugs and these led him into a pattern of offending. His first conviction
was at age 17, and he spent several short periods in prison between 1998 and 2004.
The man suffered from drug induced psychosis and needed regular medication to
control violent outbursts.
In March 2005, the man was convicted of Assault Occasioning Actual Bodily Harm
and sentenced to 27 months in prison. He served his sentence at HMP Doncaster.
On 23 June 2006, the man was released on licence to a residential and
rehabilitative care unit with 24 hour supervision from qualified mental health
professionals.
On 4 October 2006, the man was recalled from his period on licence after he
persistently made threatening and racist remarks to members of staff. He was also
accused of bullying other residents and refused to take his medication on some
occasions. He was returned to Doncaster prison.
On 24 November 2006 a Parole Board review panel concluded that the man’s recall
to prison had been appropriate and that he should be released at his licence expiry
date, 8 February 2007, subject to a satisfactory release address.
The man was released to Town Moor Approved Premises on 8 February 2007.
Included in his licence conditions were stipulations that he must address his drug
and alcohol problems and take his medication every day.
On his release, the man engaged with drug intervention programme (DIP) workers
in Doncaster. He attended his appointment with Doncaster Alcohol Services (DAS)
and met as required with his offender manager (probation officer) and his keyworker.
He contacted social services and saw a GP to obtain further medication. He took his
medication every day until the night before he died. He saw his family and began
work on a church allotment project which he enjoyed very much.
The man tested positive for heroin and crack cocaine at a routine drug test on 13
February. He admitted to taking the drugs the day after his release and said that it
was a “one off”. It was decided not to recall him from licence. He tested negative at
a further test on 20 February. Staff at Town Moor, his offender manager and the DIP
workers were all impressed with the man’s attitude and motivation during his time
there. Sadly, the man died from the fatal use of illicit heroin on 22 February.
I conclude that the man was well managed at Town Moor and that his death could
not have been foreseen. I make two recommendations.
4
THE INVESTIGATION PROCESS
1. I was notified of the man’s death on 22 February 2007. The investigation
was allocated to one of my investigators. On 9 March, notices were issued
to staff and residents at Town Moor telling them that an investigation would
be taking place and inviting those who wished to see the investigator to
make themselves known. The Coroner was contacted and a copy of the
post mortem report was requested and received.
2. My investigator visited Town Moor on 20 March. She met the manager, the
deputy manager, and an assistant chief officer for South Yorkshire Probation
Area. My investigator was provided with the man’s hostel record, and spoke
to the man’s keyworker. She visited the man’s room and spoke informally to
some residents and staff.
3. My investigator obtained the man’s prison record from HMP Doncaster. She
spoke to the prison’s senior probation officer, and a seconded probation
officer who had worked with the man. She also spoke to the man’s offender
manager, and to two drug intervention workers based in Doncaster. My
investigator spoke to a resident at Town Moor who had known the man.
4. One of my family liaison officers, contacted the man’s mother. Although she
did not feel the need for my colleagues to visit her, she asked to be kept
informed of the progress of the investigation. She said that she had had
intermittent contact with her son over the past few years because he had
been in and out of prison. He always came to see her when he was out of
prison, but it was usually “out of the blue”. She said her son had come to
see her when he was at Town Moor and that he had looked well. The man’s
mother thought that he was making progress in addressing his drug
addiction, and he had enjoyed a family meal in celebration of his son’s
birthday. She said that staff at Town Moor had been very helpful following
her son’s death. She had appreciated being able to spend some time in his
room and talk to staff about the last two weeks of his life.
5
TOWN MOOR APPROVED PREMISES
5. Town Moor opened as a bail hostel in May 1991. It was previously a private
hotel and occupies two converted houses in a residential street in
Doncaster. Until January 2007 it was one of the biggest hostels of its kind in
England and Wales, but the closure of its ‘cluster houses’ reduced the
number of beds from 39 to 18. The cluster houses were used as a half way
house between residents living in the hostel and returning to live in the
community. Staff expressed a concern to my investigator that their closure
would make it more difficult for them to prepare residents for a return to the
community.
6. Town Moor takes male residents on bail, licence or community order who
are judged to present a high or very high risk to the public according to the
Probation Service’s OASys (Offender Assessment System) risk assessment
tool. Most residents are referred as a result of a Multi-Agency Public
Protection Panel (MAPPP). The role of the hostel is to seek to reduce the
residents’ risk to others before their licence ends. To this end Town Moor
has contracts with The Garage (a substance misuse organisation which
provides Drug Intervention Programme – DIP – workers), Doncaster Alcohol
Services (DAS) and ETE (Employment, Training and Education). A
community psychiatric nurse (CPN) is available for visits, and two
psychiatrists attend the hostel weekly. The expectation is for residents to be
in work or actively seeking work.
7. Town Moor is staffed by a manager, a deputy manager, three probation
service officers (PSOs), two hostel support workers and an administrative
officer. Six other staff and one agency worker are on duty every night. The
hostel has a kitchen where three meals a day are prepared for residents,
and there is a laundry, games room and communal area with a television.
Residents have their own rooms and keys but must sign in and out when
coming and going from the hostel. Entry to the hostel is by door buzzer and
every communal area is covered by CCTV. All residents must be in the
hostel between 11.00pm and 7.00am. The demand for beds is high and
there is a long waiting list for places. The length of stay can vary from a few
days to 18 months, but most residents will remain for about four to six
months.
6
THE EVENTS LEADING UP TO THE MAN’S DEATH
From 30 March 2005 to 7 February 2007
8. On 30 March 2005, the man was sentenced at a Crown Court to 27 months
imprisonment for Actual Bodily Harm (ABH). He served his sentence in
HMP Doncaster. The seconded probation officer, arranged for the man to
meet with two DIP workers from Doncaster. They visited him in the prison
on several occasions.
9. On 23 June 2006, the man was released on licence to a residential and
rehabilitative care unit with 24 hour supervision from qualified mental health
professionals. The terms of his licence required the man to reside at care
unit and only leave the premises under escort. Other licence conditions
required him to attend medical and mental health appointments and to
address his drug and alcohol addictions.
10. On 4 October 2006, the man was recalled from his period on licence after
he persistently made threatening and racist remarks to members of staff at
the care unit. He was also accused of bullying other residents and refused
to take his medication on some occasions. He was returned to HMP
Doncaster.
11. At his first reception health screen on 5 October, the man is recorded as
looking “generally well”. He said he had not used drugs or consumed
alcohol for 18 months. He was referred to the doctor because he needed
repeat prescriptions for olanzapine and chlorpromazine (two drugs known
as ‘anti-psychotics’ and used in the treatment of schizophrenia and
psychotic depression). On the same day he was seen by a CARATs
(counselling, assessment, referral, advice and throughcare) worker and
signed a service withdrawal disclaimer form on the grounds of “no drugs
used”. A note was made on the form by the CARATs worker to review the
situation on 2 November, but there is no other CARATs documentation on
the man’s prison file.
12. On 6 October, the man was seen by the prison doctor and referred to a
visiting consultant forensic psychiatrist. The psychiatrist saw the man on 12
October. He noted on the man’s continuous clinical record that he had been
prescribed olanzapine, chlorpromazine and procycladine (a drug taken to
lessen the side effects of the anti-psychotics) but was missing his morning
dose because he did not wake up in time to receive it on the wing.
13. The psychiatrist saw the man a second time on 26 October. He said that
the man complained of having paranoid thoughts and thoughts of self-harm.
The man presented as agitated but not aggressive or threatening. The
psychiatrist made a note to increase The man’s dose of olanzapine.
Following this consultation, the psychiatrist wrote to the prison doctor. He
said that in light of the man’s thoughts of self-harm he had been moved to
the vulnerable prisoner unit and was in a shared cell.
7
14. On 24 November, a panel of the Parole Board sat to consider the decision
to recall the man from licence. The result was sent to the parole clerk at
Doncaster prison on 29 November. The panel concluded that the recall was
appropriate as he man’s behaviour at care unit indicated that he presented
too high a risk to be managed in the community. The panel thought careful
planning was needed for the man’s eventual release, and agreed with a risk
management plan prepared by the man’s offender manager that suggested
a comprehensive psychiatric assessment and suitable release address were
essential before the man could be released. The panel agreed to release
him on his notional licence expiry date (LED) on 8 February 2007. The man
should be subject to similar additional conditions to those on his previous
licence, and the nature of his accommodation would be informed by on-
going assessment.
15. The psychiatrist saw the man again on 30 November. He reported in the
man’s continuous clinical record that the man’s paranoia was not getting any
better and that he had complained that people were staring at him and
talking about him. He said the man told him that he dare not go into the
showers. The man was still getting up too late to receive his morning dose
of chlorpromazine. The psychiatrist said that the man presented as rational
and amenable to discussion and was not hostile or distraught. He made a
note to see the man in two weeks time but there is no record of this
consultation taking place. (My investigator left messages for the psychiatrist
asking if he would ring her but he did not return her calls.)
16. Following this meeting the psychiatrist again wrote to the prison doctor. He
said, “The core disturbance here is profound disturbance in his personality
which at times lends itself to psychotic episodes.” The psychiatrist said he
had rationalised the man’s medication to take account of the fact that the
man had told him he was unlikely to ever get up for his morning dose of
chlorpromazine while at Doncaster.
17. The seconded probation officer told my investigator that, when the man was
first recalled to Doncaster, he told him he had no interest in seeing either of
the DIP workers from Doncaster. He said the man was still being
supervised by an offender manager. The man was adamant that he did not
want to be released into the Nottinghamshire area because “there was
nothing for him there”. The seconded probation officer said that he saw his
role primarily as “oiling the wheels of release” and his main aim in working
with the man was to transfer him back to South Yorkshire Probation Service
(SYPS) and to find suitable accommodation for him in the Doncaster area.
18. In December 2006, the man’s offender manager and the hostel manager
exchanged emails about the possibility of the man being released to Town
Moor. The hostel manager suggested that the offender manager contact
Town Moor’s local probation office if she wished a transfer to SYPS to go
ahead. On 8 January 2007, Nottinghamshire Probation Area completed an
Approved Premises Referral Form. On 10 January, the hostel manager
emailed the offender manager and said that he had not heard anything
further about the man’s transfer. However, he had been contacted by the
8
probation department at Doncaster prison who were under the impression
that the man would be going to Town Moor on 8 February 2007. The
offender manager replied that the man’s transfer to SYPS was in progress.
The hostel manager suggested that Town Moor agree that the man was
suitable before the transfer was completed.
19. On 11 January 2007, Town Moor received a copy of the referral form, the
man’s OASys assessment and a list of his pre-convictions. The deputy
hostel manager emailed the offender manager to raise “considerable
concerns” about the man’s accommodation in Approved Premises. The
deputy manager said she was concerned that the man had been recalled
from his placement at the care unit because his risk to staff and residents
had been “too high”. She was concerned that the man was deemed to
present a considerable risk to others if he did not take his medication and if
he chose to abuse drugs and alcohol. She was also concerned that the
man was not suitable to live in a hostel environment as he said that he did
not like people and preferred to be isolated. The deputy manager said that,
if Town Moor were to be persuaded that the man was suitable, they must
attend a Multi Agency Public Protection Panel (MAPPP) before his release.
20. On 24 January, a MAPPP took place in Mansfield. The meeting was
attended by the offender manager and two other representatives from
Nottinghamshire Probation, and by the seconded probation officer, an
offender manager who was designated to become the man’s offender
manager in South Yorkshire and representatives from South Yorkshire
MAPPA unit. The seconded probation officer told the meeting that the man
was adamant that he did not wish to live in Nottinghamshire on his release.
The man’s risk factors were discussed and it was agreed that he would be
released to a hostel in South Yorkshire that could provide supervision of the
man’s medication and mental health support. An action plan was drawn up.
This included updating the man’s risk management plan, talking to the man
about working with a Drug Intervention Programme (DIP) worker, arranging
for Doncaster prison to provide the man with anti-psychotic medication for
his release, and explaining the licence conditions to the man.
21. Between 25 January and 5 February, the man’s licence conditions were
finalised and he was formally accepted for a place at Town Moor. The
seconded probation officer arranged for the DIP workers from to visit the
man in prison. Arrangements were made for him to be met on his release
from prison by oner4 of the workers and taken to see the offender manager
before being taken to Town Moor. The seconded probation officers
arranged for the man to be released with sufficient medication pending an
appointment with a GP, and arrangements were made for the man to see
the DIP team and Doncaster Alcohol Services (DAS) on 9 February.
From 8 February to 22 February 2007
22. On 8 February, the offender manager emailed the hostel manager to tell him
that she had received the man’s OASys assessment. She said that the man
had previously assaulted a prisoner after he “got on his nerves”. She said
9
that she had spoken to the seconded probation officer who had discussed
the man’s licence conditions with him. She said that the seconded
probation officer had told her that the man thought he would drink alcohol
very quickly after release.
23. Later that morning, the man was met at Doncaster prison by one of the DIP
workers and taken to see his offender manager. The offender manager
went through the man’s licence conditions with him and completed an
OASys assessment. The man’s objectives were recorded as:
“For the man to comply with his licence conditions.
To attend appointments with DIP and Community Alcohol Team
For the man to comply with his medication.”
24. After his meeting with his offender manager, the man was taken to Town
Moor. He handed in the olanzapine, chlorpromazine and procycladine that
he had left Doncaster with. He was shown his room and taken around the
hostel, and had a full induction meeting with his key worker. The key worker
completed form HRM1 (hostel record of risk assessment). He judged the
man to present a high risk to the public and staff, particularly if he failed to
take his medication. The key worker listed the proposed action to minimise
the man’s risk as, “licence conditions, supervision, keywork sessions,
drug/alcohol screening, referral to drugs/alcohol services, single room.”
25. The man signed the Town Moor drug and alcohol policy to say that he would
comply with the drug and alcohol treatment programme. He agreed to
provide a urine sample for testing every Wednesday. He signed a medical
application for a local GP practice so that he could get a prescription for his
medication. The man also signed the hostel rules and agreed to go to
Doncaster Department of Social Services (DSS) to register for benefits so
that he could pay his hostel rent.
26. On 8 February, a staff member made an entry in the man’s electronic hostel
log file that the man had returned to the hostel at 2.00pm smelling strongly
of alcohol. The offender manager, her senior probation officer, the hostel
manager and deputy manager discussed this incident but decided against
recalling the man. They took into account the fact that it was the man’s first
day out of prison, that his licence did not say that he could not drink alcohol
and that he presented no problems on his return to the hostel. The offender
manager drafted the necessary recall paperwork in case of any further
incidents and emailed it to Town Moor.
27. On 9 February, the man attended his appointments with and DIP worker and
DAS. He also registered at the medical practice and went to Doncaster
DSS. He attended a further appointment with the DIP team on 12 February.
On 13 February, the man tested positive for heroin and crack cocaine at his
weekly urine test. On 14 February, he had a keywork session with key
worker. According to his electronic log file, the man admitted to using heroin
and crack cocaine on Friday 9 February. He was adamant that this was a
‘one off’.
10
28. At his keywork session on 14 February, the man said he felt that he had
settled in well at Town Moor and liked it more than he thought he would. He
had obtained more medication and a sick note from the doctor for three
months. He said he was hoping to start taking Antabuse (medication given
to recovering alcoholics to help them abstain from alcohol) on 1 March but
he needed to have liver function tests first. He confirmed he had made a
claim to the DSS and said he had met with his DIP worker and talked about
relapse prevention. The man admitted he had been drinking alcohol but
said that he limited himself to two or three cans of lager a day. He said he
had seen his mother and son ‘most days’ and had also spent time with his
cousin. He said his mother was trying to set up a meeting with his daughter
but was having difficulty in contacting his ex-partner. The key worker
discussed the man’s limited literacy and numeracy skills. The man said he
would only consider one to one tuition as he found it difficult to cope in
groups.
29. On 16 February, the hostel manager spoke to the man about his alcohol
consumption. The man told him that he was drinking two cans of lager a
day. The manager warned him about the consequences of mixing alcohol
and his medication and the man told him that he had always done this and
there would not be a problem. Following this meeting the manager spoke to
the offender manager and confirmed that the man had tested positive for
heroin and crack cocaine on 13 February. The hostel manager also made
an entry on the man’s electronic log.
30. The offender manager told my investigator that she considered recalling the
man to prison after his drugs test. She discussed it with her senior
probation officer and the Town Moor staff and it was decided not to do so.
She said the man was adamant that it was a one off incident. It was not
unusual for someone with his profile to use on release. He was now
engaging with his DIP workers. The offender manager said that a further
failed drug test would have put a different complexion on the matter, but the
man tested negative on 20 February.
31. On 19 February, the man went to help on a church allotment project run by
the chaplain from Doncaster prison. On his return he told staff that he had
enjoyed the day and would be going again on 21 and 23 February. That
afternoon he attended a three way meeting with his offender manager and a
probation service worker from Town Moor. At the meeting it was decided
that the offender manager would work with the man on victim and racism
awareness at their weekly meetings. The meeting discussed the man’s
continued need to work with the DIP workers, especially in the light of his
recent drug test. The man said he was no longer keen on taking Antabuse,
and it was decided that a programme to help him manage his alcohol intake
might be more appropriate for him. The man expressed a willingness to do
the assessment for the Education Training and Employment (ETE) course
and thought was given to how he could do the coursework without attending
a group session. The man asked whether he could go back to living on the
streets when his licence expired because he found it less stressful. He was
11
given information about supported accommodation and seemed happy with
the idea of it. The man was praised for his behaviour in the hostel and his
conduct at the meeting.
32. On 20 February, the man tested negative at his weekly drug test. Later the
same day he attended an appointment with a DIP worker. He returned to
the hostel smelling strongly of alcohol but staff noted that he did not appear
drunk.
33. On 21 February, the electronic log sheet shows the man left the hostel at
2.29pm to go into Doncaster for “a beer”. He returned at 3.34pm and staff
noticed he smelt of alcohol. The man went out again at 4.35pm and
returned in the evening. At 10.59pm, a member of staff noted that the man
had not come down to take his evening medication. He went to the man’s
room to remind him but was unable to wake him.
34. At 8.30am on 22 February, the hostel manager was told at the morning
hand over meeting that the man had missed taking his medication the
previous evening. The manager then attended a monthly team meeting at
9.00am and went up to the man’s room at about 11.39am. The manager
told my investigator that he was not worried about the man, but intended to
speak to him because not taking his medication was a breach of his licence
conditions and he thought he might have to recall the man to prison. When
the manager entered the man’s room he found him dead in bed. An
ambulance was called and paramedics confirmed that he was dead. The
toxicology report indicates that the man had died from an overdose of
heroin.
The response to the man’s death
35. The deputy hotel manager provided the paramedics with personal
information about the man and the police were called. The deputy manager
informed an assistant chief officer with South Yorkshire Probation, and she
came straight to Town Moor. The deputy manager and the assistant chief
officer told the residents in the hostel of the man’s death. One of the
residents told staff that he had seen the man “hanging around with some
wrong ‘uns” during the day and drinking heavily. The police visited the
man’s mother and broke the news of his death. The offender manager was
told and she informed other people that had worked with the man.
36. Town Moor does not have its own local instructions telling staff what
procedures to follow in the event of the death of a resident. The hostel
manager told my investigator that he printed off a copy of Probation Circular
02/2004 ‘Deaths of Approved Premises’ Residents’. All subsequent contact
with the police and the Coroner was recorded on the man’s electronic log
file.
37. On 27 February, the man’s mother and step-father visited Town Moor to
collect the man’s belongings. They spoke to the manager and deputy
manager and spent some time alone in the man’s room.
12
WHAT STAFF AND RESIDENTS SAID
38. The seconded probation officer at Doncaster prison, said that he had known
the man since before he was released on licence to the care unit. He said
when he first met the man he was not at all co-operative and did not want
anyone to ”interfere” with him. He said the man had a strong sense of his
own independence and was very much “his own man”. The seconded
probation officer said he thought the man’s attitude had changed and he
was making progress. He said the man was “delighted” when he was
accepted at Town Moor. He added that the man had always told him the
first thing he would do on release was to go to Tescos and get drunk. He
was impressed that the man had continued to see his DIP workers and had
gone to the allotment project.
39. The man’s offender manager, said that she had spoken to the seconded
probation officer when she had first been given the man’s case. She said
the man had initially not seemed very co-operative and had always said that
he would drink on release. She thought that his attitude changed after the
MAPPP in January and the man asked to see the DIP workers again. She
said she had been concerned that the man would breach his licence within a
week of release, but he settled well at Town Moor and was engaging with
DIP and DAS. The offender manager said the man had really enjoyed the
allotment project and she had decided to relax his curfew to allow him to
attend the project all day. She had not had a chance to begin work with the
man on his racism and violence issues, and was in the process of arranging
a mental health assessment for him. She had discussed the man’s drinking
with him. She said the man knew it was a problem but he had not been
drunk or aggressive in the hostel.
40. A DIP worker said he had known the man for between 12-15 months. He
said it was a departure for the man to accept a hostel place because he had
always been resistant to going to one. The DIP worker said he thought
there had been a definite change in the man's behaviour on his release to
Town Moor. He thought that the man had realised that he wanted to live his
life in a different way and that his behaviour was affecting other people
including his children. The DIP worker said he thought the man was doing
very well at Town Moor. He had discussed the man’s drinking with him and
was satisfied that he had it under control. The DIP worker said he was
“devastated” when he heard the man had died. He thought that drugs were
no longer part of the man’s life and that he was “walking the walk as well as
talking the talk”.
41. Another of the DIP workers said that he had known the man for over a year
and had visited him in HMP Doncaster before his release to Town Moor. He
said that the man had suffered years of addiction but appeared to be
addressing his drug problem before he died. He said that the man had
appeared very positive about his future.
42. The man’s key worker described him as “a sound bloke, really motivated”.
He said the man had wanted to see his children and came across as self-
13
aware. He said the man knew that if he did not take his medication he
became “not a nice person”. The key worker said the man appeared very
positive. He enjoyed his son’s birthday and seemed to be very happy. He
was well liked in the hostel and was always polite and courteous. The key
worker thought the man had been pleasantly surprised by Town Moor as his
previous experience of hostels had not been good. He was shocked by the
man’s death.
43. A resident at Town Moor, said he had known the man for two or three years.
He described the man in Town Moor as “alert”, “happyish” and “chatty”. He
said the man obviously enjoyed working on the allotment project and had
talked a lot about his children and the family dogs. The resident said the
man had been especially cheerful after his son’s birthday meal when he had
eaten a 52oz steak. He said he had talked to some of the man’s friends and
they had also thought that he was doing well. The resident said he had
been concerned that the man was starting to drink more and he had told him
to be careful. He said the night before he died the man was laughing and
joking. He was very surprised when he found out the next day that the man
was dead.
14
ISSUES CONSIDERED DURING THE INVESTIGATION
The man’s allocation to Town Moor
44. The Parole Board said in November 2006 that the man should be released
to accommodation that could provide supervision of the man’s medication
and mental health support. It also recommended that the man undertake a
mental health assessment. I consider that Town Moor was an appropriate
allocation for the man. Staff were able to supervise his medication and keep
a record of when he took it. The hostel is visited by a Community
Psychiatric Nurse and two psychiatrists. The man’s electronic log file shows
that, at the time he died, the offender manager and staff at Town Moor were
in the process of arranging a mental health assessment for The man via his
GP.
45. Town Moor staff took appropriate steps to reassure themselves about the
man before he was accepted for a place. A MAPPP was convened in
January and the exact details of the man’s licence were determined before
his release. Staff told my investigator that they were pleasantly surprised
when they met the man. They were concerned about him because they had
heard about his reasons for recall and his attitude to other prisoners. They
were also concerned about the number of additional conditions on the man’s
licence. When they met him they found him to be cheerful and polite. As
noted at paragraph 46 above, the man’s keyworker, described him as “a
sound bloke, really motivated”. Although Town Moor staff spoke to the
man’s offender manager and SYPS staff attended the MAPPP, no one had
met the man before he arrived at the hostel. It may have helped them come
to their decision if they had visited him in Doncaster prison, in the same way
he was visited by the DIP workers.
I recommend that, should a similar situation arise in the future,
Town Moor staff should consider visiting prospective residents
before they are accepted for a bed.
The man’s management in Town Moor
46. The man was released with the following additional licence conditions:
- Notify your supervising officer of any developing relationships with
women/men
- To comply with any requirements specified by your supervising
officer for the purpose of ensuring that you address your domestic
abuse and violent offending behaviour problems
- To comply with any requirements specified by your supervising
officer for the purpose of ensuring that you address your
alcohol/drug offending behaviour problems by attending
appointments made with substance misuse workers
- Not seek to approach or communicate with two named people
without the prior approval of your supervising officer or social
services
15
- To comply with any requirements specified by your supervising
officer for the purpose of ensuring that you address your racist
behaviour problems
- To attend all appointments arranged for you with a medical
practitioner and co-operate fully with any care or treatment they
recommend, to register with a general practitioner within two days
of your release as directed by your supervising officer
- Confine yourself to an address approved by your supervising officer
between the hours of 2.00pm and 2.30pm daily unless otherwise
authorised by your supervising officer
- To permanently reside at Town Moor bail hostel and must not leave
to reside elsewhere without the prior approval of your supervising
officer.
47. With the exception of missing his evening medication on 21 February, The
man complied with all these conditions. He observed the daily curfew and
attended all his appointments with DAS and the DIP workers. He registered
with a GP within two days of release. He agreed to address his racist and
violent behaviour in weekly sessions with his offender manager. In addition,
he complied with the hostel rules requiring him to register for benefits with
social services.
48. On 19 February 2007, the man began work on the church allotment project
run by the chaplain at Doncaster prison. By all accounts, the man
thoroughly enjoyed this work and consideration was being given to relaxing
his curfew so that he could spend all day there. The man was unable to
work on his release, and engaging him in purposeful activity was an
important way of preventing the boredom that could lead him back to taking
drugs. I note also that consideration was being given to ways of helping the
man undertake an ETE course.
49. The man openly drank alcohol on a daily basis as soon as he was released
and he tested positive for heroin and cocaine on 13 February. Both these
occurrences were discussed by his offender manager, her supervising
officer and Town Moor staff. It was decided that it was not appropriate to
revoke the man’s licence and return him to prison. I consider that this was
sensible. It is not unknown for prisoners to lapse on release and then begin
the hard work involved in addressing their alcohol and drug problems. I
agree that a further positive drug test would have put the matter in a
different light. I note that the substance misuse workers who had known the
man for some time were impressed with his motivation during his time at
Town Moor.
50. The man was tested for drugs regularly and randomly during his time in
Town Moor.
The response to the man’s death
51. The man was already dead when he was found by the hostel manger on the
morning of 22 February. The ambulance and police were called promptly
16
and a log of all subsequent contact was kept. My office was contacted on
the same day. A copy of Probation Circular 02/2004 was obtained and its
instructions followed. The other residents were told promptly what had
happened. The man’s friend said he was happy with the level of support he
had received from staff following his friend’s death.
52. I am pleased that the man’s mother and step-father were able to visit Town
Moor, talk to staff and spend time in his room alone. This was good
practice.
17
CONCLUSION AND RECOMMENDATIONS
53. The man appeared to be doing well at Town Moor. He complied with the
extra conditions on his licence and engaged with substance misuse workers
and his offender manager as required. He appeared to have discovered a
new motivation for changing his life and breaking the pattern of addiction
that had been his curse for so long. Sadly, he does not appear to have
been able to remain drug free. I believe the man was well managed by
probation staff during his time in Town Moor and his death could not have
been foreseen or prevented.
54. I make a single recommendation:
I recommend that, should a similar situation arise in the future,
Town Moor staff should consider visiting prospective residents
before they are accepted for a bed.
18