Individual at Tulse Hill

Investigation into the circumstances surrounding the
death of a man in December 2009
at Tulse Hill Approved Premises
in the London Probation Trust
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2011
This is the report of an investigation into the circumstances surrounding the death of
a man. He died in Tulse Hill Approved Premises in December 2009, having arrived
there from HMP Highpoint two days earlier. He was 40 years old.
None of the man’s family were named on his files and the police have been unable
to trace his next of kin. Nevertheless, he will undoubtedly have had some family and
friends and I offer them my condolences.
The investigation was undertaken by one of my senior investigators. The
investigator and I would like to thank the manager of Tulse Hill Approved Premises
and her staff for their co-operation in the investigation. I apologise for the length of
time taken to complete the report.
The post-mortem and an additional toxicology report identified that the man had
taken a number of drugs prior to his death and the cause of his death was a result of
“opiate and codeine intoxication”.
It is impossible for me to say whether his death could have reasonably been
prevented. I have found gaps in the communications between shift workers,
particularly at weekends, which resulted in two drug tests being missed. There was
a serious omission in the routine, but very important, standard checks and regular
contact with residents. My investigation confirmed the early findings of the hostel
manager that a relief member of staff failed to carry out at least one check and to
pass key information on to his colleagues. This person is no longer employed by the
London Probation Trust and so I do not make a recommendation. I also remind
managers to consider the support needs of all the staff affected by the death of a
resident.
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
Acting Prisons and Probation Ombudsman June 2011
2
CONTENTS
Summary
The investigation process
Tulse Hill Approved Premises
Key events
Issues
Recommendations
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SUMMARY
1. The man arrived at Tulse Hill Approved Premises on the afternoon of Friday 4
December having been released from prison on licence. A long term drug user,
he had been assessed as high risk of harm to himself if he started to use drugs
again soon after his release.
2. The vulnerability to overdose after being in custody is well known and advertised
widely in prisons. Aware of this possibility, the hostel deputy manager had given
instructions that the man should be drug tested during his induction. Although he
was reminded of the risk of accidental overdose by the duty residential assistant,
there is no record that the drug test actually took place. The residential assistant
who received the instruction from the deputy manager was not the person who
eventually carried out the induction and this important opportunity to assess his
situation was missed.
3. His first night passed without incident. The man then spent most of the next day,
5 December, out of the hostel, returning in time for his curfew at about 9.00pm.
4. Staff on duty when he returned to the hostel suspected that he was under the
influence of drugs or alcohol. He was argumentative and refused to sign his
curfew sheet. He then set off a fire alarm on his way up to his room. This
information was shared with the standby hostel manager. By this time he had
apparently settled down in his room, so a drug test was ordered for the next
morning.
5. The man did not leave his room again after 9.11pm. A relief worker says that
when he went into his room during the 11.00pm curfew check, he pulled his toe
and heard him groan. He took this to mean that the man was well.
6. Staff were expected to make wellbeing checks of each resident at 8.45am the
next morning. However, the relief worker apparently did not carry out the check.
Apart from a colleague who had been on duty the previous evening, colleagues
coming on duty that day were not aware that there were any problems, and were
not told about the incident with the alarm or that a drugs test had been ordered by
the hostel manager for that morning. Furthermore, this information was not
written down in any of the hostel documents. The relief worker subsequently
misled the hostel manager about his actions on the shift in question.
7. It was only when one of the duty residential assistants decided to go to the man’s
room at about 3.00pm to check on his whereabouts that she discovered his body
lying on the bed. It appeared to her that he was dead. She told her colleague
and rang the emergency services. Attempts at cardio pulmonary resuscitation by
both workers failed and he was pronounced dead by paramedics at 4.17pm.
8. It is impossible to say whether his death could have been prevented if either of
the drug tests had taken place as planned or if he had been discovered at the
standard morning wellbeing check. Drug tests could have established whether he
had already started to take drugs and at the very least would have been another
opportunity to reinforce the risk of low tolerance after coming out of prison. From
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the duty residential assistant’s description of his body when she found him, it is
probable that he had been dead for some time. No check was made on him after
he failed to come down to sign his 7.00am curfew. The best chance for
successful intervention after that was the morning wellbeing check about ten
hours after he was last seen alive. For reasons unknown, the check was not
carried out, and the staff coming on shift in the morning were not told that the
relief worker had neglected his duties.
9. I make recommendations about passing of information between staff at the hostel
and support for staff after a death.
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THE INVESTIGATION PROCESS
10. My investigator had access to all the man’s probation records, which were
provided by the hostel. He visited the hostel, saw where the man lived, and
interviewed three members of staff. The interviews were recorded, and the
transcripts are appended to this report. CCTV recordings of the hostel were
also made available to the investigation. My investigator remained in touch with
the hostel manager throughout the investigation.
11. My investigator also wrote to two former members of hostel staff asking if he
could speak to them. He did not receive a reply.
12. Notices were displayed at the hostel to inform both staff and residents of the
investigation, and inviting their contributions. None was received.
13. My investigator also spoke to the Metropolitan Police officers who were
responsible for investigating the man’s death.
14. The man did not have any next of kin noted on his files. My investigator spoke
to the Lambeth Missing Persons Unit of the Metropolitan Police, who were
making efforts to trace next of kin for the man. At the time of issuing my draft
report, they had not located any next of kin.
15. My investigator contacted Her Majesty’s Coroner to inform him of the nature and
scope of my investigation. The Coroner’s inquest was held on 27 July 2010,
before my report was published, with a finding of non-dependent abuse of drugs.
I will forward a copy of my report to the Coroner.
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TULSE HILL APPROVED PREMISES
16. Approved premises were formerly known as probation and bail hostels. They
are approved by the Secretary of State, within Section 9 of the Criminal Justice
Act 2000. Approved premises provide a supportive, structured environment in
the community for offenders who present a high risk to the public and are difficult
to manage. The management of offenders accommodated in approved
premises is governed by the National Standards for Supervision of Offenders
and the guidance contained in the National Approved Premises Handbook.
17. Offenders can be released from prison on a licence, which contains specific
conditions they must abide by. For example, they may be required to report to
their home probation officer at a certain address and/or at a certain time. In
addition, they may not be allowed to enter a particular area where victims of their
crime live, or a specific type of premises such as public houses. If they breach
the conditions of their licence they may be recalled to prison.
18. Tulse Hill Approved Premises has 23 single and three double rooms, with a
capacity to accommodate 29 residents. Residents pay a weekly service charge
for their meals, rooms, and other hostel facilities. The hostel has closed circuit
television (CCTV), with monitors in the front office which is staffed 24 hours a
day.
19. Approved premises are staffed continually 24 hours a day by different grades of
staff working to a shift rota. Between 10.00pm and 9.30am there are two
members of staff on duty, one of whom may be a security guard. During the
day, there are up to six members of staff on duty, with a minimum requirement
for two members of staff to be on duty at all times. There is a pool of relief staff
who can be called upon to cover when staff numbers are low. All permanent
staff are first aid trained, and casual staff receive basic first aid training
20. All residents are subject to a curfew, whereby they are required to be in the
hostel between the hours of 11.00pm and 7.00am. Some residents may have
further individual curfew arrangements. Outside those hours, residents are free
to leave the premises without disclosing where they are going. Wellbeing
checks are made at regular intervals.
Documents used in approved premises
21. There are a number of documents used by staff to record information about
individual residents and key events on a daily basis. Documents used include:
the day book, a curfew checklist, a signing out sheet, and the London Probation
Trust’s computerised case management system, Delius (Delivering Information
to Users System).
22. The day book is used to note any interaction between staff and residents and to
record any incidents. Delius contains information specific to the individual
resident. Staff in hostels sometimes make a brief note in the day book about an
event and point to a more full entry in Delius. The Delius entry may be made
some time after the event happened, so the record may not run chronologically.
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All staff working in the hostel, including relief staff, have access to Delius. It
seems that the day book is used as the main method of communication between
staff.
23. The curfew checklist is a separate sheet kept which is used to collect the
signatures of residents at the 11.00pm hostel curfew time every day. Residents
subject to individual curfew times are additionally required to sign a personal
curfew sheet separately.
Previous deaths at Tulse Hill
24. The Prisons and Probation Ombudsman has investigated one previous death at
Tulse Hill. There were no similarities to the circumstances surrounding the
man’s death.
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KEY EVENTS
25. The man served a sentence of two years imprisonment for communicating false
information alleging the presence of bombs. He was released on licence to
Ellison House Approved Premises in Camberwell, London. However, on 23
August 2008 he breached his curfew and was recalled to prison. In December
2008, he transferred to HMP Highpoint, and in late 2009 preparations were
underway for him to be released on licence to Tulse Hill Approved Premises
(referred to hereafter as the hostel).
26. As part of the preparations for release on licence, an Offender Assessment
System (OASys – a system to gauge the likelihood of offenders reoffending, and
the risks they may pose) report was completed on 16 November. This report
contains contingency plans to immediately recall the man to prison should he fail
to keep to the conditions of his release licence. The report notes that his
probation officer would be responsible for any recall. In his absence,
responsibility would fall to an offender manager also based in the Public
Protection Unit at Harpenden House, one of Inner London Probation Trust’s
offices.
27. Further elements of the preparation for release included the completion of a Risk
Assessment and Public Protection Plan on 27 November. The plan shows that
the man was considered a high risk of accidental death due to reduced tolerance
to drugs in the weeks following release from custody. It is not clear what action
was taken in relation to this at this stage. He was also noted to be high risk to
hostel staff, high risk of self-harm, and high risk of suicide. It is recorded on the
form that staff should monitor, among other things, his mental health, his
compliance with any medication he might be prescribed, his use of drugs and
alcohol, and his overall compliance with the terms of his licence and the hostel’s
rules and regulations. The terms of his licence included specific conditions that
he was to be tested twice weekly for drugs, and must comply with the curfew
hours of the hostel.
28. The man was released from Highpoint on 4 December. He reported to the
probation office at Harpenden House and was seen by an offender manager.
They discussed the conditions of his licence, what was expected of him while he
was in the hostel, and dangers of using drugs after a period in prison. He said
that he was intending to remain drug-free.
29. After this meeting, the man travelled to Tulse Hill. He arrived at the hostel at
2.40pm and was met by the duty residential assistant (RA). He signed in. The
shifts changed, and the night RA took over from the day RA. She then carried
out his induction process. She reminded him of the potential danger of taking
drugs after his tolerance had decreased while he had not been using them. He
paid his deposit for his rent and board and was allocated to room 15, a room at
the end of the corridor on the first floor. He was told that his personal curfew
hours were between 9.00pm and 7.00am and he had to sign the curfew sheet. It
was pointed out that, even if he was in the hostel, it was still his responsibility to
go to the office and sign the curfew sheet.
9
30. An entry on the man’s Delius record on 4 December shows that the deputy
manager agreed with another member of staff, the day RA, who is one of the
hostel’s relief workers, that he should be drug tested as part of his induction
process. However, the RA did not carry out the induction, and the test was not
carried out.
31. Another entry on the Delius system, timed at 3.46pm, was made by the offender
manager, reminding staff that an application for recall should be completed
should the man fail to comply with his licence, the hostel’s core rules, or his
curfew. (As well being an offender manager, she also works occasional shifts
when required in approved premises. However, this entry appears to have been
made in her capacity as his offender manager.)
32. The man signed out of the hostel at 4.15pm, and returned and signed back in at
5.00pm. He signed back out at 5.15pm, and returned and signed in again at
8.15pm. The hostel’s curfew sheet bears what appears to be his signature,
timed at 9.00pm. The day book contains an entry at 9.20pm saying that he had
signed his curfew sheet. However, the hostel’s CCTV footage shows one of the
hostel’s security guards going upstairs at 10.19pm. The guard later explained to
the hostel manager that he was on his way to remind the man to sign the curfew
sheet at this stage. The man subsequently did so. The duty officer in the hostel
that evening later confirmed to the hostel manager that the man was present at
11.00pm, in line with his curfew.
33. The following morning, 5 December, the man signed the curfew sheet at
7.00am. The duty officer was responsible for the wellbeing check on residents.
At 8.55am, she made a note in the day book that she had completed the checks
and that all residents appeared to be fine. At the same time, he left the hostel.
34. The duty officer sent an e-mail to the deputy manager at 10.15am to inform her
that, although she was scheduled to work overnight from 9.30pm that day to
10.00am the following day, the relief worker (who was an experienced relief
worker) had agreed to cover her shift.
35. The man was out of the hostel all day. The relief worker and offender manager
were on duty when he returned at 9.02pm. He was unsteady on his feet, and
was verbally loud and aggressive, appearing to be under the influence of
something intoxicating. He refused to sign the curfew sheet, and the signing in
and out log does not have a return time entered. He told the offender manager
that he did not want to stay at the hostel, and asked her to return the money he
had paid the previous day. He told her that she might as well recall him to
prison, suggesting that she call the police as he had no intention of staying in the
hostel that night. He told her that he had been smoking cannabis, though she
suspected that he might be under the influence of stronger drugs.
36. However, he eventually took his room key and entered the hostel. He went up to
the first floor and, as he passed the fire alarm, he broke the glass, which set off
the alarm. The relief worker went to check the alarm, and confirmed that there
was no fire. CCTV footage shows him going into his room at 9.11pm. At this
stage staff made no further attempt to discuss what had happened with him.
10
37. At 9.58pm the offender manager made a telephone call to the duty officer
providing managerial cover to all the approved premises in Lambeth and
Southwark. By coincidence the manager providing standby cover for the area
that night was the manager of the Tulse Hill hostel. The offender manager left a
message to say that the man had returned to the hostel apparently under the
influence of something, set off the fire alarm, and asked to go back to prison. He
had, though, then settled down and was in his room. The offender manager
finished her shift at 10.00pm and she left the hostel shortly afterwards. The
relief worker remained on duty together with the security guard.
38. The manager telephoned the duty RA at 10.02pm. She said that, as the man
had just been released from prison another RA due on duty the next morning
should be asked to give him a drug and alcohol test. She said that if there were
any further problems, staff at the hostel should inform her as well as the police.
This instruction was not recorded in any of the hostel documents.
39. The relief worker said later to the day RA that he saw the man at 11.00pm as
part of the general hostel curfew check. CCTV shows that he arrived at the
man’s door at 11.09pm. He did not fully enter the room, but opened the door
and leant forward into the room for less than a minute. He said that the man
was in bed and asleep, and so he did not wake him but pulled his toe. This
made him let out a groan, and the RA judged that this was an indication that he
was okay.
40. After the RA had opened and closed the door, the CCTV shows that no-one else
went into or came out of the man’s room. The day book indicates that the
security guard patrolled the building at 1.00am, 3.00am and 5.00am and the
CCTV recordings corroborate this. No problems were encountered on any of
these occasions.
41. The man did not sign the curfew sheet at 7.00am on Sunday 6 December. The
relief worker later told the hostel manager that he did not go and check the
building because he was watching the door and, if he had left the building, he
would have seen him do so. Nevertheless, the column of the curfew sheet
where residents sign has a “T” written there, as if someone had begun to sign for
6 December. It has not been possible to find out who did this, although
consideration has been given to it being an entry in error by the man from the
day before.
42. There is a note in the day book that a wellbeing check was completed on
residents at 8.45am. The curfew check list also has a tick to indicate that the
man (along with other residents) was present at 8.45am. However, the section
of the daily task document where staff should confirm that the 8.45am wellbeing
check took place has been left blank. The relief worker subsequently told the
hostel manager that, although he did not enter the room when he made the
check, he could hear him snoring. As the man had been disruptive the previous
evening, he did not feel that he should disturb his sleep. His account is not
corroborated by the CCTV footage, which indicates that he did not leave the
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general office between 7.00am and 9.34am and no-one went to the man’s room
during this time.
43. The security guard went off duty and left the building at 9.05am. The RA shift
was due to change, with the duty residential assistant and the day RA scheduled
to begin their shifts at 9.30am. The duty residential assistant arrived at 9.05am.
CCTV shows the relief worker leaving the building to speak to his wife in the car
park at 9.34am, the only time he left the building during his shift. He could not
leave until the next two shift workers had taken over. The day RA arrived at
9.55am.
44. Before going off shift after the day RA arrived, the relief worker gave a verbal
handover to the duty residential assistant. She said that he told her that he had
seen everybody and they were all fine. She took this to mean that there were no
concerns. She said that he did not tell her that the standby duty officer had been
contacted the previous night about the man’s behaviour or that a drug and
alcohol test had been requested for that morning. He later told the hostel
manager that, as he thought that the day RA had been present when the man
returned to the hostel the previous evening, he assumed that she was aware of
this.
45. According to the CCTV footage, the only person who approached the man’s
door during the early part of Sunday was his neighbour from the next room, who
knocked once on the doors to both the man’s room and the room opposite at
12.52pm. It appears that there was no response to either knock because the
resident walked off down the corridor almost immediately afterwards.
46. The duty residential assistant said in interview that she was concerned that the
man might have kept his key after going out on the day of his arrival and she
wanted to check this with him during her shift. She had previously asked two
other residents to knock on his door but both returned to say that there was no
reply when they knocked at 2.33pm and 2.37pm respectively. The day book
notes that at 3.05pm she went herself to his room to ensure that he was on the
premises.
47. When the duty residential assistant, who is a trained first aider, knocked on the
door, she also received no reply. She tried the door and it was unlocked, so she
opened it. She saw him lying on the bed, his foot on the pillow and his head on
the mattress. She called him, and he did not respond. She saw brown fluid
coming from his nose and his mouth, and she checked for a pulse. She could
not find one and noticed that his hand was stiff.
48. She came back down the stairs and told the day RA that she thought that he had
died. She called for an emergency ambulance and explained the situation. The
day book indicates that the ambulance was called at 3.10pm. She then handed
the telephone to the RA and returned to his room. The telephone operator took
a mobile telephone number from the RA, and then rang her back as she made
her way up to the room. The operator gave advice on administering cardio
pulmonary resuscitation. (CPR incorporates chest compressions and mouth-to-
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mouth resuscitation, to force air in and out of the lungs, to try to make the heart
restart.)
49. The duty residential assistant attempted to resuscitate the man. Unable to gain
a response, she became upset, and so the RA took her place. The ambulance
arrived at approximately 3.30pm, and the paramedics then took charge. They
confirmed that he had died, and the official time of death was given as 4.17pm.
Checks of his room did not reveal any drug paraphernalia or other signs of drug-
taking.
50. The duty residential assistant telephoned the hostel manager but only managed
to reach an answering service. She telephoned the manager but, being unable
to get through to her, left voicemail messages asking her to call the hostel. She
also telephoned the London area duty manager. Shortly afterwards, at 4.10pm,
the manager called the hostel and was told what had happened. She spoke to
senior officers then made her way into the hostel. At 4.15pm, the London area
duty manager telephoned the hostel and helped staff with the contingency plans
required for a death in the hostel.
51. The London area duty manager rang the hostel again at 4.55pm to check how
things were and that the staff were okay. At 5.15pm, the manager arrived at the
hostel and took charge.
52. As part of his induction process, the man had provided details for next of kin. He
had named a friend from prison. The manager contacted him and informed him
of his death. She did not, however, have any details for any of his family. She
provided what information she could to the police, and the Lambeth Missing
Persons Unit undertook to try and trace his family. Unfortunately, they were
unsuccessful in their attempts.
53. Other residents in the hostel were informed of his death at a residents’ meeting
called for that purpose. They were told that if they needed any support they
should talk to their keyworker or one of the premises managers.
Post mortem
54. A post mortem examination was carried out on 8 December. The report gave
the official time of death as 4.17pm on 6 December 2009. The cause of death
could not be established at that time. Toxicology tests were therefore
undertaken, and they showed the presence of:
- morphine
- codeine
- 6-monoacetylmorphine (which indicates use of heroin)
- papaverine metabolite (which indicates the use of street heroin)
- cocaine (consistent with recreational use).
55. The cause of death was subsequently given as opiate and cocaine intoxification.
The pathologist further commented that there was evidence of recent heroin and
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cocaine use. Although there were low levels of these drugs at post mortem, the
man’s death was compatible with their use.
Inquest
56. The Deputy Coroner at Southwark Coroner’s Court, presided over an inquest
into the man’s death on 27 July. The inquest recorded a finding of “non-
dependent abuse of drugs”.
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ISSUES
Communication in the hostel
57. One of the main points to stand out in this investigation is the difficulty for staff
communicating information in the hostel. The various documents which are
kept, including the day book, Delius electronic notes, a curfew sheet, personal
curfew sheets, daily task lists, are all administrative pressures on staff.
Information can be missed across staff shifts, and happened twice when the
man should have been given drug tests. Also, although it is unlikely to have
impacted on the outcome in this instance, the evidence from the hostel’s records
and CCTV footage for when he signed his curfew sheet on the Friday evening
also implies that it was done at three different times. I suggest that the hostel
manager should review the way important incidents and requests for actions are
communicated between staff.
58. My recommendation may have implications for other London hostels and the
London Probation Trust should consider whether any changes should be
implemented beyond Tulse Hill.
The hostel manager should ensure that information regarding important
incidents and actions pending is being communicated between staff as
effectively as possible to avoid duplication and reduce the risk of
information being overlooked.
Missed drug tests
59. The man should have been given a drug test when he arrived in the hostel.
Even though this was agreed between staff at the hostel, it was overlooked.
Additionally, it is clear that the hostel manager had identified the need to test for
drugs and alcohol when he awoke on Sunday 6 December. She had given this
instruction to the relief worker the previous night after being told about his
disruptive behaviour. Unfortunately, this instruction was not passed to the
oncoming shift workers at the handover after 9.00am.
60. This important instruction from the hostel manager should have been noted in
day book or Delius so that staff coming on duty were reliably informed of the
situation. The relief worker said when discussing events with the manager after
the man’s death that he had made Delius entries on residents as part of his
normal RA duties. However, no electronic records were found.
61. He also told the manager that he thought there was no need to tell the day RA
that she had to drug test the man that morning because he thought she was on
duty when the manager spoke to him the previous evening. Nevertheless,
confusion could have been avoided and the drug test would have been more
certain if he had either written the instruction in the day book or handed over
verbally to the duty residential assistant. Good practice in hostels relies on the
full and accurate exchange of information to equip the next shift with the
resources to carry out their role satisfactorily. This may entail mentioning each
resident in turn and commenting verbally on each one and recording key
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information in writing. I understand that this is what should have happened. Key
information should be recorded and a routine verbal update allows an
opportunity to discuss the implications.
62. It is not possible to say whether the man’s death could have been avoided if he
had been seen earlier. The time of his death has not been established and there
is no information about whether he died suddenly or was ill beforehand. The
drugs test would have been an important opportunity to make contact several
hours earlier and the failure to hand on information meant this opportunity was
missed.
Wellbeing checks
63. Another opportunity to check the man’s wellbeing was when the relief worker
should have made the standard check that is part of each shift. The hostel
requires the duty RA to carry out various checks at fixed times of the day and he
should have undertaken a wellbeing check at 8.45am. A clear expectation of
staff is that the resident is seen, if in the building, and a brief assessment made
about their state of mind and general demeanour. He believed that the man was
still in the building as he had not seen him leave and he had been in the office
since his morning curfew of 7.00am.
64. As an experienced hostel worker, he was clearly aware of the morning wellbeing
check because according to the hostel manager he told her afterwards that he
had completed the check on the morning of 6 December. He told the manager
that he could hear the man snoring from outside his door but did not go in as he
did not want to disturb him. However, one CCTV camera revealed that he did
not leave the hostel office between 7.00am and 9.34am and another camera
showed that he did not stand outside the man’s room as he described to his
manager.
65. As with the missed drugs tests, it is impossible to say whether the missed
8.45am wellbeing check would have altered the outcome. It is, however, a
serious omission and a missed opportunity to intervene. At the very least, it
might have meant that the man could have been found earlier.
66. The preliminary consideration of events by the hostel manager uncovered
concerns about the relief worker’s behaviour during his shift on 5 and 6
December and the serious implication that he attempted to cover this up. I
understand that, as a result, he is no longer employed as a relief worker by
London Probation Trust.
It appears that in this case there was no fundamental problem with the system
for wellbeing checks, only with the performance of an individual. My investigator
was told that since the man’s death an additional wellbeing check has been
introduced at 10.30am every day. I welcome this development.
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Cardio pulmonary resuscitation
67. In interview, the duty residential assistant shared her distress at administering
cardio pulmonary resuscitation (CPR) to someone she clearly believed had
already died. She described the man’s body as being “cold” and “stiff” and she
was reluctant to embark on CPR. Indeed, the emergency service telephone
operator advised that the day RA take over as she became emotional.
68. The London Probation Trust manual of guidance and instruction for the
management and care of residents in approved premises contains guidance to
staff in the event of finding a resident who has died. The manual says:
“It must never be assumed in all cases that because the person appears
dead that they are in fact dead. In some cases it may be obvious. If safe
to enter the area where the person is then you must check for any signs of
life where death is not obvious. Having satisfied yourself that the person is
dead then leave the location and seal it off to prevent unauthorised access
to the location.”
69. The duty residential assistant was first aid trained but she did not find it easy to
be clear about her duty of care when faced with someone she did not think could
be successfully resuscitated. In the circumstances, I can understand why she
followed the advice of the emergency services. This was distressing for her.
With hindsight, it is unfortunate that she was not confident about deciding that
the man was dead and that she could quite properly make no attempt to
resuscitate him.
70. Deaths in approved premises are thankfully rare and, although the duty
residential assistant had a first aid qualification, she may well not have dealt with
a death before. The Probation Trust may wish to consider whether their manual
and the first aid training should include advice on recognising rigor mortis. More
deaths occur in prison than in approved premises, and the National Offender
Management Service unfortunately has more experience of prisoners being
found some time after they have died. My investigations into prison deaths have
commented when CPR has begun after rigor mortis has set in. It is undignified
as well as stressful for staff. I make no criticism here as the staff followed the
advice of the emergency services. However, I encourage the Trust to consider
my remarks and decide whether the manual and training covers eventualities
such as this.
Support for staff
71. It is clear that the three staff interviewed by my investigator were all aware of the
type of support that could be made available for them, from informal support
from managers, to counselling. The duty residential assistant raised concerns,
however, about the response she received after the man’s death. She felt that
managers did not demonstrate immediate empathy with her as someone who
had just discovered a deceased resident and attempted to resuscitate them.
The hostel manager pointed out that policies were followed. As well as being
offered counselling, she was also given special leave. Nevertheless, she has
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clearly been affected by what happened that day, including how she felt that
managers responded to her. She has been troubled by this and said that, in her
upset state after the man died, she did not take up the offer of counselling.
72. She did, however, express strong appreciation for the response of the London
area duty manager. He was the duty manager she spoke to after discovering
the man and she found him very supportive on the telephone. He went through
what had happened with her and was clear about what should happen next.
Even though she did not meet him in person, she said that his ability to
communicate professional support was appreciated.
73. One other member of staff who might have been more than usually affected by
the man’s death was the offender manager. She not only knew him before he
came to the hostel but was also on duty the day before he died. Indeed, she
had witnessed his disruptive behaviour and had initiated contact with the
standby manager about this. She even took the unusual step of ringing the
hostel on the Sunday afternoon to check on his wellbeing, only to be told that he
had been found dead. She did not recall subsequently being offered the support
which was offered to hostel staff.
74. This did not have any negative repercussions for the offender manager who
clearly felt fully supported by her own line manager and was aware of the
bereavement counselling service provided by the London Probation Trust.
However, in future, the needs of all staff including relief workers should be
actively considered when dealing with the aftermath of a death and its possible
impact. One way to do this could be to conduct a staff debrief after the event of
a death.
The hostel manager should review arrangements for supporting staff
involved in a death at the premises and ensure that support is available as
required.
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CONCLUSION
75. The man was a young man with a troubled past which included mental health
problems, drug abuse and periods in prison. He had spent time in approved
premises before he arrived at Tulse Hill in December 2009, and so he was
familiar with the process.
76. He was aware of the dangers of taking drugs after a period in prison, during
which his levels of tolerance to drugs would have decreased. He was reminded
of this by his offender manager when he reported to her on the day he was
released from prison. He had been assessed as presenting a high risk of harm if
he began taking drugs, and his release licence contained a condition that he
should be tested for drugs twice a week. His offender manager had sent a
reminder to staff at the hostel that, if he were to break the conditions of his
licence or not abide by his curfew, procedures should be put in place to recall
him to prison.
77. The hostel manager asked for him to be drug tested as part of his induction, but
a breakdown in communication meant that this did not happen. He spent the
first night in the hostel without incident but, when he returned on the second
evening, he appeared to be under the influence of drugs and was in a belligerent
mood. After initially refusing to sign his curfew sheet, he eventually went up to
his room, setting off a fire alarm as he went.
78. The hostel manager was informed of his behaviour, and she requested for him to
be drug tested in the morning. She also said that if he exhibited any further
problematic behaviour then both she and the police should be informed.
79. Residents should be given wellbeing checks at 11.00pm and 8.45am. The
CCTV footage shows that he was seen at the 11.00pm check, but that the
8.45am check was not done. Nor was the drug test performed. He was not
seen until shortly after 3.00pm, when a member of staff went into his room and
found him already dead. After alerting a colleague and telephoning 999, the
emergency services told her to attempt to resuscitate him. Both staff members
followed this advice and performed CPR until the ambulance staff arrived. The
paramedics confirmed that he had died.
80. I have found that there were three distinct opportunities to check on him during
the two days he was at Tulse Hill. They were the drug tests which should have
taken place during induction and on 6 December as well as the wellbeing check
which was missed later that morning. We will never know whether any of these
interventions could have saved his life, but they were serious omissions which
should never be repeated. I am pleased to hear that the relief member of staff
involved in this case is no longer employed by the London Probation Trust.
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RECOMMENDATIONS
1. The hostel manager should ensure that information regarding important
incidents and actions pending is being communicated between staff as
effectively as possible to avoid duplication and reduce the risk of information
being overlooked.
The Probation Trust has accepted this recommendation. They commented
that if approved premises are followed there should be no difficulties in
communicating information.
2. The hostel manager should review arrangements for supporting staff involved
in a death at the premises and ensure that support is available as required.
The Probation Trust has accepted this recommendation. Having assessed,
they are confident that existing arrangements provide for sufficient support to
be made available.
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