Individual at St Leonards

INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING
THE
DEATH OF A MAN ON 11 APRIL2005, AT ST LEONARD’S, A
PROBATION SERVICE APPROVED PREMISES UNDER THE
MANAGEMENT OF THE THAMES VALLEY PROBATION AREA
Report by the Prisons and Probation Ombudsman for England and
Wales
October 2005
Contents
Introduction
Summary
St Leonard’s Approved Premises
Events leading to the man’s death
Consideration and Conclusions
Recommendations
This is the report of an investigation into the death of a man who died on 11
April 2005. He had been a resident of St. Leonard’s Approved Premises in
Reading for a short time, departing from the hostel the day before his death.
He was on conditional bail. He died apparently at his own hand.
The purpose of my investigation was to discover whether the level of care
provided for him at St Leonard’s was sufficient, and whether there are any
lessons that can be learned to help prevent a similar tragedy in the future.
The man had been recently estranged from his family, but I have no doubt
that his death in such shocking circumstances affected them. I offer his family
and friends my sincere condolences. Although the man’s mother was
contacted by one of my family liaison officers, she did not wish to be involved
in the investigation and I understand and respect her wishes.
Given that he had been at St Leonard’s for only a few days, the man was not
well known to either staff or residents. As he had not returned to the house
on the day before he died, the circumstances of his death were not made
known to the other residents. Staff members were unhappy that they had not
been aware of the extent of his distress.
Two investigators from this office conducted the investigation, with the co-
operation of the Thames Valley Probation Area. I am grateful for the
assistance that the investigators received from the police and, in particular,
from the manager and staff at St Leonard’s. I am conscious that the
investigation placed an extra burden upon the manager and her staff who,
nevertheless, made facilities readily available and participated fully in the
inquiry.
The investigators conducted formal interviews with the hostel manager, the
deputy manager and two assistant wardens. The investigators also examined
documents provided by St Leonard’s. The senior investigator liaised with the
police and spoke on the telephone with the solicitor who had represented the
man in the criminal matter, and with the court duty officer who made the
referral to St Leonard’s.
The responsibility to manage numbers of high risk offenders on a daily basis
is onerous, but I am satisfied that St Leonard’s is managed in a professional
way and staffed by dedicated people. I have found no evidence to indicate
that the man’s actions could have been prevented. However, where
opportunities for general improvement have been identified, I make three
recommendations.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN
OCTOBER 2005
Summary
On 6 April 2005, at Woking Magistrates’ Court, the man admitted to an
offence against a child. He was remanded on bail to be sentenced at the
Crown Court but he was unable to return home. A condition for him to reside
at Approved Premises in Reading was therefore imposed. He was admitted
to St Leonard’s during the evening of the same day.
He was described as a quiet, mild man who conformed to requirements and
caused no problems in the short time he was a resident. It was known that
the circumstances in which his offence was committed and discovered had
led him to experience suicidal feelings, but he gave no indication to staff at St
Leonard’s that he was depressed. On the contrary, he appeared to be in
control of his affairs, and keen to prove to his family that he accepted
responsibility for his actions.
On Sunday 10 April, when he had been resident at the Approved Premises for
five days, he had an amicable conversation with two assistant wardens about
local towns and areas of interest. He then left the premises and was not seen
again. He failed to keep an appointment with his key worker at 7:00pm that
day and, when he had not returned by the 11:00pm curfew, the police were
informed that he had breached his bail.
Later that night, police informed St Leonard’s that the man would be listed as
a missing person. The following morning, staff were informed that there was
concern for his safety as he had contacted his wife telling her of his intention
to take his life.
At approximately 1:30pm on Monday 11 April, police were informed of a
burning body that had been found in woodland. The body was close to a car
containing a suicide note from him indicating that he could not live with the
guilt over the nature of his offence. There were also taped messages
indicating that he had been trying to find the courage to throw himself from
Beachy Head. The body was subsequently identified as the man’s body.
St Leonard’s Approved Premises
1. Approved premises were formerly known as Probation and Bail Hostels
and are approved by the Secretary of State within Section 9 of the
Criminal Justice and Court Services Act 2000. Their purpose is to
provide accommodation for persons granted bail in criminal proceedings,
and in connection with the supervision and rehabilitation of persons
convicted of offences. Approved Premises can provide a supportive,
structured environment in the community for high risk and difficult to
manage offenders. The management of offenders accommodated in
Approved Premises is governed by the National Standards for the
Supervision of Offenders and the guidance contained in the National
Approved Premises Handbook.
2. St Leonard’s is managed by the Thames Valley Probation Area. The
premises consist of a main building together with an annex. It can usually
accommodate 22 residents, although there is a further bed that may be
utilised in an emergency. There are two shared rooms, the remainder
being for single occupancy. The Approved Premises accepts offenders
on bail, those subject to community orders and those on licence following
prison sentences. All those on bail are accommodated in the main house
where there is CCTV and an alarm sounds if the front door is opened
during the hours of curfew. Residents must be over the age of 18, but
any type of offender will be considered.
3. Until about ten years ago, Approved Premises offered accommodation to
offenders who had nowhere else to go but, in recent years the resident
profile has changed. Nowadays, Approved Premises cater largely for
dangerous or serious offenders who are assessed as posing a risk of re-
offending or harm to the public. At any given time, St Leonard’s manages
a number of ‘high risk’ offenders.
4. The house operates a number of day-time projects to ensure that
residents use their time purposefully. All residents are required to
participate in morning and afternoon projects each weekday with the
exception of Tuesday and Friday afternoons. Some are conducted by
hostel staff and some by representatives from the community, such as the
local college. Each resident is required to sign in and out of the house at
all times, and to hand in their room keys when they leave the premises. A
log book is kept of the signing out routine. Residents are also subject to
curfew restrictions, usually from 11:00pm to 7:00am, although other
curfew hours may be enforced if either their court orders or licences
stipulate.
5. The house is usually managed by two Senior Probation Officers, each
based at St Leonard’s for half the week although, at the time of the man’s
death, one half of the post was vacant. The managers are assisted by a
deputy manager, an administrator, and six assistant wardens, with relief
staff on duty at weekends. Each assistant warden acts as a key worker
for a number of residents. Key workers are responsible for monitoring the
behaviour of their residents and for providing advice and encouragement.
They are expected to work with case managers to address offending
behaviour. As those on bail are either un-convicted or un-sentenced,
they do not have a case manager and the key worker’s role is largely
supportive. All permanent members of staff participate in a core training
programme that includes input on the management of risk. At times of
staff shortage, the Approved Premises relies upon the use of agency
staff. At least two experienced members of staff are on duty at all times
during the day.
6. There are two members of staff on the premises each night although both
are ‘sleeping-in’. This is unusual in that many Approved Premises are
staffed during the night by one waking and one sleeping member of staff.
A recent resource review undertaken by the National Probation
Directorate recommended a move towards double waking night cover
and, in the light of this, the Thames Valley area is currently reviewing its
staffing of Approved Premises. Night staff are responsible for checking
the premises to ensure that all is well at curfew and that each resident is
in his room. They do this in pairs and are required to knock, open doors
and enter rooms if the occupant cannot be identified.
Events leading to the man’s death
7. The man appeared at Woking Magistrates’ Court on 6 April and pleaded
guilty to an offence against a child. He was committed to Crown Court for
sentence and, as he could not return home, he was bailed with a
condition of residence at St. Leonard’s Approved Premises. There was a
further condition that he should not attempt to contact the victim or any
witnesses.
8. The court duty officer who interviewed him at court and completed the
hostel referral form was aware that the Crown Prosecution Service had
objected to bail for a number of reasons - including the possibility that the
man could harm himself given the nature of the offence and the likelihood
of a custodial sentence. The Prison and Probation Services use an
‘Offender Assessment System’ (OASys) to identify and assess the level
of risk that offenders pose to the public and to themselves. There is an
initial screening that triggers a full analysis if risk is identified. The OASys
form was completed in full and assessed that he had a current risk of
suicide and self harm.
9. When he arrived in his car at St Leonard’s around 7:30pm on 6 April, the
man had nothing but the clothes he was wearing. It was noted that
arrangements would have to be made for him to retrieve his belongings.
He went through the induction procedure when the rules of the house
were explained to him and he agreed to abide by them. The assistant
warden who inducted him was an experienced member of staff. She told
the investigators that she was aware of the nature of his offence, and
knew that he was a person in crisis as was the case with many residents.
She read the referral form and the OASys screening document but, in her
view, there was nothing on the forms to indicate that he was any more at
risk than other residents and he did not present as depressed or anxious.
10. The assistant warden explained the house’s anti-bullying procedures, and
advised him not to disclose the nature of his offence to other residents.
She said she tried to be as reassuring as she could and referred him to
various information leaflets that were available, including one produced
by the Samaritans. The assistant warden explained that she was to be
his key worker with responsibility to meet him weekly and assist with any
issues that were troubling him. She arranged to conduct the first key-
working session with him four days later (on the evening of Sunday 10
April). At the end of the induction procedure, after more than an hour, he
confirmed that he felt fine and was shown to his room. The man had
been allocated a shared room so that he would not be alone but, in fact,
the other resident failed to return that night.
11. Around 9:00pm, the man left the premises after asking directions to the
nearest public house. During the evening there was a telephone call from
the police at Woking to check if the man had arrived, and the hostel rules
were faxed to the police station. The assistant warden said it is unusual
for police to check if residents have arrived, but she confirmed that their
concern was to ensure he did not bother his family.
12. The man returned in good time for curfew. He smelled strongly of alcohol
but was co-operative and caused no problems. He retired to his room
where he remained until the morning of 7 April. After the morning
meeting, he was allowed to use the office telephone to speak with his
solicitor. The solicitor confirmed that he said he was fine, and the staff
had been supportive. He asked the staff for directions to the nearest
police station where he was required to sign the sex offenders’ register
and, having done so, he returned to the Approved Premises where he
handed in his passport for safe keeping. He asked advice about local
solicitors who could deal with family matters and he left the house.
13. During the day, he telephoned his solicitor again to tell her of the various
arrangements he had made, including making contact with a family
solicitor to deal with his domestic issues. He talked about the need to
sort out his finances, as he had been informed by letter that the Borough
Council had suspended his Private Hire Driver’s Licence, and he would
be unable to work during the period of bail. The solicitor said she was
impressed by how organised he appeared to be.
14. When he returned to St Leonard’s that afternoon, he was asked if he
could produce his vehicle documents to verify ownership but they were at
his home. It was explained that he was not allowed to park on the
premises’ grounds until the documents had been checked. The man took
this in good part and asked advice about the safest, nearby street
parking. That evening, when the assistant warden on duty carried out the
curfew check, she noticed a strong smell of alcohol in the room although
he was asleep. The investigators were told that the use of alcohol off the
premises is tolerated, provided it is not perceived as problematic and
does not cause a resident to be disruptive. If residents return in time for
curfew and are the worse for drink, they are advised to go to their rooms
and ‘sleep it off’.
15. On Friday 8 and Saturday 9 April, he spent much of his time away from St
Leonard’s. The deputy manager recalled a conversation with him when
he chatted about various things. The man told the deputy manager that
he had arranged to see a family solicitor the following Monday, as he
believed his wife would seek a divorce. The deputy manager described
him as a compliant, quiet man with a mild manner who was organised
and able to make his own arrangements with little assistance from
members of staff. The deputy manager was not aware of him interacting
with other residents, but said this was not unusual during the first few
days of residence. He did not perceive him to be any more depressed or
stressed than would be expected of anyone in his situation.
16. When the man returned to St Leonard’s during the evening of 9 April, a
member of staff reminded him that he should complete a numeracy and
literacy assessment form before his required attendance at a basic skills
course on Monday morning. The man asked for the form to complete in
his room so that he would not need to spend time on it the next day. He
did not appear reluctant to complete the form and gave no indication that
he did not wish to attend the course. He returned the completed form
early the next morning.
17. The man left St Leonard’s around 8:45am on Sunday 10 April. Before
doing so he had a conversation with the two members of staff who had
been on duty overnight, commenting on the pleasant weather. He asked
about other towns close by, indicating that he was bored with looking
around Reading and wanted to go further afield. The members of staff
said he did not appear worried or agitated when he left.
18. The key worker said that she was not too worried when he missed his
appointment with her on Sunday evening. She thought she would see
him later and talk about it. However, when he had not returned by
10:00pm the key worker became concerned. When he failed to appear
by the 11:00pm curfew, he was in breach of the Approved Premises rules
and consequently in breach of a bail condition. The key worker was
required to complete the necessary paperwork that would enable police to
arrest him, and she did so immediately. Due to the serious nature of the
breach, the key worker contacted local police by telephone before
midnight. She said she had no reason to be concerned for his welfare,
beyond the fact that he was likely to be remanded in custody.
19. The Approved Premises records indicate that, around 3:15am on 11 April,
police informed staff that a ‘missing person’ report would be made on him
and the following morning police visited the premises. The man’s wife
had advised them that her husband had indicated his intention to take his
life and that he seemed serious. Although a member of staff was able to
say what he had been wearing when he left St Leonard’s, the registration
number of his car could not be provided as it had not been recorded.
20. Later that day, the deputy manager was informed that a body,
subsequently identified as his body, had been found in woods in Sussex.
The man’s car was nearby. Inside was a dictation machine on which he
had left messages indicating that he was trying to find the courage to take
his life. The man had attempted to telephone his wife several times
during the night, and left a note indicating that he could not live with the
knowledge of his offence.
Consideration and conclusions
21. It was the role of this investigation to consider if the risk of self harm had
been properly assessed and managed, and whether the level of care
provided for him during his brief stay at St Leonard’s was adequate. In
doing so, I also considered whether the hostel procedures were
commensurate with the requirements for all such hostels as defined in the
Approved Premises Handbook, and familiar to staff. It was clear that the
premises provide a safe environment for residents who present a high
level of risk. The members of staff interviewed were confident about their
roles and procedures to be followed. Although no residents were
interviewed, the man had told his solicitor of the supportive environment
provided by St Leonard’s.
22. The man’s solicitor told the investigator that the court duty officer who
interviewed the man and referred him to the Approved Premises was
thorough, sensitive, and treated him with respect. On the referral form,
the officer noted that the man told police he had felt suicidal after
committing the offence but, rather than harm himself, he decided, to hand
himself in to police and face the consequences of his actions. The man
told the court duty officer that he had talked of suicide because he felt
guilty and upset after the offence was discovered.
23. From the referral form and the OASys assessment, staff at St Leonard’s
knew that he could pose a risk to himself. However, he had no history of
depression or mental health problems, there were no indications of drug
or alcohol abuse and there had been plenty of opportunity for him to harm
himself, if he wished to do so, before he surrendered to police custody. In
the few days that he spent at St Leonard’s, nothing he said or did gave
staff any reason to suppose that he intended to harm himself. His
solicitor said that she had spent a good deal of time with him and was
convinced that he wanted his family to know that he accepted full
responsibility. She was both surprised and shocked when she heard of
his death.
24. The investigators asked whether all staff would be aware of the risk
assessment. The deputy manager explained that the two assistant
wardens on duty when a referral is received decide whether the person
should be accepted, and their decision is ratified by either the deputy
manager or the manager. The manager said that all members of staff are
expected to familiarise themselves with referrals of new residents and to
draw significant information to the attention of staff on the next shift. The
deputy manager could not say for certain that all members of staff were
aware of this requirement. Commendably, St Leonard’s has since
introduced a system requiring staff to sign a form, stored in the resident’s
file, indicating that they have read all the relevant paperwork.
I recommend that the National Probation Directorate considers
introducing a requirement for all appropriate Approved Premises’
staff to record that they have read and noted relevant information
about residents.
25. All Probation Areas were required by the National Probation Directorate
to devise a strategic plan to reduce incidents of sudden death in
Approved Premises. The Thames Valley area has such a plan in place
and available at its Approved Premises. St Leonard’s has identified a
member of staff responsible for co-ordinating work on self-harm issues.
Since the man’s death, St Leonard’s has developed an ‘emotional well-
being’ form consisting of a yes/no checklist that is completed at induction
and includes reminders about the symptoms of depression. If the form
indicates that a resident has significant problems, a risk management
form is used, similar to the F2052SH in use by the Prison Service for
identifying and monitoring risk of self-harm. I commend this good practice
initiative.
26. The deputy manager commented that not all prisons pass on the
F2052SH form when a prisoner is released, and there have been times
when he has struggled to obtain information necessary for
comprehensive assessment of risk. This is not an issue relevant to the
man who had not been in custody, but it is one that has been identified by
Approved Premises in other areas, and upon which I have commented in
previous reports. At a recent inquest into the death of prisoner, a Coroner
commented that it was the duty of every person involved with an offender,
including health care professionals and legal professionals, to forward
any relevant information that could assist a prison to care appropriately
for a person. If appropriate care is to continue beyond the prison gates, it
is equally important that prisons pass on relevant information to the
Probation Service. I repeat a recent recommendation.
I recommend that the National Probation Directorate and the Prison
Service should work together to produce a protocol for the sharing
of information pertaining to risk where appropriate, on those who
are released from prison and subject to Probation Service
intervention.
27. During his stay at St Leonard’s, the man had the use of his car. In order
to park the vehicle on the premises, he was required to provide proof of
ownership, insurance etc. The man was unable to do so as the relevant
documents were not in his possession and he could not retrieve them
from his home address. Consequently, no details of the vehicle were
noted and, when he was listed as missing, the vehicle registration number
was not immediately available to police. It is unlikely that earlier access
to the registration number would have prevented his death or enabled him
to be found more quickly, but such information could be of assistance in
other situations particularly if residents abscond.
I recommend that the National Probation Directorate requires all
Approved Premises to record the registration numbers of vehicles
being used by residents.
Recommendations:
I recommend that the National Probation Directorate considers
introducing a requirement for all appropriate Approved Premises’
staff to record that they have read and noted relevant information
about residents.
After reading this report in draft, the National Probation Directorate
agreed that staff in Approved Premises should be fully aware of the
relevant information held on a resident’s file and that shift handovers
should be conducted to pass on details of developments. The directorate
will ensure that these points are included in the further guidance currently
being produced for probation Areas.)
I recommend that the National Probation Directorate and the Prison
Service should work together to produce a protocol for the sharing
of information pertaining to risk where appropriate, on those who
are released from prison subject to Probation Service intervention.
The National Probation Directorate has said that this recommendation is
accepted and is already in hand via the guidance being developed to
support the implementation of ACCT, the Prison service’s new suicide
and self harm management framework
I recommend that the National Probation Directorate requires all
Approved Premises to record the registration numbers of vehicles
being used by residents.
The National Probation Directorate has said that this recommendation is
accepted in principle but the directorate will seek legal advice on whether
it can be enforced in all cases rather than on a case by case basis.