Individual at Hopwood House

A Report by the
Prisons and
Probation
Ombudsman
Nigel Newcomen CBE
Investigation into the death of a woman, a resident at
Hopwood House Approved Premises, Rochdale,
in November 2007
Our Vision
To be a leading, independent investigatory body,
a model to others, that makes a significant contribution
to safer, fairer custody and offender supervision.
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This is the report of an investigation into the circumstances surrounding the death of
the woman in November 2007. Police officers discovered the woman in a hotel room
in Sheffield during the late evening. She had been drinking, smoking cannabis and
had taken an overdose of methadone. She had been a resident at Hopwood House
Approved Premises in Rochdale for 11 weeks. She was 41 years old.
This investigation has been undertaken by one of my investigators. I would like to
thank the staff and residents at Hopwood House for their co-operation in this
investigation.
The loss of a family member in such circumstances must be very distressing. This
cannot have been helped by the delay in producing this report, for which I apologise.
My investigator and I offer our sincere condolences to the woman’s family and
friends for their loss.
Although the woman had been subject to self-harm monitoring immediately before
her release from prison, she was considered by the approved premises staff to have
no further thoughts of self-harm and seemed to be coping satisfactorily. There is no
clear indication as to exactly why she took her life, but she had a number of
unresolved issues. It is likely that the separation from her children and her inability
to have contact with them during key events such as birthdays became too much for
her to live with.
I make three recommendations in this case relating to record keeping, risk
assessment of significant dates and the need for managers to attend following
serious incidents.
This version of my report, published on my website, has been amended to remove
the names of the woman/man who died and those of staff and prisoners involved in
my investigation.
Jane Webb
Deputy Prisons and Probation Ombudsman February 2010
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CONTENTS
Summary 5
The investigation process 7
Hopwood House 8
Key events 9
Issues 15
Conclusion 20
Recommendations 21
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SUMMARY
In January 2005, the woman was admitted to a psychiatric hospital. She left the
hospital on 2 March. Later the same day a fire occurred at her home which resulted
in her being charged with arson, being reckless. Although she was granted bail, her
youngest daughter was formally placed in the sole care of her elder daughter. On 29
March, following an argument with her eldest daughter the woman was charged with
threats to kill both her daughters. On 6 December, at Chester Crown Court she was
convicted and sentenced to three years imprisonment.
Whilst she was still in custody at HMP Styal, she was told that her ex sister-in-law
had been given special guardianship of her daughter. She was unhappy about this
and began to self-harm. The woman was eventually released from Styal on licence,
for the second time, on 16 August 2007. Immediately before leaving prison, she had
been subject to the Assessment, Care in Custody and Teamwork (ACCT)
procedures. (ACCT is a prisoner-centred assessment and care planning system for
those at risk of self-harm or suicide. It aims to identify individual needs and offer
personalised care and support before, during and after crisis, in a safe and caring
environment.)
The woman arrived at Hopwood House Approved Premises at about 3.10pm on 16
August. The Senior Probation Officer (SPO) in charge at Hopwood House, told my
investigator that she interviewed her on the afternoon of her arrival as she was
concerned about her being on an open ACCT document. The SPO said the woman
told her that she was relieved to be out of prison and had no suicidal thoughts or
intent to self-harm at that time.
A court hearing took place on 20 September, to determine custody of the woman’s
youngest daughter. The woman’s ex sister-in-law had refused to provide the woman
with photographs of her daughter. This was one of the matters expected to be
resolved at the hearing. An entry made in the woman’s contact log on 19
September, indicated that staff asked her if she wanted to discuss the case prior to
the hearing. (The contact log is used to record all contacts between staff and a
resident.) She declined and asked to be given a “wide berth” on the following day.
There are no further entries in the log relating to either the outcome of the hearing or
the woman’s reaction.
30 October was the birthday of the woman’s son and her daughter’s birthday was the
following week. Three entries were made in the contact log over the next two days
relating to her children and her mood. There is no entry on 2 November relating to
her daughter’s birthday.
The woman left Hopwood House during the morning on 4 November. At about
3.05pm, a friend of the woman who was one of the residents received a text
message from her which read “you have been great, love you”. A few minutes later
a second text was received saying ”text me straight away”. The woman’s friend
telephoned the woman and it soon became clear that she intended to take her own
life. The woman’s friend went to the office and told staff on duty.
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Throughout the day, residents and staff attempted to contact the woman to establish
her whereabouts. She refused to speak with staff. The police tried to trace her by
tracking her mobile telephone. The woman’s body was discovered late in the
evening in November in a Travelodge hotel in Sheffield. Apparently she had taken
cannabis and had been drinking wine. A half empty bottle of methadone was
discovered by her side.
The efforts made to find the woman by residents and the staff on duty at Hopwood
House during the day on 4 November should be commended. Sadly, it is possible
that if she had told her friends where she was she may not have died.
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THE INVESTIGATION PROCESS
1. My investigator made initial contact on 8 November with the SPO in charge at
Hopwood House. During the conversation, the SPO provided my investigator
with a verbal overview of the events. Numerous documents were requested
and either provided immediately or sent to my investigator shortly afterwards.
2. Prior to the investigator arriving at Hopwood House, notices were issued to staff
and residents. They announced the investigation and invited anyone who had
information about the woman’s death to make themselves known. In the event,
three residents came forward.
3. On 21 November, my investigator visited Hopwood House and collected all
other available documents likely to be required for the investigation. Interviews
commenced on the same day.
4. My investigator carried out a total of 11 interviews, eight with staff and three
with residents. All the interviews were recorded and copies of interview
transcripts are attached to this report.
5. One of my family liaison officers contacted the woman’s next-of-kin, her
brother, to explain the scope of this investigation and offer the opportunity to
participate in the investigation. I hope this report helps the family to better
understand the events leading up to her death.
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HOPWOOD HOUSE
6. Hopwood House is an approved premises managed by the Greater Manchester
Probation Trust. Approved premises were formally known as probation and bail
hostels. Their purpose is to provide an enhanced level of residential
supervision in the community for offenders, as well as a supportive and
structured environment. Each approved premises works to national standards
determined by the National Offender Management Services (NOMS).
7. Approved premises provide accommodation for people before and after
sentencing. Offenders are usually housed in such accommodation when there
is a good reason for them not to return to their previous address. There are
seven approved premises managed by the Greater Manchester Probation
Trust. Hopwood House is the only one that provides accommodation solely for
women.
8. Hopwood House accommodates up to 14 residents. Each resident normally
stays for approximately four months, however, at the time of the woman’s death
one resident had been there for over a year. Trained staff work with the
residents to help prevent re-offending and to protect the community.
9. Approved premises are managed by a senior probation officer (SPO). Each
resident has an appointed key worker who supports the resident and ensures
any offence related work is completed.
10. All residents are expected to abide by the rules and regulations of the approved
premises. They include booking in and out when they enter or leave the
premises and observing a strict overnight curfew. During the day, residents are
free to go out unaccompanied and are not required to say where they are
going.
11. Residents who are thought to be at risk of self-harm or suicide are monitored
using a Probation Service Assessment Care and Teamwork plan (ACT). This
is a similar process to the Assessment, Care in Custody and Teamwork
(ACCT) plan used by the Prison Service and has the same aims.
12. While the woman was resident at Hopwood House, she was under the care of a
local community doctor who was responsible for her medical needs. Although
the staff at Hopwood House were aware of some of her medical conditions,
medical confidentiality prevented her doctor from passing on any information.
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KEY EVENTS
13. On 2 March 2005, shortly after the woman had discharged herself from a
psychiatric hospital, she set fire to her own home. She was unhurt but was
taken to the Accident and Emergency department at Macclesfield District
General Hospital (MDGH). One of the doctors at MDGH carried out a review of
her notes from the psychiatric hospital. He considered the notes indicated that
there was no evidence of psychiatric illness. The woman’s diagnosis was
assessed as substance dependency and maladaptive personality traits. She
was placed in police custody and later released on bail.
14. During the day on 29 March, the woman had an argument on the telephone
with her eldest daughter. Her daughter was by this time the sole carer for the
woman’s youngest daughter. As a result of the argument, the woman was
charged with making threats to kill both her daughters. She was remanded in
custody and later released on bail for a short period before returning to custody.
15. On 6 December 2005, at Chester Crown Court the woman was convicted of
threats to kill and arson, being reckless. When summing up the judge said that
the previous four or five years had been tragic for the woman and her family.
He added that her actions on 2 March 2005 were desperately dangerous to all
concerned. They had been followed by threats made to her eldest daughter
some four weeks later. The woman was sentenced to three years
imprisonment.
16. During her time in custody, the woman’s mental health became stable although
there were still concerns about alcohol abuse. Her Probation Service contact
records indicate that she did not seem to think that her drinking was much of a
problem. Some difficulties were experienced finding accommodation for the
woman prior to her release. She had indicated that she did not want to move
into a hostel and wanted a place of her own but this was impossible to arrange.
The woman then told probation staff that she would live with her brother in
Congleton. Prior to her release, the youngest daughter left her sister’s home
and went to live with the woman’s ex sister-in-law in Macclesfield. (She was
the wife of her other brother.)
17. An entry was made in the probation contact records. It said that the woman
wanted to make a will as she intended to kill herself because she had nothing
else to live for. She told one of the probation staff that she would kill herself if
she was forced to go out of the Macclesfield area.
18. The woman was released on licence from HMP Styal on 2 January 2007 and
went to live with her brother in Congleton. Conditions of the licence prevented
her from communicating in any way with her children or her ex sister-in-law. It
was also a requirement that she resided at her brother’s home and address her
alcohol misuse. On 21 February, the woman breached her licence and was
recalled to Styal. A decision was soon made that she would again be released
on a licence, this time with a requirement for her to stay at an approved
premises. The Probation Service had a good deal of difficulty finding a place
for her not only because she was female but also due to the need for her to
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address her alcohol abuse. As there are no female approved premises in
Cheshire, it was planned that she would go to Adelaide House in Liverpool.
This place was later withdrawn and a place was provided at Hopwood House in
Rochdale.
19. Whilst the woman was still in custody at Styal she was told that her ex sister-in-
law had been given special guardianship for her daughter. She was unhappy
about this and began to self-harm. The woman was eventually released from
Styal on licence, for the second time, on 16 August. She was subject to an
open prison ACCT document at the time.
20. The woman arrived at Hopwood House at about 3.10pm on 16 August. She
underwent basic induction training and was allocated a shared room with
another resident. Her assigned probation officer and her key worker. The SPO
in charge at Hopwood House, told the investigator that she interviewed the
woman on the afternoon of her arrival as she was concerned about her being
on an open ACCT document. The woman told her that she was relieved to be
out of prison and had no suicidal thoughts or intent to self–harm at that time.
However, the SPO added that the woman did say that she “might go downhill”
after a few days. The SPO decided that it was not necessary to open an ACT.
At about 3.00am the next morning the woman was awake and chatted to the
night staff. An entry in the staff log indicates that she said she was on “cloud
nine” and could not believe she was out of prison.
21. During the next few days, the woman completed her induction into Hopwood
House. She met her offender manager, probation officer and assigned
probation officer for a three way risk assessment meeting. She began to settle
into Hopwood House. All the appropriate documentation was completed and
supporting entries were made in the probation contact log. Staff made
numerous contact log entries over the following few weeks. It is clear from the
entries that staff were getting to know the woman and her issues. They
included alcohol, bulimia, anxiety and lack of contact with her children.
However, the woman was not sleeping well and, for the benefit of her room
mate, she moved into a single room at the end of August.
22. On 5 September, the woman’s assigned probation officer made an entry in the
contact log. She had telephoned a social worker about an upcoming court
hearing on 20 September, regarding the custody of the woman’s youngest
daughter. The entry mentions that the woman’s ex sister-in-law was currently
refusing to provide her with photographs of her daughter. It was hoped that this
would be one of the matters resolved at the hearing. An entry in the log on 19
September indicates that staff asked the woman if she wanted to discuss the
case, due to be heard on 20 September. She declined and asked to be given a
“wide berth” on the following day. There are no further entries in the log
relating to either the outcome of the hearing or the woman’s reaction to it.
23. One of the other residents at Hopwood House, told the investigator that she
became friendly with the woman on the day she arrived at Hopwood House.
She said that the woman went to bed early each night and would always be up
early in the morning. She added they would sit and have a drink and a chat
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together at 5.00am each day as she went to work early. Their friendship
developed and she told her a good deal of information about her life. They
discussed matters relating to her children, her relationship with her siblings and
her battle with bulimia. The resident told the investigator that the woman was
informed a few days after the court hearing that her ex sister-in-law had been
given sole custody of her youngest daughter and that she took this badly. She
added that the woman began to collect items in a box that were to be given to
her daughter when she grew up.
24. It was the birthday of the woman’s son on 30 October. At 3.00am that day an
entry was made in the occurrence book. It said that she felt sick as it was her
son’s birthday that day and her daughter’s birthday the following Thursday.
There are no other entries in the occurrence book relating to the matter that
day. On the same day, the resident made an entry in the probation contact log
as the woman had told him she “felt down”. She had said that it was her son’s
birthday that day and her daughter’s birthday the following week. The entry
goes on to say that she agreed to use all available support over the difficult
period. Three entries were made in the contact log over the next two days
about her children and her mood.
25. On 2 November, the day of her daughter’s birthday, there is another entry in the
occurrence book, again at 3.00am. This entry reads, “She is depressed as it is
her daughter’s third birthday today and she says she hasn’t seen her since she
was six months old”. There are no further entries relating to this matter on that
day and no entry in the contact log on 2 November about her birthday either.
However, there is an entry on that day to the effect that the woman told staff
she had a date with two men the following day and would go out with the first
one that brought her flowers. During the evening of 3 November, she told staff
that she had been on a date and would be seeing the man again. Another
entry the same day says there were no issues with the woman at that time.
26. A second friend told the investigator that the woman had hoped to get a
telephone call from her son. She had sent him her telephone number in his
birthday card but did not receive a call. On 2 November, the woman had hoped
to receive a telephone call from her daughter’s father to let her know how her
birthday went. Again, she did not receive a call. The women’s second friend
said the woman cried and was very upset by this.
The events of 4 November
27. At about 3.00am on Sunday 4 November, the woman was awake and asked
the night staff if she could put some washing on as she had been sick after
eating a Chinese meal, cream cakes and chocolate. At about 7.50am that
morning, she was discovered using a vacuum cleaner in her room. Staff asked
the woman to stop as residents were allowed to sleep in on Sundays until
10.00am.
28. The woman’s first friend told the investigator that it was normal for the woman
to text her early in the morning at weekends, however, she did not text that
morning. The woman’s first friend found her ironing her bedding in the laundry
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room at about 8.45am. She spoke to the woman, who answered in a voice that
the first resident described as “proper high”. She thought that there was
something wrong as she seemed to be “off” with her. She spoke to another
resident who told her that the woman had been told off for hoovering her room
before 8.00am. The woman’s first friend made the woman a drink and took it to
her. However, the woman told her she had things to do and would drink it in
her room. The woman’s friend waited until about 10.00am for her to return and
then decided to go back to bed.
29. The weekend residential services worker was the second member of staff on
duty on the day. She carried out a check of residents at about 10.30am. She
told the investigator that she saw the woman on her bed writing letters. When
she asked what her plans were for the day, she replied that she was going out
for lunch with a man. They had a brief discussion and then weekend worker
left the room.
30. The woman left Hopwood House during the morning. The contact log indicates
that she left at 10.36am, however, an entry on the booking in and out sheet,
presumably made by the woman herself, indicates that she left at 11.15am.
The woman’s friend told the investigator that the woman had planned to catch a
bus at 11.15am and so she believed she would have left at about 11.10am. A
Residential Service Officer (RSO), who was in charge that day, thought that
she had left at about 11.15am.
31. At about 3.05pm, the woman’s first friend woke up with a start as her telephone
received a text message. The message was from the woman and read “you
have been great, love you”. Initially, the friend thought the message had been
sent to her accidentally and that it was intended for the woman’s brother.
However, a few minutes later, a second text was received that read ”text me
straight away”. She telephoned the woman who told her she was not coming
back and that she was far away. Initially the friend thought she was simply not
going to return to Hopwood House and told her that she would be looking over
her shoulder. The woman replied “No I won’t, and I’m not going to be here”.
The friend then went to the office and spoke to the ROS in charge that day.
32. The ROS in charge that day said she thought that the woman’s friend went to
the office at about 3.10pm. She said the woman’s friend was in tears, holding
her mobile telephone and said “she is going to do it”. A short conversation
followed. The woman’s friend said that the woman had bought a bottle of
methadone and some wine and was going to end her life. The ROS checked
the woman’s room to confirm that she was not in and then contacted the duty
SPO for advice. She was advised to gather as much information as she could
and telephone the police.
33. Throughout the afternoon, the woman’s first and second friends regularly spoke
on the telephone to the woman, each time trying to glean more information
about her whereabouts. She told them that she had bought methadone from a
friend, a former prisoner at HMP Foston Hall, and was in a flat in Burton-upon-
Trent. The RSO in charge that day told the investigator that she attempted to
contact the woman but the call went straight to the answering service. The
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second weekend worker asked one of the friends to ask the woman if she
would speak to her but she refused to to do so.
34. A police officer arrived at Hopwood House at about 4.00pm and searched the
woman’s property with the RSO in charge that day. They discovered a variety
of documents that clearly indicated that she had intended to end her life. They
included a copy of her will, money for a funeral and letters to her solicitor and
brother. The police began the search for the woman, including attempting to
trace her through her mobile telephone. The woman’s second friend was
asked to try to get as much information as she could from her whilst the RSO in
charge that day gathered information for the police, contacted her line
managers and managed the office. The second weekend worker remained
with the residents and tried to keep them calm as they attempted to contact the
woman. During conversations with her, she initially led them to believe that she
was in Burton-upon-Trent then possibly at a friend’s home in Barnsley. The
search for the woman focused on identifying the friend’s address.
35. Sometime between 5.00pm and 5.30pm, the woman’s second friend spoke to
the woman who told her that she had purchased a bottle of champagne on her
”tab”. This information was passed to staff as residents then thought it was
likely that she was somewhere in a hotel. The RSO in charge that day, in turn,
passed the information to the police. At about the same time, the police officer
told the RSO that the woman’s telephone signal had been located somewhere
in Sheffield.
36. During the telephone conversation with the second friend, the woman said that
she would like to speak to her brother. The woman’s first friend telephoned the
woman’s brother, explained the situation and asked him to call his sister. In
addition, the second friend said that the RSO in charge that day also spoke to
the woman’s brother using her telephone. She added that staff later told her
that he had spoken to the woman and she had sounded drunk. The RSO in
charge that day said that contact with the woman eventually ended at about
7.30pm. She was told by the woman’s first friend that her speech was very
slurred at that time.
37. Sometime during the afternoon, the RSO in charge that day telephoned the
senior probation officer in charge at Hopwood House at home and told her that
the woman was missing. The senior probation officer offered her support but
did not go to the premises as she was going out. At about 8.00pm, the RSO in
charge that day again spoke to the SPO. They talked for about half an hour
and the SPO again offered support.
38. The second weekend worker went off duty at about 8.40pm. At that time,
police had narrowed the search area to within one square kilometre of the
woman’s location. The RSO in charge that day briefed the oncoming staff
before she went off duty at about 9.30pm, but no further information had been
received at that time.
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39. The woman’s first friend told the investigator that she continued to call the
woman’s mobile telephone throughout the evening. The first staff on duty
overnight said the police rang her at about 9.30pm and asked for her details as
they had been checking the woman’s telephone records. At about 9.50pm, the
police informed the friend that the police had narrowed the search to within a
very small area. The friend said she went to bed thinking “they may find her in
time”.
40. Two staff on duty overnight at Hopwood House. After receiving handovers from
the staff going off duty, they spoke with residents and carried on their normal
duties. They received telephone calls from the SPO in charge at Hopwood
House and the duty SPO. Both asked if there was any news and offered
support. At about 11.00pm the police officer arrived at the premises and told
the staff that the woman’s body had been found at a Travelodge hotel in
Sheffield. Apparently, she had taken cannabis, drunk wine and a half empty
bottle of methadone was discovered by her side. The second night duty staff
telephoned the SPO in charge at Hopwood House and they discussed how to
inform the residents. The SPO in charge of Hopwood House decided they
should not be told until the morning and arranged to come in early the next day
to talk to residents and staff.
Follow-up action
41. The SPO in charge arrived at Hopwood House at approximately 7.30am on 5
November. She told the investigator that this was about an hour earlier than
normal as she wanted to speak to staff and certain residents who she was
concerned about. She also intended to talk to all the residents at their 9.00am
group meeting. She informed all the relevant authorities and followed the
Death in Approved Premises Circular Instruction. She arranged for the local
Crisis Intervention Team to visit to carry out a critical incident debrief.
42. The Director of Interventions and Support Services, and the Area Manager,
also went to Hopwood House that day to offer support and advise staff of the
availability of individual counselling and the Crisis Intervention Service.
43. The police had told the woman’s brother of her death during the evening on 4
November. Her brother attempted to confirm this with Hopwood House staff
but was advised to telephone the following morning after 9.00am. The SPO in
charge of Hopwood House spoke to him during the morning on 5 November.
After a brief conversation, they agreed that he would collect items removed by
the police and then visit Hopwood House for the woman’s other belongings.
Two days later, the visit took place and the woman’s brother received the
remainder of her property.
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ISSUES
Risk of suicide and self-harm
44. It is clear from documents and information provided during interviews that staff
at Hopwood House were fully aware of the woman’s self-harm history before
she became a resident. Staff had received the appropriate training and ACT
documents were available at Hopwood House to be used, if required.
45. There are 140 entries in the woman’s Probation Service contact log from her
initial court appearance in December 2005 until her death. The entries cover a
variety of topics. They demonstrate that staff were supporting the woman to
manage her eating disorder effectively and that her medical needs were being
addressed through a local community doctor. Regular entries were made and
most concerns were identified and documented. It is also evident from the
records that considerable time was devoted to helping the woman cope with
her life.
46. Entries made in the probation contact log on 16 August, the day the woman
arrived at the premises, confirm that staff knew she was on an open ACCT
document when she was released from Styal and had attempted self-harm by
using a ligature about eight weeks before. At interview, SPO in charge at
Hopwood House told the investigator that she discussed self-harm with the
woman on the day of her arrival and she said that she “might go downhill” after
a few days. Unfortunately, there is no record of that meeting in the contact log.
There is however, a note of a meeting between them the following day. The
notes of that meeting indicate that the SPO in charge at Hopwood House
assessed the woman’s wellbeing as she had been on an ACCT document. The
notes confirm that she was coping well and would be further assessed the
following Monday at the three way risk management plan meeting with her
assigned offender manager.
47. The woman went to the risk management meeting on 20 August. The woman’s
assigned probation officer made an entry about the meeting in the contact log
but it did not include any specific reference to the history of self-harm. On 21
August, the SPO in charge at Hopwood House made an entry in the contact log
about a meeting between the woman and a social worker. The entry indicated
that she was not expressing any thoughts of self-harm at that time and was
managing to cope with most issues. It went on to say that the trigger for her
self-harm tended to be when she dwelt on her own responsibility for the
separation from her children.
48. The woman told her first friend that she had thought about suicide quite a few
times whilst she was in prison because she could not live without her children.
The woman’s friend went on to say that the woman told her every day that she
still found it difficult to live without them, in particular her youngest daughter.
49. When asked if she had noticed any recent signs that the woman might be
considering taking her own life, the woman’s first friend told the investigator
about a conversation a couple of months earlier. The woman had told her how
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easy it would be to buy a bottle of methadone for £1,000. The first resident
challenged the woman who told her about the residence order for her youngest
daughter. A few days after the hearing, which took place on 20 September, the
woman was told that her sister-in-law had been given custody. The friend
added that they did not get on well together and the woman felt she would not
see her daughter again.
50. A few days before she died, the woman asked her first friend if she knew a
good solicitor as she wanted to make a will. The friend was surprised by this.
She asked if she thought she was a bit young and the woman replied “no”. The
friend said she realised that the woman was serious and the conversation came
to an end. The woman also bought a new set of clothes and a top as a gift for
the friend. Again, she thought this was unusual. They went out together on the
Friday evening before the woman’s death which was the birthday of her
youngest daughter. She paid for a meal for them both wanted to have some
wine with her as she said she would not get the chance to drink with her again.
51. The woman’s first friend said she did not realise the significance of any of these
events until after the woman’s death. With hindsight, she believed that the
woman had planned everything. She told the investigator that she felt the
woman could not continue to live her current lifestyle and she wanted her old
life back. A day did not go by without her talking about her children and her
brother. It is clear that the first friend was very close to the woman and was
well aware of her problems. However, the friend did not share this information
with staff. She told the investigator that neither she nor the woman was the
type of person to go to the office unless they had to.
52. The woman’s key worker told my investigator that the woman had not
discussed her offence in any detail. Her work with the woman focussed mainly
on self-harm issues. They included discussions on bulimia and anorexia. The
woman’s key worker had told her that she never felt in control and that
managing her diet gave her that control.
53. I am satisfied that appropriate efforts were made by staff to support the woman
at Hopwood House. In particular, staff were aware of the significance of
particular dates and events. There is evidence that staff considered placing the
woman on ACT monitoring but decided against doing so as she appeared to
coping. Evidence also shows that staff were aware of the significance of the
custody hearing on 20 September, although I am surprised that there does not
appear to be an entry in the contact log about the result.
54. Staff were also aware that two of the woman’s children had birthdays during the
week before she died. I am concerned that there is no entry in the log relating
to her youngest daughter’s birthday on 2 November. The woman’s key worker
made an entry in the contact log on 31 October which read:
“The woman looks better than she did yesterday and tells me that she
feels better, just down because of her son’s 18th birthday yesterday and
she was hoping he would phone her. Her daughter’s birthday on
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Friday 2nd. Hostel staff are aware D will need some support to get
through this day.”
The woman’s key worker was not on duty again after 2 November until after the
woman’s death. There are no further entries relating to her daughter’s birthday
in the log.
55. A further entry in the contact log for 2 November refers to a risk management
meeting but no details are provided. The woman’s assigned probation officer,
told the investigator that staff were concerned about her bulimia and her health
seemed to be deteriorating. When the investigator asked if she was aware that
it was the woman’s youngest daughter’s birthday that day she replied “yes”.
There is evidence that staff were also aware of the birthday on 2 November and
it is also possible that they discussed it with the woman. There is however no
documentary evidence to confirm that staff either read the woman’s key
worker’s note or acted on it. I consider that an entry should have been made
on the day to both confirm that the entry by the woman’s key worker had been
read and that it had been acted upon.
56. Had the woman been placed on an ACT document when she arrived at
Hopwood House, significant dates and events, such as birthdays, are likely to
have been identified and then managed when they arose. The entries in the
contact log merely relate to the dates. They do not contain any evidence of
how the impact would be managed.
57. I consider that when an individual with a history of self-harm or attempted
suicide is received at an approved premises, a note of significant dates likely to
have a negative impact on them should be made. The possible impact and the
vulnerability of the individual at the time of the significant date should be risk
assessed and a plan put in place to manage the individual appropriately
throughout the relevant time period. This should happen irrespective of
whether or not the individual is placed on an ACT document when they arrive.
The Probation Service should ensure that dates of particular significance
to a resident who has previously self-harmed should be recorded, risk
assessed and managed effectively. When an entry is made in a
individual’s contact log relating to a possible trigger point for self-harm,
such as a key date, a plan should be devised and recorded to manage the
individual through the particular event.
Record keeping
58. The occurrence book contains daily entries about a range of issues about the
residents at Hopwood House. Two significant entries were made in the early
hours of each morning of the birthdays of the woman’s two youngest children.
One entry clearly states that the woman said she was depressed. I can find no
evidence to confirm that any of the staff on duty the relevant days either saw
the entries or acted upon the information. I believe if staff had read the
information, it is likely that either an ACT document would have been opened or
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details of an in depth conversation with the woman would have been made in
the contact log.
59. It is essential that the information contained in the occurrence book is read on a
daily basis by an appropriate person. Any follow up action should be noted in
the occurrence book and a more in depth entry should be made in the
individuals contact log. I believe it should be the responsibility of the manager
in charge of Hopwood House to ensure that this process is followed. Written
evidence that the manager has checked the log should also be provided.
The Probation Service should ensure that the manager of the approved
premises checks the occurrence book each day and ensures that all
entries have been read and arising issues dealt with. The manager
should then sign the book to confirm that the check has taken place.
The events of November
60. The first resident was distressed and crying when she entered the office, at
about 3.25pm in November, and informed staff that the woman was missing
and threatening to take her own life. Over a period of several hours, along with
other residents, she was in contact with the woman attempting to gather
information that might help the police locate her. The staff on duty at Hopwood
House that day not only had to carry out their routine tasks but in addition had
to manage information from residents to be passed to the police who were
attempting to locate the woman. This is likely to have placed both the residents
and the staff under considerable pressure. The senior probation officer in
charge at Hopwood House was told during the afternoon that the woman had
told residents that she had taken an overdose and that police were attempting
to locate her. The duty SPO was also kept informed.
61. Both staff on duty left the premises at the end of their shifts whilst the search for
the woman continued. It is likely that they were suffering from the stress of
coping with several hours of intense incident management at the time.
Residents at Hopwood House also spent several hours involved and are also
likely to have been distressed when going to bed that night. A Probation
Service manager did not attend either during the afternoon or in the evening
before they had been made aware that the woman had died.
62. I consider this was a mistake. It is likely that both residents and staff would
have benefited from the presence and support of a manager as soon as they
were informed that the woman had taken an overdose. The duty SPO should
be responsible for ensuring a manager’s attendance. However, the late return
of a resident rarely has such a tragic outcome and so I make no
recommendation here. The Chief Probation Officer will wish to consider my
remarks.
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Follow up action
63. On 5 November, the woman’s first friend got up at 5.30 to go to work. She
asked if there was any news and was informed that they had not heard
anything yet. She left Hopwood House and went to work. She told the
investigator that she had little sleep and was worried about the woman. The
SPO in charge at Hopwood House arrived at about 7.30am and spoke to staff
on duty and most residents.
64. When a death occurs a debrief is normally carried out. They are primarily
carried out to ensure that staff have the opportunity to discuss emotive issues
following serious events before they go off duty. In this case, the staff who
went off duty before the woman was discovered and would not have been able
to attend. However, along with residents of Hopwood House who were
involved in the event, they may well have benefited by being informed on the
night of the woman’s death.
65. Neither Probation Circular 60/2005 “New procedures for monitoring deaths
under supervision” nor 18/2004 “Deaths of approved premises residents”
identifies a requirement for a manager to attend an approved premises in the
event of a death in custody of a resident. A “Practice Notice” document does
give some additional guidance to be followed following the death of an
approved premises resident. At paragraph four, the document says that the
SPO should “De-brief approved premises staff on the same day if possible”.
66. I recommend there should be a formal requirement to do so. It is my opinion
that a SPO should go to the approved premises when it is discovered that a
resident has died. This should be the relevant approved premises manager or
the duty SPO if the manager is not available. Their role should be one of
supporting staff and residents, conducting a “hot” debrief and managing the
follow up action.
The Probation Service should ensure that a manager attends the relevant
approved premises immediately after being informed that a resident has
died.
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CONCLUSION
67. It appears that the woman convinced staff at Hopwood House that she had no
intentions of taking her own life once she had left prison custody. Staff effectively
managed any risk of self-harm linked to her eating disorder. The woman’s key
worker and both her friends knew a great deal about her and her battle with
bulimia. More significantly, her friends knew of her concerns that she would not
see her children again. However, there is no evidence to suggest that the
woman went into any detail about her children after the custody hearing on 20
September. It is possible that she developed the plan to take her life sometime
after she became aware of the result of that hearing.
68. The woman appears to have been distraught during the last week of her life
when she did not receive any news of her children on their birthdays. It is
possible that she then finally decided to take her own life. Various individuals
held pieces of information about the woman. If all the information had been
available to one person, it is more likely that it would have been acted on.
69. It seems that the woman intentionally went to an area well away from her friends
and then gave them wrong information about her whereabouts to prevent them
from intervening. The efforts made by residents at Hopwood House and the staff
on duty during the day to find the woman should be commended. Had she told
her friends where she was on that day, when they desperately tried to find her,
she may not have died.
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RECOMMENDATIONS
1. The Greater Manchester Probation Trust should ensure that dates of particular
significance to a resident who has previously self-harmed should be recorded,
risk assessed and managed effectively. When an entry is made in an individual’s
contact log relating to a possible trigger point for self-harm, such as a key date, a
plan should be devised and recorded to manage the individual through the
particular event.
Greater Manchester Probation Trust response:
Due to the time that has lapsed since the death of the woman, new instructions
were issued some 12 months ago which cover this recommendation. Accepted.
2. The manager of the approved premises should check the occurrence book each
day and ensure that all entries have been read and arising issues dealt with. The
manager should then sign the book to confirm that the check has taken place.
Greater Manchester Probation Trust response:
This is not feasible. Each Approved Premises has one SPO and 1 PO – if they are
available they read and sign the log book as a matter of routine. There will be
occasions, however, when neither are available for legitimate reasons. Despite
reservations about this recommendation, SPO/PSOs in the division will be
reminded of the priority to be afforded to this task.
3. Greater Manchester Probation Trust should ensure that a manager attends the
relevant approved premises immediately after being informed that a resident has
died.
Greater Manchester Probation Trust response:
The death took place, off site, late into the night shift. The SPO in charge at
Hopwood House was not on duty but was involved throughout the night and
attended at 7.30am the following morning. She discussed the situation with staff
and the ‘out of hours’ SPO, and her assessment that there was no need for her
immediate attendance is supported by senior mangers in GMPT. Sadly there have
been previous deaths in Approved Premises in Greater Manchester and in these
cases the SPO has routinely attended. There must be room for assessment of
individual circumstances, however and therefore this recommendation is not
accepted.
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