Individual at Quay House

Investigation into the circumstances surrounding the
death of a man, a resident at
an Approved Premises in the
Wales Probation Trust, in January 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2010
This is the report of an investigation into the death of a man, a resident of an
approved premises in the Wales Probation Trust. The man died in his room in
January 2010, just five days after arriving from HMP Guys Marsh. He was 33 years
old. A post mortem established the cause of death as respiratory depression due to
a combination of illicit drugs. I offer my sincere sympathy and condolences to the
man’s family for their loss, as I do to all those who have been affected by his
passing.
The investigation was carried out by one of my colleagues. I would like to thank the
staff at the approved premises for their full and ready co-operation with the
investigation.
The man had a long history of drug misuse, for which I am surprised that he received
no treatment during his last period in prison. Following his release from Guys Marsh
to the approved premises, staff suspected that he was misusing drugs again.
However, he was engaging with the local drug agency and had been honest with
staff regarding the prescription medication he had obtained. Staff described him as
polite and determined to stop offending.
When the man returned to the approved premises on 9 January, he appeared dazed
and confused and staff therefore conducted a drug test, which showed that he had
taken opiates. He had already tested positive for cannabis and benzodiazepines
that morning. Following these positive tests, staff should have told the manager. I
make a recommendation in this regard and in ensuring that earlier drug tests take
place as directed by local policy, since the man should first have been drug tested
when he arrived at the approved premises.
When staff checked the man in his room at 11.00pm that evening, they discovered
he had vomited on his bed and was lying fully clothed on top of the covers. They
placed him in the recovery position and monitored him throughout the night. At
8.00am, staff discovered he had again vomited in his sleep, cleared his airway and
placed him in the recovery position. When they checked the man two hours later he
had stopped breathing and attempts to resuscitate him were unsuccessful.
Staff had clearly considered the man’s condition, as evidenced by their monitoring of
him throughout the night. However, it is my conclusion, that they did not understand
the seriousness of his condition. He was dazed, confused, had tested positive for
opiates and vomited twice in his sleep. I believe that an ambulance should have
been called when they discovered he had vomited on the first occasion. While it is
impossible to know if this would have led to a different outcome, it does, at the very
least, represent a serious lapse in the quality of care the man received at the
approved premises.
I will copy my report to the Governors of HMP Swansea and HMP Guys Marsh in
relation to my comments about information sharing on drug treatment.
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This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and residents involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman December 2010
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CONTENTS
Summary
The investigation process
The Approved Premises
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
On 1 October 2004, the man was sentenced to six years and six months
imprisonment at Crown Court. He was released from HMP Erlestoke to an approved
premises on 20 March 2009. Just over a month later, he transferred to a further
approved premises, to be nearer his partner. Following concerns regarding the
man’s breathing, he was taken to hospital on 23 May and was subsequently
diagnosed with pneumonia. He discharged himself four days later and did not return
to the approved premises. He was therefore recalled to prison, arrested by police
and taken to HMP Swansea the following day.
The man transferred to HMP Guys Marsh on 29 July. He remained there until he
was released back to the approved premises on 5 January 2010. During the period
of his recall, he was not regarded as a priority for drug treatment and therefore did
not receive any input until just before his release. I find this surprising, given the
man’s long history of drug misuse and consider this issue further in the report.
However, I am pleased to note that prior to being released he was given appropriate
information regarding harm minimisation and the risk of overdose and an
appointment was made with the local community drug service.
On his arrival at the approved premises, the man was given a one-to-one induction
by his keyworker. However, he was familiar with most of the rules, due to his
previous stay at the approved premises and a number of staff also knew him. All the
staff who spoke to my investigator, described the man as a polite and courteous
resident who seemed to have matured and wanted to change his lifestyle. The man
disclosed that he had last misused drugs in prison on 25 December. The keyworker
therefore took the decision not to drug test him on his arrival, since she thought the
drugs he had taken in prison would lead to a positive result.
The following day, the man attended his appointment with a support worker at the
local community drug service and with his offender manager at the local probation
office. He told them both that he wanted to obtain a diazepam prescription. On 7
January, he registered with a local general practitioner (GP) surgery and was
prescribed diazepam. He had not told approved premises staff where he was going
and had not registered with the agreed surgery, as required by the approved
premises rules. Nevertheless, on his return to the approved premises, the man gave
his medication to staff as required.
The man was out of the approved premises for most of the following day. When he
returned, staff observed that he was unsteady on his feet and sleepy, but the man
said he was still getting used to his newly-prescribed medication. On 9 January, he
was drug tested for the first time. The result was positive for cannabis and
benzodiazepines. No action was taken as staff attributed the result to his prescribed
medication and the cannabis he had disclosed that he had recently taken in prison.
When he returned to the approved premises that evening, he appeared dazed and
confused. Staff were concerned that he had misused drugs and so more tests were
carried out. The result was positive for opiates.
Staff emailed the man’s offender manager and the approved premises’ deputy
manager but immediate enforcement action was not considered necessary. Since it
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was a Saturday, these two members of staff would not have received these emails
until Monday morning. An on call manager should have been telephoned and I
make a recommendation in this regard.
When staff checked the man in his bedroom at 11.00pm, they found that he had
vomited in his sleep and was lying fully clothed on top of the bed covers. They
cleaned him, checked his airway, placed him in the recovery position and decided
that he should be monitored hourly. This continued hourly until 6.00am, when the
observations were decreased to every two hours. When he was checked at 8.00am,
the man had vomited in his sleep. Again staff cleaned him, cleared his airways and
put him in the recovery position. When he was checked two hours later he had
stopped breathing. An ambulance was called while one member of staff and a
resident attempted to resuscitate him. Whilst this member of staff responded quickly
and professionally, they were not aware of the current guidelines from the
Resuscitation Council and I make a recommendation in this regard. Soon after the
paramedics arrived, the man was pronounced dead.
According to local policy and national advice available from NHS Direct, an
ambulance should have been called much earlier, either when the man returned to
the approved premises dazed and tested positive for opiates, or when staff
subsequently discovered he had vomited in his sleep. All the staff involved were first
aid trained and had clearly considered the situation, as evidenced by their decision
to monitor him throughout the night. Seemingly, they did not comprehend its
seriousness. I make two recommendations in this regard, with the aim of ensuring
staff are fully equipped with the knowledge and confidence to act appropriately in
such emergency situations in the future.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 13 January 2010, when the investigator
visited the approved premises and issued notices announcing the
investigation to staff and residents. The notices included an invitation to those
who wished to submit information related to the man’s death to make
themselves known to the investigator. No one came forward as a result.
During the visit, the investigator was taken around the approved premises,
including the room the man had lived in, and met several members of staff.
2. My investigator was given access to the man’s files, from both the approved
premises and HMP Guys Marsh. She later returned to the approved premises
on 16 and 17 February and conducted interviews with ten members of staff
and one resident. The investigator also conducted a telephone interview with
a member of staff at Guys Marsh.
3. The investigator met the Assistant Chief Officer (ACO) on 17 February to
provide him with an update on her investigation. A summary of the issues
discussed was provided to the Assistant Chief Officer who responded to the
investigator in writing. I am grateful to the Assistant Chief Officer for his
consideration of the issues presented at this early stage of the investigation.
4. One of the Ombudsman’s family liaison officers wrote to the man’s mother on
20 January, to inform her of the investigation and invite her to raise any issues
she wished the investigation to address. My investigator and the family
liaison officer visited the man’s mother on 9 March. She was concerned that
the man had not been deemed in breach of his licence straight away and
returned to prison when he provided a positive drug test. She also asked why
medical assistance had not been called on discovering the man had vomited
at 11.00pm on the eve of the man’s death or at 8.00am on the morning of the
man’s death. I hope that this report helps the man’s family to better
understand what happened in the time leading to his death.
THE APPROVED PREMISES
5. The purpose of an approved premise is to provide an enhanced level of
residential supervision in the community for offenders assessed as presenting
a high risk of harm, within a supportive and structured environment. Whilst
residents have to comply with their individual licence or bail conditions,
curfews, and the approved premises’ house rules, they are essentially free to
come and go from the building. All residents at the approved premises are
subject to curfew at night.
6. The approved premises in which the man died is one of around 100 approved
premises in England and Wales. At the time of the man’s death, it was one of
two in the South Wales Probation Area. The four Probation Areas in Wales
merged on 1 April 2010 to form the Wales Probation Trust.
7. The approved premises in which the man died accommodates up to 25
residents in single rooms. It is staffed 24 hours a day by probation
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employees, whose role is to provide support and ensure that residents comply
with the rules and licence or bail conditions. The two approved premises in
the South Wales Probation Area share a manager, who divides their time
between the premises which are 40 miles apart. Each approved premises
has a deputy manager who is based there permanently.
8. There are several members of staff on duty during normal office hours. After
5.30pm and at weekends, this is reduced to two members of staff. During
these hours there is also a deputy manager or manager and assistant chief
officer who are on call and contactable in case of an emergency or if a
decision needs to be made regarding a resident.
9. Each resident is responsible for their own health. If they require a
consultation with a doctor or visit to hospital then, unless it is an emergency,
the onus is on the resident to arrange the appointment. During their stay,
residents are required to register with a doctor at a surgery. At the time of the
man’s death, all medication was held by the approved premises’ staff and
locked in the office. Residents had to request their medication, sign for it and
consume it in front of staff. Following the implementation of new national
guidance (Approved Premises: Probation Instruction 09/2009) this system has
now slightly changed. Following an individual risk assessment, some
residents can now keep some medication in their own possession.
10. This is the first death to occur at this particular approved premises since April
2004, when the Ombudsman’s office began investigating all deaths in
approved premises in England and Wales. There was a second death at this
particular approved premises two months after that of the man who is the
subject of this report. This was due to a heart attack. There are few
similarities between the circumstances of the two deaths.
11. My office previously investigated a death at another approved premises, the
other AP in the former South Wales Probation Area, in September 2008. The
report made two recommendations. Firstly, that all staff be trained in basic
first aid, with consideration given to training all staff in cardio-pulmonary
resuscitation (CPR). Secondly, the Ombudsman recommended that the Chief
Officer should review arrangements for supporting staff following the death of
a resident. I am pleased to report that this investigation found that all the staff
at the approved premises are trained in first aid and CPR and that staff felt
fully supported following the death of the man. However, despite this training,
there were issues with the decision-making by staff which will be discussed
further in the report.
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KEY FINDINGS
12. At the age of 16, the man left school without any qualifications. He had never
worked. The man’s mother said that he was a happy and outgoing person,
who was always willing to help others. He had two children, aged eight and
nine years. He was trying to re-establish contact with his children following
his release from prison.
13. The man had a long history of offending, dating back to 1990, when he was
14 years old. He misused drugs from an early age and much of his offending
was related to his substance misuse, either committed to fund his habit or
whilst under the influence. He had been in prison on several occasions prior
to his most recent sentence.
1 October 2004 – 4 January 2010
14. The man was sentenced to six years and six months imprisonment at Crown
Court on 1 October 2004. Having served his period in custody, the man was
released, on licence, from HMP Erlestoke to an approved premises on 20
March 2009.
15. As an offender on licence, the man had to meet with his offender manager
each week to address issues assessed as relevant to his offending. These
sessions mainly focussed on the man’s drug misuse, lack of suitable housing,
his relationship with his partner and access to his children. The Approved
Premises Service Officer (APSO), told my investigator that he remembered
the man from previously working at another approved premises. He said that
staff had concerns that he was misusing diazepam, an anti-anxiety drug, at
that time.
16. The man was transferred to his current approved premises to be nearer his
partner on 27 April. Around a week later, he was assessed by a Criminal
Justice Mental Health Liaison Nurse. She is based at the approved premises
one afternoon per week and completes mental health assessments on new
residents. On the basis of this assessment, she wrote to a doctor at the
surgery to inform him that the man had been released from prison with a
pregabalin prescription for anxiety. She said that he had no mental health
issues or history of self-harm or suicide.
17. On 14 May, the man had to be carried to his room by two other residents.
When the night supervisor checked on him he was ‘out cold’. The night
supervisor therefore stood him up and spoke to him to ensure that he did not
require any medical attention. The man denied misusing drugs.
Nevertheless, staff monitored him throughout the night to ensure his condition
did not deteriorate.
18. Staff subsequently became concerned about the man’s breathing and he was
admitted to hospital around two weeks later with suspected pneumonia. He
remained in hospital for four days until he discharged himself on 27 May.
Since he did not return to the approved premises or attend his supervision
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appointment, his offender manager completed the paperwork later that day for
the man to be recalled to prison. This was approved by the Parole Board.
Police arrested the man and he was taken to HMP Swansea the following
day.
19. Prison records note that the man asked for an appointment with the
Counselling, Assessment, Referral and Throughcare service (CARATs), the
prison drug misuse service, on 10 June. The CARATs team completed an
assessment and decided the man needed low level intervention, gave him
some worksheets to do in his cell regarding his cannabis misuse and put him
on a waiting list for the Integrated Drug Treatment System (IDTS). (IDTS
provides offenders with a range of treatments, including clinical and
psychosocial support such as symptomatic relief, detoxification, one to one
sessions and peer led group work.) The CARATs worker gave advice about
reducing the risk of an overdose.
20. The man did not receive any further support from the CARATs team at
Swansea. He transferred on 29 July to HMP Guys Marsh. There is an entry
in his CARAT record on 28 August from the CARATs team manager at Guys
Marsh to indicate that she had completed a file review and the man was on
the waiting list to be seen. She told my investigator that at the time the
CARATs team was understaffed and there was a waiting list of around 70
people. (I am pleased to learn that this has since improved.) However, she
said that if prisoners had urgent concerns they could be prioritised and seen
earlier. The man was not regarded as a priority since the notes from the
previous prison said he only needed low level intervention for cannabis
misuse.
21. Around this time, the man’s case was reallocated to a new offender manager
who has been a qualified probation officer since 2004. On 28 October, the
new offender manager completed a referral to approved premises in
preparation for the man’s eventual release. He did this at the request of the
Public Protection Casework Section (PPCS) since they had indicated that
once the man was offered a place at an approved premises, he would be
released.
22. The man’s new offender manager also completed a report for the review of re-
release by the PPCS and Parole Board (also known as an annex H) which
outlined the sentence and risk management plans, along with his assessment
of the man’s suitability for release. The offender manager based this on a
review of the man’s file, a telephone conversation with him and with his
offender supervisor at Guys Marsh.
23. The man’s new offender manager did not support the man’s release on
licence and placement at an approved premises, as he assessed his risk of
offending or harm could not be appropriately managed in the community,
particularly given his continued drug misuse when released earlier in the year.
This assessment was agreed both by his line manager and the responsible
ACO. However, the Parole Board made the decision to release the man and,
at the beginning of December, set his release date as 5 January 2010.
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24. An entry in the CARATs record on 9 December by a support worker indicates
that a release plan was opened and overdose information was discussed with
the man. In addition, he said that he needed a Subutex (used for the
treatment of opiate addiction) prescription for his release. The support worker
told him that this would not be possible since Dorset Primary Care Trust
(PCT) did not prescribe Subutex. He said he was not interested in alternative
medications as he had been prescribed Subutex before and felt it was the
most successful to stop him misusing opiates. The support worker faxed the
Criminal Justice Integrated Team (CJIT), the community drug service, a
referral form for an appointment for the man after his release.
25. The support worker received a telephone call from CJIT on 14 December
2009. They said that the man would have to go through the normal
prescribing process and it could take up to two weeks from his first
appointment for his prescription to be issued. The support worker discussed
this with the man who said that he thought he would be able to wait, but was
worried that if he gave positive drug tests he would be recalled to prison.
26. The following day, the man’s appointment with CJIT was confirmed for 6
January 2010 at 11.30am. Details of this appointment were given to him and
he was told that CJIT would disclose the results of drug tests to the approved
premises.
27. On 17 December, CJIT called the CARATs support worker at Guys Marsh to
ask whether the man’s prescription could be started in the prison. They were
told that this could not be done. The CJIT worker said that they would call the
CARATs support worker at Guys Marsh back after speaking to the doctor to
check whether prison drug tests would be enough to satisfy him that a
prescription was needed. There is no record as to whether this happened and
the last entry in the CARATs file notes that the man was released and a
release plan was completed.
28. This plan noted that the man was currently misusing unprescribed Subutex,
he should engage with CJIT on release, attend all appointments and address
his substance misuse. Recently released prisoners often have a reduced
tolerance for drugs and are more prone to overdose. The CARATs team
manager at Guys Marsh said that prior to his release, the man was spoken to
and given a booklet about minimising the risk of overdose. Having reviewed
the paperwork, she told my investigator that the man had received a good
pre-release service from CARATs staff, enabling him to engage with CJIT
services as soon as he was released.
29. The man’s offender manager was informed of his release date around 20
December. He therefore contacted the approved premises manager who
confirmed that a place would be available on 5 January. The man’s offender
manager also faxed a form to the Parole Board requesting extra licence
conditions for the man in order to manage his risk of harm and re-offending.
The man’s offender supervisor at Guys Marsh informed the man’s offender
manager of the arrangements regarding CJIT following his release.
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Tuesday 5 January
30. On 5 January 2010, the offender manager completed the man’s Offender
Assessment System (OASys) documentation. This assesses the man’s risk
of harm and re-offending, as well as outlining a plan for the rest of his
sentence. The offender manager was responsible for managing the man’s
sentence plan, involving weekly appointments with him and liaison with
approved premises’ staff. He held around 60 other cases at the time.
31. The offender manager noted that the man would need to engage with CJIT on
release with regards to his drug misuse. It was also noted that he had
overdosed previously and been “close to death”. The offender manager sent
an email to the Social Services Department with regards to trying to set up
access for the man with his children. (In response to the draft report, the
man’s family said that he had been in hospital for accidental overdoses on two
occasions.)
32. At midday, the approved premises received the man’s licence from the prison,
indicating that he was due there by 3.00pm and would be on licence until 6
March 2011. The man had signed the licence on 18 December 2009. Extra
conditions suggested by the offender manager and deputy approved premises
manager were included along with the standard conditions. The man’s
conditions were:
• To be well behaved and not re-offend.
• To keep in touch with his supervising officer and receive visits from
them as required.
• To permanently reside at the approved premises and to abide by their
rules.
• To only undertake work approved by his offender manager.
• Not to travel outside the United Kingdom.
• Not to consume alcohol or illicit substances on or off the premises.
• To report to staff at the approved premises every two hours.
• To abide by the curfew at the approved premises between 8.00pm and
10.00am
• To be excluded from an area of Swansea relating to the victim of his
offence.
• To address his substance misuse and offending behaviour.
33. The man had not arrived at the approved premises by 3.00pm and the
Approved Premises Security Officer (APSO) therefore telephoned the man’s
offender manager who agreed to extend the time limit to 4.00pm, otherwise
he would be recalled to prison. They had already checked that there had
been no known delays on the trains the man would use during his journey.
(Following receipt of the draft report, his family explained that he had
telephoned them to say that he had gone to the wrong platform and had
consequently missed his train. A family member made several attempts to
telephone the probation office to let them know, but there was no reply.)
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34. At 3.50pm, the man attended a probation office and was told to go straight to
the approved premises, where he arrived five minutes later. As is standard
for all new residents to an approved premises, the man had an induction with
an Approved Premises Officer (APO). She had also been assigned as the
man’s keyworker. She would have been the man’s first point of contact and
responsible for completing individual offence-focussed work with him every
week. She is normally keyworker to around six residents.
35. The man’s keyworker had some knowledge of him from the last time he had
stayed at the approved premises, although she had not been his keyworker
then. She said that he seemed more positive on this occasion and had
matured somewhat. He spoke of his determination not to go back to prison
for the sake of his children. His keyworker described the man as “pleasant,
polite and always respectful of staff”.
36. The keyworker explained the approved premises rules to the man, showed
him around the approved premises and issued him with keys to his room.
She also completed a suicide and self-harm assessment during which the
man did not disclose any previous or current thoughts of self-harm or suicide.
After their interview, the keyworker verified this information against the man’s
file. She referred him to the approved premises mental health nurse for an
assessment which is standard procedure.
37. As part of the induction, the keyworker also completed a general health
assessment. The man said he had “general aches and pains but was fit”. He
told the APSO he had been prescribed pregabalin for anxiety. He handed her
this medication as per approved premises policy. He also disclosed that the
last time he drank alcohol was on 26 December 2009. He considered drugs
to be his main issue since he was 11 years old and had misused heroin,
benzodiazepines, LSD and amphetamines.
38. The man told his keyworker that he last misused heroin and Rivatril (a
sedative) on 25 December when he was in prison. He also signed an
agreement that he would give all his prescribed and unprescribed medication
to approved premises staff and that he would register with the local GP
identified by the approved premises. The agreement outlined that taking his
prescribed mediation at the right time was his responsibility. It must always
be taken in front of staff and signed for in their presence.
39. After the induction, the keyworker asked the Approved Premises Security
Officer (APSO) to drug test the man four days later on 9 January. Since the
man had admitted misusing drugs in prison, she believed the test would
currently be pointless and calculated that the drugs would have left his system
by then. At 5.00pm, the keyworker made the following handover entry in the
log book:
“[The man] - new resident to be seen by his probation officer tomorrow.
To be drugs tested over the weekend and regular monitoring
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thereafter. He has a huge, longstanding drugs problem. On two hourly
signings and 8.00pm – 10.00am curfew.”
Wednesday 6 January
40. The following day, the man’s offender manager telephoned the approved
premises to find out how he was settling into the approved premises and
remind him of his appointment later that day.
41. The man went to CJIT and spoke to a support worker regarding obtaining a
diazepam prescription. She explained that all information he discussed with
her would be passed on to the approved premises and suggested he talk to a
GP about the diazepam prescription. This appointment with CJIT was not
noted in the approved premises diary and the man had therefore attended the
agency without notifying staff of his intentions. The staff considered that this
was unhelpful in the context of trying to assist him stop offending. However,
this appointment was known to both the man’s offender manager and Guys
Marsh, who could also have passed this information on.
42. Later that day, the man’s keyworker helped him apply for a crisis loan from
the Department for Work and Pensions (DWP). She also noted that he had
attended CJIT and was waiting for his medication, which he was hoping to
receive the following day.
43. At 3.00pm, the man attended his appointment with the offender manager at
the local probation office. They discussed his licence conditions, drug
misuse, access to his children and health issues. He told the offender
manager that he was trying to obtain a diazepam prescription and the
offender manager advised him to be honest with staff at the approved
premises. The offender manager was concerned that the man was so eager
to obtain a prescription straight after being released from prison. At that
stage, the offender manager was unaware whether he had been prescribed
diazepam in prison. However, he knew that when the man had been released
earlier in the year, he had not been honest with the approved premises’ staff
about the amount of diazepam he had been prescribed. They also discussed
the man’s housing needs and the possibility of him visiting his grandmother.
44. During their interview, the offender manager thought that the man had
seemed anxious about complying with all of his licence conditions and wanted
to succeed. However, he also seemed happy and motivated and the offender
manager’s main focus was to try to set realistic targets with the man, rather
than attempt to address all of his issues at once.
Thursday 7 January
45. On 7 January, the offender manager telephoned the Criminal Justice Mental
Health Liaison Nurse. She was due to complete a standard mental health
assessment with the man the following week, since he was a new resident.
However, she told my investigator that if staff at the approved premises had
more urgent concerns, she would have completed this assessment earlier.
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46. The offender manager told the nurse that he was concerned that the man was
intending to try and obtain a diazepam prescription. The nurse said she
would talk to the man about this issue at their appointment. In the meantime,
she telephoned the prison who confirmed that he had not been prescribed
diazepam and should not need it, as he had been prescribed pregabalin to
treat his anxiety. Prison staff also informed the nurse that on a number of
occasions the man had been unable to provide a urine sample for drug
testing, but that there was no medical reason for this. (After reading the draft
report, the man’s family said that he had told them he was having difficulty
urinating.)
47. The nurse gave the offender manager this information and he became more
concerned about the man’s desire to obtain a diazepam prescription. He
intended to discuss this issue with him at their appointment the following week
and obtained his consent to speak to any GP he registered with. The offender
manager also emailed Social Services to arrange supervised contact for the
man with his children.
48. Later that day, the man attended a GP surgery (not the usual surgery for AP
residents). Staff only became aware of where he had been when he returned
to the approved premises and gave his prescription of diazepam to staff to
lock in the medication cabinet. Staff were unclear whether the GP knew of his
past history and the medication he had already been prescribed.
49. The deputy manager challenged the man when he returned to the approved
premises about why he had not made an appointment with the surgery with
whom the approved premises has a contract. All the residents are expected
to attend this surgery. The deputy manager’s belief was that the man did not
attend the surgery as he knew they would not prescribe diazepam. He had
experienced problems monitoring his diazepam prescription during his
previous stay at the approved premises. The man denied this and said the
reason he did not attend that surgery was that he did not have a good
relationship with the GPs there. He began taking the diazepam as prescribed
that evening.
50. The deputy manager believed the man was intentionally not keeping the
approved premises’ staff informed of his movements. In addition, by
attending a different surgery the GP would have less of an understanding of
the approved premises’ policies or a working relationship with staff there. The
deputy manager discussed his concerns with the Criminal Justice Mental
Health Liaison Nurse as he had been concerned the man had possibly been
advised to attend that surgery by CJIT.
51. As a result of this conversation, the nurse telephoned CJIT who confirmed
that the man had tried to get a diazepam prescription from them but was told
that he needed to attend a GP. The nurse therefore telephoned the surgery
and spoke to the locum GP who prescribed the diazepam that morning. The
locum GP said that the man had requested this prescription and since he had
tested positive for benzodiazepines (of which diazepam is a type), she had
15
given him a week’s prescription of the drug. The doctor had agreed with the
man that the following week he would see the permanent doctor and start on
a reducing dose of diazepam. The nurse also told the locum GP that the man
was currently being prescribed pregabalin, of which the doctor had been
unaware.
52. That evening all the residents were breathalysed for alcohol as is standard
procedure. The man’s test was negative.
Friday 8 January
53. A relief APSO works at the approved premises on his days off from being a
prison officer. As a relief worker his responsibilities are the same as an
APSO, except that he is not a keyworker for any residents. He had known the
man for a number of years both in his capacity as a prison officer and when
the man was resident at the approved premises in 2009.
54. The relief APSO helped the man to apply for state benefits. He also tried to
complete a basic skills assessment with him but postponed this as he said he
was struggling because he had not yet adjusted to his new medication. The
APSO said that he believed the man was more positive than when he had met
him previously. He tried to encourage the man by telling him that there were
lots of people willing to support him. However, the relief APSO said he was
still slightly unsteady on his feet and slurred his words, which was his similar
to his previous experience of him.
55. The man was out of approved premises for most of the rest of day, although
he returned every two hours to sign in as required. At 7.50pm, he returned to
the approved premises and complained of losing £33 when visiting his partner
in a nearby hostel. The approved premises’ staff checked with staff at the
other hostel, who were unaware of any money being found.
56. A member of staff saw the man shortly after his return and observed he was
“a little unsteady on his feet”. Therefore he asked the man to sit in the
television room where he could observe him easily. The man fell asleep
immediately. He was woken up by approved premises staff who were
concerned he had taken more than his prescribed medication and assisted
him to his bedroom. They put him on his bed and left the light on. The
member of staff said the man apologised for his behaviour and believed it was
due to the new medication. The member of staff did not have serious
concerns about him and had seen him in a similar state several times when
he was previously resident at the approved premises.
57. The member of staff made an entry in the log that the man might need to be
checked throughout the night and he would discuss this with night staff. It is
not clear whether this conversation occurred but he was checked at 11.00pm,
1.00am and 1.46am and was found to be asleep on each occasion.
16
The eve of the man’s death
58. Due to staff concerns the previous day regarding the man’s demeanour and
his keyworker’s instructions, the Approved Premises Security Officer (APSO)
drug tested him at 11.45am. The man tested positive for benzodiazepines
and cannabis. The APSO believed the positive test could be explained by the
diazepam he had been prescribed and his self-reported cannabis use in
prison. For these reasons the APSO did not consider enforcement action was
necessary. Such action would not necessarily have meant an application for
the man’s recall to prison but could also have included a verbal warning or a
more formal written warning endorsed by the assistant chief officer.
59. However, the APSO told my investigator that in such situations residents are
given the benefit of the doubt and re-tested in two days. He emailed the test
results to the man’s offender manager. The APSO said that if he had had
urgent concerns about the man he would have called the on call manager,
who would have instigated an out of hours recall, if they believed the situation
to be serious enough. However, the APSO believed the man was more able
to communicate than normal. The log then notes that he went out with his
partner, whom he first introduced to the APSO. The APSO did not have any
more significant conversations with the man before he finished his shift that
evening at 7.55pm.
60. The man’s mother told my investigator during her visit that she saw her son
briefly at 12.15pm when he came to her house. However, she told him to
leave the area as it was part of his exclusion zone, which he did immediately.
Later that afternoon, her other son, the man’s brother, picked her up and they
met the man outside the approved premises at 2.15pm. They all went
shopping for clothes for the man and drove him back to the approved
premises within two hours so he could sign in again. The man’s mother said
he seemed happy and positive and said nothing which gave her cause for
concern. He was looking forward to meeting his offender manager in two
days’ time, to try and arrange access to see his children.
61. When the man returned to the approved premises at 8.00pm that evening,
staff noted that he seemed “dazed and confused” and was falling asleep as
soon as he sat down. The night supervisor had just begun his shift and asked
the man whether he had misused drugs. The man denied this but said he
was still getting used to his new medication which made him drowsy. The
night supervisor asked him to provide a urine sample in case he later had to
call a paramedic, so that he was aware of any drugs the man had taken. He
had known the man from his previous stay at the approved premises and had
needed to call an ambulance for him on that occasion. The man was unable
to provide a sample and the night supervisor therefore allowed him to have
his dinner and some more fluid before trying again. He said that during this
time the man was walking round the approved premises talking to other
residents.
17
62. At 8.30pm, a woman who staff believed was his ex-partner, came to visit the
man but visitors are not allowed in the approved premises. She was allowed
to speak to the man briefly in the reception area before being asked to leave.
63. Fifteen minutes later, the man was again unable to provide a urine sample.
The night supervisor therefore tested his saliva which was positive for opiates
and negative for all other drugs. The man denied taking any drugs other than
his prescribed medication. The night supervisor told the relief ASPO, who
was the other member of staff on duty at the time, about the results of the
test. He also emailed the man’s offender manager and the deputy approved
premises’ manager. The night supervisor said this was standard procedure
and his only concern was for the man’s safety. He therefore asked other
residents to “keep an eye” on him.
64. Since it was a Saturday and the offender manager only works weekdays, he
did not receive the Approved Premises Security Officer (APSO’s) email until
the following Monday. He said that in normal circumstances, on receipt of
such an email, he would have immediately have completed a recall report for
consideration by his line manager.
65. The night supervisor said that his impression of the man was that he was
always “under the influence of something” but would never admit to taking
anything other than his prescribed medication. He remembered him well from
his previous stay at the approved premises, when he had the habit of falling
asleep in front of the television. On one occasion the night supervisor had
checked on him throughout the night when he believed he may have misused
drugs.
66. At 11.00pm, the approved premises staff check that all the residents are in the
building. When the night supervisor and the relief APSO checked the man’s
room, they saw that he was sleeping fully clothed on top of his bed and had
vomited. Having got a response from the man, they cleaned him, made sure
his airways were clear and put him in the recovery position. They left the
room with the light on in case he became disoriented during the night.
67. Both members of staff discussed the man’s condition and decided that, as he
did not appear to be in any immediate danger, they would monitor his
condition throughout the night. They agreed to call an ambulance if his
condition deteriorated at all, for example further vomiting, if his breathing
altered or he tried to get up. The night supervisor said he was aware of the
dangers given the man’s history and because he had called an ambulance for
him the last time he stayed at the approved premises.
68. The relief APSO began his shift around 11.45pm that night. When he arrived
at the approved premises, the night supervisor and the relief APSO he was
taking over from explained what had happened with the man. From this
handover, the relief APSO understood that there were no serious concerns
about the man but that he should be checked throughout the night to make
sure his condition did not deteriorate. The relief APSO who gave the
18
handover to the current APSO left the approved premises at the end of his
shift, at around midnight.
The day of the man’s death
69. Both the night supervisor and the relief APSO checked the man at hourly
intervals between 12.10am and 6.00am. On each occasion they went into his
room, returned him to the recovery position and checked that he was
breathing. The relief APSO said he did not believe the man’s breathing was
laboured or that he showed any other symptoms of difficulty. The night
supervisor emailed the man’s offender manager to update him on the situation
(although again he would not have received this email until Monday morning)
and, with the relief APSO, decided that the checks could be reduced to every
two hours.
70. The Approved Premises Security Officer (APSO) started work at around
7.30am and the relief APSO began around five minutes later. They received
a verbal handover from the night supervisor and the relief APSO, who also
asked that they test the man’s urine since this would provide a more accurate
indication of any drug misuse and could be passed on to CJIT and the man’s
offender manager. The night supervisor then left the approved premises.
71. The APSO checked the man at 8.00am and found that he had vomited again
which had slightly impaired his breathing. However, he noted in the log that
the man was “fine” and cleared his airways. The relief APSO told the
investigator that he was not concerned that the man had been sick again. He
felt that enough time had passed since he returned to the approved premises
and the APSO did not seem worried about his condition. The relief APSO
finished his shift and left the approved premises shortly afterwards.
72. Two hours later, at 10.00am, the APSO checked the man and found that he
had vomited again and was not breathing. He said the man was pale but still
warm to the touch. He therefore moved him to the floor to make cardio
pulmonary resuscitation (CPR) more effective and did 15 chest compressions.
Since he noticed blood and vomit around the man’s mouth, he then ran
downstairs to the office to get a mouthpiece before he administered any
breaths. While downstairs, he told the relief APSO what had happened and
asked him to call an ambulance as the man had stopped breathing. The
APSO immediately went back to the man, attached the mouthpiece and
administered two breaths and then continued with the CPR cycle.
73. Meanwhile, the relief APSO called for an ambulance and remained in the
office to oversee the management and security of the building. The telephone
operator asked if he could get the telephone to the APSO and the relief APSO
gave the handsfree monitor to a resident to take to him. This resident asked
another resident which was the man’s room as he had the emergency
services on the telephone. The other resident then went to that room and
threw the telephone into the room. Having seen what had happened, the
resident went into the room and picked up the telephone but the emergency
services had been cut off in the process.
19
74. Having had some basic first aid training in his previous employment, the
resident offered to assist the APSO with CPR, which he knew could be tiring.
The APSO confirmed that the resident had some first aid training and then
accepted his offer, asking him to provide the breaths while he completed the
chest compressions. The resident blew one breath and mucus came out of
the man’s nose which he wiped away. As he was about to give another
breath, the paramedics arrived and took over, attaching their defibrillator to
the man. (A defibrillator is a portable electronic device which measures
electrical activity in the body and advises on action to be taken.)
75. At 10.30am, the APSO telephoned the covering on call duty manager and told
him that he believed that the man had died but the paramedics were currently
with him. Having checked on the welfare of his staff, the deputy manager
contacted the ACO on call as well as the ACO responsible for approved
premises. Both said they would go to the approved premises as soon as
possible.
76. The on call duty manager arrived at the approved premises at 10.53am,
passing the paramedics on the way out who confirmed that the man had died.
He checked his staff’s welfare and offered them the chance to go home. The
APSO accepted this offer. The police also arrived, along with both ACOs, a
short time later. All the staff said they felt well supported following the man’s
death. Residents were gathered in the lounge a short while later and the
ACO responsible for approved premises told them about the man’s death.
Staff were available to any resident who required support.
77. The police told the man’s next of kin, his mother, of his death by going to her
house that morning. She subsequently visited the approved premises, along
with her partner, and spoke to staff about her son.
Post mortem and toxicological findings
78. A doctor completing a toxicological analysis found the following present in the
man: tramadol (a painkiller), O-desmethyltramadol (made by the body
following consumption of tramadol, morphine (a painkiller), codeine (a
painkiller), diazepam, nordiazepam (a sedative), cocaine, beta
hydroxybutyrate (made by the body) and cannabis. The doctor concluded
that:
“There has been previous illicit heroin misuse. The tramadol and
diazepam concentrations likely represent previous therapeutic range
use. It is unlikely that any of the drugs detected would have caused
death independently at the concentrations detected, but the
combination may have had a detrimental effect on conscious levels
and respiratory drive.”
79. The post mortem established the cause of death as “respiratory depression
due to (or as a consequence of) a combination of illicit drugs”. Respiratory
20
depression, also known as hypoventilation, occurs when breathing is
insufficient to perform the necessary gas exchange. It therefore leads to an
increased concentration of carbon dioxide. It can occur after drug misuse and
can be particularly common in cases of drug misuse when opiates are taken
with benzodiazepines.
21
ISSUES
The man’s drug treatment whilst in prison
80. Following a breach of his licence, the man was recalled to HMP Swansea on
28 May 2009. On 10 June, he asked to see the CARATs team in relation to
his drug misuse. They assessed the man as suitable for low level drug
intervention for cannabis misuse and he was put on a waiting list for IDTS.
He did not receive any further input in relation to his drug misuse at Swansea
and was transferred to Guys Marsh on 28 July. A month later, Guys Marsh
CARATs team completed a file review on the man. Since his notes from
Swansea indicated that he needed low level intervention, his case was not
given high priority. The man did not approach the CARATs team himself.
81. Given the man’s well documented serious drug misuse, I am surprised that he
was not regarded as a priority by the CARATs teams in either prison. His
drug misuse was related to his offending, risk of harm to others and had
influenced the offender manager’s decision not to recommend re-release to
the PPCS and Parole Board. It is possible that the man was not honest
regarding his substance misuse to CARATs staff but they could have liaised
with his offender supervisor in the prison or offender manager in the
community. In addition, both members of staff could have liaised with the
CARATs team to ensure the man was receiving the appropriate treatment.
82. Although I do not make a formal recommendation in this regard, the
Governors of Swansea and Guys Marsh will wish to ensure that there is
sufficient information sharing between these different teams, to ensure a
prisoner receives drug treatment appropriate to his risk, history and need.
83. Once his release date had been set in December, CARATs staff met the man
who disclosed that he had been misusing unprescribed Subutex in prison and
would like a prescription for the drug once released. The CARATs team
liaised with the local drug service in the community to try and set this up but
were unable to do so. However, they discussed this with the man and gave
him an appointment with CJIT for the day after his release which he attended.
I am satisfied that he received a good handover from the prison to the
community drug service. I am also pleased to note that the man was given
the appropriate information regarding harm minimisation and the increased
risk of overdose following his release from prison.
The man’s registration with a GP surgery
84. During his induction at the approved premises, the man signed an agreement
that he would register with the approved premises’ recommended GP with
whom they had a contract to provide services. Despite this, two days later the
man registered with another surgery. He did not tell anyone that this was his
intention but on his return told approved premises staff that he had been
prescribed diazepam. In line with local policy at the time, he handed over the
medication immediately for staff to dispense to him as prescribed.
22
85. When challenged as to why he had not gone to the surgery he was told to go
to and with whom the assisted premises has a contract with, the man claimed
it was because he did not get on with the staff there. However, some
approved premises staff said they believed it to be because the contracted
surgery staff knew of his past diazepam misuse and, as a result, it would have
been difficult for him to obtain a diazepam prescription there. Staff at the
contracted surgery were also more aware of approved premises rules and
procedures. They would have been likely to contact the approved premises
before prescribing such medication, or check with the prison as to whether it
had been prescribed there.
86. During interview, the duty manager questioned whether the approved
premises had any right to force a resident to register with a specific surgery or
whether such a restriction would represent a violation of an individual’s right to
choose. Given the nature of approved premises and residents’ freedom to
leave during the day, it would be difficult to enforce a resident to attend a
particular GP. It was made clear to the man which GP he should attend, but
he chose to ignore this requirement. Furthermore, he was honest on his
return about where he had been and handed in his medication. There was
proactive sharing of information between approved premises’ staff, the man’s
offender manager, the criminal justice liaison nurse, the contracted surgery
and Guys Marsh in clarifying the man’s prescription.
87. The man was provided with the appropriate information, but made a personal
choice as to which GP to register with. In these circumstances, I am satisfied
that there was little else staff could have reasonably done to monitor the
man’s treatment and prescriptions.
Drug testing and follow-up action
88. The local policy for the management of drug misuse within approved premises
states that the man should have been drug tested when he arrived at the
approved premises. The man’s keyworker says that she did not conduct a
drug test at that time since the man had admitted to misusing heroin and
Rivatril on 25 December. She therefore requested a drug test be done on 9
January to give these drugs a chance to leave his system. However, 11 days
had already passed since his last disclosure of drug misuse, which should be
sufficient for him to provide a negative drug test. Regardless of this, the drug
test should have been conducted as a means of corroborating the man’s
disclosure and so staff were aware of any drugs in his system.
89. In the evening of 8 January, the man had to be taken to bed by staff. He was
drowsy but they believed this to be due to the new prescription medication he
was taking. The APSO, who has 17 years’ experience working in probation
hostels, said that the man’s behaviour did not seem overly concerning.
However, he felt that because the man was polite and easygoing he was
perhaps given more chances than other, more difficult residents.
90. Following concerns that the man was misusing drugs and as per the
keyworker’s instructions, the man was drug tested for the first time on the
23
morning of the eve of the man’s death. He tested positive for cannabis and
benzodiazepines. It is unclear from records whether this test was based on a
urine or saliva sample. At 8.00pm that night the man was again drug tested
as staff were concerned about his demeanour, recording that he appeared
“dazed and confused” on his return to the approved premises. This test was
positive for opiates. Since the man had been unable to provide a urine
sample, it was based on a saliva test.
91. The discrepancy between these two tests on the same day is unhelpful. It
could reasonably be expected that since cannabis can stay in the system for a
number of weeks and the man was being prescribed diazepam (a type of
benzodiazepine), the latter test would also have been positive for these two
drugs. A number of staff had concerns about the accuracy of using saliva
drug tests and preferred to use those based on urine wherever possible. The
APSO said that saliva tests can be disputed whereas urine tests are over 99
per cent accurate.
92. The local policy for the management of drug misuse within approved premises
states that if a resident disputes the results of a drug test, a second sample
should be taken and the resident should be informed that this will be
forwarded to a laboratory for analysis. Following the positive test, the man
denied misusing any opiates but a second sample was not taken. However, it
is also clear that the man often tried to hide his drug misuse. It is likely that
staff balanced their prior experience against the need to conduct a second
test.
93. Following the man’s positive drug test for opiates, the night supervisor
emailed the man’s offender manager and the deputy manager, although
neither would have received them until Monday morning. The night
supervisor said he regarded this second test as the first unexplained positive
one. He said that emailing the offender manager was standard procedure in
such an instance. He also took into account that the man had only been
released from prison a few days previously and was engaging with CJIT. He
added that he would only consider recalling someone to prison after a single
positive test if he was instructed to do so by the offender manager.
94. The duty manager said that as a result of the first test being positive to
cannabis and benzodiazepines, he would expect staff to notify the offender
manager by email and make a record in the drug test book. He said that if the
member of staff was less experienced they might also call the duty manager
for an opinion. In relation to the second test, the deputy manager would
expect the same procedure to apply. Since the night supervisor was a more
experienced member of staff he would have been satisfied with him making
the decision, especially since the man was in the approved premises at the
time. Staff therefore acted in accordance with the deputy manager’s
expectations.
95. The approved premises’ manager said that following a first positive drugs test,
she would expect staff to refer the resident to a community drug agency. She
said this is in line with national guidelines. Following the man’s second
24
positive drug test, she said the process would have been no different unless
staff had concerns regarding any increased risk the man presented to others.
If they were concerned about this risk, a duty manager should be called who
could sanction his immediate recall. The manager would then contact NOMS
and if they agreed with the reasons for recall, they would in turn contact the
police who would issue a warrant and the resident would be arrested. This
would all happen within the space of around two hours.
96. According to the OASys documentation, the man’s risk to others was related
to his substance misuse and therefore a positive test could have resulted in
an increase in his risk to others. The approved premises’ manager said this
was one of the factors which would need to be discussed with the on call
officer. Indeed, the man’s offender manager said that he would have
immediately applied for the man’s recall to prison on the basis of such
information, although he had not communicated this to the approved
premises’ staff.
97. Probation Circular 05/2006 on drug testing of residents in approved premises
says that:
“Testing positive for drugs should not automatically lead to eviction
from the hostel where the resident is motivated to accept treatment.
Management of those who test positive will depend on:
• The risk status of the resident
• The perceived effectiveness of treatment
• The number of positive tests
• The extent to which repeated breaches undermine respect
for the rules and/or encourage drug use in others
• The order or licence to which the resident is subject.
“Balancing these issues is a matter best determined on a case-by-case
basis and NPD is not proposing a detailed national enforcement
regime.”
98. South Wales Probation Trust’s policy for managing illegal drugs in approved
premises instructs that:
“The outcome of all drug and alcohol tests must be forwarded to the
offender manager without delay via e-mail and entered on CRAMS.
Where a positive test occurs out of hours then the on call officer to be
contacted immediately, with an e-mail also sent to the offender
manager to inform them of your actions and an entry made on
CRAMS.”
99. CRAMS stands for Case Recording and Management System and is used by
South Wales Probation Trust as their database of contact and decision
making with offenders. In this man’s case, it is clear that this guidance was
not followed, since the on call officer was not contacted following either
positive drug test on 9 January.
25
100. In a letter to my investigator, the ACO with overall responsibility for approved
premises in the area, made it clear that he would expect a consultation with
the on call officer to take place following a positive drug test. He wrote that:
“Had it taken place as required, a discussion about recall would also
have followed. The fact that [the man] was not considered for recall is
not inappropriate in itself however and guidance was not breached.
Further, any discussion that may have taken place would not
necessarily have resulted in recall.
The policy referred to above was issued to all staff in April 2009.
Copies were sent electronically to all and a hard copy remains in the
approved premises’ General Office in the ‘Procedures File’.”
101. I therefore make the following recommendation:
The ACO should remind all staff of the guidelines regarding drug
testing, ensuring that these tests are carried out as required and the
necessary action is taken following a positive test.
First aid training
102. All staff at the approved premises have attended a three day first aid course,
with only one member needing a one day refresher. Despite this, the APSO’s
understanding of the cardio pulmonary resuscitation guidance was out of
date. He believed that the current ratio of chest compressions to breaths to
be 15 to two. The resident also believed this to be the case (although he had
not had first aid training for around ten years). The ratio was revised by the
Resuscitation Council in 2005 which now recommends 30 chest
compressions to two breaths. I therefore make the following
recommendation:
The ACO should ensure staff are aware of the most recent Resuscitation
Council guidelines and have attended the relevant refresher first aid
courses.
103. Notwithstanding this, the APSO responded quickly and professionally to the
situation, continuing CPR until paramedics took over. The resident’s
willingness to assist the APSO should also be noted and commended.
Calling an ambulance
104. When the man returned to the approved premises at 8.00pm on 9 January,
staff noted that he appeared ”dazed and confused” and fell asleep as soon as
he sat down. He then provided a saliva sample which was positive for
opiates, although he denied misusing drugs. He had provided a positive test
for cannabis and benzodiazepines earlier that day. Staff checked on the man
in his room at 11.00pm and found that he had vomited while asleep. They
cleared his airway and put him in the recovery position and decided to check
26
on him hourly until 6.00am. Staff checked him again at 8.00am when he had
once again vomited. Once more, they put the man in the recovery position
and cleared his airway, also noting in the log book that his breathing had been
impaired due to vomit up his nose. When they checked the man again at
10.00am he was not breathing.
105. The night supervisor had agreed with the relief APSO that after the first time
the man had been sick if his condition deteriorated at all, including vomiting
again, they would call an ambulance. When they did a handover with the day
staff, they explained what had happened with the man but were not specific in
terms of what action they believed should be taken if he vomited again. They
had left the approved premises before the man vomited a second time.
106. When asked how staff would decide to call an ambulance the relief APSO
said:
“I assume it does rely on the first aid training. Experience comes into
it, commonsense comes into it. I’ve asked myself this question dozens
of times, so don’t think it’s the first time I’ve thought about this. And in
hindsight we all wish we’d called an ambulance but part of me thinks if
we had called an ambulance, because somebody’s vomited, would
they have turned up? Had they turned up, had they seen what we had
seen, would they have taken any further action? Would they have said
no, he’s not vomiting, he’s stable, he’s breathing, he’s got a pulse.”
107. When the relief APSO was questioned further about whether the man had all
his vital signs (that is pulse, breathing and blood pressure) when he was
checked and whether there was a reason to call an ambulance, he said, “I
don’t know”. He said that the longer that the night went on, and the more time
passed, the greater the staff felt that he was “safe”. When asked if the fact
that the man vomited for a second time would be a risk factor, the relief APSO
said he did not think it would be as long as he was in the recovery position.
On reflection, he said he did not think that he should have done anything
differently.
108. The APSO said he believed calling an ambulance to be a “judgement call”
and when he checked on the man at 8.00am there was no indication that an
ambulance should be called. Staff were aware of the man’s substance
misuse history and some had direct experience of dealing with him when he
had been under the influence of drugs at the approved premises before. I
believe that this may have clouded their judgement in the belief that the more
time passed, the ‘safer’ he became.
109. The approved premises’ manager said:
“I think there were always concerns with [the man] about his potential
to use drugs. And so staff were all aware of that and did keep an eye
on him. And sometimes his demeanour would lead you to believe that
he may have been under the influence of something, even though he
may have been drug tested and it was negative. There was the way
27
that he perhaps looked which made you think gosh, I wonder if he’s
taking something because he was a bit slow of speech sometimes, but
I think that was just his personality, that was just his way.”
110. The ACO responsible for approved premises expressed his concern that staff
did not call an ambulance when they discovered the man had vomited the first
time at 11.00pm. He said:
“This concern was echoed by [the approved premises’ manager] and
the police investigating the incident asked about this also. All of our
staff in our Approved Premises have received three-day, certificated
first aid training and I was surprised that, recognising that the man was
sufficiently sick to need to be placed in the ‘recovery position’, the
emergency services were not then called.
He went on to say that had a consultation with the on call manager occurred
as required, following the positive drug test at 9.00pm, he believes that the
emergency services would have been called quicker. He accepts that this is
speculation made with the benefit of hindsight.
111. Staff said there was no guidance that they knew of regarding when to call an
ambulance in such a situation, but that this relied on their personal judgment.
In response to this, the ACO responsible for approved premises referred to
the local policy on the management of drugs within approved premises. He
said:
“Section 5 refers to the administration of controlled drugs and states at
paragraph (iii) : ‘if the resident, after taking his medication, becomes
overly drowsy, lethargic or starts to slip into unconsciousness then the
emergency services should be called immediately.’
“[The man] exhibited all of these symptoms and was also taking
prescribed medication – benzodiazepines. Paragraph (iv) of the same
also states, ‘if the duty officer has any concerns [with any of the above],
then they should contact the on call officer without delay.’
“I accept that this does not refer more explicitly to changes in behaviour
or health following the misuse of illegal or non-prescribed drugs, and
the policy is being amended to make this clearer. Policy guidance
does exist however, it was made available to all staff and it would have
been appropriate in the case of the man.”
112. As the ACO responsible for approved premises comments, the above policy
could be clearer with regard to staff concerns if a resident has taken non-
prescribed or illegal drugs. I am pleased that the policy is being amended to
reflect this. Regardless of this, the ACO himself says staff should have called
an ambulance when the man first returned to the approved premises and was
dazed and confused and tested positive for opiates, especially as he had also
taken diazepam.
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113. The NHS Direct website advises that if someone has vomited and is confused
or sleepy an ambulance should be called immediately. This is regardless of
any potential drug misuse. Furthermore, when the man vomited a second
time, I believe this should have been another trigger to calling an ambulance.
None of the staff in contact with the man believed the situation serious
enough to call an ambulance. I believe that this was not the case and an
ambulance should have been called. However, it was clear from talking to
staff that they considered the man’s condition carefully and made, what they
thought were, suitable arrangements to monitor his wellbeing. I conclude that
this was not a negligent decision (not to call an ambulance), but an error of
judgement made from failing to recognise the seriousness of the situation. I
therefore make the following recommendation:
The ACO should ensure that all staff are familiar with the local policy for
the management of illegal drugs and alcohol within approved premises,
particularly in relation to when an ambulance or on call officer should be
contacted.
114. However, my concern is also that, despite first aid training, staff were unable
to recognise the symptoms the man was exhibiting as an emergency.
Resources are available to staff, as they are to the general public who have
medical concerns, such as NHS Direct. The ACO may wish to consider
publicising such resources within the approved premises.
115. Furthermore, I am unaware of any quick reference resource in approved
premises in England and Wales to provide advice to staff on action which
needs to be taken in particular medical emergencies. My investigator
contacted the head of the approved premises team at the National Offender
Management Service (NOMS), who was also unaware of a national resource.
Such information could take the form of laminate card to be displayed as a
reminder in all areas of approved premises, so that staff have the knowledge
and confidence to act as appropriate when a medical emergency or issue
occurs. For example, this could include information such as if a resident is
suspected of taking an overdose or is vomiting in their sleep, as in this man’s
case. I therefore make the following recommendation:
NOMS considers issuing all approved premises in England and Wales
with quick reference cards to be displayed throughout the approved
premises, giving information on appropriate action in a medical
emergency or if certain symptoms are exhibited by a resident.
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CONCLUSION
116. The man had a long history of drug misuse. When he was released to
approved premises in January 2010, he told staff that he was determined to
move away from offending and drug misuse for the sake of his children.
Unfortunately, it seems he was unable to desist from this lifestyle and five
days later died as a result of respiratory problems caused by the drugs he had
taken.
117. Staff at the approved premises clearly tried to motivate the man and invested
time in trying to assist him in leading a law-abiding lifestyle. All those who
encountered him described him as polite and happy. He received an
appropriate induction at the approved premises, although he was not drug
tested immediately on his arrival. Four days later, he was tested twice with a
positive result for cannabis and benzodiazepines on the first occasion and
opiates on the second. He denied any drug misuse.
118. Following this second drug test, the man appeared confused and when he
went to bed, vomited twice in his sleep. No advice was sought from the on
call manager. Staff monitored him throughout the night and put him in the
recovery position on several occasions, but did not call an ambulance. When
they checked on him at 10.00am, he had stopped breathing and staff were
unable to resuscitate him. Staff should have called an ambulance, at the
latest, at 8.00pm when he vomited for the first time. Their assessment that
the man’s condition was not serious was an error of judgement and as I have
said, at the very least represented a considerable lapse in the care the man
received at the approved premises.
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RECOMMENDATIONS
1. The ACO should remind all staff of the guidelines regarding drug testing,
ensuring that these tests are carried out as required and the necessary action
is taken following a positive test.
The Trust accepts this recommendation. Whilst Probation Circular 05/2006
does not require the automatic eviction [and thus the recall] of a resident
following a positive drug test, local policy does require that an on-call officer is
contacted for advice following such a test result. This did not happen
immediately [and for some time].
All staff in both Approved Premises have already been instructed to follow
local policy.
A draft practice direction dealing with the management of a range of health
and drug misuse issues has also been issued to all staff in both Approved
Premises. All staff members have been required to sign to acknowledge
receipt of this draft paper and comments are being sought. It will be launched
formally by the ACO and the Approved Premises’ Manager at two all-staff
events later in August. Relevant recommendations from Ombudsman’s
reports will be referenced at those meetings.
2. The ACO should ensure staff are aware of the most recent Resuscitation
Council guidelines and have attended the relevant refresher first aid courses.
The Trust accepts this recommendation with the following hopefully-helpful
qualification. The 2005 guidelines advise 30 chest compressions to every two
breaths. Prior to their revision, the ratio was 15: 2. All staff in the South
Wales area Approved Premises have received certificated first aid training
since that time and would have been advised of the guidance during that
training. The member of staff identified in the draft report received his training
last year.
The Trust routinely provides two-day certificate-renewal [‘refresher’] training
for all staff when their first aid certificates are close to expiry. This rolling
programme is already in place and staff from both Approved Premises in
South Wales are booked for training during August and September, and later
as their certificates come up for renewal.
Notwithstanding this, because of the misunderstanding over compression to
breath ratios quoted in the draft report, I have asked the Trust’s Health and
Safety Manager to prepare a short, written resuscitation guide for all
Approved Premises’ staff. This will be issued in parallel to certificate-renewal
training and will not replace it. This should be available and circulated within
a month [mid-September 2010].
3. The ACO should ensure that all staff are familiar with the local policy for the
management of illegal drugs and alcohol within approved premises,
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particularly in relation to when an ambulance or on call officer should be
contacted.
The Trust accepts this recommendation. Existing local policy covers these
matters but requires clarification to make expectations with regard to practice
more explicit. The draft practice direction attends to this [and may be clarified
further when staff responses are collated] and the staff meetings planned for
its launch will reinforce these expectations.
4. NOMS considers issuing all approved premises in England and Wales with
quick reference laminate cards to be displayed throughout the approved
premises, giving information on appropriate action in a medical emergency or
if certain symptoms are exhibited by a resident.
NOMS accepts this recommendation. It is understood that work to develop
such a card is being taken forward by the Independent Advisory Panel on
Deaths in Custody, Offender Health and the NPSA and once that is complete
NOMS will arrange to issue the card to all Approved Premises.
NOMS also undertakes to remind all staff working in Approved Premises of
the need to undergo refresher first aid training regularly and take appropriate
action when residents fall ill, ie to contact medical advice, such as from NHS
Direct, whenever there is any doubt about what medical action may be
required.
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