Individual at Ascot House

A Report by the
Prisons and
Probation
Ombudsman
Nigel Newcomen CBE
Investigation into the death of a resident at Approved
Premises in the Greater Manchester Probation Area,
in December 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 report considers the circumstances surrounding the death of a man, at
Approved Premises, on 12 December 2007. The man died as the result of falling
from a motorway bridge, after absconding from the Approved Premises shortly after
9.10pm that night. He was 34 years old.
I apologise for the delay in producing this report. The investigation was led by one of
my colleagues. I would like to thank the Senior Probation Officer and Manager of the
Approved Premises for the cooperation of staff and residents during this
investigation. I would also like to thank the Offender Manager from Atherton
Probation Service Office and Stockport Substance Misuse Service (SMS) for their
assistance. I am grateful to the Pennine Care National Health Service (NHS) Trust,
for allowing me to use their serious and untoward incident report which reviews the
care that the man received through the Stockport SMS.
The man had been convicted of a violent offence which led to him being categorised
a high risk offender. He had a history of occasional alcohol misuse, anxiety and
whilst at prison was diagnosed with histrionic and narcissistic personality disorders.
Despite this troubled past, the man had not been perceived as a risk to himself, only
to others.
On release from HMP Risley in October 2007, the man was subject to strict licence
conditions and Multi Agency Public Protection Agency (MAPPA) panel reviews.
Three of the licence conditions were that he reside at Approved Premises for high
risk offenders, abide by his curfews and address his alcohol misuse. The man
moved to the Approved Premises on the day of his release. He quickly settled and
made a positive impression on staff. A small concession was made to the
restrictions relating to alcohol in early November to reward his good progress. The
man was allowed to drink alcohol within the legal drink/drive limit, measured using
breathalyser tests as and when required. He initially chose to abstain or only drink
low alcohol drinks.
A MAPPA panel meeting, held in November 2007, discussed his risk level and
licence conditions but decided that no changes should be made at that time. The
man had hoped for some leniency and was disappointed with the decision. His
mood became changeable, often low and he disengaged with both hostel staff and
his offender manager. As he became more frustrated he began to slowly increase
his social drinking. However, this was never to a noticeable excess.
On 12 December, the man was late for his 9.00pm curfew and was asked to take a
breathalyser test. He refused to do so and left the hostel. Staff were unsuccessful in
their attempts to persuade him to come back and the duty manager and police were
immediately notified. The man’s body was found by the police at 11.00pm after he
had fallen from a nearby motorway bridge.
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Despite the events in the period leading up to his death, staff and his offender
manager all said the man’s decision to abscond and his subsequent death could not
have been predicted. He had not presented as being at risk to himself. If anything,
staff felt his risk to others might have increased, although some remarked that the
irrationality of his actions was not entirely out of character. Those who had worked
closely with the man reported that his decisions could at times be erratic.
Nevertheless, his death came as a great shock to all and I would like to offer my
sincerest condolences to the man’s friends and family.
I do not think the man’s decision to abscond was intentional, but a reaction to the
fear and possibility of being recalled to prison. Although a recall had not been
mentioned to the man, he would have known that under certain circumstances it
could happen. I am unable to come to any conclusion on the circumstances around
his fall from the bridge. However, the police investigation concluded that no third
party had been involved.
I am confident that staff at the Approved Premises and his offender manager acted
appropriately in meeting the man’s immediate needs. However, I have made two
recommendations regarding the accessibility and recording of information and one
national recommendation regarding formal guidance for staff when dealing with a
possible breach of conditions.
Stephen Shaw CBE
Prisons and Probation Ombudsman May 2009
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CONTENTS
Summary 5
The investigation process 8
The Approved Premises 12
Key events 14
Issues
Confidential review of a drug related death 38
Alcohol 39
Mental health 41
Self-harm or suicide risk 43
The question of bullying 45
MAPPA 45
Staff 46
Breach of licence conditions 47
Security 49
Post mortem and toxicology 49
Conclusion 50
Recommendations 51
Response to the draft report 52
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SUMMARY
The man was convicted of a violent crime in 2003. He received a seven year
sentence and was classed as a high risk offender under the Multi Agency Public
Protection Arrangements (MAPPA). The man was released on licence on 5 October
2007. The conditions of the licence required him to live at Approved Premises for
high risk offenders, abide by a curfew, address his alcohol issues, not enter
Lancashire, or attempt to contact his victims.
The man suffered from anxiety and depression. He had a history of periodic heavy
drinking linked to these conditions and his offending behaviour was said to have
been triggered by heavy drinking combined with his prescribed medication. During
his time in custody, the man was diagnosed with histrionic and narcissistic
personality disorder.
On release from prison, the man moved to the Approved Premises. Prior to his
move and during his introduction at the hostel, the man was told about curfews, the
hostel rules and the restrictions on consumption of alcohol. He was also warned
about breaching licence conditions and how this could lead to being recalled to
custody. The police coordinated an emergency contingency plan in the event of the
man absconding as he was a high risk offender. This was shared with probation
staff. The man was not aware of its existence.
During the man’s first week at the Approved Premises he said he felt anxious and
had difficulty sleeping. However, staff reported that the man soon settled after a
doctor from the local surgery prescribed an antidepressant.
From 8 October, the man had regular meetings with the Stockport Substance Misuse
Service (SMS) team to address his previous alcohol misuse. In the first session, the
man said his past bouts of heavy drinking were linked to depression and anxiety. In
the second session, he told the substance misuse worker that he occasionally had
suicidal thoughts. The man said he was prone to high and low moods, but these
were stabilised by his antidepressant. He told the substance misuse worker that he
had no current thoughts of harming himself.
Staff reported that the man initially made a positive impression and fully engaged
with the hostel regime. In view of his good progress, a concession was made to the
conditions relating to his alcohol contract in early November. The alcohol ban was
lifted and the man was permitted to drink to the legal drink/drive limit. As before, he
would continue to be breathalysed as and when required. The substance misuse
worker supported the move to a moderate alcohol contract.
The man regularly told staff he was frustrated with his curfew times. He requested a
relaxation in his signing times and asked if he could apply for home leave.
Residents may only make an application after eight weeks of being at the hostel.
However, his offender manager told the man that his request could be raised during
the MAPPA meeting scheduled for 15 November.
The MAPPA panel meeting on 15 November was attended by the Approved
Premises Manager, the man’s offender manager, Lancashire and Greater
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Manchester Police, and a Chairperson. The purpose of the meeting was to review
the man’s risk following his release from prison, address any arising matters and
discuss his progress.
The man’s offender manager updated the panel on the man’s progress and
suggested that consideration be given to relaxing one of his signing times in
recognition of his positive engagement. The Approved Premises manager supported
the man’s offender manager’s comments. The police raised concerns about the
man’s drinking, his prescribed medications (for anxiety), the sensitivities surrounding
a home visit (the man had been previously charged after a dispute with a neighbour)
and maintaining the ban on entering Lancashire. The panel was divided on the
issue, but decided that it was too early to relax any conditions. This would be
reviewed at the next meeting in early January.
The man’s offender manager advised the man of the MAPPA panel’s decision by
telephone the following day. The man was angry and frustrated by this decision. He
repeatedly told staff that he felt let down by the Probation Service and other
authorities. The man’s keyworker, managers and the man’s offender manager
spoke to the man regularly about his frustrations and encouraged him to remain
positive. Despite this encouragement, the man started to withdraw from life at the
hostel (refusing to eat with other residents) and said that the authorities were
conspiring against him. The man pushed the boundaries of the hostel rules on
occasion. However, this did not result in any formal warnings.
On 26 and 27 November, the man suffered panic attacks. The first was during a
group work session. The man told the deputy manager, that he did not feel
comfortable in a large crowd. The second happened the following evening. The
man went to the office, complaining of chest pains. The paramedics were called and
were able to calm him. The man saw the doctor the next day, who prescribed
sleeping tablets to help with his increased anxiety. The man attributed his stress to
being grouped with high risk offenders, group work, restricted contact with his family
and his relationship with the Probation Service.
Staff at the Approved Premises and the man’s offender manager had numerous
discussions about handling the man’s disengagement. It was thought that the
MAPPA decision had negatively impacted on their work with the man. On 29
November, the deputy manager wrote to the man’s offender manager and the
Approved Premises manager. She believed there would be therapeutic value in
relaxing the man’s signing times and thought that his increased resentment could
heighten his risk to others. The Approved Premises manager raised these concerns
with the MAPPA Chair. The Chair declined to make any changes and said it would
be for discussion at the next meeting in January.
The man started to increase his social drinking. The combination of alcohol whilst
taking prescribed medications was noted by a member of staff on 3 December, who
raised her concerns with management. It was discussed with the man, who assured
staff that he was aware of the need for caution when mixing alcohol with his
medications. He said that it was under control. However, the substance misuse
worker remained concerned and offered to refer him to an alcohol support group.
The man declined.
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During early December, staff described the man’s mood as changeable and, on
occasion, strange. Despite this there were no significant concerns. The man
maintained that his mood was caused by his licence conditions.
On 12 December, the man had a meeting with the man’s offender manager. He
appeared no more frustrated nor angry than usual. Later that afternoon, he left the
hostel and met some friends at a pub in Stockport. The man left that pub at
approximately 8.45pm. He telephoned the hostel at 8.55pm to let a member of staff
at the Approved Premises know that he would be late for his curfew as he was
experiencing difficulties contacting the taxi firm. She told him to get back to the
hostel as soon as possible. The man arrived at the hostel at 9.10pm. The taxi driver
came into the hostel with him to confirm the reason for being late.
The man had nothing other than a £10 note to pay for his taxi fare and the driver had
no change. The driver and the man left the building and got back in the car. They
drove to a nearby petrol station to sort out the fare and quickly returned. The man
had not told staff that he was leaving the hostel.
On his return, the member of staff at the Approved Premises noticed that the man
had been drinking so told him he would need to be breathalysed. The man said
“today of all days, when I will be over the limit”. He declined to participate and went
to his room. The member of staff did not tell the man that he had breached his
licence conditions. (There is an informal understanding at the Approved Premises
that residents are not informed at night if they have breached their conditions in case
of a negative reaction – absconding, increased risk of self-harm or harm to others.
The matter is left for the manager to deal with the following morning or the duty
manager if it is an emergency.)
The member of staff told her colleague that she would need to telephone the duty
manager to let her know that the man returned late. Before she was able to make
the call, the man came down to the office, said “see ya” and left the hostel. The
member of staff followed the man to the end of the driveway and called to him to
come back but he refused. As he had absconded, the member of staff notified the
duty manager and the police. The emergency contingency plan was put into place
and the Early Recall and Release Section at the Home Office was notified. At
10.50pm, the police telephoned the Approved Premises to report that someone had
died falling from the motorway bridge near the hostel. It was confirmed at 11.00pm
that the person was the man.
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THE INVESTIGATION PROCESS
1. My investigator opened the investigation on 17 December 2007. She
discussed the circumstances surrounding the man’s death with the Manager at
the Approved Premises. During the initial visit, my investigator received a
briefing from the Approved Premises manager about the man’s time at the
Approved Premises and was given a full set of documents relating to his stay at
the hostel.
2. Interviews were held in two sessions at the Approved Premises in late January
and February. My investigator interviewed probation staff, a resident and a
substance misuse and alcohol worker from Stockport Community Drug Team.
3. A Detective Inspector (DI) from Stockport police undertook an investigation on
the Coroner’s instruction. His investigation considered the events on the
evening of the man’s death and whether there were any suspicious
circumstances. The police investigation concluded that there were none. My
investigator liaised with the Detective Inspector during her the investigation.
The Detective Inspector was able to provide further information from his
enquiries for inclusion in this report.
4. My investigator did not visit HMP Risley as part of her investigation. All
information regarding the man’s time at there is taken from his probation
records and interviews with staff the Approved Premises and his Offender
Manager.
5. Pennine Care National Health Service (NHS) Trust produced a confidential
review of a drug-related death. The review was commissioned by the Trust due
to the man’s contact with the Stockport Substance Misuse Service (SMS). The
report considers the appropriateness of the care and support he received from
the service during his time at the Approved Premises. It also makes reference
to the man’s mental health. The Associate Director for Clinical Governance at
Pennine Care NHS Trust gave permission to refer to this review in my report.
6. One of my Family Liaison Officers first contacted the man’s family on 21
December. She spoke with his mother who confirmed that the family would
appreciate a visit to discuss the family’s concerns.
7. My Family Liaison Officer and my investigator met the man’s mother, her
partner and the man’s sister on 15 January 2007. His family were concerned
that the man had not been adequately prepared for his release from prison.
The man’s mother said the man had not progressed to an open prison or had
any home leave visits before being given parole. She said that when he arrived
at the Approved Premises her son found it difficult to adjust to being back in the
community. They questioned whether or not the man had been properly
inducted at the hostel.
8. Although he eventually adjusted, in the man’s mother’s opinion, her son
remained anxious, particularly about breaking the conditions of his licence or
the hostel rules. The man’s mother said that her son feared going back to
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prison and carried two mobile phones with him to ensure that he always had a
means to contact the hostel in the event of being delayed.
9. The man’s mother told my Family Liaison Officer and my investigator that her
son never spoke of being a drug user or having problems with alcohol. As a
result, the man’s family were not aware that he might have found his moderate
alcohol contract problematic.
10. The man’s mother told my investigator that her son had also told her that a
resident had bullied him to provide a urine sample. My investigator found that
the incident did take place, but there was no evidence of bullying. The man told
his outreach worker that a resident had approached him for a urine sample as
the resident wanted to use it for a drug screen test, to guarantee a negative
result. He said that he had not felt threatened by the request, but simply found
it strange that he had been asked. The outreach worker informed staff of the
incident. Staff monitored the situation and changed the drug screening policy.
11. Despite the issues discussed with his family, the man never gave them any
sign of being depressed or distressed. When they had last visited him, the man
had seemed very happy. Since his death they have spoken with his
supervising officer who told the man’s sister that he had no idea that the man
had felt suicidal. His death came as a shock to all.
12. The man’s family asked that my investigator answer the following questions as
part of her investigation:
• What does the MAPPA process involve and how are reviews
carried out?
• Why was the man’s mother unable to appeal the MAPPA decision
to not relax the man’s conditions of licence or signing times during
the November meeting?
• What were the conditions of the man’s alcohol contract?
• What are the limitations on hostel staff when on duty at night? Why
did someone not pursue him beyond the hostel driveway?
• What did staff say to the man when he arrived late for his curfew?
Was he told that he had breached his licence conditions or could be
recalled back to prison?
• Who was on duty at the hostel that night? What are agency staff
and were there any on duty on the night that the man died?
• Did staff have the man’s mother’s contact details? On ringing the
hostel the man’s mother was asked to leave her phone number so
that she could be contacted.
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• Did the Detective Inspector take a statement from the taxi driver
who brought the man back to the hostel?
• Did the Detective Inspector speak to the man’s friends who had
been in the pub with him earlier that night?
• What happened to the rucksack that the man was carrying when he
left the hostel? It was not with him when he was found.
• Was there any CCTV footage of the man’s movements after he left
the hostel?
All of these questions are addressed within the body of this report.
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THE APPROVED PREMISES
13. The Approved Premises is a 25-bed Approved Premises for adult men, run by
Manchester Probation Area. There are six double occupancy rooms and the
rest are single.
14. The hostel is staffed 24 hours a day by probation employees who provide
support to residents and ensure their compliance with the hostel rules, license
and bail conditions. There are 15 members of staff. Between the hours of
8.00am to 10.00pm there are two residential service officers (RSOs) on duty.
From 10.00pm to 8.00am there are two residential service workers (RSWs).
The main distinction between the roles is that the RSOs are keyworkers (see
below). The management team comprises a deputy manager (probation officer)
and manager (senior probation officer, SPO). Managers are present during the
daytime. A duty manager (a SPO) provides out of hours cover between
5.00pm and 9.00am. Arrangements are similar during weekends.
15. Residents have their own keys and are permitted to come and go as they
please between curfew hours. Upon entry and exit, staff record movements on
resident monitoring sheets. Residents also record their entry and exit times on
a central journal. A system of curfew operates between 11.00pm and 6.00am.
Residents have to agree to comply with this and the other rules of residence as
a condition of their court order or as a requirement of their release from
custody.
16. Each resident is registered with the local medical practice - Heaton Moor
Healthcare Centre. Prescribed medication is stored in a locked cabinet located
in the general office at the hostel, unless the resident has been assessed as
able to have medication in possession. Having medication in possession was
introduced as a pilot scheme at the Approved Premises in May 2008.
Therefore the policy was not in place when the man was a resident. In any
case, the man would not have been eligible.
17. The surgery sends residents’ prescriptions to the local pharmacy, which then
delivers the medication to the hostel. My investigator was told by the Approved
Premises manager that some doctors (possibly locums) hand the prescription
directly to the resident, who should then bring it straight to hostel staff for
collection. Residents were actively discouraged from collecting prescriptions as
it makes it difficult to monitor their medications and assess risk.
18. Residents are allocated a keyworker (one of the RSOs) soon after their arrival.
The RSO acts as their primary point of contact for dealing with practical issues.
A keyworker manages a maximum of six residents. Regular keywork sessions,
which take place approximately every ten days, give residents the opportunity
to discuss any problems in depth. Although these sessions are not governed
by a set agenda, issues such as benefits, health and move-on accommodation
are routinely discussed.
19. The day-to-day regime at the Approved Premises is relaxed, although all
residents are expected to attend the daily morning meeting which commences
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at 9.00am. The meeting is chaired by a member of the hostel staff and acts as
a forum for staff to pass on information to residents, such as details of
appointments, activities available at the hostel on that day and menu options for
the evening meal. Residents are expected to use their time at the Approved
Premises productively, and are actively encouraged to pursue training and
employment options.
20. For any resident identified as at risk of self-harm or suicide, there is a process
in place for observation and monitoring using a tool called an Assessment Care
and Teamwork (ACT) document. The ACT is modelled on the document used
by the Prison Service. The ACT is for use by all those responsible for a
resident’s care to better manage the resident’s risk. This is done by clearly
documenting interactions, observations and assessments, in addition to
detailing care plans. The document is accessible to all involved, making care
transparent with shared responsibility.
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KEY EVENTS
21. The man was convicted of a violent crime in 2003. He received a seven year
sentence, with a Home Office licence due to expire in 2013. The licence meant
that if he reoffended he could be recalled to prison. The man’s last period in
custody was spent at HMP Risley.
22. Whilst at Risley, the man submitted three complaints regarding his Offender
Assessment System (OASys) score. OASys is a standardised process for
assessing risk. It is designed to:
• assess how likely an offender is to be reconvicted
• identify and classify offending-related needs including basic
personality characters, thinking deficits and social issues
• assess risk of harm to others and also to themselves
• assist with the management of risk of harm
• link assessments with supervision plans and sentence plans
• indicate need for further specialist assessments
• measure how an offender changes during the period of
supervision/sentence.
An assessment is carried out at the pre-sentence report (PSR) stage, with
further assessments conducted (either in custody or in the community)
and at the end of sentence.
23. OASys is used for the following groups of people:
• all offenders subject to court ordered PSRs
• all adult offenders subject to community penalties
• residents of Approved Premises, including those on bail
• adults serving six months or more in custody
• young offenders serving one month or more in custody
• those released from prison on licence.
24. The main part of the OASys examines the following factors which predict the
likelihood of an offender being reconvicted:
• offending history and current offence
• social and economic factors
• personal factors: drug and/or alcohol misuse; attitude towards
offending and supervision; emotional factors such as anxiety or
depression.
OASys highlight the impact each factor has on the offender’s risk of
reconviction, as well as the risk of serious harm to others or indeed himself.
25. The man challenged his score on the basis that he had completed some of his
offending behaviour targets, but they had not been reflected on his form. The
targets read as either being ongoing or not completed. Although the prison
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dealt with his complaints, the man remained dissatisfied with his OASys report
and said it was demotivating. He said he could not see the point in engaging
and complying if he did not see positive results. The man asked that a Multi
Agency Public Protection Arrangements (MAPPA) panel meeting scheduled for
29 August 2007 be postponed until his OASys form was updated.
26. MAPPA agencies comprise Police, Probation, Prison, Housing, in some
instances Social Services and other interested parties. The agencies meet to
manage an offender’s risk once released from prison. The panel considers the
risk management of the offender themselves, to staff, to specific individuals/
victims and the general public. This is a formal arrangement, put in place to
ensure a consistency in information sharing, to protect the public and reduce
the likelihood of reoffending. A typical risk management plan might include
various degrees of police surveillance, reporting schedules, licence conditions
and requirements to undergo specialist treatment orders.
27. Violent and sexual offenders are supervised by Police, Probation, Youth
Offending Teams and Mental Health Services. Any of these organisations can
refer offenders for consideration by a multi-agency meeting. The task of the
meeting is to share information, assess the risk(s) the offender represents, and
plan safeguards to protect the public. Every case has built-in timescales for the
risk management plan, individual accountability and a mechanism for checking
progress.
28. There are three MAPPA levels:
Level 1 – agencies can individually assess and manage the risks that
people they work with present to the public.
Level 2 – cases where there is a high risk of reoffending and causing
serious harm1 that cannot effectively be assessed and/or managed by
one agency alone. Agencies together organise and manage level two
meetings when they deem it to be necessary.
Level 3 – The Multi Agency Public Protection Panel (MAPPP) uses the
same formal processes as level two, but deals with the most high risk
cases, and requires regular monthly meetings from all agencies
involved.
29. The man felt his OASys score might influence decisions made at the MAPPA
meeting. In response to his complaints, the man was told that the OASys score
would be one of many factors considered in assessing a MAPPA risk level. A
probation officer at Risley said that his concerns would be made clear to his
offender manager. The probation officer told the man she would also be at the
MAPPA meeting and could represent his views. However, the officer stressed
1
Serious harm - that which is 'life threatening and/or traumatic and from which recovery, whether
physical or psychological, can be expected to be difficult or impossible' - Offender Assessment
System (OASys) definition used by MAPPA Responsible Authorities.
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that it was ultimately the decision of MAPPA to decide on his risk level and
licence conditions.
30. During June and July, the man’s offender manager secured a placement for the
man at the Approved Premises ready for his release. The placement was
offered to the man on the basis that the man’s offender manager contact the
manager at the Approved Premises or the deputy manager to agree the
conditions of his licence and the time and date of the man’s arrival.
31. The MAPPA meeting took place on 29 August. The deputy manager attended
on behalf of the Approved Premises. Also present were the man’s offender
manager, the probation officer from Risley and representatives from Lancashire
and Greater Manchester Police. On the basis of the meeting, the man was
given a MAPPA Level 3 score and rated as a high risk of harm and
reconviction. Two further MAPPA meetings were held prior to the man’s
release, one on 6 September and a second on 27 September. The focus of the
MAPPA discussions was the man’s offence and safeguarding his victims. The
police said they would develop a contingency plan to be activated if the man
was to fail a curfew or abscond. Strict measures were to be put in place,
including a two-hour recall, which would mean an immediate return to prison
should he leave the hostel outside his curfew without prior agreement.
32. Prior to the man’s release from prison, the man’s offender manager visited him
and discussed his licence conditions. The man was given a copy of his licence.
The conditions of his release were:
• he remained under a supervision order, which would expire 7 May
2011
• he should keep in touch with his offender manager
• to permanently reside at the Approved Premises.
• comply with requirements set by his offender manager to address his
alcohol and offending behaviour problems
• provide an alcohol breath test as reasonably required by staff at the
Approved Premises
• comply with the “no alcohol” contract he signed at the Approved
Premises
• abide by the curfew – to remain on the premises between 9.00pm and
9:30am
• sign in daily at 12 noon and 4.00pm at the Approved Premises, unless
given written permission to miss a time
• not to approach or contact his victims
• provide his offender manager with details of any travel
• he should not enter the county of Lancashire
• he could be subject to a recall to prison if he breached his conditions.
The man’s offender manager also talked to him about his resettlement in the
community and explained how it would work. The man was contacted by the
Approved Premises on 26 September and sent a residents’ information pack.
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33. The man arrived at the Approved Premises on 5 October, accompanied by his
mother and her partner. He was given an introduction to the hostel (based on
the information pack he had already received) and taken through the rules and
procedures by a residential service officer (RSO).
34. The full introduction process is carried out in stages over the first two days at
the hostel. It covers:
• hostel rules
• health and safety regulations
• dietary requirements
• room allocation and rent
• job seekers’ allowance and registering at the job centre
• registering with a doctor and medication
• issues of self-harm or suicide
• allocating a key worker
• making appointments with the key worker and hostel manager
• explaining the hostel regime, groupwork, activities and education
through City College.
The man signed the induction paperwork to say that he understood and
accepted the hostel rules and regulations.
35. A senior probation officer (SPO) was acting as manager as the Approved
Premises manager was on leave. She met the man to reinforce his licence
conditions, including the exclusion zone, which stopped him from entering
Lancashire (due to his offence). An entry by the senior probation officer in the
man’s contact sheet (a record of notes is kept for every resident) indicates that
he appeared nervous at first, but became relaxed. They also discussed the use
of his laptop and Open University (OU) exam work arrangements. The man
was allowed to keep his laptop as it complied with hostel rules and he needed it
for his OU work. The man’s exam was to take place during the afternoon of 9
October.
36. After the meeting, the senior probation officer telephoned Lancashire police to
ask if the contingency plan was available. The senior probation officer was told
that it had just been completed and would be emailed to her. The plan would
then be circulated to all staff and managers of other Approved Premises in the
area.
37. The man settled in at the hostel, but initially was forgetful of his curfew times.
On the morning of 8 October, he left the hostel at 9.15am, fifteen minutes
before the curfew time of 9.30am. Non compliance meant breaching the
conditions of his licence. He was reminded of the need to abide by the curfew
and given an informal warning. His response to staff was that this particular
requirement had slipped his mind.
38. Later that day the man met a homeless outreach drug worker for the Stockport
Substance Misuse Service (SMS). The substance misuse worker provides
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outreach drugs services and works with the Criminal Justice Intervention Team.
She provides substance misuse (including alcohol) support to the Approved
Premises residents every Monday and Wednesday. The premise of this work
is to offer residents advice, support and refer them to other services. In the
man’s case, this meant alcohol support groups.
39. During her session with the man, the substance misuse worker conducted a
basic screening assessment called a drug interventions record. The
assessment is the same for both alcohol and drug interventions. After the
man’s personal details were taken down, the substance misuse worker briefly
noted his risk assessment details. She wrote:
“Probation risk assessment – high risk offender – bears grudges.
Suffers histrionic personality disorder [and] narcissistic personality
order……Drinks heavily linked to anxiety and depression.”
40. The substance misuse worker noted that the man needed a doctor’s
appointment as he had problems sleeping, adjusting, a dust allergy and a
problem with his eyes. In the section on legal details, she outlined the
conditions of his licence relating to alcohol. These were to address alcohol use
as it has been identified as a trigger for his offending behaviour. The man
would have to adhere to alcohol testing and sign an alcohol compact of
abstinence. With regard to alcohol use, the man told the substance misuse
worker that he had received help from a doctor on two occasions in the past for
his heavy drinking. He had also received counselling for a year. The man said
that he had not touched any alcohol since his release from prison and found it
easy to abstain. Prior to his offence, the man said that he did not drink
regularly, but had done so heavily on the night it happened.
41. The substance misuse worker established a care plan for her contact with the
man, which included weekly sessions for a month, to be reviewed after a
month. She identified his immediate needs as a doctor’s appointment and to
continue support with his supervising officer (the man’s offender manager) and
key worker. The man signed and agreed to the plan.
42. On 9 October, the man had a meeting with the man’s offender manager and the
senior probation officer. The meeting was to discuss the man’s progress and
find out how he was coping with life at the hostel. The man said that he was
pleased and relieved to be at the Approved Premises. However, he had some
trouble sleeping over the weekend and felt unable to rest. It was noted that he
had a doctor’s appointment at a local Healthcare Centre.
43. The senior probation officer explained to the man the importance of
demonstrating willingness to progress and address his offending behaviour.
For example, working with his alcohol support worker (the substance misuse
worker), keeping appointments and complying with hostel regulations. Meeting
this target would be considered during future risk assessments and benefit him
in terms of normalising his life. They also discussed the man’s time in prison
custody. The senior probation officer noted that the man spoke intensely about
18
his experiences at prison. He said that staff had been dismissive to him at
Risley.
44. The man saw a doctor who prescribed Amitriptyline (an antidepressant) at
25mg twice daily for anxiety and Loratadine (an antihistamine) for his allergies.
The man told staff that the doctor said he would not have to take the tablets for
a long period of time.
45. On 13 October, the man went to the staff office to enquire about home leave.
The Approved Premises staff member explained the process to the man and
told him that in order to apply for home leave he would need MAPPA approval.
She also explained that residents have to be at the Approved Premises for six
to eight weeks before they can apply. The man told the member of staff at the
Approved Premises that he wanted to spend some time at his mother’s house
sorting his belongings. They discussed the option of asking MAPPA to relax
his signing in times so he could do so. The man suggested that he could report
to the police station at his signing time.
46. The member of staff at the Approved Premises said that he would still need to
wait for six to eight weeks before the request could be made. She explained
the MAPPA process to him and that demonstrating progress under supervision
would lend to a positive report. In addition, it could possibly lead to a relaxation
in his licence conditions. The man acknowledged this. The staff member
advised him to take one day at a time and noted in his contact sheet that the
man thanked her for talking to him.
47. The substance misuse worker held a one to one session with the man on 15
October. They talked about his mental state. The man described highs and
lows in his mood. He said that the highs were “fruit bat” behaviour and his lows
were when he hated himself, the world and everything. By “fruit bat” he meant
very bubbly and sociable. The man disclosed that sometimes before going to
sleep at night he had suicidal thoughts, which he described as thinking “what is
it all for?” The substance misuse worker probed the man further on this
comment and he said that he did not have those thoughts at the time. She
wrote in her notes “no suicidal ideation at present or today”. The man said he
mentioned it to demonstrate his highs and lows, and to explain that this was
normal behaviour for him. He said that antidepressants helped stabilise his
mood and limited the extremes.
48. They also talked about alcohol. The man said that he had not really been to
many pubs since his release, but he refrained from drinking alcohol when he
did. He considered it to be low on his list of priorities. The substance misuse
worker raised the possibility of referral to support groups such as the Alcohol
and Drugs Services (ADS) or the Alcohol and Drugs Abstinence Services
(ADAS). The man said that he would consider it. The substance misuse
worker asked the man if he could identify the periods in his life when he drank
heavily. He said that there were two occasions, due to the stress of an
unfulfilling job and the death of his father. The substance misuse worker asked
the man about more positive areas of his life. He told her about his plans to
finish his OU degree before looking for a job. He described himself as
19
academic and good at everything he did. They set the date for the next
session, which was 10.00am, 22 October.
49. The following day, the man had a risk management plan meeting with the
deputy manager and the man’s offender manager. The purpose of the meeting
was to draw up a hostel intervention plan and discuss his progress. They
discussed curfew times and the contract to abstain from alcohol. It was
suggested that the contract could be reviewed during the next MAPPA meeting
with the aim of reintroducing social drinking on a gradual basis. The agreed
overall plan was that the man would:
• attend the morning meetings
• attend group work
• attend all appointments made by hostel staff
• adhere to all hostel rules
• attend alcohol support sessions
• address his low mood by talking to staff if anxiety arose
• take his prescribed medications.
The man agreed to this. The plan would be reviewed four weeks later.
50. Later that day, the man had a keywork session with both the residential service
officers at the Approved Premises. The man said that he felt settled and was
associating well with other residents. He had registered for income support and
with City College. He had also received his OU forms, which needed to be
completed and returned by 7 November. The man told them that he was not
happy to participate in the Employability group work as he felt he was being
pushed to get a job. The residential service officer explained that the point of
the group work was not to push people into employment, but to equip them with
the skills for having a job.
51. They discussed the man’s medication and sick note. The man stated that he
had been told by the doctor that he would not be taking his antidepressant in
the long-term. He also told the residential service officer that he had suffered
from stress whilst in prison but felt he had coped because he was a strong
person.
52. On 17 October, the man went to the staff office and asked to telephone Wigan
Magistrates’ Court regarding an outstanding fine for damage to the property of
his mother’s neighbour’s property. He had been charged for causing damage
prior to his prison sentence. A compensation order was in place and the man
would have money deducted weekly from his benefits. Lancashire Police were
informed of this contact.
53. Two days later, a Detective Sergeant from Lancashire Police contacted the
man’s offender manager regarding the compensation order for the damage.
Although Lancashire Police was primarily concerned with making sure the man
did not attempt to contact his victims, they closely monitored all areas of
concern. The Detective Sergeant also asked about the man’s antidepressant
medication as she was concerned that the man had access to medication
20
without full supervisory control. She wanted to know how he collected his
medications and whether staff controlled the quantity he was taking. The man’s
offender manager explained that a doctor from the local surgery, used by all
residents, had prescribed his antidepressants. The Detective Sergeant said
that she knew this, but had been led to believe that the man was collecting his
own prescription. She subsequently spoke to the hostel and was assured that
this had been an oversight and his prescriptions would be sent directly to the
Approved Premises. It is not clear where the Detective Sergeant got this
information, however she told my investigator that the police were running
ongoing surveillance and intelligence checks on the man’s movements whilst
he was at the Approved Premises.
54. There was further concern on the Detective Sergeant’s part that the medication,
in conjunction with alcohol, was thought to trigger the man’s offending
behaviour. The man’s offender manager told the Detective Sergeant that in his
opinion the medication should not be viewed in isolation as a trigger and that
probation risk management and monitoring is based on a series of factors. The
man’s offender manager assured the Detective Sergeant that the man was
being closely monitored and, when required, measures would be taken to
minimise risk. No specific incidents or measures are referred to in the man’s
offender manager’s notes.
55. At 10.00am on 22 October, the man had his one to one session with the
substance misuse worker. He told her that he had not had any alcohol, but
wanted to discuss reintroducing social drinking. The man said that he would
like to be able to do this when he went out with his mother and her partner.
The substance misuse worker made a note to ask the member of staff at the
Approved Premises if the man’s no alcohol contract had been or could be lifted
by MAPPA. They then moved on to discuss his medication. The man said that
he was now feeling the benefit of taking his antidepressant and had not felt
anxious for seven days. He said that he was starting to feel more settled at the
Approved Premises. The substance misuse worker again mentioned a referral
to alcohol and drugs support agencies. The man said that he was happy at
present and did not need such contact.
56. The man’s offender manager went to the Approved Premises for a planned
appointment with the man on 23 October. They discussed his relationships
with other residents. The man said that he was exercising appropriate caution
and had different levels of trust and contact with residents. He was aware of
the need to keep away from any trouble. This was a general conversation and
there were no particular concerns about any specific relationships or residents.
The man’s offender manager spoke to the man about the compensation order
brought against him. The man was unhappy with the amount he had to pay
and was seeking advice about its reduction.
57. The next one to one meeting with the substance misuse worker was held on 29
October. The man told her that he had been out to a pub socially, but had
refrained from drinking alcohol. He said that he had drunk a non-alcoholic beer
and felt fine in doing so. He also reported that he felt settled at the hostel. The
substance misuse worker reduced the sessions to fortnightly. The next
21
meeting was scheduled for 12 November. During interview with my
investigator, the substance misuse worker explained that this was a typical
approach to managing clients. They would initially be seen on a weekly basis
and this would reduce to fortnightly, then monthly as the client settled.
58. Later that day, the man spoke to the member of staff at the Approved Premises
about bringing his computer (a stand alone PC and not a laptop) into the hostel
so that he could complete a computer course that he had purchased. The
member of staff at the Approved Premises explained that this question would
have to be dealt with by the managers as she was unable to make a decision.
A risk assessment would need to be completed as residents are not usually
permitted to have personal computers. The man also asked whether a request
for home leave could also be submitted as he wanted to go home for
Christmas. He was told that this would have to be decided by MAPPA. The
man was not happy with this. He told the member of staff at the Approved
Premises that he was unhappy with his MAPPA category Level 3. The man
said he had understood Level 3 to be the lowest level of risk and not the
highest. The member of staff at the Approved Premises told the man that if he
wanted a fuller explanation of MAPPA and the categorisations she could
arrange for him to be given this information. The member of staff at the
Approved Premises noted that the man seemed happy with this response.
59. When the man’s offender manager met the man for a supervision appointment
on 30 October, the man told him that he had several points he wanted to
discuss – alcohol, home leave and his curfew. He told the man’s offender
manager that his sessions about alcohol with the substance misuse worker had
been going well. They had discussed a strategy for reintroducing responsible
drinking and the man wanted the opportunity to prove that he could do it. The
man then re-stated that he would like to apply for home leave. He added that
he would like his curfew hours adjusted to allow more freedom during the day
time to spend longer at the library or visit his mother. The man’s offender
manager said that these requests would all need to be put to the MAPPA panel.
He told the man that his positive engagement to date was encouraging and he
should continue as this should help support his requests.
60. The man’s offender manager explained the MAPPA Level 3 category to the
man. He said that if the man could demonstrate a reduced risk to the public,
his rating level might be reduced. The man’s offender manager told the man
that a significant factor in the level attributed to him was the lack of remorse or
empathy shown toward his victim. The man did not like this and said that this
was a historical fact and no longer true. The man’s offender manager wrote in
the contact notes that he thought the man was becoming more open to
exploring the victim’s perspective.
61. The man also approached the deputy manager on the subject of moderate
alcohol consumption. He said that he did not feel that alcohol was an issue for
him and he wanted to be able to have a drink when he went out. The man
wanted to join a gay and lesbian focus group that met in a pub on the second
Wednesday of each month. The deputy manager discussed the issue of
moderate drinking with the man’s offender manager, who in turn discussed it
22
with the MAPPA Chair. It was agreed that because of the man’s good progress
it would be safe to allow him a moderate drinking contract. On 2 November,
the man received a letter from the deputy manager confirming that the MAPPA
Chair had agreed. The new contract meant that he could be breathalysed at
any stage, but if the reading was over the legal drink/drive limit (35 micrograms
of alcohol per 100 millilitres of breath or 80 milligrams of alcohol per 100
millilitres of blood) then the man would be in breach of the contract. The deputy
manager told my investigator that the reason for this limit was to encourage the
man to approach drinking sensibly without binge drinking. The man’s offender
manager said that this was a further opportunity for him to demonstrate his
progress and that he could be trusted.
62. The same day, the man was told that he would be allowed to bring his
computer to the hostel. The computer could be kept in the group work room on
the ground floor on the proviso that the man would work on it at times
convenient to staff. He would not be allowed the computer in his room. The
man agreed to these conditions.
63. Four days later (6 November), the man had another supervisory session with
the man’s offender manager. The man reported that he was pleased with the
new alcohol contract. He had talked about it with the substance misuse worker
and she had agreed that it would be a positive step for him to start socialising in
the community. The man’s offender manager agreed.
64. They discussed the man’s request for home leave. The incident of criminal
damage to the neighbour’s car was a possible barrier to his application for
leave. There was concern that if the man came into contact with the neighbour
it could possibly set him back. The man told his offender manager that whilst
he still felt aggrieved by the situation, he acknowledged that his previous
behaviour had been inappropriate. The man’s offender manager said he felt
this demonstrated a positive shift in the man’s attitude and thinking. He was
becoming more aware of the consequences of his actions and this could act in
his favour with the MAPPA panel at the next meeting – 15 November.
65. On 9 November, the Approved Premises manager gave the man a letter that
confirmed he had been given permission a week earlier for limited use of his
computer in the group-work room on the ground floor. A member of staff gave
another copy of the contract to him. The man declined the conditions of the
contract, saying that he did not want to work alone in the group-work room in
the basement. He said that he needed to be able to use the computer at any
time and would prefer it in his room. The man added that he would rather wait
until he could do what he wanted in a couple of months. The staff member did
not know what he meant by this statement. The man asked that she tell the
Approved Premises manager that he was grateful for the offer, but he would not
accept it.
66. Later on in the afternoon at 4.45pm, the man told the staff member that he had
put his name in an internet search engine to see what information he could find.
The man was very upset to find some news reports which referred to him being
sexually abused and contained information about his offence that he
23
considered to be incorrect. He was not happy for the information to be public
knowledge. The man said that he wanted to change his name. He said that he
felt emotional and wanted to see a doctor. The staff member reported in the
man’s contact notes that he wanted an appointment before he self-destructed.
An appointment was not available until 6.15pm, so the man went for a walk
instead. The staff member later reported that he had calmed down on his
return and said he no longer needed to see the doctor.
67. The staff member informed the deputy manager of his conversation with the
man. They decided to contact the Detective Sergeant and let her know about
the man’s reaction to finding the information. The Detective Sergeant said that
she was concerned and would share this information with her colleagues.
68. At 10.15am on 12 November, the man had a one to one session with the
substance misuse worker. He presented as fed up. The man said this was
because he was being denied full access to his computer to do his OU
assignments. He said that he would probably defer his course until the
following year. The man also talked about wanting home leave so that he could
sort through some of his belongings at his mother’s house. The substance
misuse worker noted that the man appeared unsettled during this session and
was worried that if he was becoming unhappy that this may lead to an increase
in alcohol consumption. She decided to arrange an appointment for the
following week on 19 November.
69. On 14 November, the day before the MAPPA panel meeting, the Approved
Premises manager spoke to the man. The manager, who was attending the
panel meeting on behalf of the Approved Premises, had not had a great deal of
direct contact with the man as he had been on leave. The man requested that
the manager ask the MAPPA panel to withdraw his 12.30pm signing time so
that he could start to look for work. He wanted to have more time to explore
Stockport as he would not be under pressure to return to the hostel when he
left in the morning. The manager noted in the man’s contact sheet that this was
a brief but positive meeting and that he appeared to be making good progress.
70. The MAPPA panel sat the following morning. There were four representatives
from Lancashire Police (including the Detective Sergeant), one from Greater
Manchester Police (GMP), four from the Probation Service (including the
Approved Premises manager and the man’s offender manager), an
administrative officer and a chairperson. The Approved Premises manager
was not present at the start of the meeting. He told my investigator that
although he was in the building, he was not notified when the meeting began.
Consequently he did not join the discussion until the panel was deciding on
what action to take. He was however able to provide an update.
71. All MAPPA meetings have a confidentiality protocol that participants must
adhere to. Information from the meeting was not to be disclosed to other
parties without the Chair’s permission. The meeting was called to review the
man’s risk following his release from prison, address any arising matters and
updates.
24
72. The man’s offender manager gave the panel an update. He said that he had
visited the man six times since his release, and although it was early in his
licence, the man’s resettlement had so far been positive. He had been
compliant and was receptive to staff interventions and guidance. The panel
discussed his engagement with the alcohol support services and the recent
change in his contract to allow moderate drinking. The man’s offender
manager told the panel that although this plan was in place, the man had not
returned to drinking alcohol at this stage and all breath tests for alcohol use had
been negative. The man’s medication was also been discussed. The man’s
offender manager said that the man’s anxiety levels were high at the time of his
release and he had since been prescribed an antidepressant. His medication
was dispensed in accordance with hostel rules; it was kept in staff possession
and dispensed as prescribed.
73. The issue of a home visit was discussed. The police were concerned about the
man’s conviction for damaging property belonging to his mother’s neighbour.
The man’s offender manager explained to the panel that, although the man
previously disputed the compensation order, he accepted his behaviour was
inappropriate and the neighbour was entitled to compensation. The Detective
Sergeant voiced concerns regarding the risk of a home visit, particularly whilst
the compensation order was still active. A suggestion was made that the man
could have a police supervised visit. The panel rejected the idea of both an
unaccompanied and a police supervised visit and the request was therefore
denied. The man was expected to obtain his belongings from his mother’s
house by other means.
74. When the Approved Premises manager joined the meeting he told the panel
that the man had made progress at the Approved Premises and requested a
relaxation of his signing in times. The panel did not support the request at that
time, but considered that it could be a possibility in the longer term. Until then,
his curfew and signing times would remain the same.
75. The panel’s conclusion was that no evidence had been given to support the
view that his current curfew and times restricted the man’s attempt to gain
employment. It was decided that his risk and conditions of licence would not
be altered until the next MAPPA panel meeting. At the next meeting, set for 3
January, the man’s offender manager would update the panel on the relaxation
to the man’s alcohol contract. The man was to be informed of the panel’s
decisions by his offender manager immediately, followed by an official letter.
The man’s offender manager informed the man by telephone the next day.
76. On 16 November, the man had a key worker session in which he told his key
worker, the residential service officer, that he was very unhappy with the
MAPPA decision. He felt that all the positive progress to date had been
wasted. The man elaborated on this disappointment and said he was at a loss
as to what to do in order to get recognition for his compliance. He had hoped
for some relaxation of his signing times and was upset that this had not been
granted. The residential service officer explained that MAPPA decisions are
not just based on his behaviour and progress at the Approved Premises. Other
25
risk factors had also been taken into consideration, and in this instance had
taken precedence.
77. The man did not fully accept this and said that he felt let down by the Probation
Service and other authorities. He told the residential service officer that he
believed that the Probation Service had altered his OASys score [his previous
complaint] and this had affected the decision. The residential service officer
wrote in the man’s contact sheet that he appeared to be a defeated man and
he became quite upset during the session. The man said on several occasions
how he was beyond disappointment and did not know what to do next.
78. The man had a one to one session with the deputy manager during the
afternoon. She noted in his contact sheet that he was upset about the MAPPA
decision. The deputy manager told him that she was unable to explain the
MAPPA decision process to him, but the man’s offender manager would be
able to do so more fully in their next session. The man said that he regarded
the MAPPA decision as a conspiracy and it was a test to see how he would
cope with bad news. He told the deputy manager that she only empathised
with him because she was trained to and that he did not know who he could
trust.
79. Two days later, the man spoke with the residential service officer again. The
residential service officer noted that the man had been in a very low mood over
the weekend and that he and other staff had tried to engage him in
conversation to no avail. The man had spoken very little and had been seen by
the hostel chef sitting on a wall outside staring into space. The residential
service officer tried to speak to the man but he said that he did not want to talk.
He just wanted to watch the cars go by. The residential service officer said that
this had been typical of his mood in the days after the MAPPA meeting.
80. The man had his one to one meeting with the substance misuse worker on 19
November. He told her that he was unhappy with the MAPPA decision not to
relax any of his licence conditions. He said that he now drank two pints of
shandy when he went to a pub. The man said that he felt bullied by the system
and disclosed that a resident had asked to buy a urine sample from him. He
raised this matter by asking if he could tell the substance misuse worker
something confidential. She told him that it would be fine to, however there
were limits on what could remain in confidence if it could compromise hostel
security. The man said that he was happy for the substance misuse worker to
speak to staff about the incident. The substance misuse worker told my
investigator that the man did not appear under pressure from this resident, he
just found it bizarre that someone would want to purchase his urine. The
substance misuse worker did not think that he was being bullied.
81. The substance misuse worker considered the man’s behaviour to be strange
during this meeting. He asked her whether a member of the community drugs
team had been sent to check on him as he had seen someone from the team
whilst at the pub with his friends. The substance misuse worker told my
investigator that she reassured the man that it had been a coincidence.
26
82. The man continued to decline the offer of referral to an alcohol support group.
This worried the substance misuse worker as he had now progressed from
drinking low alcohol lager to pints of lager shandy. As the man was unhappy
with his conditions, the substance misuse worker was concerned this might
impact upon his drinking. She told him that he might find it a useful exercise,
but he continued to refuse. The next appointment was set for 3 December.
83. The following day (20 November), the man’s offender manager attended the
Approved Premises for his supervisory meeting with the man. The man
remained disappointed with the MAPPA decision and said he was equally
disappointed that he had to wait so long for the next meeting. The man’s
offender manager explained to the man that the period in between would be
important as his progress would continue to be monitored. The man’s offender
manager stressed that as the monitoring and reviewing was an ongoing
process, his continued positive engagement was crucial. The man’s offender
manager noted that the man’s motivation had taken a setback. However, the
man said that he was feeling a little more positive after their conversation.
84. The man appeared to settle over the next week and concentrated on his
computer course, using the hostel computer. However, he suffered a panic
attack on 26 November during a group work session. The man left the session
saying he needed a comfort break and did not return. Instead he went to speak
to the deputy manager. The man told her that he felt uncomfortable with the
number of residents in the session. He said that he found it difficult to cope
with a large crowd and also made the assumption that members of the group
were sex offenders. The man explained that sex offenders made him feel
uneasy and frightened because he had been abused in his past. After
discussing the issue, the man agreed to see if he could cope with smaller group
work sessions.
85. The deputy manager informed the Approved Premises manager of the man’s
panic attack. He said that the man could be removed from the group on the
understanding that he engaged in other work and made constructive use of his
time. For example, continuing with his computer based education. When a
smaller group activity was next scheduled, the man would be expected to
participate. The deputy manager said that she would take this up with him.
86. The next evening (27 November), the man went to the staff office at 8.30pm.
He complained of chest pains and had another panic attack. Another member
of staff was working that evening. He spoke to the man, who became more
agitated. The staff member told the man to lie down on the floor and an
ambulance was called. The paramedics arrived at 8.40pm. They calmed him
down and took him on board the ambulance to be medically assessed.
87. The Approved Premises manager was the duty manager that evening. He was
contacted at 9.00pm and informed of the situation. The Approved Premises
manager instructed staff at the Approved Premises to keep a close watch on
the man, checking him every 15 minutes whilst he was awake and periodically
throughout the night. This is an example of good practice.
27
88. When the man came out of the ambulance, staff said he seemed calmer and in
a better frame of mind. The paramedics advised the man to see a doctor as
soon as possible to discuss his anxiety. It was noted that the man already had
an appointment booked for the next day. The man went to bed at 11.00pm and
staff checked him throughout the night.
89. At 11.00am the following morning, the man spoke to the deputy manager about
his anxiety. He said that his panic attack had been triggered by the stress
placed upon him by the Probation Service and gave the following reasons for
his stress:
• He was being made to live in a place for high-risk offenders when he
believed he was not high-risk.
• He attributed his offending to a reaction to his medication. Therefore
he was not responsible for those actions and not high-risk.
• He felt that living at the Approved Premises exposed him to potential
danger from other individuals who are high-risk.
• He felt that he should not be exposed to group work as it increased his
anxiety.
• Not having access to the internet in the hostel meant he could not send
emails, which restricted contact with his family.
• He said that the substance misuse worker had told him that it was his
offender manager who could adjust his signing times and not MAPPA.
• He mistrusted probation staff as they were conspiring against him.
90. The man told the deputy manager that his mother and sister supported him on
these points. He said that he was going to exercise his right to privacy and
would no longer engage with staff at the hostel. The deputy manager tried to
empathise with his frustrations and told the man that his concerns would be
raised during the next MAPPA meeting. She explained that the substance
misuse worker was not a probation worker and consequently would not be
familiar with licence conditions and MAPPA procedures. The deputy manager
later took the matter up with the substance misuse worker, who stressed that
she had not given the man any reason to believe that his supervising officer
had the authority to remove a signing time. The substance misuse worker
confirmed this when she spoke to my investigator.
91. The deputy manager telephoned the man’s offender manager and expressed
concern that the man seemed to have taken a step back. He was no longer
accepting personal responsibility for his offending behaviour. She told the
man’s offender manager of the man’s assertion that external events had been
to blame for his situation. The deputy manager attributed this shift in his mood
to the outcome of the recent MAPPA meeting. The man’s outlook and
willingness to trust staff had deteriorated when MAPPA did not relax his licence
conditions in recognition of his progress.
92. The man attended his medical appointment the next day. The doctor
prescribed Zopiclone (sleeping tablets) and Propranolol (medication used to for
the associated symptoms of anxiety, i.e. tremor, sweating and dry mouth). The
man started the sleeping medication that night and Propranolol two days later.
28
93. On 29 November, the deputy manager sent an email to the man’s offender
manager, copied to the manager, again saying that she was becoming
increasingly concerned about the man’s deteriorating mood. She said that her
two major concerns were:
• The man now regarded all probation staff as having a hidden
agenda. He said that staff were deliberating putting stress upon him
to see how he coped. This made him difficult to work with on a day
to day basis.
• The man’s mood was such that she believed there could be potential
for self-harm or otherwise self-destructive behaviour.
94. The deputy manager said that she believed there would be therapeutic value in
relaxing his restrictions, namely the 12.00pm signing time. She recognised this
would be a risk, however the current way of working was increasing his
resentment which could heighten his risk. As both she and the Approved
Premises manager would not be available for the next MAPPA meeting on 3
January, she asked whether there was any flexibility on the date.
95. The manager forwarded the deputy manager’s email to the representative from
the Greater Manchester Area Office who Chaired the MAPPA meeting on 15
November together with a supporting email of his own. He reminded the Chair
that he had not been present for the majority of the MAPPA discussion as no
one had informed him it had started until the panel were discussing the action
points of the agenda. The Approved Premises manager said that he was
concerned that his staff were not aware of any police intelligence to suggest
that the man’s risk was increasing. He wrote that the man had made progress
since arriving at the Approved Premises which was not recognised.
96. The Approved Premises manager asked that as the panel would not reconvene
until early January, a compromise be reached over relaxing the man’s
afternoon signing requirements for some of the days of the week. He
suggested that Lancashire Police be made aware so that surveillance could be
organised if required. He asked the Chair to give the man something positive
to work towards to prevent the possibility of a difficult licence recall. The
Approved Premises manager believed there needed to be some sort of offer in
order to rebuild a working relationship with the man. These requests were not
met by the Chair at this time, but remained on the agenda for discussion at the
panel meeting set for January. The date of the meeting was changed to 10
January to enable representatives from the Approved Premises to attend.
97. The man was six minutes late for his evening curfew on 29 November because
the taxi driver who brought him back did not know where the Approved
Premises was located. The driver came into the hostel with the man and
explained to the residential service officer (who was on duty that night) what
had happened. The man did not speak as the driver was talking to the
residential service officer, but went straight to his room. He did not appear to
receive a warning, formal or informal for his late arrival.
29
98. The following day, the District Manager for Wigan/Atherton Probation Area and
the man’s offender manager conducted a review of the man’s case as a high-
risk offender. This type of review can be held at the request of the offender
manager, if there are concerns, or as part of a standard review for a MAPPA
case. In addition to the man’s offender manager’s input, the District Manager
considered supporting information from the manager and the deputy manager
at the Approved Premises, both of whom detailed the man’s deterioration in
mood since the MAPPA meeting. The District Manager said that she did not
think it appropriate to reconsider the man’s conditions at this time and they
should wait for the next MAPPA meeting in January. A proposal was made to
bring forward the MAPPA meeting, but the District Manager did not think that
there were strong enough reasons. In the meantime she asked that:
• The man’s behaviour continue to be monitored.
• The offender manager tell the man that it would be in his interest to
start engaging with staff as MAPPA would be reconsidering his signing
times during the next meeting. This decision would take into account
recent behaviour.
• Hostel staff brief MAPPA in writing if they were unable to attend the
meeting in early January.
99. Later that day, the Approved Premises manager issued a notice to the staff on
weekend duty, by email. He requested that the man be breathalysed if he went
out, particularly as it was known that the man had started consuming low levels
of alcohol when visiting the pub. This request was in keeping with his alcohol
contract. The Approved Premises manager said:
“Please be careful when asking him for a sample of breath, but ensure
that this is done. Please also ensure that staff on shift from this
evening [Friday night] know that he needs to be treated with care,
concern and with some degree of caution too. He is disappointed by
the decisions of the MAPP panel not to relax any of his signing times
and whether he has a point or not is irrelevant – this is how he sees
things and this might make him a danger to staff and his risk may now
be increasing. It is his stated reason for withdrawing his cooperation
and not engaging with staff as well as was doing previously.”
There are no entries in the man’s contact sheet for that weekend.
100. On 2 December, the residential service officer wrote in the man’s contact sheet
that the man had continued to withdraw from life at the hostel. The man went
to the office several times during the day to talk to staff. On one occasion he
told the residential service officer that he had decided not to contact a former
prisoner he knew who had come to Stockport. The next occasion he asked
why the police had contacted his solicitor for a report. The man said his
solicitor told him that the police were snooping around. He went on to say that
the man’s offender manager must have known but was hiding information from
him. The residential service officer asked the man why he thought that the
Probation Service were party to police enquiries. The man replied saying that
everyone was conspiring against him.
30
101. The man continued this line of conversation when he came to collect his
medication during the afternoon. He explained to the residential service officer
that he felt like he was being attacked from all sides and likened it to “being
scratched with nine inch nails”. He said that leaving prison should have been a
happy time, instead he had been placed in a high-risk offenders’ hostel, which
had put him in danger due to the nature of the other offenders. The man said
that he believed he was medium-risk, so did not know why he was labelled
high-risk. He said that people would have to apologise to him once it was
found that he did not have a personality disorder. He alluded to an
independent report that he would use when his solicitor said it was appropriate.
102. The man repeated that he felt the Probation Service was conspiring against
him. He told the residential service officer that he would no longer eat at the
hostel. The residential service officer noted in the contact sheet that the man
kept changing his clothes that night and had mood swings.
103. The residential service officer told my investigator that during the beginning of
December he the man sorting through some clothes in his room. The man said
he had got them from his mother’s house. It is not clear whether he had
collected them or they had been brought to the hostel. The man told the
residential service officer that he wanted to sort things out. The residential
service officer told my investigator that although there was nothing significant
about this conversation, he was concerned that the man was feeling troubled.
This event is not documented in the man’s contact sheet and is an event that
the residential service officer recalled during his interview.
104. At 9.15am on 3 December, the man had a one to one session with the
substance misuse worker. She noted that he had a negative presentation, but
attributed this to the fact that he had only just woken up and was still drowsy.
The man told her it was because of his sleeping tablets (Zopiclone). They
talked about how he was feeling. The man said that he felt like “he had given
his all and got nothing in return”.
105. They discussed his low-level alcohol use. The man said that he had been to a
pub last week for a curry and drinks with friends. The man also said that he
had met one of the residents and a previous friend from his time in prison. On
this occasion he had consumed four pints, three of them lagers. The substance
misuse worker noted that his drinking was increasing. The man told the
substance misuse worker that he would not meet his friend from prison again
as he did not think it would be a good idea.
106. The man said he had not spoken to his supervising officer for two weeks about
changing his licence conditions. The substance misuse worker noted that his
demeanour had improved by the end of the session and she had no further
concerns about his presentation. The next appointment was scheduled for 12
December. (This session did not take place because the substance misuse
worker was on sick leave.)
31
107. On the same day, 3 December, a member of staff at the Approved Premises
noted in the man’s contact sheet that staff were aware that the man had started
to drink a few pints of alcohol. However, there were concerns as he was taking
various medications – Zopiclone (sleeping tablets), Amitriptyline
(antidepressant) and Loratadine (antihistamine, non-drowsy). Each of these
medications gave instructions to avoid alcohol.
108. Two days later (5 December), the man’s offender manager wrote to the
Approved Premises manager and the deputy manager by email on the issue of
the man’s medication guidance. He emphasised that as part of their duty of
care to the man, the Approved Premises (and he) should take steps to ensure
that the man was not being exposed to a preventable risk by drinking whilst
taking medication. The man’s offender manager wrote:
“It is my view from a health and safety perspective that we need to
ensure that the man is avoiding alcohol in accordance with his
medication guidance. We are to all intents and purposes administering
his medication so we need to take steps to ensure that we are not
exposing the man to a risk that is preventable. I don’t view this as
harsh rather something that we are compelled to do under health and
safety legislation and as a duty of care.”
109. The man’s offender manager had a supervisory session with the man that
afternoon. He noted the man appeared more resistant to engaging with staff
and less motivated towards his offence focused work. The man’s offender
manager said that he found the man to be preoccupied with the idea that the
police were interfering, as they had asked his solicitor for access to psychiatric
assessments. He asked the man how he was coping with his anxiety. The
man said that nothing had changed since their last meeting. He still attributed
his stress to the MAPPA decision. The man did say that he had been to his
doctor in the interim and had been advised to continue taking his
antidepressant.
110. The man’s offender manager took the opportunity to raise the issue of drinking
whilst taking medication. He reminded the man about being careful with his
prescribed medication if he was going to drink. The man said that his doctor’s
guidance was not to drink to excess and not take more than his prescribed
dose of medication. He told his offender manager that it was not really an
issue, as he did not feel the need to drink. The man’s offender manager asked
the man about the use of the breathalyser test. Again, the man said this was
not a problem as he did not want to drink and was complying with hostel rules.
After their meeting, the man’s offender manager sent a further email to the
Approved Premises manager and the deputy manager informing them that the
man was being sensible regarding his alcohol contract and prescribed
medications.
111. During the evening, the man went to the office to provide information about his
forthcoming appointments. He told two members of staff that one of the
appointments was with his solicitor in Merseyside and asked how long it would
take to get there. She asked where in Merseyside and noted in his contact
32
sheet that he replied “Merseyside, Merseyside” in a sarcastic manner. He then
went on to say that his family had come to the decision that he should return to
live at home and asked who he would need to speak to about this. The staff
member said that he would need to talk to the man’s offender manager and the
deputy manager, but that ultimately the decision would lay with MAPPA. She
noted that the man was adamant this was not the case and that the Probation
Service wanted him at this mother’s address in the first place. The staff
member noted in the contact sheet that the conversation was icy and awkward.
112. On 6 December, an entry in the man’s contact sheet noted that he had been
acting strangely with staff. He was not forthcoming with conversation and came
out with flippant comments when asked questions. At 2.00pm the next day, the
deputy manager managed to speak with the man at length. They talked about
his anxiety, frustrations and psychiatric reports. The man told the deputy
manager that he did not need another opinion regarding his diagnosis of
personality disorder as he already had one. A report had been written by a
consultant psychiatrist, which vindicated the man from responsibility for his
offence. The man said that this report was with his solicitor and was not ready
to be released to other parties. He said that the report said he had committed
his offence due to:
• an underlying state of anxiety (not personality disorder)
• a build up of stressful events (loss of his father, job and sexual abuse)
• overdose of medication in combination with alcohol.
113. The man said that this report would help him appeal his sentence. The deputy
manager suggested that if these circumstances were the case the man should
try not to shut people out, but should explore his anxiety with his offender
manager and keyworkers. The man said that he had decided to withdraw his
cooperation with staff and exercise his right to silence. He told her that he
thought if he spoke he would be misinterpreted by the authorities and recalled
to prison. His only current anxiety related to his signing times. He felt confined
by them and the rigid framework. The deputy manager stressed that he
needed to comply in order to fulfil his licence and for MAPPA to relax his
conditions. She advised the man to write a list of advantages and
disadvantages for engaging more positively with staff and his situation.
114. Later that evening, it was brought to the deputy manager’s attention that the
man had collected his own medication from the pharmacy for the second time
that week. Although he handed the unopened medication to hostel staff, the
deputy manager told him that it could not happen again as it was against hostel
policy and prescribed medication was a listed risk factor for the man.
12 December 2007
115. On 12 December, the man was 30 minutes late for his midday signing time. He
argued with the member of staff that he was in a City College session taking
place within the building. The man said that staff knew he was inside the hostel
and so he did not see why he should have to write that he signed in at 12.30pm
33
instead of 12.00pm. The staff member reminded the man of the importance of
meeting his conditions and noted that he reluctantly signed the book.
116. The man’s offender manager was in the office when this conversation took
place. He was due to have a supervisory session with the man at 12.30pm.
They talked about his argument with the member of staff. The man’s offender
manager told him that he needed to maintain some discipline. The man
attempted to deflect this by saying there were times where he had been
delayed in signing because staff were not in the office at the required time. The
man’s offender manager wrote in the man’s contact sheet that, in his view, the
man was testing the boundaries in response to his signing times not being
relaxed by MAPPA.
117. The only positive point that the man raised was that his mother and her partner
had visited him over the weekend. He said that they had talked about him
moving home once his licence allowed. The man said that they had only
considered it as he had not been granted home leave and had therefore been
unable to spend sufficient time with his family. The man told his offender
manager that he was being tortured and it was similar to when he was kept in
prison beyond his parole eligibility date. During the meeting, the offender
manager gave the man a letter from the MAPPA Chair which re-stated the
decision made in November. Whilst he had received verbal feedback from the
meeting on their decision, this was the written confirmation. The man was
unhappy with the letter, screwed it up and put it in the bin. He told his offender
manager that, whilst he was not going to breach his conditions, he could not
see any point in engaging when good behaviour was not rewarded. The man’s
offender manager reminded him that the conditions and requests for home
leave would be reviewed at the January meeting.
118. The man’s offender manager concluded from the session that the man’s
approach to their sessions had shifted and he was mistrustful. At several
points during the session, the man referred to MAPPA decisions as the man’s
offender manager’s decisions. The man’s offender manager wrote:
“His narrative also suggests that he now views myself as an agent of
control, making comments that there is no point in our meetings as all
they are about is telling him what he cannot do so what is the point in
meeting as he knows what he cannot do. The man asked if the
meeting could be concluded as he did not feel able to go any further as
he was upset by finding out that he wouldn’t be able to go home for
Christmas. Whilst it was anticipated that the man would adversely
react to not being given granted home leave and a constructive
outcome was not envisaged, it is of greater concern that the man’s
resistance is becoming more entrenched, with it becoming increasingly
difficult to re-engage him in constructive offence focused work.”
119. The man’s offender manager found the man to be frustrated by this situation
and unwilling to engage. He told my investigator that, although the man was
upset and angry, he was not concerned about him being at risk of any harm.
34
120. After this meeting, the man went to the office to take his medication. The man’s
offender manager was with him. The member of staff noted in the hostel log
book that the man appeared very annoyed and did not want to take his
medication in front of his offender manager so he left the office whilst the man
took them.
121. The man left the hostel that evening to go to the pub with some friends. My
investigator received an account of his time at the pub from police witness
statements after his death. The man met his friends at 5.30pm. He had asked
them to meet him earlier as he wanted to see them prior to a monthly social
meeting they all attended, which started at 7.30pm. His friends told the police
that the man had spoken about his earlier issue with hostel staff concerning his
12.00pm signing time. They said that he had been concerned about this and
that staff had not listened to him. His friends told the police that they had a few
drinks, but the man said he had restrictions about how much he was permitted
to consume.
122. The man was seen speaking to the bartender at the second pub where the
social group met. The police also interviewed this man as part of their
investigation. The man told the police that he and the man chatted for a short
while before exchanging telephone numbers and agreeing to meet at the
weekend. The man told the police that the man had not appeared drunk and
he had only served him one, to one and half pints of lager that evening.
123. The friends told the police that the man appeared anxious that he might miss
his curfew and asked how long it would take to get back to the hostel in a taxi.
They told him that if a taxi arrived on time he would get back before his curfew.
The man left the second pub at 8.45pm. His friends did not see him get into a
taxi, but assumed that he had done so. They said that he had been in good
spirits that evening and did not present as a cause for concern. After the man
had left the pub, the bartender noticed that he had a missed call from the man.
He sent the man a text message asking if he was okay, but did not receive a
reply.
124. At 8.55pm, the man telephoned the hostel and spoke to the member of staff at
the Approved Premises (one of the RSOs on duty). He explained that he had
just left the pub and had been trying to get a taxi, but had been dialling the
wrong number for the last 15 minutes. The man gave her the telephone
number that he had been using and she tried to call on his behalf. It came to
light that the number was incorrect. The member of staff at the Approved
Premises spoke to the man and told him to get back to the hostel as quickly as
possible as he was going to be late for his curfew. The man sounded
concerned and estimated that it would take 25 minutes to walk there. He
succeeded in contacting the taxi firm and rang the member of staff at the
Approved Premises at 9.00pm to say that he was on his way. My investigator
asked the member of staff at the Approved Premises if the man had sounded
drunk on the phone. The member of staff at the Approved Premises said “not
overly, no”.
35
125. The member of staff at the Approved Premises telephoned a senior probation
officer (SPO) who she thought was the duty manager, to let them know that the
man was a little late for his curfew but was on his way. Unfortunately the
member of staff at the Approved Premises had read the duty roster incorrectly
and telephoned a SPO who was not on duty. In the meantime, the taxi arrived
and the man came into the hostel with the taxi driver at 9.10pm. The driver
confirmed that he had only just picked the man up and had driven him straight
to the hostel.
126. The man asked the member of staff at the Approved Premises if she had
change for a £10 note. She said that she did not. The taxi driver said that he
would get some change. The member of staff at the Approved Premises said
this was okay, thinking the driver would get the money from his car, but noticed
that the man got back into the car and the taxi drove off. The car returned a
few minutes later and the man explained that they went to the petrol station
across the road to get some money.
127. On speaking to the man, the member of staff at the Approved Premises said
that she could smell alcohol on his breath. She asked him to take a
breathalyser test. The man replied “Oh today of all days. I have had a drink
and will be over the limit…. This close to Christmas”. The member of staff at
the Approved Premises told my investigator that she said “well there’s no
problem, but for health and safety I just need to do the test to see how much
alcohol you have had”. Whilst the member of staff at the Approved Premises
prepared the test, the man stood up and said, “I tell you what, I can’t be
bothered” and walked out of the office.
128. The member of staff at the Approved Premises went to telephone the duty
manager to let her know that the man had been a few minutes late, had been
drinking and would not take the breathalyser test. Before she was able to do
this, the man returned to the office. He smiled, waved to the staff on duty and
said, “See ya”. The man then walked out of the hostel carrying his rucksack
and ran down the driveway in the direction of Stockport. The two members of
staff at the Approved Premises called after the man telling him to come back.
One of the members of staff at the Approved Premises pursued him to the end
of the driveway and repeatedly called after him but the man ignored her calls.
The member of staff at the Approved Premises was unable to continue after
him as two members of staff are required to be on the premises at all times for
the safety and security of the hostel and other residents.
129. The member of staff at the Approved Premises contacted the duty manager at
9.20pm and informed her that the man had absconded. The duty manager
remembered the police contingency plan and two hour emergency recall that
had to be urgently put into action should he abscond. She instructed the
member of staff at the Approved Premises to inform the police to implement the
contingency plan.
130. At approximately the same time, the man contacted his mother. In her police
statement, the man’s mother described the phone call as frantic. The man’s
mother said that her son told her he believed hostel staff were about recall him
36
to prison for breaching his licence conditions. It is not clear where the man got
this information. The member of staff at the Approved Premises told my
investigator and the police that she did not say this to the man when he had
returned late for his curfew. The man told his mother that he was standing
outside the petrol station near the hostel. He asked her to come and see him
for one last time before going back to prison. The man’s mother told the
member of staff at the Approved Premises that she had telephoned her son
straightaway. She said that she could tell he had been drinking, which was
influencing his actions. The man’s mother told her son not to do anything
stupid and to go back to the hostel, go to bed and apologise to staff in the
morning. The man ended the conversation and switched off his mobile phone.
131. The man’s mother received a text message at 9.42pm from the man’s second
mobile (he carried two) which said “Mum pick me up now at [petrol] garage,
would be nice to see you tonight at home before I go to jail”. His mother tried to
telephone her son on his second mobile, but she was directed straight to his
answering service. This was the last she heard from the man.
132. According to the police enquiries made after the man’s death, he had
purchased a large bottle of vodka from a local off licence after leaving the
hostel. The shop keeper told the police that the man had £6.87 in his
possession. The vodka cost £6.99. The man gave the money he had and left
two music CDs with the shopkeeper to make up the difference in cost. (A bottle
of vodka was found near the handrail close to the point where the man fell from
the bridge over the motorway.)
133. At 10.00pm, the man’s mother telephoned the hostel and spoke to the member
of staff at the Approved Premises to tell her that her son had been in contact
and she was worried. The member of staff at the Approved Premises told my
investigator that the man’s mother sounded upset and said that she could not
believe what he had done. The member of staff at the Approved Premises
telephoned the police and gave relayed this information. The police went to the
petrol station but found no trace of the man.
134. Coincidentally, the man’s friends tried to telephone him at 10.00pm. They later
told the police that they made several efforts but got no reply. One of the
women said that she was concerned by his lack of response, as it was unusual
for him not to reply.
135. The duty manager called the member of staff at the Approved Premises at
10.20pm. She said that the emergency recall paperwork had been initiated. It
was made clear to the member of staff at the Approved Premises that, should
the man return to the hostel, he should be allowed in and encouraged to go to
bed. If he did return, the police should be immediately notified. The duty
manager made her way to the hostel. Ten minutes later, the man’s mother
telephoned the hostel to see if there was any news. She had been trying to
contact her son but he was not answering his phone, which kept going straight
through to his voicemail.
37
136. Stockport Police telephoned the hostel at 10.50pm to report that someone had
fallen from the motorway bridge near the hostel. They believed it to be the
man, but could not confirm at that stage. The person who had fallen had been
taken to hospital and was in a critical condition. The police requested that a
photograph be taken to the hospital in order to identify the person and asked
for the man’s mother’s contact details.
137. The police telephoned again at 11.00pm and asked what the man was wearing
when he left the Approved Premises. Given the description, the police said
they believed that it was the man and that he had died. The police requested
that the hostel did not pass any details to his mother until someone had
formally identified the man’s body.
138. The man’s mother telephoned the hostel at 11.06pm. She asked whether there
was any news. No information was given at this stage. Lancashire Police were
given an update of the situation at 11.15pm. Fifteen minutes later Stockport
Police telephoned the Approved Premises to ask if a member of staff could go
to the hospital to identify the man’s body. The duty manager and one member
of staff at the Approved Premises attended, whilst two members of staff
remained at the hostel. Staff were asked to identify his body, rather than the
man’s mother, to prevent any undue trauma if it was not her son.
139. At 12.30am, the man’s mother telephoned again. She said that she was
worried and apologised for calling. The member of staff told her that she need
not apologise and it was understandable. Again, no information was given.
Ten minutes later, the duty manager and the member of staff returned to the
hostel and confirmed that it was the man who had died. It is not clear at what
time the police told the man’s mother, but there is a note in the contact sheet at
1.35pm the following afternoon indicating that the man’s family were aware of
his death. The procedure is that the police initially notify the next of kin after
the death of a resident at Approved Premises. Once this initial contact has
been made the hostel contact the family.
After the man’s death
140. The next day, 13 December, the deputy manager called a meeting of the
residents to explain about the man’s death and offer support. The deputy
manager ensured that residents not present at the meeting were also informed.
Flowers were placed around the hostel in remembrance and a sympathy card
was sent by the residents to the man’s family. Staff provided support to each
other and to the man’s offender manager. Two members of the senior
management team from the Area Office visited the Approved Premises that
morning to offer support to both staff and residents.
141. The deputy manager rang to speak to the man’s mother at 4.20pm that
afternoon, but his sister answered the phone. His sister told the deputy
manager that the man had been scared of all the “bag heads” (slang term for
drug users, particularly heroin) at the Approved Premises. The deputy
manager told her that this was not the case and residents and staff had
genuinely liked the man. She said that the residents were shocked and
38
distressed by the news of the man’s death. There had never been any
indication to staff that other residents had bullied the man. Likewise, my
investigator found no evidence to suggest that the man had been bullied or had
any issues with drug users at the hostel.
142. The man’s sister arranged to come to the Approved Premises the following day
to see his room. The deputy manager prepared the room by tidying a little, but
did not remove any property. The room was declared out of bounds to
everyone apart from the Coroner and the man’s family.
143. The following day the man’s mother came to the hostel with her partner to
collect his belongings. The deputy manager gave details of a bereavement
counselling service, along with some sympathy cards from staff and residents.
The Approved Premises manager, deputy manager and the man’s offender
manager offered ongoing support as well as providing information about the
man’s time at the Approved Premises and the night he died to his family as and
when required.
39
ISSUES
Confidential review of a drug related death (including alcohol)
144. After the man’s death, Pennine Care National Health Service Trust produced a
review of a drug related death report. This type of review is routinely conducted
if the deceased is a client of the area’s substance misuse services (SMS). The
review replaces a serious untoward incident report that is produced when the
deceased has had some other form of contact with a clinical organisation. The
review was undertaken because the man had received support from the SMS.
145. The Acting Team Manager of Stockport SMS, produced the report. Its findings
are based on the substance misuse worker’s notes of her support sessions with
the man whilst he resided at the Approved Premises. Pennine Care Trust
provided a copy of the records kept by the substance misuse worker to my
investigator. A full copy of the review is at Annex A.
146. The review found that the SMS protocol for outreach work at the Approved
Premises had been followed. The substance misuse worker had appropriately
recorded details of her interventions with the man. Basic and relevant
information from the sessions were recorded in the logbook kept at the
Approved Premises for probation staff to see. The book is kept the main office
and is easily accessible. The substance misuse worker would read the logbook
prior to any one to one sessions to see any entries that had been made by staff
and for updates on the man. She also liaised with the staff to see if any
significant or relevant changes had been made to the man’s licence conditions.
All future appointments made were recorded in the hostel diary.
147. The review highlighted concerns around the sharing of information on client risk
assessments between the Probation Service and other services, including
SMS. She noted that from the risk assessment documentation it was difficult to
see how the assessment was formulated and then shared with key partner
agencies. The Trust recommends that consideration be given to the quality
and nature of information sharing regarding risk assessment for contact with
clients at the Approved Premises. The substance misuse worker did not raise
this as a problem in relation to her work at the hostel during her interview with
my investigator. During the course of her investigation, my investigator did not
find this to be a concern that had impacted upon the man’s care at the
Approved Premises. Although it had not direct bearing upon the man’s
situation, I agree that importance should be placed on transparency and
information sharing between the services.
148. The Trust has drawn up a local action plan to address the issue of information
sharing. The action plan was initially discussed with the substance misuse
worker, her line manager and the Approved Premises manager on 31 January
2008. My investigator has not been informed of the outcome of this meeting.
149. A second action point was to review and amend the protocol for the homeless
outreach worker at the hostel based on the findings of the Ombudsman’s
report. I have found no need to suggest a review of the protocol.
40
Alcohol
150. When the man first went to the Approved Premises one of his licence
conditions was that he could not drink alcohol. This condition was relaxed on 2
November, after discussion with his alcohol worker, his offender manager, the
deputy manager at the hostel and finally with the MAPPA Chair. The purpose
of relaxing the condition to a moderate alcohol contract (permitting him to have
alcohol to the drink/drive limit) was to reward his good progress and encourage
sensible drinking habits. I am not convinced that this was the most obvious or
sensible of his conditions to relax, given alcohol was a known risk-factor for the
man, but I do see the initial motivation for providing a concession. In addition to
the alcohol risk, it was known that the man’s offence was committed under the
influence of a large quantity of alcohol and antidepressant medication.
151. Whilst at the Approved Premises the man was prescribed three types of
medication by his doctor – an antihistamine, an antidepressant and, later on,
sleeping tablets - all of which advise against drinking alcohol whilst medicated.
The member of staff at the Approved Premises brought this caution to
management’s attention on 3 December. In addition, the police raised
concerns about the man drinking whilst taking prescribed medication because it
had been cited as a trigger for his previous offending behaviour. The side
effects of drinking alcohol whilst taking Amitriptyline are drowsiness, possible
lack of coordination and increased affects of alcohol consumption (could make
a person drunk quickly on smaller amounts of alcohol).
152. During her interviews, my investigator asked staff at the Approved Premises
how they reconciled these concerns with permitting him to drink. The decision
had been taken by his offender manager after discussion with the deputy
manager and the substance misuse worker. The deputy manager told my
investigator that she was not absolutely certain when his prescribed medication
started or what they were, but thought it started when he moved into the
Approved Premises. She said that distributing medication was not one of her
particular duties and she would not routinely be aware of a resident’s
prescription. The deputy manager said that this would be something a
residential service officer (RSO), who would work more on a one-to-one basis,
would know.
153. The RSOs are responsible for arranging repeat prescriptions, making medical
appointments, booking in medications and dispensing. The deputy manager
said that if she was aware of a resident’s prescription this would not necessarily
mean she would know the possible side effects. So in the man’s
circumstances, she was not aware that there was a caution against drinking
with these medications until it was raised by the member of staff at the
Approved Premises - several weeks after the moderate contract had been
signed.
154. My investigator asked whether any consideration was given to revising the
contract once this information came to light. The deputy manager told my
41
investigator that the matter was discussed with the man’s offender manager in
the first instance and then again during his weekly visit to the Approved
Premises on 5 December. It was decided between them not to revoke the
contract as the man was already in a low mood after the MAPPA meeting on 15
November. It was thought that removing the contract would take away the
leeway given to the man to reward his progress. Doing so might have caused a
further negative response from the man. Their main priority was rebuilding the
man’s confidence with staff after MAPPA had declined to relax any of his
licence conditions.
155. The man’s offender manager sent an email to the Approved Premises manager
and the deputy manager on 5 December asking for guidance about the man’s
medication. He was concerned that, in having a duty of care for the man, the
Approved Premises should ensure that he was avoiding alcohol in accordance
with the medication guidance. He said that to all intents and purposes the
Approved Premises was administering the man’s medication, so steps should
be taken to ensure that the man was not exposed to an avoidable risk. The
man’s offender manager’s view was that this was something they were
compelled to do under health and safety legislation and a duty of care.
156. The man’s offender manager took the matter forward by speaking to the man at
length about his drinking during their meeting that day. The man’s alcohol
consumption since the new contract was signed had not been a problem,
however the man’s offender manager wanted to discuss drinking with his
medications. The man told the man’s offender manager that he was aware of
the advice on possible side effects. The man’s offender manager and the man
agreed during their session that there was no need to change his contract. The
man said that he was aware that he should not drink whilst taking his
prescribed medication and told the man’s offender manager that he was not
going to drink.
157. The man’s offender manager and the deputy manager decided to trust the man
and not retract his contract. The deputy manager told my investigator that to
revoke the contract might have been perceived as patronising to the man who
was an adult and aware of the consequences of drinking with prescribed
medicines. She added that the man’s behaviour and attitude towards alcohol
did not present as an issue as it had in the past (referring to his offending
behaviour). They agreed to monitor the situation.
158. I am relatively content with this reasoning, however I consider it would have
been better for the discussion to have taken place prior to the contract being
changed. This might have influenced the decision to grant a moderate drinking
contract in the first instance. I do not agree that part of a reason for not
changing a contract with a resident should be based on whether it could be
construed as patronising. However, it is not certain whether changing the
contract would have made any difference to the eventual outcome.
159. I would like to commend the staff member’s vigilance in noticing the risks from
the man’s medications and bringing them to her managers’ attention. Her
example should be followed and staff responsible for dispensing prescriptions
42
to residents should familiarise themselves with any overt warnings and
appropriately share this information.
160. No one interviewed for this investigation could offer any insight as to why the
man decided to drink above the drink/drive limit on 12 December. There was
nothing significantly different about his behaviour that day. He was noticeably
annoyed after his session with his offender manager, but neither the man’s
offender manager nor anyone else felt that the man was a risk to himself that
day.
Mental health
161. Whilst in custody, the man had been diagnosed with a histrionic and narcissistic
personality disorder. Antidepressants were prescribed to help stabilise his
mood and anxiety. At the Approved Premises he registered with the local
surgery like all other residents. The doctor prescribed Amitriptyline as the man
reported feeling anxious. During his sessions with the substance misuse
worker, the man told her that he felt these tablets stabilised his moods.
162. Initially, the doctor told him that he could only take the tablets for only a short
period. However, after the man’s panic attacks on 26 and 28 November, the
man informed staff that the doctor had advised him to stay on them for a while.
My investigator did not ask to see the man’s NHS medical notes, as she did not
consider it necessary to comment any further on his prescription.
163. It is noted in the Pennine Care Trust review that the man appeared to display
some elements of paranoia in the weeks before his death. For example, he
enquired as to whether a SMS member of staff who had been in the same pub
had been sent there to check up on him. This example, coupled with the man’s
two panic attacks and occasionally reported odd behaviour at the hostel,
suggest deterioration in the man’s mood.
164. My investigator asked staff and the man’s offender manager during interviews
whether they thought the man’s behaviour suggested paranoia. All
interviewees said that they did not feel informed enough to make that
judgement, but acknowledged that his behaviour and mood were markedly
different after the MAPPA meeting on 15 November.
165. The Approved Premises does not specialise in working with offenders with
mental health disorders. Accordingly, staff are not specifically trained to work
residents with mental health issues and the Approved Premises has no specific
mental health advisor or worker. The deputy manager told my investigator that
there had been one or two workshops for staff, given by the MAPPA support
unit (MSU) forensic psychologist, regarding personality disorders and other
issues. It was understood by staff that the man was considered to have a
personality disorder rather than a mental disorder.
166. During her interview, the deputy manager explained that if a resident required
mental health care they are referred in the first instance to the local doctor in
the first instance, who would refer them to a community mental health team
43
(CMHT). Residents who are already existing clients of a CMHT would continue
to receive care. In addition, the MSU forensic psychologist can assess and
treat highest risk offenders if required. Referral to this psychologist is decided
by the MAPPA panel and is not something that hostel staff would directly take
forward. If staff thought an urgent referral was necessary, the MAPPA Chair
could be approached rather than waiting for the next panel meeting.
167. The deputy manager told my investigator that, prior to the man’s release she
was aware that part of the MAPPA panel’s plan was to encourage him to see
the MSU forensic psychologist for further insight into his personality disorder.
However, the panel had speculated that the man would not be compliant or
would be suspicious of the motive behind asking him to do this. It was decided
that once he had been released and begun working with probation staff that the
forensic psychiatrist would then be asked to see him.
168. The deputy manager said that when the man’s engagement and mood
deteriorated after the panel’s meeting on 15 November, she had thought about
arranging for the forensic psychologist to see him and discussed this with the
man’s offender manager. The offender manager’s response was that until they
were able to secure the man’s full compliance, this would be fruitless and
counterproductive.
169. On 7 December, the man spoke at length with the deputy manager. He raised
the fact that several psychiatric and psychological reports had been compiled
about him. The deputy manager told my investigator that this information was
offered without prompting the man to discuss his mental health or asking if he
would speak to the MSU psychologist. It was during this conversation that she
considered raising the issues. However, in spite of his comment, he stipulated
that he would not cooperate with another psychiatrist or psychologist. He
believed that the existing reports were not accurate reflections and were
prejudiced, based on his offence. The man said he had a new report that he
had commissioned himself, which was with his solicitor. This report is said to
state that the man did not have a personality disorder. His offence was said to
be committed due to anxiety triggered by traumatic events and an accidental
overdose of his prescribed medication. The deputy manager suggested that
the report be made more widely available. The man refused on the grounds
that it was for him and his solicitor to decide what to do with the document. (My
investigator did not have sight of the new psychiatric report as it was not
relevant for her investigation.)
170. The deputy manager said that, given the direction of their conversation, she did
not raise seeing the MSU psychiatrist with the man. Whilst the deputy
manager’s record of the session is comprehensive, she makes no reference to
her decision not to raise a referral to the MSU psychiatrist. I would like to have
seen that any additional discussion was documented. I accept that the concern
the man might not engage was not without reason, particularly in the light of his
conversation with the deputy manager on 7 December. However speculation is
not sufficient when there is a duty of care. The matter could still have been
raised with him, perhaps at an earlier stage when he showed signs of
withdrawing and anxiety. It is not possible to determine whether an
44
appointment with MSU psychologist would have prevented his death, but it
would have given the man the opportunity to discuss his mental health with a
professional if he wanted to.
171. My investigator has not seen any documentation relating to the earlier MAPPA
plan or a record of the conversation between the deputy manager and the
man’s offender manager. Given the nature of the conversation I would have
expected to see a record in the man’s contact sheet.
The Manager at the Approved Premises should remind staff to record all
significant conversations and decisions regarding a resident.
Self-harm or suicide risk
172. The National Probation Service requires all Approved Premises to have in
place a strategy for preventing self-harm and suicide. The Approved Premises,
like other Approved Premises in the north-west, use a process for observing
and monitoring risk based on that used by the Prison Service. If any resident is
identified as at risk of self-harm or suicide a document called an Assessment
Care and Teamwork (ACT) document is opened. This form can be initiated and
used by any person responsible for the resident’s care. The purpose of the
form is to better manage the resident’s risk. This is done by documenting
interactions, observations and assessments, in addition to detailing care plans.
Any care plan has to be agreed to by the resident. The document is
accessible to all involved, making care transparent and sharing responsibility.
173. My investigator asked the man’s keyworker, the residential service officer,
whether he had considered the man to be at risk to himself at any time. The
residential service officer described the man as being a bubbly and happy
person in his first few weeks, but also very private. He said that the man was
demonstrably frustrated by his licence and MAPPA restrictions, but adhered to
them nonetheless and showed signs of progress.
174. My investigator asked the residential service officer if he ever saw the man
upset or low in mood. The residential service officer said that the man was
unhappy with his licence conditions and his time in prison. He said that the
only time that he became a little concerned was at the beginning of December
when the man was sorting through some clothes he had got from his mother’s
house. When he asked the man why he had the clothes, he replied that he
wanted to sort things out. The residential service officer told my investigator
that whilst there was nothing significant about this conversation he had a gut
feeling that the man was troubled. This was compounded by the man’s strange
behaviour on 2 December when he went to the staff office on a number of
occasions during the day to ask why the police were asking for information
about him. The man changed his clothes a number of times that evening and
told staff that he would no longer eat at the hostel.
175. The residential service officer said that the man withdrew from staff. He told
the residential service officer that he might as well give up trying, as he was not
being treated with leniency for his progress. The residential service officer said
45
that, on occasion, during the last few weeks before his death the man would not
speak to him. Staff would have to cajole the man into conversation when he
went to the office to collect his medication. The man’s mood was variable, one
day he would be friendly and the next moody, with no apparent trigger other
than the MAPPA panel decision.
176. Despite his impression that the man felt troubled, the residential service officer
told my investigator that he did not think the ACT process was needed. He
thought that the most appropriate approach was to keep a close watch on the
man. The residential service officer recorded that he had, on several
occasions, attempted to talk to the man about how he was feeling, but the man
had not wanted to discuss the matter.
177. My investigator asked the same of the substance misuse worker, particularly in
reference to her conversation with the man on 15 October when he spoke of his
mood swings and occasional suicidal thoughts. The substance misuse worker
explained that, despite the depressive nature of some of their conversation, in
her view the man displayed no current or significant suicidal thoughts or intent.
My investigator asked the substance misuse worker what she would have done
had she been concerned. The substance misuse worker said that it depended
on the level of concern. If the man had presented as acutely suicidal she would
have taken him to the Accidents and Emergency department of a hospital to
see a doctor as she would with any client if the need arose. Alternatively, she
would have suggested a doctor’s appointment.
178. Anything of concern would be raised with the resident’s key worker and either
the manager or deputy. The substance misuse worker said that she would also
record it in her logbook, which remains at the hostel for staff to read. This book
is also used for summarising the key points arising from any meeting with her
clients, for staff information. In such circumstances, the substance misuse
worker is permitted to break client confidentiality and ensure that all key people
responsible in providing care are aware of the situation.
179. The substance misuse worker stressed to my investigator that she did not think
that the man presented as a risk to himself and she would have made staff
aware of any concerns. She said that the man did not refer to having suicidal
thoughts again after their meeting on 15 October.
180. My investigator asked the deputy manager whether she had been concerned
that the man might be a risk to himself. She told my investigator that he was
low in mood during a session on 7 December. However, it was not unusual as
his mood had been changeable for some weeks. She did not consider him
then, or any other time, to be at risk of self-harm. The deputy manager
described the man’s temperament and statements of not wanting to engage or
eat his meals at the hostel as reactionary rather than a sign of risk. She
explained that the man had an impulsive character.
181. My investigator asked whether these changes in his mood could have been
attributable to a deterioration in his mental health. The deputy manager said
that, with hindsight, it could be possible to argue that this had been the case.
46
However, she stressed that at the time this did not seem a possibility as his
behaviour was more challenging than concerning.
182. Similar answers were given by all interviewees. Although the man appeared
withdrawn and had a changeable mood, no one thought that he was a risk to
himself. There was greater concern that he could impose an increased risk to
others instead of to himself. For example, the manager of the Approved
Premises issued a notice to staff on 30 November, reproduced earlier in this
report. He advised caution in their contact with the man as his disappointment
regarding the MAPPA decision might lead to an increased risk to staff. There
are no entries in the man’s contact sheet for that weekend. I am concerned by
this and would have expected to see at the least a daily entry noting that
contact had been made with the man. Even if there was no contact this should
have been recorded.
The Manager should remind staff that, particularly when careful
monitoring has been requested, records of contact are kept.
183. During the police interviews, the man’s friends said that it had been apparent
that he was unhappy about his licence conditions and the restrictions imposed
on his life at the hostel. However throughout the time they had known him, the
man had never given the impression that he was depressed or suicidal.
184. Given that the man did not present as an active risk of self-harm or suicide, it
was reasonable for staff to consider the ACT document to be inappropriate.
The man was subject to closer observation due to his change in mood and
engagement, likewise he received considerable staff attention and opportunities
to discuss his feelings. The deputy manager and the man’s offender manager
encouraged him to be more open with staff, however he increasingly chose not
to engage. When he did engage it was mostly to vent frustration.
The question of bullying
185. The man’s mother told my investigator they were concerned a resident had
bullied her son as he had told his family that a resident had approached him
and asked him to provide a urine sample. My investigator looked into this
issue. She confirmed that this event had taken place but could find no
evidence to suggest that the man had been bullied.
186. The reason for the resident’s approach was that he knew the man was not a
drug taker and could provide a clean sample. The man refused and told his
alcohol worker, the substance misuse worker, during their session on 12
November. The substance misuse worker reported the incident to hostel staff,
who noted it in the man’s contact sheet. As a result of the information, the
procedure for drug testing was changed from urine samples to oral swabs.
187. The resident who approached the man was drug tested using the oral swab
which gave a positive result for Class A drugs. The resident admitted that he
had asked the man for a urine sample. There were no further reported
47
instances of him approaching the man for samples. There was nothing in the
hostel records or from staff accounts to suggest that the man was bullied.
MAPPA
188. The man was disappointed with the MAPPA panel decision on 15 November.
He made it clear to staff that he was unhappy with this outcome and said that
he saw no point in positive engagement if it was not going to be recognised.
The man told the deputy manager, his offender manager and other members of
staff that the negative response from MAPPA was a conspiracy by the
authorities to put him under stress and make him crack under pressure. All
parties tried to reassure the man that this was not the case and that continuing
to positively engage might influence the panel’s decision at the next meeting.
189. The deputy manager told my investigator:
“The man was somebody who was quite challenging, quite demanding
and incidents seemed to attach themselves to him… He was
somebody who was very questioning and sometimes quite tortured in
his thinking and in his response and sometimes in his behaviour. But
there was a definite shift in his mood after 15 November. He was
questioning, he wanted to know about the MAPPP process and how it
had come about.”
190. Staff at the Approved Premises and the man’s offender manager, told my
investigator during interview that they thought the decision not to relax his
conditions was counterproductive and a definite turning point in his
engagement with staff. Soon after the MAPPA meeting the man noticeably
withdrew and staff found it difficult to work with him.
191. I am satisfied that staff at the Approved Premises, the substance misuse
worker and the man’s offender manager tried to motivate the man and keep
him engaged. The contact notes demonstrate that at every meeting with the
man the importance of his engagement was discussed, as was the MAPPA
process.
192. It is not within my remit to comment on whether the MAPPA decision was fair or
appropriate. The man was a high-risk offender with a detailed contingency plan
in place. The decision was based on many factors and not just those
presented by the Approved Premises staff or the man’s offender manager. His
progress at the hostel was taken into account, but it was thought that he
needed to be monitored for a longer period before any relaxation of signing
times could be considered. The panel intended to revisit the issue at the
January meeting.
193. The man’s mother asked why she was not able to appeal to the MAPPA Chair.
The MAPPA panel meetings are confidential as is the identity of its members.
Therefore the man’s mother would not have been given any contact information
to lodge an appeal. In addition, her son was an adult and therefore it would
have been his responsibility to lodge an appeal.
48
Staffing
194. The man’s family asked my investigator to provide information about the staff
who were on duty the night that he absconded. In particular, they have asked if
there were any agency staff on duty. The Approved Premises manager and the
deputy manager and told my investigator that there were no agency staff on
duty that night. There was a member of staff from another Approved Premises
providing leave cover. Using staff from another hostel is the first preference for
providing cover, but in the event that this is not possible, agency staff are used.
195. Another member of staff providing cover for the night shift that evening would
have arrived to take over from the member of staff at the Approved Premises
when she finished her shift at 10.00pm. However, given the circumstances, the
member of staff at the Approved Premises did not leave. The other member of
staff was familiar with working at the Approved Premises, but might not have
known the man very well. The two other members of staff on duty at the time
the man absconded both knew the man well.
196. Stockport Police asked if a member of staff from the Approved Premises could
go to the hospital to identify the man’s body. This request was made to prevent
the man’s mother from suffering any undue trauma should the body found not
have been her son. I appreciate that this was a difficult task for the member of
staff at the Approved Premises, particularly as she was one of the last people
to see the man. She should be commended for volunteering to do this.
Breaching conditions of licence
197. During the induction process at the Approved Premises residents have their
licence conditions explained to them, including what constitutes a breach.
Offenders released on licence know that if they do not comply with the
conditions attached to their licence they risk being recalled to prison. The man
had been made aware of this during his induction.
198. There is no formal policy at the Approved Premises setting out how to tell a
resident if they have breached licence conditions or may be recalled. However,
according to the Approved Premises manager, there is an informal practice
which all staff are aware of. The custom is to defuse the situation first. In the
event that a resident is late for curfew they would be told to return to the hostel
as soon as possible. If a resident was intoxicated on their return, they would be
encouraged to go to bed and sleep it off.
199. The Approved Premises manager told my investigator that staff would not
mention a breach or recall to a resident because of the increased risk of
absconding which could present a danger to the resident or the public. He told
my investigator that a resident might surmise the outcome of their breach and
abscond anyway. It was the Approved Premises manager understands from
conversations with the member of staff that the man may have reached this
conclusion. The member of staff stressed to the manager and the police that
49
the man was not told that he had breached his licence or that he might be
recalled.
200. I would judge that there may be some merit in formalising guidance on how to
deal with residents in breach of licence conditions. In response to the initial
draft of this report, the Director of Intervention and Support Services at Greater
Manchester Probation Trust has suggested that this could be discussed within
the Greater Manchester Trust or nationally.
201. The National Offender Management Service (NOMS) Approved Premises
policy lead was also asked for his opinion on formalising guidance. He warned
of the danger in creating a blanket policy, as each situation should be assessed
on its own merits. The policy lead said that discussing action to be taken
following on from a breach might alleviate anxiety if the sanction is to be minor,
e.g. a warning. However, there would be times when saying nothing until the
following day would be beneficial. He explained that reasons will vary, and
deciding upon a course of action is all part of the ongoing risk assessment and
risk management that hostel staff undertake on a regular basis. The policy lead
said that consideration could be given to formalising guidance, but not
necessarily along the lines of the informal practice used by the Approved
Premises. He said that it would first be necessary to canvass the Approved
Premises estate to ascertain customary policy and practice.
202. I welcome the suggestion by both parties that this issue could be discussed
more broadly to consider agreeing guidelines for all staff across the Approved
Premises estate.
NOMS should evaluate common practice across the Approved Premises
estate for dealing with a resident in breach of licence conditions, with a
view to formalising guidance.
203. The member of staff at the Approved Premises repeated what the manager had
said to my investigator during her interview. She confirmed that she had not
mentioned a breach of licence or given any warning to the man. The member
of staff also told my investigator that the man was not aggressive when she
asked him to take the breathalyser test, he simply said that he did not want to
do it. My investigator asked the member of staff if the man had appeared
anxious or frightened. She said that he did not. The man was calm when he
left the office and also when he came down from his room and left the hostel.
My investigator asked whether the man would have overhead the member of
staff tell her colleague that she was going to ring the duty manager. The
member of staff said that it was unlikely and stressed that her words were
nothing more than “I’m going to have to contact the duty SPO”.
204. The member of staff had not telephoned the duty manager before the man left
the hostel. She said that if the man had stayed in his room she would have
made the duty manager aware that he had missed his curfew, but that he had
let staff know he was on his way and would only be a little late. The member of
staff explained to my investigator that this is not uncommon as public transport
is not always reliable. As long as the resident lets them know and is only a few
50
minutes late that it is not generally a problem. However, lateness would always
need to be noted and the SPO or duty SPO would always be informed. Under
these circumstances, the duty SPO would leave it to the manager or deputy
manager to decide what action to take when they started their shift in the
morning. My investigator was satisfied with the member of staff at the
Approved Premises accounts of events and found no reason to disbelief her.
205. The SPO can make a recommendation to recall an offender. During normal
working hours, the decision has to be approved by either the relevant Area or
District Manager and by the senior manager ‘out of hours’. The hostel staff
(The member of staff at the Approved Premises in the man’s case) inform the
SPO (the duty manager) of the breach. Depending on the circumstances, the
SPO then decides whether or not to make the recommendation to the Early
Release and Recall Section (ERRS) at the National Offender Management
Service (NOMS). In the man’s case, once he had absconded there was no
option but to initiate an emergency recall and the police contingency plan.
206. The SPO (hostel manager or duty manager), or the district manager, is
responsible for making the decision on the next steps. The SPO is required to
consult with their line manager to ratify the recall. (In the man’s case the duty
manager contacted an Assistant Chief Officer, and discussed the recall.) The
Recall Officer at the ERRS, who has the power to action or reject the recall, is
then contacted. The Approved Premises manager said in his police interview
that overturning the decision is rare and, in his experience, had only happened
once in four years. Once the Recall Officer agrees the decision, the police are
informed.”
207. The decision to recall depends on the breach. A warning can be issued in
place of the recall. In the event that a resident is subject to a recall, they are
not informed until the police arrive to escort the resident back to prison.
208. Some breaches of licence are dealt with by the Approved Premises – for
example, by issuing a warning letter. More serious breaches result in a recall
to prison to serve the remainder of a sentence. There are two types of recall,
emergency and standard. Standard is for lower risk cases which are processed
within 24 hours. Emergency recalls are dealt with within two hours. The man
was subject to an emergency recall as he was on Level 3 MAPPA.
209. If a resident subject to emergency recall absconds out of hours, staff contact
the on-call duty manager by telephone. The duty manager would then initiate
the recall process by contacting the Home Office. This involves telephoning the
Recall Officer2 at the Home Office who then telephones the duty manager back,
takes details and revokes the resident’s licence. A revocation form is
completed and faxed to New Scotland Yard and the resident is added to the
Police National Computer as a ‘wanted’ offender.
2 Note the Recall Officer is part of the Offender Management Service, which is part
of the National Probation Service.
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210. A resident would not be told they were going to be recalled in any other
circumstances. To do so would increase the possibility of the resident
absconding or reacting badly to the news. It would cause undue stress for the
resident and staff alike.
Security
211. For security reasons, there is a requirement at night for at least two members of
staff to be on duty and present in the hostel at all times. When the man
decided to leave the hostel after returning for his curfew, the member of staff
followed him to the end of the driveway and called for him to come back. Due
to the security requirements relating to staff presence, she was unable to
continue following the man. The only action that the member of staff at the
Approved Premises could take at this time was to ring the duty manager, and
the police to inform them that the man had left the premises after curfew.
Post-mortem and toxicology
212. A forensic pathologist performed the post mortem on Friday 14 December. He
concluded that the injuries to the man’s body were consistent with trauma
caused by a fall from a motorway bridge. Though some of his injuries could
have been caused by contact with traffic, there was no evidence he had been
run over in the conventional sense. From a pathological perspective, the
forensic pathologist was unable to determine exactly how the man fell from the
bridge. His cause of death was the result of head injuries.
213. A toxicology report produced by a consultant clinical biochemist dated 19
March 2008 found ethanol (alcohol) to be present in the man’s system:
“at a blood concentration that may be associated with slight impairment
of mental acuity and motor-coordination. The legal blood ethanol limit
for driving is 800mg/l. As indicated by the urine concentration
[1850mg/l], the blood ethanol concentration [1280mg/l] has probably
been higher than reported here a few hours before death.”
This confirms that the man had been drinking before his death, above the level
agreed to in his moderate alcohol contract.
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CONCLUSION
214. Whilst I understand the importance of finding a way to reward the man for his
initial positive progress and provide further motivation during his first few
months the Approved Premises, I find it difficult to reconcile that the one
concession given and permitted by the MAPPA panel was related to his alcohol
contract. This is particularly pertinent given the reason for not relaxing any
other licence condition was firmly weighted on the man’s potential high risk to
others and alcohol had been cited as a trigger for his offending behaviour.
However, the onus was on the man to demonstrate that he was able to enjoy
this moderate privilege sensibly and not exceed the limit. As an adult, the man
was responsible for his own decisions. It would be unfair to apportion any
blame for his death on the relaxation of this licence condition.
215. It is clear that the man chose to refuse the breathalyser test after returning late
for his curfew and to abscond from the Approved Premises. The man had
made it clear to staff, his offender manager, the substance misuse worker and
his family that he did not want to go back to prison. It seems that he assumed
that he would be recalled, despite staff at the hostel giving no indication that
this would be the case. All offenders on licence know that they risk recall if they
breach their conditions; however recall is dependent on circumstances and is
not an automatic penalty.
216. Absconding is a serious breach of conditions, particularly for a high-risk
offender. Although the man will have been unaware of the two-hour emergency
recall or the existence of the police contingency plan, he knew that by
absconding he would have been liable to recall. This is highlighted by his
conversation with his mother shortly after running away.
217. As with the police investigation, I have no evidence to conclude whether the
man intended to fall from the motorway bridge or if it was an accident. Like all
the self-inflicted deaths investigated by my office, the man’s was a sad and
unnecessary death.
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RECOMMENDATIONS
1. The Manager at the Approved Premises should remind staff to record all
significant conversations and decisions regarding a resident.
2. The Manager should remind staff that, particularly where careful monitoring has
been requested, records of contact are kept.
3. NOMS should evaluate common practice across the Approved Premises estate
for dealing with a resident in breach of licence conditions, with a view to
formalising guidance.
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RESPONSE TO THE DRAFT REPORT
Probation Service
The Director of Interventions and Support Services for Greater Manchester
Probation Trust, commented on the draft report on behalf of the Probation Service.
In addition to highlighting some factual inaccuracies, The Director commented on the
third recommendation. This referred to developing guidance for the Approved
Premises staff on how and when to inform a resident of a licence recall. The
Director said that the recommendation should be directed to the whole Approved
Premises estate and just at the Approved Premises in isolation. This would enable a
discussion at the District Management Team level to agree guidelines for all staff in
the division.
The Head of Approved Premises, responsible for Approved Premises policy in
NOMS, was also asked to comment on the recommendation. He said that
consideration could be given to formalising guidance, but not necessarily along the
lines of the informal procedures used in the Approved Premises. The Head said that
the Approved Premises estate would need to be canvassed to ascertain customary
policy and practice. The initial view from a policy perspective would be that there are
instances where discussing what action will be taken following a breach might
alleviate anxiety when the sanction is likely to be minor, e.g. a warning. On the other
hand, there will be times where simply saying nothing until the following day is the
best course of action. The Head said that reasons will vary and deciding on what
course of action to take is part of the ongoing risk assessment and risk management
that hostel staff regularly undertake. He stressed that a blanket policy (either to
never discuss or always discuss) would probably be unwise.
I have accepted both the Director of Interventions and Support Services for Greater
Manchester Probation Trust, and The Head of Approved Premises’s advice and
have amended the recommendation accordingly.
In response to the section regarding the man’s alcohol consumption on page 40 of
the report, the Probation Service has stressed that the Chair of the MAPPP was
unaware of the discussions that had taken place about the importance of not drinking
alcohol whilst taking prescribed medication. I acknowledge that this information
would have been useful to the Chair in agreeing to relax the no alcohol contract.
However, no comment has been offered by the Chair as to whether this would have
made any difference to the man being permitted moderate alcohol consumption. I
am disappointed to learn that this important series of discussions was not fully
shared with the Chair.
The Director highlighted that the process for initiating the recall decision making
process had not been accurately explained in the draft. She said that whilst the SPO
can make a recommendation for recall, it is the Area or District Manager who
provides the approval. ‘Out of hours’ the senior manager needs to approve the
recommendation. Also a SPO has to consult with their line manager to ratify the
recall. The SPO can make a recommendation to recall an offender. I have
incorporated these comments into paragraphs 210 and 211.
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The Director’s final point was on the time taken by my office to conduct this
investigation. I appreciate that delays in issuing death in custody reports can be
stressful for both the deceased’s family and staff. Again, I reiterate my apology for
any undue distress this may have caused. I hope that staff at the Approved
Premises will understand that part of the delay in issuing the final was to afford the
man’s family adequate time to respond to the draft. I am sure that they will
appreciate that this will have been an upsetting process for the man’s family. Their
full comments were provided shortly before Christmas. I appreciate that there has
been a further significant delay. This was attributable to the investigator responsible
for the report leaving the Fatal Incidents Team. I offer my sincerest apologies for this
additional delay and any further distress this may have caused all parties.
The family’s response
The man’s mother provided a thorough response to the draft report. I recognise that
this was a difficult and emotional undertaking and thank the man’s mother for her
time taken. I have addressed each of her questions in turn below.
The man’s mother’s primary concern is the apparent discrepancy between staff
statements and accounts during interview. She has asked why it is that staff had
differing opinions of her son’s behaviour on both the months prior to and the night of
his death. Specifically, she asked:
• Why the Deputy Manager said that no alcohol was found in the man’s
room, but the Approved Premises manager said a bottle of vodka was
found.
• The duty manager said she was told the man became “stroppy and
argumentative and stormed out of the hostel”. Whereas in a member of
staff at the Approved Premises’s account she said that the man smiled,
waved and said “see ya” on leaving the hostel. The member of staff at the
Approved Premises also said that the man was not aggressive when he
refused to take the breath test.
Where there are discrepancies between staff accounts and there is no supporting
evidence to resolve the matter either way I have not drawn any conclusion. What is
clear regarding the alcohol is that the police investigation confirmed the man bought
a bottle of vodka from a shop after walking out of the Approved Premises. My
investigator was unable to establish for definite whether or not there was a bottle, but
did not think it was pertinent to the investigation to pursue the issue.
I appreciate that that the duty manager’s account during her interview differed to the
member of staff at the Approved Premises’s. However, the member of staff at the
Approved Premises’s was a first-hand account and the duty manager was offering
an interpretation of events sometime after the man’s death. Despite these
discrepancies, the fact of the matter is that the man refused to take the breath test
and walked out hostel when his curfew was in place. The man was subject to a very
stringent police contingency plan and emergency recall due to his high level of risk to
others. He seriously breached his licence in leaving the Approved Premises and
immediate action had been taken, regardless of whether he was or was not
aggressive in doing so.
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It should be recognised that it minor discrepancies between staff accounts and
statements are not exceptional during an investigation. People recall events in
different ways or can have varying perceptions of a person’s presentation. This is
why investigators do not solely rely upon singular verbal accounts in undertaking an
investigation. On occasions when there are contradictory accounts of pertinent
events, the investigator will do their utmost to identify any corroboratory evidence.
The man’s mother asked for clarification on why a question regarding her son selling
his urine had been asked. My investigator asked the Deputy Manager what she
knew about this matter because she wanted to establish whether the man had been
under any pressure or had been bullied by any of the residents at the Approved
Premises. There were references in his records about the man having told his drugs
worker that he been approached by a resident to sell his urine for the purpose of
drug testing. The Deputy Manager told my investigator that this concern had been
brought to the attention of staff by the drugs worker. However it never amounted to
anything beyond suspicion because despite enquiries (through random testing and
speaking to the man) there was no evidence to support the claim.
Concerns were raised regarding the residential service officer’s understanding of the
man’s family situation. The man’s mother was upset to read that the residential
service officer thought there may have been a rift between herself and her son. She
was also disappointed that the residential service officer did not know that the man’s
father had died. He had referred to her partner as her son’s father during his
interview. The man’s mother thought that these comments indicated that the
residential service officer did not know her son very well, despite him being her son’s
keyworker. Although I appreciate that this was a mistake on the residential service
officer’s part, my impression is that this was not intentional. The residential service
officer knew the man well enough to have an effective keyworking relationship.
In addition, she found the residential service officer’s comments about her son
displaying “strange” behaviour to be vague and odd. The residential service officer
did have difficultly qualifying what he meant in using the word “strange” to describe
the man’s behaviour on the day when he was sorting through his clothes. What he
was attempting to convey was that the man’s was behaving differently and there was
something odd about it that he could not put his finger on. My investigator did try to
get the residential service officer to elaborate on this point, but he could not put into
words. I am confident that the residential service officer had sufficient previous
contact with the man to make a judgement about his demeanour and to identify
when he was behaving any differently.
The man’s mother asked for clarification on the manager of the Approved Premises
statement that “if a resident was intoxicated on their return, they would be
encouraged to go to bed and sleep it off.” She asked why her son was not privy to
this procedure on the night of his death. The man would have been encouraged to
do so after taking the breath test. He was aware of the requirement to have random
breath tests as part of his alcohol compact. The man chose not to engage and then
left the hostel. There is nothing to suggest that the man would not have been
afforded this opportunity once he had complied. Indeed, all staff interviewed said
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that this would have been the case and his breach of licence conditions would have
been dealt with the following morning.
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