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Woman's murder in care home could have been prevented, inquiry finds Woman's murder in care home could have been prevented, inquiry finds
(35 minutes later)
The murder of a young woman by a fellow care home resident fascinated by necrophilia could have been prevented, an inquiry has found. The murder of an 18-year-old woman by a fellow resident at a care home who had previously attempted to strangle other women was both predictable and preventable, a serious case review has found.
Melissa Mathieson, 18, was strangled by Jason Conroy in 2014 at Alexandra House in Bristol, a home supporting people with autistic spectrum disorder. Jason Conroy, 18, who wanted to have sex with a dead woman, strangled Melissa Mathieson in October 2014 at the Alexandra House residential home where they both lived, and which looks after people aged from 18 to 50 with autistic spectrum disorder and Asperger syndrome.
Conroy, who once tried to strangle a teacher so he could abuse her, planned to drag the teenager’s body back to his room and have sex with her. He had also attempted to kill his mother by putting a duvet over her head for the same reason. Mathieson, who had ADHD and autism and was particularly vulnerable to abuse and exploitation by others, had been placed in the residential centre 100 miles from her family home as there was no local placement available.
Hours before she died, Mathieson – who had ADHD and autism – had complained to staff that Conroy was stalking her. She was killed hours after complaining to staff about Conroy, who was known to pose a risk to females, particularly “young, petite women who he feels he can easily overpower”. Conroy was found guilty of her murder in 2015 and sentenced to life imprisonment.
Conroy, now 21, was jailed for life in 2015 for murder and told by a judge at Bristol crown court that he would serve at least 19 years before he could be considered for parole. Bristol Safeguarding Adults Board’s investigation highlighted a number of serious failings in the care Mathieson received and in the care and management of Conroy. These included failures in making proper risk assessments, especially in respect of the known risk Conroy posed to females, and failure of communication between agencies and services.
Judge Graham Cottle said the murder was clearly sexually motivated, adding that Conroy had exhibited “sexual deviancy of the most worrying kind”. Mathieson had been in the residential home for eight weeks and Conroy for just five weeks when she told staff he was stalking her and that she was scared. Staff had previously seen him on the landing near her bedroom looking “anxious and agitated”.
The Bristol safeguarding adults board has published a serious case review of the teenager’s death, which highlights some areas of practice that need to change and makes national recommendations. He entered her third-floor bedroom at night and strangled her before trying to drag her to his second-floor bedroom. Staff, who heard a loud bang, found her unconscious on the stairs with him standing by. She died four days later.
Louise Lawton, the chairwoman of the board, said Mathieson’s death was particularly shocking and had a profound impact on all those involved. Her father, James Mathieson, said his beautiful and dearly loved daughter had had her future ripped away from her through the most basic, fundamental errors.
“The loss that Melissa’s family have suffered is immeasurable and their involvement in this process has been essential to creating a full picture of Melissa’s life and the circumstances surrounding her death,” Lawton said. She had been placed 100 miles from home, far away from the loving and supportive network set up by himself and his wife Karen, who died from breast cancer one year after their daughter’s murder. When she was placed in the home, he said, the family always expected something could go wrong. “What we never expected was for her to come home in a coffin,” he said.
“The themes arising are relevant across the country and many of the recommendations for the board focus on raising issues at a national level. The review looks at how agencies work across county borders, the transition between children and adult services and the use of risk assessments. The case review found Conroy had displayed “aggressive and sexualised behaviour” since early childhood and had been in care since the age of seven.
“How potentially dangerous people are cared for and managed is another area of focus, as is ensuring organisations are using professional language which both sides understand when individuals are moving between services. He had twice tried to kill his mother and she felt he could not be trusted around women. He had also threatened to kill a female respite foster carer. He attempted to strangle a young female member of staff at a residential school, saying he wanted to have sex with her dead body, and twice tried to strangle another female staff member.
“Information-sharing is also shown to be vital. Sadly, the review found that Melissa’s death could have been prevented if better processes had been in place. At the heart of this review is a vulnerable young woman who lost her life and I hope that the findings will help stop something like this from happening again.” In March 2013, at another residential school, he strangled another female staff member to the point of unconsciousness, before a male staff member intervened. This incident should have been immediately reported to police, the case review found, but was not. He had previously sexually assaulted another female member of staff.
Mathieson’s father, James, from Berkshire, said: “The agencies concerned need to be looking inward at themselves critically, firstly to find and rectify all faults, but they also need to listen to families and look for ways to improve their services to prevent any similar disaster befalling any other family. A forensic assessment report, passed to Alexandra House, said Conroy presented “high risk of future physical and sexually harmful behaviour” and that it was imperative he be highly supervised and particular attention paid to the recognised victim profile of young, petite women.
“We feel we have been treated with contempt and arrogance before and after Melissa’s death by the local social services, with no thought about the stress and trauma the family had been put through. When Mathieson complained about his behaviour her concerns were not heard or responded to strongly enough, the review found.
“There are far too many mistakes being made by all services around the country for this to be just an isolated case. Focusing just on the murder will not prevent this mistake happening again.” Mathieson had problems remembering to lock her bedroom door, but her parents were not told. “If we had been told that, we could have told her, in phone calls, make sure you lock your door,” her father told the Guardian. “And she would have responded to that. It is her disability that meant she would forget that sort of thing, especially when she was tired. I spoke to her that evening, and she was tired. If I had said, ‘lock your door,’ then maybe she would still be alive. But that doesn’t negate the fact [that] he was a danger to everybody. Any female in that home he was a danger to.”
He hoped that his daughter’s death would change the way services treat families of autistic young adults and young adults with mental health issues: “We do not want Melissa’s short life to have been for nothing.” There had been no proper risk assessment of his danger to fellow residents, particularly a vulnerable young woman, the review found. “That is one of the fundamentals of care. Proper risk assessment and care plans. If you can’t do the fundamentals right, it’s all going to go wrong,” said Mr Mathieson. “I am shocked at the basic errors.”
Meanwhile, the Independent Police Complaints Commission has made recommendations on how West Mercia police dealt with the allegation that Conroy assaulted his teacher in 2013. The fault lay across all the services, not just the care home, but also those who referred both his daughter and Conroy to Alexandra House, he said. “It the simple things like when he strangled the teacher. They should have reported that straight away.” he said.
The IPCC said the force should have recorded the incident as a crime when it was reported. “I hope that all agencies learn from their mistakes, but it is pretty apparent that if basic mistakes are being made – and they are basic mistakes – there is something wrong. It is quite shocking, and it’s quite frightening, really, because these are the most vulnerable people.”
The watchdog said an officer who was informed by the school of the allegation would have had a case to answer for misconduct for not recording the incident, had they not retired. Of Conroy, he said: “He was in the wrong place. He was having the wrong care, and really he was let down as much as my daughter was. One of the things I find the most shocking is that it’s hard to hate somebody that really ... well, you can’t hate him. He shouldn’t have been there. They were making decisions for him. How can you hate him for doing what he did?”
Conroy was later found guilty of attempting to cause grievous bodily harm. Mr Mathieson said his daughter’s death also highlighted the problems in transition from children’s services to adult services, with no continuity of care. He felt she was “traded across the country” and moved from place to place. The review questioned if there was adequate provision for young vulnerable adults with complex needs.
Another investigation into an incident in Devon involving Conroy in 2009, following which he was arrested for allegedly assaulting a member of school staff, found Devon and Cornwall police had responded appropriately. The review made 13 recommendations, some at national level.
Louise Lawton, chair of BSAB, said: “Sadly, the review found that Melissa’s death could have been prevented if better processes had been in place. At the heart of this review is a vulnerable young woman who lost her life, and I hope that the findings will help stop something like this from happening again.”
Charlotte Haworth Hind of Bindmans LLP, representing Mr Mathieson, said: “The findings of the serious case review reveal a system that is failing to protect vulnerable young adults in care: from a lack of local placements to poor communication and inadequate assessments.”