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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 |
| (about 21 hours later) | |
| Melissa Mathieson, 18, was strangled by Jason Conroy, who was known to pose a risk, after she said he was stalking her | |
| Caroline Davies | |
| Thu 28 Sep 2017 14.37 BST | |
| First published on Thu 28 Sep 2017 13.51 BST | |
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| 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. | 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. |
| 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. | 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. |
| 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. | 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. |
| 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. | 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. |
| An investigation by Bristol safeguarding adults board (BSAB) 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. | An investigation by Bristol safeguarding adults board (BSAB) 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. |
| 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”. | 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”. |
| 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. | 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. |
| 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. | 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. |
| 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. | 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 case review found Conroy had displayed “aggressive and sexualised behaviour” since early childhood and had been in care since the age of seven. | The case review found Conroy had displayed “aggressive and sexualised behaviour” since early childhood and had been in care since the age of seven. |
| 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. | 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. |
| 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. | 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. |
| 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. | 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. |
| When Mathieson complained about his behaviour her concerns were not heard or responded to strongly enough, the review found. | When Mathieson complained about his behaviour her concerns were not heard or responded to strongly enough, the review found. |
| 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.” | 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.” |
| There had been no proper risk assessment of Conroy’s 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.” | There had been no proper risk assessment of Conroy’s 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.” |
| 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 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. |
| “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.” | “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.” |
| 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?” | 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?” |
| 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. | 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. |
| The review made 13 recommendations, some at national level. | 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.” | 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.” | 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.” |
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