Catalogue of failures led to woman’s murder in Bristol care home, coroner finds | Social care

A “Failure Catalog” caused a young woman who was drowned in a care house by a resident with a history of sexual violence.

The top executives at the Care House in Bristol were defined by Coroner as “reckless için because he did not effectively control the 18 -year -old Melissa Mathieson’s murderer Jason Conroy.

Avon’s senior coronator Maria Voisin conroy conroy’s home local authority Guernsey states that there were failures because it allowed to be placed in Alexandra House without the necessary safety measures to keep the residents and staff safe.

Speaking outside the court, Mathieson’s father, James Mathieson, said his daughter should still be alive. He said: “He was a wonderful, warm person with an infectious personality that alleviated any room he entered.”

He said the house was disappointed with his daughter and Conroy. “He should never be given the opportunity to kill Melissa. He was well known that he was at a very high risk to kill Minion women, and he should never be allowed to walk around a nursing home.”

As a result, Voisin said: “A failure catalog, which caused an effective risk assessment, resulted in the death of Melissa.”

Coroner emphasized that Mathieson thought that Conroy, who was 18 years old at that time, was following him and he was afraid of him. Some personnel also marked concerns, but no action was taken.

The narrative, Coroner, said that Mathieson died as a result of illegal killing because of the actions and negligence of both the drowning action and the houses entrusted with care ”.

“Placement authority [the States of Guernsey]Knowing the risk of this default, he should not accept the maintenance plan and package presented; When the concerns came up, they could not take action. “

The investigation heard that Conroy had a problematic early childhood in Guernsey and sent by the government of the island to look at England at the age of seven.

While living in care homes in the UK, he exhibited “overly sexualized behavior ve and attacked three female staff.

The most serious one was 17 years old, 17 years old when he attacked a staff at the Higord School in Shropshire.

After trying to touch the staff in accordance with the staff, he put his forearm around his neck and squeezed until he lost consciousness.

Conroy admitted to Hilary Grant, a forensic psychologist, he wanted to kill staff and have sex with his body. It was compulsory that the psychologist posed a high risk for young women, especially for young women, and that it was always “very supervised”. In the report, he said that if he had not been firmly supervised, he would attack again.

Options Higford, Conroy, never let him be alone, including a very strict inspection. The school said he could not continue to look at the Guernsey states. A counselor psychiatrist described Alexandra House in Bristol on behalf of Guernsey as a potential new home.

Conroy was moved there at the end of August 2014 and was given too much freedom.

At night, he questioned that a staff was awake and that Alexandra House was watching 16 residents on three floors, so Conroy was allowed to “wander” without control. Mathieson told staff that he always felt that he was “hidden”.

In October 2014, Conroy drowned Mathieson, planning to take his body back to his room and sexually harassed it. He was imprisoned for life.

During the investigation, Alexandra House’s then Yvonne Hin said he didn’t see the important grant report after Mathieson was killed.

John Duggan, the General Manager of the house, acknowledged that the grant report was “available ına to Alexandra House since the beginning of August.

Authorized, changes in how the inhabitants were evaluated and supervised, but Coroner said he would write to the organization with concerns about the factors about how it was carried out.

Sename Abotsi, a social worker of Conroy, was a surprise during the investigation when Sename Abotsi, a Turkish delight for Guernsey states, was told that she was only a “waking” staff at night. He said there was no high -risk person placement experience.

The hearing was told that Guernsey states paid £ 1,800 a week for Conroy’s place in Alexandra House – less than half of the type of control in the options where Higford is expected to cost.

The clinical director of the expert mental health and adult disability services for Guernsey was accepted as “systemic difficulties adopted during the investigation, but the island has made extensive changes to address the problems that the case has been exposed to, he said.

“Coroner’s findings are completely damaged,” said Joseph Morgan, a lawyer of the Mathieson family. He said: “A young woman is tragic to be deprived of her life as a result of this disaster, very agency failures.”