A serious case review into the killing of an 18-year-old woman has pointed to problems with her transition from children’s to adults’ services, risk assessments, and out-of-area placements.
Melissa Mathieson, who had ADHD and autism, died four days after she was attacked by Jason Conroy, then also aged 18, in the Alexandra House private home in Bristol in October 2014.
The serious case review, published by Bristol Safeguarding Adults Board, said her death could have been prevented if “better processes had been in place”, and pointed to a “limited risk assessment” of Conroy carried out by Alexandra House, which houses adults with autism or Asperger’s Syndrome.
Melissa’s parents felt her placement at Alexandra House by Windsor and Maidenhead council was “inappropriate”, and the review said it “seems likely that Melissa might not have required an out of area placement had her needs been met by local services”.
She had been diagnosed with ADHD aged 10, then with autism. When she turned 18 she was moved almost 100 miles from her home in Windsor to Alexandra House, as there was nowhere available in her home area.
The review highlighted problems with the way in which Windsor and Maidenhead council managed Melissa’s transition from children’s to adults’ services, including that she was allocated six social workers over the last two years of her life.
Her referral to adult services, made only eight months before she turned 18, “lacked detail for someone with such complex needs”.
The review also said the management of Conroy’s transition from children’s to adult’s services by the States of Guernsey, his home authority, was “insufficient”.
Melissa showed “considerable distress” during her placement at the home and had been there for eight weeks, and Conroy for only five weeks, when the attack took place on 12 October 2014.
The review also said that the States of Guernsey “seems not to have considered” the risk that Conroy presented to the wider community, which was identified in the forensic report.
Guernsey’s adult mental health service stated that “no communications took place” between its commissioners and Bristol, the local authority area where Conroy was placed.
The review recommended that Bristol Safeguarding Adults Board “writes to the Department of Health to advise them of the absence of notification of out of area placements by the placing to the host authority so that the Department can consider what action is necessary”.
The review said Alexandra House did not refer to a forensic assessment report on Conroy, which had been completed in October 2013 and shared with them in March 2014, until two days before the attack.
This assessment had been commissioned by a residential school where Conroy had previously been placed, after he attacked a member of staff, putting his forearm around her neck and squeezing until she lost consciousness.
The report by a consultant psychiatrist and CAMHS social worker, who assessed Conroy at this school, concluded that he presented a “high risk of future physical and sexually harmful behaviour”.
In November 2013 the school agreed to search for an appropriate adult placement, and it approached Alexandra House in February 2014.
The school also wrote to Alexandra House’s general manager enclosing documents including the forensic assessment report. However, although Alexandra House acknowledged that it had received the report, it did not know when, and it was not “appropriately circulated”.
The review said Alexandra House’s assessment “erroneously linked” the attack in March 2013 to Conroy’s “inability to distinguish between ‘fantasy and reality’.” This resulted in its registered manager forming the view that the attack had occurred because Conroy had “over-stepped boundaries in a role play situation”. However, the review said there was “no suggestion in the forensic assessment report, or from any other account”, that role play was involved in that attack.
Conroy’s placement at the home began on 26 August 2014. On 9 October he “appeared anxious and agitated” when seen on the landing by Melissa’s bedroom where staff were supporting her.
The following day, at a review meeting at the home, the forensic assessment report was circulated but a consultant psychiatrist contracted by Guernsey to oversee Conroy’s care had not previously seen it.
On 12 October, Melissa mentioned to a member of staff that Conroy had been looking at her and said that she was “scared”. He attacked her that evening and she died four days later.
Conroy was found guilty of Melissa’s murder in October 2015 and sentenced to 19 years in prison.
The review was commissioned before the Care Act 2014 was introduced, so was conducted as a serious case review rather than under the safeguarding adults review framework.
Melissa’s father, James, said: “I hope that Melissa’s death will be a turning point in how the services treat families of autistic young adults, young adults with mental health issues and that Melissa’s death is used to change attitudes of all services and that they help families to cope before there is a breakdown of trust. We do not want Melissa’s short life to have been for nothing.”
Alison Alexander, managing director of Windsor and Maidenhead council, said the authority and health services in the borough “have been active participants in the review to ensure these lessons are put into practice.”
Deputy Heidi Soulsby, president of the States of Guernsey’s committee for health and social care, said that as a result of the Parry report into social care in Guernsey published in 2015, its “current arrangements for the assessment and management of islanders with complex needs, who are placed off island, now bear no resemblance to those that were in place at the time of this incident”.
“We have clear governance arrangements with a multi-agency panel that oversees all new placements, transitions and repatriations, as well as two social workers whose primary role is to provide care management to all adults who are placed off island,” she added.