School staff warned care home that resident posed danger to others, inquest told
Melissa Mathieson, 18, was strangled by Jason Conroy at Alexandra House, which provided residential care for adults with autism and Asperger's syndrome, in Bristol, in October 2014.
Conroy, now aged 28, was jailed for life for the sexually motivated killing.
Avon Coroner's Court heard how Conroy moved to Alexandra House two months before the murder after trying to strangle a teacher at a residential school. He had also previously tried to kill his mother.
Sally Kane, an educational psychologist, said the school was aware of the risk Conroy posed to others because it had received information from his previous placement.
'It became clear that they were not dealing with a young adolescent with learning difficulties, but someone with clear difficulties with behaviour around sexual boundaries,' she told the inquest.
'We upped the risk assessment. We were very concerned and put two staff members with Jason at all times during the day.
'We knew there was a risk, but we were not quite sure of the details of the incident with his mother and duvet.'
After the incident with the teacher, Dr Hilary Grant, a forensic psychologist, was commissioned to produce a report on Conroy which concluded that he posed a physical risk due to his sexualised behaviour.
The school decided it was not a suitable environment for Conroy, and he moved to Bristol in the summer of 2014.
Ms Kane told the inquest she met with Yvonne Hin, the then-manager of Alexandra House, ahead of the move to discuss Conroy.
'I went through the documents with her. We were really worried about the risk not being managed and that's why the documents were sent more than once and shared,' she said.
'That's why the Dr Grant report was shared in full because if we started quoting bits of the report or talking about some of it, you would lose the overall picture of the report.
'We shared the report with Jason's local authority, States of Guernsey, and I am sure they shared it with them.
'We were all on high alert because of the level of risk we were managing. He presented a risk of physical sexual violence.'
Referring to the meeting with Ms Hin, the witness said she remembered being told there were no clinical staff on site and residents were allowed to use external NHS services.
'I remember being absolutely aghast as she seemed to have no understanding of the risk,' she said.
'I was completely taken aback and a bit shocked. I think I went up to the office to make sure these documents were sent very soon after, if not the same day.'
The inquest heard that among the documents was a covering letter, in which Ms Kane had written about Conroy's 'successful placement and ready to move to an adult placement'.
Asked whether she regretted writing that letter, Ms Kane said: 'I didn't realise it was going to be taken out of context.
'It was with a forensic psychiatric report which said he was a high risk and had attempted to murder someone.
'With hindsight, next time I will make sure every document has the full picture built in, not just in the overall context of all the documents together.'
The inquest heard Miss Mathieson, who was from Windsor, Berkshire, had been sent to Alexandra House by social services when she turned 18, having spent the previous two years in a series of different placements.
Earlier, the hearing heard from Miss Mathieson's father, James, who said he felt 'helpless' because he and his wife Karen had not been listened to by social services.
'All we had ever wanted was to be given the support we needed to become Melissa's primary carers and to try to provide her with a stable environment she needed the most to thrive,' he said.
'In the end, it was me who said to Karen that Melissa should go to Alexandra House.
'How wrong I was. I have to live with the consequences of that every day.
'I spoke to Melissa on the night before she died. It was a nice conversation. She sounded tired. I told her to go to bed as she needed to sleep.
'She was killed in her sleep. I have to live with that.'
Mr Mathieson, a former Army serviceman, said: 'Karen and I blame Jason Conroy for our daughter's death.
'But at the same time, how can we blame him when he had said what he was going to do to professionals and was allowed to carry it out.
'We blame the people who put him there with Melissa.
'I find it hard to accept my daughter went to a place of safety and died, whereas I spent 22 years in the Army in many difficult situations and didn't get a scratch. Life is not fair.'
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