Numerous failings before Melissa Mathieson killed at care home
In a narrative conclusion, Ms Voisin told Avon Coroner's Court Ms Mathieson "died as a result of unlawful killing caused by both the act of strangulation and also due to the acts and omissions by the home entrusted with her care."The home failed Melissa in numerous ways," she said.Miss Mathieson, from Windsor, Berkshire, was sent to Alexandra House by social services when she turned 18, after spending the previous two years in a variety of placements.In a letter, she wrote how she was "dragged away from my home and everything I knew" by social services who "destroyed my life".
Conroy, originally from Guernsey, moved to the home two months before the murder after the attack on the teacher at his boarding school. The school, which in the Midlands, had commissioned a report from a forensic psychologist which concluded he posed a physical risk to others because of his sexualised behaviour.They warned the managers of Alexandra House about the risk, but this was not reflected in Conroy's care plans, which only listed basic information.The directors of the company which ran the home pleaded guilty to a health and safety offence after the murder and were fined £125,000.Ms Voisin told the coroner's court the conduct of the home's senior managers amounted to a "gross breach of duty"."This I consider to be reckless conduct at senior management level," she added.
'Failed to act'
Several staff told the inquest they would never have been alone with Conroy if they knew of the risk he posed, and described reporting their concerns to supervisors.The inquest heard Miss Mathieson complained Conroy had been stalking her hours before she was killed.In her conclusion, the senior coroner for Avon said Conroy should have been supervised at all times and the fact he was not "meant he was able to attack and strangle" Miss Mathieson.She described Miss Mathieson as vulnerable and said Conroy targeted her with the intention of killing her.She added Conroy "should not have been placed in the same facility" as her.
Ms Voisin said: "The decision was wrongly made to place him in the same facility with an ineffective care plan and risk assessment, with staff that were not trained on his level of risk, and managers who failed to act when concerns were highlighted by staff and Melissa."When Conroy was jailed, Judge Graham Cottle said he posed a very serious danger to the public, in particular to young women.
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