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Numerous failings before Melissa Mathieson killed at care home
Numerous failings before Melissa Mathieson killed at care home

BBC News

time6 days ago

  • BBC News

Numerous failings before Melissa Mathieson killed at care home

"Reckless conduct at a senior manager level" allowed a man fascinated by necrophilia to murder an 18-year-old at the care home where they lived, a coroner has Conroy was 18 when he strangled Melissa Mathieson at Alexandra House, a Bristol home providing special care for adults, in October 2014. Conroy, now 28, was jailed for life for the sexually-motivated killing. An inquest into Miss Mathieson's death heard he had previously tried to kill his mother and was sent to the home after trying to strangle a coroner Maria Voisin concluded a "catalogue of failures" allowed the murder to happen, including the risk Conroy posed not being reflected in his care plans. 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 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 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 warned the managers of Alexandra House about the risk, but this was not reflected in Conroy's care plans, which only listed basic directors of the company which ran the home pleaded guilty to a health and safety offence after the murder and were fined £125, 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 inquest heard Miss Mathieson complained Conroy had been stalking her hours before she was 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 described Miss Mathieson as vulnerable and said Conroy targeted her with the intention of killing 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.

Catalogue of failures led to woman's murder in Bristol care home, coroner finds
Catalogue of failures led to woman's murder in Bristol care home, coroner finds

The Guardian

time6 days ago

  • The Guardian

Catalogue of failures led to woman's murder in Bristol care home, coroner finds

A 'catalogue of failures' resulted in the murder of a vulnerable young woman who was strangled to death in a care home by a fellow resident with a history of sexual violence, a coroner has concluded. Senior managers at the care home in Bristol where Melissa Mathieson, 18, died were described as 'reckless' by the coroner for not effectively supervising her killer, Jason Conroy. Maria Voisin, the senior coroner for Avon, also concluded there were failings by Conroy's home local authority, the States of Guernsey, for allowing him to be placed at Alexandra House without the necessary security measures to keep residents and staff safe. Speaking outside the court, Mathieson's father, James Mathieson, said his daughter should still be alive. He said: 'She was a wonderful, warm person with an infectious personality that lightened any room she entered.' He said the home had let down his daughter and Conroy. 'He should never have been given the opportunity to murder Melissa. It was well known that he was at extremely high risk of murdering someone, particularly petite females, and he should never have been allowed to wander a care home, unsupervised.' In her conclusion, Voisin said: 'A catalogue of failures resulting in his placement with no effective risk assessment in place resulted in the death of Melissa.' The coroner highlighted that Mathieson had said she thought Conroy, who was 18 at the time, was stalking her and was frightened of him. Some staff members had also flagged up concerns but no action was taken. In a narrative conclusion, the coroner said 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'. She added: 'The placing authority [the States of Guernsey], knowing this resident's risk, should not have agreed to the care plan and package being offered; they failed to act when concerns were raised.' The inquest heard that Conroy had a troubled early childhood on Guernsey and was sent at the age of seven by the island's government to the UK to be looked after. While living in care homes in England, he exhibited 'extreme sexualised behaviour' and attacked three female members of staff. The most serious was in March 2013 aged 17 when he assaulted a staff member at Options Higford school in Shropshire. After trying to touch the staff member inappropriately, he put his forearm around her neck and squeezed until she lost consciousness. Conroy admitted to a forensic psychologist, Hilary Grant, that he wanted to kill the staff member and have sex with her body. The psychologist said he posed a high risk, especially to petite young women, and it was imperative he was 'highly supervised' at all times. The report said that if he was not supervised tightly, it was 'almost certain' he would attack again. Sign up to Headlines UK Get the day's headlines and highlights emailed direct to you every morning after newsletter promotion Options Higford introduced very strict supervision for Conroy, including never allowing him to be alone. The school told the States of Guernsey it could not continue to care for him. A consultant psychiatrist identified Alexandra House in Bristol on behalf of Guernsey as a potential new home. Conroy moved there at the end of August 2014 and was given much freedom. At night, the inquest heard, one staff member was awake and on duty monitoring 16 residents over Alexandra House's three floors, meaning Conroy was allowed to 'roam around' unsupervised. Mathieson told staff she felt he was always 'lurking'. In October 2014 Conroy strangled Mathieson, planning to take her body back to his room and sexually abuse her. He was jailed for life. During the inquest, Yvonne Hin, the then manager of Alexandra House, said she did not see the crucial Grant report until after Mathieson was killed. John Duggan, the registered general manager of the home, accepted that the Grant report was 'available' to Alexandra House from the beginning of August. He said changes had been made to how residents were assessed and supervised but the coroner said she would write to the organisation with remaining concerns about elements of how it was run. Conroy's social worker, Sename Abotsi, a locum working for the States of Guernsey at the time, expressed surprise during the inquest when told there was only one 'waking' staff member on duty at night. She said she had no experience of placing a high-risk person. The hearing was told that the States of Guernsey paid £1,800 a week for Conroy's place at Alexandra House – less than half what the type of supervision he had been under at Options Higford would have been expected to cost. Dr Dominic Bishop, the clinical director of specialist mental health and adult disability services for Guernsey, accepted during the inquest there had been as series of 'systemic difficulties', but said the island had made wide-ranging changes to address the issues the case exposed. Joseph Morgan, a solicitor for the Mathieson family said: 'The coroner's findings are utterly damning.' He said: 'It is desperately tragic that a young woman was deprived of her life as a result of these catastrophic, multi-agency failures.'

Coroner criticises senior care home managers over teenage girl's death
Coroner criticises senior care home managers over teenage girl's death

The Independent

time6 days ago

  • The Independent

Coroner criticises senior care home managers over teenage girl's death

'Reckless conduct at a senior manager level' allowed a teenager fascinated by necrophilia to murder an 18-year-old woman in a care home, a coroner has concluded in a scathing judgment. Maria Voisin, the senior coroner for Avon, said there was a 'catalogue of failures' that allowed Jason Conroy to strangle Melissa Mathieson at a care home in Bristol in October 2014. The teenager was attacked by Conroy, then aged 18, at Alexandra House, which provided residential care for adults with autism and Asperger's syndrome. Conroy, now aged 28, was jailed for life for the sexually motivated killing. Avon Coroner's Court heard how he once tried to strangle a teacher so he could abuse her and had also attempted to kill his mother. Conroy, originally from Guernsey, moved to Bristol from a boarding school in the Midlands following the incident with the teacher. The school had commissioned a report from a forensic psychologist which concluded that 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 his care plans, which only listed basic information. The directors of the company which ran the home later pleaded guilty to a health and safety offence and were fined £125,000. Ms Voisin said the conduct of senior managers at Alexandra House in failing to understand the danger Conroy posed to others amounted to a 'gross breach of duty'. 'This I consider to be reckless conduct at senior management level,' she said. 'The support plan and risk assessment drafted by Alexandra House's senior management was not sufficient to protect Melissa. 'The risk was, and should have been obvious, to Alexandra House from the school care plan and risk assessment, the numerous meetings before Jason's placement began, the Grant report, the concerns raised by staff and the concerns raised by Melissa herself, who was frightened of him. 'Based on the evidence, it was the gross breach of Alexandra House's duty of care to Melissa that caused her death, as it allowed a known dangerous young man who was under no supervision at the time the opportunity to murder her.' In a narrative conclusion, the coroner said Miss 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. 'The resident who went on to strangle her, should not have been placed in the same facility as Melissa at all based on his known risks. '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.' Support workers at the home told the inquest they did not know about his history of predatory sexual behaviour. Several staff told the hearing they would never have been alone with Conroy if they knew of the risk he posed to others, and described reporting their concerns to supervisors. 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. In a letter written before her death, Miss Mathieson blamed social services for 'destroying' her life. Titled Social Services Have Destroyed My Life, she wrote: 'This was a terrible time for me, and I felt like I was dragged away from my home and everything I knew and being completely disrupted. 'They never took into consideration my age or the distance from my family. I was still a child, just very confused.' The letter was read to the court as part of the written evidence of Miss Mathieson's mother, Karen, who died from cancer a year after her daughter's death. Mrs Mathieson said 'the system' had failed her daughter and had also failed Conroy. 'Not only has Jason Conroy ended Melissa's life, but he has also ended his own. He should have had his problems addressed a long time ago,' she said. 'The system has failed him, and it has failed Melissa. 'We question the professionals who have had the responsibility for his care, as much as we do of those who had a responsibility for Melissa's care.' Miss Mathieson's father, James, said he felt 'helpless' because he and his wife had not been listened to by social services. 'Karen and I blame Jason Conroy for our daughter's death,' he said. '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.'

Coroner criticises senior care home managers over teenage girl's death
Coroner criticises senior care home managers over teenage girl's death

Yahoo

time6 days ago

  • Yahoo

Coroner criticises senior care home managers over teenage girl's death

'Reckless conduct at a senior manager level' allowed a teenager fascinated by necrophilia to murder an 18-year-old woman in a care home, a coroner has concluded in a scathing judgment. Maria Voisin, the senior coroner for Avon, said there was a 'catalogue of failures' that allowed Jason Conroy to strangle Melissa Mathieson at a care home in Bristol in October 2014. The teenager was attacked by Conroy, then aged 18, at Alexandra House, which provided residential care for adults with autism and Asperger's syndrome. Conroy, now aged 28, was jailed for life for the sexually motivated killing. Avon Coroner's Court heard how he once tried to strangle a teacher so he could abuse her and had also attempted to kill his mother. Conroy, originally from Guernsey, moved to Bristol from a boarding school in the Midlands following the incident with the teacher. The school had commissioned a report from a forensic psychologist which concluded that 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 his care plans, which only listed basic information. The directors of the company which ran the home later pleaded guilty to a health and safety offence and were fined £125,000. Ms Voisin said the conduct of senior managers at Alexandra House in failing to understand the danger Conroy posed to others amounted to a 'gross breach of duty'. 'This I consider to be reckless conduct at senior management level,' she said. 'The support plan and risk assessment drafted by Alexandra House's senior management was not sufficient to protect Melissa. 'The risk was, and should have been obvious, to Alexandra House from the school care plan and risk assessment, the numerous meetings before Jason's placement began, the Grant report, the concerns raised by staff and the concerns raised by Melissa herself, who was frightened of him. 'Based on the evidence, it was the gross breach of Alexandra House's duty of care to Melissa that caused her death, as it allowed a known dangerous young man who was under no supervision at the time the opportunity to murder her.' In a narrative conclusion, the coroner said Miss 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. 'The resident who went on to strangle her, should not have been placed in the same facility as Melissa at all based on his known risks. '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.' Support workers at the home told the inquest they did not know about his history of predatory sexual behaviour. Several staff told the hearing they would never have been alone with Conroy if they knew of the risk he posed to others, and described reporting their concerns to supervisors. 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. In a letter written before her death, Miss Mathieson blamed social services for 'destroying' her life. Titled Social Services Have Destroyed My Life, she wrote: 'This was a terrible time for me, and I felt like I was dragged away from my home and everything I knew and being completely disrupted. 'They never took into consideration my age or the distance from my family. I was still a child, just very confused.' The letter was read to the court as part of the written evidence of Miss Mathieson's mother, Karen, who died from cancer a year after her daughter's death. Mrs Mathieson said 'the system' had failed her daughter and had also failed Conroy. 'Not only has Jason Conroy ended Melissa's life, but he has also ended his own. He should have had his problems addressed a long time ago,' she said. 'The system has failed him, and it has failed Melissa. 'We question the professionals who have had the responsibility for his care, as much as we do of those who had a responsibility for Melissa's care.' Miss Mathieson's father, James, said he felt 'helpless' because he and his wife had not been listened to by social services. 'Karen and I blame Jason Conroy for our daughter's death,' he said. '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.'

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