A Care Home 'Failed on All Accounts' leading to £125,000K Fine After Teenager's Death

On December 01st 2023, at Bristol Crown Court, a care home, Alexandra House in Bristol, was fined £125,000 following a teenager's death. They were successfully prosecuted for not doing enough to keep people safe from vulnerable patients who represented a danger not only to themselves but to others as well.

Summary of the Facts

Alexandra Homes Limited runs three care homes in Bristol. The one in question, Alexandra House is on Wells Road, Bristol. It specialises in providing a residential care service for adults with Asperger syndrome and autism spectrum disorders. Jason Conroy and Melissa Mathieson were new residents and moved into the residential home in August 2014. Jason Conroy, aged 18 at the time, murdered Melissa Mathieson, also aged 18, on 12 October 2014, whilst she was in her bed. In 2015, Jason Conroy was jailed for life and ordered to serve a minimum term of 19 years for the 'sexually motivated' murder of Melissa Mathieson.

The Investigation

The Investigation and prosecution resulting in the fine took place by the Health and Safety Executive ('HSE') and it was found that Alexandra House failed "on all accounts". Prior to Jason Conroy's move to the home, he had previously strangled and as a result, rendered unconscious, a member of staff at his school. This information was passed to Alexandra House by the school as well as a risk assessment that stated Jason Conroy presented a threat to others. Specifically, he was a threat to women due to showing sexually aggressive behaviours. A further report by a Dr Grant, provided to Alexandra House stated that Jason Conroy could be violent towards others and was a threat to staff and younger peers due to further, sexually harmful behaviours.

The above information, outlining the threat and risks that Jason Conroy posed, was passed to the care home at the start of his residential placement in August. This information was enough to highlight the need for him to be under close supervision during his placement, in order to protect other residents and staff, and should have raised concerns resulting in immediate action to protect residents. It was to be expected that a residential home would revise any support plan in place, given the information presented, yet this was not the case at Alexandra House.

Despite knowledge of the risks, Alexandra House did not have appropriately qualified members of staff to deal with Jason Conroy and there was not enough staff to ensure that efficient and effective monitoring of him. The staff that were at Alexandra House were not informed of the high level risk that he posed and therefore, they were unable to provide sufficient monitoring or implement safety methods to ensure the safety of the residents and staff as a whole.

HSE concluded the investigation by stating that Alexandra Homes was given 'clear warning signs about Jason Conroy's behaviour but simply did not act upon them. As a result, Melissa Mathieson, a vulnerable young woman lost her life in a setting that was meant to protect and help her'. Alexandra Homes Limited pleaded guilty to its failings resulting in Melissa Mathieson's devastating loss and based upon the investigation's findings. The fine of £125,000 would undoubtedly have been more if they had not accepted their failings and pleaded not guilty.

Forbes Comment

Health and safety breaches are, and always will be, a serious cause for concern and any breach of health and safety measures and regulations can cost an innocent persons life. This case highlights the need for residential care homes to not fall short of providing the necessary care required for each individual resident, in order to protect and promote the safety of the individual, other residents, staff and the public.

Since April 2015, the Care Quality Commission ('CQC') are now the regulator for patient health and safety matters, with HSE regulating health and safety for workers and members of the public. The CQC now have the power to carry out criminal investigations and bring prosecutions. The responsibilities of the both CQC and HSE are available to read on the HSE's website ( MoU between the Care Quality Commission (CQC) and HSE ).