As an organising specialising in the management of behavioural risk by providing  Positive behaviour support and Challenging behaviour training SecuriCare were shocked by the events leading up to the murder of a vulnerable young teenager in a Bristol care home. The event was made all the more tragic when subsequent reports have indicated that the death could have been prevented.

Bristol care home death was preventableIn October 2014, Jason Conroy murdered Melissa Mathieson, 18, at a Bristol home providing special care for adults.

A serious case review into her death found care home staff had not acted on recommendations in a forensic report.

The report had warned Conroy had "a high risk of future physical and sexually harmful behaviour".

The serious case review, published by Bristol Safeguarding Adults Board, said a failure to act on previous warnings of Conroy's behaviour had cost Miss Mathieson her life.

Chair of the board, Louise Lawton said: "Melissa's death could have been prevented if practitioners, staff, organisations had adhered to the processes that were in place.

Key findings of the serious case review included:

  • A forensic report, overlooked by Alexandra House, detailed Conroy's previous history and warned staff should be "aware of his victim profile - young petite women who he can easily overpower" and that he "goes to some lengths to identify potential victims including taking an interest in staff rotas".
  • Conroy attempted to kill his mother on two occasions.
  • She had tried to warn care staff about his behaviour and after one attack told staff Conroy "wanted to kill her and have sex with her".
  • In 2007, while at a residential school, Conroy became fixated on a young female member of staff and tried to strangle her with a dressing gown belt. "It is stated that he had reportedly said that he wanted to kill her and have sex with her dead body," the report said.
  • In March 2013, he sexually assaulted then tried to strangle a teacher at a residential school.
  • In a subsequent investigation, Conroy "explained that he had wanted to have sex with her but knew this was against the rules. He had therefore tried to kill her because she would no longer be a member of staff and so he could have sex with her without breaking the rules".

 Miss Mathieson's family, from Windsor, said they did not want her placed in Bristol, describing her as "vulnerable" and not "streetwise". She had been diagnosed with ADHD and autism spectrum disorder.

Lee Hollins, SecuriCare’s Risk Manager says, “This is a heart-breaking case.  It’s very very sad. From a risk management perspective information is the lifeblood of any determination on actions required, and underpins any subsequent plan to reduce or eliminate the possibility of harm to an individual. The evidence that has subsequently come to light defies belief. Why was nothing done with it? Whilst this is an extreme case I would urge people not to shy away from discussing and dealing with risks in relation to harmful behaviours. Nobody can afford to put their head in the sand, or assume someone else is dealing with it. Someone else’s personal safety is likely to depend on it..”

At a specialist training provider SecuriCare offer a range of training courses designed to ensure that parents, carers and staff are able to deliver optimal care and support. We have a hugely experienced development team and are there to meet your needs.

Contact us for more information and to discuss your needs: E: or T: 01904 492442

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