A coroner has slammed the way a probation service hostel where three residents have died has been run - with 'inadequate' staffing levels and a known culture of drug taking. Bolton Coroners Court heard eye-opening evidence on Tuesday (April 12) from workers and management involved with St Joseph's approved premises, in Eccles, during the three months Craig Akhtar Bissa lived at the site.
The court heard Mr Akhtar Bissa, from Rochdale, had wanted to join the army but his dad wanted him to go to college instead. Farzana Akhtar, Mr Akhtar Bissa's sister, said her brother was not interested in college and ended up 'falling into the wrong crowd' before spending two terms in prison and suffering mental health issues as a result.
The 27-year-old moved to St Joseph's on January 31, 2019, after being released from Risley prison on licence. Mr Akhtar Bissa became unwell on March 31 that year but refused hospital treatment, despite the advice of paramedics who attended.
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He was checked by workers at St Joseph's every five minutes, before the checks were reduced to every 15 minutes and later half-hourly after Mr Akhtar Bissa appeared stable. But after a worker found Mr Akhtar Bissa had vomited in his bed in the early hours of April 1, paramedics were called out for a second time before he was sadly pronounced dead.
Bolton Coroners Court heard evidence from five support workers involved at St Joseph's at the time, along with a duty manager for the weekend Mr Akhtar Bissa died and the site's then-manager. John Pollard, assistant coroner for Manchester West, heard evidence that the hostel had limited numbers of staff, a reliance on agency workers at certain times and a lack of routine drug testing for residents.
Two workers, who were based permanently at St Joseph's, had been working on March 9, 2019, when Mr Akhtar Bissa first appeared unwell. Steven Rogers and Maggs Charleson told the coroner Mr Akhtar Bissa appeared to be slurring his words during brunch, but he did not smell of alcohol.
Ms Charleson said she believed he could have been under the influence of illegal drugs, but Mr Akhtar Bissa denied this to both workers and claimed he was just tired. The court heard Mr Akhtar Bissa went back to his room and quickly fell asleep, snoring loudly.
Both Ms Charleson and Mr Rogers were concerned for Mr Akhtar Bissa's welfare, and said a loud shout was required to wake him back up. After initially being reluctant, Mr Akhtar Bissa agreed to go to Salford Royal Hospital, where he underwent blood tests.
'Abrogation of responsibility'
The court heard that Mr Akhtar Bissa was ordered a taxi to go to the hospital, as Ms Charleson and Mr Rogers were the only two members of staff on duty at St Joseph's. Mr Akhtar Bissa was 'fully coherent with his speech and not unsteady on his feet' - but had he been too unwell to travel to the hospital alone, the inquest was told an ambulance would have been called for him.
Mr Pollard described this as an 'abrogation of responsibility' and described staffing levels as 'inadequate'. Responding to evidence from Sarah Conroy, who was manager at St Joseph's from 2018 to 2020, the coroner added: "The ambulance service is absolutely torn to bits - it certainly has not got room to cover for a lack of staff at the probation service."
Ms Conroy said the service is faced with the same issue now, three years later. Asked by Mr Pollard whether this was sensible, she replied: "No."
On the same day Mr Akhtar Bissa attended hospital, another resident - David Topping - raised concerns to staff about people taking ketamine at the site. It was another example of drug taking being discussed at St Joseph's, the court heard, with other mentions of residents having used cannabis, crack cocaine and heroin.
Mr Rogers said he did not report the potential use of ketamine to Salford Royal Hospital when Mr Akhtar Bissa was admitted. The court heard drug testing of residents did not take place on that day either, while probation case worker Jim Murray said he was not aware Mr Akhtar Bissa was ever tested for illegal drug use at St Joseph's.
Ms Charleson told the court she believed one resident in particular was the 'ringleader' for illicit drug taking at St Joseph's, and was bullying a number of residents including Mr Akhtar Bissa. She said that on one occasion, the male resident - who was eventually recalled to prison - pretended to be a female member of staff so he could enter Mr Akhtar Bissa's room and use his phone to contact a drug dealer.
"[Mr Akhtar Bissa] was a lovely young man," Ms Charleson added. "He was well-mannered, respectful and liked by all the staff. I believe he genuinely wanted to sort himself out and not get dragged into trouble, but sadly he got dragged into things by other residents - one in particular."
Agency staff 'stretched'
The court heard that three workers were at St Joseph's on the night Mr Akhtar Bissa died. Part-time Philip Knight was deemed to be the most senior of the three, while Aftab Mirza and Nada Mohamed were also both agency workers.
All three were given a handover from St Joseph's daytime workers on March 31, 2019, and told Mr Akhtar Bissa had become unwell during the day. He returned to his bed, where he was heard snoring loudly, and was being checked regularly.
At the time the night staff began work, Mr Akhtar Bissa was being checked every 15 minutes, but this was relaxed to every half an hour with the permission of weekend duty manager Claudia Ricketts-Royle. She told the court that staff told her there was 'no deterioration' in Mr Akhtar Bissa's condition.
Mr Philips claimed a reason for making the checks half-hourly was because staff were too stretched, although Ms Ricketts-Royle denied this. The court heard that the staff took turns to check on Mr Akhtar Bissa, who had been breathing and snoring, but remained in the same position on his side in bed.
The court heard Mr Topping had visited Mr Akhtar Bissa's room at around midnight to pick up a pouch of tobacco the pair had bought. Mr Topping, a friend of Mr Akhtar Bissa at St Joseph's, claimed he had been responsive at that time - saying 'yo' to him and agreeing he could take the pouch of tobacco.
But an hour later, Mr Philips checked on Mr Akhtar Bissa and discovered he had vomited in his bed and was now unresponsive. He told Mr Pollard he had a mobile phone from the probation service kept in a bag for when he carried out checks, in case of emergency.
Initially, Mr Philips believed he had no phone signal to call an ambulance, but he told the court he may have not known how to use the device. He told the court he went down to the office to use the landline 'after a few seconds' to call 999 instead, taking instructions from North West Ambulance Service.
Along with Ms Mohamed, Mr Philips moved Mr Akhtar Bissa onto the floor. Neither worker used the facility's defibrillator to help Mr Bissa before paramedics arrived.
Despite Ms Mohamed telling the inquest she noticed a 'slow pulse' on the resident, she said it did not occur to her to use it, while Mr Philips believed he would only be able to use it if Mr Akhtar Bissa had stopped breathing. Ms Mohamed added that she had worked at St Joseph's 'several times' before that night, but did not know where the defibrillator was kept.
Police were called out to the scene after paramedics attended. The court heard that there had been 'hearsay' of drug taking at St Joseph's before Mr Akhtar Bissa became ill on March 31, but Det Insp Simon Edgington said no drug paraphernalia was found in his room.
Issues 'apparent'
Former manager Ms Conroy admitted to the court that she was aware Mr Akhtar Bissa was the third resident to have died at St Joseph's. As evidence came to a close on Tuesday, Mr Pollard hinted at serious issues at St Joseph's which he will likely refer to in a prevention of future deaths report, warning legal representatives: "I think it's becoming apparent that there are one or two issues I will be looking into with regard to regulation 28."
Following the hearing, Ms Akhtar told the Manchester Evening News : "As a big sister, I would like to get him justice. The level of care the department has given Craig - they have failed him.
"He was a very caring person, a lovely guy to know. He had a lovely childhood with us under the same roof, he saw my children growing up, he was a lovely brother and son.
"He really cared about family and he wanted to protect everyone. Unfortunately, circumstances have taken him away."
Proceeding.
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