Clinical Negligence & Catastrophic Injury Solicitors
Teenager's murder was 'preventable'.
The murder of a vulnerable teenager who was stalked and later strangled to death could have been prevented, a report has found.
Jason Conroy murdered Melissa Mathieson, 18, In October 2014, 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 that had warned Conroy had "a high risk of future physical and sexually harmful behaviour.”
The serious case review by Bristol Safeguarding Adults Board said a failure to act on previous warnings about Conroy's behaviour had cost Miss Mathieson her life. Conroy, from Guernsey, was jailed for life for her murder in October 2015.
Chair of the board, Louise Lawton, said: "Melissa's death could have been prevented if practitioners, staff and organisations had adhered to the processes that were in place. That didn't always happen and there were a number of missed opportunities."
Miss Mathieson was killed at Alexandra House, a residential care home specialising in caring for adults with autism or Asperger's Syndrome.
Her father James Mathieson said: "I believe that both Melissa and Jason Conroy were badly let down. They were both failed by the services that were supposed to protect them."
Key findings of the serious case review included that a forensic report, overlooked by Alexandra House, detailed Conroy's previous history.
This included trying to kill, and have sex, with his mother and a residential schoolteacher. The report warned that 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.”
The Adult Disability Panel at Conroy’s home authority also raised concerns about his placement at Alexandra House as no consultant care was provided.
Conroy, who had been in residential placements since the age of seven, was moved to Alexandra House as his behaviour was too challenging for a residential school to deal with.
However, the review concluded that his initial assessment made by the care home was too positive and did not take seriously the warnings of the forensic assessment.
Appropriate levels of supervision were not put in place that ultimately led to him being allowed to murder Ms Mathieson, the report found.
Miss Mathieson's family, from Windsor, did not want her placed in Bristol, describing her as "vulnerable" and not "streetwise.” She had been diagnosed with ADHD and autism spectrum disorder.
Mr Mathieson said: "Even though the Safeguarding Adults Board's investigation rightly found that Melissa's death could have been predicted and prevented, as a family, we are still left with so many questions about how this could have ever happened."
A spokesman for Alexandra Homes said: "We are truly sorry for the numerous failures and sincerely regret the mistakes and shortcomings that the review has identified. Quite simply, we failed in our duty to Melissa and her family.
"The offender should have been properly assessed and supervised, and this did not happen, with tragic consequences. It was clearly wrong for a manager to describe our previous processes as 'robust'."
The home added that it had since taken appropriate action and in May 2016 care home watchdog, the Care Quality Commission (CQC), rated the home as 'good' in all areas.
The States of Guernsey, which was responsible for putting Conroy into care, said since the tragedy it had "reviewed and strengthened its processes".