Mathieson Coroner's Inquest: Lessons for residential care providers
Melissa Mathieson was murdered at Alexandra House in 2014. She was killed by another resident who had known violent tendencies. Senior Coroner Maria Voisin has found Alexandra House was jointly responsible for Ms Mathieson's death because of systemic failures in its risk procedures, training, and supervision.
The Coroner's recommendations are lessons for all organisations in the care and social services sectors. They highlight the importance of conscious, documented risk management, transparent care planning, and safety protocols that are tailored to each individual.
Below, we set out the details of this case and six findings that organisations in this sector should review to ensure vulnerable individuals are not placed at risk.
Background
Alexandra House is a care home for residents with autism operated by Alexandra Homes Ltd. Social services placed Ms Mathieson, aged 18, in Alexandra House in August 2014, against her and her family's wishes. Mr Conroy has since been convicted of her murder.
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Subscribe nowThe care home knew that Mr Conroy had a high risk of violence towards others, harmful sexual behaviour, and had said previously he wanted to kill somebody. Ms Mathieson and Alexandra House staff had raised concerns about him.
On 12 October 2014, Mr Mathieson was not adequately supervised during the night. He left his room and killed Ms Mathieson. He has since been convicted of her murder.
Key findings
The Coroner identified a "catalogue of failings" by Alexandra House:
- Mr Conroy should not have been placed in Alexandra House at all: he posed too great a risk.
- Mr Conroy's care and management plan said he would be supervised with a 1:1 ratio, but this did not happen.
- At night, the care ratio was as low as 16:1.
- Insufficient staff training to manage known risks.
- Failure to act on concerns raised by staff and residents.
- Inadequate or complete lack of formal inductions, reviews, and risk assessments.
The Coroner found Alexandra House's actions and failings had caused Ms Mathieson's death. She issued a Prevention of Future Deaths Report listing Alexandra House's failings and requiring its parent company, Alexandra Homes Ltd, to respond to the concerns.
Lessons for the care sector
The publication of Prevention of Future Death Reports provides a valuable opportunity for others in the sector to reflect, learn, and take proactive steps to reduce the risk of similar incidents.
Care providers should:
- Review their risk assessments and the threshold where they would refuse to admit a resident.
- Match supervision levels to each resident’s assessed needs, including at night. This may require prioritising staffing that is necessitated to fulfil care plans.
- Ensure key terms in care plans are not misleading. For example, 1:1 care means one supervisor is always with one resident.
- Introduce and update support plans and risk-assessment protocols on a regular, documented basis.
- Provide targeted training for staff on managing high-risk behaviour.
- Establish clear, documented, escalation pathways for concerns raised by staff or residents.
Contact us to discuss your needs
Fieldfisher can assist in reviewing safeguarding frameworks, policies, and procedures to ensure they meet legal and regulatory standards.
We also have extensive experience representing clients in Coroner's Inquests and advising on risk management in care environments.
If your organisation would like to discuss safeguarding or representation before an Inquest further, please contact Harrison Cunningham, Sarah Ellson and Oliver Carlyon.
