The inquest into the death of 18-year-old Melissa Mathieson concluded today, with the coroner finding that Melissa died by unlawful killing due to the acts and omissions of Alexandra Homes Ltd (based on the offence of corporate manslaughter) after being strangled by her murderer Jason Conroy.

The inquest was heard over nine days at Avon Coroner’s Court in front of HM Senior Coroner Maria Voisin.

Melissa was tragically murdered on 12 October 2014 by a fellow resident of Alexandra House, a care home for residents with autism operated by Alexandra Homes Ltd. Melissa had autism and had recently transferred to Alexandra House by her local social services after turning 18, against her family’s wishes.

The inquest heard how Jason Conroy, who also had autism and whose care was managed by his local authority, State of Guernsey, was known to be a serious risk of sexual violence long before his placement at Alexandra Homes in August 2014. 

Melissa’s father, James Mathieson said:

My daughter should still be here today and I miss her terribly. She was a wonderful, warm person with an infectious personality that lightened any room she entered.  Alexandra Homes let down both Melissa, and Jason Conroy.  He should never have been given the opportunity to murder Melissa.  It was well known that he was at extremely high risk of murdering someone, particularly petite females, and he should never have been allowed to wander a care home, unsupervised. Care home providers, social services and governing bodies have a duty of care to every one of their residents.

Joseph Morgan, solicitor for the family said:

The coroner’s findings are utterly damning. They reflect the gravity of the failures of the management of Alexandra Homes, who were ultimately responsible for the welfare of their residents. In essence, they welcomed a known sexual predator into their care home with no risk management plan, at the same time as admitting a young woman who matched his known victim profile. Even with these failures, the coroner’s conclusion rightfully acknowledges the role Guernsey played in Melissa’s death through their woeful handling of Jason Conroy’s transition to Alexandra Homes. It is desperately tragic that a young woman was deprived of her life as a result of these catastrophic, multi-agency failures.

A year before in March 2013, My Conroy had strangled a teacher at his previous school until she lost consciousness. A forensic psychiatric assessment was then commissioned by the school which detailed in stark terms Mr Conroy’s risks, including that he had intended to kill his teacher and have sex with her dead body, that he intended to do this again, and that he had a victim profile of young petit females. 

This forensic report led Mr Conroy’s school to end his placement with them early due to concerns they could not manage his risk. Having just turned 18, this led to a process whereby he was transferred by Guernsey to a placement at Alexandra House.

The assessment process was conducted by the care home’s General Manager Yvonne Hin.  The inquest heard how Ms Hin was warned about Mr Conroy’s risks by staff at Mr Conroy’s school, including by directing her to the forensic report in person and sending her the forensic report and their Behavioural Support Plan in the post.  Ms Hin denied having received the forensic report at the time of her assessment.  In fact, the coroner found that the home had received the forensic report at the outset of the assessment process, and had specifically been directed towards it by staff at Mr Conroy’s school.

Ms Hin did acknowledge having received a Behavioural Support Plan which highlighted Mr Conroy’s high risk of sexual aggression and provided for him to be supervised by 2 staff members at all times during the day and with one staff member with a line of sight of his bedroom door at night, and another staff member nearby and his bedroom window locked.

Nevertheless, after assessing Mr Conroy, Alexandra Homes confirmed they could accept him  on the basis of a support plan where he was given 1:1 support “at all times”. The inquest heard that this was interpreted by Mr Conroy’s social worker from Guernsey, Sename Abotsi, as meaning Mr Conroy would be supervised 24/7. However Ms Hin confirmed that it was only intended to mean that someone would be available support Mr Conroy in engaging with tasks during waking hours, and not to constantly supervise him as a means of managing his risk. Ms Hin accepted that under her care plan, Mr Conroy would be free to roam Alexandra Homes during the day and at night, unsupervised.  The homes Registered Manager, John Duggan, made the offer of a placement at Alexandra House without having read the homes care plan, or any of the documents relating to Jason.

Ms Hin attended a meeting 5 August 2014 with Mr Conroy’s social worker from Guernsey and a psychiatrist who had been brought in to input to his risk management plan, to confirm and agree the risk management plan ahead of his arrival at Alexandra House. A record of the meeting confirmed it was agreed by all present there had not been any repeat of Mr Conroy’s offending behaviour due to the tight risk management plan in place the school and that this plan would be continued at his  placement at Alexandra Homes. Ms Hin was unable to explain why she agreed to this, when she knew the risk management plan at the school was nothing like the support plan she had formulated.

The inquest also heard that there were there were a number of incidents in the weeks after Mr Conroy’s arrival at Alexandra Homes which should have caused alarm bells, yet only one of these was reported back to Guernsey. These included Melissa herself reporting to several support workers over the weekend before her murder that she was being stalked by Mr Conroy and that she was scared of him. The inquest heard how one of these support workers reported this to her manager, who dismissed her concerns by saying that Melissa was “full of rubbish”.

The inquest heard that on 10 October 2014, the programme manager at Alexandra House found the forensic report detailing Mr Conroy’s risks on the care home’s computer systems and printed it out ahead of a meeting with his social worker and psychiatrist. This was the first time either the social worker from Guernsey or the psychiatrist had read the report.  No additional steps were taken in response to having identified the forensic report, notwithstanding the programme manager having been ‘shocked’ by its contents.

On 12 October 2014, after all residents had gone to bed, Jason Conroy was allowed to enter Melissa’s bedroom and murder her by strangulation.  

The coroner considered all the evidence she had heard and the Submissions made by legal representatives on corporate manslaughter.

The elements of corporate manslaughter are:

– the organisation owing a relevant duty of care to the deceased,

– a gross breach of that duty of care due to the way the organisation’s activities are managed or organised by senior management,

– that this breach caused the death.

The coroner found, on the balance of probabilities, that all the elements of the test had been met by the actions of Alexandra Homes and concluded Melissa Mathieson had been unlawfully killed by their acts and omissions. This was in addition to being unlawfully killed by Jason Conroy, who was convicted of her murder.

Mr Mathieson was represented by Joseph Morgan of Bindmans as solicitor, and Sam Jacobs of Doughty Street Chambers as Counsel