Hostel staff "provided effective care" to a released prisoner who died after bleeding to death when he cut his own penis off, a new report has found.
Reginald Alan Roach had been convicted of a sexual offence on October 31, 2022 and jailed for eight weeks, but due to the time he had spent on remand at HMP Berwyn he was released immediately on licence to Ty Newydd Approved Premises (AP). Just days later a dog walker discovered the 63-year-old in a field on the outskirts of Bangor, he was rushed to hospital but was later pronounced dead.
An investigation was launched by the Prisons and Probation Ombudsman. It heard that when Roach arrived at AP he was given a short induction. He denied thoughts of suicide or self-harm and said he felt safe at the AP. He talked about his offence of exposure and said that he had not meant to hurt anyone. He said the best thing for him would be to cut off his penis and testicles which, in the context of their conversation, she considered he said in jest. Staff monitored him hourly during his first night and every half an hour on his second night.
He had a history of mental health issues, substance misuse and self-harm. It also noted that he had been diagnosed with schizophrenia and brain damage following a road traffic accident decades earlier. Staff reported his mood had improved by the next morning and he spoke about a new flat he was due to be allocated.
He was rushed to hospital (Daily Post Wales)At 10am on November 5, Mr Roach walked out of the AP without signing out or telling staff where he was going. AP staff tried to phone Mr Roach several times that day but he failed to respond. He had not returned to the AP before the curfew time of 11pm. The on-call manager started the emergency process for recalling Mr Roach’s licence. At around 10am the next day, the police contacted the AP and told them that Mr Roach had been taken to hospital after a member of the public had found him earlier that morning, unconscious in a field, around a mile from the AP.
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Adrian Usher, Prisons and Probation Ombudsman was tasked with investigating the death. He said there was "clear evidence of good joined-up working and communication within the criminal justice system when Mr Roach was released from prison". He added: "Probation and the Community Resettlement Team referred him promptly to the community mental health team and his GP due to his ongoing mental health concerns.
"AP staff appropriately and promptly repeated these actions when Mr Roach arrived at Ty Newydd AP. They also promptly arranged for him to receive his prescribed medication. Although Mr Roach refused to take his medication at the AP, it is unlikely that it would have had an immediate positive impact on his mental health in such a short period of time."
He said: "Mr Roach had made comments to his probation officer and AP staff during his induction about removing his genitals. None of the staff considered these comments were made with meaningful intent and on balance, it is reasonable, without the benefit of hindsight, that AP staff thought that he made the comments in jest rather than as an expression of his intention to harm himself."
The report stated: "Mr Roach’s behaviour appeared irrational and unpredictable and the AP staff appropriately escalated the matter to the police, recognising his risk to the public and himself. Mr Roach was also well supported by his probation officer and the AP manager who regularly checked on him."
Mr Usher concluded that although Mr Roach died in violent circumstances, AP staff provided effective care and did their best to meet his needs during his short time at the AP. An previous inquest into Roach's death heard from Home Office pathologist Dr Brian Rodgers who said Roach went into cardiac arrest and was taken to Ysbyty Gwynedd in Bangor for treatment, but was pronounced dead.
"It's likely he would have bled profusely," he said. Dr Rodgers' view was Mr Roach died from shock and haemorrhaging. Kate Robertson, senior coroner for north west Wales, recorded a conclusion of suicide.
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