A probation worker failed to help a hostel resident who had suffered an overdose because they thought he was just sleeping. Louis Maniatt was not checked again until two hours later when he was confirmed dead.
Background of the case
The 43-year-old had been released from jail just under a month before his death. He had been serving a sentence of seven and a half years for a knifepoint robbery of the Premier convenience shop in Beaufort Road, St Julians, Newport.
An ombudsman report into the death found several failings by the probation service, which runs the Ty Newydd hostel in Bangor, Gwynedd. Mr Maniatt, like most of the facility's residents, had been released from prison on licence.
Details of the incident
The overdose on April 22, 2023, was caused by inhaling butane gas from a canister for refilling lighters. The highly dangerous substance is sometimes used recreationally for a feeling of euphoria.
Mr Maniatt, who had a history of drug abuse and mental health problems, ran out of his antipsychotic medication "for several days" leading up to his death, said the ombudsman Adrian Usher.
The night before Mr Maniatt died, he played pool with other residents. He went to bed at around midnight.
Mr Usher said: "At 9am the next morning, a residential worker did not obtain a roused response from Mr Maniatt as they were supposed to, but was not concerned about him, believing he was asleep."
"At 11am another residential worker found Mr Maniatt unresponsive and further investigation revealed that he had died."
Ombudsman findings
Butane canisters are used to refill lighters and, as Mr Maniatt smoked, any discovery of a small amount of cannisters is unlikely to have caused concern had he been searched.
"Although two residents told police that they knew Mr Maniatt abused butane, they were not prepared to give any further information about this, so we cannot say whether it was something staff should have detected."
Mr Usher found the residential worker's welfare check was not "to the required standard" but was satisfied the probation service had "pursued appropriate avenues to discipline the member of staff".
He added: "Mr Maniatt ran out of medication, but the approved premises now uses a different GP surgery which prescribes more than just one week’s supply of medication at a time.
"We have also asked the head of residential public protection for Probation Wales to ensure staff understand the system for ordering more medication when necessary."
The ombudsman also revealed staff failed to check they had the correct contact details for Mr Maniatt’s next of kin. "As a result, their letter of condolence was sent to the wrong address," said Mr Usher.
Conclusion
Mr Maniatt had been handed the prison term in 2018 after pleading guilty at Newport Crown Court to robbery and possession of a knife in public.
An inquest concluded he died by misadventure with the medical cause of death given as butane toxicity.
