THE family of a former prisoner who died in Bangor after cutting off his own genitalia should have been contacted by the hostel where he was being kept within 48 hours of his death, a report has found.

Reginald Roach, 63, was a resident at Ty Newydd, Gwynedd, but died at Ysbyty Gwynedd from shock and haemorrhage caused by incised wounds after he removed his genitalia on November 6, 2022.

A report by the Prisons and Probation Ombudsman has now found that, while Ty Newydd afforded Mr Roach “good and effective care”, it should have contacted his family within two days of his death.

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Mr Roach had been released from prison six days before he died, and had a history of mental health issues, substance misuse and self-harm.

Adrian Usher, who compiled the report, wrote: “Although Mr Roach died in violent circumstance, staff provided good and effective care, and did their best to meet his needs and manage his risk appropriately.

“There was clear evidence of good joined-up working on Mr Roach’s release from prison.

“It was positive to see that HMP Berwyn also did their best to ensure Mr Roach’s safety on release by escorting him 80 miles to meet his probation officer.

“The probation service and the community resettlement team referred him promptly to the community mental health team and his GP.

“Staff appropriately assessed Mr Roach’s risk of self-harm during his induction and offered a supportive environment in which he could address his offending behaviour.

“Although the police broke the news of Mr Roach’s death to his family, Ty Newydd should have contacted his family within 48 hours, in line with national instructions.”

Mr Roach was sentenced to eight weeks’ imprisonment on October 31, 2022 for a sexual offence.

Due to the time he had served on remand, he was released on licence to Ty Newydd the following day.

But at 10am on November 5, Mr Roach left Ty Newydd, and failed to return before his curfew time at 11pm - staff reported him as unlawfully at large.

The following day, a member of the public found him unconscious in a park, having removed his genitals.

An inquest into Mr Roach’s death led to Kate Robertson, senior coroner for North West Wales, recording a conclusion of suicide.

Mr Usher added in his report: "Mr Roach had made comments to his probation officer and Ty Newydd staff during his induction about removing his genitals.

“None of the staff considered these the comments were made with meaningful intent and on balance, it is reasonable, without the benefit of hindsight, that staff thought that he made the comments in jest rather than as an expression of his intention to harm himself.

“Mr Roach’s behaviour appeared irrational and unpredictable, and 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 Ty Newydd manager, who regularly checked on him."

While Mr Roach’s absence did not break Ty Newydd rules, he had failed to sign out of the premises and tell staff where he was going, before ultimately never returning.

Mr Usher added: “We cannot know whether the police would have found him earlier and before he harmed himself if AP staff had reported him missing earlier in the day."

Ty Newydd staff, meanwhile, were found not to have made initial contact with Mr Roach’s family until 18 November, 12 days after his death.

“Given that Mr Roach lived at Ty Newydd and was under their care, they should have done so sooner,” Mr Usher wrote.

“Staff have acknowledged this delay."