Man died of butane toxicity at approved premises in Bangor

A letter of condolence from Ty Newydd Approved Premises, intended for the next of kin of Louis Maniatt, was also sent to the wrong address.

Mr Maniatt died aged 43 of butane toxicity at Ty Newydd on April 22, 2023, less than a month after he had been released from prison.

Adrian Usher, the Prisons and Probation Ombudsman, found there were “gaps in him receiving his medication” in a report he compiled, published on Tuesday (August 4).

Mr Maniatt was jailed for seven-and-a-half years in September 2018 for robbery, and was released from HMP Oakwood, Staffordshire to Ty Newydd on March 27, 2023.

He had a history of substance misuse and mental health issues, but was engaging with substance misuse services.

In the week prior to his death, Mr Maniatt ran out of his medication, olanzapine, for several days.

At 9am on April 22, a residential worker at Ty Newydd did not obtain a response from Mr Maniatt as she was supposed to, and found him in bed, face-up with his foot sticking out.

But the worker was not concerned about him, believing he was asleep, and did not attempt to get a response or check for signs of life.

Another residential worker found Mr Maniatt unresponsive at 11am, and further investigation revealed he had died.

Police notified Mr Maniatt’s family of his death at 5.40pm that day, while the manager of Ty Newydd also contacted his family by phone the following day.

Mr Usher wrote: “A residential worker did not carry out a welfare check to the required standard on the morning of April 22, but we are satisfied that the approved premises pursued appropriate avenues to discipline the member of staff.

“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.

“Approved premises staff did not check Mr Maniatt’s next of kin’s contact details to ensure they had the correct address. As a result, their letter of condolence was sent to the wrong address.”

Mr Maniatt’s death was the second at Ty Newydd in three years – in the case of the other, in November 2022, staff also delayed contacting the deceased’s family.

Mr Usher found that Ty Newydd staff made “reasonable efforts” to help Mr Maniatt during his time at the approved premises, and they “appropriately” referred him to a substance misuse service.

Mr Maniatt has also not shown “any obvious signs” that he was abusing butane, Mr Usher added.

Two butane canisters were found in his room after his death – though two residents told police they knew Mr Maniatt abused butane, they were not prepared to give any further information about this.

The staff member who did not carry out the 9am welfare check thoroughly was given a 12-month final written warning, but was then dismissed following a further incident.

Mr Usher added that approved premises’ daily handover notes should state if new medication has been ordered for residents.

But he wrote: “In Mr Maniatt’s case, this had been missed.

“Combined with the GP’s practice of only prescribing Mr Maniatt’s medication one week at a time, this led to gaps in him receiving his medication.”

Though, no recommendations were made in this regard because Ty Newydd now uses a different GP surgery and has not encountered any similar issues.

An inquest into Mr Maniatt’s death, held in September 2025, resulted in a conclusion of misadventure being recorded.