Overview

• The inquest concluded on July 18, 2025, with Voisin finding a “catalogue of failures” and reckless management at Alexandra House that allowed Jason Conroy to roam unsupervised.
• Voisin held the States of Guernsey accountable for agreeing to Conroy’s placement without effective risk assessment or security measures.
• Directors of the company running Alexandra House pleaded guilty to a health and safety offence and were fined £125,000 by the court.
• Guernsey authorities have pledged comprehensive changes to adult residential care following the coroner’s narrative conclusion.
• Melissa Mathieson’s family continues to press for wide-ranging reforms to safeguard vulnerable adults in residential care.