Recurring concern

Unreliable safe-release arrangements for high-risk offenders

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First reported 29 Mar 2017•Latest report 13 Mar 2024

Definition

What this concern includes

Includes failures in the dedicated high-risk-offender release process, including sentencing and release-risk information for courts, release-date communication, alerts to relevant agencies, release planning, accommodation suitability and coordination of protective arrangements where these directly affect safe release.

Not included

  • Excludes general community monitoring or supervision failures after release where no deficiency in the release arrangements themselves is identified.
  • Excludes generic probation, police or prison communication, training or staffing deficiencies unless they directly impair high-risk-offender release arrangements.
  • Excludes sentence-calculation or recall-process failures unless they directly affect the safety of a high-risk offender's release decision or arrangements.
  • Excludes failures concerning ordinary prisoner release where the high-risk-offender safety qualifier is not supported.
  • Excludes downstream offending or harm where no deficiency in the high-risk-offender release process is identified.
Reports
6

Distinct published reports

Individual concerns
7

A report can raise multiple concerns

Date range
2017–2024

First to latest report issue date

Stated actions
14

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service3
Ministry of Justice3
Birmingham and Solihull Mental Health NHS Foundation Trust1
G4S1
Home Office1
Lancashire Constabulary1
Liverpool City Council1
Recipient name withheld1
Swansea Bay University Local Health Board1
West Midlands Police1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Birmingham and Solihull

    AI-generated summary

    Jacob Michael Nicholas BILLINGTON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jacob Michael Nicholas Billington was unlawfully killed when he was stabbed in the neck during a night out in Birmingham on 6 September 2020. The concerns included inadequate coordination and information-sharing between agencies during the release of a high-risk prisoner with serious mental health difficulties, and a lack of clear cross-agency guidance and understanding of responsibilities.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of cross-agency provisions and guidance for release planning of high-risk prisoners with mental health difficulties

    Wider context from the report

    “3. Cross agency guidance regarding release of high risk prisoners with mental health difficulties at their sentence end date. There are no provisions available nor any cross agency guidance in place for when a high-risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community. ”

    Source location

    Jacob Michael Nicholas BILLINGTON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce resettlement-services drop-in sessions for prisoners approaching release.

    Verbatim wording from the response

    “• Resettlement services drop-in sessions have been introduced and approved laptops have been received from HMPPS to roll out remote sessions under resettlement activities, to encourage engagement with resettlement services by prisoners approaching release and to provide opportunities to gather further information.”

    Source location

    Response from G4S Care Justice Services (UK) Ltd
    Page 3 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Roll out remote resettlement-services sessions using approved laptops.

    Verbatim wording from the response

    “• Resettlement services drop-in sessions have been introduced and approved laptops have been received from HMPPS to roll out remote sessions under resettlement activities, to encourage engagement with resettlement services by prisoners approaching release and to provide opportunities to gather further information.”

    Source location

    Response from G4S Care Justice Services (UK) Ltd
    Page 3 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Require offender managers to notify Community Offender Managers about sentence-end releases involving no fixed abode and provide release-destination information.

    Verbatim wording from the response

    “• Whilst Community Offender Managers have responsibility for the coordination of release planning, notice was given by email to all offender managers within HMP & YOI Parc that they must notify the relevant Community Offender Manager when a prisoner is being released at sentence end date and will be of no fixed abode. When doing so, they must provide any information relating to a prisoner’s intentions in terms of where they are going on the day of release. This will assist the Community Offender Manager to effectively manage the prisoner’s release, and to coordinate and link in with other external agencies believed by the Community Offender Manager to be relevant to coordinate interagency working.”

    Source location

    Response from G4S Care Justice Services (UK) Ltd
    Page 3 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Include the BSMHFT MAPPA Clinical Lead in developing a sustainable MAPPA engagement strategy and identifying alternative arrangements for gaps.

    Verbatim wording from the response

    “The Deputy Medical Director chaired an initial scoping meeting in response to these issues identified by the PFD on 10th April 2024, culminating in agreement on 3 primary areas of focus:”

    Source location

    Response from BSMHFT
    Page 1 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the Prison Discharge Coordinator job description, role scope and potential additional resource requirements.

    Verbatim wording from the response

    “2. Role of the Prison Discharge Coordinator. The Standard Operating Procedure has been revised. In addition to this there is an intention to review the Job Description of this role and understand in more depth the scope of what this role can achieve currently or will need to achieve in the future including any potential additional resource requirements. This review is aimed at aligning the role’s”

    Source location

    Response from BSMHFT
    Page 1 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the Prison In-reach and CMHT interaction process, complete a gap analysis and develop a plan to strengthen continuity of care.

    Verbatim wording from the response

    “3. Interface between Prison In-reach and the CMHT- A comprehensive review of the current interaction process between the Prison In-reach team and the CMHT is planned. This will involve a detailed gap analysis to determine areas needing strengthening. We aim to develop a clear plan to enhance this interface, thereby improving continuity of care and ensuring that individuals receive the necessary support as they transition from prison to community-based services.”

    Source location

    Response from BSMHFT
    Page 2 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement an improved referral and discharge procedure through the updated standard operating protocol.

    Verbatim wording from the response

    “In the meantime we can offer you assurances that since the events that culminated in Mr Billington’s death the Trust has improved the structure and supervision surrounding the prison discharge coordinator roles, such that the practitioners have weekly supervision with opportunity to escalate cases of concern, and an improved system of referrals and discharge procedures, reflected in the updated standard operating protocol. This means that in the event of a similar situation occurring again, there would be sufficient structure to ensure and support the flexibility in service provision to prevent such an individual falling between services, even where they had been discharged from active multiagency management by MAPPA.”

    Source location

    Response from BSMHFT
    Page 2 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Hold formal admission handovers and pre-release meetings with transferring mental-health teams or prisons and relevant agencies.

    Verbatim wording from the response

    “• Formal hand over of care is received from the transferring Community Mental Health Team (CMHT) or previous prison via a formal meeting”

    Source location

    Response from Swansea Bay University Health Board
    Page 3 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct multidisciplinary pre-discharge reviews and formal pre-release planning meetings four to six weeks before known release dates.

    Verbatim wording from the response

    “Discharge to Community”

    Source location

    Response from Swansea Bay University Health Board
    Page 3 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide policing support to partners concerning high-risk prisoners with mental health difficulties released at sentence end.

    Verbatim wording from the response

    “This issue will be addressed by HMPPS, however we will ensure we provide support from a policing perspective to partners in relation to high-risk prisoners with mental health difficulties at their sentence end date. From a policing perspective, it is important to note that the IT systems now in place (as described in evidence during the inquest) have changed meaning that there are now better opportunities to identify someone if they have been assessed as being at an increased risk to themselves or others.”

    Source location

    Response from West Midlands Police
    Page 4 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Revise and reissue the sentence-end-date release practice document, and embed its expectations in staff development sessions.

    Verbatim wording from the response

    “For a prisoner to still be detained in custody at the point of sentence expiry is usually as a result of them having been recalled to custody. This means they remain the responsibility of the Probation Community Offender Manager (COM) until the point of release at the sentence end date (SED). There is no statutory authority for Probation supervision of a prisoner released into the community at SED. The sharing of information prior to release into the community in an effective manner with relevant agencies is therefore of paramount importance. The Probation Service West Midlands has a practice document which sets out the expectations for Practitioners when cases are being released at SED. This document has been revised and reissued to all staff and embedded in development sessions delivered by the Regional Quality Team.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Promote the NHS Reconnect Service to probation practitioners to support referrals for through-the-gate transition support.

    Verbatim wording from the response

    “NHS-England are commissioned to provide healthcare in Prisons. The sharing of information between health in custody and health in the community is a core feature of the nationally rolled out NHS-England Reconnect Service. West Midlands Probation Service has actively promoted the Reconnect Service with Probation Practitioners in recent months to ensure they are aware of how to refer into this service in Prison for support “through the gate”, the transition period from prison into the community.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Concerns about SystmOne, cross-agency release guidance and the MAPPA discharge coordinator fall outside G4S’s power to address.

    Verbatim wording from the response

    “G4S confines its response to the first concern identified relating to the management of release from prison and interagency working.”

    Source location

    Response from G4S Care Justice Services (UK) Ltd
    Page 2 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    G4S cannot influence release management or interagency working at private prisons operated by other providers or HMPPS.

    Verbatim wording from the response

    “In addition, G4S has no power to influence the management of release of prisoners from, and/or to ensure interagency working at, private prisons operated by other providers or HMPPS operations.”

    Source location

    Response from G4S Care Justice Services (UK) Ltd
    Page 2 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Other interested persons addressed by the report are better placed to consider concerns 2, 3 and 4 and determine any response.

    Verbatim wording from the response

    “G4S has no power to take action regarding concerns 2, 3 and 4, and, therefore, is not in a position to assist HM Senior Coroner with regard to these concerns. Other interested persons to whom the Regulation 28 report has been addressed are better able to consider the concerns raised, take action and/or explain why no action is proposed.”

    Source location

    Response from G4S Care Justice Services (UK) Ltd
    Page 2 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    HMPPS is responsible for providing and operating resettlement services, which are delivered by HMPPS-commissioned external providers.

    Verbatim wording from the response

    “HMPPS has responsibility for provision and operation of resettlement services. Such resettlement services at HMP & YOI Parc are commissioned by HMPPS from external providers who are based within the prison to facilitate resettlement services for prisoners approaching release from custody. G4S is not party to the procurement or placement of resettlement services within HMP & YOI Parc or the direct delivery of these services. G4S’ focus is on ensuring alignment and integration with third party service providers to ensure effective interagency working.”

    Source location

    Response from G4S Care Justice Services (UK) Ltd
    Page 2 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Health Board lacks jurisdiction or power over the cross-agency actions required for release planning at sentence end.

    Verbatim wording from the response

    “There are no provisions available nor any cross agency guidance in place for when a high-risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community.”

    Source location

    Response from Swansea Bay University Health Board
    Page 7 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    HMPPS will address cross-agency guidance for releasing high-risk prisoners with mental health difficulties at sentence end.

    Verbatim wording from the response

    “This issue will be addressed by HMPPS, however we will ensure we provide support from a policing perspective to partners in relation to high-risk prisoners with mental health difficulties at their sentence end date. From a policing perspective, it is important to note that the IT systems now in place (as described in evidence during the inquest) have changed meaning that there are now better opportunities to identify someone if they have been assessed as being at an increased risk to themselves or others.”

    Source location

    Response from West Midlands Police
    Page 4 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Probation has no statutory authority to supervise prisoners released into the community at sentence expiry.

    Verbatim wording from the response

    “For a prisoner to still be detained in custody at the point of sentence expiry is usually as a result of them having been recalled to custody. This means they remain the responsibility of the Probation Community Offender Manager (COM) until the point of release at the sentence end date (SED). There is no statutory authority for Probation supervision of a prisoner released into the community at SED. The sharing of information prior to release into the community in an effective manner with relevant agencies is therefore of paramount importance. The Probation Service West Midlands has a practice document which sets out the expectations for Practitioners when cases are being released at SED. This document has been revised and reissued to all staff and embedded in development sessions delivered by the Regional Quality Team.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 19 March 2024

    Open published response
  2. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Daniel-John VARNDELL · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Daniel-John Varndell, who was considered at high risk of serious harm and had mental health and drug-use concerns, was released on licence to an approved premise in May 2020. After a licence condition concerning appointments with mental health practitioners was removed without discussion with MAPPA professionals or a mental health practitioner, he absconded following an altercation and was later the subject of an investigation into his death. The report raises concern that unilateral removal of licence conditions could contribute to a future death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure that licence conditions requiring attendance with a specific practitioner are suitable and operational before release

    Wider context from the report

    “The MAPPA meeting (consisting of over 20 professionals due to the complexity of the release planning) decided that various Conditions should apply to Daniel-John Varndell's Licence as he posed such a high risk to himself and others. One of these was: "Attend all appointments arranged for him with a psychiatrist/psychologist/medical practitioner and co-operate fully with any care or treatment they recommend" This was for use with a specific named practitioner, who must have agreed to treat him and he should have consented to this prior to the condition being added so unless something had been set up prior to release this condition may not have been suitable. The condition was unilaterally removed by a probation officer possibly because consent was not in place or for another reason. The point is there was no discussion with MAPPA professionals or any mental health practitioner prior to removal notwithstanding that the Chair of MAPPA indicated that the conditions were appropriate and necessary. Whilst this may not have affected the outcome in the present sad case such unilateral removal of a Licence Condition could result in a future death. ”

    Source location

    Daniel-John VARNDELL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Manchester South

    AI-generated summary

    Philip Vernon Owen · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Philip Vernon Owen was found dead in his flat on 30 October 2016 after being killed by a stab wound to the neck. The report describes failures in mental health risk assessment, discharge planning and communication after the perpetrator’s release from custody, and concerns about how risks associated with short custodial sentences were communicated to sentencing courts and managed by relevant services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure safe release from custody for high-risk offenders eligible for immediate release after very short custodial sentences

    Wider context from the report

    “The Inquest heard evidence from the Prison and Probation Service that, as was demonstrated in this case, there are significant challenges that are difficult to mitigate to ensure a safe release from custody where a very short custodial sentence is imposed which means an individual who is a high risk offender is eligible for immediate release. This is compounded where as in this case there is no significant licence period that the Probation Service can supervise; There was a lack of clarity as to how effectively these risks had been communicated to those involved in sentencing and what if any guidance existed support them in taking steps to minimise the risks to the public; It was unclear how much information was shared with the court regarding the level of risk by the Prosecution or the Probation Service and what expectations were or guidance to those assisting a sentencing court in the discharge of their duty. ”

    Source location

    Philip Vernon Owen · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of guidance for sentencing participants on minimising risks to the public

    Wider context from the report

    “The Inquest heard evidence from the Prison and Probation Service that, as was demonstrated in this case, there are significant challenges that are difficult to mitigate to ensure a safe release from custody where a very short custodial sentence is imposed which means an individual who is a high risk offender is eligible for immediate release. This is compounded where as in this case there is no significant licence period that the Probation Service can supervise; There was a lack of clarity as to how effectively these risks had been communicated to those involved in sentencing and what if any guidance existed support them in taking steps to minimise the risks to the public; It was unclear how much information was shared with the court regarding the level of risk by the Prosecution or the Probation Service and what expectations were or guidance to those assisting a sentencing court in the discharge of their duty. ”

    Source location

    Philip Vernon Owen · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  4. Lancashire and Blackburn with Darwen

    AI-generated summary

    Cherylee Yvette Shennan · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Cherylee Yvette Shennan, a 40-year-old woman, was murdered on 17 March 2014 by a former offender who had subjected her to domestic abuse, including serious violence. The report raised concerns about inadequate inter-agency communication and management of the perpetrator, including the absence of a mandatory process for sharing information when an offender with a known history of domestic abuse was managed at MAPPA Level 1.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of mandated joined-up inter-agency communication at offender release or when new personal relationships develop

    Wider context from the report

    “1) During the course of the inquest statistics regarding the nature of domestic abuse were repeatedly reviewed and accepted by senior member of both probation and police services. In particular domestic abuse features in about half of all cases managed by probation staff and that in the year to the end of 2018 of the 659 homicides 1 in 10 were committed by a partner. Evidence was heard of the MAPPA process, for the managing of risk of offenders to be released on licence, and for the interagency sharing of information regarding those offenders. During the course of the evidence it was made clear that the perpetrator in this instance was a very dangerous individual, who was described as controlling and manipulative, and who, it was accepted by the witnesses involved in his management, was likely to have controlled his meetings by his nature, and by partial disclosures of information. The underlying issue that arose from both the various reviews that took place after the death of Cherylee Shennan, and from the inquest was that there was no substantial interagency communication following the perpetrator's release on licence, which would, the jury found, have allowed the sharing of his licence conditions and action plans to be put in place by local police forces. The jury concluded that such a failing possibly contributed to the death on the 17th March 2014. At the inquest no evidence was heard regarding any changes to MAPPA or the guidance given. Whilst the evidence heard was that the MAPPA level allocated to an individual is fluid, and would be based upon their risks and presentation at that time, my concern centres on the issue that an offender who has served a significant sentence and accordingly has never been fully tested before release on licence, and who has a significant history of domestic abuse and violence, will still be released on MAPPA level 1. On the evidence that was heard there remains no mandated process for joined up inter-agency working or communication at the point of their release, or when they develop new personal relationships. ”

    Source location

    Cherylee Yvette Shennan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Refresh MASH staff messaging periodically on identifying life-licensed perpetrators as high risk and sharing referral information to prompt safeguarding action.

    Verbatim wording from the response

    “The Lancashire Constabulary are a key stakeholder in the MASH (Multi-Agency Sharing Hub), which has dedicated and co-located National Probation Service staff able to access national databases to ensure quality research can be conducted on criminal matters subject of safeguarding referrals – in particular those with previous convictions and actionable orders – such as licence conditions.”

    Source location

    2019-0244-Response-by-Lancashire-Constabulary_Redacted
    Page 2 · response
    Published 9 September 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Pan-Lancashire MARAC operating protocol already addresses urgent referrals and high-risk prioritisation for relevant offenders.

    Verbatim wording from the response

    “Specifically, with regards to perpetrators with homicide convictions and urgent MARAC referral, a Pan-Lancashire MARAC Operating Protocol Document was agreed in April 2016 which referenced specifically the procedure relating to Emergency MARAC, and reflects a response to the DHR in question.”

    Source location

    2019-0244-Response-by-Lancashire-Constabulary_Redacted
    Page 2 · response
    Published 9 September 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Responsibility for referring relevant life-licensed offenders to MARAC lies with the offender manager.

    Verbatim wording from the response

    “Specifically, with regards to perpetrators with homicide convictions and urgent MARAC referral, a Pan-Lancashire MARAC Operating Protocol Document was agreed in April 2016 which referenced specifically the procedure relating to Emergency MARAC, and reflects a response to the DHR in question.”

    Source location

    2019-0244-Response-by-Lancashire-Constabulary_Redacted
    Page 2 · response
    Published 9 September 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing MASH arrangements provide research, information sharing and referral of life-licensed perpetrators to relevant agencies, including Probation and Social Care.

    Verbatim wording from the response

    “The Lancashire Constabulary are a key stakeholder in the MASH (Multi-Agency Sharing Hub), which has dedicated and co-located National Probation Service staff able to access national databases to ensure quality research can be conducted on criminal matters subject of safeguarding referrals – in particular those with previous convictions and actionable orders – such as licence conditions.”

    Source location

    2019-0244-Response-by-Lancashire-Constabulary_Redacted
    Page 2 · response
    Published 9 September 2019

    Open published response
  5. Birmingham and Solihull

    AI-generated summary

    Jacqueline Oakes · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jacqueline Oakes was a vulnerable woman who suffered repeated assaults by a man she met in supported living accommodation. Her body was found in her flat on 14 January 2014, and the man was later convicted of her murder; the medical cause of death was multiple injuries. The principal concern was that no agencies were alerted when a high-risk offender was released after completing his sentence, limiting their ability to manage the risks he posed.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a mechanism to alert other agencies when high-risk offenders are released after completing their full sentence

    Wider context from the report

    “When an offender is released having completed their full sentence who is known to be a high risk to others there is no mechanism for any other agencies to be alerted to that person’s release. Had an alert been provided to other agencies that came into contact with Jacqueline and ████████ it would have meant they were better able to manage the risks he posed. Consideration should be given to whether such alerts can be provided. ”

    Source location

    Jacqueline Oakes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Write guidance on sentence termination activity, including expectations for sharing offender plans with other agencies under lawful information-sharing practice.

    Verbatim wording from the response

    “Guidance on activity that is required at termination of sentence is currently being written as part of the HMPPS transition to a new model for managing offenders in custody. This will set out a clear expectation that plans are shared with other agencies involved with the offender in line with lawful information sharing practice.”

    Source location

    2018-0419-Response-by-HM-Prison-and-Probation-Service
    Page 5 · response
    Published 16 October 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    After sentence termination, probation has no responsibility or powers to manage the offender.

    Verbatim wording from the response

    “Relevant agencies that have been, or will continue to be involved post sentence, should be informed about the final plan and also notified that Probation will no longer be responsible for managing the sentence of the court and do not have any further powers in relation to the offender. If there are concerns in relation to a known child (or children) probation providers have a duty to report these concerns to the Local Authority, following local referral procedures.”

    Source location

    2018-0419-Response-by-HM-Prison-and-Probation-Service
    Page 4 · response
    Published 16 October 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Where no organisation remains in contact with an offender, information cannot be passed on at sentence termination.

    Verbatim wording from the response

    “Where an offender is not in contact with any other organisations at the end of sentence, it is clearly not possible to pass information on at that point the offender will no longer be subject to monitoring or supervision by the NPS. However, Probation will contribute to any ongoing MAPPA management under Category 3, Multi Agency Risk Assessment Conferences for high risk victims of domestic abuse and can provide relevant and proportionate information to supplement that provided by the police on offenders they have previously managed.”

    Source location

    2018-0419-Response-by-HM-Prison-and-Probation-Service
    Page 4 · response
    Published 16 October 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Police decide whether to disclose pertinent risk information to relevant agencies in other situations.

    Verbatim wording from the response

    “In all other situations, the Police already have access to the information regarding the offending history, the sentence and licence and are able to consider disclosure of any pertinent risk information to any relevant agencies where they consider it appropriate to do so. This information will be supplemented by the additional information stored on VISOR.”

    Source location

    2018-0419-Response-by-HM-Prison-and-Probation-Service
    Page 5 · response
    Published 16 October 2018

    Open published response
  6. Liverpool and the Wirral

    AI-generated summary

    John Clarke Jaundoo · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    John Clarke Jaundoo, aged 24, was found with multiple stab wounds under Garston Bridge in the early hours of 15 April 2010 and died later in hospital. Three men who lived in the same supported living accommodation were subsequently convicted of his murder, and the inquest concluded that he died as a result of unlawful killing. The inquiry identified concerns about the referral and accommodation of high-risk offenders, failures to provide accurate and up-to-date information and review risk assessments, and missed oversight opportunities by Liverpool City Council.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to refer or admit high risk offenders only to accommodation capable of appropriately managing their risks

    Wider context from the report

    “In respect of the then Probation Trust (1) Offender 2 should have been recalled to prison and not referred to or accepted into supported living accommodation, it was wholly unsuitable for him and in particular when his behaviour was deteriorating to such an extent in the Approved Premises that his bed was withdrawn. (2) Offender 3 a high risk offender should never have been referred to or admitted to supported living accommodation (upon his release from prison), the only suitable accommodation where the risks that he posed could be appropriately managed being Approved Premises. (3) Timely, accurate and up to date information was not provided in respect of offenders 2 & 3 and; (4) The risk assessment which should have been a dynamic process was not reviewed/revised in particular as it should have been in respect of offender 2 when his behaviour started to deteriorate so substantially and which also included alcohol consumption a known precursor to his offending. In respect of Liverpool City Council (Adult Social Services) (1) Missed a number of significant opportunities to properly exercise their influence and oversight function of both the then supported living accommodation provider and the Probation Trust, they also missed opportunities to perform regular, timely validation visits and to satisfy themselves of the procedures that were in place to ensure the aims of the service were being effectively delivered and that public protection (including of staff and other service users) was the overriding priority. ”

    Source location

    John Clarke Jaundoo · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report
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Data last updated 7 September 2026