Recurring concern

Failure to maintain and share security and offender risk intelligence

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First reported 29 May 2014•Latest report 22 Jan 2025

Definition

What this concern includes

Includes failures to record, maintain, access or share security and offender-risk intelligence across responsible criminal-justice or security functions.

Not included

Excludes generic communication, documentation or staffing deficiencies that are not explicitly tied to an operational intelligence picture or risk-management process.
Excludes failures concerning unrelated factual databases or intelligence systems where no shared operational risk-management concern is supported.
Excludes the specific consequential risks, harms or clinical-care deficiencies resulting from incomplete intelligence; those are outcomes or separate concerns rather than the intelligence-system failure itself.

Reports: 13
Individual concerns: 17
Date range: 2014–2025
Stated actions: 75

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Ministry of Justice7

Home Office5

HM Prison and Probation Service4

Probation Service3

Greater Manchester Police2

Lancashire Constabulary2

Metropolitan Police Service2

National Police Chiefs’ Council2

West Midlands Police2

Berkshire Healthcare NHS Foundation Trust1

Birmingham and Solihull Mental Health NHS Foundation Trust1

College of Policing1

Department for Education1

G4S1

Independent Office for Police Conduct1

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.

22 Jan2025
Manchester South
Concerns raised1
1. Failure of the prison-to-probation process to share and locate key risk information
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Use the new digital referral process to combine prison and probation information, including custodial behaviour and suicide and self-harm risk, for Approved Premises assessments.
  Stated by Ministry of JusticeStated completed
AI-generated summary

Nathan Harry SHEPHERD · 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

Nathan Harry Shepherd died in hospital on 16 January 2024 after being found suspended from a ligature in his room at approved premises, following an unsuccessful attempt to gain immediate entry because the room had been barricaded. The inquest concluded that the death was suicide, with medical cause of death recorded as hypoxic brain injury and hanging. Concerns included the lack of policies and training for barricaded-room incidents, movable furniture that enabled barricading, ligature points, inadequate assurance of agency staff first-aid and CPR capability, and ineffective sharing of risk information.

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 of the prison-to-probation process to share and locate key risk information
Wider context from the report
“6. Evidence from Probation and Prison staff showed a lack of understanding of how the prison system could update the probation system and where that information could be found. This meant that key information was not shared effectively creating a risk that probation staff in the community would not have a full picture of risk. ”
Source location
Nathan Harry SHEPHERD · 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
Use the new digital referral process to combine prison and probation information, including custodial behaviour and suicide and self-harm risk, for Approved Premises assessments.

Verbatim wording from the response
“There is now a new digital referral process in place that pulls information from both prison and probation systems as part of the referral process, allowing for much more accurate and timely sharing of information. The information is pulled directly from CNOMIS into a live referral document and this is reviewed by the practitioner and also the AP Manager who assesses the referral. The information includes custodial behaviour and issues around suicide and self harm risk.”

Source location
Response from HMPPS
Page 2 · response
Published 22 January 2025
Open published response
26 Jul2024
East London
Concerns raised2
1. Failure to provide prison risk intelligence to Integrated Offender Management meetings
2. Failure of prison offender managers to gather and share evidence relevant to risk formulation
This report raised 23 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Use CONNECT and Proactive Management Plans as the primary searchable police record for integrated offender management.
  Stated by Metropolitan Police ServiceStated completed
2. Action
  Develop and use a process map guiding Police Offender Managers and supervisors to obtain, record and manage risk information before and after prison releases.
  Stated by Metropolitan Police ServiceStated completed
3. Action
  Require Prison Offender Managers to be invited to all Integrated Offender Management pre-release case conferences or provide written updates when absent.
  Stated by HM Prison and Probation ServiceStated completed
1. Action
  Use the mandated Information Sharing Form to standardise information sharing between prisons and community colleagues for short-term prisoners.
  Stated by HM Prison and Probation ServiceStated completed
AI-generated summary

Zara Natasha Aleena · 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

Zara Natasha Aleena died at the Royal London Hospital on 26 June 2022 after sustaining a severe traumatic brain injury during an unprovoked attack while walking home in Ilford. The report identifies concerns about understaffing, risk assessment, information sharing, supervision, recall procedures and coordination across the Probation Service, police and other agencies, as well as concerns about training and reporting of predatory behaviour.

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 provide prison risk intelligence to Integrated Offender Management meetings
Wider context from the report
“(15)The Integrated Offender Management meetings did not receive the necessary intelligence from the prison setting. There was no system in place to ensure that either the prison offender manager was invited to attend, or that the prison offender manager was asked to provide written information around risk incidents. ”
Source location
Zara Natasha Aleena · Prevention of Future Deaths report
Page 4 · 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
Failure of prison offender managers to gather and share evidence relevant to risk formulation
Wider context from the report
“(11) The role of the prison offender manager is to gather evidence to assist with the formulation of risk. Prison offender managers do not however receive focussed risk assessment training. Neither of the prison offender managers in this case gathered evidence to assist with the formulation of risk. There were multiple intelligence logs and records that should have been obtained by them. The logs included findings of possession of weapons, drug taking, threats to harm others and a sustained assault on a servery worker using an improvised weapon. This information was not gathered and shared appropriately. ”
Source location
Zara Natasha Aleena · Prevention of Future Deaths report
Page 4 · 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
Use CONNECT and Proactive Management Plans as the primary searchable police record for integrated offender management.

Verbatim wording from the response
“Since 2022, the MPS has introduced CONNECT, a large-scale technology system for crime and intelligence reporting and record keeping. This has provided police offender managers with access to a feature called Proactive Management Plans (“PMP”). PMPs are now the primary police record for IOM offender management. PMPs allow IOM records to be searchable, linked with other police records and readily available to all MPS staff. HM Prison & Probation Service do not have direct access to these records, but PMPs create a permanent record of what has been shared between the MPS and its partners.”

Source location
Response from Metropolitan Police
Page 5 · response
Published 2 August 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
Develop and use a process map guiding Police Offender Managers and supervisors to obtain, record and manage risk information before and after prison releases.

Verbatim wording from the response
“Following inquest, the MPS has reflected on the sufficiency of information sharing from the HM Prison & Probation Service and the need for clarity around recalls to prison. The MPS has developed a new process map, which provides clarity and guidance for Police Offender Managers to ask HM Prison & Probation Service a broad range of questions, with the intention to increase the likelihood of all relevant information being shared with IOM partners. The new process highlights and clarifies the actions to be undertaken by Police Offender Managers and their supervisors, both before and after prison releases, including the recording of informed risk management decisions.”

Source location
Response from Metropolitan Police
Page 5 · response
Published 2 August 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 Prison Offender Managers to be invited to all Integrated Offender Management pre-release case conferences or provide written updates when absent.

Verbatim wording from the response
“15.2. To ensure that all appropriate agencies involved in an Integrated Offender Management (IOM) case are included in any pre-release work, the National IOM”

Source location
Response from HMPPS and MoJ
Page 11 · response
Published 2 August 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
Use the mandated Information Sharing Form to standardise information sharing between prisons and community colleagues for short-term prisoners.

Verbatim wording from the response
“15.1. We acknowledge that prison staff did not share intelligence about ████████ ████████ with their colleagues in the Probation Service. We have agreed processes in place to ensure that prisons communicate information to the COM for sentenced prisoners, but these processes did not function properly in this case, as explained in the SFO review. For long-term prisoners, information sharing from the POM to the COM occurs at point of handover. In November 2023, we standardised expectations for those prisoners serving a short-term custodial sentence.”

Source location
Response from HMPPS and MoJ
Page 11 · response
Published 2 August 2024
Open published response
20 May2024
Central Criminal Court
Concerns raised1
1. Failure to maintain and disseminate an adequate intelligence picture
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 18
1. Action
  Continue implementing the One Team model, including One Assessment and place-based multidisciplinary post-assessment meetings.
  Stated by Berkshire Healthcare NHS Foundation TrustStated in progress
2. Action
  Strengthen community-custody transitions through proactive Prison and Probation engagement, named-worker handovers and explicit responsibility arrangements.
  Stated by Berkshire Healthcare NHS Foundation TrustStated planned
3. Action
  Maintain named CMHT representatives’ participation in MAPPA discussions and liaison for inpatient and crisis teams.
  Stated by Berkshire Healthcare NHS Foundation TrustStated in progress
1. Action
  Replace Mercury with the Intelligence Management Service and roll out probation access to prison intelligence.
  Stated by Ministry of JusticeStated in progress
2. Action
  Publish guidance requiring prison staff to link Mercury intelligence records to nominal records, including after release.
  Stated by Ministry of JusticeStated planned
3. Action
  Issue prison intelligence-assessment guidance and a template for comprehensive MAPPA Level 2/3 information-sharing reports.
  Stated by Ministry of JusticeStated completed
4. Action
  Create MAPPA Category 4 and amend information-sharing powers to cover terrorism-risk offenders and relevant agencies.
  Stated by Ministry of JusticeStated completed
5. Action
  Use the joint Prevent case management system to flag previous referrals and expose data trends for risk-assessment oversight.
  Stated by Home OfficeStated completed
6. Action
  Roll out the independently endorsed Prevent assessment framework nationally to improve referral triage and cumulative-risk assessment.
  Stated by Home OfficeStated in progress
7. Action
  Complete the CTPSE Fixed Intelligence Management Unit review and identify necessary changes to resourcing, training, assessment, dissemination, supervision and monitoring.
  Stated by Counter Terrorism Policing South-East and Thames Valley PoliceStated in progress
8. Action
  Develop new training for local-force call handlers and FIMU staff on CTPSE capabilities, limitations and effective information-sharing questions.
  Stated by Counter Terrorism Policing South-East and Thames Valley PoliceStated planned
9. Action
  Open discussions with CTPHQ about providing a dedicated database for rapid access to information on proscribed organisations.
  Stated by Counter Terrorism Policing South-East and Thames Valley PoliceStated planned
10. Action
  Use Management Logs, searchable open actions and weekly supervisory checks to track, reallocate and evidence FIMU intelligence actions.
  Stated by Counter Terrorism Policing South-East and Thames Valley PoliceStated completed
11. Action
  Strengthen CTPSE FIMU supervisory checking by adding qualitative assessment of intelligence completeness and decision quality, with learning fed back to staff and the national capability board.
  Stated by Counter Terrorism Policing South-East and Thames Valley PoliceStated in progress
12. Action
  Incorporate supervisory learning into quarterly reporting and disseminate applicable lessons through the Counter Terrorism Policing Intelligence Capability Board.
  Stated by Counter Terrorism Policing South-East and Thames Valley PoliceStated completed
13. Action
  Maintain the process linking FIMU intelligence with CT Nominal Management, including immediate alerts, coordinated decision-making and appropriate case-management flags.
  Stated by Counter Terrorism Policing South-East and Thames Valley PoliceStated completed
14. Action
  Request a CTPHQ peer review of CTPSE FIMU after the current review concludes.
  Stated by Counter Terrorism Policing South-East and Thames Valley PoliceStated planned
15. Action
  Implement NCIA access and associated Developed Vetting for relevant CTPSE Prevent staff.
  Stated by Counter Terrorism Policing South-East and Thames Valley PoliceStated in progress
Respondent positions 3
1. Position
  The organisation is not responsible for organising MAPPA meetings, but will support the process and ensure appropriate attendance and advice.
  Stated by Berkshire Healthcare NHS Foundation TrustOutside remit
1. Position
  CTPHQ is responsible for operational Prevent risk management and monitoring, including the operational issues identified in the Report.
  Stated by Home OfficeRedirects responsibility
2. Position
  All FIMU assessments cannot be reviewed because of assessment volumes, so a percentage-based dip-checking regime is used.
  Stated by Counter Terrorism Policing South-East and Thames Valley PoliceUnable to act
AI-generated summary

James Furlong and 2 others · 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

James Furlong, Joseph Ritchie-Bennett and David Wails were murdered by Khairi Saadallah in a premeditated attack in Forbury Gardens, Reading, on 20 June 2020. The principal concerns were failures by multiple bodies to assess and share intelligence about Saadallah’s risks, provide an adequate integrated response, and provide adequate mental healthcare in the community and prison; the report states these failures probably or possibly contributed to the three deaths.

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 maintain and disseminate an adequate intelligence picture
Wider context from the report
“The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to: a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading; b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder); c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison. The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD. The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police) The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust) ”
Source location
James Furlong and 2 others · Prevention of Future Deaths report
Page 4 · 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
Continue implementing the One Team model, including One Assessment and place-based multidisciplinary post-assessment meetings.

Verbatim wording from the response
“BHFT have continued the development of the One Team model as described in February and helpfully summarised in the Regulation 28 report. This is an ongoing and gradual roll out of associated changes to service delivery. There are monthly team updates and a number of engagement events that have taken place with BHFT staff, external stakeholders (such as local authorities in Berkshire, Primary Care Networks,”

Source location
Response from Berkshire Healthcare
Page 1 · response
Published 23 May 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
Strengthen community-custody transitions through proactive Prison and Probation engagement, named-worker handovers and explicit responsibility arrangements.

Verbatim wording from the response
“Where individuals move between the community and custody, there will be greater proactive engagement with Prison and Probation colleagues both principally and on a case-by-case basis. Where someone receives a short sentence, it would be important to maintain CMHT input and involvement in planning for post release. For more lengthy sentences requiring ongoing mental health input in custody, they will transition from community (e.g. CMHT) to Prison Mental Health Services. In such situations, the named worker in the community will ensure that a handover takes place with prison colleagues. The Reconnect roles, as described above, will allow for easier transition back into CMHT's on release if required.”

Source location
Response from Berkshire Healthcare
Page 7 · response
Published 23 May 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
Maintain named CMHT representatives’ participation in MAPPA discussions and liaison for inpatient and crisis teams.

Verbatim wording from the response
“BHFT recognises that we play a key role in sharing communications particularly around risk. While we are not responsible for the organisation of MAPPA meetings, we are committed to supporting these processes, ensuring that the right people attend the meetings and that we continue to have named representatives from each CMHT within BHFT. This attendance includes contributing to discussions/providing advice to MAPPA case discussions for those that may not be under CMHT. In addition, those named workers will act in a liaison role for inpatients and CRHTT. CRHTT and inpatient teams are less likely to be in a position to attend MAPPA, particularly at short notice, and CMHT representatives are best placed to communicate into and out of MAPPA where inpatient or CRHTT may have been involved in a case.”

Source location
Response from Berkshire Healthcare
Page 7 · response
Published 23 May 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
Replace Mercury with the Intelligence Management Service and roll out probation access to prison intelligence.

Verbatim wording from the response
“15. Other new services are being developed to share information across systems to make sure that HMPPS staff have the information that they need. Whilst some of these services are still in development, several have been launched since 2020, including in particular the Pathfinder IT service which supports the management of terrorism-related nominals across the prison and probation services. Pathfinder IT is addressed in more detail at paragraphs 30 to 32 below.”

Source location
Response from Ministry of Justice
Page 6 · response
Published 23 May 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
Publish guidance requiring prison staff to link Mercury intelligence records to nominal records, including after release.

Verbatim wording from the response
“19. Whilst the Mercury system is still operational, there is also a plan to publish specific guidance to ensure that all prison staff are aware that Mercury Intelligence Records need to be linked to a nominal’s record, even if the subject is no longer in custody. This will be published by Autumn 2024. The working assumption is that intelligence on former prisoners is linked to their records, and it is the case that the vast majority of information is correctly linked. However, this requirement is not formally stated anywhere within HMPPS training or processes. This new guidance will address this lacuna.”

Source location
Response from Ministry of Justice
Page 7 · response
Published 23 May 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
Issue prison intelligence-assessment guidance and a template for comprehensive MAPPA Level 2/3 information-sharing reports.

Verbatim wording from the response
“50. In your factual findings you identified that there was an incomplete intelligence picture for KS. This included prison intelligence which did not reach KS’s COM. The National Intelligence Unit (NIU) within HMPPS has reviewed the way prisons share security information and intelligence within MAPPA, specifically when contributing to MAPPA level 2 and 3 meetings.”

Source location
Response from Ministry of Justice
Page 13 · response
Published 23 May 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
Create MAPPA Category 4 and amend information-sharing powers to cover terrorism-risk offenders and relevant agencies.

Verbatim wording from the response
“55. There has also been an independent review of MAPPA by Jonathan Hall,⁹ as a result of which a discrete new MAPPA category, Category 4 was created. This was to ensure that all offenders convicted of terrorism offences are automatically referred to and managed under MAPPA and to enable offenders who are assessed as presenting a terrorism risk to be managed under MAPPA, even where they have not been convicted of terrorism offences. We also introduced amendments to part 13 of the Criminal and Justice Act 2003¹⁰ to put beyond doubt Duty to Co-operate (DTC) agencies’ powers to share information under MAPPA and extended these powers to cover any agency the Responsible Authority considers may contribute to the assessment and management of the risks presented by MAPPA offenders, for example GPs.”

Source location
Response from Ministry of Justice
Page 14 · response
Published 23 May 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
Use the joint Prevent case management system to flag previous referrals and expose data trends for risk-assessment oversight.

Verbatim wording from the response
“I understand that the Home Office and CTPHQ launched a new joint Prevent case management system in May 2024. In developing this system, I am told we have ensured that when a new Prevent referral is registered, any previous referrals are automatically flagged to ensure this information is fully considered during the initial assessment stage and throughout the individual’s Prevent pathway. I am concerned about the specific issue of repeat Prevent referrals falling below the threshold and am committed to look closely at this. This new case management system also provides CTPHQ and the Home Office access to data trends, which allows for consideration of any outliers in decision making. These outliers can be flagged for potential further action.”

Source location
Response from the Home Office
Page 2 · response
Published 23 May 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 the independently endorsed Prevent assessment framework nationally to improve referral triage and cumulative-risk assessment.

Verbatim wording from the response
“As I understand Chief Constable ████████ will also be addressing in Thames Valley Police’s response to you from the operational perspective, the Home Office and CTPHQ have also worked with the national CT Assessment and Rehabilitation Centre (CT-ARC)⁴ to develop a new Prevent assessment framework (PAF). I understand that this replaces the Vulnerability assessment framework and is designed to ensure that the triaging of referrals into Prevent is consistent, rigorous, and proportionate. I am told the PAF, which has been independently endorsed, will ensure that thresholds and decision-making are implemented consistently across all ideological threats by creating a framework that is easily understood, easily completed, and supports CTCOs in their decision making.”

Source location
Response from the Home Office
Page 3 · response
Published 23 May 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
Complete the CTPSE Fixed Intelligence Management Unit review and identify necessary changes to resourcing, training, assessment, dissemination, supervision and monitoring.

Verbatim wording from the response
“The headline point as regards CTPSE’s management of intelligence is that a comprehensive review of CTPSE’s Fixed Intelligence Management Unit (FIMU) began in March 2024, and will be completed by the end of the year. CTPSE initiated this review (the CTPSE FIMU review) in response to the issues canvassed in these Inquests. It is being carried out by CTPSE’s Head of Intelligence, an officer of Detective Superintendent rank.”

Source location
Response from Thames Valley Police
Page 2 · response
Published 23 May 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
Develop new training for local-force call handlers and FIMU staff on CTPSE capabilities, limitations and effective information-sharing questions.

Verbatim wording from the response
“Second, your findings highlighted the importance of clear and timely communications between local police forces and CTPSE. I acknowledge that, as far as possible, information sharing needs to be based more consistently on an approach of ‘dare to share’, rather than ‘need to know’. This can be challenging, particularly where intelligence is sensitive, requiring ‘action on’ permissions or agreed forms of words. Nevertheless, the culture must be one that pushes the boundaries where necessary to facilitate the management of risk. CTPSE and the joint Contact Management Department of TVP and Hampshire & Isle of Wight Constabulary have met to discuss how the passage of information between CTPSE and local forces can be enhanced.”

Source location
Response from Thames Valley Police
Page 3 · response
Published 23 May 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
Open discussions with CTPHQ about providing a dedicated database for rapid access to information on proscribed organisations.

Verbatim wording from the response
“The CTPSE FIMU review will also consider the level of knowledge of staff in relation to proscribed groups, and how this can be enhanced. Currently, when a group is proscribed, communications are issued centrally from CTPHQ. Those staff in post at that time therefore receive an update, but this does not help individuals who join after the point of proscription. Present thinking is that having more concise guides available could help understanding in this”

Source location
Response from Thames Valley Police
Page 4 · response
Published 23 May 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
Use Management Logs, searchable open actions and weekly supervisory checks to track, reallocate and evidence FIMU intelligence actions.

Verbatim wording from the response
“The CTPSE FIMU review will also examine how actions are monitored and tracked within the FIMU, and how supervisory reviews take place. I am aware that the evidence heard at the Inquests indicated that actions set by or for the CTPSE FIMU were not consistently tracked or followed through. At the end of 2021, ‘Management Logs’ (MLs) were introduced to CTP FIMUs nationally to provide an easier way for FIMU assessors and supervisors to manage the intelligence development space. ‘Open actions’ on NCIA can now easily be searched for and managed accordingly. Supervisors carry out weekly checks to review and, if necessary, reallocate actions. FIMU assessors can add auditable entries to the MLs to demonstrate efforts made to complete enquiries.”

Source location
Response from Thames Valley Police
Page 5 · response
Published 23 May 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
Strengthen CTPSE FIMU supervisory checking by adding qualitative assessment of intelligence completeness and decision quality, with learning fed back to staff and the national capability board.

Verbatim wording from the response
“Across CTP, supervisory reviews are now carried out on a set percentage of FIMU assessments. It is not possible to review all assessments due to the volume, so a ‘dip checking’”

Source location
Response from Thames Valley Police
Page 5 · response
Published 23 May 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
Incorporate supervisory learning into quarterly reporting and disseminate applicable lessons through the Counter Terrorism Policing Intelligence Capability Board.

Verbatim wording from the response
“The key points learnt from the supervisory framework will be incorporated into regular quarterly reporting cycles. This will complement the current CTP Intelligence Capability Assurance Report reporting process that looks at metrics measurable from the NCIA database and is examined at the ICB. The local review process will add qualitative learning that helps to improve decision making as well as ensuring that supervisors are compliant. This qualitative learning will then be disseminated to the ICB to ensure that any applicable lessons are learnt across the whole CTP network.”

Source location
Response from Thames Valley Police
Page 6 · response
Published 23 May 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
Maintain the process linking FIMU intelligence with CT Nominal Management, including immediate alerts, coordinated decision-making and appropriate case-management flags.

Verbatim wording from the response
“I would also like to draw to your attention the increased sharing of information between CTPSE’s Intelligence function and its Nominal Management Team (NMT), which forms part of its Interventions function. Both the CT Nominal Management (CTNM) Manual of Guidance and the national Prevent process require compliance with the National Standards of Intelligence Management (NSIM) which requires submission of intelligence back into FIMUs as part of the intelligence cycle. This ensures visibility of individuals subject to Prevent or CTNM within the intelligence space.”

Source location
Response from Thames Valley Police
Page 6 · response
Published 23 May 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
Request a CTPHQ peer review of CTPSE FIMU after the current review concludes.

Verbatim wording from the response
“After the CTPSE FIMU review has concluded, CTPSE will ask CTPHQ for a peer review of CTPSE FIMU to provide external scrutiny and reassurance of effective working. As I hope is clear from the above, this CTPSE FIMU review is intended to be a wide-ranging and thorough review that covers not only the matters you have raised in the PFD report, but also builds on previous and ongoing work within both CTPSE and nationally. I can assure you that the entire chain of command within CTPSE, from myself down, is committed to implementing any necessary or desirable changes that the CTPSE FIMU review identifies.”

Source location
Response from Thames Valley Police
Page 7 · response
Published 23 May 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 NCIA access and associated Developed Vetting for relevant CTPSE Prevent staff.

Verbatim wording from the response
“I acknowledge the concerns you set out regarding Prevent at §§19-21 of your regulation 28 report. The changes made or planned to the FIMU described above clearly interlock with these concerns: for example, ensuring that there is an assessment of the totality of the available evidence of sufficient quality, made available by the FIMU to Prevent staff to ensure that they can make a properly considered assessment of risk. This should ensure that Prevent staff, in future, would be aware of an individual’s links to proscribed organisations or other terrorist offenders, where this information is known by CTPSE. To support this, CTPSE has begun to implement access to NCIA (and the associated requirement for Developed Vetting) for some Prevent staff. The Prevent Gateway Team within CTPSE has also, since 2019, been co-located with the FIMU.”

Source location
Response from Thames Valley Police
Page 7 · response
Published 23 May 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 organisation is not responsible for organising MAPPA meetings, but will support the process and ensure appropriate attendance and advice.

Verbatim wording from the response
“BHFT recognises that we play a key role in sharing communications particularly around risk. While we are not responsible for the organisation of MAPPA meetings, we are committed to supporting these processes, ensuring that the right people attend the meetings and that we continue to have named representatives from each CMHT within BHFT. This attendance includes contributing to discussions/providing advice to MAPPA case discussions for those that may not be under CMHT. In addition, those named workers will act in a liaison role for inpatients and CRHTT. CRHTT and inpatient teams are less likely to be in a position to attend MAPPA, particularly at short notice, and CMHT representatives are best placed to communicate into and out of MAPPA where inpatient or CRHTT may have been involved in a case.”

Source location
Response from Berkshire Healthcare
Page 7 · response
Published 23 May 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
CTPHQ is responsible for operational Prevent risk management and monitoring, including the operational issues identified in the Report.

Verbatim wording from the response
“The Home Office's Prevent directorate provides the strategic direction for Prevent, including Prevent relevant training to non-police Prevent statutory partners within local authorities. The police are responsible for managing the terrorism risk of individuals throughout all stages of the Prevent pathway, as well as the policy, assessment tools, and training of police officers and staff conducting these assessments. As all of KS’s referrals were closed at the initial assessment stage by Counter Terrorism Policing Prevent officers, the Home Office Channel programme did not manage the case. Therefore, effective monitoring of the operational Prevent issues raised in the Report is best addressed by CTPHQ.”

Source location
Response from the Home Office
Page 2 · response
Published 23 May 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
All FIMU assessments cannot be reviewed because of assessment volumes, so a percentage-based dip-checking regime is used.

Verbatim wording from the response
“Across CTP, supervisory reviews are now carried out on a set percentage of FIMU assessments. It is not possible to review all assessments due to the volume, so a ‘dip checking’”

Source location
Response from Thames Valley Police
Page 5 · response
Published 23 May 2024
Open published response
13 Mar2024
Birmingham and Solihull
Concerns raised1
1. Failure to coordinate interagency release management and share critical information
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 20
1. Action
  Hold monthly strategy meetings monitoring first-night accommodation and whether released prisoners’ whereabouts are known to community services.
  Stated by G4SStated completed
2. Action
  Record travel-warrant destinations and email them to the OMU group for communication to relevant offender managers and agencies.
  Stated by G4SStated completed
3. Action
  Require offender managers to notify Community Offender Managers about sentence-end releases involving no fixed abode and provide release-destination information.
  Stated by G4SStated completed
1. Action
  Continue streamlining internal data recording so information is shared through the national prisons IT system, DPS.
  Stated by G4SStated in progress
2. Action
  Include the BSMHFT MAPPA Clinical Lead in developing a sustainable MAPPA engagement strategy and identifying alternative arrangements for gaps.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated planned
3. Action
  Review the Prison In-reach and CMHT interaction process, complete a gap analysis and develop a plan to strengthen continuity of care.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated planned
4. Action
  Implement an improved referral and discharge procedure through the updated standard operating protocol.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completed
5. Action
  Approach SystemOne to discuss the feasibility of adding a local field for community mental health team information.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completed
6. Action
  Hold formal admission handovers and pre-release meetings with transferring mental-health teams or prisons and relevant agencies.
  Stated by Swansea Bay University Local Health BoardStated completed
7. Action
  Conduct multidisciplinary pre-discharge reviews and formal pre-release planning meetings four to six weeks before known release dates.
  Stated by Swansea Bay University Local Health BoardStated completed
8. Action
  Provide documented discharge summaries and comprehensive handovers to primary care, general practitioners, patients and, with consent, probation officers.
  Stated by Swansea Bay University Local Health BoardStated completed
9. Action
  Use weekly discharge information, prison NOMIS access and a Governor Grade officer at Single Point of Access meetings to verify release dates.
  Stated by Swansea Bay University Local Health BoardStated in progress
10. Action
  Continue updating ViSOR records for each individual so information can be shared across agencies.
  Stated by West Midlands PoliceStated completed
11. Action
  Work with agencies to clarify key roles and systems, improve information sharing and management, and protect the public.
  Stated by West Midlands PoliceStated planned
12. Action
  Visit managed offenders after prison release regardless of their MAPPA process status.
  Stated by West Midlands PoliceStated completed
13. Action
  Provide policing support to partners concerning high-risk prisoners with mental health difficulties released at sentence end.
  Stated by West Midlands PoliceStated planned
14. Action
  Revise and reissue the sentence-end-date release practice document, and embed its expectations in staff development sessions.
  Stated by HM Prison and Probation ServiceStated completed
15. Action
  Continue reviewing and refining MAPPA practices to improve interagency working and risk-information sharing.
  Stated by HM Prison and Probation ServiceStated in progress
16. Action
  Reinforce the statutory information-sharing requirement for MAPPA duty-to-cooperate agencies.
  Stated by HM Prison and Probation ServiceStated completed
17. Action
  Promote the NHS Reconnect Service to probation practitioners to support referrals for through-the-gate transition support.
  Stated by HM Prison and Probation ServiceStated completed
Respondent positions 7
1. Position
  G4S cannot influence release management or interagency working at private prisons operated by other providers or HMPPS.
  Stated by G4SOutside remit
1. Position
  HMPPS is responsible for providing and operating resettlement services, which are delivered by HMPPS-commissioned external providers.
  Stated by G4SRedirects responsibility
2. Position
  G4S cannot implement changes to streamline IT systems used by HMPPS, the NHS and third-party providers.
  Stated by G4SUnable to act
3. Position
  Issues concerning information sharing on NDelius should be addressed to HMPPS.
  Stated by G4SRedirects responsibility
4. Position
  National Systemone interface issues must be addressed by other Interested Parties, although the Trust is exploring a local amendment.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustRedirects responsibility
5. Position
  A unified prison interagency IT system cannot be implemented because the Health Board lacks the necessary power.
  Stated by Swansea Bay University Local Health BoardUnable to act
6. Position
  Liaison with MAPPA is the Offender Management Unit’s responsibility, while the Responsible Authority must notify Health and arrange relevant meetings.
  Stated by Swansea Bay University Local Health BoardRedirects responsibility
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
Failure to coordinate interagency release management and share critical information
Wider context from the report
“1. Management of release and lack of interagency working. The management of the perpetrators release was not coordinated and there was inadequate communication between relevant agencies. In effect agencies worked in silos. Critical information is not being shared and agencies work in different IT systems meaning there is no one place where information is collated and hence a comprehensive account of matters known to each agency is not easily available to those professionals who may need to know a high risk prisoner’s whereabouts on release. This concern was reinforced by evidence heard during the inquest that changes made since Jacob's death did not include the resettlement information being given to Mental Health In reach teams in the prison. The failure to share information leads to a concern of future deaths as high risk seriously unwell prisoners may be released without key agencies knowing where they are meaning any are not traced and treated assertively in the community. ”
Source location
Jacob Michael Nicholas BILLINGTON · 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
Hold monthly strategy meetings monitoring first-night accommodation and whether released prisoners’ whereabouts are known to community services.

Verbatim wording from the response
“• Monthly strategy meetings at the prison show consistently high (c 90%) levels of prisoners released from custody are housed on the first night of their release, so that their whereabouts immediately post release is known to relevant community services.”

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
Record travel-warrant destinations and email them to the OMU group for communication to relevant offender managers and agencies.

Verbatim wording from the response
“• At HMP & YOI Parc, a member of the cashiers team issues a travel warrant for each prisoner shortly before they are released from custody. The cashier previously recorded on CMS, the prison’s central electronic messaging system, the fact that a travel warrant had been issued. The cashier now records where the travel warrant has been issued to, and, in addition, sends an email to a new OMU email group, which includes healthcare admin and the Heads of Offender Management, to indicate that a travel warrant has been issued with details of where the travel warrant has been issued to. This email is automatically received by all offender managers within OMU. This information is then communicated to the Community Offender Manager and any other individuals/agencies involved with the prisoner.”

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
Continue streamlining internal data recording so information is shared through the national prisons IT system, DPS.

Verbatim wording from the response
“The HMPPS primary national electronic records system used in all prisons in England and Wales is DPS (formerly PNOMIS). Other agencies involved in OMU and resettlement utilise other records systems, including NDel ius (the Probation Service), SystmOne/other electronic clinical records systems, and other records systems used by third party providers. G4S has no power to implement changes to streamline IT systems used by HMPPS, the NHS and/or other third party providers. Other interested persons may be better able to assist HM Senior Coroner in relation to this issue. G4S will, however, continue to streamline its own data recording, to ensure as much information as possible is shared through the primary national prisons IT system, DPS. G4S has very limited access to NDel ius, but information on this system is regularly accessible to Probation Service”

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 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
Approach SystemOne to discuss the feasibility of adding a local field for community mental health team information.

Verbatim wording from the response
“Systemone Whilst this point is an issue which will need to be addressed at a more national level by other Interested Parties, the Trust has also looked at its own Systemone interface in HMP Birmingham to see if this can be amended locally.”

Source location
Response from BSMHFT
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
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 documented discharge summaries and comprehensive handovers to primary care, general practitioners, patients and, with consent, probation officers.

Verbatim wording from the response
“A Formal discharge meeting is also held between the MHIR and Primary Care Teams when patients / prisoners within the prison setting are being discharged from secondary care services (MHIR) back to primary care services within the prison. This meeting includes a full”

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
Use weekly discharge information, prison NOMIS access and a Governor Grade officer at Single Point of Access meetings to verify release dates.

Verbatim wording from the response
“• On a weekly basis the MHIR Team are sent the discharge information of prisoners from the Offender Management Unit (OMU). We don’t request travel warrant information as the travel warrant is only issued on the day of travel. We also now have access to the prison NOMIS system which we didn’t previously (training for use is being rolled out to the whole team with 50% already achieved). This system is updated by the Resettlement Team and OMU regarding release dates. These layered approaches help to avoid the risk of the team not being aware of relevant information”

Source location
Response from Swansea Bay University Health Board
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
Continue updating ViSOR records for each individual so information can be shared across agencies.

Verbatim wording from the response
“Visor is the shared IT system accessible to numerous agencies. West Midlands Police will ensure we continue to update Visor records for each individual to ensure information can be shared across agencies.”

Source location
Response from West Midlands Police
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
Work with agencies to clarify key roles and systems, improve information sharing and management, and protect the public.

Verbatim wording from the response
“We will work with all agencies to understand key roles and systems to better share information, manage individuals and protect the public.”

Source location
Response from West Midlands Police
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
Visit managed offenders after prison release regardless of their MAPPA process status.

Verbatim wording from the response
“Finally, as explained in evidence during the inquest: West Midlands Police’s approach to visiting managed offenders has changed since Mr Billington’s death. The position now is that a West Midlands Police officer will try to visit a managed offender when they are released from prison, regardless of the status of the MAPPA process.”

Source location
Response from West Midlands Police
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
Continue reviewing and refining MAPPA practices to improve interagency working and risk-information sharing.

Verbatim wording from the response
“MAPPA arrangements are overseen by a Strategic Management Board (SMB) and in the West Midlands this Board will continue to review and refine practices to ensure interagency working is effective and to support the sharing of relevant risk information. The findings in this case have been presented to MAPPA SMB. The SMB is committed to ensuring their part in providing avenues to share information. Furthermore, the SMB has reinforced the statutory requirement for all duty to cooperate agencies in the MAPPA arena.”

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
Reinforce the statutory information-sharing requirement for MAPPA duty-to-cooperate agencies.

Verbatim wording from the response
“MAPPA arrangements are overseen by a Strategic Management Board (SMB) and in the West Midlands this Board will continue to review and refine practices to ensure interagency working is effective and to support the sharing of relevant risk information. The findings in this case have been presented to MAPPA SMB. The SMB is committed to ensuring their part in providing avenues to share information. Furthermore, the SMB has reinforced the statutory requirement for all duty to cooperate agencies in the MAPPA arena.”

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
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
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
G4S cannot implement changes to streamline IT systems used by HMPPS, the NHS and third-party providers.

Verbatim wording from the response
“The HMPPS primary national electronic records system used in all prisons in England and Wales is DPS (formerly PNOMIS). Other agencies involved in OMU and resettlement utilise other records systems, including NDel ius (the Probation Service), SystmOne/other electronic clinical records systems, and other records systems used by third party providers. G4S has no power to implement changes to streamline IT systems used by HMPPS, the NHS and/or other third party providers. Other interested persons may be better able to assist HM Senior Coroner in relation to this issue. G4S will, however, continue to streamline its own data recording, to ensure as much information as possible is shared through the primary national prisons IT system, DPS. G4S has very limited access to NDel ius, but information on this system is regularly accessible to Probation Service”

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 position was interpreted

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

PFD Monitor interpretation
Issues concerning information sharing on NDelius should be addressed to HMPPS.

Verbatim wording from the response
“The HMPPS primary national electronic records system used in all prisons in England and Wales is DPS (formerly PNOMIS). Other agencies involved in OMU and resettlement utilise other records systems, including NDel ius (the Probation Service), SystmOne/other electronic clinical records systems, and other records systems used by third party providers. G4S has no power to implement changes to streamline IT systems used by HMPPS, the NHS and/or other third party providers. Other interested persons may be better able to assist HM Senior Coroner in relation to this issue. G4S will, however, continue to streamline its own data recording, to ensure as much information as possible is shared through the primary national prisons IT system, DPS. G4S has very limited access to NDel ius, but information on this system is regularly accessible to Probation Service”

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 position was interpreted

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

PFD Monitor interpretation
National Systemone interface issues must be addressed by other Interested Parties, although the Trust is exploring a local amendment.

Verbatim wording from the response
“Systemone Whilst this point is an issue which will need to be addressed at a more national level by other Interested Parties, the Trust has also looked at its own Systemone interface in HMP Birmingham to see if this can be amended locally.”

Source location
Response from BSMHFT
Page 3 · 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
A unified prison interagency IT system cannot be implemented because the Health Board lacks the necessary power.

Verbatim wording from the response
“Swansea University Health Board recognise that there is not a shared database for interagency working in place across England and Wales prison establishments to enable the transfer and access to key information by agencies coordinating the discharge of high risk individuals.”

Source location
Response from Swansea Bay University Health Board
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
Liaison with MAPPA is the Offender Management Unit’s responsibility, while the Responsible Authority must notify Health and arrange relevant meetings.

Verbatim wording from the response
“In respect of MAPPA, Swansea Bay University Health Board undertake the role of a ‘Duty to Cooperate Agency’ with Probation, HMP and the Police as the Responsible Authority – it is the Responsible Authority’s responsibility to inform Health if a MAPPA eligible individual is scheduled for discharge and ensure we are invited to relevant meetings to coordinate release / discharge management. The MHIR Team liaise directly with the prison based Offender Management Unit and not directly with MAPPA. Liaison with MAPPA is the responsibility of the Offender Management Unit.”

Source location
Response from Swansea Bay University Health Board
Page 3 · response
Published 19 March 2024
Open published response
3 Nov2021
London City
Concerns raised3
1. Failure to inform MAPPA panels about regularity and form of overt offender-management contact
2. Failure to share and consider counter-terrorism police intelligence in MAPPA management
3. Failure to provide MAPPA panels important prison-history information
This report raised 21 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 14
1. Action
  Design risk-based home-visit regimes and provide MAPPA panels with visibility of police activity supporting risk-management plans.
  Stated by West Midlands PoliceStated planned
2. Action
  Feed offender-visit activity into MAPPA panels to synchronise visits across agencies and account for MAPPA requirements.
  Stated by West Midlands PoliceStated completed
3. Action
  Strengthen MAPPA guidance requiring police to report contact frequency and outcomes and consider panel recommendations.
  Stated by Ministry of JusticeStated planned
1. Action
  Operate the Joint Counter Terrorism Prison and Probation Hub to improve secure intelligence and information sharing into MAPPA.
  Stated by West Midlands PoliceStated completed
2. Action
  Require relevant assessments and information to be available and incorporated into risk-management planning for allocated offenders.
  Stated by West Midlands PoliceStated completed
3. Action
  Develop and operationalise the covert-overt bridge for reviewing, revealing and appropriately sharing sensitive intelligence with MAPPA.
  Stated by West Midlands PoliceStated in progress
4. Action
  Escalate delayed prison Form F submissions, challenge variable quality, and seek additional analytical support for security information.
  Stated by West Midlands PoliceStated in progress
5. Action
  Vet CT MAPPA Chairs and specialist offender-management staff, and use Joint Extremist Unit support to bring intelligence into MAPPA meetings.
  Stated by West Midlands PoliceStated completed
6. Action
  Establish the Joint Counter Terrorism Prisons and Probation Hub to coordinate multi-agency risk management and intelligence sharing.
  Stated by Home Office and The Security ServiceStated completed
7. Action
  Create and use the Covert/Overt Bridge to share sensitive intelligence directly with appropriately cleared MAPPA participants.
  Stated by Home Office and The Security ServiceStated completed
8. Action
  Work with relevant case-management forums to coordinate covert and overt risk management and share proportionate intelligence with HMPPS from prison entry.
  Stated by Home Office and The Security ServiceStated in progress
9. Action
  Maintain Northern Hub intelligence support and information-sharing channels with WMCTU senior managers and CT MAPPA attendees for Staffordshire-linked nominals.
  Stated by Staffordshire PoliceStated completed
10. Action
  Amend the MAPPA document set and meeting template to retain prison information and record intelligence, ERG conclusions, and risk factors.
  Stated by Ministry of JusticeStated planned
11. Action
  Operate the covert-overt bridge framework to identify, review, reveal, and disclose sensitive intelligence for MAPPA risk-management decisions.
  Stated by Ministry of JusticeStated completed
Respondent positions 3
1. Position
  Other bodies are taking forward substantive work on the concerns, so further College guidance or training would risk duplicating their work.
  Stated by College of PolicingRedirects responsibility
1. Position
  Matters concerning MAPPA intelligence sharing, security-sensitive information and police contact reporting are predominantly operational and assigned to other named bodies.
  Stated by Home Office and The Security ServiceRedirects responsibility
2. Position
  Responsibility for CT MAPPA nominal management, attendance decisions and related offender contact rests with WMCTU’s Nominal Management Team and Senior CT Managers.
  Stated by Staffordshire PoliceRedirects responsibility
AI-generated summary

Saskia Jones and 2 others · 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

On 29 November 2019, Usman Khan carried out a terrorist attack at Fishmongers’ Hall, fatally stabbing Saskia Jones and Jack Merritt before being fatally shot by firearms officers on London Bridge. The report raised concerns about risk assessment and communication for events involving high-risk offenders, and about the assessment, information-sharing, supervision and management of terrorist offenders released into the community.

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 inform MAPPA panels about regularity and form of overt offender-management contact
Wider context from the report
“The facts of this case give cause for concern that MAPPA panels responsible for managing terrorist offenders may be unaware of the regularity and form of contact with police officers responsible for overt offender management. ”
Source location
Saskia Jones and 2 others · Prevention of Future Deaths report
Page 39 · 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
Failure to share and consider counter-terrorism police intelligence in MAPPA management
Wider context from the report
“This case gives cause for concern that counter-terrorism police may be in possession of intelligence or information which may be useful to the management of an offender by the MAPPA panel, but that such intelligence or information may not be brought to the knowledge of or taken into account by MAPPA agencies. ”
Source location
Saskia Jones and 2 others · Prevention of Future Deaths report
Page 35 · 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
Failure to provide MAPPA panels important prison-history information
Wider context from the report
“The facts of this case give cause for concern that some members of MAPPA panels responsible for managing extremist offenders may not be aware of important information from the offender’s time in prison. ”
Source location
Saskia Jones and 2 others · Prevention of Future Deaths report
Page 35 · 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
Design risk-based home-visit regimes and provide MAPPA panels with visibility of police activity supporting risk-management plans.

Verbatim wording from the response
“Response from NCTPHQ”

Source location
2021-0362-Response-from-West-Midlands-Police_Published
Page 11 · response
Published 3 November 2021
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
Feed offender-visit activity into MAPPA panels to synchronise visits across agencies and account for MAPPA requirements.

Verbatim wording from the response
“41. CTP West Midlands now feed this into the MAPPA panel to ensure synchrony of visits across agencies, and to take account of any MAPPA requirements.”

Source location
2021-0362-Response-from-West-Midlands-Police_Published
Page 12 · response
Published 3 November 2021
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
Strengthen MAPPA guidance requiring police to report contact frequency and outcomes and consider panel recommendations.

Verbatim wording from the response
“• We will strengthen the MAPPA meetings chapter of the statutory guidance to put beyond doubt the expectation that police share full information about regularity and outcomes of any contact and consider recommendations of the panel.”

Source location
2021-0362-Response-from-MoJ_Published
Page 13 · response
Published 3 November 2021
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
Operate the Joint Counter Terrorism Prison and Probation Hub to improve secure intelligence and information sharing into MAPPA.

Verbatim wording from the response
“22. A Joint Counter Terrorism Prison and Probation Hub (‘JCTPPH’) has been formed. This is a collaboration between HMPPS, CTPHQ and the Security Service. One of its core functions is to enhance the flow of intelligence and information between covert and overt functions, noting that there is an obvious and necessary ‘firewall’ between the two. MAPPA chairs will consider how core groups will contribute in each case. The creation of core groups will ensure a secure and clear pathway for the sharing of sensitive intelligence/information into MAPPA. CTPHQ have provided guidance through their Manual of Guidance to require CTP Nominal Management specialist officers and Lead Responsible Officers to ensure that all relevant information is at hand to develop effective risk management plans for their allocated nominals, including those managed under MAPPA.”

Source location
2021-0362-Response-from-West-Midlands-Police_Published
Page 7 · response
Published 3 November 2021
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 relevant assessments and information to be available and incorporated into risk-management planning for allocated offenders.

Verbatim wording from the response
“22. A Joint Counter Terrorism Prison and Probation Hub (‘JCTPPH’) has been formed. This is a collaboration between HMPPS, CTPHQ and the Security Service. One of its core functions is to enhance the flow of intelligence and information between covert and overt functions, noting that there is an obvious and necessary ‘firewall’ between the two. MAPPA chairs will consider how core groups will contribute in each case. The creation of core groups will ensure a secure and clear pathway for the sharing of sensitive intelligence/information into MAPPA. CTPHQ have provided guidance through their Manual of Guidance to require CTP Nominal Management specialist officers and Lead Responsible Officers to ensure that all relevant information is at hand to develop effective risk management plans for their allocated nominals, including those managed under MAPPA.”

Source location
2021-0362-Response-from-West-Midlands-Police_Published
Page 7 · response
Published 3 November 2021
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
Develop and operationalise the covert-overt bridge for reviewing, revealing and appropriately sharing sensitive intelligence with MAPPA.

Verbatim wording from the response
“31. The JCTPPH will ensure the right information gets to the right place at the right time. A major focus, in its first year, has been the development and operationalisation of a covert-overt bridge framework. This provides an effective, safe, process through which sensitive intelligence can be revealed and subsequently, appropriately, disclosed to support defensible decision making regarding risk management. Originally focused on supporting better disclosure into the Parole Board process learning has been taken and applied to MAPPA where the bridge has already been tested on five cases bringing to the attention of MAPPA information previously only known to the security service.”

Source location
2021-0362-Response-from-West-Midlands-Police_Published
Page 9 · response
Published 3 November 2021
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
Escalate delayed prison Form F submissions, challenge variable quality, and seek additional analytical support for security information.

Verbatim wording from the response
“26. Where there are delays in receipt of the Form F, these are escalated as a matter of urgency to the prison concerned. The quality of the Form F can be variable, and locally the West Midlands MAPPA chair is challenging this position, and seeking a greater level of analytical support from the JCTPPH around security information, to better support MAPPA decisions.”

Source location
2021-0362-Response-from-West-Midlands-Police_Published
Page 8 · response
Published 3 November 2021
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
Vet CT MAPPA Chairs and specialist offender-management staff, and use Joint Extremist Unit support to bring intelligence into MAPPA meetings.

Verbatim wording from the response
“34. CT MAPPA chairs are now Develop Vetted, and that the key staff (CTNM & National Security Division) who actively manage the offenders, have specialist roles, are also vetted to a level suitable for CT and work together outside of the formal MAPPA meetings. The Chairs now work with the Joint Extremist Unit to facilitate intelligence”

Source location
2021-0362-Response-from-West-Midlands-Police_Published
Page 10 · response
Published 3 November 2021
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
Establish the Joint Counter Terrorism Prisons and Probation Hub to coordinate multi-agency risk management and intelligence sharing.

Verbatim wording from the response
“At the time of the attack perpetrated by Usman Khan at Fishmongers’ Hall in 2019, the Security Service relied on counter-terrorism police (“CTP”) to pass intelligence to and represent the Security Service’s interest in MAPPA. As indicated to the inquest, CTP were the bridge between the Security Service and MAPPA. This is no longer the case. In direct response to Jonathan Hall QC’s MAPPA review, the Joint Counter Terrorism Prisons and Probation Hub (“JCTPPH”) was set up with the aim of ensuring that there is a shared understanding of who poses a risk, and why, and to enable management of those individuals”

Source location
2021-0362-Response-from-Home-Office_Published
Page 3 · response
Published 3 November 2021
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
Create and use the Covert/Overt Bridge to share sensitive intelligence directly with appropriately cleared MAPPA participants.

Verbatim wording from the response
“through multi-agency partnerships and engagement with the appropriate statutory bodies. The JCTPPH composes staff from the Security Service, CTP and HMPPS. The key piece of work that is being undertaken to achieve this aim is the JCTPPH-owned “Covert / Overt Bridge”. The Bridge will facilitate the sharing of sensitive intelligence into the MAPPA process and, importantly, other key forums. The JCTPPH has created a mechanism for directly sharing sensitive intelligence with those within the MAPPA process, most notably the MAPPA Chair(s), as well as others who hold appropriate clearances, regarding individuals subject to MAPPA. Use of the Bridge will support MAPPA in making informed decisions but will also ensure that the intelligence is shared in a way which ensures that the Security Service complies with the requirements as set out in the Security Service Act 1989.”

Source location
2021-0362-Response-from-Home-Office_Published
Page 4 · response
Published 3 November 2021
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
Work with relevant case-management forums to coordinate covert and overt risk management and share proportionate intelligence with HMPPS from prison entry.

Verbatim wording from the response
“The JCTPPH is also working with other forums in the case management of those of counter-terrorism interest in the Prisons and Probation sector to enable further co-ordination of covert and covert risk management, such as Pathfinder, the Parole Board and the Prison Separation Centre Management Committee. This will provide us with the ability to share intelligence, where assessed to be necessary and proportionate, with HMPPS from the moment an individual enters the Prison estate, meaning that case management decisions will be able to take into account the entirety of what is known about the individual rather than a part of the picture. Once in place, this means that towards the end of a prisoner’s sentence, when the individual is managed by MAPPA, there will be a full and detailed narrative that draws on all sources of information and intelligence to inform decision-making.”

Source location
2021-0362-Response-from-Home-Office_Published
Page 4 · response
Published 3 November 2021
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
Maintain Northern Hub intelligence support and information-sharing channels with WMCTU senior managers and CT MAPPA attendees for Staffordshire-linked nominals.

Verbatim wording from the response
“Part of the changes to this enhanced Regional collaboration saw Staffordshire Police personnel cease to attend CT MAPPA meetings. Further, the well-established working practices (Post November 2019) were maintained with the WMCTU Northern Hub continuing to provide intelligence support to CT Policing where nominals with established links to the Staffordshire Force area are subject to MAPPA proceedings.”

Source location
2021-0362-Response-from-Staffordshire-Police_Published
Page 2 · response
Published 3 November 2021
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
Amend the MAPPA document set and meeting template to retain prison information and record intelligence, ERG conclusions, and risk factors.

Verbatim wording from the response
“• We will amend the document set to ensure that key information from the MAPPA F is retained for future meetings post release from custody. The new MAPPA meeting template will include a section for key up-to-date intelligence, key conclusions of the most recent ERG assessment and provide for a clear record of risk factors.”

Source location
2021-0362-Response-from-MoJ_Published
Page 11 · response
Published 3 November 2021
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
Operate the covert-overt bridge framework to identify, review, reveal, and disclose sensitive intelligence for MAPPA risk-management decisions.

Verbatim wording from the response
“• The Joint Counter-Terrorism Prisons and Probation Hub (JCTPPH) is a collaboration between HMPS, CTP and the Security Service to ensure the right information gets to the right place at the right time. Launched in 2021, a major focus has been the development and operationalisation of a covert-overt bridge framework. This provides an effective, safe, process through which sensitive intelligence can be revealed and subsequently, appropriately, disclosed to support defensible decision-making regarding risk management. Originally focused on supporting better disclosure into the Parole Board, the framework is now being applied to MAPPA where the bridge has been tested using information previously only known to the Security Service.”

Source location
2021-0362-Response-from-MoJ_Published
Page 12 · response
Published 3 November 2021
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 bodies are taking forward substantive work on the concerns, so further College guidance or training would risk duplicating their work.

Verbatim wording from the response
“In developing our response, we are grateful to the other addressees (and national Counter Terrorism policing) who have shared their responses with us. We note from their responses that these addressees have taken forward, or plan to take forward, substantive work to address the seven MCs listed above.”

Source location
2021-0362-Response-from-College-of-Policing_Published
Page 4 · response
Published 3 November 2021
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
Matters concerning MAPPA intelligence sharing, security-sensitive information and police contact reporting are predominantly operational and assigned to other named bodies.

Verbatim wording from the response
“The Home Office has liaised closely with operational partners and other Government Departments regarding the collective Matters of Concern (MCs). Three MCs - 19, 20 and 21 - will be addressed by the Chief Constables of West Midlands Police and Staffordshire Police and the Secretary of State for Justice. The Home Office has reviewed these responses and agrees with their content.”

Source location
2021-0362-Response-from-Home-Office_Published
Page 2 · response
Published 3 November 2021
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 CT MAPPA nominal management, attendance decisions and related offender contact rests with WMCTU’s Nominal Management Team and Senior CT Managers.

Verbatim wording from the response
“In line with the collaborative arrangements between West Midlands CTU and Staffordshire Police, all nominals who are subject to the CT MAPPA process are now owned by the CT Nominal Management Team from within WMCTU. They are therefore managed in the manner outlined within the West Midlands Police response above.”

Source location
2021-0362-Response-from-Staffordshire-Police_Published
Page 4 · response
Published 3 November 2021
Open published response
29 Aug2019
Manchester North
Concerns raised2
1. Insufficient capacity to cross-reference offender intelligence across offenders and agencies
2. Failure to record licence conditions on the Police National Computer
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Publish and update the Intelligence Collection, Analysis and Dissemination Policy Framework to standardise intelligence handling and sharing within HMPPS and with partner agencies.
  Stated by HM Prison and Probation Service and Ministry of Justice and Probation ServiceStated completed
2. Action
  Continue collaborative work with the Police National Computer Bureau to review and improve the provision of licence information to police.
  Stated by HM Prison and Probation Service and Ministry of Justice and Probation ServiceStated in progress
Respondent positions 7
1. Position
  Operational matters within each force, including the concerns raised, are the responsibility of the respective chief constable.
  Stated by National Police Chiefs’ CouncilRedirects responsibility
1. Position
  The NPCC lacks authority to direct chief constables to take or refrain from specific operational action.
  Stated by National Police Chiefs’ CouncilOutside remit
2. Position
  A full response to concerns about serious further offence reviews, curfews, and police records was delayed pending subject-matter expert consideration.
  Stated by National Police Chiefs’ CouncilUnable to act
3. Position
  Police need not record specific licence conditions because they are accessible from the National Probation Service, which determines any breach.
  Stated by Greater Manchester PoliceExisting arrangements considered sufficient
4. Position
  Recording all licence conditions would require a significant increase in administrative time, which is not justified by the available information.
  Stated by Greater Manchester PoliceUnable to act
5. Position
  The National Probation Service is responsible for determining whether licence or supervision conditions have been breached.
  Stated by Greater Manchester PoliceRedirects responsibility
6. Position
  The Police and Home Office own and operate the Police National Computer, while HMPPS provides licence information through established arrangements.
  Stated by HM Prison and Probation Service and Ministry of Justice and Probation ServiceRedirects responsibility
AI-generated summary

Michael Hoolickin · 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

Michael Hoolickin was attacked and stabbed in an unprovoked assault on 14 October 2016 and died at Manchester Royal Infirmary on 17 October 2016. The report identifies organisational and management failures in supervising the perpetrator, including failures concerning drug testing, information sharing and provision of relevant information, which resulted in a missed opportunity to initiate recall to prison. The Inquest found that this probably contributed to Michael Hoolickin’s death, although it was not causative of the attack.

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
Insufficient capacity to cross-reference offender intelligence across offenders and agencies
Wider context from the report
“During the course of the Inquest questions were raised around the ability of the NPS to cross reference intelligence received in respect of different offenders. In addition whether there was capacity to cross reference intelligence held by other agencies such as the Youth Offending Team. ”
Source location
Michael Hoolickin · Prevention of Future Deaths report
Page 5 · 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
Failure to record licence conditions on the Police National Computer
Wider context from the report
“The Court heard that an offenders’ licence conditions are not held on the Police National Computer database. Hence if an offender is arrested by a different force they are unlikely to know whether the offender may be in breach of their licence. ”
Source location
Michael Hoolickin · Prevention of Future Deaths report
Page 5 · 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
Publish and update the Intelligence Collection, Analysis and Dissemination Policy Framework to standardise intelligence handling and sharing within HMPPS and with partner agencies.

Verbatim wording from the response
“Questions were raised around the ability of the NPS to cross reference intelligence received in respect of different offenders. In addition, whether there was capacity to cross reference intelligence held by other agencies such as the Youth Offending Team.”

Source location
2019-0292-Response-from-HM-Prison-and-Probation-Service-Redacted.pdf
Page 3 · response
Published 25 October 2019
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
Continue collaborative work with the Police National Computer Bureau to review and improve the provision of licence information to police.

Verbatim wording from the response
“An offenders’ licence conditions are not held on the Police National Computer database. Hence if an offender is arrested by a different force they are unlikely to know whether the offender may be in breach of their licence. Hence it is not clear how any potential breaches would ever be shared effectively with the NPS. There is an established process for prisons to inform the police about an offender’s release on licence and a specialist central unit uploads information on to the Police National Computer (PNC). The”

Source location
2019-0292-Response-from-HM-Prison-and-Probation-Service-Redacted.pdf
Page 3 · response
Published 25 October 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
Operational matters within each force, including the concerns raised, are the responsibility of the respective chief constable.

Verbatim wording from the response
“I was not previously aware of this incident, and I am very sorry to learn of the tragic circumstances surrounding the death of Mr Hoolickin. You will appreciate that I am unable to comment on the specific facts of this case, but I can address your concerns regarding policing practice more generally. I understand that you have made contact with the chief constables of Greater Manchester Police and Lancashire Constabulary, both whom will no doubt wish to respond separately in addressing the issues you have raised with specific reference to the actions of their respective forces.”

Source location
2019-0292-Response-from-the-National-Police-Chiefs-Council-1
Page 1 · response
Published 25 October 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 NPCC lacks authority to direct chief constables to take or refrain from specific operational action.

Verbatim wording from the response
“It is important to understand the distinct role of the National Police Chiefs’ Council (NPCC). As you know, each chief constable is ultimately responsible for operational matters within their own force area, which includes all of those issues referred to within the matters of concern you have raised. Whilst the NPCC seeks to encourage chief constables to work collaboratively in the national interest (for example, the way in which forces implement policies or practice), the NPCC does not have the authority to direct a chief constable to take (or not to take) a specific course of action. That said, we do recognise the need for consistency across forces whenever possible, which we know can lead to better outcomes for the public. The way the NPCC”

Source location
2019-0292-Response-from-the-National-Police-Chiefs-Council-1
Page 1 · response
Published 25 October 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
A full response to concerns about serious further offence reviews, curfews, and police records was delayed pending subject-matter expert consideration.

Verbatim wording from the response
“In order to provide a useful response to the matters of concern you have raised, it has been necessary for me to consult with a number of national leads across several portfolios. I am unfortunately not able to provide you with a full response to all of your concerns today because some of those I have consulted with are still in the process of considering the matters of concern, and no doubt further consulting with subject matter experts. However, I hope you are willing to accept this letter in part response to the issues raised.”

Source location
2019-0292-Response-from-the-National-Police-Chiefs-Council-1
Page 2 · response
Published 25 October 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
Police need not record specific licence conditions because they are accessible from the National Probation Service, which determines any breach.

Verbatim wording from the response
“At this time the PNC does not hold the specific licence conditions because of the volume of offenders on licence, many of whom have multiple conditions, which are subject to variation. After respectful consideration of the evidence gathered in this inquest and the concerns expressed in the Regulation 28 letter the disadvantage is felt that maintaining a timely and accurate record of all licence conditions would require a significant increase in administrative time which would not be justified given the information is accessible from the NPS who will in any case make a determination on breach.”

Source location
2019-0292-Response-from-Greater-Manchester-Police-Redacted
Page 3 · response
Published 25 October 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
Recording all licence conditions would require a significant increase in administrative time, which is not justified by the available information.

Verbatim wording from the response
“At this time the PNC does not hold the specific licence conditions because of the volume of offenders on licence, many of whom have multiple conditions, which are subject to variation. After respectful consideration of the evidence gathered in this inquest and the concerns expressed in the Regulation 28 letter the disadvantage is felt that maintaining a timely and accurate record of all licence conditions would require a significant increase in administrative time which would not be justified given the information is accessible from the NPS who will in any case make a determination on breach.”

Source location
2019-0292-Response-from-Greater-Manchester-Police-Redacted
Page 3 · response
Published 25 October 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 National Probation Service is responsible for determining whether licence or supervision conditions have been breached.

Verbatim wording from the response
“Response: The PNC is a national database and an entry on the CU page of a person record, concerning supervision or licence details, is completed using a set wording. This includes contact details for the national probation service or Spotlight team managing the subject and the dates between which the licence or supervision is effective. It is accepted that the PNC does not hold specific licence conditions. All persons authorised for detention at a police station should be checked on PNC and it is the responsibility of officers in the force where the subject is arrested to make contact with the relevant probation service office to share details of the arrest from which the NPS can assess whether the licence or supervision conditions have been breached.”

Source location
2019-0292-Response-from-Greater-Manchester-Police-Redacted
Page 3 · response
Published 25 October 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 Police and Home Office own and operate the Police National Computer, while HMPPS provides licence information through established arrangements.

Verbatim wording from the response
“An offenders’ licence conditions are not held on the Police National Computer database. Hence if an offender is arrested by a different force they are unlikely to know whether the offender may be in breach of their licence. Hence it is not clear how any potential breaches would ever be shared effectively with the NPS. There is an established process for prisons to inform the police about an offender’s release on licence and a specialist central unit uploads information on to the Police National Computer (PNC). The”

Source location
2019-0292-Response-from-HM-Prison-and-Probation-Service-Redacted.pdf
Page 3 · response
Published 25 October 2019
Open published response
19 Jul2019
Lancashire and Blackburn with Darwen
Concerns raised1
1. Failure to maintain mandatory inter-agency information sharing for MAPPA Level 1 management
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Lead a multi-agency redesign of MARAC to test live-time information sharing, tasking, lead-professional coordination and wider household safeguarding.
  Stated by Lancashire ConstabularyStated in progress
2. Action
  Refresh MASH staff messaging periodically on identifying life-licensed perpetrators as high risk and sharing referral information to prompt safeguarding action.
  Stated by Lancashire ConstabularyStated completed
3. Action
  Implement a merits-based MASH safeguarding model focused on individual vulnerability, partnership working, information sharing and early intervention.
  Stated by Lancashire ConstabularyStated completed
1. Action
  Replace system-generated email sharing with personal email addresses in Connect so senders receive delivery-failure alerts and can rectify unsuccessful information transfers.
  Stated by Lancashire ConstabularyStated completed
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
Failure to maintain mandatory inter-agency information sharing for MAPPA Level 1 management
Wider context from the report
“The perpetrator was managed on release at MAPPA Level 1. Following his release there were no local MAPPA 1 meetings, no inter-agency meetings and no significant inter-agency communications regarding the perpetrator, no detailing of his licence conditions, and no information regarding either his nature or the trigger factors for his offending. Evidence was heard regarding the findings of two separate reviews that took place following the death of Cherylee, and the recommendations that were made as a result of those reviews, in particular centred on the lack of inter-agency communications. My concern is that despite this, and the findings of the report, when evidence was heard regarding how systems had changed, there is still no mandatory process for the sharing of information between agencies where the offender despite a known, and extensive, history of domestic abuse and identified trigger factors, is then managed at MAPPA Level 1. ”
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
Lead a multi-agency redesign of MARAC to test live-time information sharing, tasking, lead-professional coordination and wider household safeguarding.

Verbatim wording from the response
“Lancashire Constabulary are leading a multi-agency systems thinking review of the MARAC process and this is encompassing the journey from initial referral through to the MARAC meeting itself.”

Source location
2019-0244-Response-by-Lancashire-Constabulary_Redacted
Page 1 · response
Published 9 September 2019
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
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 action was interpreted

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

PFD Monitor interpretation
Implement a merits-based MASH safeguarding model focused on individual vulnerability, partnership working, information sharing and early intervention.

Verbatim wording from the response
“A Corporate systems thinking review of MASH was conducted from 2016-18 and amongst a number of changes implemented was a move from a process-driven response to safeguarding referrals to a model where MASH staff understood their role in supporting people and keeping them safe, achieving this by considering each case on its merits, including the specific needs of the victim, adult and/or children and responding accordingly in partnership. Staff Supervisors/Team Leaders were trained and are now focused on this approach to recognising the risk, sharing information to achieve early interventions.”

Source location
2019-0244-Response-by-Lancashire-Constabulary_Redacted
Page 3 · response
Published 9 September 2019
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
Replace system-generated email sharing with personal email addresses in Connect so senders receive delivery-failure alerts and can rectify unsuccessful information transfers.

Verbatim wording from the response
““In 2014 the force recorded vulnerability reports via an IT system called “Sleuth”. This was achieved through the submission of a PVP (Protecting vulnerable persons) report, which the MASH would share. At that time, information was predominantly shared by a system generated email within sleuth. It was identified that sending emails directly through the Sleuth system did not inform the sender if they failed to be delivered. In light of this when the constabulary changed its IT system from “Sleuth” to “Connect” on 27th November 2018, the operating practice for sharing information changed with it. It was agreed that when information is shared via email it must be done via a personal email address rather than a system generated address.”

Source location
2019-0244-Response-by-Lancashire-Constabulary_Redacted
Page 3 · response
Published 9 September 2019
Open published response
17 Jun2019
South Yorkshire (Western)
Concerns raised1
1. Failure to share relevant information with the Probation Service after identifying details become available
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mr John Gogarty · 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

Mr John Gogarty was unlawfully killed at his home on 13 July 2015 by two people who planned to steal money to pay a drug debt; he was stabbed 69 times. The report identified missed opportunities and inadequate monitoring by the Probation Service, including failures relating to licence breaches, drug testing and recall. It also identified a missed opportunity for information about an offender’s relationship with a female patient to be shared with the Probation Service.

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 share relevant information with the Probation Service after identifying details become available
Wider context from the report
“Your Trust was solely concerned with the care of ████████. During that care your patient was associating with who had a very considerable history and was under the supervision of the National Probation Service following a sentence for murder. Although original offers were made to contact the Probation Service to pass on information, these came to nothing because insufficient details about the male were known. However, within a relatively short time further information to identify this male became apparent but there was no further follow up with the Probation Service. No specific criticism is made of the member of staff involved at that time, it might very well be that many staff might have assumed that there was nothing to be gained. However, in reality, if the Probation Service had been aware of your patients background they would have at least had the opportunity to consider the conditions of the parole afresh, potentially putting in place further safeguards. It is respectfully suggested that the lesson here is that small pieces of information properly shared on an inter-agency basis might well add up to a bigger picture for other organisations. ”
Source location
Mr John Gogarty · Prevention of Future Deaths report
Page 3 · concerns
Open source report
12 Jun2019
Sunderland
Concerns raised1
1. Failure to share relevant police information with Probation
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Operate the MK-flag and MASH process to queue relevant offender-record changes, share information with NPS, and retain emails for audit.
  Stated by Northumbria PoliceStated completed
2. Action
  Update Category 2 Level 1 offender warning screens with instructions requiring officers to share risk-relevant information with the relevant probation area.
  Stated by Northumbria PoliceStated completed
3. Action
  Disseminate force-wide bulletins informing and reinforcing officers’ responsibility to share relevant information with NPS.
  Stated by Northumbria PoliceStated completed
1. Action
  Add newly notified Category 2 Level 1 offenders to Northumbria Police systems immediately upon notification from NPS.
  Stated by Northumbria PoliceStated planned
Respondent positions 2
1. Position
  Existing Northumbria Constabulary information-sharing steps are accepted by MAPPA and NPS representatives as a permanent solution at this time.
  Stated by HM Prison and Probation ServiceExisting arrangements considered sufficient
1. Position
  The agreed police and probation information-sharing process is considered definitive and sufficient, although it may evolve with future IT development.
  Stated by Northumbria PoliceExisting arrangements considered sufficient
AI-generated summary

Miss Nguyen Ngoc Quyen · 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

Miss Nguyen Ngoc Quyen died on 15 August 2017 at Success Road, Shiney Row, Houghton Le Spring; her death was consistent with the effects of fire. The report identified concerns about failures to act sufficiently, promptly and in a coordinated manner on known breaches of life licence conditions, including failures in information sharing between the Police and Probation Service, alongside wider organisational and supervision failings.

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 share relevant police information with Probation
Wider context from the report
“In April 2015 due to high operational demand there was a direction from the senior management team of Northumbria Police to stop monitoring Category 2 Level 1 offenders and to remove the markers on the log. As a result, the Multi Agency Public Protection Arrangements (MAPPA) department were no longer actively managing Category 2 Level 1 offenders. The responsibility for sharing information was solely with the sourcing officer. With ████████ his Police computer record was not updated, and attending Police Officers for incidents in 2015 and 2017 did not pass information to the relevant Probation Officer. The responsibility goes wider though to Control Room Staff, Patrol Sergeants, Patrol Constables and Supervising Sergeants too, when markers, flags and warnings were evident. ”
Source location
Miss Nguyen Ngoc Quyen · 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
Operate the MK-flag and MASH process to queue relevant offender-record changes, share information with NPS, and retain emails for audit.

Verbatim wording from the response
“In December 2018 Northumbria Police devised a process to ensure compliance for the purpose of information/intelligence sharing on every record for a Category 2 (violent) Level 1 MAPPA offender.”

Source location
2019-0194-Response-by-Northumbria-Police
Page 2 · response
Published 15 August 2019
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
Update Category 2 Level 1 offender warning screens with instructions requiring officers to share risk-relevant information with the relevant probation area.

Verbatim wording from the response
“Included within the process implemented in December 2018 was that all Category 2 Level 1 offenders would also have an NPICCS warning marker updated with a new instruction on the IS record for that offender. This will highlight the requirement for any officer who is in possession of relevant information to inform the relevant probation area.”

Source location
2019-0194-Response-by-Northumbria-Police
Page 3 · response
Published 15 August 2019
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
Disseminate force-wide bulletins informing and reinforcing officers’ responsibility to share relevant information with NPS.

Verbatim wording from the response
“To ensure staff were aware of this change, a force wide bulletin was sent to officers and staff informing them of the process and that it was their responsibility to share any relevant information/intelligence with NPS.”

Source location
2019-0194-Response-by-Northumbria-Police
Page 3 · response
Published 15 August 2019
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
Add newly notified Category 2 Level 1 offenders to Northumbria Police systems immediately upon notification from NPS.

Verbatim wording from the response
“In relation to new Category 2 Level 1 offenders, when we receive notification from NPS to the MOSOVO Department, they will be added to Northumbria Police systems immediately.”

Source location
2019-0194-Response-by-Northumbria-Police
Page 3 · response
Published 15 August 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 Northumbria Constabulary information-sharing steps are accepted by MAPPA and NPS representatives as a permanent solution at this time.

Verbatim wording from the response
“The regulation 28 report acknowledges that some of the issues identified by the investigation into the death have already been addressed by Northumbria Constabulary. However, you raised concern that actions taken provided an interim rather than a permanent solution. By way of confirmation, I have set out below in an addendum to this response, the actions I am advised have been taken by Northumbria Constabulary and am able to confirm that these steps are acknowledged and accepted by the MAPPA representatives and Heads of Service in the NPS North East Division in both the North of Tyne and South of Tyne Local Delivery Units as being correct and a permanent solution at this time.”

Source location
2019-0194-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 15 August 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 agreed police and probation information-sharing process is considered definitive and sufficient, although it may evolve with future IT development.

Verbatim wording from the response
“The final point in relation to the current process was your concern that the Police were of the view this was a permanent solution to this issue, whereas NPS were viewing it as an interim solution. This concern may have emerged because of the way the evidence came out at the inquest. We have contacted NPS with regards to the content of this letter and they confirm that they agree this process is definitive going forward. It may of course evolve in the future as IT systems are further developed and the two organisations co-operate to further improve the system but at present the system outlined above is agreed as the operating model going forward.”

Source location
2019-0194-Response-by-Northumbria-Police
Page 3 · response
Published 15 August 2019
Open published response
12 Jul2016
Inner West London
Concerns raised1
1. Risk of loss of access to Europol intelligence
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Promote greater criminality-information sharing within the EU and establish robust criminal-record-sharing arrangements for the UK’s future relationship with the EU.
  Stated by Home OfficeStated in progress
Respondent positions 1
1. Position
  Specific future security and intelligence-sharing arrangements cannot be addressed before negotiations with European partners.
  Stated by Home OfficeUnable to act
AI-generated summary

Alice Poppy Madeleine Gross · 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

Alice Poppy Madeleine Gross, aged 14, was murdered in a sexually motivated attack near the River Brent in Hanwell, Ealing, on or soon after 28 August 2014; her body was discovered concealed and weighted down in the river on 30 September 2014. The principal concerns included inconsistent checking of foreign criminal convictions on arrest, incomplete international conviction data and weaknesses in the border watch-list system.

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
Risk of loss of access to Europol intelligence
Wider context from the report
“(6) That the UK does not lose access to Europol intelligence when and if the UK leaves the EU. ”
Source location
Alice Poppy Madeleine Gross · 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
Promote greater criminality-information sharing within the EU and establish robust criminal-record-sharing arrangements for the UK’s future relationship with the EU.

Verbatim wording from the response
“Within the EU the UK has been a leading proponent of greater information exchange between countries for public protection reasons, including at the border, supporting an EU ‘Roadmap’, endorsed by the Justice and Home Affairs Council in June this year, which seeks to enhance the sharing and management of criminality information systems. This envisages exchanges of data between the Schengen and non-Schengen countries, which includes the UK.”

Source location
2016-0488-Response-by-Home-Office
Page 3 · response
Published 12 July 2016
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
Specific future security and intelligence-sharing arrangements cannot be addressed before negotiations with European partners.

Verbatim wording from the response
“The Prime Minister has put the whole machinery of Government behind getting the best deal as the UK leaves the EU. A great deal of work is going on across Government to ensure that happens. The Prime Minister has made clear that whilst we are leaving the EU, cooperation on security with our European and global allies will continue and we will do whatever is necessary to keep our citizens safe. Clearly it would be wrong to be drawn on the specifics of any future arrangements in advance of negotiations with our EU partners.”

Source location
2016-0488-Response-by-Home-Office
Page 4 · response
Published 12 July 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of the prison-to-probation process to share and locate key risk information

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised2

Failure to provide prison risk intelligence to Integrated Offender Management meetings

Failure of prison offender managers to gather and share evidence relevant to risk formulation

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised1

Failure to maintain and disseminate an adequate intelligence picture

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.18

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to coordinate interagency release management and share critical information

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.20

Actions described in response 1

Actions described in response 4

Actions described in response 18

Respondent positions 3

Actions described in response 20