Recurring concern

Unreliable safety decisions to approve or change offender licence conditions

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First reported 3 Nov 2021•Latest report 29 Nov 2022

Definition

What this concern includes

Includes failures in the dedicated offender licence-condition decision process, including assessing risks before granting permissions or variations, confirming that conditions are suitable and operational, consulting MAPPA or relevant clinical professionals, documenting the rationale, and reviewing or escalating proposed changes or removals.

Not included

Excludes general offender release planning, accommodation, supervision or post-release monitoring failures where the licence-condition decision process is not itself deficient.
Excludes failures to enforce or respond to a breach after a licence-condition decision has been reliably made, unless the assertion also concerns changing or removing the condition.
Excludes generic probation, MAPPA or mental-health communication deficiencies unless they directly impair a safety-critical decision about an offender licence condition.
Excludes ordinary administrative amendments to licence conditions where no material safety risk, suitability issue or deficient governance is identified.

Reports: 2
Individual concerns: 5
Date range: 2021–2022
Stated actions: 7

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.

College of Policing1

Department for Education1

Home Office1

Learning Together CIC1

Ministry of Justice1

Office for Students1

Recipient name withheld1

Staffordshire Police1

The Security Service1

University of Cambridge1

West Midlands Police1

Concerns and responses across reports

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

29 Nov2022
Hampshire, Portsmouth and Southampton
Concerns raised2
1. Failure to ensure that licence conditions requiring attendance with a specific practitioner are suitable and operational before release
2. Unilateral removal of licence conditions without consultation with MAPPA and mental health professionals
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

Daniel-John VARNDELL · Prevention of Future Deaths report

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

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure that licence conditions requiring attendance with a specific practitioner are suitable and operational before release
Wider context from the report
“The MAPPA meeting (consisting of over 20 professionals due to the complexity of the release planning) decided that various Conditions should apply to Daniel-John Varndell's Licence as he posed such a high risk to himself and others. One of these was: "Attend all appointments arranged for him with a psychiatrist/psychologist/medical practitioner and co-operate fully with any care or treatment they recommend" This was for use with a specific named practitioner, who must have agreed to treat him and he should have consented to this prior to the condition being added so unless something had been set up prior to release this condition may not have been suitable. The condition was unilaterally removed by a probation officer possibly because consent was not in place or for another reason. The point is there was no discussion with MAPPA professionals or any mental health practitioner prior to removal notwithstanding that the Chair of MAPPA indicated that the conditions were appropriate and necessary. Whilst this may not have affected the outcome in the present sad case such unilateral removal of a Licence Condition could result in a future death. ”
Source location
Daniel-John VARNDELL · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unilateral removal of licence conditions without consultation with MAPPA and mental health professionals
Wider context from the report
“The MAPPA meeting (consisting of over 20 professionals due to the complexity of the release planning) decided that various Conditions should apply to Daniel-John Varndell's Licence as he posed such a high risk to himself and others. One of these was: "Attend all appointments arranged for him with a psychiatrist/psychologist/medical practitioner and co-operate fully with any care or treatment they recommend" This was for use with a specific named practitioner, who must have agreed to treat him and he should have consented to this prior to the condition being added so unless something had been set up prior to release this condition may not have been suitable. The condition was unilaterally removed by a probation officer possibly because consent was not in place or for another reason. The point is there was no discussion with MAPPA professionals or any mental health practitioner prior to removal notwithstanding that the Chair of MAPPA indicated that the conditions were appropriate and necessary. Whilst this may not have affected the outcome in the present sad case such unilateral removal of a Licence Condition could result in a future death. ”
Source location
Daniel-John VARNDELL · Prevention of Future Deaths report
Page 2 · concerns
Open source report
3 Nov2021
London City
Concerns raised3
1. Failure to properly reason and record offender-manager licence-condition approvals
2. Failure to directly address risks when approving licence-condition changes
3. Failure of MAPPA panels to conduct clearly reasoned discussion and decision-making on licence-condition changes
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 7
1. Action
  Continue working with partners and stakeholders to update offender-management guidance and products to reflect changes resulting from the report.
  Stated by College of PolicingStated in progress
2. Action
  Use Core Groups to examine case detail and recommend decisions to MAPPA panels for final approval.
  Stated by West Midlands PoliceStated completed
3. Action
  Arrange emergency MAPPA panels with documented decisions and rationales when urgent matters require timely responses.
  Stated by West Midlands PoliceStated completed
1. Action
  Publish guidance on licence variation and authorisation, requiring decisions and rationales to be recorded on NDelius.
  Stated by Ministry of JusticeStated completed
2. Action
  Develop and consolidate the Licence Conditions Policy Framework, including recording and partner-engagement requirements for licence decisions.
  Stated by Ministry of JusticeStated planned
3. Action
  Implement guidance requiring licence variations or relaxations to use an up-to-date reviewed risk assessment.
  Stated by Ministry of JusticeStated completed
4. Action
  Amend and reissue MAPPA guidance with an updated minutes template and guidance on digitally recording meetings.
  Stated by Ministry of JusticeStated planned
Respondent positions 2
1. Position
  Licence conditions are a matter for HMPPS, with police supporting MAPPA discussions when its input is required.
  Stated by West Midlands PoliceRedirects responsibility
1. Position
  MAPPA does not make final decisions to apply, remove or authorise licence conditions; those decisions are recorded on case management systems.
  Stated by Ministry of JusticeRedirects 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 properly reason and record offender-manager licence-condition approvals
Wider context from the report
“This case gives rise to concern that offender managers may take significant decisions to give approvals under licence conditions without those decisions being properly reasoned and recorded. ”
Source location
Saskia Jones and 2 others · Prevention of Future Deaths report
Page 24 · 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 directly address risks when approving licence-condition changes
Wider context from the report
“This case gives cause for concern that an offender manager and/or MAPPA panel participants could approve a permission, variation or relaxation in relation to a licence condition without directly addressing the potential risks involved. ”
Source location
Saskia Jones and 2 others · Prevention of Future Deaths report
Page 14 · 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 MAPPA panels to conduct clearly reasoned discussion and decision-making on licence-condition changes
Wider context from the report
“The facts of this case give rise to concern that important decisions on approvals, variations and relaxations in relation to licence conditions may be taken without clearly reasoned discussion and decision-making in MAPPA panels. ”
Source location
Saskia Jones and 2 others · Prevention of Future Deaths report
Page 25 · 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 working with partners and stakeholders to update offender-management guidance and products to reflect changes resulting from the report.

Verbatim wording from the response
“The ‘offender management’ guidance and products have been developed over a number of years and we will continue to work with partners and stakeholders to ensure they are updated to”

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 action was interpreted

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

PFD Monitor interpretation
Use Core Groups to examine case detail and recommend decisions to MAPPA panels for final approval.

Verbatim wording from the response
“10. As the Coroner is aware, West Midlands Police has had a CT MAPPA arrangement in place for some years. It has included regular discussions around proposed licence conditions and any variations through the MAPPA process. Licence conditions are now firmly a matter for HMPPS but if MAPPA’s input is required, as CTPHQ describe at paragraph 7 above, there is a clear process for this to take place in a structured way. Since the attacks at Fishmongers’ Hall, developments have also taken place to improve the structure and quality of decision-making, including the introduction of Core Groups which consider the operational detail of a particular case, and enable detailed discussion by key professionals involved in that case. These Core Groups make recommendations to the MAPPA panel for debate and final sign off.”

Source location
2021-0362-Response-from-West-Midlands-Police_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
Arrange emergency MAPPA panels with documented decisions and rationales when urgent matters require timely responses.

Verbatim wording from the response
“12. A dedicated Minute Taker (Probation Service National Security Division) will be recruited to provide consistency and continuity in note-taking, and final minutes are reviewed by the MAPPA Chair prior to dissemination, to ensure accuracy. Additionally, where events are urgent and require a more timely response, emergency MAPPA panels can be arranged at short notice with documented records made of decisions and rationale. These improvements, fully supported by a senior CTWM Manager, have enabled the MAPPA panel to operate in a more efficient and structured way and ensured that notes taken can more accurately reflect the more focussed discussion taking place.”

Source location
2021-0362-Response-from-West-Midlands-Police_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
Publish guidance on licence variation and authorisation, requiring decisions and rationales to be recorded on NDelius.

Verbatim wording from the response
“• We have published guidance on Licence Variation and Authorisation. A draft version of the Licence Conditions Policy Framework is currently being considered by stakeholders and will update and consolidate all changes into policy following the Royal Assent for the Police, Crime, Sentencing and Courts Bill, expected in February 2022. This Framework will set out expectations of probation and prison staff in relation to both changes in licence conditions and the specific authorisation which must be obtained before an offender is permitted to undertake an activity which would otherwise be prohibited by the licence. One of the key policy changes will be the introduction of a requirement that practitioners ensure that any discussions and decisions around whether or not to vary a licence condition or authorise activity outside of a condition are recorded in case notes on NDelius.”

Source location
2021-0362-Response-from-MoJ_Published
Page 5 · 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 consolidate the Licence Conditions Policy Framework, including recording and partner-engagement requirements for licence decisions.

Verbatim wording from the response
“• We have published guidance on Licence Variation and Authorisation. A draft version of the Licence Conditions Policy Framework is currently being considered by stakeholders and will update and consolidate all changes into policy following the Royal Assent for the Police, Crime, Sentencing and Courts Bill, expected in February 2022. This Framework will set out expectations of probation and prison staff in relation to both changes in licence conditions and the specific authorisation which must be obtained before an offender is permitted to undertake an activity which would otherwise be prohibited by the licence. One of the key policy changes will be the introduction of a requirement that practitioners ensure that any discussions and decisions around whether or not to vary a licence condition or authorise activity outside of a condition are recorded in case notes on NDelius.”

Source location
2021-0362-Response-from-MoJ_Published
Page 5 · 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
Implement guidance requiring licence variations or relaxations to use an up-to-date reviewed risk assessment.

Verbatim wording from the response
“• New guidance was introduced in December 2021 which ensures that decisions to vary or relax licence conditions must always be subject to an up-to-date and reviewed”

Source location
2021-0362-Response-from-MoJ_Published
Page 6 · 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 and reissue MAPPA guidance with an updated minutes template and guidance on digitally recording meetings.

Verbatim wording from the response
“• Relevant parts of the statutory MAPPA Guidance will be amended and re-issued in April 2022, with an updated template for minutes of MAPPA meetings and guidance of the digital recording of MAPPA meetings.”

Source location
2021-0362-Response-from-MoJ_Published
Page 6 · 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
Licence conditions are a matter for HMPPS, with police supporting MAPPA discussions when its input is required.

Verbatim wording from the response
“7. Licence conditions are a matter for HMPPS but if it is determined a discussion at MAPPA would be helpful then Local CT policing will support this through new specialist CT MAPPA arrangements. The Probation Service National Security Division have specialist administrators to support the new operating model for specialist CT MAPPA and to ensure effective minute taking and sharing which are set out in more detail at paragraph 12 below.”

Source location
2021-0362-Response-from-West-Midlands-Police_Published
Page 3 · 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
MAPPA does not make final decisions to apply, remove or authorise licence conditions; those decisions are recorded on case management systems.

Verbatim wording from the response
“• The final decision for applying/removing/authorising a licence condition is not made by MAPPA: these decisions will be recorded on case management systems, including where stakeholders have been involved including MAPPA and the Police. The new model introduced by the NSD will enable greater oversight of cases and decision-making by Senior Managers. Management oversight will be monitored through performance and quality assurance measures.”

Source location
2021-0362-Response-from-MoJ_Published
Page 6 · response
Published 3 November 2021
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

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

Unilateral removal of licence conditions without consultation with MAPPA and mental health professionals

Concerns raised3

Failure to properly reason and record offender-manager licence-condition approvals

Failure to directly address risks when approving licence-condition changes

Failure of MAPPA panels to conduct clearly reasoned discussion and decision-making on licence-condition changes

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.7

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 7

Respondent positions 2