Recurring concern

Unreliable monitoring and management of high-risk offenders in the community

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First reported 23 Oct 2014•Latest report 1 Aug 2024

Definition

What this concern includes

Includes failures of the dedicated community offender-management process for high-risk offenders, including MAPPA or comparable multi-agency supervision, risk monitoring, active management, markers or warnings, breach detection, information sharing and coordinated action where these controls are intended to protect the public.

Not included

  • Excludes generic police, probation or safeguarding information-sharing deficiencies that are not specifically tied to community management of high-risk offenders.
  • Excludes prison-only supervision and monitoring failures where the offender is not being managed in the community.
  • Excludes generic staffing, training, workload or governance deficiencies unless they directly impair the dedicated high-risk-offender management process.
  • Excludes monitoring of patients, detainees, premises or non-offender hazards.
  • Excludes individual offending outcomes or breaches where no failure of the offender-management or supervision process is identified.
Reports
4

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
10

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Ministry of Justice4
HM Prison and Probation Service2
Home Office2
College of Policing1
Department for Education1
Government Legal Department1
House of Commons Home Affairs Committee1
Lancashire Constabulary1
Learning Together CIC1
Office for Students1
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.

  1. Milton Keynes

    AI-generated summary

    Leah Shannon Croucher · 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

    Leah Shannon Croucher left home to walk to work on 15 February 2019 but did not arrive, and her body was found in a Milton Keynes house in October 2022. The inquest concluded that she was unlawfully killed. The report raises concerns about the supervision of a known repeat sex offender and information sharing between the police and 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 adequately monitor sex offenders in the community

    Wider context from the report

    “Leah Croucher was unlawfully killed by a man who was subject to supervision by the probation service and the police. Despite that supervision he was in breach of the terms of his probation and was able to kill Leah when it was known that he was a predator and danger to females. There should be a fundamental review of the process for monitoring sex offenders in the community and the sharing of information between all agencies particularly the police and probation service to ensure that a similar death can be prevented. ”

    Source location

    Leah Shannon Croucher · 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

    Introduce policy frameworks for pre-sentence reports, home visits and MAPPA level 1 case management.

    Verbatim wording from the response

    “Probation Service, when the former Community Rehabilitation Companies were dissolved in 2021, and attendant changes to organisational structure, policy and practice. Since then, the Probation Service has taken steps to strengthen our management of those who have committed sexual offences. We have streamlined risk assessments for such offenders and introduced a new national learning programme for all experienced probation officers to improve their knowledge and skills in this vital area of public protection work. We have also introduced new policy frameworks covering the preparation of pre-sentence reports, requirements to undertake home visits and expectations when it comes to cases managed at level 1 under MAPPA. ████████ was managed at MAPPA level 1 at the time Leah Croucher was killed).”

    Source location

    Response from HMPPS - Probation Service South Central
    Page 2 · response
    Published 13 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

    Oversee a review of multi-agency processes for monitoring sexual offenders and exchanging police and probation information.

    Verbatim wording from the response

    “The Chair of the SMB has accepted that the Board should oversee a piece of work to review the effectiveness of the multi-agency processes for monitoring sex offenders and for information exchange between police and probation. This will build on the extensive learning which came from the MAPPA Serious Case Review (SCR) and associated action plan, which is due to be implemented in full by August 2025.”

    Source location

    Response from HMPPS - Probation Service South Central
    Page 2 · response
    Published 13 August 2024

    Open published response
  2. London City

    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 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 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
  3. Lancashire and Blackburn with Darwen

    AI-generated summary

    Cherylee Yvette Shennan · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to allocate an appropriately protective MAPPA level for offenders with significant domestic abuse histories who have not been fully tested before release

    Wider context from the report

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

    Source location

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

    Open source report

    Source evidence

    How this 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

    Implement a Pan-Lancashire MARAC protocol requiring immediate emergency referral and high-risk prioritisation for relevant life-licensed domestic-abuse homicide offenders.

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent 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
  4. Essex

    AI-generated summary

    Maria Christina Stubbings · 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

    Maria Christina Stubbings was murdered in December 2008 by a man who had previously served a life sentence in Germany for murder and had been arrested for assaulting her. The principal concerns relate to gaps in the identification, notification, monitoring and control of people with serious foreign convictions entering or residing in the UK.

    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

    Exclusion of foreign murder convictions from the Notification Order framework

    Wider context from the report

    “Notwithstanding the changes that have occurred (i) enabling a Violent Offender Order to be made in relation to someone who has a conviction for murder (including murder abroad) in May 2014 and (ii) the EU Directive which requires EU member states to notify the UK of foreign convictions of UK Nationals, at the time of conviction (as opposed to later than this which occurred in the ████████ case) and (iii) the electronic system now in place at the Central Authority – it seems that there are further opportunities that might be considered which would reduce the likelihood of another individual (with a murder conviction like ████████) entering the UK without conditions and without any police force being made aware of that person’s existence, until arrested for different offence. I ask the Home Office/MoJ to give consideration to further steps that could be taken to address the issues, including those detailed below. In making the suggestion below it is recognised that the issues are complex. (i) The Central Authority needs to be notified now of all EU nationals currently serving a sentence for serious crimes such as murder in those countries. We understand the new notification system which obliges an EU state to notify at the time of conviction, is not retrospective. Accordingly, there are likely to be a pool of older prisoners who are UK nationals, serving sentences in EU prisons, which the Central Authority is not yet aware of. Further consideration could be given to making a request of each country in order to identify who these individuals are and the offences for which they have been convicted; (ii) Consideration could be given to some form of “warning marker” which could be placed on an individual’s passport which would alert the authorities to the entry of a UK national convicted of murder, back into the UK. Furthermore, it might be possible for the Immigration Rules to be amended to enable a passport officer to request details from that individual as to the address they are going to stay at in UK; details of any car to be used by them; details of relatives; people they intend to stay with etc. The police are aware from the evidence disclosed in the Inquest (notably pre-sentence reports on ████████ that he was told by the German authorities upon his deportation that he would be met by Security Officers in the UK, who would ensure that he was given advice and keep an eye on him. It appears that this did not happen and he was free to enter the UK at Heathrow airport of 24th January, 2008 and met his father who was waiting for him; (iii) Consideration needs to be given to putting in place a mechanism which notifies local police that someone with a conviction like the murder conviction ████████ has come to reside in their area. (iv) There could be an amendment to allow for a Notification Orders to be applied for. The principle response of the Home Office/MoJ was to amend the law to allow for the police to apply for the Violent Offender Order (VOO) However, as you are aware such orders will only be granted if there is a risk that the individual is likely to commit one of more of the specified offences in Section 98(3) of the Criminal Justice and Immigration Act 2008. Those offences are 6 types of serious violent offences from Section 20 OAPA 1861 upwards to manslaughter. It is doubtful that a VOO would have been granted in the case of ████████ following the incident in July 2008, as he had only been convicted of the offence of common assault and the circumstances of the sexual offence left on file would not be relevant. (v) It may be possible for an amendment to be made to Schedule 3 of the Sexual Offences Act 2003 to include a foreign conviction for murder. With the benefit of hindsight this would allow the police to have applied for a Notification Order against ████████ as soon as they were aware of his existence. This would require him to comply with the notification requirements under section 83(5) of that Act requiring him to state his date of birth; national insurance number; home address and specify any address at which he stays on a periodic basis. It would be a useful mechanism to monitor an individual’s movements when no licence conditions would apply. ”

    Source location

    Maria Christina Stubbings · 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

    Ineligibility of individuals with foreign murder convictions for a Violent Offender Order where the specified-offence risk threshold is not met

    Wider context from the report

    “Notwithstanding the changes that have occurred (i) enabling a Violent Offender Order to be made in relation to someone who has a conviction for murder (including murder abroad) in May 2014 and (ii) the EU Directive which requires EU member states to notify the UK of foreign convictions of UK Nationals, at the time of conviction (as opposed to later than this which occurred in the ████████ case) and (iii) the electronic system now in place at the Central Authority – it seems that there are further opportunities that might be considered which would reduce the likelihood of another individual (with a murder conviction like ████████) entering the UK without conditions and without any police force being made aware of that person’s existence, until arrested for different offence. I ask the Home Office/MoJ to give consideration to further steps that could be taken to address the issues, including those detailed below. In making the suggestion below it is recognised that the issues are complex. (i) The Central Authority needs to be notified now of all EU nationals currently serving a sentence for serious crimes such as murder in those countries. We understand the new notification system which obliges an EU state to notify at the time of conviction, is not retrospective. Accordingly, there are likely to be a pool of older prisoners who are UK nationals, serving sentences in EU prisons, which the Central Authority is not yet aware of. Further consideration could be given to making a request of each country in order to identify who these individuals are and the offences for which they have been convicted; (ii) Consideration could be given to some form of “warning marker” which could be placed on an individual’s passport which would alert the authorities to the entry of a UK national convicted of murder, back into the UK. Furthermore, it might be possible for the Immigration Rules to be amended to enable a passport officer to request details from that individual as to the address they are going to stay at in UK; details of any car to be used by them; details of relatives; people they intend to stay with etc. The police are aware from the evidence disclosed in the Inquest (notably pre-sentence reports on ████████ that he was told by the German authorities upon his deportation that he would be met by Security Officers in the UK, who would ensure that he was given advice and keep an eye on him. It appears that this did not happen and he was free to enter the UK at Heathrow airport of 24th January, 2008 and met his father who was waiting for him; (iii) Consideration needs to be given to putting in place a mechanism which notifies local police that someone with a conviction like the murder conviction ████████ has come to reside in their area. (iv) There could be an amendment to allow for a Notification Orders to be applied for. The principle response of the Home Office/MoJ was to amend the law to allow for the police to apply for the Violent Offender Order (VOO) However, as you are aware such orders will only be granted if there is a risk that the individual is likely to commit one of more of the specified offences in Section 98(3) of the Criminal Justice and Immigration Act 2008. Those offences are 6 types of serious violent offences from Section 20 OAPA 1861 upwards to manslaughter. It is doubtful that a VOO would have been granted in the case of ████████ following the incident in July 2008, as he had only been convicted of the offence of common assault and the circumstances of the sexual offence left on file would not be relevant. (v) It may be possible for an amendment to be made to Schedule 3 of the Sexual Offences Act 2003 to include a foreign conviction for murder. With the benefit of hindsight this would allow the police to have applied for a Notification Order against ████████ as soon as they were aware of his existence. This would require him to comply with the notification requirements under section 83(5) of that Act requiring him to state his date of birth; national insurance number; home address and specify any address at which he stays on a periodic basis. It would be a useful mechanism to monitor an individual’s movements when no licence conditions would apply. ”

    Source location

    Maria Christina Stubbings · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026