Recurring concern

Inadequate recording of multi-agency offender risk meetings

Get email alerts

Request correction

First reported 29 Aug 2019•Latest report 16 Feb 2024

Definition

What this concern includes

Includes absent or inadequate agendas, attendance records, minutes, summaries, decisions and action records for MAPPA, IOM and comparable multi-agency offender-risk meetings.

Not included

Excludes defects in offender-risk assessment or management where the meeting record itself is adequate.
Excludes single-agency clinical, prison or probation meetings unless they form part of a multi-agency offender-risk process.
Excludes generic meeting administration unrelated to offender or public-protection risk.

Reports: 2
Individual concerns: 2
Date range: 2019–2024
Stated actions: 9

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 Justice2

Cygnet Health Care Limited1

Derby City Council1

Derbyshire Constabulary1

Derbyshire Healthcare NHS Foundation Trust1

Greater Manchester Police1

Lancashire Constabulary1

National Police Chiefs’ Council1

National Probation Service1

Probation Service1

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.

16 Feb2024
Derby and Derbyshire
Concerns raised1
1. Inadequate recording of risk meetings, decisions and actions
This report raised 11 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
  Provide regular jointly funded Social Supervisor training, including introductory Part 3 Mental Health Act training and annual refresher training.
  Stated by Derby City CouncilStated completed
2. Action
  Publish updated MAPPA meeting guidance with a revised minutes template and aide-memoire to improve recording, follow-up and risk-focused decision-making.
  Stated by Ministry of JusticeStated completed
3. Action
  Publish learning resources for MAPPA chairs and administrators on risk-focused meetings, agency accountability and risk-management actions.
  Stated by Ministry of JusticeStated completed
1. Action
  Require all staff to complete a report-writing and record-keeping skills workbook during Cygnet induction.
  Stated by Cygnet Health Care LimitedStated completed
2. Action
  Monitor and audit section 117 and transfer-of-care meetings to ensure current reports or addenda and detailed minutes are recorded, focusing on specified high-risk discharges.
  Stated by Cygnet Health Care LimitedStated completed
3. Action
  Review ARMS recording processes, adapt Standard Operating Procedures, and rectify incorrectly recorded assessments.
  Stated by Derbyshire ConstabularyStated completed
4. Action
  Scrutinise MAPPA meeting minutes through partnership learning reviews and regional peer review.
  Stated by Derbyshire ConstabularyStated in progress
AI-generated summary

Sobia Tabasim Khan · 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

Sobia Tabasim Khan, aged 37, was murdered shortly after moving from Bradford to Derby to live near a man subject to a restricted hospital order and supervision by multiple agencies. The inquest concluded that her death was an unlawful killing and identified concerns including failures to act on information about the relationship, inadequate supervision and risk assessment, over-reliance on self-reporting, poor record-keeping, and insufficient scrutiny of the man’s discharge and recall.

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
Inadequate recording of risk meetings, decisions and actions
Wider context from the report
“h. Record-keeping. This was a thread that ran through the case and applied both to the clinical notes but also the notes of meetings, such as MAPPA, which are necessarily a summary but which did not always include sufficient information to enable those reviewing them to understand what had been discussed and what actions taken. In terms of clinical records, whilst basic, mundane matters such as his sleeping habits and appetite were recorded, much of what mattered was not. The paucity of records and the poverty of their quality meant that ████████ was not aware of the history of manipulation and the other factors which indicated an ample need for reassessment. In terms of the SOTP, whereas there was a conflict of evidence as to why the group programme was not available at Cygnet hospital, the keeping of proper records would have ensured that there was a ready answer if needed. The discharge meetings were poorly recorded, with the spousal assault risk assessment not having featured at all. There were repeated instances of witnesses not being able to remember, understandably, what had happened with respect to certain events. There was no excuse for professional witnesses to be put in this embarrassing position. The MoJ are reliant on what they are told in writing, but given that there is a culture of poor record-keeping, until and unless that record-keeping is improved to an acceptable level, they have to be more pro-active and more prepared to question things. ”
Source location
Sobia Tabasim Khan · 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
Provide regular jointly funded Social Supervisor training, including introductory Part 3 Mental Health Act training and annual refresher training.

Verbatim wording from the response
“The Council has also introduced training for social supervisors funded jointly by health and social care; previously this was provided on an "ad hoc" basis and was agency specific. Broadly covering all of the matters of concern, in September 2019 Derby City Council in conjunction with Derbyshire County Council commissioned regular training for social supervisors. There is a two day introduction to Part 3 Mental Health Act 1983 and the role of the Social Supervisor and a one day annual refresher.”

Source location
Response from Derby City Council
Page 2 · response
Published 22 February 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 updated MAPPA meeting guidance with a revised minutes template and aide-memoire to improve recording, follow-up and risk-focused decision-making.

Verbatim wording from the response
“Record-keeping was a thread that ran through the case and applied both to the clinical notes but also the notes of meetings, such as MAPPA, which are necessarily a summary but which did not always include sufficient information to enable those reviewing them to understand what had been discussed and what actions taken. The National MAPPA Team in the Ministry of Justice has sought to improve the quality of MAPPA meetings and the recording of decisions. Specifically, in May 2022 updated Statutory Guidance was published on the conduct and recording of MAPPA meetings, including attendance, a clear focus on decisions relating to risk assessment and management, and that actions are clearly recorded and followed up. The Guidance is supported by a revised minutes template and an aide-memoire for MAPPA Chairs.”

Source location
Response from Ministry of Justice
Page 3 · response
Published 22 February 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 learning resources for MAPPA chairs and administrators on risk-focused meetings, agency accountability and risk-management actions.

Verbatim wording from the response
“Furthermore, in April 2023 the National MAPPA Team published learning resources for MAPPA Chairs and administrators with the aim of building confidence in ensuring that meetings are focused on risk and that all agencies are clear about their contribution to risk management planning and are accountable for agreed actions.”

Source location
Response from Ministry of Justice
Page 3 · response
Published 22 February 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 all staff to complete a report-writing and record-keeping skills workbook during Cygnet induction.

Verbatim wording from the response
“1. All staff complete a report writing and record keeping developmental Skill workbook as part of their Cygnet induction.”

Source location
Response from Cygnet
Page 3 · response
Published 22 February 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
Monitor and audit section 117 and transfer-of-care meetings to ensure current reports or addenda and detailed minutes are recorded, focusing on specified high-risk discharges.

Verbatim wording from the response
“3. Section 117 and transfer of care meetings are monitored and audited at Cygnet Derby to ensure up to date reports or addendums are submitted, and detailed minutes recorded, the main focus being on MoJ, MAPPA, and high profile service user discharges.”

Source location
Response from Cygnet
Page 3 · response
Published 22 February 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 ARMS recording processes, adapt Standard Operating Procedures, and rectify incorrectly recorded assessments.

Verbatim wording from the response
“Following feedback from His Majesty’s Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS), we have recently reviewed how we comply with the national ViSOR operating standards in recording Active Risk Management System (ARMS) assessments. We have reviewed our processes in response and adapted our Standard Operating Procedures to ensure that we are compliant and have rectified those that had been incorrectly recorded. The minutes of all Multi-Agency Public Protection Arrangements (MAPPA) meetings are recorded and are subject to scrutiny during the learning reviews conducted by the MAPPA partnership every six months. Additionally, we work with other forces in the region to peer review and scrutinise each other’s minutes from MAPPA meetings.”

Source location
Response from Derbyshire Constabulary
Page 3 · response
Published 22 February 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
Scrutinise MAPPA meeting minutes through partnership learning reviews and regional peer review.

Verbatim wording from the response
“Following feedback from His Majesty’s Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS), we have recently reviewed how we comply with the national ViSOR operating standards in recording Active Risk Management System (ARMS) assessments. We have reviewed our processes in response and adapted our Standard Operating Procedures to ensure that we are compliant and have rectified those that had been incorrectly recorded. The minutes of all Multi-Agency Public Protection Arrangements (MAPPA) meetings are recorded and are subject to scrutiny during the learning reviews conducted by the MAPPA partnership every six months. Additionally, we work with other forces in the region to peer review and scrutinise each other’s minutes from MAPPA meetings.”

Source location
Response from Derbyshire Constabulary
Page 3 · response
Published 22 February 2024
Open published response
29 Aug2019
Manchester North
Concerns raised1
1. Inadequate agenda, minutes, attendance records and meeting records for IOM cohort meetings
This report raised 14 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
  Revise the Greater Manchester IOM Manual of Guidance to cover multi-agency reviews, curfew management, escalation, information sharing, record keeping and key decisions.
  Stated by Greater Manchester PoliceStated in progress
2. Action
  Use structured IOM cohort meeting paperwork, including agendas, action logs, named attendees and timescales, to improve recording of decisions and actions.
  Stated by Greater Manchester PoliceStated completed
Respondent positions 3
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
  Detailed arrangements for integrated offender management meetings should be agreed locally rather than prescribed through national guidance.
  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
Inadequate agenda, minutes, attendance records and meeting records for IOM cohort meetings
Wider context from the report
“The evidence before the Court was that in respect of the multi-agency IOM meetings there was no formal agenda, no formal minutes, no accurate record kept of these meetings by either GMP or the NPS and no way of ascertaining who had attended these meetings. ”
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
Revise the Greater Manchester IOM Manual of Guidance to cover multi-agency reviews, curfew management, escalation, information sharing, record keeping and key decisions.

Verbatim wording from the response
“This shared approach to reviews will be included in updates to the Greater Manchester IOM Manual of Guidance (August 2018).”

Source location
2019-0292-Response-from-Greater-Manchester-Police-Redacted
Page 2 · 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
Use structured IOM cohort meeting paperwork, including agendas, action logs, named attendees and timescales, to improve recording of decisions and actions.

Verbatim wording from the response
“Response: The concerns raised about IOM practice in 2016 are accepted. However, it is important to emphasise that since 2016, there have been improvements to record keeping in line with the content of the revised IOM framework circulated in August 2018. The framework is supported by new paperwork and templates, including draft agendas and action logs with names and timescales. Learning from this case will inform further revision to the IOM guidance to include the process for escalating cases where police officers consider recall is required with the associated rationale. The revised guidance will also ensure that cases with increasing levels of risk are not only escalated but considered for referral into MAPPA within the individual case reviews.”

Source location
2019-0292-Response-from-Greater-Manchester-Police-Redacted
Page 4 · 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
Detailed arrangements for integrated offender management meetings should be agreed locally rather than prescribed through national guidance.

Verbatim wording from the response
“In respect of the multi-agency IOM meetings there was no formal agenda, no formal minutes, no accurate record kept of these meetings by either GMP or the NPS and no way of ascertaining who had attended these meetings. Of note these meetings are to discuss the ongoing management of high risk offenders being managed in the community and is an opportunity to discuss how effective the management plan is. There is no national guidance to forces or agencies on how these meetings should be structured or recorded.”

Source location
2019-0292-Response-from-HM-Prison-and-Probation-Service-Redacted.pdf
Page 4 · response
Published 25 October 2019
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Inadequate recording of risk meetings, decisions and actions

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

Concerns raised1

Inadequate agenda, minutes, attendance records and meeting records for IOM cohort meetings

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.2

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

Actions described in response 7

Actions described in response 2

Respondent positions 3