Recurring concern

Inadequate recording of multi-agency offender risk meetings

First to latest report 29 Aug 2019 — 16 Feb 2024

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
9

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.

What is 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 and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Derby and Derbyshire

    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

  2. Manchester North

    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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026