Recurring concern

Unreliable offender risk assessment and review

First to latest report 29 Mar 2017 — 26 Jul 2024

Reports that mention this concern
7
Times this concern has been raised
7
Stated actions linked to this concern
13

What this concern includes

Includes failures in offender-specific risk-assessment and review processes, including OASys or equivalent assessments, timely completion, dynamic reassessment after material changes or trigger events, and revision of risk and needs assessments when evidence indicates changing risk.

What is not included
  • Excludes generic risk-assessment failures without an offender, probation or offender-management context.
  • Excludes failures in recording or sharing offender information where the offender risk-assessment or review process itself is adequate.
  • Excludes decisions about recall, release, accommodation or community supervision after an adequate offender risk assessment has been completed, unless the asserted deficiency is failure to update or review that assessment.
  • Excludes generic staff training, staffing or documentation deficiencies that are not directly part of offender risk assessment and review.
  • Excludes risk assessments belonging to a separately named hazard or service system when that named system supplies the more specific supported boundary.

Reports and published responses 7 reports

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

  1. East London

    AI-generated summary

    Zara Natasha Aleena · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to conduct timely risk assessments with complementary risk management plans

    Wider context from the report

    “(3) The understanding around risk assessment was poor, at all levels of staffing. The practical application of risk assessment was poor at all levels of staffing. Risk was not assessed at appropriate times, and the assessment of risk was not accompanied by a complementary risk management plan. Risk management plans were once prepared before risk was fully assessed (as occurred with the setting of licence conditions). One practitioner was advised to set a risk level to match other completed documents (without analysis of risk itself). Practitioners did not holistically assess risk and take account of potential indicators of serious harm, to include use of weapons; attitudes supportive of violence; callousness and high increased frequency of lower-level violence. ”

    Source location

    Zara Natasha Aleena · 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

    Deliver revised risk-assessment training to new practitioners and introduce new training for experienced staff.

    Verbatim wording from the response

    “3.3. As set out in our response to His Majesty’s Inspectorate of Probation Serious Further Offence Review, the RoSH Guidance is based on the right evidence, including learning from Serious Further Offence Reviews and Domestic Homicide Reviews, but there are ongoing organisational challenges in its implementation. We are taking steps to address the barriers to its effectiveness, but we know there is more to do, and we will publish a new HMPPS Public Protection Strategy by the end of March 2025. We have already made changes to the suite of risk training which all new learners on the Probation qualification route and new Probation Service Officers complete.”

    Source location

    Response from HMPPS and MoJ
    Page 4 · response
    Published 2 August 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver further risk-assessment training events for practitioners responsible for managing people in the community.

    Verbatim wording from the response

    “3.4. The structured process of risk assessment as set out in the RoSH Guidance, if followed, supports staff to think about an individual’s behaviour holistically, not just the index offence; and make reflective, logical, and informed decisions about risk. The section on risk management provides a structure to produce risk management plans that address the identified risks and set actions to protect people at risk.”

    Source location

    Response from HMPPS and MoJ
    Page 4 · response
    Published 2 August 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop, pilot and launch the Continuing Professional Development risk-learning product for experienced practitioners.

    Verbatim wording from the response

    “4.4. Experienced Probation Practitioners are required to revisit and complete their training in relation to Child Safeguarding and Domestic Abuse on a three-year cycle. Knowledge and understanding of risk assessment and management are further developed through experience of the work and its supervision. However, historically there has not been a requirement to attend further formal training on risk assessment and management. Having recognised that risk practice is not consistently at a sufficient standard, in December 2023 a new Continuing Professional Development risk learning product was commissioned to address this gap. This is intended to enable experienced practitioners to explore in-depth concepts related to risk assessment and to ensure their practice knowledge is up to date.”

    Source location

    Response from HMPPS and MoJ
    Page 5 · response
    Published 2 August 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and roll out the ARNS digital assessment and sentence-planning service with supporting staff learning.

    Verbatim wording from the response

    “7.4. More broadly, we are investing in the Assessing Risks, Needs and Strengths (ARNS) project, the replacement for OASys to be used in prisons and by the Probation Service. The project aims to deliver a transformational change in how we assess offenders, using the latest international evidence, including that on criminal desistance. In addition to a new enabling digital service for assessment and sentence planning, there is a comprehensive new learning and development offer to support staff to adapt and enhance their practice. The roll-out of ARNS is scheduled to begin in the third quarter of 2025 and be in place fully by the third quarter of 2026.”

    Source location

    Response from HMPPS and MoJ
    Page 7 · response
    Published 2 August 2024

    Open published response

  2. Derby and Derbyshire

    AI-generated summary

    Terri Liz Harris and 3 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

    Terri Liz Harris, her children John-Paul Bennett and Lacey Bennett, and their friend Connie Gent were discovered deceased at Terri’s home on 19 September 2021. They had been murdered by Terri’s partner, Damien Bendall, who inflicted severe head injuries on all four; the report also states that he raped Lacey. The deaths were contributed to by acts and omissions in offender supervision and electronic monitoring, including concerns about risk-recording, domestic abuse and child-safeguarding checks, reporting of threats, and notification of missed treatment appointments.

    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 review offender records at critical risk-assessment points

    Wider context from the report

    “The inquests identified that very concerning information regarding Damien Bendall was made known to the PS (including violent assault and injury of a partner, and an incident of possible child sexual abuse) but was not recorded clearly or prominently for subsequent PS practitioners to read and evaluate in risk assessment and decision-making, and indeed was not read at key and critical points. Although this was in part due to the recording made by individual PS practitioners it was also the result of confusing proformas (e.g. the OASys misleading drop-down boxes and the open and closed sections), imprecise arrangements and expectations of how and where such information should be recorded, and where checks should be directed to and made when the records needed to be reviewed. The inquests were informed of current PS expectations for recording offender risk information and assessments, but I remain very unsure that there are clear and efficient recording arrangements and systems to ensure that risk information is accurate, prominent, easily seen, and easily updateable by PS practitioners. ”

    Source location

    Terri Liz Harris and 3 others · 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

    Develop and roll out a new assessment service presenting relevant risk information in an updateable, practitioner-focused interface.

    Verbatim wording from the response

    “A new assessment service is in development and aims to present relevant information about risk, needs and strengths back to the practitioner to draw together threads and support holistic and high-”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 29 November 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Add guidance for practitioners and court report writers on locating risk information in OASys and NDelius.

    Verbatim wording from the response

    “There are ‘Registers’ within NDelius, the key purpose of which is to alert all staff, including court staff, to key risk information. In response to the concerns raised we will add to existing guidance for practitioners and court report writers on ‘where to find risk related information on case records’, covering both OASys and NDELIUS.”

    Source location

    Response from HM Prison and Probation Service
    Page 3 · response
    Published 29 November 2023

    Open published response

  3. Cheshire

    AI-generated summary

    Angela Vanessa CRADDOCK · 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

    Angela Vanessa Craddock died on 11 April 2018 after an offender attended her address and inflicted survivable injuries. Concerns included failures to identify and share information about breaches of a restraining order, incomplete risk assessment and recall information, and ineffective deployment of police resources to enforce the recall notice.

    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 include restraining order breach information in OASys risk assessments and prison recall reports and reviews

    Wider context from the report

    “During the 39 days between conviction and release the offender phoned Angela Craddock on 160 occasions. Most of the calls did not connect. The offender also wrote several letters to Angela Craddock from prison in breach of the Restraining Order. Details of the Restraining Order were sent to HMP Altcourse and on receipt a paper copy of the conditions were placed in an envelope to be delivered to the Public Protection Department. This was never received so the relevant staff were not aware of the Restraining Order. Consequently, upon release on licence the community rehabilitation service were unaware of the breaches of the Restraining Order and were unable to include this information in the OASys risk assessment or the prison recall report and review, ultimately sent on to the police for the enforcement of the recall notice. ”

    Source location

    Angela Vanessa CRADDOCK · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Operate a single Probation Service to simplify information sharing between releasing prisons and receiving probation areas.

    Verbatim wording from the response

    “At the relevant time, the post sentence supervision was being delivered by the Cheshire & Greater Manchester Community Rehabilitation Company Limited (CRC) and the separation of the delivery of probation supervision had added to the complexity of arrangements to share information between prisons and probation. The CRCs ceased to hold contracts to deliver probation services on the 25th June 2021 and there is now one Probation Service. This has simplified and therefore improved the sharing of information between releasing prisons and the receiving probation service area.”

    Source location

    Response from HM Prison and Probabtion Service
    Page 2 · response
    Published 1 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Establish a documented workflow for copying court documents, identifying risks, applying restrictions, updating custody warnings, and obtaining approval for monitoring requests.

    Verbatim wording from the response

    “A series of actions were then put in place to ensure we had assurance of no future reoccurrence. Those actions were:”

    Source location

    Response from Sodexo Government
    Page 1 · response
    Published 1 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide staff conducting public protection risk assessments with access to live probation and court information through digital casework systems.

    Verbatim wording from the response

    “Since 2018 the Prison has gained access to probation and court documents via N Delius, Digital Prison System and the Common Platform (Courts). These systems give us significant information to allow staff completing Public Protection risk assessments to have access to live and up to date information.”

    Source location

    Response from Sodexo Government
    Page 2 · response
    Published 1 June 2023

    Open published response

  4. 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 complete the full structured assessment before changing an OASys risk rating

    Wider context from the report

    “The facts of this case give rise to concern that an OASys risk rating for an offender may be changed without the offender manager conducting the full assessment exercise (using the structured form) and that the change may be recorded without proper rationale. ”

    Source location

    Saskia Jones and 2 others · Prevention of Future Deaths report
    Page 14 · 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

    Issue staff instructions requiring formal risk assessment before recorded risk levels are reduced.

    Verbatim wording from the response

    “• We will issue an instruction to staff by January 2022 that sets out the requirement that changes in recorded risk level must be informed by completing a formal risk assessment and may never be reduced without such an assessment regardless of wider resource constraints.”

    Source location

    2021-0362-Response-from-MoJ_Published
    Page 4 · response
    Published 3 November 2021

    Open published response

  5. 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

    Failure to update OASYS risk assessments

    Wider context from the report

    “At no stage after March 2016 was the offenders OASYS risk assessment updated. Moreover the lack of formal supervision meant this was not addressed. ”

    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

    Roll out the National Supervisory and Line Management Framework, including required supervision, practice observation, case review and recording oversight.

    Verbatim wording from the response

    “At no stage after March 2016 was the offender’s OASys risk assessment updated. Moreover, the lack of formal supervision meant this was not addressed.”

    Source location

    2019-0292-Response-from-HM-Prison-and-Probation-Service-Redacted.pdf
    Page 2 · response
    Published 25 October 2019

    Open published response

  6. Sunderland

    AI-generated summary

    Miss Nguyen Ngoc Quyen · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to complete timely OASys risk and needs assessments

    Wider context from the report

    “On the evidence, there were multiple occasions when information about ████████ could and should have been shared between the Police and Probation, and for him to be challenged in a more meaningful way than he was. A Probation expert gave evidence about: • the limitations of what can be achieved through the supervisory process; • the frequency of the assessments in relation to ████████ appear to “have fallen below good practice standards” but had further reviews taken place, the risk assessments would not have changed; • the absence of an Offender Assessment System (OASys) assessment on ████████ for over 3 years fell below good practice. Such an assessment would have assessed the risks and needs of an Offender; • if Northumbria Police had passed on information to Probation about 2 incidents involving ████████ there would have been enforcement action, but short of recall as the threshold criteria had not been met. ”

    Source location

    Miss Nguyen Ngoc Quyen · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Operate Lifer Review Panels to provide senior oversight and scrutiny of risk assessments and progress for supervised life-sentence offenders.

    Verbatim wording from the response

    “This framework sits alongside the new Lifer Review Panels, which were outlined at the Inquest. The aim of these Panels is to ensure Heads of Local Delivery Units have oversight of the lifer cohort under their responsibility and to scrutinise the robustness of the risk assessment/progress of life sentence offenders subject to supervision in their area. An initial lifer panel review will be completed within three months of release and annual reviews will take place thereafter. In preparation for Panel meetings, the offender manager is required to review OASys and the offender manager uses the review as a discussion topic with the lifer to gain their perspective on progress to date. The offender manager and Scottish Probation Officer discuss lifer cases in supervision prior to the Panel meeting and undertake appropriate manager oversight recording in NDElius.”

    Source location

    2019-0194-Response-by-HM-Prison-and-Probation-Service
    Page 2 · response
    Published 15 August 2019

    Open published response

  7. Liverpool and the Wirral

    AI-generated summary

    John Clarke Jaundoo · 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

    John Clarke Jaundoo, aged 24, was found with multiple stab wounds under Garston Bridge in the early hours of 15 April 2010 and died later in hospital. Three men who lived in the same supported living accommodation were subsequently convicted of his murder, and the inquest concluded that he died as a result of unlawful killing. The inquiry identified concerns about the referral and accommodation of high-risk offenders, failures to provide accurate and up-to-date information and review risk assessments, and missed oversight opportunities by Liverpool City Council.

    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 review and revise risk assessments dynamically

    Wider context from the report

    “In respect of the then Probation Trust (1) Offender 2 should have been recalled to prison and not referred to or accepted into supported living accommodation, it was wholly unsuitable for him and in particular when his behaviour was deteriorating to such an extent in the Approved Premises that his bed was withdrawn. (2) Offender 3 a high risk offender should never have been referred to or admitted to supported living accommodation (upon his release from prison), the only suitable accommodation where the risks that he posed could be appropriately managed being Approved Premises. (3) Timely, accurate and up to date information was not provided in respect of offenders 2 & 3 and; (4) The risk assessment which should have been a dynamic process was not reviewed/revised in particular as it should have been in respect of offender 2 when his behaviour started to deteriorate so substantially and which also included alcohol consumption a known precursor to his offending. In respect of Liverpool City Council (Adult Social Services) (1) Missed a number of significant opportunities to properly exercise their influence and oversight function of both the then supported living accommodation provider and the Probation Trust, they also missed opportunities to perform regular, timely validation visits and to satisfy themselves of the procedures that were in place to ensure the aims of the service were being effectively delivered and that public protection (including of staff and other service users) was the overriding priority. ”

    Source location

    John Clarke Jaundoo · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

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