Concerns raised 3 Lack of probation officer knowledge of services for obtaining necessary mental health assessments View source Poor engagement and collaborative working with agencies and family View source Failure to engage with appropriate mental health services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Todd James Salter · 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
Todd James Salter was released from prison on licence in July 2019 and later experienced difficulties obtaining housing, drug support and mental health support. On 1 October 2019, he hanged himself outside Doncaster police station. The concerns included inadequate probation knowledge of available services, poor engagement and collaborative working between agencies and family, and the apparent progression toward criminal acts to obtain treatment and support.
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. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of probation officer knowledge of services for obtaining necessary mental health assessments
Wider context from the report “(1) The lack of knowledge of the Probation officer as to the services she could contact to obtain necessary mental health assessments . This would appear at the very least to suggest this gap in knowledge may be due to inadequate training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Poor engagement and collaborative working with agencies and family
Wider context from the report “(3) Generally poor engagement and collaborative working with both agencies and family alike .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to engage with appropriate mental health services
Wider context from the report “(2) Mr Salter being driven to desperate measures of committing criminal acts in an effort to be arrested or recalled in order to secure treatment and support; this appeared to be the way matters were moving forward without engaging with appropriate mental health services .
” Open source report
29 Aug 2019 Michael Hoolickin · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 15 Insufficient capacity to cross-reference offender intelligence across offenders and agencies View source Failure to require ACOs to access offender records View source Lack of formal information-sharing procedures for integrated teams View source Poor or absent records by SPOs and ACOs View source Failure to undertake multi-agency reviews after high-risk offenders under multi-agency management kill someone View source Lack of training on accessing drug test results View source Failure to update OASYS risk assessments View source Insufficient planning and preparation for service amalgamation View source N-Delius failing to provide timely access to current offender information View source Inadequate agenda, minutes, attendance records and meeting records for IOM cohort meetings View source Failure to accurately share information about offenders between police forces View source Lack of induction training and office procedures on local drug-testing practices View source Lack of clarity and specific instructions on ACO warnings View source Lack of clear arrangements for initiating police curfew checks View source Failure to record licence conditions on the Police National Computer View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity to cross-reference offender intelligence across offenders and agencies
Wider context from the report “During the course of the Inquest questions were raised around the ability of the NPS to cross reference intelligence received in respect of different offenders . In addition whether there was capacity to cross reference intelligence held by other agencies such as the Youth Offending Team .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to require ACOs to access offender records
Wider context from the report “There is no expectation for an ACO to access an offenders records on the case management system in order to inform themselves or to consider whether there is any further relevant information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of formal information-sharing procedures for integrated teams
Wider context from the report “The evidence before the Court was there are no Standard Operating procedures or formal processes in place for the sharing of information when teams are integrated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Poor or absent records by SPOs and ACOs
Wider context from the report “The Court had serious concerns as to the poor records or complete lack of records particularly by SPOs and the ACOs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake multi-agency reviews after high-risk offenders under multi-agency management kill someone
Wider context from the report “The failure to undertake a multi-agency review in cases where a high risk offender subject to multi-agency management has gone on to take someone’s life means both organisational and individual failings are not identified and there is a missed opportunity to learn lessons in order to prevent future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of training on accessing drug test results
Wider context from the report “The Court found there was an ineffective national system in use in 2016 (N Delius) for which there had been no training on how to access Drug test results . As a result individual offices had implemented their own systems for storing drug test results. However there is no induction training, information available to staff in individual offices by way of office procedures which informs staff of local practices.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient planning and preparation for service amalgamation
Wider context from the report “The Court has concerns as to the planning and preparation required for the amalgamation of any new service in order to alleviate the evidenced problems which occurred as a direct result of the previous Transforming Rehabilitation programme.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation N-Delius failing to provide timely access to current offender information
Wider context from the report “Numerous witnesses gave evidence as to the difficulties in accessing this system , its design and the time it takes to access the different parts which hold pertinent information about an offender , describing this as prohibitive. For example for Offender managers trying to read through the file to obtain current information there is nowhere which would easily show the most up to date curfew or the most up to date position as to how often drug testing is being conducted .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately share information about offenders between police forces
Wider context from the report “There was a complete breakdown of communication and information sharing between GMP and Lancashire Constabulary which lead to only information about one of the two offenders being passed on . More importantly there was confusion between the forces as to which offender was being discussed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of induction training and office procedures on local drug-testing practices
Wider context from the report “The Court found there was an ineffective national system in use in 2016 (N Delius) for which there had been no training on how to access Drug test results. As a result individual offices had implemented their own systems for storing drug test results. However there is no induction training, information available to staff in individual offices by way of office procedures which informs staff of local practices .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity and specific instructions on ACO warnings
Wider context from the report “The Court found there is a lack of clarity and specific instructions to the NPS on this point.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of clear arrangements for initiating police curfew checks
Wider context from the report “The Court was satisfied from the evidence that there is no clear understanding as to the initiation of curfew checks . It was clear to the Court there was confusion as to whether an offender on a curfew will automatically be subject to curfew checks carried out by the Police or whether such checks will only be conducted following a specific request by the NPS .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to record licence conditions on the Police National Computer
Wider context from the report “The Court heard that an offenders’ licence conditions are not held on the Police National Computer database . Hence if an offender is arrested by a different force they are unlikely to know whether the offender may be in breach of their licence.
” Open source report
29 Sep 2015 Lee Anthony Boden · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 5 Resident remaining undiscovered in bathroom for almost four hours View source Failure to provide timely information about intended placement View source Increased risk of heroin use following sudden hostel arrival View source Failure to recognise vulnerable residents View source Lack of a protocol for continuing monitoring of vulnerable new arrivals View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lee Anthony Boden · 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
Lee Anthony Boden was released from prison to an approved premises in Milton Keynes on 13 February 2015 and was found unresponsive in a bathroom later that night, where drugs and drug paraphernalia were found. He was confirmed dead at 12.10am on 14 February 2015; the stated cause of death was central respiratory depression associated with illicit heroin use. Concerns included limited advance notice of his placement, lack of forward planning, insufficient recognition of his vulnerability, the length of time before he was discovered, and an apparent absence of a protocol for monitoring vulnerable new arrivals.
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. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Resident remaining undiscovered in bathroom for almost four hours
Wider context from the report “(3) That he had been in the bathroom for almost four hours before he was discovered .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely information about intended placement
Wider context from the report “(1) That the deceased was not informed of his intended placement in Milton Keynes until the day before his release .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Increased risk of heroin use following sudden hostel arrival
Wider context from the report “(2) The sudden arrival at the hostel would have increased his risk of using heroin .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise vulnerable residents
Wider context from the report “(4) Having just been released from prison and being unable to return to his home, he should have been recognised as a vulnerable resident .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol for continuing monitoring of vulnerable new arrivals
Wider context from the report “(5) There appears to be no protocol in place for continuing monitoring of new arrivals who remain vulnerable .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations