Recipient

Probation Service

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First report 29 Sep 2015•Latest report 27 Jan 2025

Recipient record

Reports, concerns and published responses

Other public bodies · Sub-organisation. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
15

Naming this recipient

Published responses
40%

Found for named reports

Concerns addressed
21

Across all linked responses

Stated actions
39

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

40%published responses found
39stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Probation Service linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Liverpool and the Wirral

    AI-generated summary

    WILLIAM CAMPBELL BISSETT · 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

    William Campbell Bissett, aged 88, died by suicide by hanging in his cell at HMP Wymott on 13 October 2023, shortly before his planned release on licence. The report raised concerns about inadequate advance planning for his accommodation, insufficient engagement by prison offender management and probation services, and the failure to notify local authorities that he would be homeless on release.

    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to engage prisoners about accommodation when they cannot find housing

    Wider context from the report

    “(2) On 23rd June 2023 Mr Bissett was informed of the terms of his licence upon release. He was informed that he would not be allowed to return home. No sufficient attempt was made to engage with Mr Bissett to discuss accommodation in the event that he was unable to find a place to live himself. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to commence accommodation planning with the relevant local authority

    Wider context from the report

    “(3) 56 days before release, it being clear that Mr Bissett had nowhere to go, planning for accommodation should have been commenced with Fylde Borough Council who would have the duty to provide temporary housing and who would have engaged with Mr Bissett to discuss his requirements. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to inform local authorities of impending prisoner homelessness before release

    Wider context from the report

    “(4) 56 days before release HMP Wymott should have informed the Fylde Coast Local Authorities that Mr Bissett would be homeless upon release so that his name appeared on the agenda for the monthly Prison Release Meeting. This was not done. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to arrange an early pre-release meeting with prisoners

    Wider context from the report

    “(1) Evidence was heard to the effect that in the 8-month period before a prisoner is released arrangements for release are the responsibility of the Community Offender Manager with the Prison Offender Manager acting as a conduit of information. Further it was said that the Community Offender Manager should arrange an early meeting with the prisoner. Mr Bissett a man aged 88 in failing health only saw his Community Offender Manager on 5th October 2023, 8 days 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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide support to prisoners facing permanent separation from their spouses

    Wider context from the report

    “(5) Lack of planning for release and lack of engagement left Mr Bissett only with the knowledge that he would probably have to live the rest of his life separated from his wife. No attempt was made to help him come to terms with this reality. ”
    Open source report

  2. West Sussex, Brighton and Hove

    AI-generated summary

    Kirsten Hocking · 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

    Kirsten Hocking, aged 31, died in hospital on 24 May 2023 as a result of a heroin overdose after being released from prison and found in a public toilet. The concerns identified included a lack of specialist rehabilitation accommodation for some women leaving prison, training needs for probation officers arranging accommodation and release plans, and unclear placement-offer and decision-making systems at a specialist accommodation charity.

    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate recording and structuring of accommodation offer decisions

    Wider context from the report

    “S2R started providing this kind of specialist accommodation because there was such a pressing need for more of it. They are to be welcomed for having done so. However, like many small organisations which have grown, it appears that their systems have not always grown with them. Work is already being done, but there remains a continuing risk. Placement offers and the conditions and expectations which attach to them are too unclear. The recording of decisions around offers, withdrawal, and reconsideration, also needs to be better, not just to ensure that decisions are recorded, but also to ensure that decision-making is properly structured and takes all relevant matters into account. Withdrawing accommodation offers without first speaking to the requesting organisation (in this case staff at the prison) also gives rise to risks. As this case shows, these are critically important decisions, and great care is required. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Withdrawal of accommodation offers without consultation with requesting organisations

    Wider context from the report

    “S2R started providing this kind of specialist accommodation because there was such a pressing need for more of it. They are to be welcomed for having done so. However, like many small organisations which have grown, it appears that their systems have not always grown with them. Work is already being done, but there remains a continuing risk. Placement offers and the conditions and expectations which attach to them are too unclear. The recording of decisions around offers, withdrawal, and reconsideration, also needs to be better, not just to ensure that decisions are recorded, but also to ensure that decision-making is properly structured and takes all relevant matters into account. Withdrawing accommodation offers without first speaking to the requesting organisation (in this case staff at the prison) also gives rise to risks. As this case shows, these are critically important decisions, and great care is required. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in finding CAS3 accommodation after specialist placement failure

    Wider context from the report

    “Concern (2) is linked to the first, in that the probation officers, who have primary responsibility for finding accommodation and building release plans, need to understand what accommodation is and is not available. This case showed that no-one, including the relevant officer, realised that an AP might in theory have been available. It also showed a failure to appreciate that once the first specialist placement fell through, a second was very unlikely to be found and so CAS3 accommodation was realistically the only option. That therefore needed finding quickly, so that a support plan could be built around it. There does therefore seem to be a training need. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Unclear placement offers, conditions and expectations

    Wider context from the report

    “S2R started providing this kind of specialist accommodation because there was such a pressing need for more of it. They are to be welcomed for having done so. However, like many small organisations which have grown, it appears that their systems have not always grown with them. Work is already being done, but there remains a continuing risk. Placement offers and the conditions and expectations which attach to them are too unclear. The recording of decisions around offers, withdrawal, and reconsideration, also needs to be better, not just to ensure that decisions are recorded, but also to ensure that decision-making is properly structured and takes all relevant matters into account. Withdrawing accommodation offers without first speaking to the requesting organisation (in this case staff at the prison) also gives rise to risks. As this case shows, these are critically important decisions, and great care is required. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of probation officers to understand accommodation availability when planning release

    Wider context from the report

    “Concern (2) is linked to the first, in that the probation officers, who have primary responsibility for finding accommodation and building release plans, need to understand what accommodation is and is not available. This case showed that no-one, including the relevant officer, realised that an AP might in theory have been available. It also showed a failure to appreciate that once the first specialist placement fell through, a second was very unlikely to be found and so CAS3 accommodation was realistically the only option. That therefore needed finding quickly, so that a support plan could be built around it. There does therefore seem to be a training need. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Unclear access and eligibility criteria for specialist rehabilitation provision

    Wider context from the report

    “Concern (1) is that there was and remains a real lack of specialist rehabilitation for women, and in particular, women who represent only a low or medium risk of harm to others, but a high risk of self-harm. This cohort are for the most part shut out from Approved Premises (“AP”) (it appears that it is possible for medium risk women to be admitted to an AP but that possibility is not well understood and the reality is that it is not available; that kind of accommodation being very over-subscribed in any event). This means there is little or no effective system of rehabilitative provision for that cohort. This is a cohort in which the state has invested a great deal of time and money (in imprisoning and rehabilitative work) only, the evidence suggests, for that investment to be at risk of being squandered on release. It also means that provision can become dependant on small charities and related acts of individual generosity, which is patchwork and may bring problems of unclear access and unclear criteria (as happened here). The evidence was that this was being looked at by the Probation Service, which does not generally provide specialist rehabilitation accommodation itself but which has an obvious interest in it being available and so is monitoring the situation. However the evidence was also that the situation is getting worse not better, particularly for women (who tend to have higher levels of self-harm), and this is despite things like the Corston review in 2007 and the case of Voll SVJ seen later, which found discrimination because of the gender disparity with respect to the availability of APs. There is now a similar lack, and apparent gender impact, with regard to specialist rehabilitation accommodation too. The circumstances creating the risk of other deaths therefore subsist, and might benefit from some renewed focus. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of specialist rehabilitation accommodation for women at low or medium risk of harm to others and high risk of self-harm

    Wider context from the report

    “Concern (1) is that there was and remains a real lack of specialist rehabilitation for women, and in particular, women who represent only a low or medium risk of harm to others, but a high risk of self-harm. This cohort are for the most part shut out from Approved Premises (“AP”) (it appears that it is possible for medium risk women to be admitted to an AP but that possibility is not well understood and the reality is that it is not available; that kind of accommodation being very over-subscribed in any event). This means there is little or no effective system of rehabilitative provision for that cohort. This is a cohort in which the state has invested a great deal of time and money (in imprisoning and rehabilitative work) only, the evidence suggests, for that investment to be at risk of being squandered on release. It also means that provision can become dependant on small charities and related acts of individual generosity, which is patchwork and may bring problems of unclear access and unclear criteria (as happened here). The evidence was that this was being looked at by the Probation Service, which does not generally provide specialist rehabilitation accommodation itself but which has an obvious interest in it being available and so is monitoring the situation. However the evidence was also that the situation is getting worse not better, particularly for women (who tend to have higher levels of self-harm), and this is despite things like the Corston review in 2007 and the case of Voll SVJ seen later, which found discrimination because of the gender disparity with respect to the availability of APs. There is now a similar lack, and apparent gender impact, with regard to specialist rehabilitation accommodation too. The circumstances creating the risk of other deaths therefore subsist, and might benefit from some renewed focus. ”
    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 Female Approved Premises briefings for all practitioners, emphasising placements for women with complex needs who pose a medium risk of harm.

    Verbatim wording from the response

    “The Central Approved Premises Team are currently promoting the use of community disposals with Probation Court Teams across the county – which prevent the loss of accommodation due to a period in custody. They are also engaging with regional females leads (senior probation officers) to promote the availability of placements in an Approved Premises for women with complex needs who pose a medium risk of harm. From September this year, there will be Female AP briefings for all practitioners where this exact point will be emphasised.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 12 November 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

    Operate a Central Referral Process with a dedicated Female Central Referral Unit Manager to assess women’s need for Approved Premises placements.

    Verbatim wording from the response

    “With specific reference to the female Approved Premises estate, the need to accommodate women with a wide range of needs is recognised and the estate does aim to accommodate women with complex needs who may pose a medium risk of harm. There is a new Central Referral Process which is managed by a dedicated Female Central Referral Unit Manager who has experience of such cases and can best assess the need for an AP space. Such spaces are also available for women who are subject to a community-based disposal, not just for those on licence release.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 12 November 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

    Engage regional female leads to promote Approved Premises placements for women with complex needs who pose a medium risk of harm.

    Verbatim wording from the response

    “The Central Approved Premises Team are currently promoting the use of community disposals with Probation Court Teams across the county – which prevent the loss of accommodation due to a period in custody. They are also engaging with regional females leads (senior probation officers) to promote the availability of placements in an Approved Premises for women with complex needs who pose a medium risk of harm. From September this year, there will be Female AP briefings for all practitioners where this exact point will be emphasised.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 12 November 2024

    Open published response

  3. West Sussex, Brighton and Hove

    AI-generated summary

    Lee Spencer PURKIS · 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 Purkis, aged 54, was found in an advanced state of decomposition on the floor of his home on 9 March 2023, having been there for up to two months; the cause of death was unascertainable. Before his death, he was subject to a mental health treatment requirement, but the receiving Trust was not informed of it and discharged him without learning about it. The report identifies a risk that failures to transfer or oversee such requirements could affect their proper administration in other cases.

    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of probation oversight to ensure awareness and proper administration of mental health treatment requirements

    Wider context from the report

    “My concern here is that Lee Purkis had been, in the period leading up to his death, the subject of a mental health treatment requirement (MHTR) imposed by the Crown Court as part of a community order, but the Trust that ended up treating him were not aware of it, and discharged him from its care without learning about it. There is no evidence that it made any difference in this case but that is because of the particular (and unfortunate) circumstances of how long it took to find Mr Purkis and the corresponding absence of evidence about how he died. There is, however, a real risk that it might make a difference in another case. This order was handed down by a sympathetic Crown Court judge, supported by probation in the pre-sentence report, and it seems to have been a potentially creative solution for a complex man. The use of MHTRs is, it seems to me on the evidence, to be encouraged, but that objective will be undermined if they are not understood and administered properly and so people don’t see them working. In Mr Purkis’s case, the particular problem appears to have occurred because the Trust that agreed the order (a requirement of it being imposed in the first place) then transferred the care because the accommodation area changed. That is not unusual, but the relevant Trust then failed to transfer or inform the receiving Trust of the fact of the MHTR and what it required. This means that it was, of course, a Trust error, but I am sending this report to probation because the evidence suggests that it is probation that should have oversight, and it should be ensuring all involved in the administration of the requirement are aware of it. I therefore consider there is a risk associated with these circumstances, and that action should be taken, such as ensuring that probation officers keep an eye on MHTRs when they have them, and ensure the other services do so too. There are not many of them; there probably should be more; but again, that means ensuring the ones that there are get used properly. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to transfer and communicate mental health treatment requirements to receiving Trusts

    Wider context from the report

    “My concern here is that Lee Purkis had been, in the period leading up to his death, the subject of a mental health treatment requirement (MHTR) imposed by the Crown Court as part of a community order, but the Trust that ended up treating him were not aware of it, and discharged him from its care without learning about it. There is no evidence that it made any difference in this case but that is because of the particular (and unfortunate) circumstances of how long it took to find Mr Purkis and the corresponding absence of evidence about how he died. There is, however, a real risk that it might make a difference in another case. This order was handed down by a sympathetic Crown Court judge, supported by probation in the pre-sentence report, and it seems to have been a potentially creative solution for a complex man. The use of MHTRs is, it seems to me on the evidence, to be encouraged, but that objective will be undermined if they are not understood and administered properly and so people don’t see them working. In Mr Purkis’s case, the particular problem appears to have occurred because the Trust that agreed the order (a requirement of it being imposed in the first place) then transferred the care because the accommodation area changed. That is not unusual, but the relevant Trust then failed to transfer or inform the receiving Trust of the fact of the MHTR and what it required. This means that it was, of course, a Trust error, but I am sending this report to probation because the evidence suggests that it is probation that should have oversight, and it should be ensuring all involved in the administration of the requirement are aware of it. I therefore consider there is a risk associated with these circumstances, and that action should be taken, such as ensuring that probation officers keep an eye on MHTRs when they have them, and ensure the other services do so too. There are not many of them; there probably should be more; but again, that means ensuring the ones that there are get used properly. ”
    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

    Collaborate with the Forensic and Specialist Directorate to examine Kent Secondary Care Mental Health Treatment Requirement practice and responsibilities across the intervention.

    Verbatim wording from the response

    “More specifically in Kent we have begun collaborating with the Service Director of the Forensic and Specialist Directorate to explore current practice with Secondary Care MHTRs from pre-sentence stage through to delivery of the treatment requirement and the roles both Probation and Secondary Care play in the intervention. We aim to upskill Secondary Care Responsible Clinicians and Probation Court and Sentence Management staff to ensure we are identifying the right people at Court who may benefit from this Order and overseeing the case in a robust manner.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 8 August 2024

    Open published response

  4. West Sussex, Brighton and Hove

    AI-generated summary

    Francis Ian WILLIAMS · 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

    Francis Williams, who was subject to an imprisonment for public protection sentence, was evicted from accommodation after struggling with alcohol and was facing possible recall to prison. He told his probation officer he intended to kill himself and was found dead from a heroin overdose in a tent in Bognor Regis on 28 January 2023. The report identified concerns about probation officers recognising suicide and self-harm risks among IPP offenders and about processes for suspending and cancelling parole licence supervision.

    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of probation officers to understand processes for suspending and cancelling parole licence supervision

    Wider context from the report

    “My investigation reveals two relevant concerns: 1.        That probation officers need to understand, and be constantly alert to, the risk of suicide/self-harm in IPP offenders. It is clear from Mr Williams’ case, but also from other cases and other evidence, that this cohort often experiences a particular kind of despair. That is fuelled in part by the particular sense of unfairness that they feel about being on an IPP at all, now the sentence has been abolished and all agree that IPP sentences were a terrible idea. The other factor is the absence of hope of ever getting off it. 2.        Linked to that second point, it is crucial that probation officers are also fully versed in the processes for suspending parole licence supervision and then cancelling it altogether. One of the real tragedies of Mr Williams’ case is that in 2019 he had been free for ten years, so he should have been referred for licence cancellation. It did not happen, and it is not clear why, but it may have been because no-one was actively looking at him given that his supervision had been suspended. In any event, the referral system did not work and Mr Williams was never referred, at any stage, for cancellation. Mr Williams was then overtaken by lockdown and related matters in 2020, which pulled the rug on his business and other protective factors, and he then returned to supervision and ultimately recall to prison. Following release in 2022 he was still not referred, and even at the end of that year - which I note was now after the amendments to s.31A of the Crime (Sentences) Act 1997 and the introduction of an entitlement to automatic referral to the Parole Board for cancellation – no referral had been made. By then, of course, Mr Williams might have found cancellation much more difficult. However, it is noteworthy that even with those well publicised changes, which Mr Williams had heard about, his probation officer seemed to be struggling to find out how the process worked (entries in the probation records in December 2022 confirm). Again, the point is that there is a particular kind of despair among the IPP cohort. The main safeguard is the facility for getting off that, or at least giving these men hope that they may be able to get off it. Mr Williams and his probation officer were struggling to find out how to access even that limited (and automatic) safeguard. It was very shortly after that (within a month or so) that he took his life. The jury was clear that the fact of the IPP caused his state of mind and so caused his death. It seems to me that these two concerns at least give rise to a training need. There may be more. But I consider that action should be taken. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the referral system to refer eligible people for parole licence cancellation

    Wider context from the report

    “My investigation reveals two relevant concerns: 1.        That probation officers need to understand, and be constantly alert to, the risk of suicide/self-harm in IPP offenders. It is clear from Mr Williams’ case, but also from other cases and other evidence, that this cohort often experiences a particular kind of despair. That is fuelled in part by the particular sense of unfairness that they feel about being on an IPP at all, now the sentence has been abolished and all agree that IPP sentences were a terrible idea. The other factor is the absence of hope of ever getting off it. 2.        Linked to that second point, it is crucial that probation officers are also fully versed in the processes for suspending parole licence supervision and then cancelling it altogether. One of the real tragedies of Mr Williams’ case is that in 2019 he had been free for ten years, so he should have been referred for licence cancellation. It did not happen, and it is not clear why, but it may have been because no-one was actively looking at him given that his supervision had been suspended. In any event, the referral system did not work and Mr Williams was never referred, at any stage, for cancellation. Mr Williams was then overtaken by lockdown and related matters in 2020, which pulled the rug on his business and other protective factors, and he then returned to supervision and ultimately recall to prison. Following release in 2022 he was still not referred, and even at the end of that year - which I note was now after the amendments to s.31A of the Crime (Sentences) Act 1997 and the introduction of an entitlement to automatic referral to the Parole Board for cancellation – no referral had been made. By then, of course, Mr Williams might have found cancellation much more difficult. However, it is noteworthy that even with those well publicised changes, which Mr Williams had heard about, his probation officer seemed to be struggling to find out how the process worked (entries in the probation records in December 2022 confirm). Again, the point is that there is a particular kind of despair among the IPP cohort. The main safeguard is the facility for getting off that, or at least giving these men hope that they may be able to get off it. Mr Williams and his probation officer were struggling to find out how to access even that limited (and automatic) safeguard. It was very shortly after that (within a month or so) that he took his life. The jury was clear that the fact of the IPP caused his state of mind and so caused his death. It seems to me that these two concerns at least give rise to a training need. There may be more. But I consider that action should be taken. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of probation officers to understand and remain alert to suicide and self-harm risk in IPP offenders

    Wider context from the report

    “My investigation reveals two relevant concerns: 1.        That probation officers need to understand, and be constantly alert to, the risk of suicide/self-harm in IPP offenders. It is clear from Mr Williams’ case, but also from other cases and other evidence, that this cohort often experiences a particular kind of despair. That is fuelled in part by the particular sense of unfairness that they feel about being on an IPP at all, now the sentence has been abolished and all agree that IPP sentences were a terrible idea. The other factor is the absence of hope of ever getting off it. 2.        Linked to that second point, it is crucial that probation officers are also fully versed in the processes for suspending parole licence supervision and then cancelling it altogether. One of the real tragedies of Mr Williams’ case is that in 2019 he had been free for ten years, so he should have been referred for licence cancellation. It did not happen, and it is not clear why, but it may have been because no-one was actively looking at him given that his supervision had been suspended. In any event, the referral system did not work and Mr Williams was never referred, at any stage, for cancellation. Mr Williams was then overtaken by lockdown and related matters in 2020, which pulled the rug on his business and other protective factors, and he then returned to supervision and ultimately recall to prison. Following release in 2022 he was still not referred, and even at the end of that year - which I note was now after the amendments to s.31A of the Crime (Sentences) Act 1997 and the introduction of an entitlement to automatic referral to the Parole Board for cancellation – no referral had been made. By then, of course, Mr Williams might have found cancellation much more difficult. However, it is noteworthy that even with those well publicised changes, which Mr Williams had heard about, his probation officer seemed to be struggling to find out how the process worked (entries in the probation records in December 2022 confirm). Again, the point is that there is a particular kind of despair among the IPP cohort. The main safeguard is the facility for getting off that, or at least giving these men hope that they may be able to get off it. Mr Williams and his probation officer were struggling to find out how to access even that limited (and automatic) safeguard. It was very shortly after that (within a month or so) that he took his life. The jury was clear that the fact of the IPP caused his state of mind and so caused his death. It seems to me that these two concerns at least give rise to a training need. There may be more. But I consider that action should be taken. ”
    Open source report

  5. Cornwall and Isles of Scilly

    AI-generated summary

    Michaela Hall · 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

    Michaela Hall was stabbed through the eye by her partner on 31 May 2021 and was found deceased the next day; life was formally pronounced extinct on 1 June 2021. The report identified shortcomings in recruitment, pre-sentence reporting and risk assessment, including the partner’s risk being assessed as medium rather than high. It also raised concerns about how Children and Adult Services assessed, recorded, shared and acted on information concerning domestic abuse, safeguarding and potential mental impairment.

    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to undertake health-related enquiries in response to potential mental impairment

    Wider context from the report

    “Be curious. There were multiple examples of potential mental impairment – a diagnosis of OCD, mentions of suicidality and depression, the Acton email, yet no health-related enquiries appear to have been undertaken. ”
    Open source report

  6. 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. The report was sent to Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient or absent probation domestic abuse and child safeguarding checks

    Wider context from the report

    “The inquests identified that DA and SG checks were either insufficient or wholly lacking at various stages of Damien Bendall’s offender management. The current evidence is that DA and SG checks remain generally insufficient or are not being done with consequent on-going risks to children and women. Insufficient or absent PS DA and SG checks has been a theme of HM Inspectorate of Probation reports and reviews for at least the last 5 years. On HM Inspectorate of Probation case sampling to determine whether domestic abuse and child safeguarding enquiries were being undertaken when indicated, the HM Inspectorate of Probation Annual Report for 2022/2023 states at page 38:- where inspectors judged that these enquiries needed to be made by the probation practitioner, child safeguarding enquiries were carried out in 55 per cent of cases, domestic abuse enquiries were only carried out in 49 per cent of cases and risk of harm was only properly addressed in 39 per cent. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient or untimely domestic abuse and child safeguarding training for probation practitioners

    Wider context from the report

    “A significant issue in the inquests was the fact that the very inexperienced staff who were (wrongly) allocated Damien Bendall’s case on transfer to the East Midlands PS region had insufficient DA and SG training. The PS states it has introduced more robust DA and SG training, but it is unclear whether PS practitioners are receiving this before cases are allocated to them to manage. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure that PSR reports accurately evidence completed checks

    Wider context from the report

    “There is no evidence that DA and SG checks were made by the PS practitioner in respect of Damien Bendall’s PSR report. Via the report the court was informed that checks had been conducted. The PS practitioner put forward a curfew provision as appropriate and the report was written in such a way to indicate that the report writer had checked the suitability of the curfew address, when she had not in fact done so. Had the court not been misled it is unlikely that the court’s disposal would have included a curfew requirement. The inquests heard that PSRs written by the same PS practitioner, reviewed before her submission of Damien Bendall’s PSR, and reports reviewed after the murders, also lacked evidence of DA and SG checks having been made even though they were stated to have been done in the reports. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to report potentially risk-indicating offender comments from electronic monitoring

    Wider context from the report

    “Damien Bendall made the comment “If this relationship goes bad I’ll murder my girlfriend and the children” to the EMS field operative who fitted his tag and monitoring equipment but this was not reported back by the field operative to her manager nor to the PS. EMS has stated that it has introduced relevant training but the inquest heard evidence from the field operative that comments made by offenders which can be interpreted as potentially posing risk are currently routinely not being reported back by EMS field operatives. The inquests examined the relevant contract terms between the Ministry of Justice and Capita (EMS) relating to reporting concerns and there did appear to be lack of clarity on reporting mechanisms and issues to report. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain accurate, prominent and readily updateable offender risk records

    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. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to complete domestic abuse and child safeguarding checks before proposing curfew conditions

    Wider context from the report

    “The PS is not currently conducting SG checks in all cases where an offender will live with or have access to children. The PS has mandated that in all cases where a curfew condition is proposed to the court in a pre-sentence report (PSR) DA and SG checks will be conducted prior to the proposal and submission of the PSR: this is not being done in all cases. I am also unclear whether contact to the address homeowner/lead tenant for a potential curfew condition to discuss the suitability of a curfew condition is being undertaken in all cases. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Uncertainty about contacting homeowners or lead tenants to assess curfew-address suitability

    Wider context from the report

    “The PS is not currently conducting SG checks in all cases where an offender will live with or have access to children. The PS has mandated that in all cases where a curfew condition is proposed to the court in a pre-sentence report (PSR) DA and SG checks will be conducted prior to the proposal and submission of the PSR: this is not being done in all cases. I am also unclear whether contact to the address homeowner/lead tenant for a potential curfew condition to discuss the suitability of a curfew condition is being undertaken in all cases. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to promptly notify the Probation Service of missed substance misuse appointments

    Wider context from the report

    “The precise number is not clear on the records, but he missed 4 or 5 appointments with the service between 21 July and his first attended appointment on 17 September 2021, but the required proforma attendance/non-attendance forms were not sent by the substance misuse service to notify the PS. Such non-attendance is non-compliance with the court-imposed alcohol treatment requirement and should be considered by the PS practitioner for referral back to the court as a breach of the court order. Clearly it is vital that non-attendance is formally and quickly notified to the PS practitioner especially where there is a relationship between use of substances and violent offending. ”
    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 Probation Service; that does not assign responsibility.

    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. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct child safeguarding checks where offenders will live with or access children

    Wider context from the report

    “The PS is not currently conducting SG checks in all cases where an offender will live with or have access to children. The PS has mandated that in all cases where a curfew condition is proposed to the court in a pre-sentence report (PSR) DA and SG checks will be conducted prior to the proposal and submission of the PSR: this is not being done in all cases. I am also unclear whether contact to the address homeowner/lead tenant for a potential curfew condition to discuss the suitability of a curfew condition is being undertaken in all cases. ”
    Open source report

  7. Addressed to National Probation Service, now represented here by Probation Service.

    Hertfordshire

    AI-generated summary

    Katie Louisa Locke · 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

    Katie Louisa Locke was unlawfully killed at Theobalds Park Hotel on 24 December 2015 by forceful and prolonged compression of her neck, accompanied by serious sexual violence. The report identifies concerns about gaps in information held by public bodies, insufficient information-sharing, and inadequate dissemination and understanding of the potentially dangerous persons process, creating a continuing risk that it may not be properly used to protect the public.

    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient dissemination and understanding of the PDP process across agencies

    Wider context from the report

    “Evidence in the Inquest revealed that, whilst the two police forces who dealt with the murderer both had a PDP process in place, however, the existence of the process and its operation was not known and understood by everyone working at all levels in the police. Furthermore, whilst all other relevant public agencies should have had an awareness of the PDP process and how to make contact via the Police, it seems that knowledge of the PDP process amongst those staff of the Hertfordshire Partnership NHS Foundation Trust and Hertfordshire Probation Service who gave evidence at the inquest was sporadic. It is not possible for me to know whether this is a fair reflection of the broader understanding and engagement in the PDP process by the respective organisations. Nevertheless, it gives rise to the concern that information about the PDP process is not sufficiently well disseminated throughout all of the agencies who need to work together within the PDP process to make it work and that further training and/or exchange of information may be helpful. I consider that unless some action is taken there is a continuing risk that the PDP process will not be properly used to achieve its purpose and provide protection to the public from potentially dangerous people. ”
    Open source report

  8. Addressed to National Probation Service, now represented here by Probation Service.

    South Yorkshire (Eastern)

    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 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 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 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

  9. Addressed to National Probation Service, now represented here by Probation Service.

    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. The report was sent to 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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

  10. Addressed to National Probation Service, now represented here by Probation Service.

    South Yorkshire (Western)

    AI-generated summary

    Mr John Gogarty · 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

    Mr John Gogarty was unlawfully killed at his home on 13 July 2015 by two people who planned to steal money to pay a drug debt; he was stabbed 69 times. The report identified missed opportunities and inadequate monitoring by the Probation Service, including failures relating to licence breaches, drug testing and recall. It also identified a missed opportunity for information about an offender’s relationship with a female patient to be shared with the 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. The report was sent to Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain random drug testing for people not resident at a Probation Hostel

    Wider context from the report

    “The evidence showed that there was appropriate random drug testing for ████████ whilst he was resident at the Probation Hostel. However, when he left the hostel there was no system in place for random testing. This, in the view of the court, was a relevant issue. It is accepted that the evidence further showed that there is now a system in place for random testing of those not resident at a Probation Hostel. However, the purpose of this Regulation 28 report is to underline the courts view of the importance of such testing. Should a time come in the future when the operation of random testing becomes more difficult, whether through financial restraint or otherwise, the court will be concerned if random testing was stopped. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to share relevant information with the Probation Service after identifying details become available

    Wider context from the report

    “Your Trust was solely concerned with the care of ████████. During that care your patient was associating with who had a very considerable history and was under the supervision of the National Probation Service following a sentence for murder. Although original offers were made to contact the Probation Service to pass on information, these came to nothing because insufficient details about the male were known. However, within a relatively short time further information to identify this male became apparent but there was no further follow up with the Probation Service. No specific criticism is made of the member of staff involved at that time, it might very well be that many staff might have assumed that there was nothing to be gained. However, in reality, if the Probation Service had been aware of your patients background they would have at least had the opportunity to consider the conditions of the parole afresh, potentially putting in place further safeguards. It is respectfully suggested that the lesson here is that small pieces of information properly shared on an inter-agency basis might well add up to a bigger picture for other organisations. ”
    Open source report

  11. Addressed to National Probation Service, now represented here by Probation Service.

    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. The report was sent to Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Probation staffing and accommodation deficiencies

    Wider context from the report

    “The Inquest highlighted many other issues: - • The Probation Service in Sunderland had staffing and accommodation problems. Operations and efficiency appeared to be in stark contrast between North West and North East. • The time spent with ████████ was short and in a working environment not conducive to meaningful engagement. • Unwin undermined the supervisory process by attending appointments with his child and not progressing in a more timely way the request to create a portfolio of his employment, culminating in an unsigned reference dated 25th July 2017. • There were no contemporaneous computer records from 13th December 2016 until 18th August 2017, the day before ████████ appeared in Court for murder. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of integrated information technology

    Wider context from the report

    “However, I remain concerned. For example, Probation were of the view that the present solution was an interim one, whereas the Police thought it was finalised. There were further issues considered, such as the lack of integrated IT, failures of communication from a number of sources, supervision, issues of risk management and staff turnover, and pressures upon staff performance and the ability to investigate self-report. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient time and unsuitable environment for meaningful probation engagement

    Wider context from the report

    “The Inquest highlighted many other issues: - • The Probation Service in Sunderland had staffing and accommodation problems. Operations and efficiency appeared to be in stark contrast between North West and North East. • The time spent with ████████ was short and in a working environment not conducive to meaningful engagement. • Unwin undermined the supervisory process by attending appointments with his child and not progressing in a more timely way the request to create a portfolio of his employment, culminating in an unsigned reference dated 25th July 2017. • There were no contemporaneous computer records from 13th December 2016 until 18th August 2017, the day before ████████ appeared in Court for murder. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of contemporaneous probation computer records

    Wider context from the report

    “The Inquest highlighted many other issues: - • The Probation Service in Sunderland had staffing and accommodation problems. Operations and efficiency appeared to be in stark contrast between North West and North East. • The time spent with ████████ was short and in a working environment not conducive to meaningful engagement. • Unwin undermined the supervisory process by attending appointments with his child and not progressing in a more timely way the request to create a portfolio of his employment, culminating in an unsigned reference dated 25th July 2017. • There were no contemporaneous computer records from 13th December 2016 until 18th August 2017, the day before ████████ appeared in Court for murder. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Over-reliance on offender self-reporting and ineffective challenge of accounts

    Wider context from the report

    “There was an over reliance on self-reporting by the offenders. The evidence exposed a system for the protection of the public, which was at times dysfunctional, contributed to by human factors. Evidence heard during the hearings demonstrated that there was a disconnect between the reality on the ground and, in particular, ████████’s accounts to his Probation Officer. Although inevitably he would minimise his actions, there was little or no evidence that he was challenged effectively. ”
    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 Probation Service; that does not assign responsibility.

    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. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to share relevant police information with Probation

    Wider context from the report

    “In April 2015 due to high operational demand there was a direction from the senior management team of Northumbria Police to stop monitoring Category 2 Level 1 offenders and to remove the markers on the log. As a result, the Multi Agency Public Protection Arrangements (MAPPA) department were no longer actively managing Category 2 Level 1 offenders. The responsibility for sharing information was solely with the sourcing officer. With ████████ his Police computer record was not updated, and attending Police Officers for incidents in 2015 and 2017 did not pass information to the relevant Probation Officer. The responsibility goes wider though to Control Room Staff, Patrol Sergeants, Patrol Constables and Supervising Sergeants too, when markers, flags and warnings were evident. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failures of communication across relevant sources

    Wider context from the report

    “However, I remain concerned. For example, Probation were of the view that the present solution was an interim one, whereas the Police thought it was finalised. There were further issues considered, such as the lack of integrated IT, failures of communication from a number of sources, supervision, issues of risk management and staff turnover, and pressures upon staff performance and the ability to investigate self-report. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to monitor and actively manage Category 2 Level 1 offenders

    Wider context from the report

    “In April 2015 due to high operational demand there was a direction from the senior management team of Northumbria Police to stop monitoring Category 2 Level 1 offenders and to remove the markers on the log. As a result, the Multi Agency Public Protection Arrangements (MAPPA) department were no longer actively managing Category 2 Level 1 offenders. The responsibility for sharing information was solely with the sourcing officer. With ████████ his Police computer record was not updated, and attending Police Officers for incidents in 2015 and 2017 did not pass information to the relevant Probation Officer. The responsibility goes wider though to Control Room Staff, Patrol Sergeants, Patrol Constables and Supervising Sergeants too, when markers, flags and warnings were evident. ”
    Open source report

  12. Addressed to National Probation Service, now represented here by Probation Service.

    West Yorkshire Eastern

    AI-generated summary

    Scott Patrick Carton · 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

    Scott Patrick Carton was released from prison on 5 January 2017 to the Westgate Project Hostel in Wakefield and was found dead there on 10 January 2017. His death involved the synergistic combination of prescribed methadone, pregabalin and tramadol. Concerns included the suitability of his hostel placement, the lack of anticipated psychological support and a clear management plan, and wider gaps in support for prisoners with mental health and drug dependence issues before and after release.

    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of appropriate psychological input in release accommodation

    Wider context from the report

    “1. A probation report dated 18 July 2016 recommended Mr Carton’s release on licence, notwithstanding a failed release on licence in summer 2015, in which he swiftly reverted to illicit drugs. The 18 July 2016 report envisaged specialist psychological input at Approved Premises which had access to psychological resources and a ‘robust risk management plan in place’ In the event Mr Carton was sent to a different hostel which did not provide psychological inputs of the type envisaged, nor was any clear management plan communicated to the hostel staff who had to deal with Mr Carton's challenging behaviour. The likelihood of the hostel placement proving beneficial was thus compromised from the outset. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to arrange immediate GP registration after release

    Wider context from the report

    “6. To maximise the prospect of a successful reintegration into society, prisoners with mental health issues and/or drug dependence need appropriate support services to be in place prior to their release and arrangements made to have them registered with a GP immediately (so as to provide a conduit to community mental health services) ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to establish appropriate support services before release

    Wider context from the report

    “6. To maximise the prospect of a successful reintegration into society, prisoners with mental health issues and/or drug dependence need appropriate support services to be in place prior to their release and arrangements made to have them registered with a GP immediately (so as to provide a conduit to community mental health services) ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate a clear management plan to release-accommodation staff

    Wider context from the report

    “1. A probation report dated 18 July 2016 recommended Mr Carton’s release on licence, notwithstanding a failed release on licence in summer 2015, in which he swiftly reverted to illicit drugs. The 18 July 2016 report envisaged specialist psychological input at Approved Premises which had access to psychological resources and a ‘robust risk management plan in place’ In the event Mr Carton was sent to a different hostel which did not provide psychological inputs of the type envisaged, nor was any clear management plan communicated to the hostel staff who had to deal with Mr Carton's challenging behaviour. The likelihood of the hostel placement proving beneficial was thus compromised from the outset. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to respond to relevant information about safe release placement

    Wider context from the report

    “2. The parents’ strenuous attempts to alert the Probation Service to the difficulties their son faced and the need for a placement at Approved Premises in a different area so as to avoid his drug connections, went unheeded. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of appropriate psychological interventions in prison

    Wider context from the report

    “4. Having been diagnosed with an emotionally unstable personality disorder in 2013 Mr Carton needed to be allocated to a prison establishment which did provide appropriate psychological interventions. In the event he was placed in HMP Wealstun which did not provide such services. This diminished any prospect of him succeeding in the community when released. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient psychological resource for prisoners released on licence

    Wider context from the report

    “5. Evidence taken at the inquest emphasised the paucity of psychological resource available to prisoners released on licence with emotionally unstable personality disorder and drug dependence issues. In consequence, individuals such as Mr Carton are released into the community when they are ill prepared. Unless adequate resources are available the result is likely to be that individuals will consume police and hospital resources as their condition deteriorates to the point where they are recalled to prison or their life ends in tragedy. ”
    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate medical support in the release placement

    Wider context from the report

    “3. Evidence was taken from several witnesses who expressed views to the effect that the Westgate Project was not the appropriate place for Mr Carton as he needed ‘medical help’ ”
    Open source report

  13. Addressed to National Probation Service, now represented here by Probation Service.

    Manchester South

    AI-generated summary

    Christopher Stewart HUTTON · 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

    Christopher Stewart HUTTON, a 48-year-old man who lived alone, was found hanging in an upstairs bedroom on 30 June 2017 after failing to attend a probation appointment. The investigation concluded that his death was suicide, with the medical cause recorded as hanging. A substantive concern was that he had not commenced an intensive probation treatment programme because of high demand and significant backlogs, despite its being a key part of his sentence.

    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 Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in allocating places on intensive Probation treatment programmes

    Wider context from the report

    “(1) As part of his sentence, the deceased had been referred for an intensive Probation treatment programme. This formed a key part of the sentence. He was anxious to complete that part of the order. He had indicated that he would find it beneficial to complete the course. Despite the time that had passed since sentencing, he had not commenced the treatment plan. The reason given to the Court was that there was a high volume of demand and significant backlogs which meant that allocating places was very challenging. ”
    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

    Undertake a scoping exercise for a central referral system to streamline sex-offender treatment allocation.

    Verbatim wording from the response

    “A further 10 staff will then be trained and in post by the end of 2018. In addition, the North West Division is undertaking a scoping exercise for a central referral system to streamline the allocation process.”

    Source location

    2018-0011-Response-by-HM-Prison-and-Probation-Services
    Page 1 · response
    Published 7 March 2018

    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

    Increase North West sex-offender group-work staffing from 23 to 35 facilitators through training and appointing additional staff.

    Verbatim wording from the response

    “We are grateful for your comments and recommendation for improvement. You are concerned that the sex offender treatment programme that Christopher Hutton was to undertake had not yet commenced at the time of his death. You will be aware that there has been a significant increase in the number of persons convicted of sexual offences; this has resulted in increased demand for sex offender treatment programmes. To address this high demand, work is in progress nationally to increase the number of staff delivering sex offender group work. In the North West, the staff profile is increasing from 23 facilitators to 35. (These are full time equivalents: some of the new staff will also have offender management responsibilities as part of their role.) We envisage that the 11 new facilitators who are currently being trained will be in post by June 2018.”

    Source location

    2018-0011-Response-by-HM-Prison-and-Probation-Services
    Page 1 · response
    Published 7 March 2018

    Open published response

  14. Addressed to National Probation Service, now represented here by Probation Service.

    Milton Keynes

    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 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 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 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 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 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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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

40%
40%All other recipients 58%
0%100%

How actions were described at the time

This respondent
15%64%21%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026