Recipient

Steps2Recovery

First report 11 Nov 2024•Latest report 11 Nov 2024

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 3
Stated actions: 12

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.

100%published responses found

12stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Steps2Recovery linked to the concerns in each report. Select any concern, action or position to view the source wording.

11 Nov2024
West Sussex, Brighton and Hove
Concerns raised7
1. Inadequate recording and structuring of accommodation offer decisions
2. Withdrawal of accommodation offers without consultation with requesting organisations
3. Delays in finding CAS3 accommodation after specialist placement failure
1. Unclear placement offers, conditions and expectations
2. Failure of probation officers to understand accommodation availability when planning release
3. Unclear access and eligibility criteria for specialist rehabilitation provision
4. Lack of specialist rehabilitation accommodation for women at low or medium risk of harm to others and high risk of self-harm
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 7
1. Action
  Record prospective-client communications, discussions and decisions in Lamplight and audit them through senior management.
  Stated planned
2. Action
  Contact referring services two weeks before arrival to confirm circumstances and obtain input before withdrawing an offer.
  Stated planned
3. Action
  Add clearer written and verbal assessment parameters covering risks and circumstances that may affect admissions.
  Stated planned
1. Action
  Provide further staff training on Lamplight to improve system use and documentation accuracy.
  Stated planned
2. Action
  Collaborate with Lamplight to configure the case-management system for more efficient and effective operation.
  Stated in progress
3. Action
  Use an implemented Offer/Acceptance document to record offer conditions and share them with relevant parties.
  Stated completed
4. Action
  Provide mandatory continuous staff training on updated processes, decision recording, policies and procedures.
  Stated completed
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 Steps2Recovery; 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 Steps2Recovery; 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 Steps2Recovery; 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 Steps2Recovery; 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 Steps2Recovery; 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 Steps2Recovery; 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 Steps2Recovery; 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
Record prospective-client communications, discussions and decisions in Lamplight and audit them through senior management.

Verbatim wording from the response
“○ To provide further robustness and transparency all communications, discussions, and decisions, with regards to the prospective client, will be recorded on Lamplight, and regularly audited by our new senior management team. This ensures robust documentation and accountability of decision making.”

Source location
Response from Steps2Recovery
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
Contact referring services two weeks before arrival to confirm circumstances and obtain input before withdrawing an offer.

Verbatim wording from the response
“○ In addition to our normal application process, and to ensure preparedness, S2R will contact the referring service two weeks prior to the client’s arrival to confirm there have been no changes in circumstances. If circumstances have changed, which may lead to the withdrawal of the offer, the referring service will be contacted and have input into the final decision before it is made.”

Source location
Response from Steps2Recovery
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
Add clearer written and verbal assessment parameters covering risks and circumstances that may affect admissions.

Verbatim wording from the response
“○ All potential admissions are informed during the assessment process that they are required to remain fully abstinent from drugs and alcohol. Additionally, it will now include clearer parameters relating to issues such as, but not limited to; self-harm, suicide, prescribed medication, criminality, mobility and physical health. Any changes in these circumstances may lead to a re-evaluation of their application by a”

Source location
Response from Steps2Recovery
Page 1 · 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
Provide further staff training on Lamplight to improve system use and documentation accuracy.

Verbatim wording from the response
“○ S2R has undertaken a thorough review of its case management system, Lamplight, and is collaborating with Lamplight to ensure the system operates at its most efficient and effective configuration. ○ Comprehensive further staff training on the Lamplight system will then be provided to ensure its optimal use and accuracy in documentation.”

Source location
Response from Steps2Recovery
Page 3 · 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
Collaborate with Lamplight to configure the case-management system for more efficient and effective operation.

Verbatim wording from the response
“○ S2R has undertaken a thorough review of its case management system, Lamplight, and is collaborating with Lamplight to ensure the system operates at its most efficient and effective configuration. ○ Comprehensive further staff training on the Lamplight system will then be provided to ensure its optimal use and accuracy in documentation.”

Source location
Response from Steps2Recovery
Page 3 · 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
Use an implemented Offer/Acceptance document to record offer conditions and share them with relevant parties.

Verbatim wording from the response
“multidisciplinary team, which may include third-party input and may result in the withdrawal of their offer. This information will always be provided in writing in clear and unambiguous terms, as well as communicated verbally. We have implemented a new ‘Offer/Acceptance’ document that details the offer, on which any conditions placed on our offers will be clearly communicated in written form and sent to the main point of contact and where appropriate cc’d to other involved parties. This single document can then be accessed by other involved parties and eliminates any confusion as to what is required to fulfil a successful placement. As part of the review of our case management system ‘Lamplight’, this form will be available on clients’ individual files.”

Source location
Response from Steps2Recovery
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
Provide mandatory continuous staff training on updated processes, decision recording, policies and procedures.

Verbatim wording from the response
“○ S2R provides mandatory continuous training to ensure all staff are fully trained on the updated processes, recording of decision-making, policies and procedures.”

Source location
Response from Steps2Recovery
Page 3 · response
Published 12 November 2024
Open published response

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

Reports, concerns and published responses

Reports over time

Concerns raised7

Inadequate recording and structuring of accommodation offer decisions

Withdrawal of accommodation offers without consultation with requesting organisations

Delays in finding CAS3 accommodation after specialist placement failure

Unclear placement offers, conditions and expectations

Failure of probation officers to understand accommodation availability when planning release

Unclear access and eligibility criteria for specialist rehabilitation provision

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

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.7

Actions described in response 7