PFD report

Francis Ian WILLIAMS · Prevention of Future Deaths report

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Issued 27 Mar 2024•West Sussex, Brighton and Hove

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
9

Described in responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Report evidence summary

Concerns raised3

  1. Failure of probation officers to understand processes for suspending and cancelling parole licence supervision
  2. Failure of the referral system to refer eligible people for parole licence cancellation
  3. Failure of probation officers to understand and remain alert to suicide and self-harm risk in IPP offenders
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Develop further comprehensive suicide-prevention training for probation staff.

    Stated by HM Prison and Probation Service and Ministry of JusticeStated in progressThe respondent said that this action was in progress when they made their response on 3 April 2024.
  2. Action

    Issue and provide EQUiP access to guidance and a briefing on terminating IPP licences.

    Stated by HM Prison and Probation Service and Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
  3. Action

    Provide introductory suicide-prevention training to probation staff.

    Stated by HM Prison and Probation Service and Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Develop further comprehensive suicide-prevention training for probation staff.

Verbatim wording from the response

“available to all probation staff since September 2023. Over 1700 staff have now completed this training. Further comprehensive suicide prevention training is in the training development pipeline.”

Source location

Response from HM Prison and Probation Service
Page 2 · response
Published 3 April 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

Issue and provide EQUiP access to guidance and a briefing on terminating IPP licences.

Verbatim wording from the response

“Guidance for Probation staff on Consideration of the Suitability for Termination of IPP Licences was issued in September 2023 alongside a 7 Minute Briefing on Termination of IPP Licence and this is available to staff on EQUiP (as referred to above).”

Source location

Response from HM Prison and Probation Service
Page 2 · response
Published 3 April 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 introductory suicide-prevention training to probation staff.

Verbatim wording from the response

“The MoJ/HMPPS now provides Introductory Suicide Prevention Training for probation staff developed in collaboration with the Zero Suicide Alliance (ZSA) which has been”

Source location

Response from HM Prison and Probation Service
Page 1 · response
Published 3 April 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 a seven-minute suicide-prevention briefing highlighting risks for people serving IPP sentences.

Verbatim wording from the response

“A 7 minute briefing on suicide prevention has been developed for Probation staff and is available on EQUiP, an electronic database of guidance and process maps. This draws attention to those serving IPP sentences.”

Source location

Response from HM Prison and Probation Service
Page 2 · response
Published 3 April 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. 1

    Work with other government departments to improve prison leavers’ access to healthcare, drug treatment, employment and stable accommodation.

    Stated by HM Prison and Probation Service and Ministry of JusticeStated in progressThe respondent said that this action was in progress when they made their response on 3 April 2024.
  2. 2

    Require Probation Practitioners with at least six months’ service to complete the SEEDS2 practitioner package.

    Stated by HM Prison and Probation Service and Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
  3. 3

    Provide dedicated learning products for probation practitioners managing IPP cases on trauma-aware, person-centred and motivational-interviewing practice.

    Stated by HM Prison and Probation Service and Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
  4. 4

    Evaluate and review the probation learner offer in September 2024.

    Stated by HM Prison and Probation Service and Ministry of JusticeStated plannedThe respondent said that this action was planned when they made their response on 3 April 2024.
  5. 5

    Develop an IPP staff guide and practitioner briefing events addressing the sentence’s impact and recall.

    Stated by HM Prison and Probation Service and Ministry of JusticeStated in progressThe respondent said that this action was in progress when they made their response on 3 April 2024.

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

Work with other government departments to improve prison leavers’ access to healthcare, drug treatment, employment and stable accommodation.

Verbatim wording from the response

“Under the current engagement model between Health/ Justice/ NHS / Social Care teams the MoJ are working closely with other government departments to ensure prison leavers, including those serving IPP sentences, can access healthcare, drug treatment and support with securing employment and stable accommodation.”

Source location

Response from HM Prison and Probation Service
Page 2 · response
Published 3 April 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Require Probation Practitioners with at least six months’ service to complete the SEEDS2 practitioner package.

Verbatim wording from the response

“The MoJ/HMPPS has a current Suicide Prevention Action Plan within which one of the identified goals is to provide staff with the necessary knowledge, skills, and resources to support good quality suicide prevention practice. As part of the refreshed probation learner offer, Probation Practitioners who manage IPP cases are provided with dedicated learning products aimed at increasing their knowledge and skills around trauma aware/person centred practice, as well as opportunities to practice motivational interviewing approaches. The Skills for Effective Engagement Development and Supervision (second generation) (SEEDS2) practitioner package, which is required learning for all Probation Practitioners who have been in post for at least six months, has motivational interviewing/relational practice as the core principle.”

Source location

Response from HM Prison and Probation Service
Page 2 · response
Published 3 April 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 dedicated learning products for probation practitioners managing IPP cases on trauma-aware, person-centred and motivational-interviewing practice.

Verbatim wording from the response

“The MoJ/HMPPS has a current Suicide Prevention Action Plan within which one of the identified goals is to provide staff with the necessary knowledge, skills, and resources to support good quality suicide prevention practice. As part of the refreshed probation learner offer, Probation Practitioners who manage IPP cases are provided with dedicated learning products aimed at increasing their knowledge and skills around trauma aware/person centred practice, as well as opportunities to practice motivational interviewing approaches. The Skills for Effective Engagement Development and Supervision (second generation) (SEEDS2) practitioner package, which is required learning for all Probation Practitioners who have been in post for at least six months, has motivational interviewing/relational practice as the core principle.”

Source location

Response from HM Prison and Probation Service
Page 2 · response
Published 3 April 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

Evaluate and review the probation learner offer in September 2024.

Verbatim wording from the response

“The probation learner offer will be evaluated and reviewed in September 2024.”

Source location

Response from HM Prison and Probation Service
Page 2 · response
Published 3 April 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Develop an IPP staff guide and practitioner briefing events addressing the sentence’s impact and recall.

Verbatim wording from the response

“As part of an IPP Action Plan, HMPPS is drawing together a holistic staff IPP guide and series of practitioner briefing events which will promote HMPPS operational staff awareness of the IPP sentence and its impact on those subject to it. This guide and series of events will include a focus on recall.”

Source location

Response from HM Prison and Probation Service
Page 2 · response
Published 3 April 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
2/2

Data last updated 7 September 2026