Mr John Gogarty · Prevention of Future Deaths report

On 17th July 2015 I commenced an investigation into the death of Mr John Gogarty. The investigation had to await the conclusion of a Crown Court trial and then the preparation of reports from both the Probation Service and the Mental Health Trust but concluded following an inquest in April 2019 where the narrative conclusion set out that;

On the 13th July 2015 Mr Gogarty was unlawfully killed at his home by two persons who planned to steal £500 so that a drug debt might be paid. This was a particularly brutal attack in which Mr Gogarty was stabbed no less than 69 times.

One of the offenders had previously been convicted of a similarly violent murder. He had been released on life licence on 9th December 2013 after serving eighteen years imprisonment. It is not the function of the inquest to comment upon the Parole Board’s decision.

The offender breached his licence conditions within a matter of weeks and was inappropriately given an ACO final warning. This was an error. Whilst a warning may have been sufficient sanction at that time for the breach involved, the fact that it was issued as a final warning left the Probation Service nowhere to progress in the face of more serious breaches in May 2014.

The May 2014 breaches related to two positive tests for methadone, refusals in respect of urine testing and failure to attend a drug agency. Another final warning was issued, giving an inappropriate message to the offender. Nor was his status reviewed as it should have been.

Whilst a decision on recall was subject to careful discussion by appropriate persons, the events of May 2014 as a whole amounted to a missed opportunity to take action which would, more likely than not, have safeguarded Mr Gogarty from an attack the following year.

The offender progressed without further apparent breach and in November 2014 was allowed to leave the approved premises although still subject to weekly reporting for a further three months. At that time the Probation Service had no provision for drug testing in the community, which was a major omission, leaving the offender with much reduced scrutiny. This lack of an adequate system in place to provide effective monitoring was, on the balance of probabilities, a more than minimal contribution to the circumstances of Mr Gogarty’s death.

Over the ensuing months Offender 1 became less controlled and took to drink and more particularly drugs without this becoming apparent to his Offender Manager. His supervisory appointments fluctuated between fortnightly and monthly.

In late 2014 the male offender developed a relationship with the female offender who had a significant history of drug abuse. Some of the circumstances became apparent to the Mental Health Trust assisting the female offender but an initial unsuccessful effort to liaise was not pursued when further information on identity became available only a short time later. At the least, this was a lost opportunity for meaningful communication, which would have led to valuable information being given to the Probation Service, there is a possibility, but not probability, that this would have altered the outcome.

The circumstances of the death are set out in some detail in the findings and conclusion previously supplied to the Interested Persons but a copy is attached hereto.

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.