Master Alex Malcolm · Prevention of Future Deaths report

On 1st December 2016, I opened an inquest into the death of Master Alex Malcolm aged 5 (died 22.11.16) case ref: 03101-2016 (JB) and suspended it under Coroners & Justice Act 2009 Sch 1(2) at the request of the police. The medical cause of death was reported as 1a Head Injury. A perpetrator was found guilty of murder on 21st July 2017.

On 12th July 2018 after hearing lengthy submissions and seeking his counsel’s opinion, the Senior Coroner decided that there was an arguable breach of Article 2 of the European Convention on Human Rights by the National Probation Service (NPS), on the application of Osman, and resumed the inquest, a decision accepted by NPS at inquest. It was heard before a jury and concluded on 2nd September 2019. The jury concluded that she was unlawfully killed and delivered a narrative conclusion.

Matters recorded by the jury as contributing to the death included:

1. The perpetrator being wrongly classified as MAPPA Category 2 Level 1 before release from prison
2. Failure to identify the perpetrator’s relationship with the deceased’s mother
3. Failure to share information with relevant agencies who could have notified the deceased’s mother of the perpetrator’s history of violent offending and put in place safeguarding measures
4. Allocation of a high risk offender to a newly qualified probation officer without adequate supervision
5. Failure to refer the perpetrator for a place in Approved premises
6. Failure of relevant agencies to identify, request and share relevant information
7. Failure to adequately challenge or to take action to recall the perpetrator in response to his failures to comply with licence conditions.

Defects in the system were found which contributed to the death and included:

1. Changes to the NPS in 2014 leading to higher case workloads
2. NPS understaffing
3. Significant shortages of places in Approved Premises
4. Poor partnership working between prison and NPS and shortage of offender supervisors in prison

Significant steps have been taken and action plans implemented to reduce the chance of future preventable deaths.

1. A senior NPS divisional head said that providing more Approved Premises places would potentially save lives. It is understood the matter is under review but details of what steps have since been taken were not heard by the coroner.

2. The Chair of the Serious Case Review subgroup of Lambeth Safeguarding Children Board said that strengthening any arrangements around domestic violence, including putting MARACs on a statutory basis had the potential to save lives. The senior Coroner raised this issue in a Prevention of Future Deaths Report to the Secretary of State for Health earlier this year, triggered by the chair of a domestic homicide review into the death of Donna Williamson. Her evidence was clear that there were arguments for MARAC and other bodies to be put on a statutory footing and for the system to be reviewed. The response from the ministry did not specifically address the issue.

3. A senior NPS divisional head said that there were still difficulties in recruitment and retention of probation officers, one factor in which was low pay. It is understood the matter is under review but details of what steps have since been taken and their adequacy were not heard by the coroner.