PFD report

Leah Shannon Croucher · Prevention of Future Deaths report

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Issued 1 Aug 2024•Milton Keynes

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
11

Described in responses

Recipients and published 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.

Concerns raised2

  1. Failure to adequately monitor sex offenders in the community
    Part of recurring concern: Unreliable monitoring and management of high-risk offenders in the community
  2. Failure to share information between agencies supervising sex offenders
    Part of recurring concern: Unreliable interagency sharing of safeguarding risk information
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.7

  1. Action

    Continue improving ViSOR delivery as the region’s primary multi-agency information-sharing system.

    Stated by Ministry of JusticeStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2024.
  2. Action

    Review information-sharing practice at pre-sentence report stage and throughout order or licence management, concluding by 31 March 2025.

    Stated by Ministry of JusticeStated plannedThe respondent said that this action was planned when they made their response on 13 August 2024.
  3. Action

    Provide capacity to train 40 staff monthly in ViSOR.

    Stated by Ministry of JusticeStated in progressThe respondent said that this action was in progress when they made their response on 13 August 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 to adequately monitor sex offenders in the community

Wider context from the report

“Leah Croucher was unlawfully killed by a man who was subject to supervision by the probation service and the police. Despite that supervision he was in breach of the terms of his probation and was able to kill Leah when it was known that he was a predator and danger to females. There should be a fundamental review of the process for monitoring sex offenders in the community and the sharing of information between all agencies particularly the police and probation service to ensure that a similar death can be prevented. ”

Is this part of a recurring concern?

Yes — Unreliable monitoring and management of high-risk offenders in the community.

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 to share information between agencies supervising sex offenders

Wider context from the report

“Leah Croucher was unlawfully killed by a man who was subject to supervision by the probation service and the police. Despite that supervision he was in breach of the terms of his probation and was able to kill Leah when it was known that he was a predator and danger to females. There should be a fundamental review of the process for monitoring sex offenders in the community and the sharing of information between all agencies particularly the police and probation service to ensure that a similar death can be prevented. ”

Is this part of a recurring concern?

Yes — Unreliable interagency sharing of safeguarding risk information.

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

Continue improving ViSOR delivery as the region’s primary multi-agency information-sharing system.

Verbatim wording from the response

“We will work with the national Assessment and Management of Sexual Offending (AMSO) Team within HMPPS to share the findings from our review, to support any learning on a national basis, disseminating any outcomes or proposed practice changes which arise from it. This will include continued improvement of the effective and efficient delivery of ViSOR as the primary means of multi-agency information sharing in the region. National projects are ensuring that all areas are working to establish the use of ViSOR as a business-as-usual system in sentence management. Over the last 3 years these projects have seen a steady rise in the number of HMPPS staff with access to ViSOR, rising from less than 300 to more than 3500. These numbers continue to increase by approximately”

Source location

Response from HMPPS - Probation Service South Central
Page 2 · response
Published 13 August 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

Review information-sharing practice at pre-sentence report stage and throughout order or licence management, concluding by 31 March 2025.

Verbatim wording from the response

“Within the Probation Service, we will focus our review on information sharing practice at the pre-sentence report stage and throughout the management of an order or licence, building on the actions set out in the internal Serious Further Offence (SFO) review. The Pathfinder to Improved Pre-Sentence Advice (PIPA) project is piloting in the South Central Probation Region. This project aims to improve the quality of Pre-Sentence advice to the Judiciary. This includes reviewing cases further in advance of upcoming hearings. This gives staff more time to gather information from other agencies and consider the implications for risk and the suitability of various sentencing options. We will specifically consider how this is supporting the preparation of reports on registered sex offenders in light of this case.”

Source location

Response from HMPPS - Probation Service South Central
Page 2 · response
Published 13 August 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 capacity to train 40 staff monthly in ViSOR.

Verbatim wording from the response

“300 a month and the intention is that more than 12,000 HMPPS members of staff will have access to ViSOR by the time it is replaced by a more dynamic and agile system (MAPPS) in 2026. In South Central ViSOR usage has been increased steadily and now 35% of in scope staff have access to the database. We will continue to provide capacity to train 40 staff a month and pending vetting being timely will deliver full access in a year.”

Source location

Response from HMPPS - Probation Service South Central
Page 3 · response
Published 13 August 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

Oversee a review of multi-agency processes for monitoring sexual offenders and exchanging police and probation information.

Verbatim wording from the response

“The Chair of the SMB has accepted that the Board should oversee a piece of work to review the effectiveness of the multi-agency processes for monitoring sex offenders and for information exchange between police and probation. This will build on the extensive learning which came from the MAPPA Serious Case Review (SCR) and associated action plan, which is due to be implemented in full by August 2025.”

Source location

Response from HMPPS - Probation Service South Central
Page 2 · response
Published 13 August 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

Consider how the PIPA project supports preparation of reports on registered sex offenders.

Verbatim wording from the response

“Within the Probation Service, we will focus our review on information sharing practice at the pre-sentence report stage and throughout the management of an order or licence, building on the actions set out in the internal Serious Further Offence (SFO) review. The Pathfinder to Improved Pre-Sentence Advice (PIPA) project is piloting in the South Central Probation Region. This project aims to improve the quality of Pre-Sentence advice to the Judiciary. This includes reviewing cases further in advance of upcoming hearings. This gives staff more time to gather information from other agencies and consider the implications for risk and the suitability of various sentencing options. We will specifically consider how this is supporting the preparation of reports on registered sex offenders in light of this case.”

Source location

Response from HMPPS - Probation Service South Central
Page 2 · response
Published 13 August 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

Deliver full ViSOR access to in-scope South Central staff within a year, subject to timely vetting.

Verbatim wording from the response

“300 a month and the intention is that more than 12,000 HMPPS members of staff will have access to ViSOR by the time it is replaced by a more dynamic and agile system (MAPPS) in 2026. In South Central ViSOR usage has been increased steadily and now 35% of in scope staff have access to the database. We will continue to provide capacity to train 40 staff a month and pending vetting being timely will deliver full access in a year.”

Source location

Response from HMPPS - Probation Service South Central
Page 3 · response
Published 13 August 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

Introduce policy frameworks for pre-sentence reports, home visits and MAPPA level 1 case management.

Verbatim wording from the response

“Probation Service, when the former Community Rehabilitation Companies were dissolved in 2021, and attendant changes to organisational structure, policy and practice. Since then, the Probation Service has taken steps to strengthen our management of those who have committed sexual offences. We have streamlined risk assessments for such offenders and introduced a new national learning programme for all experienced probation officers to improve their knowledge and skills in this vital area of public protection work. We have also introduced new policy frameworks covering the preparation of pre-sentence reports, requirements to undertake home visits and expectations when it comes to cases managed at level 1 under MAPPA. ████████ was managed at MAPPA level 1 at the time Leah Croucher was killed).”

Source location

Response from HMPPS - Probation Service South Central
Page 2 · response
Published 13 August 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.4

  1. 1

    Share learning from the death’s circumstances more widely with probation colleagues.

    Stated by Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 13 August 2024.
  2. 2

    Share review findings with the national AMSO Team and disseminate resulting learning or proposed practice changes.

    Stated by Ministry of JusticeStated plannedThe respondent said that this action was planned when they made their response on 13 August 2024.
  3. 3

    Introduce a national learning programme for experienced probation officers on managing sexual-offence cases.

    Stated by Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 13 August 2024.
  4. 4

    Streamline risk assessments for people convicted of sexual offences.

    Stated by Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 13 August 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

Share learning from the death’s circumstances more widely with probation colleagues.

Verbatim wording from the response

“Thank you for bringing this matter of concern to my attention. Please be assured that learning from the circumstances of this tragic death has been shared more widely with colleagues and will continue to inform improvements across all the Probation Regions.”

Source location

Response from HMPPS - Probation Service South Central
Page 3 · response
Published 13 August 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

Share review findings with the national AMSO Team and disseminate resulting learning or proposed practice changes.

Verbatim wording from the response

“We will work with the national Assessment and Management of Sexual Offending (AMSO) Team within HMPPS to share the findings from our review, to support any learning on a national basis, disseminating any outcomes or proposed practice changes which arise from it. This will include continued improvement of the effective and efficient delivery of ViSOR as the primary means of multi-agency information sharing in the region. National projects are ensuring that all areas are working to establish the use of ViSOR as a business-as-usual system in sentence management. Over the last 3 years these projects have seen a steady rise in the number of HMPPS staff with access to ViSOR, rising from less than 300 to more than 3500. These numbers continue to increase by approximately”

Source location

Response from HMPPS - Probation Service South Central
Page 2 · response
Published 13 August 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

Introduce a national learning programme for experienced probation officers on managing sexual-offence cases.

Verbatim wording from the response

“Probation Service, when the former Community Rehabilitation Companies were dissolved in 2021, and attendant changes to organisational structure, policy and practice. Since then, the Probation Service has taken steps to strengthen our management of those who have committed sexual offences. We have streamlined risk assessments for such offenders and introduced a new national learning programme for all experienced probation officers to improve their knowledge and skills in this vital area of public protection work. We have also introduced new policy frameworks covering the preparation of pre-sentence reports, requirements to undertake home visits and expectations when it comes to cases managed at level 1 under MAPPA. ████████ was managed at MAPPA level 1 at the time Leah Croucher was killed).”

Source location

Response from HMPPS - Probation Service South Central
Page 2 · response
Published 13 August 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

Streamline risk assessments for people convicted of sexual offences.

Verbatim wording from the response

“Probation Service, when the former Community Rehabilitation Companies were dissolved in 2021, and attendant changes to organisational structure, policy and practice. Since then, the Probation Service has taken steps to strengthen our management of those who have committed sexual offences. We have streamlined risk assessments for such offenders and introduced a new national learning programme for all experienced probation officers to improve their knowledge and skills in this vital area of public protection work. We have also introduced new policy frameworks covering the preparation of pre-sentence reports, requirements to undertake home visits and expectations when it comes to cases managed at level 1 under MAPPA. ████████ was managed at MAPPA level 1 at the time Leah Croucher was killed).”

Source location

Response from HMPPS - Probation Service South Central
Page 2 · response
Published 13 August 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

Data last updated 7 September 2026