Kirsten Hocking · Prevention of Future Deaths report

On 01 June 2023 I commenced an investigation into the death of Kirsten HOCKING aged 31. The investigation concluded at the end of the inquest on 08 November 2024. The conclusion of the inquest was that:

Kirsten Hocking was 31 years old when she died as a result of a heroin overdose. She had been released from prison on 19 May 2023, and found in a public toilet in Worthing on 20 May 2023. She was taken to Worthing Hospital where she died at 16:45 on 24 May 2023.

Kirsten Hocking was 31 years old when she died as a result of a heroin overdose. She had been released from prison on 19 May 2023, and found in a public toilet in Worthing on 20 May 2023. She was taken to Worthing Hospital where she died at 16:45 on 24 May 2023.

Please also refer to the findings of fact, which accompany this report and set out the circumstances of Kirsten Hocking’s death and Box 4 of the Record of Inquest (the narrative conclusion). I have three concerns about future risks, two of which are for the Probation Service (and/or the Ministry of Justice (“MOJ”)). The other is for the charity Steps to Recovery (“S2R”):

TO THE PROBATION SERVICE/MOJ:

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.

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.

TO S2R:

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.