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.
On 26th August 2022 I commenced an investigation into the death of Elizabeth Sarah Jayne McCann. The investigation concluded on the 19th April 2024 and the conclusion was one of unlawful killing. The medical cause of death was 1a) Ligature strangulation.
Circumstances of the death
Elizabeth Sarah Jayne McCann was raped and murdered on 25th August 2022 at the home address of her murderer, 91 Manchester Road, Ashton-under-Lyne. Her murderer was on a life licence at the time and on the Sex Offenders Register as a consequence of his convictions in 2009 for rape, sexual assault and Section 20 assault.
He had met Elizabeth through the Health and Wellbeing College run by Pennine Care. Whilst he was on licence, he had been signposted by Probation to the Wellbeing College run by Pennine Care NHS Foundation Trust. The College and Probation had previously agreed the college would accept some Probation clients.
There was a failure by the college and Probation to set up a clear, documented system for how this would work and how risk would be managed. Within the college there was a failure to ensure that there was a system for how this information from Probation would be received and scrutinised effectively. There was a failure by the college to set up a risk management system for attendees such as him. As a consequence of these failures her murderer joined the college without any risk assessment having been undertaken and without the college recognising the risk he posed. It is probable that had there been an effective system in operation that: either he would not have been accepted at the college at all or would not have been accepted without a stringent plan to manage his risk, these failures by the college and Probation probably contributed to Elizabeth's death.
It was known to Greater Manchester Police (GMP) and Probation that he posed a risk in certain circumstances. The areas of focus for an increase in risk were alcohol use, lone females, intimacy and rejection. Whilst he was being supervised under licence and in accordance with the Sex Offenders Register management, both his Probation Officer and Police Offender Manager had caseloads far in excess of what were safely manageable. This was because Greater Manchester Police had failed over a period of years to adequately staff the Sexual Offender Management Unit and the Probation service did not have sufficient probation officers available due to recruitment challenges.
Whilst managing him in March 2022, he disclosed to his Police Offender Manager that he had recently had a small relapse with alcohol but Chang Grow Live had declined to assist him. That information was not shared with Probation and not investigated further probably due to the excessive workload of the Police unit.
On 6th April he disclosed to Probation that he had met a woman and believed it would develop into an intimate relationship. The information was shared that day with Greater Manchester Police. There was a failure by Greater Manchester Police and Probation to action that information. In addition, the officer working for Greater Manchester Police who was spoken to failed to appropriately record the information. This was probably due to the excessive workload in the unit against the staff numbers.
On 12th April when it was indicated that the woman had decided not to pursue the relationship with him, Police and Probation failed to exhibit any professional curiosity as to whether the relationship was as described and in particular failed to speak to the woman; and failed to recognise that the basis on which his risk had been assessed was changing. There was a failure to consider if additional work needed to be undertaken with him. It is probable that the large caseloads contributed to the lack of professional curiosity as it meant there was little time available to consider the emerging picture. It is possible that this lack of action by Greater Manchester Police and Probation contributed to Elizabeth's death.
In July 2022 he approached a woman he had met at college at a public house in Ashton. He was under the influence of alcohol. He touched her and tried to kiss her without her consent. She reported the incident to the college Senior Management team because she was very concerned about the incident. The college Senior Manager failed to recognise it was a safeguarding issue and spoke to him informally.
On 18th August 2022 she made it clear to him that she did not want a relationship with him. Had there not been a failure by the college and Probation to set up an effective referral system and had there not been a failure by the college to set up a system for dealing with referrals from Probation then it is probable the college would have known his status and have escalated the event to Probation and recognised it as high risk in relation to his behaviour. It is probable that the college would have taken action that would have prevented him from accessing the college after the reported incident. It is probable that Probation would have recognised this was a deteriorating situation, reassessed risk and taken steps to reduce the risk he posed to the public and in particular to women. None of these actions happened as a consequence of the failure to have an effective system in place to manage high risk referrals such as him. As a consequence, he continued at the college and Probation were unaware of these events and no action was taken by them.
It is probable that had there not been a failure to share the July 2022 incident which was caused by the previous failures Elizabeth McCann would not have died on the day she did.
Coroner’s concerns
1. The inquest heard evidence that the probation staff were carrying significant caseloads. This was due to challenges in recruiting sufficient staff. The evidence was that there is still a national shortage of probation officers. Steps have been taken to recruit and train further probation officers which provides some assistance but means that overall, a significant number of probation officers are young in service and experience.
2. The evidence before the inquest was that it was important that newly qualified probation staff were closely supervised and supported by their managers. Without that supervision performance issues identified by the trackers were not being tackled. Ensuring this had been and was challenging as the number of staff line managed by senior probation officers had been too high. This was being addressed but was only achievable if sufficient senior staff were retained.
3. Evidence before the inquest was that if probation referred clients under supervision to places such as the Health and Wellbeing College this would, if not implemented effectively pose a significant risk to vulnerable users of such institutions. If referrals were made without a protocol being in place that dealt with managing risk then the risk posed increased further.
4. Clear Information Sharing protocols between Probation and such groups as drug and alcohol services were limited. Without clear agreements understood by both sides there was a significant risk that crucial information that impacted risk assessments would not be shared.
5. The inquest was told that nationally a significant number of police forces were struggling to adequately staff their Sexual Offender Management Units. As a consequence, the level of supervision of sex offenders in the community was being risk managed posing a risk to communities.
6. In the case of Greater Manchester Police, the staffing issues had been known by senior managers for a number of years (many years before Covid) and a decision taken to risk mange far below the appropriate staffing numbers taken. The consequence was that the staff in the unit could not effectively manage their caseloads that were far in excess of the recommended level. The numbers in the unit were increasing but the caseloads were still high.
7. The GMP investigation into their role in relation to Elizabeth’s death was poor in quality and there was no evidence that any senior officer had considered the report. The inquest was told that the quality and lack of referral upwards of a report was not unique to Elizabeth’s case.
8. There was no evidence before the inquest of any professional curiosity by senior GMP officers as to the role of GMP and if lessons could be learnt. It was unclear as to why senior officers were unsighted.
9. It was accepted that there needed to be a level of professional curiosity by staff dealing with high-risk offenders such as in this case and that training for probation officers and police staff needed to reinforce that.
10. The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place. There was also a need for effective information sharing protocols and effective well understood safeguarding provisions.
11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised19
Inadequate management structure and oversight in the health and wellbeing college
Failure to comply with GDPR in the health and wellbeing college
Inadequate safeguarding provisions in health and wellbeing colleges
Continue working with police forces to improve the effectiveness and efficiency of systems for managing sex offenders and preventing further harm.
Stated byHome OfficeStated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024.
Action
Develop a multi-agency public protection system with improved offender-management functionality and information sharing.
Stated byHome OfficeStated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024.
Action
Review national expectations for managing the highest-risk offenders.
Stated byHome OfficeStated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024.
Action
Ask police to prioritise and pursue perpetrators posing the greatest risk to women.
Stated byHome OfficeStated plannedThe respondent said that this action was planned when they made their response on 31 May 2024.
Action
Review and redistribute offender-manager caseloads to balance risk profiles, prioritising balanced workloads over geographical boundaries and repeating the exercise as demand and risk change.
Stated byGreater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Revise the Police Internal Management Review process, brief Detective Inspectors, reinforce senior leadership compliance and track review timeliness and quality.
Stated byGreater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Discuss case learning with Sex Offender Management Unit staff and incorporate it into initial offender-manager training and continuing professional development.
Stated byGreater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Increase the Specialist Offender Manager team to transfer administrative work from community offender managers and enable greater focus on active management, risk assessments and visits.
Stated byGreater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Implement the Operation Maidera recovery plan and invest force resources to reduce registered sex offender caseload ratios for offender managers.
Stated byGreater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Increase the Sex Offender Management Unit establishment by 18 full-time-equivalent staff, including additional offender managers, a criminal investigation team and a proactive intelligence function.
Stated byGreater Manchester PoliceStated plannedThe respondent said that this action was planned when they made their response on 31 May 2024.
Action
Strengthen Police Internal Management Reviews through independent quality assurance and improved connectivity with the Strategic Organisational Learning Board.
Stated byGreater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Introduce daily management meetings and senior-led silver reviews to identify learning, improve information sharing, revise risk plans and commission Police Internal Management Reviews where required.
Stated byGreater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Refresh staff training to embed professional curiosity, information sharing, multi-agency challenge, risk assessment triggers and MAPPA learning, including refresher training for existing staff.
Stated byGreater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Apply a safeguarding policy covering College students when staff identify safeguarding concerns or incidents.
Stated byPennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Implement a standard operating procedure governing referral, enrolment, clinical-system checks, external risk information, and managerial authorisation for College students.
Stated byPennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Conduct a tabletop review of the investigation process and identify learning on investigation triggers, recording, scope, investigator capability, and quality assurance.
Stated byPennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Apply documented onsite risk controls, including recording concerns, checking student files against registers, and verifying online registers before classes.
Stated byPennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Maintain safeguarding training compliance, verify staff compliance before the September term, and provide scheduled and termly safeguarding learning sessions.
Stated byPennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024.
Action
Introduce a Central Safety Summit and associated governance processes for significant patient-safety investigations, with Trust Board and Quality Committee oversight.
Stated byPennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Commission a training programme to enhance staff capability in reviewing and learning from patient-safety incidents.
Stated byPennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024.
Action
Establish information-sharing requirements for students, clinical teams, external agencies, and College partners through permissions, risk liaison, and signed partnership agreements.
Stated byPennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Operate twice-daily staff briefings and termly College meetings to share course, staffing, risk, and other operational information.
Stated byPennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Establish a controlled generic College email account with defined access, daily checking, welfare and risk escalation routes, and absence cover.
Stated byPennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Disseminate the updated College standard operating procedures through staff email briefing, team briefings, and accessible electronic and hard-copy storage.
Stated byPennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Complete an external review of the College’s risk-management issues and use its findings to identify further development opportunities.
Stated byPennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024.
Action
Report safeguarding compliance data quarterly through the Trust’s governance systems.
Stated byPennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 May 2024.
Action
Integrate investigation-process recommendations into the Trust’s organisational change under the Patient Safety Incident Response Framework.
Stated byPennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024.
Action
Run regular information-governance sessions for College staff and volunteers on safe sharing of information from other agencies.
Stated byPennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Develop and support compliance with a more robust safeguarding policy for College enrollees.
Stated byDepartment of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Conduct the externally commissioned review of the Health and Wellbeing College’s risk management protocols.
Stated byDepartment of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024.
Action
Provide safeguarding learning sessions and an ongoing support programme for College staff and volunteers.
Stated byDepartment of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Develop risk management systems and processes for the Health and Wellbeing College.
Stated byDepartment of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024.
Action
Implement an enrolment standard operating procedure requiring agency, clinical-record and risk checks, consent-based liaison, and clinical-team input on enrolment.
Stated byDepartment of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Establish governance systems for safeguarding-training compliance, risk reporting and access to core governance processes.
Stated byDepartment of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.8
Position
Existing local and national audit arrangements assure the quality of risk assessment and management practice.
Stated byHM Prison and Probation Service and Ministry of JusticeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Chief constables and elected police and crime commissioners decide how police funding and resources are utilised.
Stated byHome OfficeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
A discretionary MAPPA Serious Case Review was not considered necessary because police and probation internal management reviews would provide the relevant findings.
Stated byGreater Manchester PoliceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Health and Wellbeing College risk management, safeguarding and information-sharing matters are for the Department of Health and Social Care to address.
Stated byGreater Manchester PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
National police staffing and community supervision of registered sex offenders are primarily matters for the Home Office to address.
Stated byGreater Manchester PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Probation staffing, supervision, referral risk management and information-sharing matters are primarily for the Ministry of Justice to address.
Stated byGreater Manchester PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Most concerns fall to the Ministry of Justice, Home Office and Greater Manchester Police, which will respond to the report.
Stated byDepartment of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Concerns about health and wellbeing colleges are assigned to NHS England and Pennine Care NHS Foundation Trust, with the Trust responding directly.
Stated byDepartment of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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.9
1
Assure local and national risk assessment and management practice through team audits and annual sentence management audits, with findings informing improvement plans.
Monitor whether systems for managing sex offenders and preventing violence against women and girls are working effectively.
Stated byHome OfficeStated plannedThe respondent said that this action was planned when they made their response on 31 May 2024.
3
Review the role of offender management in police and crime plans while developing plans to halve violence against women and girls.
Stated byHome OfficeStated plannedThe respondent said that this action was planned when they made their response on 31 May 2024.
4
Introduce specialist rape and sexual offences teams in every police force.
Stated byHome OfficeStated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024.
5
Introduce a Neighbourhood Policing Guarantee, including additional officers, community support officers and special constables and named local officers.
Stated byHome OfficeStated plannedThe respondent said that this action was planned when they made their response on 31 May 2024.
6
Work with the College of Policing and NPCC to improve training for police officers.
Stated byHome OfficeStated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024.
7
Conduct monthly meetings between Greater Manchester Police and Probation public protection leads to improve interagency communication and awareness of operational challenges.
Stated byGreater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
8
Report progress on embedding investigation governance structures through Trust Board, quality compliance, ICB, and regulator reporting mechanisms.
Stated byPennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
9
Introduce a Board-approved Central Safety Summit with defined governance, Quality Committee reporting and continuing oversight.
Stated byDepartment of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1
1
A mandatory MAPPA Serious Case Review could not be commissioned because the offender’s Level 1 management did not meet the applicable criteria.
Stated byGreater Manchester PoliceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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