Terance Alfred RADFORD · Prevention of Future Deaths report

On 21 May 2019, I commenced an investigation into the death of Terance Alfred RADFORD, aged 87 years. The investigation concluded at the end of the inquest on 14 January 2022.

The conclusion of the inquest was that:

At around 09.30 hours on 19 April 2019, Mr Terance Alfred Radford was stood waiting at the bus stop on Worcester Avenue, Mansfield Woodhouse, Nottinghamshire, when he was struck by a car, driven at speed directly into collision with him, by a male driver who had taken the car from its owner shortly before the said collision. Mr Radford died at the scene as a result of his injuries.

Mr Radford was unlawfully killed.

On 20 April 2020, a jury sitting at Nottingham Crown Court, convicted ████████ of the manslaughter of Terry.

The inquest learned that ████████ had been released from HMP Ranby, Nottinghamshire, less than 24 hours prior to Mr Radford’s death. His release from prison was contrary to the national Home Detention Curfew Policy Framework, because he was, at the material time, awaiting the resolution of an Independent Prison Adjudication, dated 13 April 2019.

A decision to downgrade the level of adjudication from independent to internal, made by three Governors on 15 April 2019, not including the original decision-making Governor, had no basis in prison policy or procedure, and was driven by a desire to circumvent the terms of postponement set out within the Home Detention Curfew policy framework, in order to release ████████ from custody on 18 April 2019, rather than post-29 April 2019, when the Independent Adjudication was due to be heard.

This decision provided ████████ with the opportunity to bring about the death of Mr Radford in the circumstances described above. But for the decision to release ████████ on Home Detention Curfew, Mr Radford would not have died when he did and in the manner he did.

At the time of ████████ release from prison, he was considered by prison staff to pose a risk of causing harm to others, such that he could not be safely managed on the general residential block, and instead had been detained in the segregation unit since 29 March 2019. While in the segregation unit, he had continued to engage in behaviour that placed others at risk of harm, including fire setting and assault. At the material time, the Home Detention Curfew Policy Framework did not expressly prohibit prisoners from being released early from their sentence on home detention curfew directly from the segregation unit or on account of their behaviour while in custody.

The Probation Support Officer had not completed a pre-release risk assessment, and had not considered any risks associated with his release above and beyond the suitability of the proposed release address.

There was no information sharing between prison, mental health services and probation staff, that considered ████████ risk of harm to others on release, in the context of a prisoner who was known to have stopped taking his mental health medication and had disengaged from mental health services, who required isolation in the segregation unit due to his repeated violent outbursts, and who had displayed unusual and bizarre behaviour in the 48 hours prior to his release.

1. The national Home Detention Curfew Policy Framework permits the release of eligible prisoners directly from the prison's segregation unit, in circumstances where the prisoner has been placed in the segregation unit because the elevated risk of harm they pose to staff and other prisoners cannot be safely managed within the general prison population.

The public may rightly be concerned that prisoners deemed ‘too risky’ to reside within the general prison population; with its strict curfews and regime, use of locked cells, and trained prison personnel with protective gear, can still be released early from their sentence under the terms of the Policy.

2. The national Home Detention Curfew Policy does not expressly require consideration or assessment of the prisoner’s risk of harm to others, beyond the suitability of the proposed release address. If a broader assessment of risk of harm to others is anticipated by the Policy, there is no guidance on who should complete the assessment (singular or multi-agency input), when it should be completed, and what factors ought to be considered as part of that assessment.

3. The national Home Detention Curfew Policy contains no framework for multi-agency information sharing with regards to the assessment and management of risk for those deemed eligible for early release under the terms of the Policy.