PFD report

Mark Groombridge · Prevention of Future Deaths report

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Issued 17 Apr 2015•Staffordshire South

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.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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

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Concerns raised2

  1. Probation staff lacking a correct understanding of the recall process
    Part of recurring concern: Unreliable probation recall processes
  2. Lack of direct communication between offender managers and hospital clinicians before recall decisions
    Part of recurring concern: Unreliable multi-agency communication procedures
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.4

  1. Action

    Remind all probation staff of recall procedures through senior-leader communication.

    Stated by Directorate of Probation in NOMSStated plannedThe respondent said that this action was planned when they made their response on 17 April 2015.
  2. Action

    Review recall guidance and confirm that its processes are clear.

    Stated by Directorate of Probation in NOMSStated completedThe respondent said that this action was complete when they made their response on 17 April 2015.
  3. Action

    Organise recall practitioner forums in each National Probation Service division to discuss recall issues and review practice.

    Stated by Directorate of Probation in NOMSStated plannedThe respondent said that this action was planned when they made their response on 17 April 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Existing recall guidance is considered clear and sufficient to ensure recall follows full consideration of relevant facts.

    Stated by Directorate of Probation in NOMSExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Probation staff lacking a correct understanding of the recall process

Wider context from the report

“(2) There was confusion about the recall process. The local offender manager believed that recall papers could be sent to the central NOMS unit in London and that they could be held there pending further direction. The evidence from London was that this would never happen and all recall requests are processed according to their urgency. Should all probation staff be reminded of what the correct process is? ”

Is this part of a recurring concern?

Yes — Unreliable probation recall processes.

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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

Lack of direct communication between offender managers and hospital clinicians before recall decisions

Wider context from the report

“(1) Before the recall paperwork was issued there was no direct conversation between the local offender manager and the clinician responsible for Mr Groombridge’s care in hospital. Should it not be policy for such a discussion to take place in any case where an offender is in hospital (be it for physical or mental reasons) before the recall is issued? ”

Is this part of a recurring concern?

Yes — Unreliable multi-agency communication procedures.

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

Remind all probation staff of recall procedures through senior-leader communication.

Verbatim wording from the response

“Probation Instruction 07/2013 has now been replaced by Probation Instruction 27/2014, with the same title, which became effective from 1 June 2014. It was updated on 1 February 2015. The Director of Probation is of view that the guidance given on the recall process remains clear, but is asking Deputy Directors to ensure that all probation staff are reminded of the procedures by 31 August. Public Protection Casework Section (PPCS), will be issuing a Senior Leaders Bulletin covering recall actions which will include a reminder of processes for all Probation staff to follow, PPCS will also be organising Recall Practitioner Forums in each National Probation Service (NPS) division at the end of the year. These forums will give staff and managers the opportunity to come together to discuss issues surrounding recall and review practice.”

Source location

2015-0142-Response-by-NOMS
Page 2 · response
Published 17 April 2015

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 recall guidance and confirm that its processes are clear.

Verbatim wording from the response

“At the time of Mr Groombridge’s death the relevant guidance concerning the recall of offenders was Probation Instructions 07/2013 (Recall Review & Re-release of Recall Offenders) and 08/2013 (Determinate Sentenced Prisoners transferred under the Mental Health Act 1983). This guidance has been reviewed and the Director of Probation is of the view that the processes to be followed in that guidance were clear. The guidance states that offender managers are required to gather evidence and assemble the relevant facts to support a request for recall and that this will include liaising with anyone directly involved, including medical staff at a hospital at which an offender was a patient.”

Source location

2015-0142-Response-by-NOMS
Page 1 · response
Published 17 April 2015

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

Organise recall practitioner forums in each National Probation Service division to discuss recall issues and review practice.

Verbatim wording from the response

“Probation Instruction 07/2013 has now been replaced by Probation Instruction 27/2014, with the same title, which became effective from 1 June 2014. It was updated on 1 February 2015. The Director of Probation is of view that the guidance given on the recall process remains clear, but is asking Deputy Directors to ensure that all probation staff are reminded of the procedures by 31 August. Public Protection Casework Section (PPCS), will be issuing a Senior Leaders Bulletin covering recall actions which will include a reminder of processes for all Probation staff to follow, PPCS will also be organising Recall Practitioner Forums in each National Probation Service (NPS) division at the end of the year. These forums will give staff and managers the opportunity to come together to discuss issues surrounding recall and review practice.”

Source location

2015-0142-Response-by-NOMS
Page 2 · response
Published 17 April 2015

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

Replace and update the recall guidance governing recall processes.

Verbatim wording from the response

“Probation Instruction 07/2013 has now been replaced by Probation Instruction 27/2014, with the same title, which became effective from 1 June 2014. It was updated on 1 February 2015. The Director of Probation is of view that the guidance given on the recall process remains clear, but is asking Deputy Directors to ensure that all probation staff are reminded of the procedures by 31 August. Public Protection Casework Section (PPCS), will be issuing a Senior Leaders Bulletin covering recall actions which will include a reminder of processes for all Probation staff to follow, PPCS will also be organising Recall Practitioner Forums in each National Probation Service (NPS) division at the end of the year. These forums will give staff and managers the opportunity to come together to discuss issues surrounding recall and review practice.”

Source location

2015-0142-Response-by-NOMS
Page 2 · response
Published 17 April 2015

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing recall guidance is considered clear and sufficient to ensure recall follows full consideration of relevant facts.

Verbatim wording from the response

“At the time of Mr Groombridge’s death the relevant guidance concerning the recall of offenders was Probation Instructions 07/2013 (Recall Review & Re-release of Recall Offenders) and 08/2013 (Determinate Sentenced Prisoners transferred under the Mental Health Act 1983). This guidance has been reviewed and the Director of Probation is of the view that the processes to be followed in that guidance were clear. The guidance states that offender managers are required to gather evidence and assemble the relevant facts to support a request for recall and that this will include liaising with anyone directly involved, including medical staff at a hospital at which an offender was a patient.”

Source location

2015-0142-Response-by-NOMS
Page 1 · response
Published 17 April 2015

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