Dear / Annwyl Ms Mundy,

Inquest into the death of Mr Todd James Salter

Thank you for your Regulation 28 Report, issued following the Inquest into the death of Mr. Salter. I am replying as the Director General of Probation and Wales, part of Her Majesty’s Prison & Probation Service (HMPPS).

I know that you will share a copy of this response with the family and I would first like to express my sincere condolences for their loss. Every death in such circumstances is a tragedy and the implementation of learning from this is my absolute priority.

I set out below the response to the matters you have raised giving rise to concern.

(1) The lack of knowledge of the Probation Officer as to the services she could contact to obtain necessary mental health assessments. This would appear at the very least to suggest this gap in knowledge may be due to inadequate training.

(2) Mr Salter being driven to desperate measures of committing criminal acts in an effort to be arrested or recalled in order to secure treatment and support; this appears to be the way matters were moving forward without engaging with appropriate mental health services.

First, please be assured that the identified lack of knowledge and training gaps have been and continue to be dealt with at an individual level with the specific member of staff concerned in accordance with organisational policy and procedure. In addition, the Regional Psychologist has delivered briefing sessions to staff on suicide prevention and processes have been updated in EQUIP, the probation service process management data base.

More widely, and prior to this death, it was known that there was a much higher prevalence of mental health problems with those in society who came into contact with the criminal justice system and it was acknowledged that they often encountered problems accessing mental health services in a way that catered for their multiple and complex needs.

In September 2019, because of the complexity of, and interdependences between the health and justice systems, the Probation Service published a Health & Social Care Strategy 2019 – 2022. This included the following three commitments:

• Improve the health and well being of people under probation supervision, and contribute to reducing health inequalities within the criminal justice system

• Reduce re-offending by addressing health and social care related drivers of offending behaviour to reduce victims of crime

• Support the development of robust pathways into services for people under probation supervision, including improving continuity of care between the custodial and community setting

To support the delivery of these commitments the following actions have been taken:

A Reducing Re-Offending Directorate was established within Her Majesty’s Prison & Probation Service and the Executive Director has responsibility for the collaborative working with health partners to deliver improved mental health and substance misuse outcomes. This Directorate works across government and with the wider public and voluntary sector to reduce reoffending, primarily through improving accommodation, employment and substance misuse outcomes for those in the criminal justice system, particularly when leaving prison.

The Probation Service, as part of its unification programme, developed a new Target Operating Model (published in February 2021) which includes the implementation of the commitments set out in the Health & Social Care Strategy to enable the further development of collaborative working at a local level.

(3) Generally poor engagement and collaborative working with both agencies and family alike.

The development of the Health & Social Care Strategy, the creation of a Directorate with specific responsibility for reducing re-offending and the implementation of the new Target Operating Model will enable the Regional Probation Directors to lead a successful implementation of improved collaborative working at a local level with every member of staff having the knowledge and confidence to work with agencies and third sector providers to improve mental health and substances misuse outcomes for those in the criminal justice system. Within your specific area, this means the creation of new community integration teams specifically to deal with these areas of work.

Thank you for bringing these matters of concern to my attention. Please be assured that learning from the circumstances of this tragic death will also be shared more widely with colleagues across the NPS Divisions.