Dear Sir Adrian Re: Regulation 28 Report to Prevent Future Deaths – James Furlong, Joseph Ritchie-Bennett and David Wails who died on 20 June 2020 in the Forbury Gardens terror attack

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 20 May 2024 concerning the deaths of James Furlong, Joseph Ritchie-Bennett and David Wails on 20 June 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to the families and loved ones of James, Joseph and David. NHS England are keen to assure the families and the Coroner that the concerns raised in your Report about the prior care of the perpetrator of the attack have been listened to and reflected upon. 

My response focuses on those concerns that fall under the remit of NHS England, namely those summarised at paragraphs 43-45 of your Report, regarding secondary healthcare service arrangements and resourcing within prison establishments. In particular you have raised that the evidence at the Inquests made clear that there were wider issues with the shortage of staff in prisons to provide psychological treatment, and with the processes to prioritise and track prisoners on the waiting list to ensure that they were seen.

I have not specifically addressed your concerns relating to the deficiencies of Pathfinder (set out at paragraphs 18 and 25-30 of your Report), as these are best addressed by the Secretary of State for Justice, who has responsibility for the service, along with Thames Valley Police. It is, however, acknowledged that NHS England and HMPPS jointly issued Guidance entitled “Increasing the Engagement of Prison Integrated Healthcare Teams in Pathfinder” in June 2022, following the Forbury Gardens attack and the review conducted by the Joint Extremism Unit (JEXU) on the mental health provision.

In response to your concerns directed to NHS England, I provide you with details about NHS England’s work below.

Mental health pathways programme of work

The NHS England Mental Health Programme has recently embarked on new work to review the current service provision for adult individuals in contact with the criminal justice system. This has focused on the changes required to provide sustainable and National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

ongoing consistency of service provision, for those adults who need care and treatment for mental ill health, and associated disorders.

To enable these changes, a Mental Health Criminal Justice Pathway is in development. This Pathway is overseen by a ‘Health and Justice Mental Health Pathway Expert Working Group’ and this work aims to:

• Ensure, from a patient perspective, that the Pathway is robust, seamless, individualised, and responsive to a person’s needs and requirements.

• Provide people with mental health concerns timely, consistent, high-quality advice, treatment, and support that is effectively communicated across all services.

• Reduce reoffending and improve health outcomes by addressing underlying mental health issues at the earliest opportunity.

• Strengthen pre-sentence community-based health options by working in partnership with health and justice agencies.

• Reduce the number of people with mental health issues who are remanded or sentenced to custody, ensuring they receive appropriate care and treatment in the right settings at the earliest opportunity.

• Work with partners to make available appropriate healthcare alternatives, in place of remand in custody and short custodial sentences, for those with mental health issues.

• Reduce the number of people being sent to custody with mental health issues, resulting in a reduction of individuals requiring transfer to hospital under the Mental Health Act 1983.

Psychology provision/equivalence

The Service Specification for Integrated Mental Health Service for Prisons in England (2018) states that there should be access to suitable, evidence-based psychological / psychosocial and clinical interventions. Importantly, services are required to ensure all patients have a diagnosis and clinical formulation, and should provide evidence-based psychological interventions adapted to patients’ needs. Patients within secure settings should receive an equivalent level of healthcare to patients in the community (in terms of the range of interventions and services available, quality and standards).

The service specification requires that patients have a robust discharge plan to enable continuity of care in the community. Where patients exit a service due to a transfer from custody, extensive and timely multi-disciplinary planning is required and expected. Similarly, where a patient is transferred to another prison, a comprehensive handover is expected to be actioned and coordinated.

I would also like to highlight the work of NHS England’s RECONNECT and the enhanced RECONNECT ‘care after custody’ services. RECONNECT seeks to improve the continuity of care of people leaving prison by working with them before they leave and supporting their transition to community-based services, thereby safeguarding any health gains made whilst detained.

RECONNECT is not a service providing clinical interventions. What it offers is liaison, advocacy, signposting, and support to those leaving prison, to aid engagement with community-based health and support services. It provides support and release planning for up to 12 weeks prior to release (or as soon as the person is referred) and will work with them for up to 6 months post release date, or when all health care needs are met, whichever comes soonest.

Enhanced RECONNECT (ER), which is a trauma informed service working with people from 6 months prior to release until 12 months post release, builds on the RECONNECT service as an enhanced pathway of care, and is NHS England’s response to the management of individuals identified as a high risk of harm to the public and who have complex health needs. The enhanced service is a pilot scheme currently operating in the North East, North West and South West of England. The service works collaboratively with partners (including from other services and organisations) to support any high-risk individual with complex health needs, which may impact on their risk of reoffending.

Additionally, since the tragic events of 20 June 2020, NHS England’s South East region has re-procured mental health services at HMP Bullingdon and HMP Huntercombe. These services are now provided by Oxford Health NHS Foundation Trust (OHFT) at both sites.

Further to the above, there is an integrated model of mental health care across both primary and secondary care mental health services, with access to the Health and Justice Information Services (HJIS) records, along with community mental health records, to better support continuity of care and information sharing.

The provision of psychological therapies is still commissioned, although recruitment challenges mean there is a longer wait for initial assessment for psychological therapy than is ideal at present. Prison mental health teams do maintain a 5 day wait for routine mental health referrals, however, increasing the availability and accessibility of talking therapies is a priority.

OHFT and NHS England’s South East Region continue to prioritise increasing the availability of access to evidence based talking therapies at the prisons, whilst developing a more sustainable workforce to deliver the interventions.

It is also positive that clinical information sharing between prisons when a prisoner is transferred is much more robust in 2024 than it was in 2020. Patient information is now routinely shared on a digital Prisoner Escort Record (PER) and via HJIS notes, and the transfer of clinical information between prisons and community providers is locally audited on an annual basis alongside other performance indicators.

Community Mental Health Services

Additionally, as part of its NHS Long Term Plan commitments to improve mental health care, NHS England has increased the investment in adult and older adult community mental health services by £1 billion per year since 2019/20. This additional funding has meant that over 370,000 people were able to access transformed models of care in 2023/24. These new models, as described in the Community Mental Health Framework (September 2019), are aimed at ensuring that adults and older adults with severe mental health problems are better able to access a high quality of care that meets their clinical and social needs, and that care is easily 'stepped up' or 'stepped down' depending on their needs.

However, NHS England recognises that further national work is needed to ensure that people with severe mental illness, who pose a risk of harm to others when unwell, are properly supported and can access appropriate care to avoid relapses in their mental health. NHS England has therefore asked all Integrated Care Boards to review their community services by September 2024, to ensure that they have clear policies and practices in place for patients with serious mental illness, who require intensive community treatment and follow-up, but where engagement is a challenge. To support system reviews, NHS England has convened an expert advisory group to advise on the development of national guidance, setting out the key principles in this area that should be reflected in local policies and practices.

Trust Provision

We note that you have also addressed your Report to Berkshire Healthcare NHS Foundation Trust (BHFT), who are the appropriate organisation to respond to many of the concerns raised about the quality of care previously delivered to the perpetrator of the terrorist attack. We also note that Midlands Partnership University NHS Foundation Trust (MPFT) are required to respond to you, demonstrating that they are continuing to make appropriate changes to the services they provide to other prison establishments. We have ensured that all regions where MPFT has a prison provision footprint (as this extends outside of the Midlands region) are aware of the concerns raised in your Report.

My regional colleagues in the South East have also been asked to engage with BHFT on the concerns raised, and with OHFT who, as set out above, are now providing the secondary mental health services to HMPs’ Bullingdon and Huntercombe. We note that OHFT are required to provide assurance of current practices at these two prisons, including the current position on the level of available psychological services against the background of the previous failure by MPFT to provide these to the perpetrator of the attack whilst he was in prison. We will carefully consider the Trusts’ responses, once sighted on these.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Sir

Inquests arising from the deaths in the Forbury Gardens terror attack of 20 June 2020; James Furlong, Joseph Ritchie-Bennett and David Wails

Regulation 28 Response – Berkshire Healthcare NHS Foundation Trust

I write on behalf of Berkshire Healthcare NHS Foundation Trust ("BHFT") further to the above inquests which took place between 15 January 2024 and 23 February 2024, and the Factual Findings delivered on 26 April 2024. I have set out below BHFT's response to the Regulation 28 Report dated 20 May 2024.

Introduction

BHFT acknowledges the Findings and Conclusions of the Inquests and has carefully reflected upon any failings or areas of concern that were highlighted. BHFT is grateful that Sir Adrian noted in his Regulation 28 report the promising changes made by our organisation since the events in July 2020. BHFT shares the view that it is of utmost importance that the effectiveness of the services and those changes are rigorously and regularly assessed.

As described by in the written and oral evidence on behalf of the Trust, there has been a wholesale change in the framework for delivery of community mental health services and necessarily this is an evolutionary process. I wanted to therefore provide an update on the matters relevant to BHFT's services since February 2024 which demonstrate that BHFT continues to drive forward and monitor these improvements.

As an initial comment, the actions described herein are included in the BHFT audit programme where a review of progress on key topics is audited by an externally commissioned partner.

One Team / Care Coordination / Communication with other agencies

BHFT have continued the development of the One Team model as described in February and helpfully summarised in the Regulation 28 report. This is an ongoing and gradual roll out of associated changes to service delivery. There are monthly team updates and a number of engagement events that have taken place with BHFT staff, external stakeholders (such as local authorities in Berkshire, Primary Care Networks, London House London Road Bracknell Berkshire RG12 2UT

Voluntary, Community and Social Enterprise (VCSE) events, and local communities (including service users and carers)) to socialise the changes and take feedback from interested parties to influence the approach we are taking. The changes noted in the Regulation 28 evidence remain a clear focus and evaluating the impact of service changes will be measured over time.

The One Team model is being implemented in stages and the new One Assessment and multidisciplinary team post assessment place-based meetings (MDT) will be implemented with a gradual transition starting on July 8th 2024 with full roll out in August 2024. The One Assessment has been developed in response to feedback relating to referrals bouncing between services and was noted in the KS case where there were referrals between CPE, CRHTT, BTSS, CMHT, with no clear plan at times. The One Assessment is carried out by the local team. This is a full mental health assessment which captures all the details any team/ service may need to know. The assessment is available for all teams to access to prevent the patient from having to retell their story to each person they interact with.

This central assessment will provide the basis, and each time it’s revisited, up-to-date information can be added. The post assessment review will have a range of professionals from Health, Adult Social Care and increasingly our (VCSE) sector and Lived Experience Practitioners (LExP) colleagues to help staff identify the most suitable interventions to address the assessed need. All mental health teams within a locality will work jointly for people in their area so the patient won't feel like they are bouncing between the teams. This puts the patient at the centre and the professionals come to them rather than the other way around. This could include how to support with stabilisation prior to any structured psychological intervention being able to commence.

For example, the PFD evidence described how Elmore Community Services had been commissioned by BHFT to provide community support (non-mental health treatment) for adult residents in Berkshire, with significant and/or enduring complex mental health needs, often associated with a diagnosis of personality disorder. The post assessment review would formalise a plan to engage with Elmore, potentially supported by a community connector.

Since February the Peer Support Network (LExPs) has been established and this would be an additional support that could help to engage the individual with short term stabilisation working towards a longer-term plan around more formal treatment interventions (e.g. trauma therapy).

The MDT will identify a named worker when agreeing individual plans for those referred into services. The named worker will be assigned to anyone who is opened to services and receiving treatment, and a named worker will be assigned to people awaiting treatment held on waiting lists. A workstream dedicated to defining the elements of the named worker role is established and the named key worker role will be formally rolled out in September 2024. As set out in the national guidance, there will be a named key worker for all service users open to BHFT services with a multidisciplinary team approach at Place (i.e. geographical locality) taking overall responsibility for coordinating care - this will be integrated with social care and VCSE and an example is offered above.

There will be a streamlined, holistic, personalised care and support plan, co-produced between the service user and the named key worker and regularly reviewed. A new risk form went live on 15 June 2024, and this is a more streamlined record of risk assessment that is easier to navigate for all clinicians involved.

More focus within this assessment has been given to risk to others. Alongside this more contemporary risk assessment is a new care plan format which will complement the risk assessment and is due to be launched in July 2024.

The MDT described above will agree a clear formulation which will help inform the care plan, as well as identify the best person to lead on the plan of care using the named key worker approach. Where mental health services are not indicated, a clear rationale will be communicated to referrers and any other relevant parties. Risk training has been reviewed and a new programme of risk training has started which will encapsulate elements discussed within this response and case studies based on real clinical cases will help to inform this training.

The direction of the changes will ensure that people referred back into services are considered in a timely manner and that would include the MDT decision around CMHT input. Our mental health services are moving away from the potential for a 'catch 22' dilemma as described in the Regulation 28 report, rather they will use the resources available to them to help support stabilisation, working closely with partners such as drug and alcohol services to maximise opportunities to support people to reach the stability required to engage in more formal therapies.

These changes offer more robust communications with other organisations such as sharing plans for patients that are offered care coordination as well as a clear rationale where CMHT decline care coordination. Multi-agency and multi-disciplinary forums will ensure information is not lost or misunderstood and holistic, trauma informed care plans are collaboratively created. This mechanism will also ensure needs are being met by the most appropriate service and expectations are realistic and clearly communicated.

In addition, BHFT Drug and Alcohol Lead chairs a COMAD (Co-occurring mental health, alcohol and drug) forum which is a cross agency group and includes all drug and alcohol service providers from the six localities in Berkshire alongside mental health services, including CMHTs. This forum has a shared learning focus, provides opportunity to discuss particular cases, and has helped to facilitate a shared understanding of each other’s services and which services are, or are not, involved in a particular individual's care.

Escalation of differences between professionals

An escalation Standard Operating Procedure was produced for the Judge Coroner at the Inquests. Since the Inquests, escalation processes have been further aligned with the new One Team model. The MDT described above will enable shared decision making and where agreement cannot be reached this will be escalated to Heads of Service. An enhanced MDT can be arranged to support this process. On the rare occasion that the Head of Service decision and enhanced MDT is challenged, this will be escalated to the Clinical Director who will make the final decision regarding the plan. In addition to the Positive Risk Panel referred to in the inquest proceedings, an additional ‘Harm to Others’ MDT risk panel is being established. This is in recognition of the increasing awareness of vulnerable individuals who may not fit neatly into a forensic pathway but carry a level of risk. This panel will be made up of clinicians with experience of managing people with a risk of harming others and can offer expertise to inform care planning for this group. The Harm to Others MDT Risk Panel will be effective from July 2024.

BHFT Mental Health Service Dashboard

A Mental Health Service Dashboard will monitor impacts of the changes described through One Team in addition to existing national and internal processes, such as waiting list monitoring. A method of flagging cases that are referred into BHFT on more than three occasions over a year on the RIO system is being explored. These processes will allow Place level managers and performance managers to see what is working and what isn't to allow increased focus on any gaps. The new One Assessment means that CPE will manage any urgent responses if needed or short term need and those put through for a Place one assessment (routine) will now be subject to a collaborative MDT discussion straight after the assessment clinic (or within 1 working day) where rather than bounce around services to consider at another allocation meeting for teams, there will be representatives from all disciplines who can make a decision on that day, as described above. This should support an appropriate offer of something being agreed and avoiding the potential for exclusion. A monthly schedule of reviews has been designed to monitor impacts more broadly. Any risks that may emerge will be managed through existing processes escalating through Heads of Service, to Director, to Executive if necessary.

The Service User Network

The Service User Network (SUN) has been reviewed and data from 2020 to June 2024 indicates that there has been a 20.3% reduction in appointments with the crisis team, a 21.2% reduction in appointments at emergency departments, and a reduction of inpatient admission by 60.1% for this particular patient group. This suggests that the SUN model is effective and a more helpful approach to working with people who experience some of the personality difficulties and distress that KS experienced when he touched BHFT services.

Nurse Consultant Network

Our Nurse Consultant Network has expanded, and this has allowed for an enhanced focus on supporting our teams to improve clinical effectiveness across our inpatient and community services. The evidence presented at the Inquests described a pilot project between Probation and BHFT using Nurse Consultants as a conduit to offer a layer of decision-making where conflict arises. This project has now been evaluated. Recommendations have been made to Probation and BHFT are building upon the learning that has come from the Pilot. The Nurse Consultants will continue to offer this additional support to Probation colleagues, and the learning sessions delivered by the Nurse Consultants to Probation will continue twice yearly. Internally, BHFT sessions have been reviewed to reflect the findings of the project alongside the learning from these Inquests. Twice yearly ‘harm to others’ sessions will continue to facilitate ongoing learning and refresh for our staff, alongside shorter bespoke sessions for individual teams. The feedback from the Probation and BHFT sessions has been positive and has helped both to gain a better understanding of each other’s ways of working. The increased escalation processes that have come about following the early release scheme described below will also supplement these processes.

Reconnect Service & ECSL

Our Reconnect service has seen increasing numbers of service users over time and are playing a valuable role in bridging the gap between leaving prison and accessing the best community support to meet the needs of vulnerable people. Reconnect offers the bridge between prison, probation and health, and we have good evidence of those workers playing a key role in engaging prisoners prior to leaving prison, or soon after, with community services that best support their needs. For example, supporting people to attend housing appointments or drug and alcohol appointments. We have noted below the additional challenges that early release may bring alongside mitigations agreed with Probation colleagues. BHFT will be closely monitoring impacts and escalating concerns locally and nationally as they arise.

It should be noted that the End of Custody Supervised License (ECSL) and Probation reset which has been implemented since the Inquest proceedings, has been an additional driver to increase scrutiny of communications regarding people released from prison with mental health vulnerabilities. BHFT are engaged locally and nationally as the impact of these changes evolve. While these changes are not directly related to this case, it has provided an opportunity to double down the focus on inter-agency communication. To this end BHFT are working closely with Probation and Prison colleagues to establish additional escalation processes for this client group. A weekly multi-agency forum, chaired by Probation and attended by a range of partners including drug and alcohol providers and VCSE, has allowed for concerns to be raised in a timely way and share examples for learning across organisations. Probation colleagues have been responsive to working closely with us and agree shared escalation processes.

'Harm to Others' Steering Group

A 'Harm to Others' Steering Group has been set up internally within BHFT to focus specifically on this agenda and will supplement the work that was shared in PFD evidence presented at the inquest. Objectives of the steering group in include –

i) To agree areas of priority related to the harm to others agenda; ii) To identify key data sources to identify gaps and measure progress; iii) To agree any workstreams that need to support the work of this group (e.g. early release, probation pilot work, MAPPA processes/standard work); iv) To oversee the progress and outputs of workstreams; and v) To ensure effective communication to relevant stakeholders, internally and externally.

A quarterly oversight group has also been set up with senior Probation and Prison colleagues to continue this focus and allow for shared decision making, shared learning and consider together risks across organisations.

Strategic Planning

A broader piece of work, led by our Director of Specialist Mental Health Services, has reviewed data from a range of sources more recently to help inform strategic planning. This review has identified that there is a

cohort of men in Berkshire (predominantly Slough and Reading) who are affected by multiple inequalities (lack of stable housing, higher levels of deprivation, diagnosed serious mental illness) who also have overlaps with the criminal justice system and increased detention under the Mental Health Act. A case study has been developed by our Criminal Justice Liaison & Diversion (CJLD) service to highlight how early intervention can improve these health outcomes at an earlier stage, supporting engagement with support services, and improving life outcomes. This work will be built upon and conversations with other partners (e.g. the Police) to consider this particular cohort in terms of future early intervention work.

Entry / navigation between services

In addition to the community connector roles described in the Regulation 28 evidence, we now have an additional resource in our Common Point of Entry (CPE) by way of mental health Care Navigator roles. These workers help people to navigate the complex variety of support on offer within the community for people with mental health vulnerability.

The role of these practitioners is to support individuals that have been referred to mental health services, to access VCSE and external partner agencies where they may be best placed to support an individual’s primary presenting problems or where there might not be an appropriate treatment pathway within BHFT. This includes access to services such as Drug and Alcohol support, debt advice and housing support. Where an individual requires more intensive support than the navigators can offer, they will bridge the individual into appropriate local services such as Berkshire Mind, Wokingham CAB project, drug and alcohol services, or the East Berkshire wellbeing service. This role has expanded within CPE and there are now 4 full time navigators. The support offer is also increasing with the Trust introducing direct access to non-clinical CBT programmes such as sleep, money worries and stress modules. This means the navigators can provide direct access to individuals using silver cloud which is a platform providing online CBT modules. Work is also underway to develop a trust wide service directory and social prescribing software that will mean clinicians across Berkshire will more easily be able to refer individuals to VSCE and partner agencies to support their psychosocial or low level psychological and engagement needs. The care navigators have supported over 500 people to access support since they started. That is primarily with just 2 of them as another 2 have just recently joined us. As a core role in CPE the navigators can escalate cases directly to clinicians where there are concerns of risk or escalating mental health needs.

A Peer Support Network is now established which aims to offer support to vulnerable people from others who have lived experience of mental health problems. The service is led by a team of Lived Experience Practitioners (LExPs). LExPs use their own lived experience of mental distress, alongside their training and professional experience of supporting others, to help service users achieve their personal recovery goals. All LExPs receive ongoing training and supervision to make sure that they are confident and competent in their role.

In addition, the Let’s Connect service has also been established in Berkshire and is hosted by BHFT. Let’s Connect is a social network to support the wellbeing of citizens over the age of 18 by connecting with each other, with organisations and services and with the many opportunities in our community. Those who join the network will bring their own strengths as well as gaining from the support of others, based on their own personal choices.

Transition between community / custody

Where individuals move between the community and custody, there will be greater proactive engagement with Prison and Probation colleagues both principally and on a case-by-case basis. Where someone receives a short sentence, it would be important to maintain CMHT input and involvement in planning for post release. For more lengthy sentences requiring ongoing mental health input in custody, they will transition from community (e.g. CMHT) to Prison Mental Health Services. In such situations, the named worker in the community will ensure that a handover takes place with prison colleagues. The Reconnect roles, as described above, will allow for easier transition back into CMHT's on release if required. Where CMHT input is not indicated, a clear rationale will be shared between relevant parties and our teams will support other organisations, such as probation, to understand the rationale and help them to navigate other more appropriate services if necessary. Clarity around responsibilities will be made explicit for all cases.

In addition, an option to include an automatic flag for people that have been referred into services over three times in a year is being explored with our RIO (electronic records) team. This would be an additional way to flag a review of these cases. Where these cases are flagged, an additional review of the case could be undertaken by Head of Service/MDT to ensure that all options have been fully explored.

Information sharing

BHFT recognises that we play a key role in sharing communications particularly around risk. While we are not responsible for the organisation of MAPPA meetings, we are committed to supporting these processes, ensuring that the right people attend the meetings and that we continue to have named representatives from each CMHT within BHFT. This attendance includes contributing to discussions/providing advice to MAPPA case discussions for those that may not be under CMHT. In addition, those named workers will act in a liaison role for inpatients and CRHTT. CRHTT and inpatient teams are less likely to be in a position to attend MAPPA, particularly at short notice, and CMHT representatives are best placed to communicate into and out of MAPPA where inpatient or CRHTT may have been involved in a case. We are active participants in a range of mental health collaboratives where other partners, including VCSE, people with lived experience, and carers, can escalate concerns, working together to inform strategy and direction, and agree priorities across Berkshire.

Within BHFT our Mental Health Transformation Board is chaired by our Director of Transformation and our Director of Strategic Planning oversees our partnership work. A recent VCSE workshop had 81 attendees to consider a shared vision of co-production. A commitment to regular meetings and a forum which will supplement existing collaboratives has been made.

We are disappointed that on behalf of the British Red Cross did not feel that progress had been made regarding the impact of changes that are in progress, and we acknowledged in our evidence that it is early days in terms of transformational changes that will take place over a period of time. We have reached out to to try and get a better understanding of the particular concerns of British Red Cross and hope that will help inform the broader range of ongoing work that we are undertaking with our VCSE partners. To date he has not responded to an initial approach. BHFT Director of Strategic Planning has advised that British Red Cross were included as a member in the BHFT VCSE task and finish group that

ran throughout 23/24 with oversight of the development of the BHFT VCSE strategy. She reports that they engaged in the first few meetings and then dropped out of attending. They would have continued to receive papers and would have been invited to attend the above VCSE conference however we do not have a record of them attending the conference. We will continue to reach out to British Red Cross as part of our wider VCSE engagement described above.

The Regulation 28 evidence outlined BHFT input into MAPPA processes as well as monitoring of key performance indicators which includes CMHT attendance. An escalation process is in place where any concerns around MAPPA attendance can be raised up to Director level. For example, a recent case was escalated where it was not clear that the named worker would be attending a MAPPA meeting. It was established that the worker had the meeting in his calendar and was intending to attend the meeting. This example suggests that escalation processes are working effectively.

Summary

BHFT takes the matters raised throughout the proceedings, the Judge Coroner's Findings and Regulation 28 report extremely seriously and is continuously working to improve its practice to provide the highest possible standard of care. Representatives from Berkshire Healthcare were present in court throughout the inquest to ensure that the learning from this matter was captured understood and disseminated.

The substantive changes and introduction of new services aim to promote the inclusive nature of mental health assistance in Berkshire and seek to avoid the 'not for our team' exclusionary response perhaps illustrated in KS's case. Such offerings are to enable service users such as KS to build up better community links and support, which in turn may help to improve mental health stability to be in a position to be able to engage in the therapies relevant to addressing underlying difficulties and mitigating potential risks.

I hope that this response provides some measure of reassurance to HM Judge Coroner and the families of James Furlong, Joseph Ritchie-Bennett and David Wails.

Dear Judge Fulford,

The Forbury Gardens Inquests Report on Action to Prevent Future Deaths Response of Oxford Health NHS Foundation Trust

Thank you for your letter of 20 May 2024. I write to respond to your concerns.

Paragraph 45 of your report is directed at Oxford Health NHS Foundation Trust (“OHFT”). My colleague , Forensic Service Manager, provided a statement to the inquests in which she explained that OHFT has held the contract for provision of integrated mental health services into Bullingdon and Huntercombe prisons since October 2022. The contract that OHFT signed to provide integrated mental health services is between OHFT and a company called Practice Plus Group, rather than direct between OHFT and the Prison Service. Practice Plus Group holds the contract with the Prison Service for overall provision of medical care into the prison.

Paragraph 45 records –

As regards MPFT, they no longer provide secondary healthcare services in HMP Bullingdon and Huntercombe. Therefore, this Report (in this context) is directed primarily at OHFT; nonetheless it will be provided to MPFT who continue to provide services in other prison establishments. I have also directed that it is sent to NHS England so that appropriate national action in this area can be considered. , service manager for OHFT, was specifically asked to address the “tracking” of prisoners as they moved between prisons. It became clear during the evidence that there were wider issues with the shortage of staff in prisons to provide psychological treatment and with the processes to prioritise and track prisoners on the waiting list to ensure that they were seen (regardless of whether they transferred or not). As a result, and without criticism of her statement, does not address the current position on the level of psychological services at HMP Bullingdon and HMP Huntercombe against the background of the previous failure by MPFT to provide these to KS at any stage whilst he was in prison. I suggest that for a prisoner demonstrating KS’s risk factors, he should have been offered, within the limits of available resources, the opportunity to participate in long term psychology sessions. I request that this issue is addressed by OHFT in its response to this Report, in order to prevent future deaths.

2

OHFT currently provide psychological services for HMP Bullingdon and HMP Huntercombe as part of the integrated mental health team. The evidence based psychological interventions are delivered based on clinical need and sentence length, in line with the NHS Stepped Care Model and National Institute of Clinical Excellence guidance. These include psychotherapy, cognitive behavioural therapy [CBT], trauma focussed-CBT, and eye movement desensitisation and re-processing.

Any staff who work within the prison can make referrals into the mental health team, as well as self-referrals from any prisoners themselves. All referrals made to the team will have a face-to-face triage appointment. A multidisciplinary team (MDT) discussion follows each referral. If the MDT identifies a need for psychology that person will receive a full assessment through which their needs and treatment pathway will be determined. Anyone who is waiting to start psychological treatment will be placed on an electronic waiting list on SystmOne, and assigned a mental health nurse who will meet with that person monthly until their appropriate psychological treatment has commenced. Mental health nurses also deliver emotional management and coping skills groups, which can be offered during the waiting period. The waiting list is managed by the psychology staff, and when a prisoner is discharged after they finish their treatment, the next person on the waiting list will then be offered a place to start their treatment. The waiting list is determined on a first come first served basis. The exception to that is when a prisoner is a veteran of HM Forces, which is standard practice across all prisons.

If a prisoner has commenced a psychological treatment, they would be placed on a medical hold to prevent a transfer to another prison. That is so they can finish their treatment. If a prisoner is transferred elsewhere whilst waiting to start psychology, the receiving prison would be informed that the prisoner in question was on the waiting list through detailed handovers, and both oral and email confirmation. Standard process would be for the prisoner to then be placed on the waiting list (for psychology) at the receiving prison. The prisoner would then be seen by the receiving prison’s psychologist for a triage assessment, subject to the receiving prison having a psychology provision. Timescales vary at establishments based on demand.

At HMP Bullingdon the current staffing model is a 0.8 whole time equivalent (WTE) band 7 psychotherapist, a 0.3 WTE band 8a forensic psychologist, and two band 5 psychological wellbeing practitioners who are currently due to start in the service in July 2024. In the past 12 months there have been 116 referrals for psychology, 17 patients are engaged in therapy currently, and 34 patients waiting. The average waiting time is around 14 weeks. We also have a Consultant Forensic Psychologist who oversees the governance of the psychological therapies pathways within the mental health teams, including managing caseloads of the psychologists and psychological therapists.

At HMP Huntercombe the current staffing model is one WTE band 4 assistant psychologist and 0.3 WTE band 8a psychologist. The service has not been able to fill these posts and a business case was submitted by the service to commissioners that proposed three alternatives to the staffing model. The purpose of the business case is to give us the best chance to recruit into posts, to increase the provision for psychology and to expand the service which can be offered. The business case has been submitted and we hope to receive a decision in July 2024. There are high levels of trauma within the establishment and the focus will be to treat the trauma and any associated symptoms.

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In terms of actions that it will be helpful for the Trust to consider, the service will consider if they should introduce guidance for psychological therapy staff about what to record when an individual declines treatment in the prison pathway, to include guidance that declined offers of treatment are always considered in caseload management supervision.

I hope that this response provides you with the information that you require, but of course please do not hesitate to contact me if OHFT can assist further.

Dear Sir Adrian

Preventing Future Deaths response of the Chief Constable of Thames Valley Police

I write in response to your report under regulation 28 of the Coroners (Investigations) Regulations 2013 dated 20 May 2024 (the PFD report), for which I am grateful. This is a consolidated response which addresses the position both of Thames Valley Police (TVP) as the local force for which I am the chief officer, and of Counter Terrorism Policing South-East (CTPSE), which is one of the regional collaborations within the Counter Terrorism Policing (CTP) network and for which I am the lead chief officer.

The inquests into the deaths of James Furlong, Joseph Ritchie-Bennett and David Wails which you heard between January and April 2024 shone a light on many procedures and practices within both TVP and CTPSE. TVP and CTPSE have taken the time to consider your findings of fact and the PFD report in detail. On behalf of TVP and CTPSE, I wholly accept your findings. They were not easy reading: it is clear that some of the service provided by both CTPSE and TVP fell short – sometimes far short – of expectations.

I am grateful for the opportunity to set out, in response to your concerns in the PFD report, the action that has been taken to date to address the risk of future fatalities, and the action that will be taken in future.

In this response, I address the following topics raised in the PFD report for which you requested a response by CTPSE or TVP:

 The maintenance and dissemination of an adequate intelligence picture by CTPSE;  Prevent  MAPPA  Operation Plato  Support for the Force Incident Manager (FIM) Jason Hogg Chief Constable

Thames Valley Police HQ Oxford Road Kidlington OX5 2NX

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While I address these topics separately below, I recognise the substantial overlap between them, and between those areas for which I, as Chief Constable, am responsible, and other linked areas such as Pathfinder which are the responsibility of HM Prison & Probation Service (HMPPS), or national policy on Prevent which falls under the Secretary of State for the Home Department. I ought also to note that CTPSE forms part of a wider network, with national policy and guidance set by Counter Terrorism Policing Headquarters (CTPHQ), which is led by the Commissioner of Police of the Metropolis. As well as taking action as regards CTPSE’s activity, CTPSE both implements CTPHQ’s policy and guidance and contributes to action being taken as part of national-level projects under CTPHQ’s auspices.

As you note in the PFD report, of TVP and CTPSE and of CTPHQ, in their written and oral evidence (particularly their statements dated 10 November 2023 and 17 November 2023 respectively), set out many and various steps which have been taken since 2020 to address a number of the issues that became apparent as a result of this attack. I do not wish simply to repeat information of which you are already aware, and so ask that this response be read in conjunction with the evidence you have already received from them.

The maintenance and dissemination of an adequate intelligence picture by CTPSE

The headline point as regards CTPSE’s management of intelligence is that a comprehensive review of CTPSE’s Fixed Intelligence Management Unit (FIMU) began in March 2024, and will be completed by the end of the year. CTPSE initiated this review (the CTPSE FIMU review) in response to the issues canvassed in these Inquests. It is being carried out by CTPSE’s Head of Intelligence, an officer of Detective Superintendent rank.

For context, most of the general intelligence analysis and dissemination within CTPSE takes place within the FIMU. The exceptions are work on specific operations and work on reactive operations (such as following the Forbury Gardens attack).

As well as being a response to these Inquests, the CTPSE FIMU review also reflects national work undertaken by the CTP Intelligence Capability Board (ICB), a national oversight mechanism for intelligence capability run by CTPHQ. In February 2024 a paper was presented to the ICB which identified growing demand on FIMUs across the country, and the need for them to remain focused on their core role of identification and assessment of terrorist risk. Those issues are relevant to the concerns you have raised about how CTPSE can maintain and disseminate an adequate intelligence picture, and so the CTPSE FIMU review will examine them as well as address concerns arising specifically from the Inquests. In the event that there are any national recommendations or direction from the ICB, these will be incorporated into the CTPSE FIMU review.

The CTPSE FIMU review will cover a number of key themes, with an overarching aim of ensuring that the assessment, analysis, and dissemination of intelligence about terrorist risk by the CTPSE FIMU is properly resourced, trained, delivered and monitored.

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First, the CTPSE FIMU review will consider the training which FIMU assessors receive. They are required to undertake nationally mandated training to ensure that their work is compliant with the National Standards of Intelligence Management (NSIM). Compliance with this requirement is good, with 97.5% of staff in roles where this is a requirement having undergone this training. However, there has been feedback that this training focuses on the mechanics of assessment and does not adequately provide an understanding of the broad underpinning principles for why actions are undertaken. CTPSE has raised this with the CTPHQ Organisational Development Unit (who manage this national course) to ensure that the course remains fit for purpose and incorporates the learning from your findings in this case.

Nationally, the ICB is also reviewing the training and professional standards of certain roles within Intelligence functions, under the leadership of the Head of Intelligence of another CTP region. CTPSE have representation on that group and will ensure that the learning from your findings in this case is reflected in that national review.

Second, your findings highlighted the importance of clear and timely communications between local police forces and CTPSE. I acknowledge that, as far as possible, information sharing needs to be based more consistently on an approach of ‘dare to share’, rather than ‘need to know’. This can be challenging, particularly where intelligence is sensitive, requiring ‘action on’ permissions or agreed forms of words. Nevertheless, the culture must be one that pushes the boundaries where necessary to facilitate the management of risk. CTPSE and the joint Contact Management Department of TVP and Hampshire & Isle of Wight Constabulary have met to discuss how the passage of information between CTPSE and local forces can be enhanced.

One result of these meetings is that CTPSE and the Contact Management Department are to develop training for call handlers to build awareness around the role, capabilities and limitations of CTPSE, including in how to ask CTPSE effective questions about any information shared. There will also be new training for those within the FIMU who take calls from Contact Management.

While the CTPSE FIMU review will determine the detail, one potential option is to incorporate a template that can be added to force command and control systems (Contact Management Platform – CMP in TVP’s case). This template would contain basic details such as what was known, what was shared, what was not shared and why, which is intended to assist in providing the clarity needed. This model will, of course, need to be replicated across all the forces that CTPSE serve, and I intend that this work will be carried out at pace.

I would like to emphasise that since 2020, we have already seen a marked improvement in information recorded within CMP logs by CTPSE, and an even greater improvement in recording information and clarifying ownership of work/risk on Niche. This will be the subject of future supervisory audits, a point I will return to below.

The CTPSE FIMU review will also consider how to approach issues of mental health where it intersects with extremism. CTPSE’s FIMU assessors have all attended awareness sessions for the newly established CTPHQ Clinical Consultancy Service (a national CTPHQ

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programme that has replaced the Vulnerability Support Hub about which I know you heard evidence), and are being actively encouraged to refer suitable cases where needed. Much work has been undertaken in this area to reinforce the concept that extremism and mental health are not mutually exclusive. CTP casework (and by definition FIMU assessments) regularly involves cases where both are present. Checking that assessors are not delineating the two will continue through the supervisory frameworks being put in place.

I would add that I recognise that, prior to 2020, FIMUs had a tendency to require evidence of defined ideologies and specific group affiliations (ISIS/Al Qaeda, etc.). In recent years, FIMU assessors and supervisors have become more aware of the terrorist risk arising from or contributed to by individual psychologies, including mental health, or ideology, rather than links to groups. This change in emphasis reflects the network-wide dissemination of CTP learning from the various terrorist attacks in 2017-2020, as well as the changing threat which we continue to confront. As compared with 2020, I am confident that the FIMU do not dismiss threats based on mixed/unclear ideologies or mental health, and do not regard mental health as a mitigating factor for someone becoming a terrorist or holding an extremist ideology.

The CTPSE FIMU review will also consider how the FIMU handles the totality of an intelligence picture. As accepted in his evidence before you, simply adding a new piece of intelligence to a previous assessment is not an effective way to consider the entirety of risk. CTPSE’s intention is to free up capacity among assessors to enhance their ability to review all relevant intelligence when considering a case. This may represent something of a culture change which will need to be reinforced through supervisory processes. The demand that this creates will also need to be carefully monitored. There will inevitably be a balance between speed and complete totality of assessment.

Inevitably, IT systems such as the National Common Intelligence Application (NCIA), the platform used by CTP nationwide, have a role to play in how this change of culture is embedded. Whilst NCIA was transformational in bringing all CTP intelligence nationally onto a single system, it does have limitations as regards searching and accessing information, some of which I know were apparent in the evidence you heard. There are also issues around different access control levels for different kinds of users, which the CTPSE FIMU review will consider. Nationally, CTP is already undertaking a significant project to replace NCIA with a new IT platform for intelligence handling. This is expected to be introduced in 2026/27. It will provide FIMU intelligence assessors (and all those in CTP requiring access) with a more intuitive, accessible and user-friendly platform to accelerate and improve assessment of often complex and detailed intelligence. This will address the concern that it is in some situations difficult to get a meaningful summary out of NCIA at pace. This work will also help to address concerns around the sharing of adequate relevant information with partner agencies, including HMPPS and MI5, to assist them in carrying out their functions.

The CTPSE FIMU review will also consider the level of knowledge of staff in relation to proscribed groups, and how this can be enhanced. Currently, when a group is proscribed, communications are issued centrally from CTPHQ. Those staff in post at that time therefore receive an update, but this does not help individuals who join after the point of proscription. Present thinking is that having more concise guides available could help understanding in this

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area. This links to the culture change I described above, which encourages assessors to take a holistic approach to the assessment of intelligence.

Additionally, CTPSE intends within the next four weeks to open discussions with CTPHQ as to how a dedicated database which provides easy, instant access to information on proscribed organisations around the world to inform assessments might be made available. Such databases are available to some of CTP’s partner agencies, which it is hoped will provide a model for this development.

The deputy Senior Investigating Officer (SIO) for the original Forbury Gardens investigation (who was also the SIO for Operation Cropland, CTPSE/TVP’s response to these Inquests) has, on behalf of CTPHQ, created a learning video presentation on the case which will soon be available online to all staff in the CTP network. The CTPSE FIMU review will also consider how the FIMU can better identify indicators of an imminent attack. Since 2021, CTPSE has utilised a set of indicators from the learning from previous attacks, and they are used by FIMU staff. They are also used nationally, and the SIO for Operation Cropland through CTPHQ delivers training nationally using previous cases, including Reading, to increase awareness of these indicators. These indicators are based on a more general approach to using behavioural science and academic support to increase understanding of 1) what indicates someone is mobilising towards violence and 2) what factors make someone more likely to be violent to assist case prioritisation. The idea is to move away from a model that simply identifies explicit threats, to a more holistic approach to the threat.

CTPSE have also piloted the Self-Initiated Terrorist oversight group, which is now led by a Detective Inspector. The point of it is to consider cases such as KS that fall below the threshold for coverage or intervention by MI5, to make sure they are being addressed correctly, to ensure that they sit in the right space for intervention, the cases are escalated quickly where necessary, and to provide staff with a further support in their risk assessment decision making. This approach is being rolled out in other parts of the country but it is most developed in the South East as a direct result of the Forbury Gardens attack.

The CTPSE FIMU review will also examine how actions are monitored and tracked within the FIMU, and how supervisory reviews take place. I am aware that the evidence heard at the Inquests indicated that actions set by or for the CTPSE FIMU were not consistently tracked or followed through. At the end of 2021, ‘Management Logs’ (MLs) were introduced to CTP FIMUs nationally to provide an easier way for FIMU assessors and supervisors to manage the intelligence development space. ‘Open actions’ on NCIA can now easily be searched for and managed accordingly. Supervisors carry out weekly checks to review and, if necessary, reallocate actions. FIMU assessors can add auditable entries to the MLs to demonstrate efforts made to complete enquiries. Whilst there is already a high degree of confidence in MLs, the new intelligence handling IT system referred to above should improve this process even further.

Across CTP, supervisory reviews are now carried out on a set percentage of FIMU assessments. It is not possible to review all assessments due to the volume, so a ‘dip checking’

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regime is in place. National standards now stipulate that 5% of all records are checked but this is subject to review, and is likely to be increased. The checking regime within CTPSE will also be strengthened to include more qualitative assessments, such as whether the totality of intelligence has been assessed and checking the quality of decisions made. Where areas for improvements are identified these will be fed back, either individually or to the entire team. The emphasis will be on continuous learning as opposed to blame and on creating an open culture of reflective practice excellence in decision making.

The key points learnt from the supervisory framework will be incorporated into regular quarterly reporting cycles. This will complement the current CTP Intelligence Capability Assurance Report reporting process that looks at metrics measurable from the NCIA database and is examined at the ICB. The local review process will add qualitative learning that helps to improve decision making as well as ensuring that supervisors are compliant. This qualitative learning will then be disseminated to the ICB to ensure that any applicable lessons are learnt across the whole CTP network.

Closely linked to the supervisory review framework will be a reassessment of the measurement of demand and performance in the FIMU. Currently, performance reporting largely focuses on volumes of intelligence documents assessed, their measurable outcomes, and timeliness. While these are important metrics, the scope of performance reporting requires expansion to cover overall FIMU demand and a qualitative assessment of the work being undertaken. The CTPSE FIMU review will consider whether there are further steps, in addition to those described above, that can be taken in this regard.

I would also like to draw to your attention the increased sharing of information between CTPSE’s Intelligence function and its Nominal Management Team (NMT), which forms part of its Interventions function. Both the CT Nominal Management (CTNM) Manual of Guidance and the national Prevent process require compliance with the National Standards of Intelligence Management (NSIM) which requires submission of intelligence back into FIMUs as part of the intelligence cycle. This ensures visibility of individuals subject to Prevent or CTNM within the intelligence space.

There are still challenges as regards the sharing of intelligence between FIMUs and CTNM nationally due to the lack of a single national CTP case management system which has resulted in a variety of methods of recording across the country. The Home Office owned Violent Sex Offender Register (ViSOR) provides a partial solution as a national system for recording cases shared with HMPPS. However this system is significantly outdated, not initially designed for CT use, and has access requirements which are not compatible with the majority of the CTP estate. To address this challenge, CTP will be the first adopters of the new Multi- Agency Public Protection System (MAPPS), a replacement for ViSOR, which is expected to be delivered in 2025/26. MAPPS has been designed from commissioning for use in terrorism cases and has modern access requirements compatible with the CTP estate.

There is also a well-defined CTPSE process which ensures that FIMU have visibility into all individuals on NCIA who are within the CTNM cohort. In summary, this process ensures that each new instance of intelligence or enquiry relating to a CTNM subject is drawn immediately

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to the attention of CTNM officers. Where necessary, this results in case conferences but either way ensures decision making between FIMUs and CTNM is well coordinated and jointly made. This process has been tested recently with FIMU being alerted to concerns around a CTNM cohort member, swiftly gaining access to the nominal’s CTNM record, and putting in place appropriate management plans. This all occurred out of hours and no problems were encountered with accessing the information.

FIMU are also responsible for setting up the flags and markers required for such nominals, plus their closure.

FIMUs also have visibility of the Prevent cohort as they have access to the Prevent Case Management Tracker Enhanced system. All Prevent staff are aware of the necessity and process for submitting intelligence. Regular monthly meetings between FIMU managers and Prevent managers have enhanced CTPSE processes in this area.

After the CTPSE FIMU review has concluded, CTPSE will ask CTPHQ for a peer review of CTPSE FIMU to provide external scrutiny and reassurance of effective working. As I hope is clear from the above, this CTPSE FIMU review is intended to be a wide-ranging and thorough review that covers not only the matters you have raised in the PFD report, but also builds on previous and ongoing work within both CTPSE and nationally. I can assure you that the entire chain of command within CTPSE, from myself down, is committed to implementing any necessary or desirable changes that the CTPSE FIMU review identifies.

Prevent

I acknowledge the concerns you set out regarding Prevent at §§19-21 of your regulation 28 report. The changes made or planned to the FIMU described above clearly interlock with these concerns: for example, ensuring that there is an assessment of the totality of the available evidence of sufficient quality, made available by the FIMU to Prevent staff to ensure that they can make a properly considered assessment of risk. This should ensure that Prevent staff, in future, would be aware of an individual’s links to proscribed organisations or other terrorist offenders, where this information is known by CTPSE. To support this, CTPSE has begun to implement access to NCIA (and the associated requirement for Developed Vetting) for some Prevent staff. The Prevent Gateway Team within CTPSE has also, since 2019, been co- located with the FIMU.

To address the weaknesses in training in Prevent, it is now a requirement that all CTP Prevent staff undergo a CTPHQ-accredited training pathway. This training aims to build on existing policing expertise, whilst providing additional knowledge, skills, and awareness for the CTP context. The National Interventions Foundation Programme (NIFP) has four online modules, one day face-to-face on the assessment framework and one day face-to-face on welfare/disguised compliance. An interactive exercise will be included in the NIFP but is still under development at the time of writing. While the NIFP and its training courses are signed off/accredited by CTPHQ, there is no official external accreditation for the content of those courses.

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In relation to supervision and selection, within CTPSE both Prevent supervisors (generally at Sergeant rank) and managers (at Inspector and Chief Inspector rank) are now required to be (at least) PIP2 Detectives. This is a change from the previous position, where this was not a requirement for supervisors. This new requirement has two key impacts. First, it ensures a high level of investigative competence and leadership within the team at both supervisory and management levels. Second, it means that all CTPSE recruitment into Prevent is undertaken by accredited detectives, with the requisite experience and an investigative mind-set. While Prevent staff below supervisory/management level are not required to be accredited detectives, those selecting and recruiting them are. That helps to ensure that our selection process for these roles is rigorous, prioritising experienced individuals with the right attitude and approach, who can effectively manage complex cases.

To help put this into context, in 2021 the number of Prevent supervisors in the Reading and Berkshire area increased from one to two, as I understand you heard in the Inquests. At the time, neither was an accredited detective: they have both since been sponsored by CTPSE to complete their PIP2 accreditation. The most recent supervisory appointment to CTPSE’s Prevent department was an experienced Detective Sergeant with a background of working in Public Protection.

Additionally, both current Prevent Detective Inspectors within CTPSE have completed the Management of Serious Crime Investigation Development Programme. They have a background in intelligence, and keep this skillset current by supporting the on-call rota for CTPSE’s Intelligence department.

Furthermore, we have re-posted managers across our departments – Nominal Management, Prevent, and Intelligence – over recent years. A Detective Chief Inspector from Prevent has moved into the Nominal Management Team; a Detective Inspector from Intelligence has moved to Prevent (as alluded to above); and a Detective Inspector from Prevent has moved the other way, into Intelligence. This deliberate approach fosters the transfer of knowledge and reduces the risk of silos, thereby enhancing overall efficiency and cohesion.

This comprehensive approach ensures that all Prevent officers are well-versed in the latest methodologies and best practices in risk management. Continuous professional development (CPD) events are also accessible and mandated for all staff, ensuring that they remain updated with evolving strategies and maintain high standards of professional competency. These CPD events provide ongoing learning opportunities that reinforce and expand on the foundational training, ensuring that staff are continuously improving their skills and knowledge base.

There has also been substantial recent and ongoing work on structured assessments within Prevent. Following a recommendation from the Independent Review of Prevent, CTPHQ and the Home Office’s Homeland Security Group (HSG) have been working with HMPPS to develop an upgraded version of the current Prevent risk assessment tools. HMPPS were commissioned to develop the new tool to harness the best practice from the success of their well-known ERG22 CT risk assessment. The new tool has been informed by up-to-date

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research and plans for ongoing evaluation and improvement. It consolidates two previous tools into one for a more streamlined user friendly and time efficient process. It directs the focus of the assessment to early closure of referrals that have no terrorism/extremism relevance allowing resources to be focused on those susceptible to becoming terrorists or supporting terrorism.

This new methodology was piloted in two regions (not including CTPSE) between November 2023 and May 2024. Feedback indicates that it has been well received with staff commenting that it has assisted with justification and reinforcement of decisions around whether to progress a case or not. It has improved confidence in closing cases with no terrorism/extremism risk and prevented wasted time. It has focused practitioners to make decisions based on facts rather than preconceptions. It has been peer reviewed by two academic experts, and has had oversight from the Correctional Services Advice and Accreditation Panel who recently signed off on national roll out. The CTP network is currently in the training stages for adoption of this new methodology and are hopeful that it will be launched nationally in September 2024.

The requirement to embed professional curiosity more consistently when dealing with potential terrorists is a theme within both Intelligence and Prevent. This is particularly relevant to the phenomenon that is often called ‘Disguised Compliance’ but is increasingly being referred to by CTP as ‘Sincerity of Change’. Training in this area forms part of the initial Prevent ‘Conversations’ module, which is delivered for Prevent staff by CTPHQ (see above). Additionally, CTPHQ ODU (Operational Development Unit) have recently released a new face- to-face training package entitled ‘Interventions Welfare Training’, which specifically focuses on Sincerity of Change. All CTPSE Prevent and Nominal Management Team (NMT) staff will be completing this training in 2024, and a request has been made to CTPHQ ODU for further sessions to include FIMU and SERPIT (South East Region Prison Intelligence Team) personnel.

You have raised a concern about how CTPSE handles repeat Prevent referrals in light of the fact that KS was referred to Prevent on four separate occasions between 2017 and 2019. CTP Prevent policy has now been amended to provide additional scrutiny to the cumulative impact of repeat referrals related to the same subject, even if the subject had been closed from Prevent previously at an early juncture without management or interventions. In such cases, Counter Terrorism Case Officers (CTCOs) and their supervisors are now required to obtain the authorisation from a senior officer (Inspector or above) before closing a ‘repeat referral’ from the case management system. This change is intended to bring added assurance that, in cases where CTP has been notified of a radicalisation risk more than once, greater scrutiny is afforded to the case circumstances and decision making within it. The improvements to supervision and scrutiny within Prevent, set out above, of course also contribute to the effectiveness of this process.

To further enhance support for repeat referrals, CTPHQ has established a case review process for cases where an individual referred to Prevent goes on to commit or attempt to commit high harm offences to establish if all opportunities to protect the public, and safeguard individuals were maximised.

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The focus of CTPHQ’s process is primarily concerned with risk identification and organisational learning, not on finding fault nor apportioning blame. Where failings of duty or misconduct are identified, these are brought to the attention of the Regional Prevent Co- ordinator for their consideration and progression.

MAPPA

In addressing your concerns around MAPPA, I hope it will be helpful to outline the position regarding terrorist and terrorist risk offenders, who now fall under Counter Terrorist MAPPA (CT MAPPA), and also regarding non-CT MAPPA offenders.

I should state at this juncture that I am also confident that the changes to intelligence handling and assessment by CTPSE set out above mean that an individual such as KS would now and in future be appropriately identified as being a terrorist risk offender, and so would be subject to the CT MAPPA process.

In relation to CT MAPPA offenders, following the 2022 report of the Independent Review of Terrorism Legislation ( ) into MAPPA, a new category for such offenders was created by the Crime, Sentencing & Courts Act 2022. Very considerable work, under Project Semper, has been undertaken to ensure that the new CT MAPPA process is effective. It is also linked to the ongoing development of the CT Nominal Management capacity, and the joinder, through Project Eleos, of CTP’s national Nominal Management and Prevent functions into a single Interventions Capability.

The CT MAPPA process ensures that there is a forum where intelligence can be shared appropriately, with input from the right subject matter experts including from CTPSE and HMPPS’ National Security Division. Attendance at CT MAPPA meetings from a member of the CT Nominal Management team is mandatory. There is also a route for sensitive information to be shared with MAPPA chairs, via the Joint CT Prison & Probation Hub.

MAPPA training is covered in the CTNM foundation course, with additional specific training for MAPPA chairs. Additionally all staff within the CTP network now have access to a MAPPA awareness video, accessible to all training managers to share across their portfolios and as well as regional Training and Development Coordinators to share across their regions. This will be made mandatory for all CTPSE staff.

I know that these changes were covered extensively in ’s and ’s evidence to you. By way of an update, in 2024 CTPSE appointed a Detective Chief Inspector into a newly created role to lead its NMT and fulfil the role of Lead Responsible Officer for CT Nominal Management. This involves co-chairing MAPPA Category 4 Level 3 meetings. Category 4 Level 2 meetings are chaired by a CTPSE Detective Inspector, and the number of individuals carrying out this role has been increased to provide additional resilience. All MAPPA chairs or co-chairs have undergone the national training required for the role, which includes training on when MAPPA referrals can be closed.

As regards non-CT MAPPA, within the TVP force area this falls to TVP as the local force,

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rather than to CTPSE. There are national policies and guidance in respect of which I anticipate the Secretary of State for Justice will respond to you. also covered the changes since 2020 in his witness statement at paragraphs 19-34, but I hope it will assist if I provide some additional detail on the action that has been taken.

In 2022, TVP created a dedicated Management of Sexual or Violent Offenders (MOSOVO) department to ensure there was structured and consistent management of Registered Sex Offenders (RSOs), as well as those being managed under Category 2 or 3 (violent offenders) of MAPPA. MOSOVO received an uplift of staff which created an additional Detective Inspector, one Detective Sergeant and four Constable posts. The sole role for these constable posts is to focus on Category 2 and 3 offenders. These staff are referred to as MAPPA officers. In addition to this uplift to TVP’s MAPPA capacity, a further four constable posts have been created for officers are specially trained in digital capability who can, for example, assist with searching for individuals who may be ‘wanted’. Most of TVP’s MAPPA work relates to the management of RSOs, of whom there are more than 1,000 in the TVP area. These fall within Category 1 of MAPPA. The overwhelming majority of them are managed at Level 1.

There are currently 90 Category 2 or 3 offenders managed within the Thames Valley area (although eighteen of those live outside of TVP). Of the 90, 66 are Level 2 and 24 are Level
3. All bar two of the 90 are Probation-led, with TVP providing Probation with support in risk management.

The MAPPA officers, alongside appropriate supervisors (Detective Sergeant for Level 2, and Detective Inspector for Level 3) represent TVP at all Level 2 and Level 3 MAPPA meetings for Category 2 or 3 offenders. They work with Probation and other partners in supporting the risk management of that individual, including preparing trigger plans; advising on tactics and options available; engaging with and briefing the local police area; identifying cases/individuals that are suitable for MAPPA or should be considered for escalation to a higher MAPPA level. If an individual is police-led, then they will always be Category 3 and it is now well-understood that they therefore will always be at least under Level 2 MAPPA management. This will ensure there are regular MAPPA meetings with an appropriate Chair and multi-agency panel risk management.

In terms of oversight, supervising Sergeants direct the work of the MAPPA officers through review meetings, and there are weekly meetings between Detective Inspectors and supervisors, and a monthly review by the Detective Chief Inspector for offender management. There is then a reporting and governance chain through the Head of Public Protection and Safeguarding (a Detective Chief Superintendent) to the ACC for Crime. This governance and supervision structure is supported by a data dashboard, the Managed Offender Review Framework (MORF) that enables a current and accurate assessment of performance, the identification and escalation of individuals where additional intervention is required, and focus on areas of challenge that need to be prioritised. This has facilitated a much stronger organisational grip on TVP’s management of sexual or violent offenders. For example, the MORF is used to prompt risk level reviews for those managed by TVP at MAPPA Level 1. This framework enables a current and accurate assessment of performance and demand of not

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only the management of Registered Sex Offenders in Category 1, but also those being managed under Category 2 or 3. In addition to the MORF, there is a weekly management meeting, whereby any new information or intelligence received by TVP in the previous week is assessed. This is in addition to the ‘notify if’ flags that are applied to all Category 2 or 3 offenders, which I address below.

In May 2023, HM Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) conducted a National Child Protection Inspection for the Thames Valley area. The subsequent report commented that in ‘Cases assessed involving sex offender management in which children have been assessed as at risk from the person being managed’ there was ‘very good liaison and information exchange with the probation service, including holding joint police and probation meetings with the registered sex offender’ (pages 14 & 15). It also concluded on page 45 that:

‘The quality of work with partner organisations to reduce risk from registered sex offenders is good. […] In our case audits we found very good liaison and information exchange with probation officers from the National Probation Service, who manage offenders subject to court-imposed licence restrictions.’

While this aspect of the inspection predominantly focused on TVP’s management of RSOs managed in Category 1, Category 2 and 3 MAPPA cases make use of the same information sharing processes with Probation and other partner organisations.

You have already referred in the PFD report to changes such as notification flags on Niche to provide MAPPA with relevant information. I would like to expand on this change since 2019-
2020. The automatic ‘notify if’ marker for managed offenders notifies officers dealing with an individual that they are a managed offender, and directs them to the MOSOVO team, but also provides a notification to the MOSOVO offender manager whenever new information is added about that individual. It therefore provides assurance in two ways, to help MOSOVO offender managers to promptly make any necessary re-assessment threat, harm and risk, and to assist them in recording and sharing that information appropriately.

While I acknowledge that there is always scope for better joint working, and close liaison with HMPPS as regards both CT MAPPA and non-CT MAPPA, I am confident that the position as regards MAPPA in the TVP force area is far better than it was in 2019-2020.

Operation Plato and Force Incident Managers

You have also raised concerns over the declaration of Operation Plato, and the demands on Force Incident Managers (FIMs). Both of these matters fall primarily to TVP, as the local force.

The current version of the Operation Plato guidance is clear that a Tactical Firearms Commander (TFC) based in a force control room is responsible for the formal declaration of Operation Plato.

All FIMs are accredited Initial Tactical Firearms Commanders (ITFC) both occupationally and

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operationally. Prior to commencing the role, any officer who wishes to become a FIM must attend and pass a national ITFC course. This is a residential course consisting of both classroom learning and scenario-based assessments. One of the scenarios covers the declaration of Operation Plato and how to respond to a rapidly unfolding Marauding Terrorist Attack (MTA). If the course is successfully passed, then the FIM is considered occupationally competent.

Once in role the FIM undergoes a period of mentoring, which on average is 3 months. They are allocated a mentor, who will ensure the FIM reaches operational competency. This not only covers firearms command but any other incidents/tasks that the FIM would be responsible for during their duty. FIMs are required to present evidence in a portfolio to show their operational competence. This evidence is reviewed and signed off by the Superintendent for firearms and Assistant Chief Constable for the Joint Operations Unit. To maintain operational competence all FIMs are required to attend two command-training days per year. For the 2023-24 training year one of the training packages was a table-top exercise based on an Operation Plato scenario at Blenheim Palace, Oxfordshire. The training was attended by Police, Fire and Ambulance service. It covered Joint Operating Principles for the Emergency Services and was structured around a series of paper feeds detailing an MTA. The issue of identifying an Operation Plato incident and the declaration of Operation Plato were specifically covered within this training package.

Every FIM must attend an ITFC reaccreditation course every five years. This must be passed to maintain competence. This course covers the declaration of Operation Plato and includes a MTA scenario in the final assessment.

In October 2023 all FIMs attended multi-agency training in response of the release of an updated Operation Plato policy. A training package is being developed to capture any new FIMs who have joined since this training.

Following the internal reviews of the response to the deaths that were the subject of these inquests, and the national learning from the Manchester Arena Inquiry, a number of amendments have been made to the TVP Operation Plato plan. You have referred to some of these in your report, but they include setting out clearly that only the FIM (as an ITFC) or another TFC could call Operation Plato, revisions to where the Plato control room would be situated (so that it corresponded to where the FIM was based, rather than being a pre-set location), the implementation of a ‘hot line’ to the Strategic Firearms Commander, the creation of Bronze Supervisor and FIM staff officer roles once Plato is declared, the allocation of an additional assistant to the FIM, and the implementation of the Emergency Services Inter Control Talkgroup. Each of these is intended to contribute to relieving the pressure on a FIM as and when Operation Plato is called.

I agree with your view that these arrangements need to be stress-tested, and am pleased to say that this is well in hand. On 24 April 2024 TVP, in conjunction with other agencies, undertook Exercise Pinnacle at Legoland Windsor in conjunction with a variety of other agencies. This tested the initial operational response to an MTA with a specific focus on the Operation Plato plan and control room communications in the immediate stages of such an

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incident. As well as the operational staff on the ground, over 100 volunteers were employed to act as members of the public suffering from various injuries.

Exercise Pinnacle included the setting up of a dedicated Control Room, with the aim of stress testing the initial actions of the TVP Plato plan. This focused on the communication element with the aim of testing the effectiveness of the information flow and joint emergency service working.

The scenario was initially led by Fire and Rescue as an emergency response to a report of a fire at the entrance to Legoland. It then developed into an MTA, with reports of subjects attacking members of the public with bladed weapons. This triggered an unarmed, and then armed, response based on information provided to the Control Room.

Twenty-four pre-written calls were introduced at specific points during the operation, with the purpose of testing the communication flow of information from call to FIM to operational staff on the ground. Initial informal feedback has acknowledged the effectiveness of the Plato plan and that it appears fit for purpose.

A formal multi-agency debrief from this exercise took place on 18th June 2024, and the learning from it will be incorporated into further revisions to the Plato policy, which will be tested again in future in the same manner.

Publication

I acknowledge that this response will be sent to the Chief Coroner and other Interested Persons, and that you may send it to any other person who you believe may find it useful or of interest. I have no representations to make regarding publication of this response.

Conclusion

I would like to again express my gratitude for the opportunity to respond to your PFD report, and for the care and attention which you brought to the inquests. TVP and CTPSE remain committed to a close relationship with the families of Joseph Ritchie-Bennett, David Wails and James Furlong, who have made clear their wish to be kept up to date on the changes and reforms we are implementing as a result of the Inquests. In the same spirit, I would be very happy to meet with you to discuss any of the matters covered in your findings, the PFD report, or this response, if you would find that helpful at all.

Dear Sir Adrian,

Re: Regulation 28 Report to Prevent Future Death arising from the inquest into the deaths at Forbury Gardens June 2020

Further to your correspondence dated 20th May 2024 please find a summary below of the actions being taken by Midlands Partnership NHS Foundation Trust (“MPFT”), and specifically the Health in Justice Services department, to address the concerns that you identified regarding secondary mental health care during the periods that Mr Saadallah was in custody at HMP Bullingdon and HMP Huntercombe between 2016-2020.

Responses to the points raised by Judge Fulford

• It was identified that there was a ‘(F)ailure by MPFT to take steps to retain Mr Saadallah on the waiting list for psychological treatment or restore him to that waiting list, in order to provide him with adequate psychological treatment’

Following the tragic deaths in Forbury Gardens MPFT undertook an internal review; the report summarising the outcome of this internal review was disclosed to the inquest and formed part of the evidence bundle. The internal review identified the need to address psychological care pathways and the management of psychology waiting lists.

Action was taken to refresh the psychology pathway, including updating referral criteria. There has been a further piece of work across the Prisons we work in to standardise practice in regard to psychological care pathways which is due to be completed by the end of August 2024.

MPFT have existing guidance for all clinicians as to the process to be followed when an individual who is receiving treatment from the Trust whilst in Prison is transferred to another establishment. This stipulates that a handover must be provided to the receiving team which details the current plan of care and identified risks.

• It was identified that ‘prisoners demonstrating Mr Saadallah’s risk factors should have opportunity to participate in long term psychology sessions’

Trust Headquarters St George's Hospital Corporation Street Stafford ST16 3SR

Together we are making life better for our communities All individuals currently referred to Mental Health Services within MPFT Health in Justice Services receive a face-to-face assessment in order to identify immediate needs, risk and their appropriateness to be taken onto caseload. This is a holistic assessment which is designed to assist with the identification of need and allocation to the most appropriate clinician to take forward comprehensive assessment, risk management, care planning and delivery of interventions. Following assessment, complex cases are discussed in a weekly Multi-Disciplinary Team meeting to agree the appropriate plan of care.

If a specific Psychological assessment is indicated this will be conducted and this assessment will consider all information and an agreed formulation and potential plan will be developed which will be shared with all involved parties.

• It was identified that ‘there was a shortage of staff in prisons to undertake psychological treatment’

We wholeheartedly agree that there would be a myriad of benefits to increasing the psychological workforce in prisons and in community services. We regularly review the skill mix of our prison teams in order to ensure that, within the constraints of the funding available, we employ the right combination of staff to deliver effectively on all aspects of our contracts, including psychological work.

MPFT have worked with NHS England to develop a pilot of the Mental Health & Wellbeing Practitioner (MHWP) role which is a new role within some Health in Justice services. This role is one of the newer psychological professions. MHWPs are trained to provide low intensity psychological interventions to people with severe and enduring mental health difficulties.

Staff have access to an ongoing programme of training which supports our overall Psychological care of people in prisons. This includes learning about Cognitive Behavioural Therapy (CBT), Dialectic Behaviour Therapy (DBT), Trauma Informed care and working with co- occurring conditions.

MPFT would welcome the opportunity to employ more psychological practitioners in prisons, however given the constraints of our current budgets this is not possible. Close partner relationships with individual establishments enable us to take an active part in Health Needs Assessments and, where indicated, to work with NHS England to develop business case submissions to request additional funding for psychological provision in addition to the actions already taken above.

Kind regards.

Dear Sir Adrian,

Introduction

Thank you for your letter of 20 May 2024 sent to my predecessor as Lord Chancellor and Secretary of State for Justice enclosing your Prevention of Future Deaths (PFD) report. Please also accept my thanks for allowing the Ministry of Justice (MoJ) until 9 September 2024 to provide our response. I take this opportunity to offer my sincere condolences to the families and friends of James Furlong, Joseph Ritchie-Bennett and David Wails who were tragically killed in Forbury Gardens, Reading on 20 June 2020. I am grateful these findings have been brought to my attention. I am determined to do all I can to keep the public safe from terrorism and prevent similar attacks in the future. In your PFD report you identified significant shortcomings in several areas: A. the provision of adequate mental healthcare to (KS) in both custody and the community; B. the assessment and sharing of information and intelligence; C. the risk assessment and management of KS through Pathfinder; and D. the risk assessment and management of KS through MAPPA. In the response that follows, the MoJ’s work to address shortcomings is set out sequentially in the same areas, though, as is to be expected, there is some overlap between the issues identified in these areas and our response. Supporting documents have been referenced in footnotes. During the inquests you heard PFD evidence from: , the Chief Probation Officer; , Executive Director of the Security Directorate of His Majesty’s Prison and Probation Service (HMPPS); and , Head of National Security Unit (East and South Central) HMPPS National Security Division (NSD). It is not The Right Honourable Sir Adrian Fulford PC KC HM Judge Coroner C/O TLT LLP 20 Gresham Street London EC2V 7JE

Email only:

2 intended that this response will repeat their PFD evidence but there will be some limited reiteration to provide necessary context.

A. Mental Health Provision
1. Whilst the operational delivery of mental healthcare is for the relevant NHS trusts, this case raises wider concerns about the continuity of healthcare provision between custody and the community, the treatment and management of offenders with personality disorders and the support afforded to probation practitioners in working with offenders with complex mental health and substance and personality issues.
2. Together with NHS England, the MoJ and the Government are firmly committed to improving the way health and justice services address the needs of people in prison and under the supervision of probation services. This commitment is established in the National Partnership Agreement on Health and Social Care in England, published on 23 February 2023 which sets out defined roles for all partners (Department of Health and Social Care (DHSC), HMPPS, MOJ, NHS England and the UK Health Security Agency) and core objectives for delivering better care.1
3. Following the attacks in Forbury Gardens, the Prime Minister at the time commissioned an internal Rapid Review of mental health services for people under HMPPS supervision. Providing further independent scrutiny, in September 2021, the Justice Select Committee published its report on Mental Health in Prisons and a Joint Thematic Inspection report on these themes was published by HM Inspectorate of Probation shortly afterwards in November 2021.2 Taken together, these reports called for system- wide changes.
4. The MoJ, HMPPS, the DHSC and NHS England have worked collaboratively to drive improvements in the areas of concern identified across each of these reports, including: ensuring needs are identified early throughout the system; improving data collection and information-sharing across health and justice agencies; strengthening learning and development for all staff; continuing to ensure that mental health provision meets the needs of people in prison; and delivering greater continuity of care throughout the pathway and on release.
5. We set out key commitments and actions on these issues in our Action Plan, published on 4 March 2022 and updated on 27 March 2023.3 This included the following activity: i) Testing and evaluating a new model within Approved Premises (APs), enabled by £2.4 million funding over three years up to 2025. This provides targeted, enhanced mental health support to high-risk prison leavers with the most complex needs, building a clear bridge into services in the community, as recommended in the Rapid Review. The initial formal evaluation review will be available in Autumn 2024.

1 National Partnership Agreement for Health and Social Care (publishing.service.gov.uk) 2 Mental Health in Prison (parliament.uk), Justice Select Committee, 2021. A joint thematic inspection of the criminal justice journey for individuals with mental health needs and disorders (justiceinspectorates.gov.uk), HM Inspectorate of Probation, 2021. 3 An updated response to: A Joint Thematic Inspection of the Criminal Justice Journey for Individuals with Mental Health Needs and Disorders, March 2023: Updated plan (publishing.service.gov.uk)

3 ii) Recruiting 47 Health and Justice Partnership Coordinators (HJPC) and 12 Health and Justice Partnership Managers (HJPM) roles. 46 HJPCs and 12 HJPMs have been recruited to date and are in post across England and Wales. The management of these roles sits with the Heads of Community Integration within probation. Their purpose is to strengthen the links between substance misuse and health services in prisons and the community to support access to treatment. This includes working through the Local Combatting Drugs Partnerships, to ensure referrals to treatment, consistent information-sharing and the shaping of local commissioning to meet the needs of offenders. They also work across probation regions within Probation Delivery units to support and upskill probation practitioners. iii) Building confidence in information-sharing through the establishment of a joint NHS/HMPPS Information Sharing Advisory Group (ISAG) in 2021. The ISAG provides guidance and advice on information-sharing and looks ahead to new initiatives and projects to ensure that implications for information-sharing are considered and issues are addressed. The ISAG has overseen the development of two guidance products for operational staff, with further products in development, including a Prison Managers Guide, Probation Guide and a series of themed learning bulletins. iv) Developing an Adult Health, Care and Wellbeing Core Capabilities Framework to strengthen learning and development for MoJ staff, working with Skills for Justice.4 The framework will describe the skills, knowledge and behaviours required for those working with vulnerable individuals in custody, detention environments or on probation to enable them to recognise individuals who have health, care and wellbeing needs, identify the support that is available to them and help them access it. The framework is on track to be published by the end of
2024.
6. Beyond work set out in the Action Plan, we have gone further to strengthen the way we support people with mental health needs, including the following activity: i) We have renewed grant funding to the Samaritans, providing total funding of just under £2 million between 2022 and 2025. This is primarily for the delivery of the Listener Scheme through which selected prisoners are trained to provide support to fellow prisoners in emotional distress. ii) The NHS RECONNECT service was launched in some areas in 2019 to improve continuity of care and support vulnerable people leaving prison to access community services. It is the largest health and justice commitment in the NHS Long Term Plan, with £20m of funding for 2023/24, and is on target for 100% rollout across England by April 2025. RECONNECT provides release planning to offenders with an identified health need whilst they are still in custody, but approaching their release date, and then follows through with support for a period of up to six months post-release. The new Health and Justice Partnership

4 Established in 2002, Skills for Justice is the Sector Skills Council for the UK Justice, Community Safety, Fire and Rescue, Central and Local Government sectors. Skills for Justice is licensed by the UK Government and is a not-for-profit organisation and registered charity.

4 Coordinators are working strategically with RECONNECT services to strengthen and develop collaborative working and referral pathways. iii) NHS England have also committed £3m for piloting Enhanced RECONNECT services in four locations in England during 2023/24. Enhanced RECONNECT supports offenders with complex needs who are identified as high risk of harm to the public to engage with and get the right treatment from community services for an extended period of up to a year after release. Offenders are also supported by expert care navigators working with health and probation services. DHSC have commissioned the National Institute for Health and Care Research to conduct an evaluation of the four pilot sites which is due to end in October 2025, so that a decision can be taken as to a national rollout of Enhanced RECONNECT. I understand that more information on this is provided in NHS England’s PFD Response.
7. In December 2023, NHS England and HMPPS published a refreshed Offender Personality Disorder (OPD) Pathway Strategy for 2023 to 2028.5 The OPD Pathway is a set of psychologically informed services operating across criminal justice and health, underpinned by a set of principles and quality standards. Using evidence-based relational and environmental approaches, it aims to reduce risk associated with serious reoffending and improve mental health within a high-risk, high-harm cohort likely to meet the clinical threshold for a diagnosis of ‘personality disorder’. The refreshed OPD Pathway builds on the work done in the past decade pursuant to the original OPD Pathway strategy which was launched in 2011 and then updated in 2015. “The OPD pathway was established as an efficiency change program to recycle existing resources and provide an innovative, jointly delivered set of services for those with the most complex needs within the criminal justice and health systems. This vision is broadly being achieved; however, the experience of OPD pathway services to date, reflected through the ongoing commissioning cycle and wider feedback gathered during the strategic review, identifies that some highly complex individuals, particularly among those in custodial settings, have difficulties that are not yet being adequately addressed. This impacts on the public purse, poses an ongoing risk to public protection, and has implications for the health and wellbeing of those living and working in custodial and community settings. Gaps remain in service provision and there is more work to do to enable the vision of a holistic pathway.” “The OPD pathway adds significant expertise to the treatment and management of high-risk individuals with pervasive psychological difficulties in the criminal justice and health systems. Collaborative partnerships, along with effective signposting and a commitment to developing coordinated approaches to care, will therefore continue to be essential to the success of the OPD pathway as it looks to consolidate its work over the next phase of delivery.”
8. The strategic ambitions identified in the refreshed strategy include the following which appear to be relevant to the issues that arose in the management of KS’s risk: A1. Responding to unmet complexity of need. Expand support for those in scope who the OPD pathway has not yet reached, helping more people become stable enough to progress, while seeking to extend OPD pathway approaches to working with complexity across the wider system.

5 NHS England » The offender personality disorder (OPD) pathway: a joint strategy for 2023 to 2028

5 A2: Pathway consistency and quality. Develop national pathway consistency and quality by consolidating existing service provision, addressing regional disparities and creating opportunities for progression. A3. Enhancing identification, pathway planning, referrals and access. Improve access to OPD pathway services across the country by raising awareness of services, so that staff, participants and external stakeholders can make well-informed decisions about sentence planning and pathway progression. A4. Strengthening transitional support. Develop service handovers to be consistently managed and well planned at times of transition and improve information-sharing between OPD services, and with service participants and external partners. A5. Supporting a whole system approach to complexity, risk and need. Develop the pathway to become more outward facing, providing consultancy and training beyond the OPD pathway and strengthening partnerships, to support a whole system response to the management of complexity, risk and need.
9. The Intensive Intervention and Risk Management Service (IIRMS) provision is part of the OPD Pathway. IIRMS expanded rapidly following an increase in funding from 2019.This was to ensure that it is available in every region which had not been the case previously. This expansion has strengthened the way we support prison leavers with personality disorders. Local provision will be reviewed against the national IIRMS guidance to ensure that the service offer is consistent. This process will provide assurance that people subject to probation supervision receive a consistent service irrespective of where they live. This work will take place throughout the duration of the current strategy up to 2028.

B. Information-sharing
10. In your PFD report you noted that deficiencies in information-sharing between the various organisations involved in the risk management of KS had contributed to the failure to provide an adequate response to the risk posed by KS. Information-sharing processes within the specific contexts of MAPPA and Pathfinder are set out in their own respective sections. This section describes the changes which have been made to improve information-sharing between the prison service and the probation service.
11. Since June 2020 there have been significant developments in the digital offering in both prisons and probation. There is greater automated information-sharing between the core systems used in prisons (NOMIS and DPS6) and NDelius. All Offender Manager Unit staff, including Prison Offender Managers (POMs), now have access to the Probation Services’ electronic record system, NDelius, on a read-only basis.
12. Manage POM Cases (MPC) is a digital service which sits on DPS and is used to manage the allocation and the responsibility of cases to POMs during an individual’s time in custody and transition into the community. MPC determines all allocations in accordance with Offender Management in Custody (OMiC) policy. Once sentencing calculations are done by the prison, MPC automatically determines whether a case should be managed by the POM or Community Offender Manager (COM) responsible for the offender. MPC

6 DPS (Digital Prison Services) is a suite of newer digital services being developed for use by prison staff and prisoners (specific services).

6 then transfers handover dates onto NDelius meaning both POM and COM can easily see this information.
13. Contact entries made straight into NDelius will not transfer back onto MPC or DPS so there remains a responsibility for practitioners to communicate with one another regarding key progress points in an offender’s sentence. However, other useful information has been extracted from NDelius and made more visible in the screens that are used by MPC users in the Offender Management Unit (OMU) who are based in the prison. For example, MPC users can now see an individual’s MAPPA level and the last OASys (Offender Assessment System, a risk assessment tool used by Probation) risk level on their screens, so they do not have to access NDelius or OASys to check this.
14. A specific subset of case notes written up by prison staff in NOMIS are transferred to NDelius and displayed in the NDelius contact log. This automatic transfer occurs for entries which relate to the following recorded activities, regardless of who has made the entry: i) Person released from institution. ii) Person transferred. iii) General observations. iv) Alerts active. v) Alerts inactive. vi) All OMiC events. vii) All OMiC OPD events viii) Keyworking events.
15. Other new services are being developed to share information across systems to make sure that HMPPS staff have the information that they need. Whilst some of these services are still in development, several have been launched since 2020, including in particular the Pathfinder IT service which supports the management of terrorism-related nominals across the prison and probation services. Pathfinder IT is addressed in more detail at paragraphs 30 to 32 below.
16. A project to replace the Mercury Intelligence System with the Intelligence Management Service (IMS) is underway, with the roll-out of the new live system planned for Spring
2025. IMS will enable, for the first time, some probation staff to have direct access to intelligence held by the prisons. This is in contrast to Mercury, which, for contractual reasons, only prison staff were permitted to use. Probation staff access to IMS will be for POMs in the first instance, though the potential for probation staff working in the community to have access will also be explored. In addition, IMS is a modern digital system which is much faster than Mercury and has a user interface that is much more intuitive as it is based on the Government Digital Service standards originally devised for public-facing services. We will be able to deliver improvements to IMS more quickly and easily and ensure that we provide the right data at the right time to enable robust decision making.
17. Information from IMS will be disseminated to HMPPS staff and partner agencies more effectively. Probation staff will be able to identify intelligence that is useful to inform risk assessment and management and formally request that it is released to them from the prison’s security department. Sharing information with partners will be the same as it is now with Mercury but with more controls and audits in place to monitor it.

7
18. IMS will assist with the dissemination of information from the POM to the COM. In the initial release of IMS, it will be the responsibility of the POM to identify the material of use to the COM and request it from the prison’s security department. The security department will provide a usable form of words to be passed to the COM with the form of words being dictated by the sensitivity of the intelligence. Ultimately, it is intended that COMs will have direct access to IMS. However, given the size of the HMPPS workforce this is a large undertaking which will require time to achieve.
19. Whilst the Mercury system is still operational, there is also a plan to publish specific guidance to ensure that all prison staff are aware that Mercury Intelligence Records need to be linked to a nominal’s record, even if the subject is no longer in custody. This will be published by Autumn 2024. The working assumption is that intelligence on former prisoners is linked to their records, and it is the case that the vast majority of information is correctly linked. However, this requirement is not formally stated anywhere within HMPPS training or processes. This new guidance will address this lacuna.
20. The Assessment Care in Custody Teamwork (ACCT)7 process is still largely paper- based although the fact that an offender is being monitored on an ACCT should be recorded in NOMIS, which will automatically send an alert through onto NDelius.

C. Pathfinder
21. In your PFD report you identified numerous shortcomings in the operation and effectiveness of the Pathfinder process in KS’s case, including failures to arrange a pre- release Pathfinder review, failures by Pathfinder to secure the engagement of Mental Health services and failures to ensure that a complete intelligence picture was available to those who were tasked with the management of KS’s risk within the prison and probation services and amongst policing partners. The MoJ recognises that KS’s case raises concerns that systemic problems within Pathfinder could present risks that offenders’ extremism risks are not identified and responded to appropriately.
22. This response on Pathfinder seeks to detail the steps MoJ has taken to address the failures in the Pathfinder process which you identified; the further changes which the MoJ has identified and implemented to improve the Pathfinder process; to provide assurances to you that improvements are being effectively implemented by MoJ; and future changes which the MoJ is intending to make as part of a process of continuous ongoing improvement to Pathfinder. Failure to arrange a pre-release Pathfinder Meeting
23. In March 2021, the Dormant Review Standard Operating Procedure (DR SOP) was introduced. This provided detailed guidance as to when and how to complete a review of a dormant Pathfinder case, and who should do it. Previously, staff were reliant on the very limited detail about the Dormant Review requirement that was included in the Managing Extremism Policy Framework (Annex C of Managing Extremism Amongst Offenders in Custody and Annex L of Managing Extremism Amongst Offenders in the Community). The Dormant Review process ensures that those who have previously

7 ACCT is the Prison Service system for identifying and managing prisoners at risk of suicide and self-harm.

8 presented a terrorist risk are reviewed before a significant change of circumstances, such as release from custody.
24. All Pathfinder nominals, save for those previously assessed and managed at the lowest risk level, must be classified as ‘Dormant Review’ when the decision is taken to remove their ‘active’ Pathfinder status. Following the Dormant Review process set out below, nominals will be classed as dormant where they have been assessed as no longer presenting with an engagement or susceptibility to terrorism. The Prison Prevent Lead (PPL) or CT Specialist Probation Practitioner (CTSPP) is notified, via the Pathfinder IT system, of the prisoner’s release date and will seek information regarding the prisoner three months prior to release. Once this notification of an impending release has been received, there will be a review which commences with alerting all the agencies engaged with Pathfinder of the prisoner’s imminent release. If all are satisfied that the threat and risk are mitigated, then the prisoner will be made ‘dormant’, and this will be recorded on the Pathfinder system. (Once a case has been made ‘dormant’ in custody prior to release, the offender will only be discussed at Community Pathfinder meetings if new concerns arise that lead to a new referral being made to Community Pathfinder.) If not made ‘dormant’, then they are made ‘active’ and will transfer into the community as ‘active’ on Pathfinder. This process ensures that this is a multi-agency decision.
25. Dormant Review cases are now discussed at every Prison Pathfinder meeting as a standing item on the Pathfinder meeting agenda. Any Pathfinder prisoners classified as ‘Dormant Review’ who either (1) have been a Dormant Review case for 3 months or (2) are approaching a significant change in their custodial status will be considered by the Pathfinder committee and made an ‘active’ case again if any risk is identified.
26. The change to the Pathfinder Dormant Review process described under scenario (1) above, ensures that cases which have remained ‘dormant’ are still regularly discussed and assessed for any changes in risk. Therefore, all Dormant Review cases are considered on an ongoing basis. In respect of scenario (2) above, a case will be discussed in more depth if the offender that is subject to Dormant Review is approaching a significant milestone, such as if the offender is due for parole, to be released or re- categorised. If no risks are identified at the last Prison Pathfinder meeting prior to release, an offender’s case will be made ‘dormant’.
27. A member of the Probation Counter-Terrorism Team (PCTT) will not always attend the Prison Pathfinder Dormant Review meeting in person. However, the PCTT are always consulted for their view on the Dormant Review cases by the Regional Counter- Terrorism Team (RCTT) and any view they have will be fed in via a PCTT representative or the PPL on behalf of the network.
28. Two dedicated audits have taken place since the introduction of the Dormant Review SOP to test compliance and the quality of application. In the period 1 March 2021 to 31 August 2022, 455 cases were screened. It was found that only 10 had a requirement for a review in the last three months of custody to decide whether to make them ‘active’ or ‘dormant’. Six of these cases were dealt with in accordance with the SOP, three followed the SOP for the most part with minor areas of non-compliance with the procedure identified and one case had been overlooked for technical reasons which were subsequently addressed. In the period 1 March 2024 to 25 June 2024, 572 cases were screened. 23 cases had a requirement for a review in the last three months of custody to decide whether the cases should be made ‘active’ or ‘dormant’. 20 of these cases were reviewed in accordance with the requirements of the SOP. For the remaining three, the process was followed in the sense that the risks of the individuals were properly

9 reviewed, however the three cases were each made ‘dormant’ at the three month point rather than the last Pathfinder meeting prior to release.
29. In order to provide assurances that the expectations of Pathfinder in the pre-release period are maintained to a high standard, it is now the responsibility of the Regional Pathfinder Chairs to assure themselves that the appropriate identification and management of Dormant Review cases is undertaken in the pre-release window. Assurance processes to ensure that standards are maintained in the Dormant Review process will also be included as part of the updated community and local custody Pathfinder SOPs. Pathfinder IT
30. The Dormant Review process is supported by Pathfinder IT (PFIT), which was created in 2020. PFIT is a centralised case management system which enables professionals across HMPPS staff to manage the CT Cohort, which encompasses Terrorist and Terrorist-Risk nominals across both the Custody and Community arena. It is accessible by Joint Extremism Unit (JEXU) Prison and Probation networks, JEXU HQ and various external partners (e.g. Joint Counter Terrorism Prisons and Probation Hub (JCTPPH) & CT Policing).
31. PFIT draws live data from primary frontline case management systems across HMPPS, specifically NDelius and NOMIS. This is to ensure that key dates, e.g. the Calculated Release Date, are accurate and aligned consistently with wider HMPPS data platforms. Should a frontline prison or probation team amend any of these dates e.g. if a sentence is recalculated, the amended date will automatically be updated within PFIT once a change has been recorded within either NOMIS or NDelius. This means that in cases such as KS’s, the PPL and the Regional Counter Terrorism Lead would automatically become aware from the data recorded via PFIT that a prisoner’s release was impending, either when a prisoner enters the final three months of their sentence or if their release date is brought forwards. This enables the RCTT to ensure that the Dormant Review case is considered ahead of the prisoner’s early release to ensure risk is fully assessed. This flag prompts further discussion and consideration at Prison Pathfinder meetings.
32. Furthermore, PFIT has an integrated notification feature which ensures that an alert is automatically generated and sent to relevant users (determined as those users who have the nominal listed within their caseload) to make them aware of any change to a key date. New Pathfinder tools – guidance and assurance
33. In October 2022, the Pathfinder Guidance Framework (PGF) Operational Delivery Guidance was issued. The PGF assesses susceptibility to extremism and what is required by way of interventions to address this. It has been designed to help document, structure and support decision making and the case management of terrorist risk offenders. It should be completed alongside the Controls and Interventions Matrix (CIM). It should be used by CT Specialists to guide consideration of the extremism concerns and to help direct further actions and interventions. It was issued to trained assessors, supervisors and staff involved in the management of terrorist risk cases across HMPPS. The PGF is an assessment tool which must be completed for all terrorist risk offenders who have been made an active case of concern at Pathfinder. It must be completed within 8 weeks of the offender being made ‘active’. It informs CT specialists in providing advice and guidance to those outside the CT network. The PGF assessment can only

10 be completed by staff who have attended a full day training event and successfully completed the post training assessment. The PGF replaced the Extremism Risk Screening (ERS) which was used in KS’s case.
34. The Counter Terrorism Quality Development Tools (CTQDTs), first launched in 2021, have been developed in collaboration with the Improvement Support Group (ISG), OMiC Team, Probation Service NSD and JEXU’s Prison and Probation CT Operational Network of specialist staff. The Tools, deployed by regional CT Leads, have two main aims:
a. Quality Development – Providing Regional CT Teams and Prison & Probation Practitioners with feedback to improve quality standards in operational delivery, including sharing notable positive practice.
b. First Line Assurance – Providing Regional CT Leads with a mechanism to ensure that CT delivery meets a minimum standard and address any shortfalls which are identified. This allows Regional CT Leads to build capability and confidence within their respective teams. Additionally, national themes and trends are analysed, and presented to senior leaders to address any wider or systemic gaps (e.g., where guidance may need updating). Failures by Pathfinder to secure mental health engagement
35. Terrorist and terrorist-risk offenders commonly have multiple, complex needs and face difficulties in accessing services. As healthcare does not allocate treatment based on national security risk but rather on clinical need, terrorist and terrorist-risk offenders cannot be auto-prioritised. To date, HMPPS has limited levers to use to secure healthcare attendance at Pathfinder and escalate issues where mental health services are lacking.
36. In June 2022, HMPPS and NHS England jointly issued guidance for healthcare staff entitled “Increasing the Engagement of Prison Integrated Healthcare Teams in Pathfinder”. This followed a JEXU Review of mental health provision after the attacks in Forbury Gardens. The review identified the need to improve the engagement of healthcare teams in Pathfinder. The aim of this guidance has been to encourage healthcare attendance at case management meetings in custody, and in turn to help ensure mental health information is being used to inform the assessment and management of terrorist risk. Follow-up surveys on the implementation of this guidance show an increase of 21 percentage points in healthcare’s attendance at Pathfinder meetings from 59% in the first half of 2022 to 80% in the second half of 2022. The surveys were not mandatory but provide an indicative representation. HMPPS have been informed by the NHS that they have sent out this guidance to all mental health providers involved in Pathfinder.
37. To better support probation teams in navigating the barriers that operational staff face when accessing mental health and complex needs services for this offender cohort, JEXU has issued further guidance setting out the different national provisions available for terrorist and terrorist-risk individuals with suspected or diagnosed mental health needs once they have been released into the community. This includes information on services that can support in cases where offenders do not engage with the services available to them. JEXU has also developed specific training on the interaction between mental health issues and terrorism risk, with the purpose of supporting those involved in

11 case management (specifically Pathfinder partners) and healthcare colleagues in better understanding this interaction.
38. As part of ongoing continuous improvement activities, HMPPS is taking steps to improve how Pathfinder is delivered including re-defining the roles and responsibilities of Pathfinder partners. These include links that have been established between Pathfinder forums and the Counter Terrorism Clinical Consultancy Service (CTCCS) which replaced Vulnerability Support Hubs in April 2024. CTCCS are embedded multi-disciplinary mental health teams that work with individuals who are deemed susceptible to radicalisation and who also present as having mental health issues. Failures by Pathfinder concerning Information-sharing
39. In April 2021, the JCTPPH, a new national body with co-located staff from CT Policing, HMPPS and MI5 became operational. The core function of the JCTPPH is co-ordinating quicker and better information and intelligence exchange between operational partners. The JCTPPH provides a range of new capabilities and services that enable more effective management of individuals of national security concern in prison or under probation supervision in the community. The JCTPPH is focussed around placing the right intelligence, appropriately protected, into the right forums to ensure the most effective risk management decisions are made. Working with partners, the JCTPPH ensures there is a shared understanding of who poses a risk, and why, to enable management of these individuals through multi-agency partnerships and engagement with the appropriate statutory bodies and functions.
40. Since 2020, HMPPS have also enhanced our ability to access intelligence and information from partners through improvements to regional Pathfinder, which provides a multi-agency working environment for HMPPS, CT Policing and partners to discuss cases, make decisions, plan releases and share information pertaining to CT case management. Pathfinder meetings are held regularly and there is a requirement for minutes to be taken and shared with partners to ensure decisions made are recorded and actions required are documented. Pathfinder conclusion
41. As part of ongoing continuous improvement activities, HMPPS and partners are planning to make further improvements to Pathfinder. These reforms will build on the established foundations of multi-agency, CT-specialist case management processes already operating in the prison and probation sector, developing these further to improve our ability to make agile, informed decisions around CT case management, by creating timely, secure access to the right information and intelligence, at the right time, by the right people.
42. Amongst those planned improvements are the following: HMPPS will review the thresholds for referring and adopting cases to Pathfinder and will review the appropriate risk levels for each threshold; HMPPS will also ensure that there is a consistent and aligned understanding of terrorist risk that is shared by Pathfinder partners; HMPPS will strengthen its ability to respond to risk by setting up a new National Pathfinder process, which will provide senior oversight and additional assurance on case management. National Pathfinder will, among other things, be a forum for escalating issues affecting case management or risks where national support may be required, as well as overseeing high risk cases.

12

D. Multi-Agency Public Protection Arrangements (MAPPA)
43. In your PFD report you identified numerous shortcomings in the operation and effectiveness of MAPPA in KS’s case. Your report encouraged the MoJ and the Chief Constable of Thames Valley Police to work together to remedy these deficiencies. The problems you identified included the ineffectiveness of MAPPA in formulating a complete picture of the risk posed by KS and the corresponding failure of MAPPA to effectively disseminate intelligence between organisations. Your report noted that if these intelligence failures had not taken place, it was possible that MAPPA could have upgraded KS to ‘very high risk’ and designated him a Critical Public Protection Case, resulting in his management at MAPPA Level 3. Such a change could have impacted KS’ licence conditions, the availability of Approved Premises and the speed of a recall of KS. Further, you identified the erroneous assignment of KS to a non-existent MAPPA risk level, errors in the information considered by MAPPA about available mental health treatment options, misconceptions in meetings about how KS’ mental health conditions impacted his risk, an incorrect decision to remove KS from the MAPPA agenda and a failure to regularly secure the engagement of key stakeholders. The MoJ recognises its part in these failures and the risks which would arise in the future if these issues are not properly addressed. Thames Valley MAPPA
44. Thames Valley MAPPA drafted an action plan in response to the MAPPA Serious Case Review of 5 October 2021 (MAPPA SCR). The October 2023 updated action plan was exhibited to ’ PFD witness statement. The main actions taken as a result of this post-MAPPA SCR action plan were set out in the PFD witness statements of and of . An updated version of this action plan (‘TVP Local Action Plan’), now addresses points arising from your PFD report. There is an element of crossover in findings between the MAPPA SCR and your PFD report. This local action plan shows when recommendations from the MAPPA SCR have been progressed if they are relevant to your findings and issues raised in your PFD report.
45. The actions identified in the TVP Local Action Plan which are new and are therefore not described in either of the witness statements of or are summarised below. Training and reminders about the correct MAPPA processes have been provided to probation practitioners as follows: i) Training on identifying cases that would benefit from MAPPA management was provided to probation case administrators on 1 May 2024. ii) The MAPPA Chairs Compendium of Learning has been amended to emphasise the need for chairs to indicate what circumstances might lead to a case needing to be re-referred into MAPPA Level 2/3. iii) The Head of Public Protection has reminded probation practitioners of their responsibility to ensure that any case that is outside MAPPA or is at Level 1 and needs to be heard in a meeting must have a new referral submitted to the thresholding panel. This has been included in the Compendium of Learning referenced above.

13 iv) The Head of Public Protection has reminded probation practitioners (as the lead for most MAPPA cases) of their responsibility to ensure the MAPPA administrator is aware of who to invite to meetings, not just at the point of referral but throughout the MAPPA management of the offender. This has been included in guidance documents and ongoing training for Chairs.
46. As described at paragraph 56(ii) of ’ PFD witness statement there is now an escalation process to monitor and address non-attendance at MAPPA meetings. The MAPPA Coordinator and the Strategic Management Board continue to maintain a list of escalation points so that the attendance and meaningful participation of agencies at MAPPA is pursued.
47. Local Strategic Management Boards (SMBs) are responsible for delivering MAPPA within their respective Criminal Justice areas. These boards provide governance and are required to have quality assurance processes in place. Thames Valley MAPPA SMB has implemented quality assurance of the MAPPA process. This has included audits on 18 March 2024 and 15 April 2024 for referrals rejected by the thresholding panel and audit of MAPPA Minutes on 19 February 2024 for the management of MAPPA Level 2/3 meetings. These aspects were specifically chosen as they had been identified as not working well by the author of the MAPPA SCR.
48. In the first audit, 12 cases were selected at random and the thresholding of referring cases to MAPPA Level 2 was analysed. In 11 cases the auditors agreed with the referral decision, with them disagreeing with the referral in one case only. The robust approach taken by the audit team has identified clear goals for improvement in several areas of the MAPPA process. Audit reports are presented to the MAPPA SMB to identify any actions. Learning from the audit around presenting risk information, risk assessment and the identification of how MAPPA will add value to the risk management of the case will now be disseminated within the Thames Valley area. This will be done via the Thames Valley MAPPA SMB Quality and Monitoring Sub-group and the MAPPA Chairs Forum.
49. In the second audit, six cases were selected at random and the meeting minutes analysed. The record of the audit outcome meeting on 19 February 2024 identified some areas of improvement especially in respect of the attendance of other agencies. In response a detailed action plan was drawn up and this set out steps such as refresher training for MAPPA Chairs, the escalation processes to be invoked, and reminders to agencies to attend. Assessing Intelligence in its entirety
50. In your factual findings you identified that there was an incomplete intelligence picture for KS. This included prison intelligence which did not reach KS’s COM. The National Intelligence Unit (NIU) within HMPPS has reviewed the way prisons share security information and intelligence within MAPPA, specifically when contributing to MAPPA level 2 and 3 meetings.
51. In consultation with the national MAPPA team, the NIU have produced additional guidance for prison security departments to improve the quality of the intelligence assessment which forms part of the information-sharing report (MAPPA F) which prisons complete for each level 2/3 pre-release MAPPA meeting. The guidance includes a new template to structure the intelligence assessment and instructions on the process to

14 follow. This has been designed to ensure that the intelligence provided by prisons to MAPPA panels is comprehensive.
52. In addition to providing relevant intelligence, it is now required that prisons will attend all pre-release MAPPA Level 2/3 meetings. At a national level, their attendance is monitored by the Responsible Authority National Steering Group (RANSG), which a senior representative from the Prison Service attends. The data shows that, nationally, prison attendance at MAPPA Level 2/3 meetings is consistently high. Where there is a dip in a particular area the RANSG will commission localised work to improve attendance. At present prison attendance at Level 2/3 meetings stands at over 93% against a target of 90%. Addressing Risk
53. The quality of how MAPPA meetings are managed is monitored using the Quality Improvement Tool which was launched in April 2023. The National MAPPA team is now assessing the data collected in the last year. Initial findings from the Quality Improvement toolkit show that overall, the management of cases is meeting the set criteria including the quality of chairing and the quality of minutes. There are some areas for improvement and the National MAPPA Team will address these in the coming months. The National MAPPA team will continue to use the findings from the Quality Improvement Tool to address deficiencies and highlight where areas are doing well.
54. In addition, MAPPA are subject to independent scrutiny by the three Criminal Justice Inspectorates. The joint thematic inspection of MAPPA was published in 20228. This concluded “that for cases managed at Levels 2 and 3, MAPPA largely achieves its aim of managing the risks that violent and sexual offenders pose to the public”, but that “for Level 1 cases, further improvements are needed”.
55. There has also been an independent review of MAPPA by Jonathan Hall,9 as a result of which a discrete new MAPPA category, Category 4 was created. This was to ensure that all offenders convicted of terrorism offences are automatically referred to and managed under MAPPA and to enable offenders who are assessed as presenting a terrorism risk to be managed under MAPPA, even where they have not been convicted of terrorism offences. We also introduced amendments to part 13 of the Criminal and Justice Act 200310 to put beyond doubt Duty to Co-operate (DTC) agencies’ powers to share information under MAPPA and extended these powers to cover any agency the Responsible Authority considers may contribute to the assessment and management of the risks presented by MAPPA offenders, for example GPs.
56. In July 2023 there was a joint inspection of the management of terrorist offenders11 which stated that it was evident that many of Jonathan Hall KC’s recommendations from his 2020 review of the management of terrorist offenders through MAPPA have been implemented.

8 Criminal Justice Joint Inspection of MAPPA by HM Chief Inspectors of Probation, Prisons and Constabulary July 2022 9 Independent Review of Statutory Multi-Agency Public Protection Arrangements May 2020 by Jonathan Hall KC 10 https://www.legislation.gov.uk/ukpga/2003/44/part/13 11 Counter Terrorism Joint Inspection – National Security Division and multi-agency arrangement for the management of terrorist offenders in the wake of terror attacks – July 2023

15 Conclusion
57. Finally, I wish to thank you for the care and consideration with which you and your legal team conducted these inquests. Your factual findings and PFD report identify extensive learning points for the MoJ. Whilst much of the improvement work was already in train, the need for greater scrutiny of some key issues and further important improvements has been identified as a direct result of these inquests. I hope that these will provide some reassurance to you and to the families and friends of James Furlong, Joseph Ritchie- Bennett and David Wails.

1

Home Secretary 2 Marsham Street London SW1P 4DF

SIR ADRIAN FULFORD PC

By email only 9 September 2024

FORBURY GARDENS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS RESPONSE OF THE SECRETARY OF STATE FOR THE HOME DEPARTMENT

Thank you for all the diligent work you and your legal team have undertaken during the inquests arising from the deaths of James Furlong, Joseph Ritchie-Bennett and David Wails in the Forbury Gardens terror attack of 20 June 2020. Before responding to your letter of 20 May 2024, I would like to express my deepest condolences to the families and loved ones of James, Joseph and David, as well as my thoughts to all those impacted by this tragic incident. It is crucial that we do everything within our power to prevent this from happening again.

I am grateful for your recognition in the Regulation 28 Report to Prevent Future Deaths (the Report) that the Home Office has made several improvements since this tragic incident. I fully accept and support your conclusion that there must be effective monitoring of these improvements to ensure they meet their purpose and I address the relevant measures in this regard below.

I would like to acknowledge that the events described cover a period under a previous government and reiterate my commitment as Home Secretary to treat the failures with the utmost seriousness. I will be overseeing the proper implementation of recommendations and any new commitments made.

Prevent

The Home Office, along with our partners, continuously drives improvements to our capabilities to strengthen our approach to supporting those vulnerable to being drawn into terrorism. We do this through regularly reviewing elements of the Prevent system, both at an operational and strategic level. As I will detail further in my response, this includes conducting process reviews, case assurance and producing annual statistics to inform and improve policy and strategy. We also commit to implementing improvements from the independent evaluation of the Home Office Channel programme, which is currently underway and expected to report in 2025/20261. As Michael Stewart, Director of Prevent,

1 As stated in Michael Stewart’s witness statement, evaluation of the Prevent system is a priority. We are evaluating Channel’s effectiveness to understand its impact on counter-terrorism outcomes and risk. The core objective is to fill these evidence gaps by consolidating best practice in preventing or countering violent extremism (‘P/CVE’), evaluation, and trialling innovative approaches to significantly build the evidence base and to shape government responses to the threat of violent extremism. This will be an independent evaluation, conducted by Ipsos and University College London. This is a significant piece of work and will be the first of its kind in this field.

2

said in his evidence, we know that no programme of this type can offer a complete guarantee of success, however, we must do everything we can to ensure we are working to the best of our ability to stop such terrible attacks occurring in future. Any failure must be treated with the utmost seriousness.

The Home Office is also keeping the Joint Enhanced Casework Team’s (JECT) operations under close review and is continuing to develop and improve its processes. This includes oversight of JECT to ensure that the range of interventions available are effectively managing individual cases. Oversight is through the CONTEST Board which is a senior officials board that meets monthly to monitor the implementation of CONTEST and ensures that we maintain collective decision-making and effective co-ordination across government. It brings together senior operational and policy leaders from each of the government departments included in CONTEST, Counter Terrorism Policing Headquarters (CTPHQ) and the security and intelligence agencies. As well as being part of regular discussions in the monthly CONTEST board structure, every six months JECT’s performance is considered as one part of CONTEST’s wider performance review.

The failure to maintain and disseminate an adequate intelligence picture: Prevent2

The Home Office's Prevent directorate provides the strategic direction for Prevent, including Prevent relevant training to non-police Prevent statutory partners within local authorities. The police are responsible for managing the terrorism risk of individuals throughout all stages of the Prevent pathway, as well as the policy, assessment tools, and training of police officers and staff conducting these assessments. As all of KS’s referrals were closed at the initial assessment stage by Counter Terrorism Policing Prevent officers, the Home Office Channel programme did not manage the case. Therefore, effective monitoring of the operational Prevent issues raised in the Report is best addressed by CTPHQ.

However, as part of the Home Office’s efforts to improve the Prevent system, we are working with partners including CTPHQ on multiple projects. These aim to better manage risk and improve the quality of our data, to further enable robust monitoring of the effectiveness of Prevent. I have set out the developments and monitoring in place for the three areas of concern identified in the Report for Prevent, which are within the Home Office’s remit.

a) Overall failure to revisit and review the overall intelligence and risk assessment picture in light of newly acquired information

I understand that the Home Office and CTPHQ launched a new joint Prevent case management system in May 2024. In developing this system, I am told we have ensured that when a new Prevent referral is registered, any previous referrals are automatically flagged to ensure this information is fully considered during the initial assessment stage and throughout the individual’s Prevent pathway. I am concerned about the specific issue of repeat Prevent referrals falling below the threshold and am committed to look closely at this. This new case management system also provides CTPHQ and the Home Office access to data trends, which allows for consideration of any outliers in decision making. These outliers can be flagged for potential further action. This includes additional training for the Counter Terrorism Case Officers (CTCOs)3, who undertake the assessment of Prevent referrals, or the Channel panel, or further investment in the local area if the threat has increased.

2 Responding particularly to paragraphs 18-21 of Judge Coroner’s Report of 20 May 2024. 3 CTCOs are responsible for managing referrals and cases through the Channel process (including ensuring case information is kept up to date on the case management system), reviewing and amending the Prevent assessment framework, assessing any escalating risk, and transferring cases to police led partnership/Pursue where appropriate.

3

As I understand Chief Constable will also be addressing in Thames Valley Police’s response to you from the operational perspective, the Home Office and CTPHQ have also worked with the national CT Assessment and Rehabilitation Centre (CT-ARC)4 to develop a new Prevent assessment framework (PAF). I understand that this replaces the Vulnerability assessment framework and is designed to ensure that the triaging of referrals into Prevent is consistent, rigorous, and proportionate. I am told the PAF, which has been independently endorsed, will ensure that thresholds and decision-making are implemented consistently across all ideological threats by creating a framework that is easily understood, easily completed, and supports CTCOs in their decision making. It covers referral details, indicators of concern, a susceptibility assessment, engagement factors, intent factors, capability factors, protective and risk mitigating factors, and support planning. The PAF also captures repeat referrals to ensure consideration is given to cumulative risk, which is an issue I am concerned about. I understand that this new tool is more reflective of current research and understanding of those vulnerable to being drawn into terrorism; it will identify referrals suitable for Prevent and the Channel process earlier and more accurately; and it will improve the quality and effectiveness of risk assessments of referrals adopted as cases.

The PAF is being rolled out in Autumn of 2024 to all regions. Prior to using it, CTCOs must attend an assessed training day to become familiar with the PAF, how to complete it, how it fits into current processes, and to practise completing it. During the training day there are three assessment points where attendees will be assessed as either ‘Ready’ or ‘Not Yet Ready’ to complete a PAF for live cases. If awarded ‘Not Ready’, attendees will be provided a further opportunity to complete the task training.

I understand that the PAF has been piloted since November 2023 in the South-West and Eastern regions. During this pilot stage, as well as receiving feedback on the PAF, I am told that CT-ARC have been quality assuring the PAF process monthly to assess the quality of use and completion by looking at how integrity to the guidance is upheld. We will continue to monitor the PAF with CT-ARC and CTPHQ to ensure it is robust, efficient, evidence- informed, operationally viable and well-integrated into the current system. Details of how longer-term quality assurance will be conducted will be finalised in August ahead of national PAF rollout later in autumn. However, this will include continuous and regular review of PAF use, as well as a longer-term evaluation. As the PAF is embedded into the Prevent pathway it will also feature within existing Home Office quality assurance systems, specifically quality assuring the PAF’s operational application by Channel panels in the assessment of risk and provision of support.

b) Failure by Prevent to correctly assess risk, by over emphasising mental health difficulties

Improving the quality of Prevent referrals

4 The CT Assessment and Rehabilitation Centre (CT-ARC) is a national HM Prison & Probation Service (HMPPS) body comprising a network of specialist psychologists, probation officers, and other staff who focus on standards for risk assessment, risk reduction and rehabilitation.

4

In 2023 the Home Office updated the Prevent duty guidance (England and Wales)5 and the Channel duty guidance6. My understanding is that this is to better enable those sectors subject to the Prevent duty (such as local authorities, police, health, education, and prisons and probation) as well as those working on Channel panels, to be effective at understanding and mitigating terrorism risk, and to have structures in place that identify and support people vulnerable to radicalisation. The new guidance provides clearer advice on how to understand and manage risk, including by ensuring comprehensive training and risk assessments take place. It also introduces new tools for frontline practitioners to ensure that those meeting the Prevent threshold are progressed for Prevent specific support, with a focus on ideology as a determinant of Prevent thresholds. I outline relevant training packages on ideology later under the subheading of training.

Our updated guidance advises front-line staff to use the national Prevent referral form to submit their initial concerns. This single Prevent national referral form, while not mandatory, has been provided to all partners to promote consistency. I have been told that it has been designed to be completed by front-line staff who may not have specialist knowledge of radicalisation. It requests information around ideologies, behaviours and relevant factors, encouraging the person submitting the referral to provide as much relevant information as possible. This is to ensure specialist officers can make an effective assessment of risk, including in the PAF, and improve data recording. We have also updated the GOV.UK Prevent page7 to make clear that referrals should be made where there is a genuine concern of radicalisation, and that ideology should be a critical consideration.

We are using Prevent referral data (from the new case management system) and training data to identify where the quality of referrals is lower, or not in line with the risk in that area or sector. This has enabled us to better target Prevent outreach and training to improve the quality of referrals. Alongside this, a refreshed list of ideology categories has also been created for use in the new case management system, which will be accompanied by updated training and guidance for case officers to ensure accurate recording of data and evidence about ideology. We will review the ideology categories on an annual basis to ensure they are reflective of the wider ideological picture and routinely monitor Prevent data, carrying out dip sampling to provide assurance that there are no disparities in decision-making throughout the Prevent pathway.

Improving mental health management within Prevent cases

The relevance mental ill-health conditions play in the threat varies by case. Mental ill-health can contribute to the radicalisation of some individuals, acting as a risk factor, while in other cases it may act as an inhibitor.8 The majority of Prevent practitioners are not mental health professionals and anecdotal evidence from those practitioners indicates that they remain concerned about the incidence of diagnosed and undiagnosed mental health conditions within Prevent casework. That is why it is essential that there is multi-agency involvement in the Channel process so that Channel panels can pull on the professional expertise of mental health practitioners when progressing cases. This includes advice on the type of activities

5 England and Wales: https://www.gov.uk/government/publications/prevent-duty-guidance. Statutory guidance for Scotland was issued on 7 May 2024 under Section 29 of the Counter-Terrorism and Security Act 2015: https://www.gov.uk/government/publications/prevent-duty-guidance-for-specified-authorities-in- scotland. 6 The Channel duty guidance for England and Wales: https://www.gov.uk/government/publications/channel- and-prevent-multi-agency-panel-pmap-guidance. 7 https://www.gov.uk/guidance/get-help-if-youre-worried-about-someone-being-radicalised. 8 See p. 15, paragraph 27 of CONTEST 2023: https://www.gov.uk/government/publications/counter-terrorism- strategy-contest-2023.

5

that should be included in a support package9, as well as attending panels to provide an update on the progress of support given.

The Clinical Consultancy Service (CCS)10 can also be drawn on to provide Prevent officers with advice, guidance and options to help manage the individuals in their casework with mental health needs. Through this service Prevent officers are given access to a multi- disciplinary team, including NHS mental health nurses, psychologists and psychiatrists. The Home Office are part of the oversight board of the CCS to monitor its effectiveness in helping to reduce the risk of those individuals vulnerable to being drawn into terrorism.

The PAF is used by Channel to guide decisions about whether someone needs support to address their radicalisation risk, and the nature of support that they need. PAF training makes clear that mental health concerns can be a potential indicator of concern or a safeguarding factor, directing that any mental health support being received may form part of the information gathering process on an individual who has been referred. Mental health and complex needs are also considered as potential engagement factors, so consideration must be given as to whether the existence of any mental health difficulties could contribute to make an individual more vulnerable to engaging with an extremist group, cause or ideology.

As a challenging area for research, we recognise the importance of ensuring that Prevent practitioners have up to date guidance which assists them in understanding how best to understand the relevance of mental health for an individual. The latest Channel duty guidance reinforces that having mental health issues does not exclude a person from being suitable for Prevent. Rather, any relevant mental health issue is one of several factors which should guide decisions about whether the individual needs support to address their risk of radicalisation, and the kind of support that they need. Several of the case studies within the guidance have mental health elements to illustrate this. The Home Office will continue in its guidance to be clear that for Prevent, cases should not be presented as a binary choice between mental health interventions or counter-terrorism ones. We keep our operational policy approach to Prevent under constant review, and we will continue to look at mental health issues and neurodiversity as part of this, to identify areas we can strengthen.

To further this point, we have written to all Channel Chairs to raise awareness of the concern in the report that KS’s risk assessment was incorrectly focused on his mental health difficulties, and to reinforce that the purpose of Channel is both to safeguard individuals and to manage the potential terrorist risk they may pose. Therefore, the existence of or need for wraparound mental health support for an individual does not negate the need for the person to receive Prevent support. We also reminded Channel Chairs that the CCS is available to provide Prevent officers with advice, guidance and options to help manage the individuals in their casework with mental health needs.

c) Failures of training, supervision and selection

Training

9 See paragraph 157 of the Channel duty guidance 2024 for examples on the type of support which could be offered: https://www.gov.uk/government/publications/channel-and-prevent-multi-agency-panel-pmap- guidance 10 The Clinical Consultancy Service (CCS) was launched by CTPHQ on 2 April 2024, (building on the Vulnerability Support Hub pilots which you heard from several witnesses on) to provide access to a nationally consistent service.

6

The Home Office Prevent directorate is one small part of the Prevent system, which operates at a mainly strategic level. The successful delivery of Prevent is dependent on the engagement of national, regional and local partners across multiple sectors, including the community and voluntary sector. Public sector frontline staff have been identified as a key group that can make an important contribution to identifying and referring people who may be at risk of radicalisation. Likewise, the success of the Channel programme is dependent on the co-operation and co-ordinated activity of partners so that a wide network of support is brought together to reduce a person’s terrorism or radicalisation risk.

Prevent staff in the Home Office

In July 2023, I am told, we created and started implementing a Prevent Professionalisation Plan to upskill Home Office officials working on Prevent through compulsory training and a new induction programme. All directorate staff were mandated to complete the Prevent duty training (both the awareness course and the referral course, which are part of the e-learning package referred to below)11 by end of September 2023. All directorate staff must retake the awareness and referral courses every two years and complete the refresher course in the year between. All new starters must complete the awareness and referrals courses within three months of starting in role, as part of their wider Prevent induction. In addition, a specialist ideology training package was developed by the Commission for Countering Extremism (CCE), which provides the government with impartial and expert advice on terrorism and extremism matters. I understand that this was rolled out as face-to-face training for Prevent directorate staff by the CCE in March and April 2024, training approximately 88% of the directorate in post at the time. Future training requirements will be kept under review.

Frontline staff subject to the Prevent duty

I have been told that the Prevent duty e-learning training package was updated in August
2023. Each of the four courses12 has specific learning outcomes to support awareness of Prevent and radicalisation; making a referral; and the Channel programme. Following this refresh, we monitor training uptake monthly and publish monthly performance data13. Over
1.4 million people have completed the training since it went live in August 2022. The current process provides learners with a certificate at the end of the training which they keep for their own records and to use as evidence for completion of training. I have been told that some sectors have created a Prevent learning goal/objective on their internal performance or training systems, which requires completion of the Home Office e-learning, particularly for front line staff. Staff upload a copy of the learning completion certificate to the platform to demonstrate it has been completed. This has aided supervisors at a local level to have consistent oversight of training. The published monthly regional performance data14, provides an insight into the extent of training delivery at a regional level. Whilst this would not be suitable for individual local authorities to monitor training, it does provide insight into training uptake across different regions.

A new face-to-face training package to raise awareness of Prevent has also been developed and is being implemented. This is designed to help attendees understand what may make people vulnerable to radicalisation and understand more about the local context. This will enable specialist trainers to have more detailed discussions, including on how to make high quality referrals that are relevant to Prevent. It also enables training to be tailored to the

11 https://www.gov.uk/guidance/prevent-duty-training. 12 https://www.gov.uk/guidance/prevent-duty-training. 13 https://www.support-people-susceptible-to-radicalisation.service.gov.uk/service-performance. 14 https://www.support-people-susceptible-to-radicalisation.service.gov.uk/service-performance.

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specific sector, location or role. During the pilot waves we are testing the service with existing trainers, and new Prevent training leads across England, Scotland and Wales. I understand the pilots have been running since 20 May 2024, and are being run nationally across health, local authority and education sectors with the final pilot in early September. We are piloting this service until late autumn, with wider rollout to follow once any final changes and improvements have been made based on user feedback.

We are also developing a new ideology training course to include as part of our face-to-face and e-learning training packages. The course has been developed with experts from the CCE and other subject matter experts within the Home Office. The ideology course includes modules on Islamist ideology, Extreme Right-Wing ideology, antisemitism and other types of concern. It is being developed to support frontline staff under the Prevent duty to understand the ideological nature of terrorism and to enable them to make an informed referral where the ideology present is identified and known. This will provide learners with a basic understanding of extremist ideology and radicalisation. The training will outline factors to consider when making a referral, such as the importance of ideology, common narratives, and a reflection of the current threat picture. This increased understanding will support sectors in making more appropriate and relevant Prevent referrals that can progress to Channel. The ideology training course will be available across the education, health, police and local authority sectors in England, Scotland, and Wales. The intention is for suitable trainers from each of these sectors to deliver in-person or virtual sessions, with the training package available on our online platform for registered trainers to access and deliver. I have been told that user research sessions were delivered with trainers across four identified sectors for police, education, local authority and health during January to early February
2024. The training modules were allocated to regions in accordance with the risk and threat in the area to ensure it was relevant to the local audience. Sessions were delivered in both virtual and in-person settings to gather feedback and understand the impact of different methods. Final iterations were made in response to feedback from learners and trainers. The training will be piloted and rolled out alongside the face-to-face training package in late autumn.

Channel panel members

Alongside sector specific training, Channel panel members and partners should complete the previously mentioned Prevent duty training courses. The Channel course of the Prevent e-learning package has tailored content for Channel chairs and for those who are new to attending Channel panels. Channel chairs and deputy chairs are also required to complete mandatory ‘delivering Channel locally’ training within six months of starting these roles, which is centred on building understanding of the Channel duty guidance requirements and standards. The Home Office has also commissioned a range of additional training (including training on different ideologies, the online threat picture and neurodivergence) to meet the needs of Channel chairs, deputy chairs and panel members in fulfilling the requirements set out within this guidance and to understand the national risk and threat picture.

Supervision and assurance

Identifying and supporting those vulnerable to radicalisation helps to keep us safe and specified authorities play a vital and valued role in this. The Prevent duty guidance sets out best practice and expectations for each sector and, by following it, specified authorities will be well placed to comply with the duty, underpinned by the Counter-Terrorism and Security Act 2015 (CTSA 2015). The guidance details at Section 4 the monitoring and assurance arrangements for each sector subject to the Prevent duty. There are a range of existing

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powers available to encourage compliance15. However, where a specified body is not complying with the duty, the Secretary of State may use the power of direction under Section 30 of the CTSA 2015 to give directions. These directions may be enforced by court order. 

I have been told that in support of our role in supervising local delivery, in 2021 we established an expert network of region-based Home Office Prevent Advisers who work together with partners across England, Scotland and Wales to raise Prevent delivery standards and hold local authorities to account. Prevent Advisers also deliver an annual assurance exercise, which assesses the extent to which local authorities are meeting the Prevent duty. As part of the Prevent duty guidance refresh in 2023, I understand that the Home Office updated its assurance process to help ensure that local authorities are delivering their statutory Prevent duty in line with the Prevent duty guidance. The Prevent duty toolkit for local authorities16 outlines eight benchmarks that Prevent delivery is measured against and includes suggested examples of good and best practice. The Home Office has worked with all local authorities in England and Wales to complete a Prevent assurance exercise for FY23/24 against seven of the eight Prevent duty benchmarks17. This is the third year that we have assessed local authorities in this way. This exercise provides the Home Office with assurances that the Prevent duty is being met in proportion to the threat and risk in each area. It also helps to understand where there are gaps in Prevent delivery, to identify and share good practice, and to improve performance and standards, which often involves direct support from the Home Office.

Following the introduction of the Channel Quality Assurance Framework in 2021, we are introducing an improved and strengthened quality assurance process. This includes routine assessment of Channel panel performance and case management. We will also utilise the data trends drawn from the new case management system to identify areas (regional or thematic) to provide additional case assurance and direct improvements where needed. We will use this quality assurance process and performance monitoring to further drive-up standards of delivery. I have been informed that this process started in April 2024 and initial results are expected to be shared with Channel panels in April 2025.

Where serious case reviews, safeguarding adult reviews or domestic homicide reviews are triggered due to a serious incident or a death involving a person supported through Channel, input from local Prevent practitioners (including the Channel chair and CTPHQ) should be sought to support the identification of practice improvements and shared learning. The Home Office is currently working with relevant partners to raise awareness of this new process to ensure that the Home Office is notified in these instances. Report findings detailing recommendations and any identified learning should also be forwarded. Where terrorism offences or incidents of serious violence are committed by people with a Prevent history and a statutory review process is not triggered, a Prevent learning review may be undertaken to identify national learning and drive system improvement. Where these instances are assessed as high harm by the Home Office, Prevent learning reviews may run in tandem with statutory review processes. The focus of a Prevent learning review is not to apportion blame, but to use reviews to identify good practice and where improvements are

15 For example, for local authorities: if there are concerns about compliance, the Home Office may consider the appropriateness of using existing mechanisms such as appointing an inspector, requiring the local authority to undertake specific actions, requesting an inquiry, or issuing a direction. Powers under the Local Government Act 1999 or the Local Government and Elections (Wales) Act 2021 may be used. 16 https://www.gov.uk/government/publications/prevent-duty-toolkit-for-local-authorities. 17 An assurance of the eighth benchmark, Channel, was not completed, as this is subject to a separate process (i.e., the Channel Annual Assurance Statement).

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needed, which can inform and strengthen Prevent legislation, policy or practice at the national level.

A new independent Standards and Compliance Unit (StaCU) was established in February 2024 by the CCE. This provides a clear route for both the public and practitioners to raise concerns about Prevent activity and delivery18. The unit triages complaints to the relevant body for investigation and ensures these complaints are handled promptly, fairly and transparently. The unit monitors data trends and any trends are reported into the Prevent Ministerial Oversight Board19 (PMOB), where Ministers can instruct investigations into specified authorities where there is concern over a failure to discharge the Prevent duty. Prevent senior management will also consider the findings of StaCU outside of the PMOB meeting cycle. This acts as a quality assurance mechanism for the Prevent system to ensure any systemic issues are resolved quickly and that Prevent continuously improves.

Selection of support providers

Multi-agency involvement in the Channel process is essential to ensure that people at risk of radicalisation have access to a wide range of support, from specialist services to diversionary activities. As mentioned above, Channel panels can pull on the professional expertise of mental health practitioners when progressing cases. It also ensures the full range of information is accessible to the panel, so that ideological drivers, risk, vulnerabilities and support needs can be fully assessed. Therefore, the Channel panel chair is responsible for inviting the appropriate representatives to each meeting as panel members and for establishing effective relationships across partners of the panel to ensure effective co- operation, information sharing, attendance at panel meetings and delivery of support.

Where a Channel panel identifies that an individual would benefit from an Intervention Provider (IP), the Channel case officer20 is responsible for arranging the provision of that service. IPs are vital to Prevent and work directly with Channel and Desistance and Disengagement Programme participants to help reduce their risk, often challenging and supporting individuals with a wide range of complex needs. IPs are experienced in assessing ideological drivers, possess an expert understanding of radicalising extremist narratives, can counter these narratives, and receive comprehensive Home Office training to support their work. When commissioning an IP the priority will always be to match the specific IP skillsets to the requirements of the person receiving support, and so Channel case officers will present three potential IPs to the panel wherever possible.

IPs work on a one-to-one basis with people who are vulnerable and potentially dangerous, and they are therefore subject to a rigorous recruitment process and must receive ministerial approval to work on the programme. Strengthened due diligence processes for IPs have been in place since July 2020. Continued professional development and professionalisation of the network of IPs is essential. A comprehensive IP training programme (called the IP Professionalisation Programme) was introduced in 2019 in support of their roles, which includes a range of mandatory skills-based courses to improve consistency in delivery, and to increase their knowledge and understanding of key themes. A monthly operational update ensures IPs are regularly provided with a contemporaneous picture of online activism. This

18 Complaints about how the Prevent duty has been applied, including any problems with Prevent training, can be made online: https://www.gov.uk/guidance/make-a-complaint-about-prevent. 19 The Prevent Ministerial Oversight Board is chaired by the Security Minister and convenes bi-annually. The PMOB increases oversight of Prevent, enables a truly cross-government approach to Prevent and is a clear decision-making forum. 20 Any reference to the Channel case officer refers to either the police CTCO or the Home Office-funded Channel co-ordinator, employed by the local authority.

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is intended to assist IPs in maintaining their understanding of how their referrals may be using social media applications to connect with extremists, as well as their appreciation of the extremist content found on these platforms.

Immigration Status/Deportation Issues21

Immigration Enforcement is committed to continuous learning and improvement. It is a cause of utmost concern to me that, although you concluded the failings identified within Immigration Enforcement did not contribute directly to the deaths of James Furlong, Joseph Ritchie-Bennett and David Wails, you found that ‘in different circumstances [they] could have been of real significance’.

Your Prevention of Future Deaths Report recognises the significant systemic changes within the Home Office since KS’s case was handled by Immigration Enforcement, including the reintroduction of exit checks, the new workflow management system (Define), improvements to the Voluntary Returns Service and the introduction of the Detention Gatekeeper. These wide-ranging improvements were set out in the witness statements of to the inquest.

I elaborate in this response on the changes outlined by in relation to Foreign National Offenders Returns Command (FNORC) staff training; subsequent developments since the inquest; and, I outline the assurance review which is now underway to evaluate the impact and sufficiency of the full breadth of changes which have taken place since KS's case was handled in Immigration Enforcement.

The training requirements of Foreign National Offenders Returns Command staff

The FNORC People Strategy and the FNORC Learning & Development Strategy set out the command’s high-level approach to training and staff development. The strategies were last refreshed in November 2022 and will be next revisited in November 2024. Under the current strategies, which were briefly touched upon in ’s witness statement of 15 November 2023 (paragraph 6), the command’s learning needs are met by a 14-person operational training team.

For new entrants, the training team delivers intensive initial casework training, initial administrative officer training and early in-role support. For existing staff, the team provides ongoing professional development. This includes refresher training, offered several times annually, for any staff who are changing role or who are returning to work after a significant period of absence. The training team also provides role-specific training, such as line- manager training, to meet demand, and targeted topical training where further learning needs are identified or where legislative, policy or process changes necessitate staff updates. The team also ensures staff are compliant with their mandatory learning requirements, including participation in courses introduced in response to the Windrush Lessons Learnt review.

Since June 2023, I am told that the training team has included an innovative ‘mobile mentoring’ unit of geographically mobile staff with significant casework experience, deployed to provide consistent, face-to-face support to new caseworkers. I understand that the approach was initially piloted between June 2023 and March 2024 to meet the needs of a large intake of new staff. During this period, 237 staff received mentoring support, and the pilot was subject to an internal evaluation in March 2024.

21 Responding to paragraphs 47-51 of Judge Coroner’s report of 20 May 2024.

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Following the internal evaluation, I am informed that Senior Civil Servant (SCS) approval was given on 1 April 2024 for the mobile mentoring unit’s work to be made permanent and to transition from being solely for new starters to include all staff, in line with business needs. The mentors’ remit now includes embedding and refreshing the skills of existing staff through a coaching-centred approach on live cases, based on thematic training needs identified through staff feedback and quality assurance. Current areas of focus include the duties of administrative grade staff, casework decision-making and the writing of release referrals. The unit remains flexible to shape its future offer to meet staff and business needs.

The current focus of the wider training team is the expansion of its learning and development support to non-traditional or non-casework functions within FNORC. This started with the design, in July 2024, of a casework overview package for staff working in the Electronic Monitoring (EM) Hub, to complement their existing functional training and ensure their understanding of the wider FNORC processes within which their work sits. The training package will be trialled in August and September 2024 before being made available to all relevant EM Hub staff. The training team will focus next on analysing and responding to the training needs of the Intake & Triage team (scheduled for Autumn 2024) and then those of the Criminality Assessment and Returns Unit (late 2024/early 2025).

In addition, since May 2024, I am told that an improved supervision offer has been introduced within FNORC and will be fully implemented across all sites by the end of 2024. The role of the Senior Caseworker (a Higher Executive Officer grade post) has been refocused on coaching and support, with the aim of maximising staff productivity, consistency and quality. There is a particular emphasis on reviewing staff work, both through the formal quality assurance framework and through informal responses to queries, providing constructive feedback and building teams’ technical expertise. Senior caseworkers also participate in a benchmarking cycle to review and grade the work of each casework decision maker on a quarterly basis and work with the individual’s line manager to address their development needs. These activities are underpinned by a newly produced Development Framework and Skills Matrix to help the Senior Caseworker identify and record staff learning and development needs, and where trends appear across units, they take a role in collaborating with other units, including the learning and development team, to ensure that these needs are addressed.

Assurance review

In response to the Regulation 28 Report to Prevent Future Deaths, FNORC has commissioned an assurance review of the reforms introduced since KS' case was handled by the department and which were outlined by at the inquest.

The assurance review was commissioned in June 2024 and is being conducted by the Immigration Enforcement Assurance, Integrity, Risk and Resilience (IE AIRR) Team.

IE AIRR sits in the Strategic Services and Transformation directorate within Home Office Immigration Enforcement. The assurance team offers bespoke, independent assurance reviews across teams in Immigration Enforcement to interrogate best practice and highlight areas of risk. As part of any final report issued by IE AIRR, actionable recommendations will be made in much the same way as external review bodies such as the Independent Chief Inspector of Borders and Immigration (ICIBI).

Assurance managers within IE AIRR are specialist trained staff and are accredited by the Institute of Internal Audit and Assurance. The postholder within the team with responsibility

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for recommendations also holds the internal auditors’ qualification from the Chartered Institute of Internal Auditors.

The review will be overseen by as the Senior Responsible Officer given her insight into the issues which concerned the inquest. The terms of reference and problem definition statement for the review have been agreed at Senior Civil Servant level and set out that the review will address the following questions:

1. Are adequate systems in place to ensure that all appropriate information is before the relevant Grade 7 when considering discontinuance of impending prosecutions?

2. Have the relevant Grade 7s received appropriate training to assess the prospects of removal when considering the discontinuance of impending prosecutions?

3. Has the implementation & reintroduction of new systems, including exit checks, workflow management tools, the triage system – ‘Define’, changes to the Voluntary Returns Scheme (VRS) & the detention gatekeeper addressed the issues raised by Judge Coroner?

4. Have the training requirements of FNORC staff been adequately met?

The review will provide an independent assessment of the changes made by FNORC and whether they are sufficient to mitigate a recurrence of the failures noted by at the inquest and reflected in your factual findings. If appropriate, the review will also highlight where further improvements can be made.

To assess the effectiveness of the introduction, re-introduction and/or improvement of systems and processes made by FNORC, IE AIRR is assessing the controls that have been implemented. Methods include ‘dip sampling’ (a random review of a sample) of FNORC cases to evaluate whether the systems are being correctly implemented, staff observation, and staff and stakeholder engagement. The latter is being used in particular in response to the fourth research question, to assess caseworkers’ self-assessment of training received, their understanding of their role and any concerns they may have.

The fieldwork for the assurance review is currently underway and is due to report by 11 October 2024. The report will detail key findings in response to the questions outlined in the problem definition statement and will make recommendations where there is scope for further improvement. Both will be backed by relevant data and guidance extracts.

Prior to final sign off, the assurance report will go through several levels of quality assurance and governance to ensure accuracy before the findings and recommendations are presented to . Once agreed, the recommendations will be logged on both the local FNORC recommendation register and the central IE recommendation register. Progress against the recommendations will be monitored on a regular basis by IE AIRR to ensure timely implementation. I am also personally committed to ensuring the proper implementation of any recommendations that will be made following completion of the review.

Discontinuance of Proceedings

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I understand that ’s witness statement of 15 November 2023 (paragraphs 13-22) also outlined the significant changes made to the processes by which the discontinuance of an impending prosecution can be requested. Most notably, junior FNORC casework staff can only request updates from the police and Crown Prosecution Service, as opposed to requesting discontinuance. Precautions have been designed into the process so that Grade 7 authority to request discontinuance of the prosecution must be sought and recorded in all cases, through amended documentation. These changes minimise risks of an inappropriate discontinuance request being made, or of the omission of the required authorisation. These changes are supported by improved recording via the Atlas casework system, to which FNORC fully transitioned on 19 October 2022 (i.e., the date on which FNORC ceased use of the legacy casework system).

The implementation and sufficiency of these changes form part of the IE AIRR assurance exercise and are the focus of two of the four questions which the review seeks to address:

1. Are adequate systems in place to ensure that all appropriate information is before the relevant Grade 7 when considering discontinuance of impending prosecutions?

2. Have the relevant Grade 7s received appropriate training to assess the prospects of removal when considering the discontinuance of impending prosecutions?

In addition to the general methodology outlined above for the assurance review, the review manager is conducting focused activity to assure the training, process and risks associated with the discontinuance of impending prosecutions. This includes interviewing the Grade 7s who have received the relevant training to assess their understanding, and analysing the process, particularly the origin of the required information and how it is received. To understand pressures that risk compromising the process being operationalised as intended, Grade 7s will also be interviewed about their expected levels of work and conflicting priorities.

Conclusion

I hope that my response to your Report has provided reassurance that the Home Office has fully considered your findings and concerns and that we intend to do all we can to prevent such tragic loss of lives in the future. This is both through ensuring our immigration processes are fit for purpose, and that we intervene early to stop people from becoming terrorists or supporting terrorism. I am committed to treat any failures with the utmost seriousness and oversee the proper implementation of recommendations and commitments. I will be extending an invitation to the families of James Furlong, Joseph Ritchie-Bennett and David Wails, should they wish to discuss the findings in relation to the Home Office or my response.

Home Secretary