Sobhia Khan
PFD Report
All Responded
Ref: 2024-0088
All 5 responses received
· Deadline: 12 Apr 2024
Response Status
Responses
5 of 5
56-Day Deadline
12 Apr 2024
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
a. Scrutiny of s.41 MHA 1983 cases by the Mental Health Tribunal. In this case was discharged by the Ministry of Justice (MoJ) following the receipt of reports from Cygnet Hospital which were inadequate and misrepresented the progress he had made and the risk that he posed. Nonetheless there were indicators which should have led the MoJ to question whether this case should have been referred to a Mental Health Tribunal, such as minimising his culpability for his previous offending. The offences against his former wife were of the utmost gravity, particularly in the context of his behaviour during the marriage that she later disclosed. This indicated a risk of such a level as to make it not only desirable but essential that discharge was not contemplated until there had been close and careful scrutiny by those with expertise in forensic risk assessment. The MoJ Guidance on restricted patients says that “the vast majority” of discharge decisions are made by the Tribunal. In a patient with risk profile it is difficult to envisage circumstances whereby that should have been displaced.
b. Ensuring that s.41 restricted patients are supervised under a forensic pathway. In this case no such pathway even existed in the locality. This meant that Mustafa’s supervision was inadequate having regard to the risk that he posed. Such orders are imposed to protect the public from the risk of serious harm. Even where it has been adjudged that any previous offending would not have happened but for a mental disorder, there is still the need for a forensic approach. The risk component must not be overlooked as it was here. Forensic pathways must be available across the country.
c. Police power to arrest where there is a reason to believe a person is at risk of death/serious injury. Whilst I was critical of the failure of the police to take measures that were reasonably available to them to investigate the intelligence that had been received that was in a relationship, the one power that was not available to them was to arrest him. This leaves a significant gap in the powers that are available to the police to protect individuals who are at risk of death/serious injury. Although I cannot say whether the threshold would have been met in Sobhia’s case, such a power could in future cases ensure that it is understood that where an individual poses a significant risk of causing serious harm in relationships, and there is evidence that he is concealing a relationship, he can be arrested.
d. Ministry of Justice power to recall where a patient poses a significant risk to the public. The MoJ will not generally recall dangerous individuals unless there is a decline in their mental health presentation notwithstanding the fact that s.41 MHA 1983, to which was subject, is designed to protect the public from serious harm. Whilst there is the possibility of the judge imposing a hybrid order, and that was not considered appropriate in this case, it did not mean that risk only existed in the context of a decline in his mental health. If an individual subject to a s.41 restriction order poses a significant risk to the public then the public can only be protected if he can be recalled to hospital where further assessment can be undertaken. If it then transpires that, as likely was the case here, the mental health component had previously been exaggerated, this would at the very least allow for a discharge plan to then be prepared which takes account of this and ensures that there is adequate focus on managing the risk. One way of achieving this would be a power to arrest being attached to the patient’s discharge conditions, enforceable where there is a significant risk of serious harm.
e. Travel overseas for s.41 restricted patients. was permitted to travel to and from Pakistan freely and to return seemingly as and when he saw fit. Whilst he was outside the jurisdiction there was no way of checking on him, including in terms of his mental health, but also his risk. There were concerns, for example, that he may have been arranging a forced marriage for his niece. He could have entered into a relationship, for all the authorities knew. It also allowed him an opportunity to push and test the boundaries. He was permitted to travel out of the jurisdiction as he pleased, sometimes returning late, sometimes early. By contrast, had he been on licence after serving a custodial sentence, he would in all probability have been prevented from travelling outside the jurisdiction, at least in the early stages. Whilst I acknowledge that there are qualitative differences between a prison sentence and a hospital order, it remains legitimate if not necessary to ensure that those who have recently discharged from a s.41 order are carefully monitored, in the jurisdiction, at least for the first 12 months. This is beneficial not only in terms of monitoring mental health, but also risk.
f. Clinicians should be provided with full reports when considering discharge. This was a particular concern in relation to the fact that those recommending discharge were not provided with the full Spousal Assault Risk Assessment, but only a summary. Given risk profile, and the catastrophic consequences that were liable to result from him being pre-emptively discharged, and that discharge was being recommended without recourse to the Tribunal, it was essential that the s.117 meeting was informed by detailed reports which, had they been properly considered, would have indicated a need for circumspection.
g. Over-reliance on self-reporting. This was a theme that ran throughout the inquest and the various agencies involved. This was a case that required a forensic approach throughout, both in hospital and in the community. It was recognised that was narcissistic and manipulative but he was nonetheless relied upon to provide updates as to his mental health, his travel plans and the reasons for them, and – critically - whether or not he was in a relationship. risk arose primarily in the context of relationships and he was not somebody that could be relied upon to disclose them. On the contrary, he had shown himself willing and adept at concealing them. This underlined why his self-reporting could not be relied upon and this was something that should have featured in his management throughout, and flagged at the point of discharge.
h. Record-keeping. This was a thread that ran through the case and applied both to the clinical notes but also the notes of meetings, such as MAPPA, which are necessarily a summary but which did not always include sufficient information to enable those reviewing them to understand what had been discussed and what actions taken. In terms of clinical records, whilst basic, mundane matters such as his sleeping habits and appetite were recorded, much of what mattered was not. The paucity of records and the poverty of their quality meant that was not aware of the history of manipulation and the other factors which indicated an ample need for reassessment. In terms of the SOTP, whereas there was a conflict of evidence as to why the group programme was not available at Cygnet hospital, the keeping of proper records would have ensured that there was a ready answer if needed. The discharge meetings were poorly recorded, with the spousal assault risk assessment not having featured at all. There were repeated instances of witnesses not being able to remember, understandably, what had happened with respect to certain events. There was no excuse for professional witnesses to be put in this embarrassing position. The MoJ are reliant on what they are told in writing, but given that there is a culture of poor record-keeping, until and unless that record-keeping is improved to an acceptable level, they have to be more pro-active and more prepared to question things.
i. Familiarisation of professionals with cultural issues. In this case there appears to have been a reluctance to make enquiries with the Mosque and the Islamic Meat Centre, and to be aware of how the family dynamics are impacted by cultural issues. Although it was intended that a family tree would be completed, and this should have been done pre-discharge, was able to some extent to throw a curtain around his family and thereby prevent those working with him from understanding the lengths they were prepared to go to protect him. It was noted that him becoming the Head of the family after his father’s death was significant, but the wider consequences were not properly considered.
b. Ensuring that s.41 restricted patients are supervised under a forensic pathway. In this case no such pathway even existed in the locality. This meant that Mustafa’s supervision was inadequate having regard to the risk that he posed. Such orders are imposed to protect the public from the risk of serious harm. Even where it has been adjudged that any previous offending would not have happened but for a mental disorder, there is still the need for a forensic approach. The risk component must not be overlooked as it was here. Forensic pathways must be available across the country.
c. Police power to arrest where there is a reason to believe a person is at risk of death/serious injury. Whilst I was critical of the failure of the police to take measures that were reasonably available to them to investigate the intelligence that had been received that was in a relationship, the one power that was not available to them was to arrest him. This leaves a significant gap in the powers that are available to the police to protect individuals who are at risk of death/serious injury. Although I cannot say whether the threshold would have been met in Sobhia’s case, such a power could in future cases ensure that it is understood that where an individual poses a significant risk of causing serious harm in relationships, and there is evidence that he is concealing a relationship, he can be arrested.
d. Ministry of Justice power to recall where a patient poses a significant risk to the public. The MoJ will not generally recall dangerous individuals unless there is a decline in their mental health presentation notwithstanding the fact that s.41 MHA 1983, to which was subject, is designed to protect the public from serious harm. Whilst there is the possibility of the judge imposing a hybrid order, and that was not considered appropriate in this case, it did not mean that risk only existed in the context of a decline in his mental health. If an individual subject to a s.41 restriction order poses a significant risk to the public then the public can only be protected if he can be recalled to hospital where further assessment can be undertaken. If it then transpires that, as likely was the case here, the mental health component had previously been exaggerated, this would at the very least allow for a discharge plan to then be prepared which takes account of this and ensures that there is adequate focus on managing the risk. One way of achieving this would be a power to arrest being attached to the patient’s discharge conditions, enforceable where there is a significant risk of serious harm.
e. Travel overseas for s.41 restricted patients. was permitted to travel to and from Pakistan freely and to return seemingly as and when he saw fit. Whilst he was outside the jurisdiction there was no way of checking on him, including in terms of his mental health, but also his risk. There were concerns, for example, that he may have been arranging a forced marriage for his niece. He could have entered into a relationship, for all the authorities knew. It also allowed him an opportunity to push and test the boundaries. He was permitted to travel out of the jurisdiction as he pleased, sometimes returning late, sometimes early. By contrast, had he been on licence after serving a custodial sentence, he would in all probability have been prevented from travelling outside the jurisdiction, at least in the early stages. Whilst I acknowledge that there are qualitative differences between a prison sentence and a hospital order, it remains legitimate if not necessary to ensure that those who have recently discharged from a s.41 order are carefully monitored, in the jurisdiction, at least for the first 12 months. This is beneficial not only in terms of monitoring mental health, but also risk.
f. Clinicians should be provided with full reports when considering discharge. This was a particular concern in relation to the fact that those recommending discharge were not provided with the full Spousal Assault Risk Assessment, but only a summary. Given risk profile, and the catastrophic consequences that were liable to result from him being pre-emptively discharged, and that discharge was being recommended without recourse to the Tribunal, it was essential that the s.117 meeting was informed by detailed reports which, had they been properly considered, would have indicated a need for circumspection.
g. Over-reliance on self-reporting. This was a theme that ran throughout the inquest and the various agencies involved. This was a case that required a forensic approach throughout, both in hospital and in the community. It was recognised that was narcissistic and manipulative but he was nonetheless relied upon to provide updates as to his mental health, his travel plans and the reasons for them, and – critically - whether or not he was in a relationship. risk arose primarily in the context of relationships and he was not somebody that could be relied upon to disclose them. On the contrary, he had shown himself willing and adept at concealing them. This underlined why his self-reporting could not be relied upon and this was something that should have featured in his management throughout, and flagged at the point of discharge.
h. Record-keeping. This was a thread that ran through the case and applied both to the clinical notes but also the notes of meetings, such as MAPPA, which are necessarily a summary but which did not always include sufficient information to enable those reviewing them to understand what had been discussed and what actions taken. In terms of clinical records, whilst basic, mundane matters such as his sleeping habits and appetite were recorded, much of what mattered was not. The paucity of records and the poverty of their quality meant that was not aware of the history of manipulation and the other factors which indicated an ample need for reassessment. In terms of the SOTP, whereas there was a conflict of evidence as to why the group programme was not available at Cygnet hospital, the keeping of proper records would have ensured that there was a ready answer if needed. The discharge meetings were poorly recorded, with the spousal assault risk assessment not having featured at all. There were repeated instances of witnesses not being able to remember, understandably, what had happened with respect to certain events. There was no excuse for professional witnesses to be put in this embarrassing position. The MoJ are reliant on what they are told in writing, but given that there is a culture of poor record-keeping, until and unless that record-keeping is improved to an acceptable level, they have to be more pro-active and more prepared to question things.
i. Familiarisation of professionals with cultural issues. In this case there appears to have been a reluctance to make enquiries with the Mosque and the Islamic Meat Centre, and to be aware of how the family dynamics are impacted by cultural issues. Although it was intended that a family tree would be completed, and this should have been done pre-discharge, was able to some extent to throw a curtain around his family and thereby prevent those working with him from understanding the lengths they were prepared to go to protect him. It was noted that him becoming the Head of the family after his father’s death was significant, but the wider consequences were not properly considered.
Responses
Derby City Council has introduced regular joint-funded training for social supervisors and a rolling programme of unconscious bias training to enhance cultural competence. They have also been working with a Forensic Community Mental Health Team since 2019 and are finalizing an MoU to employ a Senior Social Work Practitioner.
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Dear Sir Re: Response Regulation 28: REPORT TO PREVENT FUTURE DEATHS This is Derby City Council's response to your report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 16 February 2024, following the tragic and unlawful killing of Sobhia Tabasim Khan on 27 May 2017. Thank you for your conduct of the inquest and for your identification of a number of matters of concern, which are set out in the report. The Local Authority accepts your findings. Since the tragic events Derby City Council has made significant changes to the way we manage mentally disordered offenders subject to conditional discharge from a s.37 hospital order with s.41 restrictions under the Mental Health Act 1983, and support to staff discharging their role as Social Supervisors. This has been informed by internal and external reviews of systems and practice. With particular reference to the Coroner's concern, 5b, in July 2019 Derbyshire Healthcare NHS Foundation Trust secured funding for the creation of a Forensic Community Mental Health Team. The Local Authority has been working alongside the team to support supervision of mentally disordered offenders under a forensic pathway. Derbyshire Health Care NHS Foundation Trust and Derby City Council are at the next stage of the implementation of the forensic pathway and are finalizing a Memorandum of Understanding between the two organisations in order to employ a Senior Social Work Practitioner, with lead responsibilities for Forensic Mental Health. The post is designed to work across both organisations. To enable cohesive working across both social care and healthcare, and to maintain clear social work links and social work identity, it is agreed that the post is co-located cross the site of both agencies. The Council House, Corporation Street, Derby, DE1 2FS derby.gov.uk To view Derby City Council Privacy Notices please visit derby.gov.uk/privacy-notice Please recycle this letter 12
The role shall provide a social work contribution and responsibility to those that ordinarily receive services in Derby City engaged with the Forensic Division and/or under Part 3 of the Mental Health Act 1983. This specifically refers to the statutory duties of the Local Authority under Care Act 2014, Mental Health Act 1983 and associated legislation and policy. The Senior Social Work Practitioner will maintain all statutory responsibilities and professional governance will be in accordance with the standards set out by Social Work England, and the Department of Health Forensic Mental Health Social Work: Capabilities Framework 2016. In addition to this, the role will work on key aspects of service and practice development by:
• Sharing good practice and learning from case work
• Sharing knowledge, resources, and expertise
• Setting standards, expectations, and consistency around the Social Supervisor Role
• Process and discussion around best practice in relation to recall.
• Develop a centralised training agenda across organisations.
• Share developments from ADASS (Association of Directors of Adult Social Services) forensic network
• Maintain the Social Supervisor Register.
• Develop a countywide Social Supervisor Network, facilitating thematic reflective discussions.
• Develop a mentoring and buddying system across forensic work. The recruitment for this role will commence by July 2024 and a full workplan detailing the service developments above will be in place by end of December 2024. The Council has also introduced training for social supervisors funded jointly by health and social care; previously this was provided on an "ad hoc" basis and was agency specific. Broadly covering all of the matters of concern, in September 2019 Derby City Council in conjunction with Derbyshire County Council commissioned regular training for social supervisors. There is a two day introduction to Part 3 Mental Health Act 1983 and the role of the Social Supervisor and a one day annual refresher. The course includes:
• Overview of the role of the Social Supervisor.
• The responsibilities associated with the role.
• Exploration of the multi-disciplinary approach to the role of Social Supervisor.
• Discharge planning and information sharing.
• Reflections on local policy and Code of Practice guidance, underpinning this work.
• Exploring conditional discharge under Part III MHA and reference guide, including Mental Health Tribunals.
• Good practice regarding record keeping, writing reports, recall, supervision and good liaison with the Ministry of Justice. Derby City Council currently holds a register of trained Social Supervisors across Derbyshire including their training record. With particular reference to the Coroner's concern, 5i, Derby City Council have introduced a rolling programme of Unconscious Bias training in relation to developing cultural competence. 13
Sobhia’s death shocked the services involved, system wide. The loss of Sobhia, and the circumstances surrounding that, have had a profound effect on the local system and professionals involved. Our hearts go out to her family and friends. She remains in our thoughts, and we offer our sincerest condolences to her family.
The role shall provide a social work contribution and responsibility to those that ordinarily receive services in Derby City engaged with the Forensic Division and/or under Part 3 of the Mental Health Act 1983. This specifically refers to the statutory duties of the Local Authority under Care Act 2014, Mental Health Act 1983 and associated legislation and policy. The Senior Social Work Practitioner will maintain all statutory responsibilities and professional governance will be in accordance with the standards set out by Social Work England, and the Department of Health Forensic Mental Health Social Work: Capabilities Framework 2016. In addition to this, the role will work on key aspects of service and practice development by:
• Sharing good practice and learning from case work
• Sharing knowledge, resources, and expertise
• Setting standards, expectations, and consistency around the Social Supervisor Role
• Process and discussion around best practice in relation to recall.
• Develop a centralised training agenda across organisations.
• Share developments from ADASS (Association of Directors of Adult Social Services) forensic network
• Maintain the Social Supervisor Register.
• Develop a countywide Social Supervisor Network, facilitating thematic reflective discussions.
• Develop a mentoring and buddying system across forensic work. The recruitment for this role will commence by July 2024 and a full workplan detailing the service developments above will be in place by end of December 2024. The Council has also introduced training for social supervisors funded jointly by health and social care; previously this was provided on an "ad hoc" basis and was agency specific. Broadly covering all of the matters of concern, in September 2019 Derby City Council in conjunction with Derbyshire County Council commissioned regular training for social supervisors. There is a two day introduction to Part 3 Mental Health Act 1983 and the role of the Social Supervisor and a one day annual refresher. The course includes:
• Overview of the role of the Social Supervisor.
• The responsibilities associated with the role.
• Exploration of the multi-disciplinary approach to the role of Social Supervisor.
• Discharge planning and information sharing.
• Reflections on local policy and Code of Practice guidance, underpinning this work.
• Exploring conditional discharge under Part III MHA and reference guide, including Mental Health Tribunals.
• Good practice regarding record keeping, writing reports, recall, supervision and good liaison with the Ministry of Justice. Derby City Council currently holds a register of trained Social Supervisors across Derbyshire including their training record. With particular reference to the Coroner's concern, 5i, Derby City Council have introduced a rolling programme of Unconscious Bias training in relation to developing cultural competence. 13
Sobhia’s death shocked the services involved, system wide. The loss of Sobhia, and the circumstances surrounding that, have had a profound effect on the local system and professionals involved. Our hearts go out to her family and friends. She remains in our thoughts, and we offer our sincerest condolences to her family.
Derbyshire Healthcare NHS Foundation Trust has invested in a Forensic Community Mental Health Team, implemented Systm1 as its electronic patient record system with ongoing audits, and employed an Equality, Diversity and Inclusion Lead. The FCMHT has also undertaken cultural awareness training with partners.
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Dear Sir Re: Regulation 28 response: an inquest touching the death of Sobhia Khan May I first begin on behalf of the Trust by conveying my deepest condolences to the family of Ms Khan for their loss, which is most tragic, and our thoughts are with them. The Trust notes that the Prevention of Future Death Report is wide ranging and encompasses different areas, some of which are out of the control of the Trust as they would require legislative changes. In answering below, the Trust has focused on those matters that are under its control as an organisation. Scrutiny of s. 41 cases by the Mental Health Review Tribunal (“MHRT”) Whilst it is acknowledged that was discharged by another Interested Party to the inquest (namely Cygnet) the Trust does operate a low secure male unit within its healthcare portfolio and would like to offer assurance that it seeks to utilise the tribunal process as the norm for discharges of patients subject to s. 41 MHA restrictions. The Trust’s standard practice for discharge is to engage the receiving community service approximately 6 months prior to discharge. To ensure that the patient is ready for discharge the Trust utilises the Assertive Transition Service from IMPACT (see below for an explanation of what IMPACT is) during the patient’s leave prior to discharge. To allow for oversight at a collective level, the IMPACT Case Manager for the patient will routinely be invited to MDT, CPA meetings and 117 meetings. They are also kept informed of discharge plans. Ensuring that s.41 restricted patients are supervised under a forensic pathway With the support of commissioners, the Trust has invested into a Forensic Community Mental Health Team (“FCMHT”) over a 4-year period. The sum invested is £2.7 million. The monies provided have created a full multi-disciplinary team which provides care to the patients of Derbyshire. The approach taken by the FCMHT is guided by evidence from The Royal College of Psychiatrists and NHS England. The Trust is mindful of the complex nature of those patients who are under the care of the FCMHT and as such seeks only to recruit experienced clinicians. Trust Headquarters, Ashbourne Centre, Kingsway Hospital, Derby DE22 3LZ
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The Trust still has a small number of patients subject to s. 41 restrictions who are not under the care of the FCMHT. This approach is based on clinical need and the progress to recovery each patient has made; balancing the potential benefit of being supported by a FCMHT against the potential for a new clinical team in destabilising their recovery. Where clinicians do hold a restricted s. 41 patient on their caseload, they are mandated to receive forensic clinical supervision from the FCMHT. More broadly the FCMHT reviews any s. 41 restricted patient who are not under the care of the FCMHT to ensure they are receiving the appropriate level of care, support and supervision as would be expected of a patient subject to restrictions. In addition to the above, the Trust is an active member of IMPACT – the East Midlands Provider Collaborative made up of nine NHS and independent sector organisations that jointly provide specialised mental health services for patients. Clinicians should be provided with full reports when considering discharge The Trust is conscious that clinical teams, the Ministry of Justice and the MHRT rely on the information that is provided to them to consider risk and understand their own role in a patient’s care. To that end the Trust’s FCMHT has been provided with training on report writing to ensure that the information contained within the reports that it writes (to other clinicians, to MHRT and the MoJ) are of the standards associated with a FCMHT. Further, and in addition, specific training has been completed with those that undertake the social supervision role so that it is clear what standards and expectations are required. Any report written by a social supervisor employed by the Trust is scrutinised by a senior member of the FCMHT prior to being submitted. Where required and appropriate to the clinical discussion the MoJ is invited to attend and contribute to MDT meetings. Over-reliance on self-reporting The initial assessment of a patient before they are accepted into the FCMHT will be conducted by two staff members followed by a full MDT discussion – the purpose of this approach is to reduce the possibility of having a subjective view of a patient’s need and risks. The FCMHT are trained in conducting structured risk assessments to assess the level of risk posed and structured diagnostic assessments to support diagnosis. These tools are used to augment subjective clinical decision making with objective measures of assessment. Examples of the tools used: the Psychopathy Checklist and International Personality Disorder Examination Assessment. Employees working in the FCMHT have received external clinical supervision from an expert within Forensic Services to assist with analysing and understanding risk. The FCMHT has also accessed specific training around the management of patients subject to s.41 restrictions provided by the MoJ. The forensic pathway (both the FCMHT and inpatient teams) meet on a weekly basis to enable additional clinical discussion and scrutiny of cases that are causing clinical concern. The aforementioned Forensic Supervision offered by FCMHT for clinicians in CMHT provides safeguards against over-reliance on self-reporting as the risk based 16
approach would foster clinical curiosity. Record keeping During the time was under the care of the Trust it transitioned from hardcopy records to an electronic patient record, PARIS. Since that time, the Trust has now adopted Systm1 as its electronic patient record system across all its services. This enables all services to see what information is inputted by other services within the Trust. In addition, Trust clinicians can see information inputted by GPs and colleagues from the local community Trust enabling better, more holistic, care. The Trust conducts ongoing record keeping audits of the medical records of all patients who are subject to a s.37/41 to ensure that they meet the standards required. This audit process is reinforced by a robust supervision process for all nurses / AHPs working with those patients. Familiarisation of professionals with cultural issues The Trust recognises the importance of caring for an individual holistically and considering all facts that are relevant to a bio-psycho-social model of care. The FCMHT has undertaken shared cultural awareness training with the police and probation to explore unconscious bias, family loyalty etc. A gap analysis of all staff training is being conducted to further understand what areas are already strong and which areas are to be improved, this analysis will include whether there is a need for further cultural awareness training. More widely throughout the Trust, it has employed an Equality, Diversity and Inclusion Lead who offers support to employees when needed to help navigate challenging cultural normal within specific cases. I hope that this information reassures you and the family of Ms Khan that steps have already been taken to address the issues raised in the Prevention of Future Death report however if I, or the Trust, can be of any more assistance, please do not hesitate to contact me.
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The Trust still has a small number of patients subject to s. 41 restrictions who are not under the care of the FCMHT. This approach is based on clinical need and the progress to recovery each patient has made; balancing the potential benefit of being supported by a FCMHT against the potential for a new clinical team in destabilising their recovery. Where clinicians do hold a restricted s. 41 patient on their caseload, they are mandated to receive forensic clinical supervision from the FCMHT. More broadly the FCMHT reviews any s. 41 restricted patient who are not under the care of the FCMHT to ensure they are receiving the appropriate level of care, support and supervision as would be expected of a patient subject to restrictions. In addition to the above, the Trust is an active member of IMPACT – the East Midlands Provider Collaborative made up of nine NHS and independent sector organisations that jointly provide specialised mental health services for patients. Clinicians should be provided with full reports when considering discharge The Trust is conscious that clinical teams, the Ministry of Justice and the MHRT rely on the information that is provided to them to consider risk and understand their own role in a patient’s care. To that end the Trust’s FCMHT has been provided with training on report writing to ensure that the information contained within the reports that it writes (to other clinicians, to MHRT and the MoJ) are of the standards associated with a FCMHT. Further, and in addition, specific training has been completed with those that undertake the social supervision role so that it is clear what standards and expectations are required. Any report written by a social supervisor employed by the Trust is scrutinised by a senior member of the FCMHT prior to being submitted. Where required and appropriate to the clinical discussion the MoJ is invited to attend and contribute to MDT meetings. Over-reliance on self-reporting The initial assessment of a patient before they are accepted into the FCMHT will be conducted by two staff members followed by a full MDT discussion – the purpose of this approach is to reduce the possibility of having a subjective view of a patient’s need and risks. The FCMHT are trained in conducting structured risk assessments to assess the level of risk posed and structured diagnostic assessments to support diagnosis. These tools are used to augment subjective clinical decision making with objective measures of assessment. Examples of the tools used: the Psychopathy Checklist and International Personality Disorder Examination Assessment. Employees working in the FCMHT have received external clinical supervision from an expert within Forensic Services to assist with analysing and understanding risk. The FCMHT has also accessed specific training around the management of patients subject to s.41 restrictions provided by the MoJ. The forensic pathway (both the FCMHT and inpatient teams) meet on a weekly basis to enable additional clinical discussion and scrutiny of cases that are causing clinical concern. The aforementioned Forensic Supervision offered by FCMHT for clinicians in CMHT provides safeguards against over-reliance on self-reporting as the risk based 16
approach would foster clinical curiosity. Record keeping During the time was under the care of the Trust it transitioned from hardcopy records to an electronic patient record, PARIS. Since that time, the Trust has now adopted Systm1 as its electronic patient record system across all its services. This enables all services to see what information is inputted by other services within the Trust. In addition, Trust clinicians can see information inputted by GPs and colleagues from the local community Trust enabling better, more holistic, care. The Trust conducts ongoing record keeping audits of the medical records of all patients who are subject to a s.37/41 to ensure that they meet the standards required. This audit process is reinforced by a robust supervision process for all nurses / AHPs working with those patients. Familiarisation of professionals with cultural issues The Trust recognises the importance of caring for an individual holistically and considering all facts that are relevant to a bio-psycho-social model of care. The FCMHT has undertaken shared cultural awareness training with the police and probation to explore unconscious bias, family loyalty etc. A gap analysis of all staff training is being conducted to further understand what areas are already strong and which areas are to be improved, this analysis will include whether there is a need for further cultural awareness training. More widely throughout the Trust, it has employed an Equality, Diversity and Inclusion Lead who offers support to employees when needed to help navigate challenging cultural normal within specific cases. I hope that this information reassures you and the family of Ms Khan that steps have already been taken to address the issues raised in the Prevention of Future Death report however if I, or the Trust, can be of any more assistance, please do not hesitate to contact me.
Derbyshire Constabulary has implemented new training for cultural awareness, revised neighbourhood profiles to capture cultural information, and reiterated the importance of record-keeping. They also escalated the concern regarding arrest powers to the national policing lead for consideration.
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Dear HHJ Goldstone I am writing in response to the Regulation 28: Report to Prevent Future Deaths dated 16th February 2024 following the inquest into the death of Sobhia Tabasim Khan on 27th May 2017 in Derbyshire. Sobhia’s death was a tragic incident that robbed her loved ones of a much-loved daughter, sister and friend. At the conclusion of the inquest, Assistant Chief Constable offered in the media a sincere and unreserved apology to Sobhia’s family and friends for any failings of the force, and I would like to take the opportunity to offer my own sincere apology to them at this time. The Khan family have shown immense dignity since Sobhia’s death, and I hope our response shows how the force has worked to improve the management of sexual and violent offenders since 2017 as well as other actions we have taken to protect victims and improve officers’ cultural awareness. In your report, you highlight nine areas of concern (A-I). The areas we understand to be relevant to Derbyshire Constabulary are stated and addressed below: C) Police power to arrest where there is a reason to believe a person is at risk of death/serious injury There is no specific order or power of arrest where there is reason to believe that a person is at risk of death/serious injury, and this is something that requires national consideration. A letter explaining the circumstances of this case and the context concerning this recommendation has been sent to Assistant Chief Constable national policing lead for the Management of Sexual Offenders and Violent Offenders (MOSOVO), for his consideration. However, the force does have powers where there are risks to a known victim, and we have made significant progress in how we protect vulnerable people from harm by strengthening the protection that we can offer. Civil orders such as Domestic Violence Protection Orders (DVPO) and Stalking Protection Orders (SPO) have powers of arrest attached to them so that a perpetrator can be arrested if the conditions are breached. The introduction of dedicated Derbyshire Constabulary, Headquarters, Butterley Hall, Ripley, Derbyshire, DE5 3RS Incoming telephone calls and communications may be monitored and recorded 9
2 operational teams in January 2023 strengthened our capacity to proactively manage the perpetrators who pose the greatest risk of harm. The performance of these teams is monitored through internal governance structures that focus on compliance and quality. G) Over-reliance on self-reporting This issue was also highlighted in the Domestic Homicide Review (DHR) into this case that took place in 2017, where the following recommendation was made to all agencies involved: ‘To be aware of and receive information and guidance on manipulation by offenders linking to the broader notion of disguised compliance, enabling staff to make further assessment of the behaviours and intention of individuals in an effort to identify and mitigate any such intentions.’ Since the recommendations from the DHR were received, the force has made several changes with both training and compliance. We have invested in additional training to upskill our officers and staff and equip them with the skills and knowledge to enable them to effectively manage self-reporting and disguised compliance. All officers and staff working in the Management of Sexual and Violent Offenders (MOSOVO) team have completed the College of Policing MOSOVO training course. Several changes have been made within the MOSOVO team to ensure compliance with national guidelines and Authorised Professional Practice (APP). We have strengthened our supervisory capability by investing in an additional Detective Sergeant within MOSOVO, increasing the number from three to four. This has improved the supervision of the work conducted by the Offender Managers. In addition, the MOSOVO Detective Inspector conducts 10 quality assurance checks each month to monitor compliance with our Standard Operating Procedures. At the end of 2023, several officers and staff members were trained to deliver the College of Policing MOSOVO training course so that new people joining the team could be trained in-house and equipped with the skills and knowledge from the outset. Continuing Professional Development (CPD) events are held throughout the year in order to refresh the skills of our officers and staff and so that they can share best practice. On a wider level, Vulnerability training was delivered to all frontline officers and staff during 2023 and 2024 and this has included the topics of controlling and coercive behaviour and disguised compliance. The Offender Managers generally conduct unannounced home visits to perpetrators, double- crewed, as this is recognised best practice to minimise the risk of disguised compliance. We can report that our compliance rates in the last six months are 86% for unannounced visits and 84% for double-crewed attendance. On the occasions of non-compliance, a supervisor will ratify the decision with supporting rationale. In May 2023, we recruited a Digital Media Investigator (DMI) into the MOSOVO team to further strengthen our capability to manage and monitor compliance. The DMI accompanies the Offender Manager on unannounced home visits to proactively conduct checks of digital devices, such as laptops, mobile phones and tablets, to ensure compliance with any conditions of a licence or other order. H) Record keeping To record our interactions with offenders within the MOSOVO department, we use a national system called Violent and Sex Offender Register (ViSOR). This provides a national database for the Police and Probation Service to jointly register, risk assess and manage sex, dangerous and violent offenders. ViSOR catalogues an offender’s previous risk assessment reports and provides a link to the Police National Computer (PNC), which allows access to an offender’s full 10
3 criminal record. All officers and staff attend a training course prior to being given access to ViSOR and are expected to adhere to ViSOR operating standards. Following feedback from His Majesty’s Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS), we have recently reviewed how we comply with the national ViSOR operating standards in recording Active Risk Management System (ARMS) assessments. We have reviewed our processes in response and adapted our Standard Operating Procedures to ensure that we are compliant and have rectified those that had been incorrectly recorded. The minutes of all Multi-Agency Public Protection Arrangements (MAPPA) meetings are recorded and are subject to scrutiny during the learning reviews conducted by the MAPPA partnership every six months. Additionally, we work with other forces in the region to peer review and scrutinise each other’s minutes from MAPPA meetings. Improving investigations is a key strategic priority and we have a comprehensive programme of activity to raise standards and improve record keeping, led by our Head of Crime, Detective Chief Superintendent . The importance of record keeping has been reiterated as part of key messaging to frontline officers, staff, and supervisors through their senior management teams and force wide communications. I) Familiarisation of professionals with cultural issues All officers and staff embarking on a career in Derbyshire Constabulary now receive training on many cultural aspects, including diversity, equality and inclusion, human rights, the history of policing, the Police Race Action Plan, hate crime, forced marriage, honour-based abuse, and community policing. The force also has a page on our internal intranet site entitled ‘Cultural Competence’ which has been produced by our Head of Equality, Diversity and Inclusion. It signposts officers and staff to ways in which they can communicate effectively with people and be aware of the cultural differences that may impact their communication with people within those communities. We have recently revised our Neighbourhood Profiles so that Safer Neighbourhood Teams can capture vital cultural information to enable them to understand the needs of the community and improve their engagement. The profiles outline the demographics of the area and identify key community groups and religious establishments, as well as identifying significant persons within them such as religious leaders, Councillors, headteachers and community workers. The work and recommendations noted within this report will continue to be progressed and monitored by Detective Chief Superintendent to ensure that we provide the very best possible service to our many and varied communities and cultures in Derbyshire. I hope the above response provides you with the necessary assurance of the actions we have taken, and continue to take, since Sobhia’s tragic death.
2 operational teams in January 2023 strengthened our capacity to proactively manage the perpetrators who pose the greatest risk of harm. The performance of these teams is monitored through internal governance structures that focus on compliance and quality. G) Over-reliance on self-reporting This issue was also highlighted in the Domestic Homicide Review (DHR) into this case that took place in 2017, where the following recommendation was made to all agencies involved: ‘To be aware of and receive information and guidance on manipulation by offenders linking to the broader notion of disguised compliance, enabling staff to make further assessment of the behaviours and intention of individuals in an effort to identify and mitigate any such intentions.’ Since the recommendations from the DHR were received, the force has made several changes with both training and compliance. We have invested in additional training to upskill our officers and staff and equip them with the skills and knowledge to enable them to effectively manage self-reporting and disguised compliance. All officers and staff working in the Management of Sexual and Violent Offenders (MOSOVO) team have completed the College of Policing MOSOVO training course. Several changes have been made within the MOSOVO team to ensure compliance with national guidelines and Authorised Professional Practice (APP). We have strengthened our supervisory capability by investing in an additional Detective Sergeant within MOSOVO, increasing the number from three to four. This has improved the supervision of the work conducted by the Offender Managers. In addition, the MOSOVO Detective Inspector conducts 10 quality assurance checks each month to monitor compliance with our Standard Operating Procedures. At the end of 2023, several officers and staff members were trained to deliver the College of Policing MOSOVO training course so that new people joining the team could be trained in-house and equipped with the skills and knowledge from the outset. Continuing Professional Development (CPD) events are held throughout the year in order to refresh the skills of our officers and staff and so that they can share best practice. On a wider level, Vulnerability training was delivered to all frontline officers and staff during 2023 and 2024 and this has included the topics of controlling and coercive behaviour and disguised compliance. The Offender Managers generally conduct unannounced home visits to perpetrators, double- crewed, as this is recognised best practice to minimise the risk of disguised compliance. We can report that our compliance rates in the last six months are 86% for unannounced visits and 84% for double-crewed attendance. On the occasions of non-compliance, a supervisor will ratify the decision with supporting rationale. In May 2023, we recruited a Digital Media Investigator (DMI) into the MOSOVO team to further strengthen our capability to manage and monitor compliance. The DMI accompanies the Offender Manager on unannounced home visits to proactively conduct checks of digital devices, such as laptops, mobile phones and tablets, to ensure compliance with any conditions of a licence or other order. H) Record keeping To record our interactions with offenders within the MOSOVO department, we use a national system called Violent and Sex Offender Register (ViSOR). This provides a national database for the Police and Probation Service to jointly register, risk assess and manage sex, dangerous and violent offenders. ViSOR catalogues an offender’s previous risk assessment reports and provides a link to the Police National Computer (PNC), which allows access to an offender’s full 10
3 criminal record. All officers and staff attend a training course prior to being given access to ViSOR and are expected to adhere to ViSOR operating standards. Following feedback from His Majesty’s Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS), we have recently reviewed how we comply with the national ViSOR operating standards in recording Active Risk Management System (ARMS) assessments. We have reviewed our processes in response and adapted our Standard Operating Procedures to ensure that we are compliant and have rectified those that had been incorrectly recorded. The minutes of all Multi-Agency Public Protection Arrangements (MAPPA) meetings are recorded and are subject to scrutiny during the learning reviews conducted by the MAPPA partnership every six months. Additionally, we work with other forces in the region to peer review and scrutinise each other’s minutes from MAPPA meetings. Improving investigations is a key strategic priority and we have a comprehensive programme of activity to raise standards and improve record keeping, led by our Head of Crime, Detective Chief Superintendent . The importance of record keeping has been reiterated as part of key messaging to frontline officers, staff, and supervisors through their senior management teams and force wide communications. I) Familiarisation of professionals with cultural issues All officers and staff embarking on a career in Derbyshire Constabulary now receive training on many cultural aspects, including diversity, equality and inclusion, human rights, the history of policing, the Police Race Action Plan, hate crime, forced marriage, honour-based abuse, and community policing. The force also has a page on our internal intranet site entitled ‘Cultural Competence’ which has been produced by our Head of Equality, Diversity and Inclusion. It signposts officers and staff to ways in which they can communicate effectively with people and be aware of the cultural differences that may impact their communication with people within those communities. We have recently revised our Neighbourhood Profiles so that Safer Neighbourhood Teams can capture vital cultural information to enable them to understand the needs of the community and improve their engagement. The profiles outline the demographics of the area and identify key community groups and religious establishments, as well as identifying significant persons within them such as religious leaders, Councillors, headteachers and community workers. The work and recommendations noted within this report will continue to be progressed and monitored by Detective Chief Superintendent to ensure that we provide the very best possible service to our many and varied communities and cultures in Derbyshire. I hope the above response provides you with the necessary assurance of the actions we have taken, and continue to take, since Sobhia’s tragic death.
Cygnet has shared the PFD action plan with teams and management for bi-monthly review, and a presentation on learning points has been delivered. They require all staff to complete a record-keeping workbook during induction and conduct regular audits of records and meeting minutes.
AI summary
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Dear HH Goldstone KC I write in response to your Report to Prevent Future Deaths (hereafter “PDF”) dated 16 February 2024 concerning the death of Sobhia Tabasim Khan on 28 May 2017. In advance of responding to the specific concerns raised in your Report, on behalf of Cygnet Health Care, I would like to express my deep condolences to Ms Khan’s family and loved ones. To reassure you and Ms Khan’s family that the concerns raised in your PFD have been listened to and reflected upon, the following steps have been taken:
1. The PFD action plan was reviewed at Clinical Governance meetings on 22 March
2024. It is listed to be an agenda item every month until September 2024 and provided that all actions are embedded at that point, it will be closed.
2. The action plan has been shared with the Senior Management Team for, and the Multi-Disciplinary Team (MDT) and all staff involved in Mr Mustafa’s care at, Cygnet Hospital Derby.
3. The action plan is included in Cygnet Derby Overarching Local Action Plan (OLAP) and reviewed bi-monthly by the General Manager, Hospital Manager, and Clinical Manager to ensure completion and embedding of the actions.
4. The action plan was discussed and agreed at Medical Advisory Committee (MAC) (8 March 2024).
5. To ensure ‘Ward to Board’ learning and dissemination a presentation on learning points and actions from the PFD has been, and will be presented, at the following meetings: Regional Governance for East and West Midlands Managers (13 March
2024) and Secure Services steering group (30 April 2024), Regional Governance Medical Leads (9 July 2024).
6. The action plan will also be disseminated to NHS IMPACT Contract meeting for Commissioner scrutiny and openness of process (23 May 2024). 1 18
Cygnet Health Care responds to your PFD concerns as follows: Concern 1: Clinicians should be provided with full reports when considering discharge: Those recommending discharge were not provided with the full Spousal Assault Risk Assessment, but only a summary. Given risk profile, and the catastrophic consequences that were liable to result from him being pre-emptively discharged, and that discharge was being recommended without recourse to the Tribunal, it was essential that the s.117 meeting was informed by detailed reports which, had they been properly considered, would have indicated a need for circumspection. Response:
1. Spousal Assault Risk Assessment (SARA) document are provided in full in professionals CPA meeting/s.117 meeting report packs. There document will be sent as a full document to the Ministry of Justice when applying for section 17 leave permissions from the MOJ. It will be indicated on the Request for Discharge that it is available for the MoJ to view (as the request for discharge form does not allow for attachments).
2. A yearly service audit to be conducted by the psychology team at Cygnet Derby, to have as its focus in 2024, the delivery and evidence base of service users’ understanding and implementation of skills taught in sex offender, violent offender, and arson treatments. Concern 2: Over-reliance on self-reporting: It was recognised that Mustafa was narcissistic and manipulative but he was nonetheless relied upon to provide updates as to his mental health, his travel plans and the reasons for them, and – critically - whether or not he was in a relationship. Mustafa’s risk arose primarily in the context of relationships and he was not somebody that could be relied upon to disclose them. On the contrary, he had shown himself willing and adept at concealing them. This underlined why his self-reporting could not be relied upon and this was something that should have featured in his management throughout, and flagged at the point of discharge. Response: The MDT may be vulnerable to manipulation by service users and team ‘splitting’ can occur which can lead to poor decision making on risk factors and discharges.
1. The manipulation measurement tool, currently used for females, to be added as an addendum to the HCR-20 (a Secure Services Standard Risk Assessment tool for baseline risk assessment) and used for males going forward. 2 19
2. Potential Manipulation and Measurement tool to reviewed at CPA/s.117 meetings To be completed by audit on 31 May 2024.
3. A second opinion of a medical specialist, such as a neuropsychiatry specialist, to be sought in cases of high risk, or where the need for a speciality outside the remit of the MDT is identified. The need to consider the need for a second opinion will be added to the CPA checklist along with the relevant actions indicated if the need for a second opinion is identified. This will be monitored via MHAA audit. Concern 3: Record-keeping: This was a thread that ran through the case and applied both to the clinical notes but also the notes of meetings, such as MAPPA, which are necessarily a summary but which did not always include sufficient information to enable those reviewing them to understand what had been discussed and what actions taken. In terms of clinical records, whilst basic, mundane matters such as his sleeping habits and appetite were recorded, much of what mattered was not. The paucity of records and the poverty of their quality meant that Dr Kumar was not aware of the history of manipulation and the other factors which indicated an ample need for reassessment. In terms of the SOTP, whereas there was a conflict of evidence as to why the group programme was not available at Cygnet hospital, the keeping of proper records would have ensured that there was a ready answer if needed. The discharge meetings were poorly recorded, with the spousal assault risk assessment not having featured at all. There were repeated instances of witnesses not being able to remember, understandably, what had happened with respect to certain events. There was no excuse for professional witnesses to be put in this embarrassing position. The MoJ are reliant on what they are told in writing, but given that there is a culture of poor record-keeping, until and unless that record-keeping is improved to an acceptable level, they have to be more pro-active and more prepared to question things.
1. All staff complete a report writing and record keeping developmental Skill workbook as part of their Cygnet induction.
2. Cygnet audits on triangulation of records completed 3 monthly to ensure cross referencing of information in different streams of records.
3. Section 117 and transfer of care meetings are monitored and audited at Cygnet Derby to ensure up to date reports or addendums are submitted, and detailed minutes recorded, the main focus being on MoJ , MAPPA, and high profile service user discharges. 3 20
Kind regards
Executive Director of Nursing Cygnet 4 21
1. The PFD action plan was reviewed at Clinical Governance meetings on 22 March
2024. It is listed to be an agenda item every month until September 2024 and provided that all actions are embedded at that point, it will be closed.
2. The action plan has been shared with the Senior Management Team for, and the Multi-Disciplinary Team (MDT) and all staff involved in Mr Mustafa’s care at, Cygnet Hospital Derby.
3. The action plan is included in Cygnet Derby Overarching Local Action Plan (OLAP) and reviewed bi-monthly by the General Manager, Hospital Manager, and Clinical Manager to ensure completion and embedding of the actions.
4. The action plan was discussed and agreed at Medical Advisory Committee (MAC) (8 March 2024).
5. To ensure ‘Ward to Board’ learning and dissemination a presentation on learning points and actions from the PFD has been, and will be presented, at the following meetings: Regional Governance for East and West Midlands Managers (13 March
2024) and Secure Services steering group (30 April 2024), Regional Governance Medical Leads (9 July 2024).
6. The action plan will also be disseminated to NHS IMPACT Contract meeting for Commissioner scrutiny and openness of process (23 May 2024). 1 18
Cygnet Health Care responds to your PFD concerns as follows: Concern 1: Clinicians should be provided with full reports when considering discharge: Those recommending discharge were not provided with the full Spousal Assault Risk Assessment, but only a summary. Given risk profile, and the catastrophic consequences that were liable to result from him being pre-emptively discharged, and that discharge was being recommended without recourse to the Tribunal, it was essential that the s.117 meeting was informed by detailed reports which, had they been properly considered, would have indicated a need for circumspection. Response:
1. Spousal Assault Risk Assessment (SARA) document are provided in full in professionals CPA meeting/s.117 meeting report packs. There document will be sent as a full document to the Ministry of Justice when applying for section 17 leave permissions from the MOJ. It will be indicated on the Request for Discharge that it is available for the MoJ to view (as the request for discharge form does not allow for attachments).
2. A yearly service audit to be conducted by the psychology team at Cygnet Derby, to have as its focus in 2024, the delivery and evidence base of service users’ understanding and implementation of skills taught in sex offender, violent offender, and arson treatments. Concern 2: Over-reliance on self-reporting: It was recognised that Mustafa was narcissistic and manipulative but he was nonetheless relied upon to provide updates as to his mental health, his travel plans and the reasons for them, and – critically - whether or not he was in a relationship. Mustafa’s risk arose primarily in the context of relationships and he was not somebody that could be relied upon to disclose them. On the contrary, he had shown himself willing and adept at concealing them. This underlined why his self-reporting could not be relied upon and this was something that should have featured in his management throughout, and flagged at the point of discharge. Response: The MDT may be vulnerable to manipulation by service users and team ‘splitting’ can occur which can lead to poor decision making on risk factors and discharges.
1. The manipulation measurement tool, currently used for females, to be added as an addendum to the HCR-20 (a Secure Services Standard Risk Assessment tool for baseline risk assessment) and used for males going forward. 2 19
2. Potential Manipulation and Measurement tool to reviewed at CPA/s.117 meetings To be completed by audit on 31 May 2024.
3. A second opinion of a medical specialist, such as a neuropsychiatry specialist, to be sought in cases of high risk, or where the need for a speciality outside the remit of the MDT is identified. The need to consider the need for a second opinion will be added to the CPA checklist along with the relevant actions indicated if the need for a second opinion is identified. This will be monitored via MHAA audit. Concern 3: Record-keeping: This was a thread that ran through the case and applied both to the clinical notes but also the notes of meetings, such as MAPPA, which are necessarily a summary but which did not always include sufficient information to enable those reviewing them to understand what had been discussed and what actions taken. In terms of clinical records, whilst basic, mundane matters such as his sleeping habits and appetite were recorded, much of what mattered was not. The paucity of records and the poverty of their quality meant that Dr Kumar was not aware of the history of manipulation and the other factors which indicated an ample need for reassessment. In terms of the SOTP, whereas there was a conflict of evidence as to why the group programme was not available at Cygnet hospital, the keeping of proper records would have ensured that there was a ready answer if needed. The discharge meetings were poorly recorded, with the spousal assault risk assessment not having featured at all. There were repeated instances of witnesses not being able to remember, understandably, what had happened with respect to certain events. There was no excuse for professional witnesses to be put in this embarrassing position. The MoJ are reliant on what they are told in writing, but given that there is a culture of poor record-keeping, until and unless that record-keeping is improved to an acceptable level, they have to be more pro-active and more prepared to question things.
1. All staff complete a report writing and record keeping developmental Skill workbook as part of their Cygnet induction.
2. Cygnet audits on triangulation of records completed 3 monthly to ensure cross referencing of information in different streams of records.
3. Section 117 and transfer of care meetings are monitored and audited at Cygnet Derby to ensure up to date reports or addendums are submitted, and detailed minutes recorded, the main focus being on MoJ , MAPPA, and high profile service user discharges. 3 20
Kind regards
Executive Director of Nursing Cygnet 4 21
Report Sections
Investigation and Inquest
On 28 May 2017 an investigation was commenced into the death of Sobhia Tabasim Khan, aged 37.
The investigation concluded at the end of the inquest on 16 February 2024.
The conclusion of the inquest was unlawful killing. I found that there were numerous failures by the various state agencies involved with Sobhia, including one that was causative of her death, namely the failure of Derbyshire Police to act on information received indicating that Sobhia’s killer was in a relationship with a woman in Bradford and was planning to marry her in February 2017.
The investigation concluded at the end of the inquest on 16 February 2024.
The conclusion of the inquest was unlawful killing. I found that there were numerous failures by the various state agencies involved with Sobhia, including one that was causative of her death, namely the failure of Derbyshire Police to act on information received indicating that Sobhia’s killer was in a relationship with a woman in Bradford and was planning to marry her in February 2017.
Circumstances of the Death
Sobhia formed a relationship with a man named who was subject to conditional discharged from a s.37 hospital order with s.41 restrictions following violent and sexual offences against his former wife. His discharge conditions included that he should notify the authorities of any developing relationships. He failed to notify the authorities that he had begun a relationship with Sobhia, and after the relationship had been ongoing for around a year he persuaded her to move from Bradford to Derby. Within little more than 5 weeks of her doing so he brutally murdered her. He ran a defence of diminished responsibility but was convicted of her murder. At the time of the murder was being supervised by numerous agencies: the police, social services, the community mental health team, MAPPA, and the Ministry of Justice. That he was nonetheless able to form a relationship with Sobhia in secret, and to murder her, was surprising and concerning. This formed the focus on my inquest.
Copies Sent To
2. Ministry of Justice
3. Derbyshire Police
4. Derbyshire NHS Foundation Trust
5. Derby City Council
6. Cygnet Health Care
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.