Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Marta Elena Vento who died on 9 December 2020.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 11 March 2025 concerning the death of Marta Elena Vento on 9 December 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Marta’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised relevant to the perpetrator of Marta’s death and this incredibly sad incident have been listened to and reflected upon.

Your Report raises the concern that there is a lack of national guidance to assist healthcare providers in ensuring continuity of care for a prisoner with physical or mental health needs upon release from prison, and lack of practical guidance around delivery of care to ensure such continuity. Your Report also raises a concern that there is no national guidance about the continuity of care for prisoners upon release from prison when homeless, as some Mental Health Trusts will not accept a referral where a person is homeless.

My response to the Coroner has been aided by engagement with NHS England’s national Health and Justice, Mental Health and South West regional teams.

As part of the 2024/25 NHS Priorities and Operational Planning Guidance, NHS England required all Integrated Care Boards (ICBs), the organisations with responsibility for commissioning (paying for) local mental health services, to complete a review of their community mental health services by the end of September (Quarter
2) 2024/25.

The aim of this was to ensure that Systems have robust policies and practices in place to support individuals with serious mental illness who require intensive community treatment and follow-up, particularly where engagement may be challenging.

NHS guidance emphasises a ‘no wrong door’ approach, to ensure individuals can access holistic mental health care regardless of where they first seek support, and any people experiencing psychosis receive evidence-based treatment that enables them National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

25 April 2025

to recover from a psychotic episode and/or live a meaningful life while managing ongoing symptoms.

Some individuals, however, can face challenges in accessing appropriate care and barriers to this may include services struggling to meet their needs, the impact of symptoms such as paranoia, or a lack of insight into their condition. For such individuals, it is crucial that mental health services provide tailored support through flexible engagement strategies, continuity of care, and a range of treatment options suited to varying symptom severity.

A significant change in circumstances, such as discharge from hospital or release from prison, can be associated with heightened risk, especially when individuals return to unstructured or unsafe environments. Therefore, individuals with serious mental illness and co-occurring needs, which might include homelessness, a history of violence or offending behaviour, and who also have difficulty engaging with services, should receive intensive and assertive community treatment, in line with national guidance.

Local ICB reviews can ensure appropriate intensive and assertive mental healthcare and treatment in the community is available to meet the needs, and to support the wellbeing of a particular group, of people with severe mental health illness: NHS England » Guidance to integrated care boards on intensive and assertive community mental health care

To support this approach when individuals are leaving prison, there are services in place such as RECONNECT, a non-clinical ‘care after custody’ service that seeks to improve the continuity of care of individuals with identified health needs, by working with them before they leave the secure estate. RECONNECT supports transition to community-based services, enabling the safeguarding of health gains made whilst in the secure estate, with the aim of helping to reduce inequalities and address health- related drivers of offending behaviours.

RECONNECT offers support and release planning to individuals for up to twelve weeks prior to release, or as soon as they are referred, and works with them up to six months post-release, or when all health care needs are met, whichever is soonest. Referrals can be taken from anyone, including His Majesty’s Prison and Probation Service (HMPPS), prison healthcare, family members and self-referrals. At the time of Marta’s perpetrator’s release, RECONNECT services were not in place. However, I hope that this provides some assurance to the Coroner and Marta’s loved ones that processes are now in place to provide more support to people leaving prison in similar circumstances.

From a prison mental health perspective, continuity of care is included in the current Integrated Mental Health Service Specification for Prisons in England, which was published in 2018, as one of three key measurable objectives which are:

1. Improved mental health and emotional wellbeing.
2. The rehabilitation of prisoners and a reduction in reoffending through the improvement of mental health and contribution to sentence planning where appropriate.

3. Improved continuity of care through the gate and within the prison system.

This service specification highlights essential and expected standards for delivery of different elements of the service, which include:
• Onward referrals to community services.
• Inviting community teams to discharge/release planning and Care Programme Approach (CPA) meetings.
• A follow-up interview with the patient/new care co-ordinator or service provider within fourteen days of release.

At present, there is no specific national pathway guidance setting out what an individual on release can expect from their local Community Mental Health Team (CMHT). The guidance relating to the Adult Mental Health Team is generic rather than focused on the prison population.

While there are no plans currently to develop national pathway guidance, NHS England will be considering this in the longer-term, working with the Adult Mental Health Team to ensure services are able to fully support those leaving prison.

There is also, at present, a review and refresh of the service specification mentioned above underway, and learning from this case will be taken into consideration as part of this refresh. Attention will be given to strengthening the service specification to ensure continuity of care is robust, to ensure successful transfer of care arrangements from prison healthcare to community healthcare teams.

I understand from my regional South West colleagues that a full investigation was undertaken into Marta’s death. A multi-agency investigation stakeholder group was convened with the following organisations contributing to the investigation process:

• Dorset Council
• Orchid House Surgery/Dr Grana
• HMP Winchester
• NHSE Health & Justice team (South East)
• NHS Dorset (ICB)
• Practice Plus Group (PPG)
• Dorset & Hampshire Police
• Dorset Healthcare University NHS Foundation Trust

The perpetrator did not contribute to the process, and the perpetrator’s family did not wish to contribute to the process or receive the report, although this was offered. I understand that Marta’s family have been provided with a copy of the investigation report.

There has also been a learning event held to help understand how different parts of the system work together to meet the needs of an individual who presents with mental health needs, in addition to their offending behaviours. This was well attended with engagement throughout the session from various agencies, including but not limited to; NHS England (regional health and justice and independent investigation teams),

police, healthcare within prisons, NHS healthcare services, Local Authority, housing, and HM Prison & Probation Service.

During the learning event, consideration was given to how an individual is assessed for their mental health needs when entering and leaving prison, how ongoing mental health and social care needs are shared with colleagues in health and local authority services, alongside the public protection responsibilities under the Multi-Agency Public Protection Arrangements (MAPPA), in assessing and managing the risks posed by the most serious offenders. Common themes identified were:

• Data and information sharing (including application of consent)
• Impact of the courts on the pathway(s), such as early release and notification of release
• Clearer communication channels between all agencies

The NHS England South West Independent Investigations Team will support next steps from the learning event to be shared, and then taken forward within the Serious Case Review Subgroup, led by the Chief Inspector of Dorset Police.

Nationally, the findings, information and any learning from this Report will be tabled at a future NHS England Health and Justice Delivery Oversight Group (HJDOG). The HJDOG is the senior leadership forum, which holds responsibility for the oversight of delivery and continuous improvement in Health and Justice commissioned services, through both national and regional teams. All health and justice related Reports to Prevent Future Deaths are shared and discussed at the HJDOG, and assurance is sought from regions where learning and action is identified. This case will also be tabled and discussed at the NHS England Health and Justice and Sexual Assault Referral Centres (HJ&SARCs) meeting scheduled for 13 May 2025, where the learning and any improvements will be shared. These meetings are attended by Health and Justice Quality leads and representatives.

Your report also raises a concern that, in the South West region, all Integrated Care Boards (ICBs), apart from NHS Dorset, are at some stage of implementing the use of the National Record Locator (NRL) system so that South West Ambulance Service NHS Foundation Trust (SWASFT) can access this information to assist in the provision of care to those they treat. You raised that the lack of implementation by NHS Dorset would limit the information SWAST has access to about a patient in Dorset.

NHS Dorset and the Dorset Care Record (DCR) Partnership are involved in the regional and national work to adopt sharing information via the National Record Locator and were founding members of the One South West Programme. The current focus of the work across the One South West programme is supporting ambulance crews to access care plans supporting patients with frailty and palliative care. In order to also support the sharing of mental health care plans, the One South West programme would need to expand their activity. NHS England understands that NHS Dorset would actively support the expansion of this work.

In the absence of this capability, the DCR Partnership is looking to have the capability to share information with others using the NRL from March 2026 onwards, which will meet the national deadline set by NHS England. The DCR Partnership will then start

sharing records to others using the NRL, meaning that SWASFT can access the data through this method.

NHS Dorset remain keen to work with SWASFT to enable access to the Dorset Care Record directly. However, SWASFT have prioritised the NRL approach to sharing data. The DCR Partnership is hoping to work with Dorset Healthcare to share their information to the DCR in 2025, which will be another critical part of the solution.

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 around events, such as the sad death of Marta, 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 HM Coroner Griffin, Re: Regulation 28 Report following the Inquest into the death of Ms Marta Vento Thank you for the Regulation 28 Report, following your inquest into the tragic death (and unlawful killing) of Ms Marta Vento by . I acknowledge your finding, that “evidence was given extensively throughout the Inquest about the management of sexual and violent offender (MOSOVO) unit within Dorset Police. Each police force in England and Wales has a MOSOVO unit with a team of staff managing sexual and violent offenders. Evidence was given that predominantly this is for the management of sexual offenders. [That] there is Approved [Authorised] Professional Practice (APP) guidance issued by the College of Policing regarding the operation of MOSOVO units. This guidance details the risk assessments to be undertaken which are a crucial stage in the management of these offenders.”

You have further noted, “The risk assessments detailed in the guidance are aimed at the assessment of the sexual risk of offenders and evidence was given that there is no bespoke risk assessment tool or guidance to assess the violence of such offenders to assist staff within MOSOVO units to undertake their role. There is, therefore, a lack of guidance on how to risk assess and manage offenders who are managed under MOSOVO when they present with the risk of violence, or an escalating risk of violence. You have surmised that you are “concerned that [the current arrangements] will result in a failure to identify the risk of violence, or the increasing risk of violence, in those being managed by MOSOVO which may lead to a further death.” The College is responsible for providing guidance to forces in the form of APP for several areas of policing. The management of sexual and violent offenders (MOSOVO) is an area where we provide comprehensive guidance to forces in line with statutory MAPPA guidance, relative legislation and evidence-based practice. We aim to ensure the guidance remains up-to-date and current in line with emerging practice, lessons from review and new legislation. MOSOVO APP provides an array of information, from overview, through to the introduction to managing sexual offenders and violent offenders, multi-agency public protection arrangements, identification of MOSOVO offenders, managing public protection information, and the identification, assessing and management of risk.

The identification of risk section outlines that the process requires information from a range of sources, outlining that risk assessment(s) necessitate establishing the likelihood of a behaviour or event occurring, the frequency with which it may occur, whom it will or may affect and the extent to which that behaviour will cause harm. The APP outlines that while some risk assessment tools are sexual offending specific (i.e. ARMS), there are other risk factors that should be considered for all offending types. For example, although not comprehensive, static and dynamic risk factors can be of great value in designing and delivering risk management plans. Irrespective of offending type, risk management plans should be created for all registered offenders and comply with the broader MAPPA framework, if relevant. Further information on the available risk assessment guidance can be found here. A number of actuarial tools are cited within the APP, along with more generic risk assessment factors, and the importance of professional judgement is outlined. However, it would be remiss of us not to further explore the specific application of a risk assessment tool. I have asked my Policing Standards Manager, to consult further with the NPCC Lead for MOSOVO and relevant subject matter experts to see where we can further improve our guidance and direction. Similarly, I shall also ask Sharon to liaise with Dorset Constabulary, to ensure that they are fully sighted on the current guidance and available material, to better address the risks posed by violent offenders in a MOSOVO setting. If I can offer you any further assistance or reassurance, please do not hesitate to contact me.

Dear Ms Griffin,

Regulation 28 Report – Marta Elana Vento

I write on behalf of the National Polcie Chiefs Council (NPCC) in relation to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, in relation to the prevention of future deaths report sent via email to the NPCC dated 11th March 2025.

The notice sets out concerns following the inquest into the death of Marta Elena Vento, namely that there is a lack of guidance on how to risk assess and manage offenders who are managed under MOSOVO when they present with the risk of violence, or an escalating risk of violence and you are concerned that this will result in a failure to identify the risk of violence, or the increasing risk of violence, in those being managed by MOSOVO which may lead to a future death. I am very sorry to read of Marta’s death, in extremely violent circumstances. My sympathies are with her family and friends.

I have noted that there has been similar correspondence to the Chief Executive Officer of the College of Policing and in my response I have liaised with both the College and the Portfolio lead for the Management of Sexual Offenders and Violent offenders (MOSOVO), Assistant Chief Constable .

The Police management of offenders in a statutory context sits primarily within Multi Agency Public Protection Arrangements (MAPPA), as a responsible authority under S325-7, of the Criminal Justice Act 2003. These arrangements provide a statutory framework for the three responsible authorities

of Police, HM Prisons and HM Probation (HMPPS), to work together to manage the risks posed to the public by eligible offenders in the community. The management of violent offenders is generally undertaken within category two (2), of MAPPA when an offender is subject of statutory supervision. This places the lead agency responsibility on to HM Probation Service to undertake a risk assessment and formulate a risk management plan with consultation of statutory partners.

However, in this particular circumstance the offender left custody at sentence end date was therefore not subject to statutory supervision by HM Probation. This ordinarily would have meant no statutory police involvement as regards a risk of violent offending unless a referral to Category 3 was being considered. This was not required in this case as the offender was subject of notification requirements under the Sexual Offences Act 2003, which made him automatically eligible for MAPPA under Category 1 and made him subject of police lead agency. The offender was managed a sexual offender as this was the basis for their MAPPA eligibility.

It is therefore uncommon for a violent case not subject of statutory supervision by HM Probation to be managed by the police as lead agency. In these circumstance the police have no direct powers to require an offender not subject of statutory supervision to cooperate with a violence risk assessment process. In this case however, police had the statutory powers to manage the offender as a sexual offender with the subsequent authority to require them to submit to a risk assessment and to formulate risk management plan.

The risk assessment process police use for sexual offenders is the Active Risk Management System (ARMS), which has been in use by Police in England and Wales since 2014 and is well established. This system assesses 11 factors both risk and protective bespoke to the offenders personal circumstances at the time of assessment alongside their static risk of sexual recidivism based on the OASys Sexual Predictor (OSP). These are combined to provide an overall level of risk and most importantly a risk management plan articulating the plan to mitigate the risks identified and to support the offenders desistance. We would expect that this activity should look at the offenders circumstances holistically and should identify risks of serious violence as part of the overall assessment if known to the assessor and if undertaken adequately.

The NPPC MOSOVO Lead liaises regularly with the College of Policing who develop the training for MOSOVO staff in England and Wales and who produce Authorised Professional Practice. I will ask that the NPCC Lead request the College of Policing review their APP and training material to highlight more strongly the consideration of violence within the assessment when considering the formulation of the risk management plan. In addition, we have previously requested from the College of Policing a full review of the ARMS process as part of normal good practice and will reiterate this need.

I hope the information provided will go some way to address your concerns. Please do not hesitate to contact me if you require any further information in relation to my response.

Kind regards

Dear Mrs Griffin

Re: Prevention of Future Deaths Report for Marta Elena Vento

Please accept my apologies for the delay in submitting our response to your letter of 11th March regarding the Prevention of Future Deaths Report issued following the inquest touching the death of Marta Elena Vento.

The full report was considered as part of the system Mortality Surveillance Group on the 4th of April with intention of assuring proposed actions triggered by your findings of:

o Slippage in mental health care following discharge from HMP Winchester o Communication breakdown between prescriber, 111 clinicians, GPs and patient about medication required. o No processes in place to ensure medication continued in community. o Learning around communication across sectors and across county boundaries.

We were assured that the case has been subject to an independent review Case-no.-2020- 23751-Summary-Report-Final-Version.pdf. The Independent Investigation report was published by NHS England 7/11/23. No specific recommendations were identified for NHS Dorset although we have supported system and regional partners in the subsequent improvement work. To this end an in-person learning event, led by the NHSE regional team, took place in November 2024 with the aim to help understand how different parts of the system work together to meet the needs of an individual who presents with mental health needs in addition to their sexual and violent offending behaviours.

Themes for learning included information sharing, however this was not specific to the availability of information in the National Record Locator used by the ambulance service referred to in your report but on risk information shared through Multi-agency Public Protection Arrangements (MAPPA), in PPN (public protection notices) and in transferring the prescribing and clinical needs of prisoners on release from prison, particularly when at short notice. With regards to your specific concerns regarding information sharing within Dorset:

(4) The National Record Locator (NRL) allows health or social care workers to find and access patient information shared by other health and social care organisations across England to support the direct care of a patient. Evidence was given by the Head of Clinical Development and Organisational Development at South West Ambulance Service NHS Foundation Trust (SWAST) that in the South West region all Integrated Care Boards (ICBs), apart from the ICB in Dorset, NHS Dorset, are at some stage of implementing the use of NRL so that SWAST can access this information to assist in the provision of care to those they treat. Evidence was given that as this would limit the information SWAST had access to about a patient in Dorset, this would impact upon the care provided to those in Dorset by SWAST which could lead to a future death. Rachael Griffin HM Senior Coroner to Dorset BCP Council Civic Centre Bourne Avenue Bournemouth BH2 6DY

It is important to point out that some of the allegations made are not factually accurate regarding the involvement of Dorset ICB in addressing the issues of connection to the National Record Locator.

NHS Dorset and the Dorset Care Record (DCR) Partnership are involved in the regional and national work to adopt sharing information via the National Recorder Locator and were in fact founding members of the One South West Programme. This is a complex area and although a number of ICSs in the South-West are making progress, there is much work to be done. The issue is not as simple as suggested, and the current focus of the work across the One South West programme is supporting ambulance crews to access care plans supporting patients with frailty and palliative care. The One South West programme would need to expand their activity significantly to also support the sharing of mental health care plans. We would actively support the expansion of this work.

Meanwhile in the absence of this capability DCR is looking to have the technical capability to share information with others using NRL from March 2026 onwards. Currently our system supplier has not been able to delivery this capability. Importantly, this will meet the national deadline set by NHS England, which is important because the benefit of using a single system to share is enjoyed when all parties are consistent. Shortly after this, DCR will then start sharing records to others using NRL, which will mean that SWASFT can access the data through this method.

Although this technical capability is essential, there are other critical requirements, including that Dorset Healthcare NHS Trust shares the mental health care plans (and other data), and that SWASFT themselves make sure that their existing system has a significantly improved uptake by their ambulance crews.

NHS Dorset remain keen to work with SWAST to enable access to Dorset Care Record directly, which is a possibility today, meaning that SWAST personnel could access all the information held on our ICS shared care record (DCR). However, SWASFT have prioritised the NRL approach to sharing data, meaning that the delivery is pushed back.

The DCR partnership is continuing to work with Dorset Healthcare to share their information to DCR in 2025, another critical part of the solution. This has been highlighted as an urgent area of focus for the Dorset Healthcare team.

NHS Dorset and the DCR Partnership remain at the forefront of using shared care records to support the efficient, effective and safe delivery of care, allowing professionals across organisational boundaries to see the information they need to give the best and safest possible care to their patient.

However, it is recognised that this is not the first Prevention of Future Deaths notice that has been issued where the lack of visibility/accessibility of important information across system partners has been raised. The solutions to this lie across different partner organisations and not within the ICB. In order to ensure that there is active scrutiny of this area and to ensure that progress is being made a risk has been opened on the system risk register where all system partners have a role in ensuring active mitigation of any on going risk.

Please let me know if you require further information. I hope that I have been able to address your concerns.

Dear Mrs Griffin,

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS – MARTA ELENA VENTO

Thank you for your Regulation 28 report of 11 March 2025 following the inquest into the death of Marta Elena Vento. I apologise for the delay in responding, which has been the result of the need to work through the complex issue that you have raised about the sharing of risk information between the prison and the sentencing court where a prisoner has been held in custody on remand.

I know that you will share a copy of this response with Ms Vento’s family, and I would first like to express my condolences for their loss in such tragic circumstances.

HMPPS is conscious of the complex and challenging issues associated with the management of people on remand who may be subject to release immediately from court on bail or on licence, or as a result of time served, and we are undertaking a range of activities better to understand and address these issues.

The National Immediate Release Task and Finish Group has established immediate release pathfinders in three prisons, with a focus on developing multi-agency approaches to identify in advance those people who may be immediately released from court and to take steps to ensure that they are supported and managed effectively. This includes exploring methods of information exchange for those on remand who have an upcoming court case which may result in immediate release.

More generally, our Prison Safety Policy Framework requires Governors to ensure that risk information is shared with probation services and others with responsibilities for the prisoner on release. However, whilst this broad requirement is clear, there is currently no routine way

of sharing with courts information about behaviour in custody that may impact on risk of harm or offending. In response to the concerns that you have raised, I have asked the Safety Group in HMPPS to give further consideration to this specific area when they undertake a review of this policy framework later in the 2025-26 business year. This work will be informed by the results of the pathfinder projects described above.

Thank you again for bringing your concerns to my attention and I trust that this response provides assurance that we will be taking forward action to address them.