Jacqueline Oakes

PFD Report Partially Responded Ref: 2018-0419
Date of Report 16 October 2018
Coroner Louise Hunt
Response Deadline est. 11 December 2018
1 of 2 responded · Over 2 years old
Sent To
Response Status
Responses 1 of 2
56-Day Deadline 11 Dec 2018
Over 2 years old — no identified published response
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
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion  there is a risk that future deaths will occur unless action is taken. 1. When an offender is released having completed their full sentence who is known to be a high  risk to others there is no mechanism for any other agencies to be alerted to that person’s  release. Had an alert been provided to other agencies that came into contact with Jacqueline  and   it would have meant they were better able to manage the risks he posed.  Consideration should be given to whether such alerts can be provided.
Responses
HM Prison and Probation Service
7 Dec 2018
Response received
View full response
Dear Mrs Hunt

Thank you for your letter of 16th October 2018, enclosing your Regulation 28 Report following the inquest into the death of Jacqueline Oakes.

We are grateful for your comments and recommendation for improvement, which we have considered in detail. You recommended that:

When an offender is released having completed their full sentence who is known to be a high risk to others there is no mechanism for any other agencies to be alerted to that person’s release. Had an alert been provided to other agencies that came into contact with Jacqueline and it would have meant they were better able to manage the risks he posed. Consideration should be given to whether such alerts can be provided.

In response I have identified the current arrangements that are in place to ensure risk information is shared to partner agencies when a high risk offender comes to the end of their sentence and will no longer be under the statutory supervision of the Probation Service. I have also outlined the steps that are already underway to strengthen this area of public protection practice.

Offender Management policy requires that offenders assessed as high or very high risk of harm remain the responsibility of the National Probation Service until the end of their sentence, regardless of whether or not they will be released from custody on licence or at sentence end date.

Multi-Agency Public Protection Arrangements, or MAPPA, are framework of statutory arrangements operated by criminal justice and social care agencies that seek to manage and reduce the risk presented by sexual and violent offenders in order to reduce re-offending and protect the public. This is done by sharing information and establishing a coordinated risk management plan that will allow offenders to be effectively managed.

In line with current MAPPA Guidance, the National Probation Service (NPS) must review all MAPPA offenders at least six months prior to release in order to assess the risk they pose and determine the level of MAPPA management at which an offender should be managed. Where they are assessed as meeting the appropriate criteria, an offender would then be referred to MAPPA level 2 or 3. This is a priority in cases where the individual is released without a license at the point of sentence expiry.

ViSOR is a secure, shared MAPPA database. It provides a central store for up-to-date risk related information about offenders that can be accessed and updated by the three Responsible Authority agencies (NPS, HMPS and Police). It is classified as Official (Sensitive) and enables the prompt sharing of risk assessment and risk management information on individual offenders who are deemed to pose a risk of serious harm to the public and members of staff. It improves capacity to share intelligence and enhances public protection measures by improving the safe transfer of key information when these offenders move between areas and establishments.

Under current arrangements ViSOR is the primary tool for communicating the release of all registered sexual offenders (Category 1) and those most concerning violent offenders (Category 2) who meet the criteria for management at MAPPA Level 2 or 3. It is a mandatory requirement for police and probation respectively to create a ViSOR record which allows them to store and share risk related information on the offender during and after their sentence. The presence of a ViSOR record is flagged on the front screen of an offender’s record on the Police National Computer (PNC).

Violent offenders who did not meet the criteria for level 2 or 3 MAPPA management are the only cohort of MAPPA offenders who have not routinely had records created on ViSOR. This identified gap in public protection provision is being addressed by a significant programme of change which will see the NPS increase staff access to ViSOR. It will be available to probation officers on their laptop computers for the first time and NPS will create ViSOR records for all MAPPA eligible violent offenders. Training is being scheduled and NPS will adopt a phased approach ensuring all relevant eligible offenders have a ViSOR record, starting with newly sentenced offenders, those already in the community or due for release and working back to those with longer to serve in custody. This will commence in February
2019.

In the case of , a Category 2 Level 1 offender, it must be remembered that the Police were aware that he had been released from prison, as they arrested him a number of times. However, the new ViSOR arrangements will allow relevant risk information, gathered throughout his sentence to be recorded centrally and available nationally so that police officers can more readily access it.

Further measures are available, outlined within the MAPPA Guidance and HMPS Public Protection Manual (PPM), to enable information sharing in relevant cases to enable public protection concerns to be managed post sentence by relevant agencies.

All Category 1 and 2 offenders managed at Level 2 or 3 who are coming to the end of their notification requirements or period of licence must be reviewed and considered for registration as a Category 3 offender. Registration as a Category 3 offender should only occur if the offender meets the criteria and continue to require active multi-agency management.

Additionally, the most recent update to the Guidance has included further advice on specific offenders who are not automatically eligible for management under MAPPA, to be referred into MAPPA. This includes those sentenced for offences of “Controlling or Coercive Behaviour in an Intimate or Family Relationship” and serial domestic abuse perpetrators. Where the lead agency deems that these offenders pose a risk of serious harm that requires active multi-agency management, they should consider referral into Category 3.

The latest PPM requires prisons to notify Children’s Services of the release date of all offenders identified as presenting a risk to children at least six weeks before they are discharged from custody and to copy the notifications to the Police, and the probation or youth offending team.

The PPM also sets out harassment public protection measures which require case by case consideration to be given to notifying the Police on discharge of any prisoner who is under harassment measures or subject to no-contact requests, if the information is not being shared under MAPPA. This should particularly be considered when dealing with persistent offenders. The notification of release will allow the Police time to consider whether any additional mechanisms are needed to enhance the victim’s safety in the community. Offenders are assessed throughout their sentence and plans are developed to manage identified risk of harm presented by the offender. The plan must indicate which agencies are involved with the case and the role of each agency in managing the risk. Those responsible for implementing any aspect of the plan should be provided with a copy of it. If NPS or HMPS refer anyone to an accommodation provider they are expected to pass on all relevant risk information to inform the providers’ decision on the offender’s suitability for the accommodation and to inform their on-going relationship with the offender.

At termination of the sentence, whether the offender is in custody or the community probation officers are required to review the assessment and plan for high risk prisoners. This is to ensure that any available risk management strategies are identified and can be used to support any agency providing ongoing resettlement services, albeit without the controls which are available through a licence. During this process it is essential that probation practitioners identify any further concerns that would require the Police, local authority or other agency to be informed prior to the release of an offender and the plan should be clear what support or control measures might remain in place once probation supervision has ended. Relevant agencies that have been, or will continue to be involved post sentence, should be informed about the final plan and also notified that Probation will no longer be responsible for managing the sentence of the court and do not have any further powers in relation to the offender. If there are concerns in relation to a known child (or children) probation providers have a duty to report these concerns to the Local Authority, following local referral procedures.

Where an offender is not in contact with any other organisations at the end of sentence, it is clearly not possible to pass information on at the point the offender will no longer be subject to monitoring or supervision by the NPS. However, Probation will contribute to any ongoing MAPPA management under Category 3, Multi Agency Risk Assessment Conferences for high risk victims of domestic abuse and can provide relevant and proportionate information to supplement that provided by the police on offenders they have previously managed.

The NPS also contribute to information sharing and safeguarding decisions of known or previously known offenders as part of their duty to safeguard children as set out in Section 11 of the Children Act 2004. This is through engagement with Multi Agency Safeguarding Hubs (MASH). MASH is a structure that exists in most of the 152 Local Authority areas, aiming to improve the safeguarding response for children by facilitating information sharing and decision making on a multi-agency basis. Often, though not always, the MASH includes the co-location of staff from the local authority, health agencies and police and sometimes also from education, probation providers and Youth Offending Service. There are different names for this multi-agency safeguarding structure within some Local Authorities (e.g. MACE, MAST) and although the MASH were primarily established to safeguard children, increasingly areas are integrating safeguarding adults and in some areas sharing information in relation to domestic abuse.

The level and specific model of NPS engagement in MASH is determined at divisional management team level and ranges from identifying a single point of contact for the MASH, providing a virtual link through access to shared systems/emails or by providing seconded staff. This allows for the relevant sharing of risk information even after an offender is no longer subject to supervision, where proportionate and necessary, to safeguard children and/or adults at risk. The NPS engagement with the MASH is set out in the National Partnership Framework for England dated August 2016.

In all other situations, the Police already have access to the information regarding the offending history, the sentence and licence and are able to consider disclosure of any pertinent risk information to any relevant agencies where they consider it appropriate to do so. This information will be supplemented by the additional information stored on ViSOR.

Guidance on activity that is required at termination of sentence is currently being written as part of the HMPPS transition to a new model for managing offenders in custody. This will set out a clear expectation that plans are shared with other agencies involved with the offender in line with lawful information sharing practice.
Report Sections
Investigation and Inquest
On 22/01/2014 I commenced an investigation into the death of Jacqueline Oakes. The investigation  concluded at the end of an inquest on 11 October 2018. The conclusion of the inquest by the jury was  “To conclude, the victim was killed unlawfully.  However the victim was also a vulnerable lady which was  a factor in her making a number of naive decisions, despite knowing the offenders history.  Following the inappropriate placement of the offender in the same property as the victim, a relationship  between the 2 developed.  The offender committed numerous offences which failed to lead to any prosecution.  The support that the victim needed was available although Domestic Abuse (where identified) and  mental health sufferers need extra attention due to their sensitivity and complexity and this wasn't  always provided.”
Circumstances of the Death
Jacqueline Oakes suffered from mental health difficulties and was vulnerable and at the end of 2012 she  became homeless and moved into supported living accommodation in January 2013. It was there that  she met   who had recently been released from prison for a serious offence against his  previous partner.   had been sentenced to 30 months in custody with extended licence  for 24 months. He had been released on parole on 12/11/09 but was recalled to prison several days later  on 14/12/09 as he had missed his curfew and failed to attend a meeting with his probation officer. After  his return to prison he was refused further parole and was released on 11/02/13 at the end of his  sentence. His last Oasys assessment had confirmed him to be a high risk to future partners and a medium  risk to the public. He was MAPPA Cat 2 level 1. As he had served his full sentence no agencies were  notified about his release.   met Jacqueline at the beginning of April 2013. 

 was abusive to Jacqueline and frequently assaulted her. He was arrested and charged with 3  counts of assault and harassment (fear of violence) in June 2013 but Jacqueline later retracted her  statement and he was released. Further assaults occurred in September 2013 and he was again arrested  and charged with assault. He was released on 04/11/13 as Jacqueline had provided a retraction  statement and a victimless prosecution was unsuccessful. There were further assaults in December 2013  and January 2014 and   was arrested on 08/01/14 but later bailed pending further  enquiries. On 14/01/14 Jacqueline’s body was found in the flat where she was staying and

 was convicted of her murder on 15/07/14 and sentenced to a minimum term on 18 Years in  prison.  

Following a post mortem/Based on information from the Deceased’s treating clinicians the medical cause  of death was determined to be: 

1a. MULTIPLE INJURIES
Copies Sent To
Swanswell  Sustain  West Midlands Police I am also under a duty to send the Chief Coroner a copy of your response Signature Mrs Louise Hunt HM Senior Coroner Birmingham and Solihull
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.