Dear Ms Kearsley,

Prevent Future Deaths Report for Michael Hoolickin (Deceased) Thank you for your correspondence of 29 August 2019 in relation to the Inquest into the death of Michael Hoolickin, along with the Regulation 28 Report to Prevent Future Deaths.

I was not previously aware of this incident, and I am very sorry to learn of the tragic circumstances surrounding the death of Mr Hoolickin. You will appreciate that I am unable to comment on the specific facts of this case, but I can address your concerns regarding policing practice more generally. I understand that you have made contact with the chief constables of Greater Manchester Police and Lancashire Constabulary, both whom will no doubt wish to respond separately in addressing the issues you have raised with specific reference to the actions of their respective forces.

It is important to understand the distinct role of the National Police Chiefs’ Council (NPCC). As you know, each chief constable is ultimately responsible for operational matters within their own force area, which includes all of those issues referred to within the matters of concern you have raised. Whilst the NPCC seeks to encourage chief constables to work collaboratively in the national interest (for example, the way in which forces implement policies or practice), the NPCC does not have the authority to direct a chief constable to take (or not to take) a specific course of action. That said, we do recognise the need for consistency across forces whenever possible, which we know can lead to better outcomes for the public. The way the NPCC A.15

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achieves this is by allocating specific areas of national responsibility to different chief officers in various forces across the country. These chief officers act as the NPCC’s national lead on specific matters of policy and practice on behalf of their colleagues across all forces.

Your report raises a number of very important matters of concern:

1. Serious Further Offence Reviews
2. Curfew Requirements
3. Police National Computer and Licence Conditions
4. Integrated Working
5. Integrated Offender Management Cohort Meetings

In order to provide a useful response to the matters of concern you have raised, it has been necessary for me to consult with a number of national leads across several portfolios. I am unfortunately not able to provide you with a full response to all of your concerns today because some of those I have consulted with are still in the process of considering the matters of concern, and no doubt further consulting with subject matter experts. However, I hope you are willing to accept this letter in part response to the issues raised.

I have discussed the matters of Integrated working (concern 4) and Integrated Offender Management (concern 5) with the national lead for this area, Deputy Chief Constable Jon Stratford of Gloucestershire Constabulary. DCC Stratford advises me that unlike Multi-Agency Public Protection Arrangements (MAPPA), Integrated Offender Management (IOM) operates on a non-statutory basis. The agencies involved commit to joint working voluntarily in furtherance of their individual aims and because it is in the public interest for them to do so. This means that the precise nature of each IOM scheme is very much a function of the local partnership landscape, circumstances and priorities. The resultant diverse range of ways of working does not lend itself to strict codification at a national level, however IOM guidance does exist, and I have attached to this letter two “IOM Key Principles” guidance documents that have been designed to provide best practice guidance within which local schemes can operate.

The guidance documents attached do specify the need for effective information sharing. For example, paragraph 1.6 of the 2015 document states that “all necessary Information Sharing Agreements (ISAs), protocols and processes are in place to ensure swift and appropriate real time sharing of information and intelligence”. However, the precise ISA and ways of working must be built around the needs and ways of working of each individual scheme, which is impractical to provide at a national level. The guidance also describes cohort selection in detail, again emphasising the requirement for this to be tailored to meet local needs.

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Being statutory in nature, MAPPA arrangements will always have primacy over IOM schemes although, as set out in the Key Principle documentation, IOM working can be useful in complementing the measures agreed in MAPPA.

I am therefore content that sufficient IOM guidance does exist to support forces alongside the statutory requirements of MAPPA, but as I described earlier, it is a matter for each chief constable to ensure that appropriate arrangements are in place within their force. In order to encourage learning from this Inquest, it is my intention to share your report, this response and the IOM guidance with chief constable colleagues in all forces across the country, in case there are areas of practice within their own force which they feel may benefit from review.

I am sorry that at this stage I have been unable to provide you with a response to matters of concern 1, 2 and 3. I assure you these are being carefully considered by subject matter experts, and I will endeavour to provide a full response to these recommendations in the coming days.

Thank you for providing me with the opportunity to comment on the areas of concern you have identified. Please do not hesitate to get in touch if you have any further queries about the content of this letter.

Dear Ms Kearsley

Inquest into the death of Mr Michael Hoolickin

Thank you for your Regulation 28 Report, issued following the Inquest into the death of Mr. Hoolickin. I am replying as the Director General of Probation and Wales, part of Her Majesty’s Prison & Probation Service (HMPPS) on behalf of the Secretary of State for Justice and Ms Hamilton of the National Probation Service North West Division.

I know that you will share a copy of this response with the family and I would first like to express my sincere condolences that they were victims of such a terrible crime. The implementation of learning from this case is my absolute priority. We are grateful for your comments and recommendations for improvement, which we have considered in detail.

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

The failure to undertake a multi-agency review in cases where a high-risk offender subject to multi- agency management has gone on to take someone’s life means both organisational and individual failings are not identified and there is a missed opportunity to learn lessons in order to prevent future deaths.

There are arrangements in place for undertaking Serious Case Reviews on a multi-agency basis in a range of circumstances, including for certain offenders managed under Multi Agency Public Protection Arrangements (MAPPA) and for cases of Domestic Homicide. These reviews support organisational learning across agencies. The management of the perpetrator in this case was not captured under these arrangements as he was managed as MAPPA level 1 and under the current statutory guidance, his management did not meet the criteria for a mandatory MAPPA Serious Case Review. The MAPPA Guidance is statutory guidance issued by the Secretary of State for Justice under the Criminal Justice Act (CJA) 2003, to help the relevant agencies in dealing with MAPPA offenders. We will review the MAPPA guidance on which cases should be subject to a mandatory Serious Case Review. As part of the process we will consult with partners, including the Home Office and police, on strengthening the guidance on undertaking Serious Case Reviews where high risk MAPPA offenders have been convicted of Murder. A.55

The Court has concerns as to the planning and preparation required for the amalgamation of any new service in order to alleviate the evidenced problems which occurred as a direct result of the previous Transforming Rehabilitation programme.

The Department is determined to ensure a smooth transition to future probation arrangements which minimises disruption for staff and service users. We are working closely with the Community Rehabilitation Companies to ensure we get the transition to the new system right. Extensive planning for the transition is underway within HMPPS, drawing on lessons learned from Transforming Rehabilitation and from our experience in Wales, where offender management functions transfer over to the National Probation Service (NPS) in December 2019 ahead of Divisions in England.

The Court was extremely concerned as to whether the N Delius case management system is fit for purpose, particularly when attempting to capture all relevant, recent information about a high-risk offender in order to reach an informed decision such as recalling them to prison

HMPPS is engaged on a programme of work to modernise tools available to probation practitioners in their management of offenders. Those responsible for this work closely with operational staff in NPS to ensure that changes we make reflect their priorities and support front line staff in the way that they work. The team will look at the issues raised in this case as soon as possible, and establish what improvements can be made quickly. The team will consult front line staff to ensure any solutions developed reflect practitioners’ needs. Updated Guidance on professional judgment decision making and recording on NDelius has already been added to the EQUIP database.

There is no induction training, information available to staff in individual offices by way of office procedures which informs staff of local practices. This is particularly pertinent if staff transfer from other offices.

It is fully accepted that where there are local office practices in place there must be effective communication of such local practices to staff new to an office. I have therefore taken immediate steps to ensure that the National Induction Pack is updated so that it makes clear that specific induction on local practice and processes must be completed both for staff new to the organisation and for staff moving offices. We will also put in place a mechanism to record that this has taken place.

Lack of clarity and specific instructions to the NPS on the system of SPO and ACO warnings issued to offenders and serious concerns as to the poor records or complete lack of records particularly by SPOs and the ACOs.

The requirement for recording evidence of professional judgment has always been an essential element of record keeping in individual cases. In April 2019, HMPPS strengthened guidance by publication of the ‘Compliance and Engagement on Licence’ document. This paper outlines evidence based best practice guidance that encompasses several critical areas of management of offenders on licence from pre-release engagement to licence variation and recall thresholds. There is a chapter which provides specific guidance and outlines expectations relating to recording of and accountability for all decisions taken.

At no stage after March 2016 was the offender’s OASYS risk assessment updated. Moreover, the lack of formal supervision meant this was not addressed.

The Probation Instruction on sentence planning sets out the expectation that Offender Managers review OASys assessments and update the risk management plan in response to changes of circumstance and, in particular, changes which may impact on risk. The assessment and risk management plan should have been reviewed and updated in this case. The fact that that this had not A.56

been done should have been picked up through management oversight and our supervisory arrangements.

We have developed a new National Supervisory and Line Management Framework to better support front line probation staff in their role which is being rolled out across the NPS Divisions. This Framework is designed to ensure a consistent and appropriate level of management oversight through practice supervision sessions and observation of practice as well as review of cases. Through observation of practice, senior probation officers will be able to see whether staff are being sufficiently challenging and adopting a properly investigative approach in their face to face supervision of the offender. There is a minimum requirement of four practice supervision meetings and two practice observations per annum for all probation officers with their Senior Probation Officer/line manager. Within this framework, Senior Probation Officers with line management responsibility will ensure that work is undertaken in line with expected standards and that decision making is being properly recorded.

Questions were raised around the ability of the NPS to cross reference intelligence received in respect of different offenders. In addition, whether there was capacity to cross reference intelligence held by other agencies such as the Youth Offending Team.

We recognise the importance of sharing information about offenders both within teams and our own organisation and with partner agencies, including YOT. In March, HMPPS published a new Policy Framework on Intelligence Collection, Analysis and Dissemination and recently updated the policy in October. Its purpose is to ensure staff within HMPPS adopt consistent approaches to the collecting, handling, analysis and dissemination of intelligence. Its stated aims include that staff are confident in submitting and collecting intelligence to combat ongoing criminality. Staff are required to share intelligence appropriately within HMPPS or disseminate it to other agencies, so that through the proactive use of intelligence to identify potential risks, the public are protected as far as possible from the threat of harm. In addition, it is a clear principle of Integrated Offender Management (IOM) that all partners manage offenders effectively together, which means agreeing the means to share information and intelligence as a basis for multi-agency problem solving. This is set out in HMPPS guidance on IOM.

There is no clear understanding as to the initiation of curfew checks. It was clear to the Court there was confusion as to whether an offender on a curfew will automatically be subject to curfew checks carried out by the Police or whether such checks will only be conducted following a specific request by the NPS. As a result, in this case the offender was only subject to 2 curfew checks in 8 months. In addition, there was a lack of clarity as to whether the Police would only report a curfew check if the offender was not present at the time of the check.

The process for undertaking curfew checks should be set out in the risk management plan, stating clearly who is responsible for what, and in cases such as this it should be agreed at multi-agency IOM meetings. I have set out further below the arrangements that have now been put in place to strengthen IOM arrangements in Greater Manchester. You may also be interested to know that electronic monitoring is also available to monitor curfews for certain offenders, as is location monitoring, which allows an offender manager to request retrospective information about a subject’s whereabouts at any time during the lifetime of their supervision.

An offenders’ licence conditions are not held on the Police National Computer database. Hence if an offender is arrested by a different force they are unlikely to know whether the offender may be in breach of their licence. Hence it is not clear how any potential breaches would ever be shared effectively with the NPS. There is an established process for prisons to inform the police about an offender’s release on licence and a specialist central unit uploads information on to the Police National Computer (PNC). The A.57

system is owned and operated by the police and sits under the Home Office. HMPPS works collaboratively with the PNC Bureau to keep the process under review and ensure that we are providing them licence information in the most effective manner and will continue to do so.

There were no Standard Operating procedures or formal processes in place for the sharing of information when teams are integrated. The Court found this led to a culture of more informal discussions and means of sharing information.

The Greater Manchester Combined Authority Integrated Offender Management Framework was launched in August 2018 which established a clear governance structure for Greater Manchester IOM schemes. The Framework establishes steering groups, exit/entry meetings, and regular case discussion/tasking meetings for IOM cohorts and specifies the need to record and circulate minutes and actions and timescales for doing this. It identifies key cohorts and their criteria as well as the IOM offer. It provides clear guidance regarding the sharing, reviewing and recording by IOM partners of criminogenic and risk information relating to nominals.

In respect of the multi-agency IOM meetings there was no formal agenda, no formal minutes, no accurate record kept of these meetings by either GMP or the NPS and no way of ascertaining who had attended these meetings. Of note these meetings are to discuss the ongoing management of high risk offenders being managed in the community and is an opportunity to discuss how effective the management plan is. There is no national guidance to forces or agencies on how these meetings should be structured or recorded.

The Home Office has set out the key principles for IOM, one of which is that it delivers a local response to local problems. While we have issued national guidance for NPS staff on IOM, we think it is right that detailed arrangements should be agreed locally. The Greater Manchester Combined Authority IOM Framework establishes tasking meetings for all Greater Manchester IOM schemes. These meetings cover specific tasking, sequencing of delegated tasks, reviewing and concluding on outcomes. Partnership attendance is voluntary, but intelligence sharing is mandatory. These meetings provide an opportunity to review individual action plans, emerging intelligence, set priorities for action, enabling risk management planning to be implemented and contingency plans to be reviewed. The Framework requires the sharing of minutes from these meetings in a timely manner. It also requires these meetings to be held a minimum of three times per week.

The Greater Manchester IOM Framework is currently subject to review and your concerns will be considered as part of this review. Where deemed necessary further guidance or clarification including templates such as draft agenda, minutes and action logs will be included.

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

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