Luke Barnes
PFD Report
All Responded
Ref: 2025-0136
All 1 response received
· Deadline: 6 May 2025
Coroner's Concerns (AI summary)
Probation staff lack access to specialist medical reports and adequate training on neurodiverse conditions, hindering effective supervision. A loophole also prevents unactioned court sentences from being referred back for review.
View full coroner's concerns
a.Probation staff are not always aware of or have access to relevant and/or specialist medical reports prepared for Liaison and Diversion Service and other bodies including mental health providers. Further evidence obtained from HMPPS indicates that reports prepared for Liaison and Diversion Service or mental health service providers by specialist medical practitioners (including learning disability practitioners) may not always be notified to the probation service and that the sharing of such information relies to an extent on ad hoc arrangements. The coroner has been told that this issue has been identified previously in a Serious Further Offences Review.
b.Whether there is sufficient training for all frontline probation service staff about neurodiverse conditions and their impact on post sentence supervision. The Court heard from Mr Barnes’ probation practitioner, they had limited awareness of neurodiversity issues as they might affect the supervision of Mr Barnes or probation service policy in this area. Although further evidence from HMPPS confirms that since 2021 all trainee probation officers are required to attend a face-to-face training session on neurodiversity and probation officers and qualified probation officers have training available to them it is not clear if this training is sufficient and for all frontline probation staff.
c. That a loophole exists whereby a sentence of the court, not actioned by probation service staff, (in this case a DRR) might not be referred back to the court for review.
b.Whether there is sufficient training for all frontline probation service staff about neurodiverse conditions and their impact on post sentence supervision. The Court heard from Mr Barnes’ probation practitioner, they had limited awareness of neurodiversity issues as they might affect the supervision of Mr Barnes or probation service policy in this area. Although further evidence from HMPPS confirms that since 2021 all trainee probation officers are required to attend a face-to-face training session on neurodiversity and probation officers and qualified probation officers have training available to them it is not clear if this training is sufficient and for all frontline probation staff.
c. That a loophole exists whereby a sentence of the court, not actioned by probation service staff, (in this case a DRR) might not be referred back to the court for review.
Responses
Action Taken
HMPPS updated its Drug Rehabilitation Requirement (DRR) Guidance in June 2025 to standardise the approach across England and Wales and ensure consistency during DRR Reviews. (AI summary)
HMPPS updated its Drug Rehabilitation Requirement (DRR) Guidance in June 2025 to standardise the approach across England and Wales and ensure consistency during DRR Reviews. (AI summary)
View full response
Dear Madam, Inquest Touching the Death of Luke Harry Brockwell Barnes I refer to your Regulation 28 Report following the Inquest into the death of Mr. Barnes and am issuing this response on behalf of His Majesty’s Prison & Probation Service (HMPPS). I know that you will share a copy of this response with his family, and I would like to take this opportunity to express my sincere condolences for their loss. You raised the following concerns –
Probation staff are not always aware of or have access to relevant and/or specialist medical reports prepared for Liaison and Diversion Service and other bodies including mental health providers. Concerns around the lack of universal access for NHS Liaison and Diversion (L&D) services to the Common Platform used by HM Court & Tribunal Service (HMCTS) has now been raised at Ministerial level. This has resulted in a review of the access arrangements and, as a result, HMCTS intends to remove the need for manual handling for the upload of L&D reports to the Common Platform and DCS as well as other evidence required from Criminal Justice System partners within the sentencing processes. This should remove the risk of Probation staff not always being aware of or having access to relevant reports with the Liaison and Diversion Service.
Whether there is sufficient training for all frontline probation service staff about neurodiverse conditions and their impact on post sentence supervision All frontline Probation staff have access to training which covers Neurodiversity – Learning Disabilities and Challenges Neurodiversity - Brain Injury Neurodiversity - Autism and ADHD Diversity and Inclusion Learning and Development
This training is a requirement for all those training to become qualified Probation Officers and has been since 2021. HMPPS keeps the training it provides to all Probation frontline staff under review to ensure it is sufficient and current and meets the demands of the work being undertaken. It is part of the professional responsibility of Probation Practitioners to access relevant training to meet the diverse needs of those subject to Probation supervision and ensure that they can comply with the requirements of the Policy Framework for Sentence Management in the Community.
That a loophole exists whereby a sentence of the court, not actioned by probation service staff, (in this case a DRR) might not be referred back to the court for review. HMPPS has very recently (June 2025) updated its Drug Rehabilitation Requirement (DRR) Guidance (including DRR Reviews Guidance) to help create a standard approach across England and Wales. The updated Guidance will ensure a consistent approach is used during DRR Reviews and following sentencing to a DRR and also simplify the process by providing clarity of roles and responsibilities and an improved DRR Review template. The aim of the updated Guidance is to improve efficiency; speed up referrals into drug treatment; increase the number of Order completions and increase judiciary confidence in the Orders. The update Guidance documents are available to all Probation staff on a comprehensive computer database known as EQuiP (Excellence & Quality in Process) which provides easy access to operational processes and procedures.
Thank you again for bringing your concerns to our attention. I trust that this response provides assurance that action is being taken to address the issues you raised.
Probation staff are not always aware of or have access to relevant and/or specialist medical reports prepared for Liaison and Diversion Service and other bodies including mental health providers. Concerns around the lack of universal access for NHS Liaison and Diversion (L&D) services to the Common Platform used by HM Court & Tribunal Service (HMCTS) has now been raised at Ministerial level. This has resulted in a review of the access arrangements and, as a result, HMCTS intends to remove the need for manual handling for the upload of L&D reports to the Common Platform and DCS as well as other evidence required from Criminal Justice System partners within the sentencing processes. This should remove the risk of Probation staff not always being aware of or having access to relevant reports with the Liaison and Diversion Service.
Whether there is sufficient training for all frontline probation service staff about neurodiverse conditions and their impact on post sentence supervision All frontline Probation staff have access to training which covers Neurodiversity – Learning Disabilities and Challenges Neurodiversity - Brain Injury Neurodiversity - Autism and ADHD Diversity and Inclusion Learning and Development
This training is a requirement for all those training to become qualified Probation Officers and has been since 2021. HMPPS keeps the training it provides to all Probation frontline staff under review to ensure it is sufficient and current and meets the demands of the work being undertaken. It is part of the professional responsibility of Probation Practitioners to access relevant training to meet the diverse needs of those subject to Probation supervision and ensure that they can comply with the requirements of the Policy Framework for Sentence Management in the Community.
That a loophole exists whereby a sentence of the court, not actioned by probation service staff, (in this case a DRR) might not be referred back to the court for review. HMPPS has very recently (June 2025) updated its Drug Rehabilitation Requirement (DRR) Guidance (including DRR Reviews Guidance) to help create a standard approach across England and Wales. The updated Guidance will ensure a consistent approach is used during DRR Reviews and following sentencing to a DRR and also simplify the process by providing clarity of roles and responsibilities and an improved DRR Review template. The aim of the updated Guidance is to improve efficiency; speed up referrals into drug treatment; increase the number of Order completions and increase judiciary confidence in the Orders. The update Guidance documents are available to all Probation staff on a comprehensive computer database known as EQuiP (Excellence & Quality in Process) which provides easy access to operational processes and procedures.
Thank you again for bringing your concerns to our attention. I trust that this response provides assurance that action is being taken to address the issues you raised.
Sent To
- HMPPS
Response Status
Linked responses
1 of 1
56-Day Deadline
6 May 2025
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
An inquest into Mr Barnes death was opened on 14 May 2024. The inquest was resumed and concluded on 16 December 2024 with further submissions in respect of Regulation 28 matters received on 29 January 2025 and 5 March 2025. The medical cause of Mr Barnes’ death was: 1a. toxicity With respect to where, when and how Mr Barnes came by his death it was recorded at Box 3 of the Record of Inquest as follows: Luke Harry Brockwell BARNES was found dead at his home in Cobham on 9 February 2024. He had taken sufficient to result in his death from toxicity. His death was formally recorded by paramedics at 1134 hours that same day.
The inquest concluded with a short form conclusion of ‘Drug related’.
The inquest concluded with a short form conclusion of ‘Drug related’.
Circumstances of the Death
During the course of the inquest the court heard that Mr Barnes had a diagnosis of autism and a personality disorder with a history of previous convictions. He had long-term drug abuse issues including purchasing drugs online. At the time of his death Mr Barnes was subject to probation service supervision following a short period on licence and a 12 month community order made by Guildford Crown Court, this included a Drug Rehabilitation Requirement (DRR). The DRR was not implemented by the probation service. Mr Barnes was referred to a similar programme, which he attended, but which could not require him to undergo regular drug testing. The coroner heard that any such alteration to sentence requires the court itself to review the original sentence. That did not happen in Mr Barnes’ case. Following his arrest in April 2023 Mr Barnes had been referred by Westminster Court Probation Service to the Liaison and Diversion Service at Westminster Magistrates Court for assessment and review. A report was prepared by a specialist practitioner for intellectual disabilities and learning disabilities. That report included insights into his character and behaviour, discussion about his autism and recommendations as to how best to manage Mr Barnes in the future. In June 2023 post sentence probation supervision for Mr Barnes was passed from London to Staines. The court heard that the report prepared by the Liaison and Diversion Service specialist practitioner was not seen by or was not available to probation staff in Staines.
Inquest Conclusion
Luke Harry Brockwell BARNES was found dead at his home in Cobham on 9 February 2024. He had taken sufficient to result in his death from toxicity. His death was formally recorded by paramedics at 1134 hours that same day.
The inquest concluded with a short form conclusion of ‘Drug related’.
The inquest concluded with a short form conclusion of ‘Drug related’.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.