Dear

Please see the response below for the Coroner.

Dear Ms Persaud,

Further to your email of Friday July 26th attaching a Regulation 28 Report following the inquest touching upon the death of Ms Zara Natasha Aleena, I can confirm that the London Borough of Redbridge has considered your findings and includes a response to each of the relevant questions below, setting out action already being taken by the Council to address these matters:

 (19) The details of training for CCTV operators includes “training on sexual harassment”, but it is not clear whether this includes identifying sexual predators and stalking type behaviour.

The training for CCTV operators encompasses modules that cover behavioural body language training and are specifically designed to detect behaviours that would fall under the remit of ‘suspicious’.  The training is based on established principles and techniques outlined in Tavcom training programs – suspicious behaviours can include gestures, mannerisms, alone or in a group, time, location, how someone is acting (i.e. drunk/disorientated), approaching people, being aggressive etc.  The training given to all LBR CCTV officers to assist them in making inferences regarding suspicious behaviours that lend themselves to multiple situations (including drug dealing, knife attacks, theft, robbery, stalking, sexual harassment and intimidation).

These modules are essential in equipping operators with the skills to identify various forms of inappropriate and potentially criminal behaviours, which includes but is not limited to, behaviours that could be interpreted by an operator as being predatory.   The goal of this training is to ensure that CCTV operators are not only capable of identifying sexual harassment but are also proficient in recognising and responding to broader patterns of suspicious behaviours. 

(20) I am unclear from the evidence provided, whether LBR have a system for checking that training provided to CCTV operators is fully understood, or whether refresher training is provided to them.

LBR ensures that the training provided to CCTV operators is fully comprehensive and regularly reinforced through evaluation and ongoing professional development.  After completing the Tavcom training, all operators must pass an exam to obtain their SIA (Security Industry Authority) licence, confirming their understanding of the training content. Additionally, LBR implements a performance management system, including mentoring from experienced operators and regular audits of work to identify any gaps in knowledge or performance. These audits inform whether additional training or guidance is needed, ensuring operators maintain high proficiency standards. Once operatives have had official training, they are regularly audited on their CCTV viewing footage and any further training needs are picked up and implemented on a case by case basis.  LBR will however, further to your findings, introduce a new annual mandatory refresher training programme for all operatives, to include suspicious behaviour (so that in the event that suspicious behaviour is observed by an operative during their patrols, we can formally demonstrate that they know the correct action to take).

Operatives’ line managers are regularly based within the CCTV control room so are able to directly observe behaviour and working practices during shifts, with regular communication and feedback.  This is in addition to regular, documented 1:1s with each staff member and regular appraisals following LBR’s One Brilliant You appraisal process which set and review operational and personal training and development objectives. All CCTV team One Brilliant You conversations are up to date and logged in the Council’s itrent HR system.

Any incidents whereby an operative closely monitors a member of the public who is behaving suspiciously must be carefully recorded in line with LBR CCTV protocols as previously supplied in LBR’s evidence.  Where this monitoring leads to action such as an arrest, this is included within performance metrics for the service which feed into regular briefings provided to management and the Cabinet Member.

I trust that this response sufficiently addresses the questions within your report, but please do ask for any clarification, if required.

Dear Miss Persaud

On behalf of the Commissioner of Police of the Metropolis, I write to provide the response to the matters of concern addressed to the Metropolitan Police Service (“MPS”) in your Report to Prevent Future Deaths, dated 26 July 2024, following the inquest into the tragic death of Zara Natasha Aleena.

On behalf of the MPS, may I first express my sincere condolences to the family and friends of Zara Natasha Aleena, our thoughts and sympathies are very much with them.

The MPS has acknowledged and reviewed all the matters of concern raised in your Regulation 28 Report and responds as follows.

The Coroner’s “Matters of Concern 16 and 17” “I am concerned about the lack of rigour, detail and independence of the MPS investigation into this case. The unit involved in this case was the East Area BCU. An independent, rapid investigation (Fast Time Review) was carried out by the Directorate of Professional Standards. Despite the very limited time to complete the review, the DPS officer reached clear and valuable findings. The findings of the DPS investigator were however rejected by more senior officers within the MPS. The officers who rejected the findings were not independent and all worked within the East Area BCU. This lack of independence is of concern”.

“The Fast Time Review did not probe into sufficient detail into the systems of the local intelligence team and the Computer Aided Dispatch process. A more detailed, independent review should have been carried out”.

MPS Response

The MPS accepts that the reviews of this case lacked sufficient rigour and detail and that the review process was not sufficiently comprehensive to identify all the potential learning arising from the police response.

The findings of the Directorate of Professional Standards (“DPS”) fast time review identified learning, some of which was accepted and was covered in the witness statement of Chief Superintendent , submitted to inquest. In addition to this review, the local East Area Basic Command Unit (“BCU”) also carried out a review and identified a number of additional learning points which were actioned. Importantly, learning and improvements required in relation to “recalls to prison” processes have been shared and informed a revised Offender Management policy, which is due to be implemented later in
2024.

The DPS fast time review following the murder of Zara Aleena was carried out in 2022. Since then the MPS has made a number of changes to our professional standards operating model and a new Gateway Team, within DPS, are now responsible for undertaking most reviews of this nature. This includes cases where DPS are asked for a conduct review (where there isn’t a public complaint). Importantly, the outcomes of such reviews are no longer considered by the Appropriate Authority (as defined in the Police Conduct Regulations) within the BCU. I discuss the role of the Appropriate Authority and independence in decision making later in this response.

If there are allegations of recordable police conduct or a public complaint, there is an existing avenue for independent investigation through a referral to the Independent Office for Police Conduct (“IOPC”). There are a number of mandatory criteria, which require the MPS to refer matters to the IOPC, the most applicable being a death or serious injury following police contact, consideration can also be given to a voluntary referral. In 2022, the MPS considered the circumstances and decided this case did not meet the criteria for referral to the IOPC.

The MPS has the capability to undertake reviews and investigations, which are independent of the BCU who responded to, or investigated, a particular case or incident. The MPS Specialist Crime Review Group (“SCRG”) is a specialist function that has the capability to undertake internal reviews of incidents, independently of operational units or teams responsible for crimes and other incidents. Review officers and staff are experienced and subject to national specialist training and professional development.

The SCRG conduct reviews on behalf of the MPS such as Domestic Homicide Reviews, Serious Case Reviews, Vulnerable Adult Reviews and reviews of undetected homicides. They also undertake fast time reviews of critical incidents and other bespoke reviews as directed by the MPS. Critical incident

reviews can be conducted at any time, where the effectiveness of the police response could have a significant impact on the confidence of victims, their families or the public.

The SCRG have been commissioned to undertake a thematic assessment of the MPS approach to statutory and non-statutory post death reviews. This will consider:
• The options currently available for reviews of incidents within the MPS, including SCRG critical incident reviews, DPS death or serious injury reviews and independent reviews by other police forces.
• Whether MPS internal review processes (including SCRG and DPS reviews) are sufficiently robust.
• Whether the policy and guidance for gold (strategic oversight) groups is sufficiently defined to assist gold commanders to consider all internal review options.

The outcome of this thematic review is due in October 2024 and is expected to identify how operational reviews, such as the one following the murder of Zara Aleena, could be improved with appropriate levels of independence.

The outcome and learning from the MPS fast time review into the circumstances surrounding the murder of Zara Aleena in 2022, were considered by the Appropriate Authority within East Area BCU. Under the Police Conduct Regulations, the Appropriate Authority is an officer, of sufficient seniority, delegated by the Commissioner to make decisions relating to matters of police conduct. Whilst the decision maker in 2022 had no direct involvement in the case, the MPS accepts that there was an opportunity for greater independence in decision making if the review outcomes had been considered by a senior leader who was not part of East Area BCU.

Since 2022, the MPS has transformed its professional standards operating model within BCU, such Appropriate Authority decision are no longer made by a member of the BCU’s senior leadership team. This responsibility has been transferred to the MPS Directorate of Professional Standards, who now undertake the role of Appropriate Authority in considering the outcomes of such reviews, independently of the BCU involved.

Following critical incidents the MPS will often introduce a clear command structure, with associated independence of decision making and oversight. A strategic commander, also known as the gold commander, can be appointed with oversight and responsibility for the MPS response. This leader may be the Chief Superintendent responsible for the geographic area where the critical incident occurred. Dependent on the nature of the critical incident and / or its implications for London, a chief officer of Commander rank or above, may be appointed as the gold commander. This introduces further levels of independence from those directly involved in the operational response.

The gold commander will decide if a review of the police response is required. Having sought expert advice they would make the decision if a review is required and how it would be undertaken. They would also inform a decision on whether there should be a mandatory or voluntary referral to the IOPC.

The Coroner’s “Matter of Concern 18” “There were clearly learning points for the police constables, police sergeants and the local intelligence team. The MPS rejected the DPS recommendation for reflective learning, “as there was no failing in performance or conduct”. It is of concern that the threshold for reflective practice is set too high”.

MPS Response

The MPS is committed to identifying and responding to individual and organisational learning arising from awful cases such as this. The inquest concluded there was learning for individual officers that may have been suitable for feedback and reflection that were not actioned. The MPS accepts that not all possible learning identified from the reviews surrounding the death of Zara Aleena were fully acted upon.

The Reflective Practice Review Process (“RPRP”) is the process for handling Practice Requiring Improvement (“PRI”), which is defined as “underperformance or conduct not amounting to misconduct or gross misconduct, which falls short of the expectations of the public and the police service as set out in the policing Code of Ethics (Reg.3(1), Police Conduct Regulations 2020)”. The definition of misconduct is ‘a breach of the Standards of Professional Behaviour that is so serious as to justify disciplinary action (written warning or above)’. RPRP is used to address lower-level breaches of the Standards of Professional Behaviour, or underperformance that does not warrant formal misconduct proceedings.

When the threshold of RPRP is not met, the MPS supports Learning Through Reflection (“LTR”). LTR is aligned with guidance laid down by the Home Office and College of Policing on the wider use of reflective practice within the police service. It is not part of legislated police conduct or performance processes, but is a scheme to improve police conduct and deal with low-level concerns by supportive line managers though a culture of reflection and learning.

The MPS recognises the Coroner’s concern about the threshold that is applied to RPRP. Since RPRP is subject to statutory guidance, the MPS is unable to make unilateral changes. In this case, it was assessed by the Appropriate Authority that learning for officers and staff did not meet the threshold for RPRP. As discussed above, the MPS has made changes since 2022 and the Appropriate Authority for such decisions is now independent of BCUs. They are aware that if they consider the threshold for RPRP is not met, Learning Through Reflection could be used and all MPS officers and staff have responsibilities towards continual learning and professional development.

The Coroner’s “Matter of Concern 14” “The system in place for sharing risk information between the probation service and the MPS was unclear. Only very limited intelligence was shared with the MPS. There was no explanation as to why that information was shared, when more concerning risk related information was not shared.”

MPS Response

Whilst this matter of concern is directed towards the Probation Service, the MPS considers the following information about changes to our processes and systems, may assist.

Since the tragic murder of Zara Aleena there have been a number of changes to the Integrated Offender Management (“IOM”) process. The Mayor’s Office for Policing and Crime (“MOPAC”) have funded the Empowering Communities with Integrated Network Systems (“ECINS”). ECINS is a web-based information sharing and case management software, which provide a multi-agency information sharing platform. This improves the sharing of IOM information and allows the allocation of actions and responses from the Multi-Agency Case Conferences. This tool is available to all IOM partners that are signatories of the IOM Data Sharing Agreement.

Since 2022, the MPS has introduced CONNECT, a large-scale technology system for crime and intelligence reporting and record keeping. This has provided police offender managers with access to a feature called Proactive Managements Plans (“PMP”). PMPs are now the primary police record for IOM offender management. PMPs allow IOM records to be searchable, linked with other police records and readily available to all MPS staff. HM Prison & Probation Service do not have direct access to these records, but PMPs create a permanent record of what has been shared between the MPS and its partners.

Following inquest, the MPS has reflected on the sufficiency of information sharing from the HM Prison & Probation Service and the need for clarity around recalls to prison. The MPS has developed a new process map, which provides clarity and guidance for Police Offender Managers to ask HM Prison & Probation Service a broad range of questions, with the intention to increase the likelihood of all relevant information being shared with IOM partners. The new process highlights and clarifies the actions to be undertaken by Police Offender Managers and their supervisors, both before and after prison releases, including the recording of informed risk management decisions.

The MPS is determined to continually improve and build confidence in our policing response to tackle violence against women and girls. The murder of Zara Aleena and the subsequent inquest show the

importance of different organisations and agencies effectively working together to prevent future deaths and to keep people safe.

Please do not hesitate to contact me should you require further information from the MPS.

Dear Ms Persaud,

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

Thank you for your Report to Prevent Future Deaths on 26 July 2024 regarding the unlawful killing of Zara Natasha Aleena.

I would like to start by recognising that at the heart of this tragic inquest is Zara Aleena and I extend my deepest condolences to her family and loved ones for their devastating loss and extend my gratitude to them for their persistence on change for the future.

I would also like to thank you for your diligence and the detailed consideration of the failings you identified in your report. These failings are shocking, and I am clear that the lessons must be learned across Government and beyond.

Tackling violence against women and girls is a top priority for this Government and we will treat it as the national emergency that it is. This Government’s mission is to halve levels of violence against women and girls within a decade, using every lever available to us. The Home Office is working closely with other departments and stakeholders in developing plans to achieve this mission. The findings you outline make it crystal clear that lessons must be learned. I will ensure that these are acted upon, not only as we build upon the existing work I outline below, but also within our future work. However, I want to be clear that this will take time – we must deliver it effectively, and we must get it right. Too often piecemeal changes have failed to change systems which are fit for the future, and we are determined not to make those mistakes.

The Home Office’s response to your report focuses on two matters of concern raised, specifically concerns 20 and 21.

Matter of concern 21

At least two other members of the public were followed by the offender before he attacked

Zara Aleena. The members of the public appear to have seen the offender and appear to be aware that he was following them. This was not brought to the attention of the emergency services. I am concerned that there is a societal acceptance that such conduct does not need to be reported.

In your report, you highlight that other members of the public were followed by the offender before he attacked Zara Aleena and that this was not brought to the attention of the emergency services. I recognise these failings and share your concern that there is a societal acceptance of such conduct which can mean that those subject to it may not feel it should be reported. I also recognise that women may not report as they do not have confidence that they will receive a robust response. Everyone has the right to live in freedom from fear, yet women and girls are still facing threats of violence, abuse and death.

The Home Office has funded a range of interventions to help tackle violence against women and girls in public spaces, including within the night-time economy. These interventions have included capable guardianship initiatives such as Street Angels or Street Pastors and educational programmes with a focus on changing attitudes and perceptions and raising awareness on these issues, as well as active bystander training, which was targeted at night-time economy staff and other members of the community. The independent evaluations of educational programmes have shown that they can have a positive influence on training beneficiaries’, including improvements in their awareness and understanding of these crimes, likelihood to report VAWG and improvements in confidence in their ability to support victims and ability to intervene in incidents.

While we welcome this activity, it is clear that this does not go far enough and we must do more. For far too long women and girls like Zara have been failed. This is why this Government will treat VAWG as the national emergency it is. We will go further, using every available tool to target perpetrators and address the causes of abuse and violence. The Home Office will use the learnings from these initiatives to help inform future policy interventions. Universal education and prevention models aimed at the general public which centre around the acceptability of these crimes will be at the heart of this governments’ mission.

Matter of concern 22

Business owners were aware of the offender’s concerning conduct on the night of Zara Aleena’s murder. For example, a public house had refused to provide more drinks to him. It is not clear whether business owners are encouraged to report such concerning behaviour to the authorities or whether they are offered any training to assist them and their staff to recognise sexualised or predatory behaviour.

I would also like to respond to concerns relating to business owners not doing enough to report sexualised and predatory behaviour, and concerns relating to staff training. All business owners are encouraged to report such concerning behaviour to the authorities. Additionally, the licensed sector often provides training to assist staff to recognise sexualised or predatory behaviour and to take the necessary action. However, your report illustrates clearly that there were failings and that much more work needs to be done to ensure this is happening in practice. I have asked my officials to consider how we can go further to encourage business owners and staff to report such predatory behaviour. As a

part of this mission, we will work across government to ensure these responsibilities are understood, and pathways are created.

Thank you for raising these important issues in your report. I hope that this response has been helpful in setting out that, as a new Government, we are fully prepared to use every available lever and resource to better safeguard victims and prevent devastating cases like this from occurring.

Home Secretary

Dear Madam,

Inquest Touching the Death of Zara Aleena

Thank you for your Regulation 28 Report of 26th July 2024, following the Inquest into the death of Zara Aleena. As Chief Probation Officer, I am responding to the Report also on behalf of the Lord Chancellor and Secretary of State for Justice. I know that you will share a copy of this response with Ms Aleena’s family, and I would like to take this opportunity to express afresh my deepest condolences to them for their loss.

In your Report, you raised the following concerns specifically in relation to the Probation Service:

1. The probation delivery unit responsible for the offender was understaffed at the time of relevant oversight. The staffing levels were 61% in 2022. The staffing levels at the time of the inquest in June 2024 were 58%. The inquest heard that this is a national problem and that there are other probation delivery units that have even lower levels of staffing. The low staffing level had an impact upon quality and depth of assessments; quality of supervision of junior staff (supervision was wholly reactive); excessively high workloads for probation officers and senior probation officers; lack of cover during annual leave for probation officers and poor record keeping.

1.1. We accept that the Probation Delivery Unit (PDU) responsible for Jordan McSweeney was understaffed at the time. Whilst at a national level, the staffing position of the Probation Service is improving, I acknowledge that raising staffing in this PDU to its full complement remains a significant challenge. Therefore, until such time as the situation improves, in this PDU and others with acute pressure remaining, staff will follow a Prioritisation Framework which we first implemented in January
2022. Those PDUs will also benefit from wider national workload relief through Probation Reset (see below at 1.4) as reflected in a refreshed Prioritisation Framework published in May 2024.

1.2. We continue to prioritise recruitment to put the Service on a sustainable footing and ensure sufficient Probation Practitioner staffing (Probation Officers and Probation Service Officers). As of 30 June 2024, the staffing level of Probation Officers working across the Probation Service was 70%, with 5,136 Full Time Equivalent (FTE) Probation Officers in post. This number shows a considerable increase relative to June 2021 (when Community Rehabilitation Companies were dissolved, and the Probation Service was unified) when we had 4,517 FTE Probation Officers in post. London had the highest vacancy rate of all regions as of 30 June 2024 with a vacancy rate of 41%.

1.3. Across HMPPS, 4,582 new Trainee Probation Officers have started their training since April 2020 (1,007 in 2020/21, 1,518 in 2021/2022, 1,514 in 2022/23 and 543 in 2023/24). Many of these trainees have already qualified and taken up Probation Officer posts, and we expect the remainder to qualify by the end of 2025, taking on Probation Officer caseloads. We are beginning to see large numbers of newly qualified officers coming through and continue to run national recruitment for Trainee Probation Officers to meet the Lord Chancellor’s commitment to bringing in at least 1,000 new Trainee Probation Officers by the end of March 2025 so that we continue to have a pipeline of qualified Probation Officers.

1.4. As well as the focus on recruitment, in response to the additional demands placed on the Probation Service as a result of measures to address prison capacity, since July 2024 we have implemented a set of measures known as Probation Reset. These measures involve prioritising early engagement at the point where offenders are most likely to breach the requirements of their licence or community sentence and, in eligible cases, end active supervision of offenders after two-thirds of the licence or community order period. In turn, this ensures that staff can maximise the amount of available supervision time on the most serious offenders. Early indications show that Probation Reset has brought capacity into the system and workloads to more manageable levels.

1.5. Internal assurance alongside the findings of His Majesty’s Inspectorate of Probation shows that there is still some way to go before assessments consistently reach an acceptable standard of quality. Whilst Probation Reset has provided us with a workload reduction, the need to prioritise and make effective decisions remains a critical ask of staff. The Prioritisation Framework, introduced in 2022, remains in place. When a PDU has reduced staffing capacity, they can re-prioritise tasks for frontline staff to ensure staff workloads are controlled and high priority work is delivered.

1.6. HMPPS recognises the pressure upon Senior Probation Officers (SPOs) and how this can affect their supervision of junior staff. The number of SPOs has increased by 249 nationally since June 2022, whilst initiatives continue to strengthen the SPO role, including a review of the Management Oversight Policy Framework and roll out of the revised Management Oversight model by December 2024, to ensure the approach to staff supervision is consistent and effective. HMPPS has invested in a suite of capability options for SPOs to further develop their skills, continual learning, and additional support from dedicated case administration officers to reduce the demand on SPOs in relation to administrative tasks.

2. There were no systems in place devised to assist the staff working in these stretched circumstances, such as easy reference checklists for supervising key decisions.

2.1. HMPPS accepts that we have to do more to help probation staff understand how to prioritise and make informed decisions in their roles, which can be complex and challenging.

2.2. As outlined in response to concern (1), whilst Probation Reset has provided us with a workload reduction, the need to prioritise work and make effective decisions remain central to what we require of probation staff. In accordance with the Prioritisation Framework, Probation Regions are assigned a red, amber, or green categorisation depending upon the degree of prioritisation required. This Framework was reviewed in June 2024 to reflect Probation Reset, given the implications for operational delivery. London Probation moved to the Prioritisation Framework at its outset in 2022. London is operating within red/amber site status, which is regularly reviewed. Alongside this, there is a specific project being run by the London Area Executive Director to review processes and practices alongside operating models. The aim of this is to identify a more refined approach to manage the acute challenges in London and ensure caseloads are manageable. An example of this would be expansion of remote support provided by an administration hub outside of London where we can recruit and retain staff while retaining the local focus on the good management of cases.

2.3. To assist with everyday operational process and procedure, Probation Practitioners have access to a comprehensive system known as EQUiP (Excellence & Quality in Process), which contains guidance and process maps for most of the operational decision-making and is continuously updated to reflect changes to policy, tasks and timings. Alongside this, HMPPS continues to develop a range of tools to support risk management practice.

2.4. Our work on Human Factors recognises the broader components of decision making and the importance of creating an environment that enables individuals and the wider organisation to learn from error. Human Factors aims to reduce the frequency and severity of mistakes by using mechanical or digital overrides or prompts and/or by introducing tools and techniques such as checklists as preventative measures. Work in Wales Probation (2022-2024), based on Human Factors, tested a model designed to assist practitioners (which can include Probation Service Officers, Trainee Probation Officers and qualified Probation Officers), Senior Probation Officers and operational leaders with managing priorities and decision making, with a key emphasis on risk. This model is now being implemented in two further regions; the work will be evaluated on completion and, as we progress, both the model and products will continue to be reviewed. We are committed to considering national implementation, with a view to providing staff with systems and processes to practise effectively and efficiently under stretched circumstances.

3. The understanding around risk assessment was poor, at all levels of staffing. The practical application of risk assessment was poor at all levels of staffing. Risk was not assessed at appropriate times, and the assessment of risk was not accompanied by a complementary risk management plan. Risk management plans were on occasion prepared before risk was fully assessed (as occurred with the setting of licence conditions). One practitioner was advised to set a risk level to match other completed documents (without analysis of risk itself). Practitioners did not holistically assess risk and take account of potential indicators of serious harm, to include use of weapons; attitudes supportive of violence; callousness and high increased frequency of lower-level violence.

3.1. We accept that the understanding and application of risk assessment did not meet expected standards in this case. Any advice given to the practitioner to set a risk

level without analysing the risk was in contravention of the content of the HMPPS Risk of Serious Harm (RoSH) Guidance, which sets out the process which Probation Practitioners must follow for assessing an offender’s risk of harm to others.

3.2. HMPPS plays a vital role in protecting the public from people who have offended, and we cannot do this effectively without understanding the risks presented by those being managed. Indeed, ensuring that an offender’s risks are fully understood as part of a comprehensive risk assessment is vital for the formulation of a robust and comprehensive risk management plan. We know there is more to do to ensure that every risk assessment is undertaken at the right time, considers all the relevant risk factors and takes account of information from all relevant sources.

3.3. As set out in our response to His Majesty’s Inspectorate of Probation Serious Further Offence Review, the RoSH Guidance is based on the right evidence, including learning from Serious Further Offence Reviews and Domestic Homicide Reviews, but there are ongoing organisational challenges in its implementation. We are taking steps to address the barriers to its effectiveness, but we know there is more to do, and we will publish a new HMPPS Public Protection Strategy by the end of March
2025. We have already made changes to the suite of risk training which all new learners on the Probation qualification route and new Probation Service Officers complete. This ensures they understand the importance of actuarial tools, the need to actively monitor changing risk and how this should inform plans and action to manage risk, and we will introduce new training for experienced staff (see response to concern 4).

3.4. The structured process of risk assessment as set out in the RoSH Guidance, if followed, supports staff to think about an individual’s behaviour holistically, not just the index offence; and make reflective, logical, and informed decisions about risk. The section on risk management provides a structure to produce risk management plans that address the identified risks and set actions to protect people at risk.

3.5. This approach has informed the newly developed risk training for new practitioners. For experienced Probation Practitioners, HMPPS delivered webinars in Spring 2024, promoting the four steps of risk assessment as set out in the RoSH Guidance, and the importance of actuarial tools to 91% of Practitioners in Court undertaking pre- sentence report writing. Further events for all Probation Practitioners responsible for managing individuals in the community will be held by November 2024, to ensure they are also aware of the importance of the use of actuarial risk predictor tools and the RoSH guidance and its value, to support them in assessing and managing risk.

3.6. In 2023, London rolled out the Skills Improvement Programme with specific modules on risk of harm for both Probation Practitioners and Senior Probation Officers. Probation Officer training within this Programme included “Risk including the 4-step risk assessment process and the 4 pillars of risk management” and Senior Probation Officer training included “Risk and Counter-signing framework”.

4. Risk assessment training is not part of the mandatory training framework within the Probation Service. Risk assessment training is not refreshed.

4.1. Whilst we recognise that in this case risk assessment practice was not at the expected standard, risk assessment training has always formed part of the required learning and ongoing development for Probation Practitioners, and I am sorry that this was not clear from the evidence we have already provided to you.

4.2. For clarity, ‘mandatory learning’ refers to the learning that all probation staff must complete for pay progression under the competency-based pay progression framework (CBF), whilst ‘required learning’ has been assessed as necessary for a particular role. Each role will, therefore, have specific ‘required for role’ learning products which are not optional.

4.3. Risk assessment is required learning for all Probation Practitioners, either as part of the Probation Officer Qualification pathway or the Probation Service Officer Pathway. Risk training is reviewed to ensure it remains up to date. In March 2023, a suite of new learning products designed for new entrant practitioners was launched, drawing upon research and best practice to provide strong foundational knowledge of risk assessment, risk management and sentence planning, and incorporating an improved understanding of actuarial predictor tools. This blended learning comprises digital resources, which can be revisited at point of need, in addition to facilitated live sessions.

4.4. Experienced Probation Practitioners are required to revisit and complete their training in relation to Child Safeguarding and Domestic Abuse on a three-year cycle. Knowledge and understanding of risk assessment and management are further developed through experience of the work and its supervision. However, historically there has not been a requirement to attend further formal training on risk assessment and management. Having recognised that risk practice is not consistently at a sufficient standard, in December 2023 a new Continuing Professional Development risk learning product was commissioned to address this gap. This is intended to enable experienced practitioners to explore in-depth concepts related to risk assessment and to ensure their practice knowledge is up to date. This product is now being developed and is currently anticipated to be available to all practitioners from February 2025.

5. There were no checks to ensure the provision of up to date and accurate risk assessments to partner agencies (such as the housing team).

5.1. We accept that in this case up to date and accurate assessments of ’s risk were not shared with partner agencies. We are committed to improving professional standards of practice and have introduced mandatory professional registration for Probation Officers, which aims to sharpen focus on Continuous Professional Development and drive improved performance and personal accountability to deliver public protection. Whilst managers do oversee Probation Officer work, we would not expect them to check every referral before it is made. The professional standards will, alongside increased staffing levels and improved digital checks/safeguards, ensure that Probation Officers do all that is required of them, including the sharing of risk information with partner agencies, whose contribution is vital to the efficacy of risk management plans.

5.2. Effective risk assessment and management is a clear HMPPS priority and is assured at both local and national levels. Locally, risk assessment and management practice is assured within teams and PDUs using the approved case audit tool. Nationally, the HMPPS internal Performance Assurance and Risk Group (PARG) undertakes an annual sentence management audit, a key component of which is the quality of risk management practice. The results of this audit are shared with regions and recommendations given, which are incorporated into their local improvement plans.

5.3. Local contract teams assure quality of referrals to partner agencies using an approved audit tool. Nationally PARG delivers annual assurance on the quality of referrals to partner agencies across some of the suppliers, who provide services

which HMPPS commission. This includes an assessment of whether the risk information included in the referral is clear, accurate, up to date, consistent with that contained in other internal records, and relevant to the Provider. We have issued recommendations to Probation Regions on how to improve their performance.

6. There was a lack of professional curiosity and a lack of sufficient probing into information relevant to risk.

6.1. We accept that there was a lack of professional curiosity and probing of risk-related information in this case. Professional curiosity is an essential part of the assessment and management of risk and is a golden thread throughout the new Risk training material. It will also feature in the new Continuing Professional Development risk learning product, which is currently being developed by HMPPS in conjunction with subject matter experts. This product will be piloted with Probation Practitioners towards the end of this year before being launched from February 2025. The need to demonstrate professional curiosity is also woven into several other learning products, most notably Skills for Effective Engagement Development and Supervision (SEEDS2) for practitioners (launched June 2022) and middle managers (originally launched 2019, paused delivery during COVID and then reviewed, updated and relaunched in 2022). In recognition of the importance of these products SEEDS2 has been identified as a now strategic learning priority for 2024-2025 with Probation Officers required to complete the learning by September 2025 as part of their Continuing Professional Development requirement

6.2. Reflective Practice supervision (a key aspect of the SEEDS2 approach) plays a crucial role in fostering professional curiosity by creating a supportive environment where practitioners reflect on casework and practice issues by critically analysing and evaluating their experiences. It encourages practitioners to question their own practice, assumptions and decisions in concert with their line manager, who provides feedback based on observations and other sources.

6.3. Probation Practitioners also have access to the HM Inspectorate of Probation Effective Practice Guide on Professional Curiosity, published in October 2022, and are encouraged to use this as a reference document to support continuous professional development and apply professional curiosity in their practice.

7. The OASYS risk assessment tool is unwieldy and difficult to navigate. It was challenging to extract the most relevant material. The content of the OASYS assessment was so dense that the probation officers seemed to get lost in the detail and failed to pull together and formulate/analyse key risk areas. One senior probation officer stated that she would not look at the OASYS when allocating cases, because OASYS assessments were “not always accurate and up to date”. It is noted that a new risk assessment tool within the probation service is a work in progress. It is envisioned that the new tool will take into account the above concerns.

7.1. We recognise that OASys (Offender Assessment System) is a complex tool for staff to use effectively, which is why we are replacing it with a modern digital tool for identifying, managing and communicating risk.

7.2. The ‘Allocate a Person on Probation’ digital tool has been implemented in London and is subject to ongoing reviews. This presents OASys information in terms of risk of harm level / risk predictor tool scores, RSR (Risk of Serious Recidivism) and OGRS (Offender Group Reconviction Scale), and active risk registrations to the

allocating Senior Probation Officer. There is also a prompt for the allocating Senior Probation Officer to check OASys.

7.3. The ’Allocate a Person on Probation’ tool, from September 2024, also supports recording of management oversight for allocation of a case. This includes any notes relating to the case, as well as the allocation suitability. This management oversight is required for all cases. On completion of the allocation of the case, this oversight is automatically recorded as a contact in the nDelius case management system.

7.4. More broadly, we are investing in the Assessing Risks, Needs and Strengths (ARNS) project, the replacement for OASys to be used in prisons and by the Probation Service. The project aims to deliver a transformational change in how we assess offenders, using the latest international evidence, including that on criminal desistance. In addition to a new enabling digital service for assessment and sentence planning, there is a comprehensive new learning and development offer to support staff to adapt and enhance their practice. The roll-out of ARNS is scheduled to begin in the third quarter of 2025 and be in place fully by the third quarter of 2026.

7.5. HMPPS will be working to ensure risk assessment is undertaken throughout the time HMPPS is responsible for the management of the sentence, and regularly updated, to support the practitioner in understanding changing levels of risk accurately.

7.6. The ARNS project is focused on making the assessment and planning process more efficient by reducing duplication and making it easy to update. Development work on the risk section within ARNS will ensure that relevant information is presented together to support staff to analyse key areas of risk holistically. The interaction between the new risk and sentence plan sections will support staff to translate their assessment of risk into comprehensive plans that both effectively manage risk and focus rehabilitation efforts to reduce risk.

7.7. ARNS is one of a number of tools being developed across HMPPS and the Criminal Justice System (CJS) to the current shared government digital standards which will, in time, allow better flow of information from one to another and therefore will support better information sharing. We are prioritising digital resource for the development of ARNS. However, ahead of its full roll out, HMPPS will work in partnership with Ministry of Justice digital colleagues to streamline the current OASys tool where it is possible to do so efficiently and in a way that supports, rather than detracts, from the development of ARNS.

8. The globe system and alert systems did not work effectively in this case. A restraining order had been put in place against the offender, but this was not highlighted, as it should have been. Key staff involved in assessing and managing the offender were unaware of the restraining order.

8.1. We recognise the importance of probation staff being aware of restraining orders and they are expected to record them in a globe in the case record system (i.e., an alert) with the start and end date, with explanatory notes. We also recognise that the globe system requires staff to look for and record relevant information. To ensure that staff are prompted to consider whether there is a restraining order and to use the information to inform the management of the case, in April 2023 HMPPS made a change to the OASys tool to prompt assessors to state if people under their supervision are subject to Civil Orders. This means that practitioners are supported to include behaviours which have resulted in the courts imposing a Civil Order in their risk assessment even if they were not convicted of an offence. It will also support them to ensure risk management concords with the aim of the Civil Order.

8.2. To further strengthen practice and ensure that practitioners do not miss the significance of a restraining order or any other Civil Order, in May 2024 we released a new Civil Order e-learning package to provide HMPPS staff with an overview and awareness of Civil and ancillary Orders and why they are important in probation work. Our target is that all staff in relevant roles will have completed this by the end of March 2025.

8.3. We will review practice guidance by December 2024, including when to add and remove a globe to ensure that HMPPS staff are clear on the need to record Civil Orders. We are also committed to a review of the globe system by March 2025 with the purpose streamlining and to make information more accessible to staff. We are committed to identifying whether digital solutions are available to improve the review, updating and termination of information on the globe system. However, this will have multi-system impacts and will need to be embedded alongside other changes as systems are developed, rather than be progressed in isolation. This will impact on timescales for this aspect of the solution.

9. There may be obstacles to increasing risk levels. The inquest heard that senior probation staff would have to approve increases in risk. As staffing levels are so stretched, there may be reticence of junior probation officers to trouble the senior team. The risk assessment policy also includes a statement that staff “should not use risk levels to inflate risk because of anxiety or to access resources”. It is a concern that this provision may inhibit decisions to increase risk.

9.1. We do not have any evidence of a widespread problem of Probation Officers being reluctant to ask SPOs to approve formal increases in assessed risk, or that this particular statement in policy is inhibiting staff from raising their assessment of an offender’s risk level, where that would be justified based on the available evidence. The percentage of those assessed as ‘high risk of serious harm’ has increased in recent years from 19.9% in 2018 to 25% in 2022. PARG's annual sentence management audit confirms agreement with the risk level in most assessments. To avoid any misinterpretation, this statement will be removed in the next review, due by November.

9.2. The RoSH Guidance sets out helpful information to support practitioners undertaking assessments determine an overall risk level, ensuring they have taken all relevant information into account. It also provides prompts for “thresholding” where practitioners may be undecided between two levels such as medium and high. Additionally, it encourages staff to consider escalating risk factors and provides learning from Serious Further Offences in relation to the types of circumstances that most often indicate escalating risk.

9.3. In response to an HMIP Thematic Report on The Role of the Senior Probation Officer and Management Oversight published in January 2024, a number of initiatives across the Probation Service are underway exploring the role of the Senior Probation Officer and aiming to improve capacity and capability to undertake that role. As part of this, by December 2024, HMPPS will put in place a clear Policy Framework for Management Oversight and first-tier assurance. This will meet the demands of the probation caseload and ensure that effective management oversight arrangements are in place at the regional and Probation Delivery Unit level to assure the quality of work to protect the public by February 2025.

9.4. The new national framework for newly qualified officers (NQOs) was rolled out at the end of July 2024. The framework builds upon already established processes to

support NQOs in their first-year post-qualification, setting out the expectations and enablers which regions should follow to provide consistency in their approach to transitioning and supporting NQOs in their development post qualification.

10. The evidence revealed a difference of opinion and understanding around when an emergency recall should be requested. A senior probation officer and probation services officer erroneously believed that an emergency recall could only be requested out of hours.

10.1. We accept that there was an inconsistency in understanding of emergency recall processes in this case. All London Probation staff have been reminded of the availability of the emergency recall process during normal working hours. Another reminder was given to all staff in preparation for SDS40 (the recent changes to standard determinate sentences, announced in July and implemented in September
2024).

10.2. The Recall Policy Framework clearly deals with Emergency Recalls at sections
4.3.13 - 4.3.15 and out of hours recalls at sections 4.6 and 6.5. Guidance is available to all probation staff on EQUiP for emergency recalls during normal working hours, as well as standard recalls during normal working hours and out of hours recalls. Our internal figures for recent months (from May to July 2024) evidence that there has been regular use of emergency recalls during normal working hours for individuals serving a determinate sentence. Recalls for those serving a life sentence are always dealt with as emergency recalls. These figures evidence the regular use of emergency recalls during normal working hours. These figures do not include recalls for those serving a life sentence which are always dealt with as emergency recalls.

11. The role of the prison offender manager is to gather evidence to assist with the formulation of risk. Prison offender managers do not however receive focussed risk assessment training. Neither of the prison offender managers in this case gathered evidence to assist with the formulation of risk. There were multiple intelligence logs and records that should have been obtained by them. The logs included findings of possession of weapons, drug taking, threats to harm others and a sustained assault on a servery worker using an improvised weapon. This information was not gathered and shared appropriately.

11.1. We agree that the role of the Prison Offender Manager (POM) is to gather evidence to assist with the formulation of risk. With this in mind, there is a designated modular training package specifically for POMs. We are sorry if our evidence did not make it clear that, as well as risk assessment being examined in all modules, there is a designated module focusing on risk assessment, planning and management. In addition to this, all POMs receive OASys training. This is a four-day training event that focuses on all aspects of the OASys assessment, including risk assessment, risk management and the sentence plan. POMs cannot receive an OASys account to complete an assessment until OASys training has been completed.

11.2. POMs are expected to complete OASys assessments on those prisoners who are serving more than ten months from point of sentence, as they are responsible for the supervision of these individuals.

11.3. For longer term sentenced prisoners there is an agreed process to share information via the POM-COM (Community Offender Manager) handover. There was no set agreed process for those prisoners serving 10 months and less. To rectify this, a mandated Information Sharing Form was introduced in November 2023. This form

examines custodial contact and behaviour and must include information that is available within the custodial setting that would not be easily accessible to community colleagues. This was introduced to standardised information sharing practices between prison and community.

12. There was no evidence that the prison offender manager from February 2021 to October 2021 paid any attention to the sentence plan in place for the offender. They did not attempt to facilitate any rehabilitative interventions. There was no evidence of supervision for the prison offender manager.

12.1. Whilst recognising there was an ongoing staff shortage at the time due to recovering from the COVID pandemic, we accept that mistakes were made and as such we have taken steps to rectify these.

12.2. HMPPS sets national standards and operating models centrally, but it is down to areas/regions/prisons to oversee practice and ensure that POMs are carrying out their duties and tasks accordingly.

12.3. In April 2022, the SPO Line Management Framework was introduced. SPOs, also known as Heads of Offender Management Delivery (HOMDs) based in the Offender Management Unit (OMU) in prisons, are line managed by the Governors, who are responsible and accountable for the delivery of case management in their prison. The SPOs are responsible for line managing both Probation and Prison POMs and are required to undertake regular supervision (although the frequency is not currently stipulated) to improve the quality of Offender Management in Custody (OMiC) work and outcomes for prisoners, offering greater consistency in approach to sentence management within a prison setting. HOMDs are also required to countersign work undertaken by POMs within the OMU.

12.4. The training referred to in (11) is designed to give POMs the necessary skills to undertake risk management and risk planning, and to deliver the sentence plan in custody. A new learning programme ‘Leading and Managing as an SPO (Sentence Management, Court and OMiC)’ was launched in May 2024 and covers leadership and management development specifically within the context of probation work. This programme includes sessions on management of risk of harm as a manager and on supporting staff to perform effectively.

12.5. More broadly, HMPPS launched the SPO Hub on the internal intranet in June 2024 as a single, accessible resource to support Senior Probation Officers (including HOMDs). The Hub includes updates on relevant inspections, audits and action plans, learning and development pathways, continuous professional development and resources such as current guidance on the staff supervision process. The Hub is being continually developed and specific consideration to the needs of HOMDs will be made in later iterations. The Hub also provides regular progress on key projects such as the review of the Management Oversight policy framework mentioned in response to concerns (1) and (9). Whilst the framework has to-date focused on community responsible cases, the planned changes in the forthcoming review will enable the framework to be applicable to both the community and custody setting.

13. There was no system in place to alert the prison offender manager to handover an offender to the community offender manager when a period of sentence ended and where the offender remained in prison, on remand.

13.1. If a prisoner’s status is remand only, there is no statutory responsibility for supervision as the prisoner is unsentenced. If a prisoner is subject to both remand and recall, they are subject to statutory supervision only to the point of the Sentence Expiry Date. All recalled prisoners remain the responsibility of the Community Offender Manager (COM). The Prison Offender Manager is not expected to handover the supervision of the case, as the COM is responsible throughout. It is the responsibility of the COM to monitor sentence expiry dates, as they will need to complete a termination OASys and close the record.

14. The system in place for sharing risk information between the Probation Service and the MPS was unclear. Only very limited intelligence was shared with the MPS. There was no explanation as to why that information was shared, when more concerning risk related information was not shared.

14.1. There is a published Joint National Protocol (JNP) - Recall Process for Offenders Subject to Licence, which sets out the high-level roles and responsibilities for all stakeholders/agencies involved in the recall process.

14.2. The JNP places a responsibility on the Probation Service to provide the local police force with any available information and intelligence about the offender’s whereabouts in order to assist the police force in apprehending the offender as quickly as possible. This includes up-to-date information regarding the offender’s behaviour whilst on licence, to assist the police force in identifying any threat to the public or specified individuals and any risk to police officers when seeking to apprehend the offender.

14.3. There is also the Recall, Review and Re-Release of Recalled Prisoners Policy Framework which stipulates in paragraphs 4.2.13 and 4.3.19 that Probation Practitioners must ensure that all available information, which might assist the police in locating and safely apprehending the individual, is detailed in the Part A recall report sent to Public Protection Casework Section (PPCS) in HMPPS HQ. PPCS is responsible for revoking an offender’s licence on behalf of the Secretary of State and then forwarding the revocation order to the Police National Computer Bureau and the local police force.

14.4. We have provided further detail on information from Prisons being fed into the offender management process below (in response to concern 15) and in response to concern (11) above.

15. The Integrated Offender Management meetings did not receive the necessary intelligence from the prison setting. There was no system in place to ensure that either the prison offender manager was invited to attend, or that the prison offender manager was asked to provide written information around risk incidents.

15.1. We acknowledge that prison staff did not share intelligence about with their colleagues in the Probation Service. We have agreed processes in place to ensure that prisons communicate information to the COM for sentenced prisoners, but these processes did not function properly in this case, as explained in the SFO review. For long-term prisoners, information sharing from the POM to the COM occurs at point of handover. In November 2023, we standardised expectations for those prisoners serving a short-term custodial sentence.

15.2. To ensure that all appropriate agencies involved in an Integrated Offender Management (IOM) case are included in any pre-release work, the National IOM

guidance has been updated to state explicitly that the POM must be invited to all multiagency case conferences in preparation for release. The guidance goes on to say that if the POM is unable to attend, a written update should be provided. The latest version of the guidance (V4.1) went live on 30 August 2024. All IOM regional leads across England and Wales have received this updated guidance and will brief their local IOM teams within region. It has also been uploaded onto EQUiP, which is a library of resources for operational staff. This case has been explicitly referenced on page 25 of that guidance to stress the importance of such communication between POM and COM when managing IOM cases, and to strengthen the learning from this tragic case.

Thank you again for bringing your concerns to my attention. I would like to reassert my condolences to the family and all those who have been affected by this tragic and terrible event.. The probation service is committed to acting on the learning from this case.