Francis Williams
PFD Report
All Responded
Ref: 2024-0169
All 1 response received
· Deadline: 22 May 2024
Coroner's Concerns (AI summary)
Probation officers require better training to identify suicide risk in IPP offenders and to understand licence cancellation processes, as a failure to refer for cancellation contributed to despair and death.
View full coroner's concerns
My investigation reveals two relevant concerns:
1. That probation officers need to understand, and be constantly alert to, the risk of suicide/self-harm in IPP offenders. It is clear from Mr Williams’ case, but also from other cases and other evidence, that this cohort often experiences a particular kind of despair. That is fuelled in part by the particular sense of unfairness that they feel about being on an IPP at all, now the sentence has been abolished and all agree that IPP sentences were a terrible idea. The other factor is the absence of hope of ever getting off it.
2. Linked to that second point, it is crucial that probation officers are also fully versed in the processes for suspending parole licence supervision and then cancelling it altogether. One of the real tragedies of Mr Williams’ case is that in 2019 he had been free for ten years, so he should have been referred for licence cancellation. It did not happen, and it is not clear why, but it may have been because no-one was actively looking at him given that his supervision had been suspended. In any event, the referral system did not work and Mr Williams was never referred, at any stage, for cancellation. Mr Williams was then overtaken by lockdown and related matters in 2020, which pulled the rug on his business and other protective factors, and he then returned to supervision and ultimately recall to prison. Following release in 2022 he was still not referred, and even at the end of that year - which I note was now after the amendments to s.31A of the Crime (Sentences) Act 1997 and the introduction of an entitlement to automatic referral to the Parole Board for cancellation – no referral had been made. By then, of course, Mr Williams might have found cancellation much more difficult. However, it is noteworthy that even with those well publicised changes, which Mr Williams had heard about, his probation officer seemed to be struggling to find out how the process worked (entries in the probation records in December 2022 confirm). Again, the point is that there is a particular kind of despair among the IPP cohort. The main safeguard is the facility for getting off that, or at least giving these men hope that they may be able to get off it. Mr Williams and his probation officer were struggling to find out how to access even that limited (and automatic) safeguard. It was very shortly after that (within a month or so) that he took his life. The jury was clear that the fact of the IPP caused his state of mind and so caused his death. It seems to me that these two concerns at least give rise to a training need. There may be more. But I consider that action should be taken.
1. That probation officers need to understand, and be constantly alert to, the risk of suicide/self-harm in IPP offenders. It is clear from Mr Williams’ case, but also from other cases and other evidence, that this cohort often experiences a particular kind of despair. That is fuelled in part by the particular sense of unfairness that they feel about being on an IPP at all, now the sentence has been abolished and all agree that IPP sentences were a terrible idea. The other factor is the absence of hope of ever getting off it.
2. Linked to that second point, it is crucial that probation officers are also fully versed in the processes for suspending parole licence supervision and then cancelling it altogether. One of the real tragedies of Mr Williams’ case is that in 2019 he had been free for ten years, so he should have been referred for licence cancellation. It did not happen, and it is not clear why, but it may have been because no-one was actively looking at him given that his supervision had been suspended. In any event, the referral system did not work and Mr Williams was never referred, at any stage, for cancellation. Mr Williams was then overtaken by lockdown and related matters in 2020, which pulled the rug on his business and other protective factors, and he then returned to supervision and ultimately recall to prison. Following release in 2022 he was still not referred, and even at the end of that year - which I note was now after the amendments to s.31A of the Crime (Sentences) Act 1997 and the introduction of an entitlement to automatic referral to the Parole Board for cancellation – no referral had been made. By then, of course, Mr Williams might have found cancellation much more difficult. However, it is noteworthy that even with those well publicised changes, which Mr Williams had heard about, his probation officer seemed to be struggling to find out how the process worked (entries in the probation records in December 2022 confirm). Again, the point is that there is a particular kind of despair among the IPP cohort. The main safeguard is the facility for getting off that, or at least giving these men hope that they may be able to get off it. Mr Williams and his probation officer were struggling to find out how to access even that limited (and automatic) safeguard. It was very shortly after that (within a month or so) that he took his life. The jury was clear that the fact of the IPP caused his state of mind and so caused his death. It seems to me that these two concerns at least give rise to a training need. There may be more. But I consider that action should be taken.
Responses
Action Planned
HMPPS is creating a staff IPP guide and briefing events to improve awareness of IPP sentences and their impact, focusing on recall; the probation learner offer will be evaluated in September 2024. Proposed changes being taken forward in the Victims and Prisoners Bill relate specifically to IPP sentences, including reducing the qualifying period to refer an IPP license to the Parole Board for termination from ten years to three years. (AI summary)
HMPPS is creating a staff IPP guide and briefing events to improve awareness of IPP sentences and their impact, focusing on recall; the probation learner offer will be evaluated in September 2024. Proposed changes being taken forward in the Victims and Prisoners Bill relate specifically to IPP sentences, including reducing the qualifying period to refer an IPP license to the Parole Board for termination from ten years to three years. (AI summary)
View full response
Dear Mr Armstrong, Inquest Touching the Death of Francis Ian Williams Thank you for your Regulation 28 Report of 27th March 2024 following the Inquest into the death of Francis Williams. I am responding on behalf of the Rt Hon Alex Chalk KC MP, Minister of Justice and the Chief Probation Officer, . I know that you will share a copy of this response with Mr. Williams’ family, and I would like to take this opportunity to express my condolences for their loss. You raised the following concerns
1. That probation officers need to understand, and be constantly alert to, the risk of suicide/self harm in IPP offenders. It is clear from Mr Williams’ case, but also from other cases and other evidence, that this cohort often experiences a particular kind of despair. That is fuelled in part by the particular sense of unfairness that they feel about being on an IPP at all, now the sentence has been abolished and all agree that IPP sentences were a terrible idea. The other factor is the absence of hope of ever getting off it.
2. Linked to that second point, it is crucial that probation officers are also fully versed in the processes for suspending parole licence supervision and then cancelling it altogether. One of the real tragedies of Mr Williams’ case is that in 2019 he had been free for ten years, so he should have been referred for licence cancellation. It did not happen, and it is not clear why, but it may have been because no-one was actively looking at him given that his supervision had been suspended. In any event, the referral system did not work and Mr Williams was never referred, at any stage, for cancellation. It seems to me that these two concerns at least give rise to a training need. The MoJ/HMPPS now provides Introductory Suicide Prevention Training for probation staff developed in collaboration with the Zero Suicide Alliance (ZSA) which has been
available to all probation staff since September 2023. Over 1700 staff have now completed this training. Further comprehensive suicide prevention training is in the training development pipeline. A 7 minute briefing on suicide prevention has been developed for Probation staff and is available on EQUiP, an electronic database of guidance and process maps. This draws attention to those serving IPP sentences. Under the current engagement model between Health/ Justice/ NHS / Social Care teams the MOJ are working closely with other government departments to ensure prison leavers, including those serving IPP sentences, can access healthcare, drug treatment and support with securing employment and stable accommodation. The MoJ/HMPPS has a current Suicide Prevention Action Plan within which one of the identified goals is to provide staff with the necessary knowledge, skills, and resources to support good quality suicide prevention practice. As part of the refreshed probation learner offer, Probation Practitioners who manage IPP cases are provided with dedicated learning products aimed at increasing their knowledge and skills around trauma aware/person centred practice, as well as opportunities to practice motivational interviewing approaches. The Skills for Effective Engagement Development and Supervision (second generation) (SEEDS2) practitioner package, which is required learning for all Probation Practitioners who have been in post for at least six months, has motivational interviewing/relational practice as the core principle. The probation learner offer will be evaluated and reviewed in September 2024. As part of an IPP Action Plan, HMPPS is drawing together a holistic staff IPP guide and series of practitioner briefing events which will promote HMPPS operational staff awareness of the IPP sentence and its impact on those subject to it. This guide and series of events will include a focus on recall. Guidance for Probation staff on Consideration of the Suitability for Termination of IPP Licences was issued in September 2023 alongside a 7 Minute Briefing on Termination of IPP Licence and this is available to staff on EQUiP (as referred to above). Alongside the learning and development/training being provided to Probation staff regarding suicide prevention and termination of IPP Licences, you may be aware that there are also proposed changes being taken forward in the Victims and Prisoners Bill which relate specifically to IPP sentences. These proposed new measures will
1. Reduce the qualifying period which triggers the duty of the Secretary of State to refer an IPP licence to the Parole Board for termination from ten years to three years;
2. Include a clear statutory presumption that the IPP licence will be terminated by the Parole Board at the end of the three-year qualifying period;
3. Introduce a provision that will automatically terminate the IPP licence two years after the three-year qualifying period, in cases where the Parole Board has not terminated the licence; and
4. Introduce a power to amend the qualifying period by Statutory Instrument Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address these matters.
1. That probation officers need to understand, and be constantly alert to, the risk of suicide/self harm in IPP offenders. It is clear from Mr Williams’ case, but also from other cases and other evidence, that this cohort often experiences a particular kind of despair. That is fuelled in part by the particular sense of unfairness that they feel about being on an IPP at all, now the sentence has been abolished and all agree that IPP sentences were a terrible idea. The other factor is the absence of hope of ever getting off it.
2. Linked to that second point, it is crucial that probation officers are also fully versed in the processes for suspending parole licence supervision and then cancelling it altogether. One of the real tragedies of Mr Williams’ case is that in 2019 he had been free for ten years, so he should have been referred for licence cancellation. It did not happen, and it is not clear why, but it may have been because no-one was actively looking at him given that his supervision had been suspended. In any event, the referral system did not work and Mr Williams was never referred, at any stage, for cancellation. It seems to me that these two concerns at least give rise to a training need. The MoJ/HMPPS now provides Introductory Suicide Prevention Training for probation staff developed in collaboration with the Zero Suicide Alliance (ZSA) which has been
available to all probation staff since September 2023. Over 1700 staff have now completed this training. Further comprehensive suicide prevention training is in the training development pipeline. A 7 minute briefing on suicide prevention has been developed for Probation staff and is available on EQUiP, an electronic database of guidance and process maps. This draws attention to those serving IPP sentences. Under the current engagement model between Health/ Justice/ NHS / Social Care teams the MOJ are working closely with other government departments to ensure prison leavers, including those serving IPP sentences, can access healthcare, drug treatment and support with securing employment and stable accommodation. The MoJ/HMPPS has a current Suicide Prevention Action Plan within which one of the identified goals is to provide staff with the necessary knowledge, skills, and resources to support good quality suicide prevention practice. As part of the refreshed probation learner offer, Probation Practitioners who manage IPP cases are provided with dedicated learning products aimed at increasing their knowledge and skills around trauma aware/person centred practice, as well as opportunities to practice motivational interviewing approaches. The Skills for Effective Engagement Development and Supervision (second generation) (SEEDS2) practitioner package, which is required learning for all Probation Practitioners who have been in post for at least six months, has motivational interviewing/relational practice as the core principle. The probation learner offer will be evaluated and reviewed in September 2024. As part of an IPP Action Plan, HMPPS is drawing together a holistic staff IPP guide and series of practitioner briefing events which will promote HMPPS operational staff awareness of the IPP sentence and its impact on those subject to it. This guide and series of events will include a focus on recall. Guidance for Probation staff on Consideration of the Suitability for Termination of IPP Licences was issued in September 2023 alongside a 7 Minute Briefing on Termination of IPP Licence and this is available to staff on EQUiP (as referred to above). Alongside the learning and development/training being provided to Probation staff regarding suicide prevention and termination of IPP Licences, you may be aware that there are also proposed changes being taken forward in the Victims and Prisoners Bill which relate specifically to IPP sentences. These proposed new measures will
1. Reduce the qualifying period which triggers the duty of the Secretary of State to refer an IPP licence to the Parole Board for termination from ten years to three years;
2. Include a clear statutory presumption that the IPP licence will be terminated by the Parole Board at the end of the three-year qualifying period;
3. Introduce a provision that will automatically terminate the IPP licence two years after the three-year qualifying period, in cases where the Parole Board has not terminated the licence; and
4. Introduce a power to amend the qualifying period by Statutory Instrument Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address these matters.
Sent To
- Probation Service
Response Status
Linked responses
1 of 1
56-Day Deadline
22 May 2024
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 03 February 2023 I commenced an investigation into the death of Francis Ian WILLIAMS aged 43. The investigation concluded at the end of the inquest on 05 March 2024. The conclusion of the inquest was that: Francis Williams was the subject of a sentence of imprisonment for public protection (“IPP”), imposed in 2006. He had always struggled with that sentence, believing that he would never be free of it. He had been released in 2009 and by 2018 had had the supervision element of the sentence removed. In 2020, however, and in part following problems experiencing during the Covid lockdown, supervision was reinstated and in March 2021 Francis was recalled to prison. Francis was re-released in April 2022 and initially seemed to be progressing well once again. In late 2022 and early 2023, however, Francis was struggling once more, and in particular, with alcohol. He had lost one set of specialist accommodation in November 2022. He then had a warning from the new one on 9 January 2023. On 27 January 2023 Francis was finally evicted from that accommodation after he had been drunk the night before and had behaved inappropriately including towards female staff. The probation service sought urgently to find alternative accommodation but without success. They started to take steps to recall him to prison. Francis realised that is what was likely to happen, and he told his probation officer he was going to kill himself . She made a warning call to police. On 28 January 2023, however, Francis was found by workmen in a tent in the sunken gardens in Bognor Regis. He had died of a heroin overdose. He was 43 years old.
Circumstances of the Death
Francis Williams was the subject of a sentence of imprisonment for public protection (“IPP”), imposed in 2006. He had always struggled with that sentence, believing that he would never be free of it. He had been released in 2009 and by 2018 had had the supervision element of the sentence removed. In 2020, however, and in part following problems experiencing during the Covid lockdown, supervision was reinstated and in March 2021 Francis was recalled to prison. Francis was re-released in April 2022 and initially seemed to be progressing well once again. In late 2022 and early 2023, however, Francis was struggling once more, and in particular, with alcohol. He had lost one set of specialist accommodation in November 2022. He then had a warning from the new one on 9 January 2023. On 27 January 2023 Francis was finally evicted from that accommodation after he had been drunk the night before and had behaved inappropriately including towards female staff. The probation service sought urgently to find alternative accommodation but without success. They started to take steps to recall him to prison. Francis realised that is what was likely to happen, and he told his probation officer he was going to kill himself . She made a warning call to police. On 28 January 2023, however, Francis was found by workmen in a tent in the sunken gardens in Bognor Regis. He had died of a heroin overdose. He was 43 years old.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.