Nguyen Quyen
PFD Report
All Responded
Ref: 2019-0194
All 2 responses received
· Deadline: 10 Oct 2019
Coroner's Concerns (AI summary)
A dysfunctional public protection system for offenders on life licence relied excessively on self-reporting and suffered from poor information sharing between police and probation, with inadequate monitoring and challenges to deceit.
View full coroner's concerns
Both hhad previous convictions for separate offences of murder: had received life sentences for those offences and met in prison. On release from prison both wwere on life licences_ lived in Sunderland, and in Blackpool: Both were Category 2 offenders managed at Level 1. Although there was no prohibition on their association, had a personal and business relationship whilst on life licence: Life licence is based on trust and, having heard evidence; it was clear to me that both broke that trust consistently and were emboldened in all of their unlawful activities by what must have perceived as the failures on the part of the authorities to expose their deceit: There was an over reliance on self-reporting by the offenders. The evidence exposed a system for the protection of the public, which was at times dysfunctional, contributed to by human factors Evidence heard during the hearings demonstrated that there was a disconnect between the reality on the ground and, in particular accounts to his Probation Officer. Although inevitably he would minimise his actions, there was little Or no evidence that he was challenged effectively The Police had 26 items of intelligence on since his release from prison; but more particularly the Probation Service had sole responsibility for their management; and the Police had a responsibility to share any relevant information with Probation. In April 2015 due to high operational demand there was a direction from the senior management team of Northumbria Police to stop monitoring Category 2 Level 1 offenders and to remove the markers on the As a result, the Multi Agency Public Protection Arrangements (MAPPA) department were no longer actively managing Category 2 Level 1 offendersThe responsibility for sharing information was solely with the sourcing officer. With his Police computer record was not updated, and attending Police Officers for incidents in 2015 and 2017 did not pass information to the relevant Probation Officer: The responsibility goes wider though to Control Room Staff; Patrol Sergeants, Patrol Constables and Supervising Sergeants too, when markers, and warnings were evident_ There was a number of examples of the disconnect between the Police and Probation that [heard evidence about_ Although there were individual shortcomings, there were organisational failings, not just within the Police: The Inquest highlighted many other issues: The Probation Service in Sunderland had staffing and accommodation problems Operations and efficiency appeared to be in stark contrast between North West and They they they log: flags
North East. The time spent withl was short and in a working environment not conducive to meaningful engagement. Unwin undermined the supervisory process by attending appointments with his child and not progressing in a more timely way the request to create a portfolio of his employment; culminating in an unsig reference dated 25uh July 2017. There were no contemporaneous computer records from 13th December 2016 until 18h August 2017, the before appeared in for murder: On the evidence, there were multiple occasions when information about] and should have been shared between the Police and Probation, and for him to be challenged in a more meaningful way than he was_ A Probation expert gave evidence about: the limitations of what can be achieved through the supervisory process; the frequency of the assessments in relation tq lappear to ~have fallen below practice standards but had further reviews taken place, the risk assessments would not have changed; the absence ofan Offender Assessment System (OASys) assessment on for over 3 years fell below practice. Such an assessment would have assessed the risks and needs of an Offender; if Northumbria Police had passed on information to Probation about 2 incidents involvings Ithere would have been enforcement action; but short of recall as the threshold criteria had not been met. It was clear that some of the issues identified by the Investigation had been addressed such as the Probation Community Lifer Panels and the Police regarding the steps that have already been taken since the death of Quyen to ensure better sharing of information in respect of Category 2 Level 1 offenders_ However; I remain concerned. For example, Probation were of the view that the present solution was an interim one, whereas the Police thought it was finalised. There were further issues considered, such as the lack of integrated IT, failures of communication a number of sources, supervision, issues of risk management and staff tumover; and pressures upon staff performance and the ability to investigate self-report Finally, if there was any additional learning from the Inquest Or training and staff support/supervision to Prevent Future Deaths, then would be pleased to hear about any such initiatives
North East. The time spent withl was short and in a working environment not conducive to meaningful engagement. Unwin undermined the supervisory process by attending appointments with his child and not progressing in a more timely way the request to create a portfolio of his employment; culminating in an unsig reference dated 25uh July 2017. There were no contemporaneous computer records from 13th December 2016 until 18h August 2017, the before appeared in for murder: On the evidence, there were multiple occasions when information about] and should have been shared between the Police and Probation, and for him to be challenged in a more meaningful way than he was_ A Probation expert gave evidence about: the limitations of what can be achieved through the supervisory process; the frequency of the assessments in relation tq lappear to ~have fallen below practice standards but had further reviews taken place, the risk assessments would not have changed; the absence ofan Offender Assessment System (OASys) assessment on for over 3 years fell below practice. Such an assessment would have assessed the risks and needs of an Offender; if Northumbria Police had passed on information to Probation about 2 incidents involvings Ithere would have been enforcement action; but short of recall as the threshold criteria had not been met. It was clear that some of the issues identified by the Investigation had been addressed such as the Probation Community Lifer Panels and the Police regarding the steps that have already been taken since the death of Quyen to ensure better sharing of information in respect of Category 2 Level 1 offenders_ However; I remain concerned. For example, Probation were of the view that the present solution was an interim one, whereas the Police thought it was finalised. There were further issues considered, such as the lack of integrated IT, failures of communication a number of sources, supervision, issues of risk management and staff tumover; and pressures upon staff performance and the ability to investigate self-report Finally, if there was any additional learning from the Inquest Or training and staff support/supervision to Prevent Future Deaths, then would be pleased to hear about any such initiatives
Responses
Action Planned
HMPPS is undertaking a robust recruitment drive and training programme to increase the number of qualified probation officers, with the expectation that current vacancies in the NPS will be filled by the end of 2021. (AI summary)
HMPPS is undertaking a robust recruitment drive and training programme to increase the number of qualified probation officers, with the expectation that current vacancies in the NPS will be filled by the end of 2021. (AI summary)
View full response
Dear Mr Winter,
Inquest into the death of Miss Nguyen Ngoc Quyen
Thank you for your Regulation 28 Report, issued following the Inquest into the death of Miss Nguyen Ngoc Quyen, addressed to the National Probation Service. I am replying as the Director General Probation and Wales as part of Her Majesty’s Prison and Probation Service (HMPPS).
I know that you will share a copy of this response with the family and I would first like to express my sincere condolences for their loss. Every death in such circumstances is a tragedy and the implementation of learning from this is my absolute priority.
You have raised a number of areas of concerns and I have drawn these together under specific headings, which I hope is of assistance to you, and respond to your concerns as follows: -
Supervision of Offenders on Life Licence (including issues of trust, self-reporting, challenge and the making of contemporaneous notes and updating OASys Risk Assessments)
The National Probation Service (NPS) is required to provide probation services by virtue of the Offender Management Act 2007. Probation is a means through which offenders are supervised and their rehabilitation is managed and Probation Services exist to protect the public by reducing reoffending and rehabilitating offenders to lead law abiding lives.
The effectiveness of probation supervision by trained probation officers/offender managers is key to the rehabilitation of offenders in the community.
To better support front line probation staff in the effectiveness of their supervision of offenders a new national Supervisory and Line Management Framework has been developed and is being rolled out across the NPS Divisions during 2019. This work forms part of the National Probation Service 2020 Change Programme and has been developed using ideas and evidence from the Skills for Effective Engagement Development and Supervision Programme (SEEDS). This Framework is designed to ensure a consistent and appropriate level of management oversight through practice supervision sessions and observation of practice. Through observation of practice senior probation officers will be able to see whether staff are being sufficiently challenging and adopting a properly investigative approach in their face to face supervision of the offender. There is a minimum requirement of four practice supervision meetings and two practice observations per annum for all probation officers with their Senior Probation Officer/line manager. Within this framework Senior Probation Officers with line management responsibility will ensure that best practice is followed and clearly evidenced and all decision making is being properly recorded following appropriate levels of challenge.
This framework sits alongside the new Lifer Review Panels, which were outlined at the Inquest. The aim of these Panels is to ensure Heads of Local Delivery Units have oversight of the lifer cohort under their responsibility and to scrutinise the robustness of the risk assessment/progress of life sentence offenders subject to supervision in their area. An initial lifer panel review will be completed within three months of release and annual reviews will take place thereafter. In preparation for Panel meetings, the offender manager is required to review OASys and the offender manager uses the review as a discussion topic with the lifer to gain their perspective on progress to date. The offender manager and Senior Probation Officer discuss lifer cases in supervision prior to the Panel meeting and undertake appropriate manager oversight recording in NDelius. MAPPA levels are reviewed and updated where required. This additional oversight ensures there is an independent review of the case to check that the offender manager is addressing the right issues in relation to risk.
The new Supervision Framework, together with the new Probation Lifer Panel Meetings are intended to ensure a stronger level of management oversight at a senior level and effective supervision and risk assessment of all offenders subject to a Life Licence.
Information Sharing with the Northumbria Constabulary as Part of MAPPA Arrangements
The regulation 28 report acknowledges that some of the issues identified by the investigation into the death have already been addressed by Northumbria Constabulary. However, you raised concern that actions taken provided an interim rather than a permanent solution. By way of confirmation, I have set out below in an addendum to this response, the actions I am advised have been taken by Northumbria Constabulary and am able to confirm that these steps are acknowledged and accepted by the MAPPA representatives and Heads of Service in the NPS North East Division in both the North of Tyne and South of Tyne Local Delivery Units as being correct and a permanent solution at this time.
Resources (including staffing, buildings and IT)
The Transforming Rehabilitation Programme (implemented from 1st June 2014) resulted in a number of resource issues, which have been widely recognised and acknowledged. These issues have been taken into consideration in the planning of further structural changes to reunify all offender management into the NPS. At the heart of this is a robust recruitment drive and training programme to increase the number of qualified probation officers in the expectation that by the end of 2021 the current vacancies in the NPS will be filled. Alongside this is a review of required office space and the
provision of mobile IT services to ensure that the necessary resources are available to deliver a high- quality probation service in the future.
Thank you for bringing these matters of concern to my attention. Please be assured that learning from the circumstances of this tragic death will also be shared more widely with colleagues across the NPS Divisions.
Inquest into the death of Miss Nguyen Ngoc Quyen
Thank you for your Regulation 28 Report, issued following the Inquest into the death of Miss Nguyen Ngoc Quyen, addressed to the National Probation Service. I am replying as the Director General Probation and Wales as part of Her Majesty’s Prison and Probation Service (HMPPS).
I know that you will share a copy of this response with the family and I would first like to express my sincere condolences for their loss. Every death in such circumstances is a tragedy and the implementation of learning from this is my absolute priority.
You have raised a number of areas of concerns and I have drawn these together under specific headings, which I hope is of assistance to you, and respond to your concerns as follows: -
Supervision of Offenders on Life Licence (including issues of trust, self-reporting, challenge and the making of contemporaneous notes and updating OASys Risk Assessments)
The National Probation Service (NPS) is required to provide probation services by virtue of the Offender Management Act 2007. Probation is a means through which offenders are supervised and their rehabilitation is managed and Probation Services exist to protect the public by reducing reoffending and rehabilitating offenders to lead law abiding lives.
The effectiveness of probation supervision by trained probation officers/offender managers is key to the rehabilitation of offenders in the community.
To better support front line probation staff in the effectiveness of their supervision of offenders a new national Supervisory and Line Management Framework has been developed and is being rolled out across the NPS Divisions during 2019. This work forms part of the National Probation Service 2020 Change Programme and has been developed using ideas and evidence from the Skills for Effective Engagement Development and Supervision Programme (SEEDS). This Framework is designed to ensure a consistent and appropriate level of management oversight through practice supervision sessions and observation of practice. Through observation of practice senior probation officers will be able to see whether staff are being sufficiently challenging and adopting a properly investigative approach in their face to face supervision of the offender. There is a minimum requirement of four practice supervision meetings and two practice observations per annum for all probation officers with their Senior Probation Officer/line manager. Within this framework Senior Probation Officers with line management responsibility will ensure that best practice is followed and clearly evidenced and all decision making is being properly recorded following appropriate levels of challenge.
This framework sits alongside the new Lifer Review Panels, which were outlined at the Inquest. The aim of these Panels is to ensure Heads of Local Delivery Units have oversight of the lifer cohort under their responsibility and to scrutinise the robustness of the risk assessment/progress of life sentence offenders subject to supervision in their area. An initial lifer panel review will be completed within three months of release and annual reviews will take place thereafter. In preparation for Panel meetings, the offender manager is required to review OASys and the offender manager uses the review as a discussion topic with the lifer to gain their perspective on progress to date. The offender manager and Senior Probation Officer discuss lifer cases in supervision prior to the Panel meeting and undertake appropriate manager oversight recording in NDelius. MAPPA levels are reviewed and updated where required. This additional oversight ensures there is an independent review of the case to check that the offender manager is addressing the right issues in relation to risk.
The new Supervision Framework, together with the new Probation Lifer Panel Meetings are intended to ensure a stronger level of management oversight at a senior level and effective supervision and risk assessment of all offenders subject to a Life Licence.
Information Sharing with the Northumbria Constabulary as Part of MAPPA Arrangements
The regulation 28 report acknowledges that some of the issues identified by the investigation into the death have already been addressed by Northumbria Constabulary. However, you raised concern that actions taken provided an interim rather than a permanent solution. By way of confirmation, I have set out below in an addendum to this response, the actions I am advised have been taken by Northumbria Constabulary and am able to confirm that these steps are acknowledged and accepted by the MAPPA representatives and Heads of Service in the NPS North East Division in both the North of Tyne and South of Tyne Local Delivery Units as being correct and a permanent solution at this time.
Resources (including staffing, buildings and IT)
The Transforming Rehabilitation Programme (implemented from 1st June 2014) resulted in a number of resource issues, which have been widely recognised and acknowledged. These issues have been taken into consideration in the planning of further structural changes to reunify all offender management into the NPS. At the heart of this is a robust recruitment drive and training programme to increase the number of qualified probation officers in the expectation that by the end of 2021 the current vacancies in the NPS will be filled. Alongside this is a review of required office space and the
provision of mobile IT services to ensure that the necessary resources are available to deliver a high- quality probation service in the future.
Thank you for bringing these matters of concern to my attention. Please be assured that learning from the circumstances of this tragic death will also be shared more widely with colleagues across the NPS Divisions.
Action Taken
Northumbria Police has sent force-wide bulletins to officers and staff informing them of the process for sharing information/intelligence with NPS when encountering a Category 2 Level 2 or 3 offender. (AI summary)
Northumbria Police has sent force-wide bulletins to officers and staff informing them of the process for sharing information/intelligence with NPS when encountering a Category 2 Level 2 or 3 offender. (AI summary)
View full response
Dear Sir RE: NGUYEN_ REGULATION 28 RESPONSE write on behalf of the Chief Constable of Northumbria Police in relation to the regulation 28 report prepared by you in relation to the death of Miss Nguyen Ngoc Quyen: Firstly, as a matter of clarification, wish to address the question of the information relating to_ which was held on the Northumbria Police computer system and which was referred to several times in the inquest_ It is also referenced in section 5 of your report The Northumbria Police Integrated Computer and Communication System, (NPICC), is used to record information relating to police activity and responses: It incorporates an Information System that stores information and intelligence on persons coming into contact with Northumbria Police_ This includes victims and offenders_ Stephen Unwin has had an Information System record since 5th February 1989. In relation to the 26 items of intelligence referred to in the Regulation 28 report respectfully seek to provide some clarity: The 26 items were recorded between 8th December 2012 and 14th November 2016. Whilst have been referred to as items of intelligence some of them are simply a record of useful information, as opposed to intelligence proper: 17 of the items recorded in record between 8th December 2012 and 4th February 2013 relate solely to his release on temporary licence. These contain information such as his release address, employment and details of his probation officer. These are information records as opposed to actionable intelligence. The remaining 9 items, recorded between 21st October 2013 and 14th November 2016 can properly be considered as intelligence. They relate to incidents or Mr RF, Heron LLB Solicitor, Mr G.S. Crute LLB Senior Solicitor Miss L Silverton LLB Senior Solicitor, Mr N Wirz BA LLM Principal Solicitor, Mr K McKernan BA Assistant Solicitor Miss H. Hebb LLB Assistant Force Solicitor; Mr D.C. Foster Assistant Solicitor Mrs K. Ramsay Assistant Solicitor (Litigation) they Force
occurrences, not 9, due to the fact that information regarding to two of the incidents are recorded over two pages this clarification assists. The regulation 28 report acknowledges that some of the issues identified by the investigation into the death have been addressed but it is felt that it would be helpful to set out the present arrangements being employed to deal with such offenders going forward_ This is set out below In December 2018 Northumbria Police devised a process to ensure compliance for the purpose of informationlintelligence sharing on every record for Category 2 (violent) Level MAPPA offender. This means that all Category 2 Level offenders managed by National Probation Service (NPS) in the community are created on our NPICCS system: This system; as set out above, is used to record information and intelligence in relation to police activity for both victims and offenders NPICCS has been updated with the creation of a marker (MK flag) to Information System (IS) record of all Category 2 Level offenders in the community. Previously the marker (MK flag) was flagged to an individual officer within the then MAPPA Department: This meant that any changes to the offender's record would be flagged to the allocated officer who would then review the informationlintelligence and share appropriately: The MK process, as explained at the Inquest, was stopped in April 2015. However a direction was given that all Category 2 Level offenders warning screens would be updated to inform officers that if encountered Category 2 Level offender would share any relevant informationlintelligence with NPS. In the case of informationlintelligence was not shared and his warning screen was not updated t0 reflect that instruction: This was an individual error but pointed up the need for failsafe system to make sure informationlintelligence on such offenders was communicated andlor actioned: The current process now in place is that the Northumbria Police MK flag is allocated to both North and South Multi Agency Safeguarding Hubs (MASH) which means that any changes to the offender's electronic record are queued for the relevant MASH, both to notify them of the information and to cause it to be shared with NPS as required_ The process by which the relevant MASH share information is via email and also includes the below information within each email, "Should you wish to act on this information you must make contact with Northumbria Police MOSOVO Department prior to doing so. The originator of the intelligence does not permit the wider dissemination of this material without prior authority The email sent to the relevant NPS mailbox is retained for audit purposes_ hope the flag they they
Included within the process implemented in December 2018 was that all Category 2 Level offenders would also have an NPICCS warning marker updated with a new instruction on the IS record for that offender: This will highlight the requirement for any officer who is in possession of relevant information to inform the relevant probation area. Below is a copy of the information updated on the WN screen of all Category 2 Level offenders. "MAPPA Category 2 (Violent) offender Managed at Level by the National Probation Service (NPS): YOU ARE RESPONSIBLE for sharing all risk relevant information with NPS. This could include arrests, involvement in DV incidents, Child/Adult concern notifications, changes of address, new relationships etc_ If offender North of Tyne: NENPS newcastleldu caseallocation@justice gov uk If offender South of Tyne: NENPS sunderland admin@justice gov_uk Please conform to Intel handling codes_ To ensure staff were aware of this change, a force wide bulletin was sent to officers and staff informing them of the process and that it was their responsibility to share any relevant informationlintelligence with NPS. further force wide bulletin has subsequently been sent to officers and staff to reinforce that it is their responsibility to share information with NPS when encountering Category 2 Level offender. It is accepted that officers having responsibility to share information and MASH also sharing information may appear to be duplication in the process: It is hoped however that this ensures appropriate sharing of information is completed in all cases In relation to new Category 2 Level offenders, when we receive notification from NPS to the MOSOVO Department; will be added to Northumbria Police systems immediately. This process will manage the immediate risk and ensure appropriate information sharing in a timely fashion: The final point in relation to the current process was your concern that the Police were of the view this was a permanent solution to this issue, whereas NPS were viewing it as an interim solution. This concern may emerged because of the way the evidence came out at the inquest: We have contacted NPS with regards to the content of this letter and confirm that agree this process is definitive going forward_ It may of course evolve in the future as ITsystems are further developed and the two organisations co-operate to further improve the system but at present the system outlined above is agreed as the operating model going forward. they have they they
this answers your concerns and if you require any further information please let me know.
occurrences, not 9, due to the fact that information regarding to two of the incidents are recorded over two pages this clarification assists. The regulation 28 report acknowledges that some of the issues identified by the investigation into the death have been addressed but it is felt that it would be helpful to set out the present arrangements being employed to deal with such offenders going forward_ This is set out below In December 2018 Northumbria Police devised a process to ensure compliance for the purpose of informationlintelligence sharing on every record for Category 2 (violent) Level MAPPA offender. This means that all Category 2 Level offenders managed by National Probation Service (NPS) in the community are created on our NPICCS system: This system; as set out above, is used to record information and intelligence in relation to police activity for both victims and offenders NPICCS has been updated with the creation of a marker (MK flag) to Information System (IS) record of all Category 2 Level offenders in the community. Previously the marker (MK flag) was flagged to an individual officer within the then MAPPA Department: This meant that any changes to the offender's record would be flagged to the allocated officer who would then review the informationlintelligence and share appropriately: The MK process, as explained at the Inquest, was stopped in April 2015. However a direction was given that all Category 2 Level offenders warning screens would be updated to inform officers that if encountered Category 2 Level offender would share any relevant informationlintelligence with NPS. In the case of informationlintelligence was not shared and his warning screen was not updated t0 reflect that instruction: This was an individual error but pointed up the need for failsafe system to make sure informationlintelligence on such offenders was communicated andlor actioned: The current process now in place is that the Northumbria Police MK flag is allocated to both North and South Multi Agency Safeguarding Hubs (MASH) which means that any changes to the offender's electronic record are queued for the relevant MASH, both to notify them of the information and to cause it to be shared with NPS as required_ The process by which the relevant MASH share information is via email and also includes the below information within each email, "Should you wish to act on this information you must make contact with Northumbria Police MOSOVO Department prior to doing so. The originator of the intelligence does not permit the wider dissemination of this material without prior authority The email sent to the relevant NPS mailbox is retained for audit purposes_ hope the flag they they
Included within the process implemented in December 2018 was that all Category 2 Level offenders would also have an NPICCS warning marker updated with a new instruction on the IS record for that offender: This will highlight the requirement for any officer who is in possession of relevant information to inform the relevant probation area. Below is a copy of the information updated on the WN screen of all Category 2 Level offenders. "MAPPA Category 2 (Violent) offender Managed at Level by the National Probation Service (NPS): YOU ARE RESPONSIBLE for sharing all risk relevant information with NPS. This could include arrests, involvement in DV incidents, Child/Adult concern notifications, changes of address, new relationships etc_ If offender North of Tyne: NENPS newcastleldu caseallocation@justice gov uk If offender South of Tyne: NENPS sunderland admin@justice gov_uk Please conform to Intel handling codes_ To ensure staff were aware of this change, a force wide bulletin was sent to officers and staff informing them of the process and that it was their responsibility to share any relevant informationlintelligence with NPS. further force wide bulletin has subsequently been sent to officers and staff to reinforce that it is their responsibility to share information with NPS when encountering Category 2 Level offender. It is accepted that officers having responsibility to share information and MASH also sharing information may appear to be duplication in the process: It is hoped however that this ensures appropriate sharing of information is completed in all cases In relation to new Category 2 Level offenders, when we receive notification from NPS to the MOSOVO Department; will be added to Northumbria Police systems immediately. This process will manage the immediate risk and ensure appropriate information sharing in a timely fashion: The final point in relation to the current process was your concern that the Police were of the view this was a permanent solution to this issue, whereas NPS were viewing it as an interim solution. This concern may emerged because of the way the evidence came out at the inquest: We have contacted NPS with regards to the content of this letter and confirm that agree this process is definitive going forward_ It may of course evolve in the future as ITsystems are further developed and the two organisations co-operate to further improve the system but at present the system outlined above is agreed as the operating model going forward. they have they they
this answers your concerns and if you require any further information please let me know.
Sent To
- National Probation Service
Response Status
Linked responses
2 of 2
56-Day Deadline
10 Oct 2019
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
Miss Nguyen Ngoc Quyen was born 0n September 1988 and died on 15th August 2017, 28 years. The cause of her death was consistent with the effects f fire: [opened and adjourned an Inquest into her death as part of my Investigation on 7th September 2017 and suspended my Investigation pending the outcome of Crown Court proceedings_ On 27th March 2018 was found guilty of murder and rape, and vas found guilty of murder_ Both were sentenced to terms of life imprisonment The Inquest was heard from 2gth to 4th June 2019 when [ gave a conclusion of Unlawful and further recorded that: Quyen Ngoc Nguyen died on ISth August 2017 at Success Road, Shiney Row, Houghton Le Spring: The perpetrators of her murder were subject to life licence conditions, the known breaches of which were not acted upon in a sufficient, timely and co-ordinated manner (including a failure of information sharing), all of which were not causative but possibly contributed to her death
Circumstances of the Death
Iresumed the Inquest as part of my Investigation because I had sufficient reason to do so as there may have been actual and/or potential systemic and individual failings on either the part of the Police and/or the National Probation Service or others charged with the Civic Centre; Burdon Road,Sunderland, SRZ 7DN Tel 0191 5617843 Fax 0191 5537803 DX 60729 Sunderland WWW.sunderlandcoroner co.uk City aged May Killing supervision of] and also to ascertain what steps may have been taken to address such failings and to prevent & reoccurrence of them:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and [ believe you have the power to take such action_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.