Nathan Shepherd

Dear Madam,

Inquest Touching the Death of Nathan Harry Shepherd

I refer to your Regulation 28 Report following the Inquest into the death of Mr. Shepherd and am issuing this response on behalf of the Ministry of Justice.

I know that you will share a copy of this response with his family, and I would like to take this opportunity to express my sincere condolences for their loss.

1. The inquest heard evidence that the Probation Service had no policy to cover incidents of residents barricading themselves into rooms at Approved Premises. This meant that staff did not have training on how to deal with a situation. The inquest was told that the Probation Service were now developing such a policy but it had not been signed off or rolled out to staff.

The Barricade Guidance referred to in evidence given at the Inquest hearing has now been finalised and is going through the final stages of sign off prior to issue to all approved premises staff on 1st August 2025. This guidance will form part of the Safe Working Practice document and staff will be required to acknowledge receipt and their understanding by the end of September 2025. This will be overseen by all Approved Premises Managers.

2. A copy of the draft policy was available to the inquest but it was unclear what if any discussion there had been with Police Forces and how it would link in with Police policies such as the GMP Right Care Policy

The Ministry of Justice is not currently a party to the National Partnership Agreement which supports working together to ensure people get the right support. At a local level your concern has been raised with Greater Manchester Police.

3. The evidence before the inquest was that Mr Shepherd was able to barricade himself with relative ease due to the mobility of the furniture in his room. The Approved Premises had no clear policy regarding furniture which meant that furniture could be used to create a barricade with relative ease.

The policy on furniture in Approved Premises is set out in a furniture specification which states that beds and wardrobes should be fixed (although this does not apply to chairs). This specification is currently being applied across all Approved Premises but it is acknowledged that this is a rolling programme and is subject to funding for renovation programmes. The Probation Estates Team are currently collating information on furniture through local estates boards and every effort will be made to prioritise funding to replace moveable furniture with fixed furniture.

4. The ceiling fire detection equipment was a ligature point. Such ligature points remained in the Approved premises. It was unclear if changes could be made to reduce the risk they presented.

Fire detection equipment that is designed to meet anti-ligature standards is available and is being introduced across the Approved Premises estate. Facilities Management providers are aware of the need for any replacement fittings to meet the anti ligature standards. In light of your concern this has now been raised with the AP Maintenance Strategy Group to undertake a review of existing equipment with a view to ensuring this replacement work is incorporated into future maintenance programmes

5. Agency staff were used under a national contract. The evidence before the inquest was that at the time of Mr Shepherd’s death there was no policy for ensuring they could deliver CPR / First Aid. It was part of the national contract that they should be so trained but there were no checks to ensure that this part of the contract was being followed. The evidence at the inquest was that the agency worker in place on the night did not appear able to deliver CPR.

The Double Waking Night Cover contract with external agencies is due to come to an end in March 2026 and thereafter night shifts at Approved Premises will no longer be contracted out and will be brough in house. This will ensure that all staff will be trained in accordance with HMPPS requirements, which includes First Aid, CPR and use of the defibrillator. There are already pilots in place across the country working to this new arrangement. Where this service is still being delivered by external agencies, it will be part of the contract management process to monitor compliance with the contractual term that requires the agency staff to be fully trained to the standard required by HMPPS.

6. Evidence from Probation and Prison staff showed a lack of understanding of how the prison system could update the probation system and where that information could be found. This meant that key information was not shared effectively creating a risk that probation staff in the community would not have a full picture of risk.

There is now a new digital referral process in place that pulls information from both prison and probation systems as part of the referral process, allowing for much more accurate and timely sharing of information. The information is pulled directly from CNOMIS into a live referral document and this is reviewed by the practitioner and also the AP Manager who assesses the referral. The information includes custodial behaviour and issues around suicide and self harm risk.

7. The inquest heard evidence that the information shared with the Approved Premises staff by other probation staff was not accurate and did not give a full picture of risk. This was in part due to the fact that it appeared key documents were being regularly completed by probation staff who were not the allocated probation officer and so were unfamiliar with the history.

Oasys is an assessment tool used by a Probation Practitioner to assess risk. The new digital referral system pulls information from Oasys directly into the form. It also brings in information from NDelius and CNOMIS. This allows for much more accurate information to be submitted for viewing by the AP Manager and staff.

Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this.