Source · Prevention of Future Deaths

Elizabeth McCann

Ref: 2024-0288 Date: 29 May 2024 Coroner: Alison Mutch Area: Manchester South Responses identified: 5 / 5 View PDF

High probation caseloads, inadequate supervision for new staff, and limited information sharing protocols between agencies, coupled with severe, long-standing understaffing in police Sexual Offender Management Units, compromised effective offender management.

Date 29 May 2024

56-day deadline 24 Jul 2024 est.

Responses identified 5 of 5

Other related deaths

Coroner's concerns

AI summary

View full coroner's concerns

1. The inquest heard evidence that the probation staff were carrying significant caseloads. This was due to challenges in recruiting sufficient staff. The evidence was that there is still a national shortage of probation officers. Steps have been taken to recruit and train further probation officers which provides some assistance but means that overall, a significant number of probation officers are young in service and experience.
2. The evidence before the inquest was that it was important that newly qualified probation staff were closely supervised and supported by their managers. Without that supervision performance issues identified by the trackers were not being tackled. Ensuring this had been and was challenging as the number of staff line managed by senior probation officers had been too high. This was being addressed but was only achievable if sufficient senior staff were retained.
3. Evidence before the inquest was that if probation referred clients under supervision to places such as the Health and Wellbeing College this would, if not implemented effectively pose a significant risk to vulnerable users of such institutions. If referrals were made without a protocol being in place that dealt with managing risk then the risk posed increased further.
4. Clear Information Sharing protocols between Probation and such groups as drug and alcohol services were limited. Without clear agreements understood by both sides there was a significant risk that crucial information that impacted risk assessments would not be shared.
5. The inquest was told that nationally a significant number of police forces were struggling to adequately staff their Sexual Offender Management Units. As a consequence, the level of supervision of sex offenders in the community was being risk managed posing a risk to communities.
6. In the case of Greater Manchester Police, the staffing issues had been known by senior managers for a number of years (many years before Covid) and a decision taken to risk mange far below the appropriate staffing numbers taken. The consequence was that the staff in the unit could not effectively manage their caseloads that were far in excess of the recommended level. The numbers in the unit were increasing but the caseloads were still high.
7. The GMP investigation into their role in relation to Elizabeth’s death was poor in quality and there was no evidence that any senior officer had considered the report. The inquest was told that the quality and lack of referral upwards of a report was not unique to Elizabeth’s case.
8. There was no evidence before the inquest of any professional curiosity by senior GMP officers as to the role of GMP and if lessons could be learnt. It was unclear as to why senior officers were unsighted.
9. It was accepted that there needed to be a level of professional curiosity by staff dealing with high-risk offenders such as in this case and that training for probation officers and police staff needed to reinforce that.
10.The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place. There was also a need for effective information sharing protocols and effective well understood safeguarding provisions.
11.The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.

Responses

5 respondents

Pennine Care NHS Foundation Trust NHS / Health Body

19 Jul 2024 PDF

Action Taken

The College has a new Standard Operating Procedure for all referrals received from external agencies. The Trust is developing an organisational approach to investigations as part of the nationally mandated work to implement the Patient Safety Incident Response Framework and is commissioning a training programme that will provide attendees with enhanced skills in reviewing and learning from patient safety incidents; the Executive Director of Quality, Nursing and Health Professionals has also introduced new governance processes. (AI summary)

View full response

Dear Ms Mutch,

RE: Inquest touching on the death of Elizabeth McCann

I set out below the Trust’s response to your letter to Pennine Care NHS Foundation Trust and the issuing of a Prevention of Future Deaths Notice (Regulation 28), arising from the inquest into the death of Elizabeth McCann. May I take this opportunity to extend my own condolences to the family of Elizabeth and apologise that you had to raise concerns relating to the services she accessed prior to her sad death. Prior to receipt of the Regulation 28 notice, the Executive team here commissioned an external review of the College. This is currently concluding with the outcome anticipated before 31 July 2024. The Network Director of Quality, Nursing and Health Professionals for our South Network ( ) is working with the team at the College in relation to all of the issues highlighted by the internal investigation report, the evidence heard at Inquest and from the early findings of the external review. I would also like to take this opportunity to assure you that the College has no partnership arrangement with the Probation Service. The Trust is of the understanding that the Probation Service has developed an in-house recovery model. The Trust sets out its response to the specific points below:
3. Evidence before the inquest was that if probation referred clients under supervision to places such as the Health and Wellbeing College this would, if not implemented effectively pose a significant risk to vulnerable users of such institutions. If referrals were made without a protocol being in place that dealt with managing risk then the risk posed increased further. A1

Trust Response: The College has a new Standard Operating Procedure within which there is a clearly articulated protocol for the referral and enrolment process for any member of the public, referring agency or clinical team referral. This protocol has a stepped approach to risk management and includes cross-reference checks with Trust clinical systems (PARIS our Electronic Patient Record system and incident reporting systems). Any referral by an external agency, such as the probation or service [e.g., third sector] will be required to share risk information that is known about the person. As a condition of enrolment, students agree to the sharing or disclosure of information to professionals/other agencies regarding concerns to their own or others safety by agreeing to the student charter on enrolment. The College leads will also perform a PARIS ‘look up’ to check for flags against any new enrolling students. During this time, they will also check new enrolment forms to ascertain if any students have answered ‘yes’ to the below question: ‘Do you have any current or recent (within the last 12 months) police or court involvement, or have you been released from prison or been under any other court mandated orders within the last 12 months? If yes, please provide the name of the police or probation officer you are/were involved with, as we will need to contact them.’ If a student has answered ‘yes’ to the above question on the student enrolment form, the details will be clarified with police/probation and the question asked as to whether this person’s current level of risk can be managed within the Health and Wellbeing College environment. No enrolment to the College is permissible until there is sufficient assurance gathered from internal and external systems. A student’s application to enrol will be kept on hold until a manager is able to either authorise or decline the person’s application based on this information. If enrolment for a student is unsuccessful due to an evaluation that there is a risk to other students, then a standard letter of ‘Unsuccessful enrolment’ is issued. If enrolment for a student is successful, then the College will manage the day-to-day presence of a student on site as follows: Once a student has had their enrolment authorised:
• If there are any risk concerns during a student’s time at the Health and Wellbeing College:
1. Discuss the concern with the Health and Wellbeing College lead(s) who will agree next steps. A2

2. Record any conversations or discussions regarding the above, in the student’s individual paper file on the notes sheet. This should be signed and dated, with the time of the note entry recorded.
3. If it is decided that a student or other person (e.g. key professional/emergency contact/safeguarding) should be contacted, this must be recorded on the student’s individual paper file on the notes sheet, along with any conversations and outcomes. Additionally, any emails or letters etc, relating to this must be printed, and attached to the notes sheet in the student’s individual file.
• Teaching staff will check each student file against the class register for any class they are teaching that day, to ensure they are aware of any risk updates or changes or new information.
• Teaching staff will ensure that the online register is open, checked and completed before the class starts/as students enter the classroom. This ensures that only those students who have enrolled and booked on a course are present. The risk management checks protocol is set out within the College’s standard operating procedure at appendix 11. The Trust’s respective Head of Quality will ensure that the risk management protocols for the college are kept under review and discussed regularly. It is anticipated that the independent review of the College will provide additional assurance as to the effectiveness of the current risk management processes, or opportunities for further development as a result of this process.
4. Clear Information Sharing protocols between Probation and such groups as drug and alcohol services were limited. Without clear agreements understood by both sides there was a significant risk that crucial information that impacted risk assessments would not be shared.

Trust Response: As outlined in our earlier response, since Elizabeth’s death, the College has developed a standard operating procedure that outlines the steps and processes required by College leads and administrators in relation to information received by the College and the steps required for every student’s successful enrolment to commence. These checks include self-disclosure by students relating to activity and engagement with other agencies in addition to checks against internal clinical systems. Any student with an open referral to another agency will be requested to give permission to contact and explore issues of risk with that agency as appropriate. For A3

any student with an open and ongoing engagement with a clinical team, the College leads have full access to the Trust’s patient record systems to enable a review of the risks associated with the student. The College leads are required to liaise with the clinical team for a position on whether or not enrolment is appropriate for the individual. Alongside the community focus, the service works in partnership with both internal partners and external organisations to co-produce and co-deliver wellbeing and recovery focussed courses, in line with the recovery college fidelity criteria and standards. All partners will agree to and sign a partnership agreement. The partnership agreement exists to support the safety and wellbeing of all College students and sets out clear expectations relating to information sharing. The College’s nominated partners are:
• Tameside Libraries
• PCFT Volunteer Service
• PCFT Chaplaincy and Spiritual Care Service
• Aminas Art and Design
• Heathfield House, Rehabilitation and High Support Hub PCFT
• My Mirror Loves Me
• Bury Community Mental Health Team
• Acorn Recovery, Stockport Early Intervention and Recovery Service
• Tameside Macmillan Unit Any Partner seeking to engage with the Trust’s Health and Wellbeing College must enter into a contract and engage in a workshop that outlines amongst others, a clear understanding of the structures, processes and working protocols of the Health and Wellbeing College in relation to risk and safeguarding. The College no longer has a working partnership with any probation service. The College team have worked closely with the Trust’s Information Governance Lead who has supported them to ensure compliance with the General Data Protection Rules. The College team have worked to develop and share protocols in relation to information governance with the staff group. These include the creation of a generic email account, access to the generic email account, standardised out of office for the account and escalation processes in relation to information received to the generic email account, an extract of which is provided here for assurance: “Protocol for Dealing with emails to the Generic Health and Wellbeing College Inbox.

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The generic e mail account is accessible by the following staff only:
• Health and Wellbeing College Administrator
• Health and Wellbeing College Leads
• Health and Wellbeing College Band 5 Practitioner

General email enquiries regarding opening times; enrolment process; courses; general college information; room bookings; web site queries; basic IT issues; ordering and invoicing; visits etc, can be dealt with by the College Administrator. It is the College Administrator’s responsibility to check and action the in box on a daily basis. In the absence of the college administrator, the in-box will be checked by the band 5 practitioner or the College Leads, as decided. Signposting information or enquiries regarding student welfare or wellbeing, or information from any internal team or external agency regarding a student, must be forwarded to the College Leads. Any enquiries about risk from any internal or external team or agencies, must be forwarded to the Health and Wellbeing College Leads, and will be dealt with as per the risk protocol. In the absence of the College Leads, the Administrator should escalate any urgent information to the band 5 practitioner, and if necessary, the band 5 practitioner will escalate this to the service line manager.” Working with the Information Governance Leads the College has established regular sessions with all staff and volunteers at the College to remind them of the importance of the General Data Protection Regulation rules when information is shared from other agencies. Information Governance Lunch and Learn Sessions – Termly:
• 14/8/24 – Classroom 3 HWC
• 10/12/24 – Classroom 3 HWC
• 17/4/25 – Classroom 3 HWC

The Trust and College acknowledge that in order to provide a safe and effective learning environment for all students to access courses to enable growth and recovery, they must be supported and enabled to do so through systems and processes that keep them safe.

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10. The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place. There was also a need for effective information sharing protocols and effective well understood safeguarding provisions.

Trust Response: The new Standard Operating Procedures for the College were shared through a briefing note e-mail of 17th April 2024 regarding the updated version of the Standard Operating Procedure (SOP) and the reminder noted in the team brief notes on 3rd July 2024. This is stored within the shared electronic folder which all staff can access, with a hard copy on file in the office for reference. The College shares information within the staff group and operates 2 x 10-minute briefings each day, at the following times:
• 09.20 – 09.30 (Team brief)
• 13.20 – 13.30 (Team brief)

This provides an opportunity to clarify the courses for the day, teaching staff and any issues for staff that day to be aware of. There is an expectation that all team members present attend, participate fully and share information in a respectful, open, constructive, and supportive way. A termly Health and Wellbeing College meeting is held, and all staff are encouraged to attend. All staff working within the Health and Wellbeing College are up to date with their safeguarding training - level 2 (College management – level 3). This is monitored by the Health and Wellbeing College Leads, in liaison with the Volunteering Team and the Temporary Staffing Team. All staff compliance will be checked before the start of the September term. The College will report quarterly compliance data for safeguarding through the Trust’s established governance systems. The Trust has set dates for the safeguarding sessions quarterly on: 14th August 2024 and 10th December 2024 as ‘lunch and learn’ sessions for all staff. As these become embedded, they will be scheduled once each term (3 times per academic year) with the Trust’s Safeguarding Team as an additional way of ensuring that Safeguarding is kept as a living and conscious statutory duty by all working within the College. If there is an occasion when that the College staff and / or Leads become aware of information or behaviours that give rise to serious and significant concerns about the potential risk of harm to other individuals at the College, then steps should be taken A6

to establish if the individual has a forensic history that may give rise to their unsuitability to being a student at the college. This approach should be made via any clinical team involved with the student (for example if they were open to a Community Mental Health Team) in the first instance. If no clinical team is involved, then an approach should be made to the Trust’s Security Lead & Police Liaison Officer, who will liaise with criminal justice agencies. The College leads must ensure the health, safety and welfare of all students and this may necessitate a temporary suspension of a current student or the temporary halt on the intended enrolment of a student, pending further enquiries. If any safeguarding concerns arise, these should be reported to a College Lead immediately, who will act accordingly. If necessary, guidance/further advice will be sought from the Trust safeguarding team. The College and the Trust’s Head of Safeguarding have developed a clear policy that covers students enrolled at the College, should the leads or staff become aware of a concern or incident that gives rise to a safeguarding concern.
11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.

Trust Response: As part of the reflections immediately post inquest, a tabletop review of the process followed in this case was requested by the Executive Director of Quality, Nursing and Healthcare Professionals, who had taken up his post in the weeks before the inquest. This review was led by a member of the Director team and identified learning. This made recommendations in relation to strengthening the triggers for an investigation, more robust systems for the recording of decisions made in relation to commissioning of investigations, for the agreement of the scope and terms of reference, and for ensuring the training and skills of investigators beyond arrangements already in place. In addition to this, it was also recommended that the quality assurance process for the presentation and ratification of investigation findings could also be reviewed and strengthened. These findings were received and accepted by our new Executive Director of Quality, Nursing and Health Professionals who is being supported by the Interim Head of Patient Safety and Clinical Effectiveness to dovetail these recommendations into our broader change in organisational approach to investigations as part of the nationally mandated work to implement the Patient Safety Incident Response Framework A7

(PSIRF). As part of this, we are also commissioning a training programme that will provide attendees with enhanced skills in reviewing and learning from patient safety incidents. This is intended to build on the existing offer available to staff, to create a robust system and pool of those able to undertake this responsibility effectively and efficiently. In order to facilitate the recommendations, the Executive Director of Quality, Nursing and Health Professionals has also introduced new governance processes into our agreed structure which should support a more robust process for the most significant patient safety investigations. One of these is a Central Safety Summit, with an approved scope and purpose agreed at Trust Board level, with reporting into our Quality Committee to ensure continuous oversight at a Non-Executive Director level. Progress in relation to the embedding of these new structures will form part of our reporting to Trust Board in relation to quality, safety, experience and effectiveness, supported by an established report provided within the private part of the Board meeting, which is focused on incident investigations, including performance and learning and inquest activity. This will also inform regular discussions with ICB colleagues and reporting within the quarterly quality compliance schedule, which is in place, as well as our established engagement mechanisms with our regulator, Care Quality Commission on a bi-monthly basis. I hope that the information within this response has provided you with the assurance that you were seeking in relation to learning from these events. Should you require any further information or clarification on the details within this letter, please do not hesitate to get in touch with me again.

Department of Health and Social Care Central Government

5 Aug 2024 PDF

Action Taken

The Trust's safeguarding leads have supported College leads in developing a more robust safeguarding policy for enrolees, provided additional learning sessions to college staff and volunteers, and have a rolling programme of support in place; Additionally, the Executive Director of Quality, Nursing and Health Professionals has introduced new governance processes including a Central Safety Summit with an approved scope and purpose agreed at Board level with reporting into the Trust’s Quality Committee for continuous oversight at a Non-Executive Director level. (AI summary)

View full response

Dear Alison,

Thank you for your Regulation 28 report to prevent future deaths dated 29 May 2024 about the death of Elizabeth Sarah Jayne McCann and I’d like to thank you for agreeing an extension. I am replying as the newly-appointed Minister with responsibility for mental health and patient safety.

Firstly, I would like to say how saddened I was to read of the circumstances of Elizabeth’s death and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.

Most of the concerns you have raised are matters for the Ministry of Justice, Home Office and Greater Manchester Police and I understand that these organisations will be responding to your report.

You have also raised concerns about health and wellbeing colleges and, in preparing this response, Departmental officials have made enquiries with NHS England and Pennine Care NHS Foundation Trust. I understand that the Trust is also in the process of responding to you directly.

The Health and Wellbeing College in Tameside is based on the ‘recovery college’ model which takes an educational approach to developing people’s strengths to enable them to understand their own challenges, become experts in their own self- care and develop the skills and confidence to manage their own recovery. Courses are co-produced, co-delivered and co-received by people with personal and professional experience of mental health problems.

In this instance, it is clear that information sharing protocols and safeguarding provisions within the College were not effective or well enough understood.

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I have been informed that prior to your report being issued, the Trust had already commissioned an external review of the Health and Wellbeing College, which is currently ongoing. The Network Director of Quality, Nursing and Health Professionals for the South Network is working with the team there in relation to risk management systems and processes.

The Trust recognises that, at the time of the incident the College did not have a clear written protocol in place to manage risk. As an educational establishment the College did not have plans or processes in place to communicate effectively with other teams within the Trust such as the clinical teams or externally to organisations such as the Probation Service about the risk of harm occurring to others. The College is bound by Trust policies in relation to safeguarding and the College team did have access to and used Trust internal incident reporting systems.

Since the incident occurred, the College has developed a standard operating procedure outlining steps and processes required by College leads and administrators in relation to information required by the College for every student's successful enrolment to commence. These checks include self-disclosure by prospective students relating to activity and engagement with other agencies in addition to checks against internal clinical systems.

Any student with an open referral to another agency will be requested to give permission to contact and explore issues of risk with that agency as appropriate. For any student with open and ongoing engagement with a clinical team, College leads will have full access to the Trust's patient record systems to enable a review of any risks associated with the student. College leads are required to liaise with the clinical team for a position on whether enrolment is appropriate for the individual.

It is expected that the ongoing review will analyse these new risk management protocols and provide the Trust with assurance or recommendations.

The Trust's safeguarding leads have supported College leads in developing more robust safeguarding policy for enrolees at the College. The safeguarding team has provided additional learning sessions to college staff and volunteers and there is a rolling programme of support in place. College leads report compliance with safeguarding training through newly established governance systems and are also receiving support to access and utilise core governance processes such as reporting and management of risk in accordance with the expectations within the organisation.

Following your inquest, a review of the process followed in this case was requested by the Trust’s Executive Director of Quality, Nursing and Healthcare Professionals to identify learning. This review made recommendations in relation to strengthening triggers for an investigation, more robust systems for the recording of decisions made in relation to commissioning investigations, agreement of scope and terms of reference and ensuring training and skills of investigators beyond arrangements already in place. It was also recommended that the quality assurance process for the presentation and ratification of investigation findings could be reviewed and strengthened.

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In response, the Executive Director of Quality, Nursing and Health Professionals has introduced new governance processes including a Central Safety Summit with an approved scope and purpose agreed at Board level with reporting into the Trust’s Quality Committee for continuous oversight at a Non-Executive Director level. Progress in relation to the embedding of these new structures will form part of the Trust’s regular discussions with integrated care board colleagues and reporting within the quarterly compliance schedule.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

All good wishes,

BARONESS GILLIAN MERRON A17

Home Office Central Government

16 Sep 2024 PDF

Action Planned

The Home Office is working with police forces to ensure improvements in effectiveness and efficiency of the system to manage sex offenders and prevent them from committing further harm, and is working with the National Police Chiefs’ Council’s Violence and Public Protection and Violence Against Women and Girls portfolios. The VKPP engages with forces and key partners to identify promising practice and share knowledge to shape future responses to serious crime that exploits vulnerability. (AI summary)

View full response

Dear Ms Mutch,

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

Thank you for Report to Prevent Future Deaths on 29 May 2024 regarding the unlawful killing of Elizabeth Sarah Jayne McCann.

Thank you for your conduct of the inquest and for your identification of a number of matters of concern, which are set out in the Report. These failings are shocking and I am clear that the lessons must be learned across Government and beyond. In providing this response to the Coroner’s Report, the Home Office wishes to repeat the offering of its sincere condolences to Elizabeth’s family, and we emphasise our commitment to addressing the matters of concerns raised.

Tackling violence against women and girls is a top priority for this Government and we will treat it as a national emergency. Our mission is to halve levels of violence against women and girls using every lever available to us. This means reforming the police response to these crimes, strengthening the criminal justice system, and empowering victims by providing access to specialist support when they need it. The Home Office is working closely with other departments and stakeholders in developing plans to achieve this mission.

We will build on the existing work I outline below, ensuring that wholesale systematic changes are made in response to the findings from your report. Making these changes will take time as we must guarantee they are delivered effectively, and that we are getting it right. Too often piecemeal changes have failed to deliver effective and lasting improvements. We are determined not to make the same mistakes. A18

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

Matter of concern five

The inquest was told that nationally a significant number of police forces were struggling to adequately staff their Sexual Offender Management Units. As a consequence, the level of supervision of sex offenders in the community was being risk managed posing a risk to communities.

Increasing police capacity

Decisions on how funding and resources are utilised is a matter for chief constables and elected police and crime commissioners (including mayors with Police and Crime Commissioner (PCC) functions). However, it is vitally important that every police force has the specialist officers and other resources necessary to support victims of rape and sexual violence, bring perpetrators to justice and manage the risks they pose.

The total number of officers nationally is 149,769 (headcount). Funding has previously been provided to forces to support the maintenance of officer numbers. In 2024/25 the police funding settlement provides funding of up to £18.5 billion for policing in England and Wales. Overall police funding available to PCCs will increase by up to £965.4 million. The Home Office will also provide additional Government grant funding of £175 million to policing in 2024/25, to support the costs of the 2024 police pay award.

On 31 March 2024, there were 8,189 police officers in Greater Manchester Police. Greater Manchester Police’s funding will be up to £815.6m in 2024-25, an increase of up to £56.4m when compared to 2023/24. However, I recognise your concerns regarding the lack of sufficient staffing amongst sexual offender management units and the impact that this has in ensuring sex offenders are being effectively managed in communities. I am committed to making our streets safer. As part of our mission to halve violence against women and girls in a decade, we will ask the police to relentlessly pursue those perpetrators who pose the greatest risk to women and use all the tools at their disposal to protect victims and get dangerous offenders off the streets. We are currently working at pace to look at our national expectations on the management of the highest-risk offenders. A19

I also recognise that visible neighbourhood policing has been the cornerstone of the British consent-based model. In too many areas it has been eroded, leaving the police a reactive service focused on crisis response, rather than preventing crime. This Government will introduce a new Neighbourhood Policing Guarantee, restoring patrols to our town centres by recruiting thousands of new police officers, police and community support officers, and special constables. Communities and residents will have a named officer to turn to when things go wrong.

Enhancing policing capability

In addition to providing the police with sufficient capacity to improve its response to violence against women and girls, we will ensure the police has the necessary tools and capabilities.

The regime for managing registered sex offenders and those who pose a risk was reformed under the previous Government through the Police, Crime and Sentencing Courts Act 2022 (“the Act”). Sexual harm prevention orders and sexual risk orders were amended to specify that the court should apply the lower civil standard of proof (balance of probabilities) when deciding an application for these civil orders. In addition, the Act enables the courts to impose positive obligations (in addition to restrictions) via these orders where appropriate, for example, requiring an individual to engage in a behaviour change programme or substance misuse services.

Violence against women and girls has been included in the Strategic Policing Requirement since 2023. All police forces in England and Wales are implementing a new National Operating Model for the investigation of rape, developed through Operation Soteria. The aim is to ensure forces have the right specialist capability and use all available levers to respond to sexual offending effectively.

Section 325 of the Criminal Justice Act 2003 requires the police, probation and prison services in each local Criminal Justice Board area to work together to manage the risk posed by sexual and other offenders. These multi-agency public protection arrangements (MAPPA) provide a common framework for the identification, assessment and management of violent and sex offenders living in the community.

Your report is clear that more must be done to enhance the police’s capability to sufficiently manage sex offender in the community, and I agree that is the case. To make sure that the police, prisons, probation service and others have the right systems in place to do this and share pertinent information on registered sex offenders and other dangerous individuals, the Home Office is developing a new A20

multi-agency public protection system (MAPPS) which will provide improved functionality that will better meet the future needs of frontline offender managers. It will enable more effective and efficient offender and risk management, improve data sharing between frontline agencies and the management of additional cohorts of offenders.

In April 2023, the Home Office published an independent review of the police’s management of sex offenders undertaken by former chief constable Mick Creedon. Chief Constable Creedon recommended that PCCs include MAPPA/sex offender management within their police and crime plans to ensure they are able to appropriately hold chief constables to account and provide them with the opportunity to inform the public of realistic expectations for sex offender management within the community.

The Government welcomes primacy being given to offender management in police and crime plans. Offender management is the mechanism that prevents reoffending and revictimization. Placing an emphasis on it in police and crime plans will raise awareness of the important preventative work that police offender managers do, which will in turn increase the level of informed accountability that police offender managers are subjected to.

I would like to assure you that I will be reviewing this as we develop our plans to halve the levels of violence against women and girls in the next decade. We will monitor closely and robustly if these systems are working.

Matter of concern 9

It was accepted that there needed to be a level of professional curiosity by staff dealing with high-risk offenders such as in this case and that training for probation officers and police staff needed to reinforce that.

I would also like to respond to your concerns relating to the lack of professional curiosity by staff dealing with high-risk offenders. This is – to my mind – perhaps the most concerning finding that you make given the significance of the task and the responsibilities that are conferred upon every individual involved in offender management. I recognise that it is crucial that offender managers understand the importance of their role; how to interrogate the data and information they hold about offenders and when and how to act to protect the public from harm. We must deliver better protection for the public and outcomes for victims. The Government will be working closely with the College of Policing and NPCC to improve training for officers. A21

Chief officers are encouraged to create and promote opportunities for officers and staff to enhance their subject matter knowledge and skills relating to vulnerability. This can be achieved through various mechanisms, for example, briefing, policy, continuing professional development (CPD) and training. The College of Policing’s evidence-based guidelines on vulnerability and risk aim to support officers to spot the signs of vulnerability and create a safe, trusting environment to identify risk, encourage the disclosure of harm and elicit information required to inform appropriate actions to keep people safe. One of the core elements of the Vulnerability and Risk guidelines from the College of Policing for police responders includes ‘Curiosity’, which outlines core components for officers and staff to consider as part of exercising professional curiosity to identify and respond to vulnerability. Another product produced by the College of Policing includes a one-day vulnerability training package which encourages frontline officers and staff to look beyond the obvious and feel empowered to use their professional curiosity when dealing with those who are vulnerable. In addition, the College of Policing’s Authorised Professional Practice (APP) is an up- to-date source of policing practice which police officers and staff are expected to have regard to in discharging their responsibilities. The APP module on identifying, assessing and managing risk sets out a range of information and intelligence that police officers and staff should draw on to consider risk for the purpose of public protection. This includes reviewing a range of historical and dynamic factors, such as offending history, biographical and relationship factors, access and proximity to victims and other criminogenic factors. The College of Policing also has a Managing Sexual and Violent Offenders (MOSOVO) learning package which is designed to prevent sex offenders from reoffending. The learning package trains offender managers in conducting an active risk management assessment to identify risk factors that may increase the propensity of a given offender to reoffend. There is a specific module within that learning package that focuses on understanding offenders’ motivation and what works in deterring offenders and encouraging desistance. The College reviews the course continually based on feedback from trainers and trainees as well as changes to the operating environment. Lastly, the Home Office currently funds the Vulnerability Knowledge and Practice Programme (VKPP), which works with the National Police Chiefs’ Council’s Violence and Public Protection and Violence Against Women and Girls portfolios. The VKPP engages with forces and key partners to identify promising practice and share knowledge to shape future responses to serious crime that exploits vulnerability. This is with a view to improving policing's overall response, reducing threat and harm, bringing more offenders to justice and improving outcomes for victims. A22

The VKPP has a workstream to consolidate learning from case reviews into death and serious harm, which analyses and draws together police learning across several types of reviews, including Child Safeguarding Practice Reviews (CSPRs) (previously Serious Case Reviews); Safeguarding Adult Reviews (SARs); and Domestic Homicide Reviews (DHRs). I acknowledge that this work is only the beginning, but I will use every tool available to target perpetrators and address the root causes of abuse and violence. For too long, violence against women and girls has been ignored. Our landmark mission to halve violence against women and girls in a decade will require a step change in our approach to it nationally. That starts with tougher enforcement and protection. Under this Government, we will be introducing specialist rape and sexual offences teams in every police force. The most prolific and harmful perpetrators will be relentlessly targeted, using tactics normally reserved for terrorists and organised crime. Once again, we would like to take the opportunity to thank you for highlighting these matters of concern, and for giving us the opportunity to respond. We will continue to work with police forces to make sure we continue to improve the effectiveness and efficiency of the system that supports policing to manage sex offenders and prevent them from committing further harm.

Rt Hon Yvette Cooper MP Home Secretary

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HM Prison and Probation Service Central Government

31 Oct 2024 PDF

Action Planned

HMPPS is developing a new Continuing Professional Development risk learning product to be piloted towards the end of this year before being launched from February 2025, and has identified SEEDS2 as a 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. (AI summary)

View full response

Dear Madam,

Inquest Touching the Death of Elizabeth Sarah Jayne McCann

Thank you for your Regulation 28 Report of the 29th May 2024, following the conclusion of this Inquest and thank you also for extending the timescale for this response which is being issued on behalf of the Ministry of Justice.

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

In your Report, you raised the following concerns specifically in relation to the Probation Service which are responded to below.

The Inquest heard evidence that the probation staff were carrying significant caseloads. This was due to challenges in recruiting sufficient staff. The evidence was that there is still a national shortage of probation officers. Steps have been taken to recruit and train further probation officers which provides some assistance but means that overall, a significant number of probation officers are young in service and experience.

It was important that newly qualified probation staff were closely supervised and supported by their managers. Without that supervision performance issues identified by the trackers were not being tackled. Ensuring this had been and was challenging as the number of staff line managed by senior probation officers had been too high. This was being addressed but was only achievable if sufficient senior staff were retained.

Whilst at a national level, the staffing position of the Probation Service is improving, it remains the case that raising staffing in some Probation Delivery Units (PDU) to a full complement remains a significant challenge. Until such time as the situation improves, in PDUs with acute pressure remaining, staff will follow a Prioritisation Framework which was A24

first implemented in January 2022. Those PDUs will also benefit from wider national workload relief through Probation Reset as reflected in a refreshed Prioritisation Framework published in May 2024.

We continue to prioritise recruitment to put the Service on a sustainable footing and secure 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. 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.

HMPPS also recognises the pressure placed 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 by way of continuing professional development, and additional support from dedicated case administration officers to reduce the demand on SPOs in relation to administrative tasks.

Clear Information Sharing protocols between Probation and such groups as drug and alcohol services were limited. Without clear agreements understood by both sides there was a significant risk that crucial information that impacted risk assessments would not be shared

The HMPPS Information Sharing Policy Framework sets out clearly the steps to be taken to share information in addition to the various statutory frameworks for the sharing of risk information. This includes guidance on the preparation of Information Sharing Agreements in the absence of a contractual arrangement with a partner agency which will include information sharing protocols.

As well as improving information sharing protocols, 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. The professional standards will, alongside increased staffing levels 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.

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 A25

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.

It was accepted that there needed to be a level of professional curiosity by staff dealing with high risk offenders such as in this case and that training for probation officers and police staff needed to reinforce that

Professional curiosity in the Probation Service is an essential part of the assessment and management of risk and is a golden thread throughout the recently updated risk training material available to all probation practitioners. It will also be incorporated into the new Continuing Professional Development risk learning product, which is currently being developed by HMPPS in conjunction with subject matter experts. This 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 and middle managers. In recognition of the importance of SEEDS2, this been identified as a 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.

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 with their line manager, who provides feedback based on observations and other sources of information.

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.

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

GMP Police / Law Enforcement

PDF

Noted

No actions or plans described. (AI summary)

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Report sections

Investigation and inquest

On 26th August 2022 I commenced an investigation into the death of Elizabeth Sarah Jayne McCann. The investigation concluded on the 19th April 2024 and the conclusion was one of unlawful killing. The medical cause of death was 1a) Ligature strangulation.

Circumstances of the death

Elizabeth Sarah Jayne McCann was raped and murdered on 25th August 2022 at the home address of her murderer, 91 Manchester Road, Ashton under-Lyne. Her murderer was on a life licence at the time and on the Sex Offenders Register as a consequence of his convictions in 2009 for rape, sexual assault and Section 20 assault. He had met Elizabeth through the Health and Wellbeing College run by Pennine Care. Whilst he was on licence, he had been signposted by Probation to the Wellbeing College run by Pennine Care NHS Foundation Trust. The College and Probation had previously agreed the college would accept some Probation clients. There was a failure by the college and Probation to set up a clear, documented system for how this would work and how risk would be managed. Within the college there was a failure to ensure that there was a system for how this information from Probation would be received and scrutinised effectively. There was a failure by the college to set up a risk management system for attendees such as him. As a consequence of these failures her murderer joined the college without any risk assessment having been undertaken and without the college recognising the risk he posed. It is probable that had there been an effective system in operation that: either he would not have been accepted at the college at all or would not have been accepted without a stringent plan to manage his risk, these failures by the college and Probation probably contributed to Elizabeth's death. It was known to Greater Manchester Police (GMP) and Probation that he posed a risk in certain circumstances. The areas of focus for an increase in risk were alcohol use, lone females, intimacy and rejection. Whilst he was being supervised under licence and in accordance with the Sex Offenders Register management, both his Probation Officer and Police Offender Manager had caseloads far in excess of what were safely manageable. This was because Greater Manchester Police had failed over a period of years to adequately staff the Sexual Offender Management Unit and the Probation service did not have sufficient probation officers available due to recruitment challenges. Whilst managing him in March 2022, he disclosed to his Police Offender Manager that he had recently had a small relapse with alcohol but Change Grow Live had declined to assist him. That information was not shared with Probation and not investigated further probably due to the excessive workload of the Police unit. On 6th April he disclosed to Probation that he had met a woman and believed it would develop into an intimate relationship. The information was shared that day with Greater Manchester Police. There was a failure by Greater Manchester Police and Probation to action that information. In addition, the officer working for Greater Manchester Police who was spoken to failed to appropriately record the information. This was probably due to the excessive workload in the unit against the staff numbers. On 12th April when it was indicated that the woman had decided not to pursue the relationship with him, Police and Probation failed to exhibit any professional curiosity as to whether the relationship was as described and in particular failed to speak to the woman; and failed to recognise that the basis on which his risk had been assessed was changing. There was a failure to consider if additional work needed to be undertaken with him. It is probable that the large caseloads contributed to the lack of professional curiosity as it meant there was little time available to consider the emerging picture. It is possible that this lack of action by Greater Manchester Police and Probation contributed to Elizabeth's death. In July 2022 he approached a woman he had met at college at a public house in Ashton. He was under the influence of alcohol. He touched her and tried to kiss her without her consent. She reported the incident to the college Senior Management team because she was very concerned about the incident. The college Senior Manager failed to recognise it was a safeguarding issue and spoke to him informally. On 18th August 2022 she made it clear to him that she did not want a relationship with him. Had there not been a failure by the college and Probation to set up an effective referral system and had there not been a failure by the college to set up a system for dealing with emails from Probation then it is probable the college would have known his status and have escalated the event to Probation and recognised it as high risk in relation to his behaviour. It is probable that the college would have taken action that would have prevented him from accessing the college after the reported incident. It is probable that Probation would have recognised this was a deteriorating situation, reassessed risk and taken steps to reduce the risk he posed to the public and in particular to women. None of these actions happened as a consequence of the failure to have an effective system in place to manage high risk referrals such as him. As a consequence, he continued at the college and Probation were unaware of these events and no action was taken by them. It is probable that had there not been a failure to share the July 2022 incident which was caused by the previous failures Elizabeth McCann would not have died on the day she did. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. –
1. The inquest heard evidence that the probation staff were carrying significant caseloads. This was due to challenges in recruiting sufficient staff. The evidence was that there is still a national shortage of probation officers. Steps have been taken to recruit and train further probation officers which provides some assistance but means that overall, a significant number of probation officers are young in service and experience.
2. The evidence before the inquest was that it was important that newly qualified probation staff were closely supervised and supported by their managers. Without that supervision performance issues identified by the trackers were not being tackled. Ensuring this had been and was challenging as the number of staff line managed by senior probation officers had been too high. This was being addressed but was only achievable if sufficient senior staff were retained.
3. Evidence before the inquest was that if probation referred clients under supervision to places such as the Health and Wellbeing College this would, if not implemented effectively pose a significant risk to vulnerable users of such institutions. If referrals were made without a protocol being in place that dealt with managing risk then the risk posed increased further.
4. Clear Information Sharing protocols between Probation and such groups as drug and alcohol services were limited. Without clear agreements understood by both sides there was a significant risk that crucial information that impacted risk assessments would not be shared.
5. The inquest was told that nationally a significant number of police forces were struggling to adequately staff their Sexual Offender Management Units. As a consequence, the level of supervision of sex offenders in the community was being risk managed posing a risk to communities.
6. In the case of Greater Manchester Police, the staffing issues had been known by senior managers for a number of years (many years before Covid) and a decision taken to risk mange far below the appropriate staffing numbers taken. The consequence was that the staff in the unit could not effectively manage their caseloads that were far in excess of the recommended level. The numbers in the unit were increasing but the caseloads were still high.
7. The GMP investigation into their role in relation to Elizabeth’s death was poor in quality and there was no evidence that any senior officer had considered the report. The inquest was told that the quality and lack of referral upwards of a report was not unique to Elizabeth’s case.
8. There was no evidence before the inquest of any professional curiosity by senior GMP officers as to the role of GMP and if lessons could be learnt. It was unclear as to why senior officers were unsighted.
9. It was accepted that there needed to be a level of professional curiosity by staff dealing with high-risk offenders such as in this case and that training for probation officers and police staff needed to reinforce that.
10.The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place. There was also a need for effective information sharing protocols and effective well understood safeguarding provisions.
11.The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.

Copies sent to

2) Tameside Metropolitan Borough Council

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Shared signals

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Report details

Reference: 2024-0288
Date of report: 29 May 2024
Coroner: Alison Mutch
Coroner area: Manchester South

Responses identified

Responses identified 5 of 5

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 24 Jul 2024 (estimated).

Sent to

Department of Health and Social Care

Greater Manchester Police

Home Office

Ministry of Justice

Pennine Care NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.