James Furlong, Joseph Ritchie-Bennett and David Wails

Dear Judge Fulford,

The Forbury Gardens Inquests Report on Action to Prevent Future Deaths Response of Oxford Health NHS Foundation Trust

Thank you for your letter of 20 May 2024. I write to respond to your concerns.

Paragraph 45 of your report is directed at Oxford Health NHS Foundation Trust (“OHFT”). My colleague , Forensic Service Manager, provided a statement to the inquests in which she explained that OHFT has held the contract for provision of integrated mental health services into Bullingdon and Huntercombe prisons since October 2022. The contract that OHFT signed to provide integrated mental health services is between OHFT and a company called Practice Plus Group, rather than direct between OHFT and the Prison Service. Practice Plus Group holds the contract with the Prison Service for overall provision of medical care into the prison.

Paragraph 45 records –

As regards MPFT, they no longer provide secondary healthcare services in HMP Bullingdon and Huntercombe. Therefore, this Report (in this context) is directed primarily at OHFT; nonetheless it will be provided to MPFT who continue to provide services in other prison establishments. I have also directed that it is sent to NHS England so that appropriate national action in this area can be considered. , service manager for OHFT, was specifically asked to address the “tracking” of prisoners as they moved between prisons. It became clear during the evidence that there were wider issues with the shortage of staff in prisons to provide psychological treatment and with the processes to prioritise and track prisoners on the waiting list to ensure that they were seen (regardless of whether they transferred or not). As a result, and without criticism of her statement, does not address the current position on the level of psychological services at HMP Bullingdon and HMP Huntercombe against the background of the previous failure by MPFT to provide these to KS at any stage whilst he was in prison. I suggest that for a prisoner demonstrating KS’s risk factors, he should have been offered, within the limits of available resources, the opportunity to participate in long term psychology sessions. I request that this issue is addressed by OHFT in its response to this Report, in order to prevent future deaths.

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OHFT currently provide psychological services for HMP Bullingdon and HMP Huntercombe as part of the integrated mental health team. The evidence based psychological interventions are delivered based on clinical need and sentence length, in line with the NHS Stepped Care Model and National Institute of Clinical Excellence guidance. These include psychotherapy, cognitive behavioural therapy [CBT], trauma focussed-CBT, and eye movement desensitisation and re-processing.

Any staff who work within the prison can make referrals into the mental health team, as well as self-referrals from any prisoners themselves. All referrals made to the team will have a face-to-face triage appointment. A multidisciplinary team (MDT) discussion follows each referral. If the MDT identifies a need for psychology that person will receive a full assessment through which their needs and treatment pathway will be determined. Anyone who is waiting to start psychological treatment will be placed on an electronic waiting list on SystmOne, and assigned a mental health nurse who will meet with that person monthly until their appropriate psychological treatment has commenced. Mental health nurses also deliver emotional management and coping skills groups, which can be offered during the waiting period. The waiting list is managed by the psychology staff, and when a prisoner is discharged after they finish their treatment, the next person on the waiting list will then be offered a place to start their treatment. The waiting list is determined on a first come first served basis. The exception to that is when a prisoner is a veteran of HM Forces, which is standard practice across all prisons.

If a prisoner has commenced a psychological treatment, they would be placed on a medical hold to prevent a transfer to another prison. That is so they can finish their treatment. If a prisoner is transferred elsewhere whilst waiting to start psychology, the receiving prison would be informed that the prisoner in question was on the waiting list through detailed handovers, and both oral and email confirmation. Standard process would be for the prisoner to then be placed on the waiting list (for psychology) at the receiving prison. The prisoner would then be seen by the receiving prison’s psychologist for a triage assessment, subject to the receiving prison having a psychology provision. Timescales vary at establishments based on demand.

At HMP Bullingdon the current staffing model is a 0.8 whole time equivalent (WTE) band 7 psychotherapist, a 0.3 WTE band 8a forensic psychologist, and two band 5 psychological wellbeing practitioners who are currently due to start in the service in July 2024. In the past 12 months there have been 116 referrals for psychology, 17 patients are engaged in therapy currently, and 34 patients waiting. The average waiting time is around 14 weeks. We also have a Consultant Forensic Psychologist who oversees the governance of the psychological therapies pathways within the mental health teams, including managing caseloads of the psychologists and psychological therapists.

At HMP Huntercombe the current staffing model is one WTE band 4 assistant psychologist and 0.3 WTE band 8a psychologist. The service has not been able to fill these posts and a business case was submitted by the service to commissioners that proposed three alternatives to the staffing model. The purpose of the business case is to give us the best chance to recruit into posts, to increase the provision for psychology and to expand the service which can be offered. The business case has been submitted and we hope to receive a decision in July 2024. There are high levels of trauma within the establishment and the focus will be to treat the trauma and any associated symptoms.

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In terms of actions that it will be helpful for the Trust to consider, the service will consider if they should introduce guidance for psychological therapy staff about what to record when an individual declines treatment in the prison pathway, to include guidance that declined offers of treatment are always considered in caseload management supervision.

I hope that this response provides you with the information that you require, but of course please do not hesitate to contact me if OHFT can assist further.

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Home Secretary 2 Marsham Street London SW1P 4DF

SIR ADRIAN FULFORD PC

By email only 9 September 2024

FORBURY GARDENS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS RESPONSE OF THE SECRETARY OF STATE FOR THE HOME DEPARTMENT

Thank you for all the diligent work you and your legal team have undertaken during the inquests arising from the deaths of James Furlong, Joseph Ritchie-Bennett and David Wails in the Forbury Gardens terror attack of 20 June 2020. Before responding to your letter of 20 May 2024, I would like to express my deepest condolences to the families and loved ones of James, Joseph and David, as well as my thoughts to all those impacted by this tragic incident. It is crucial that we do everything within our power to prevent this from happening again.

I am grateful for your recognition in the Regulation 28 Report to Prevent Future Deaths (the Report) that the Home Office has made several improvements since this tragic incident. I fully accept and support your conclusion that there must be effective monitoring of these improvements to ensure they meet their purpose and I address the relevant measures in this regard below.

I would like to acknowledge that the events described cover a period under a previous government and reiterate my commitment as Home Secretary to treat the failures with the utmost seriousness. I will be overseeing the proper implementation of recommendations and any new commitments made.

Prevent

The Home Office, along with our partners, continuously drives improvements to our capabilities to strengthen our approach to supporting those vulnerable to being drawn into terrorism. We do this through regularly reviewing elements of the Prevent system, both at an operational and strategic level. As I will detail further in my response, this includes conducting process reviews, case assurance and producing annual statistics to inform and improve policy and strategy. We also commit to implementing improvements from the independent evaluation of the Home Office Channel programme, which is currently underway and expected to report in 2025/20261. As Michael Stewart, Director of Prevent,

1 As stated in Michael Stewart’s witness statement, evaluation of the Prevent system is a priority. We are evaluating Channel’s effectiveness to understand its impact on counter-terrorism outcomes and risk. The core objective is to fill these evidence gaps by consolidating best practice in preventing or countering violent extremism (‘P/CVE’), evaluation, and trialling innovative approaches to significantly build the evidence base and to shape government responses to the threat of violent extremism. This will be an independent evaluation, conducted by Ipsos and University College London. This is a significant piece of work and will be the first of its kind in this field.

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said in his evidence, we know that no programme of this type can offer a complete guarantee of success, however, we must do everything we can to ensure we are working to the best of our ability to stop such terrible attacks occurring in future. Any failure must be treated with the utmost seriousness.

The Home Office is also keeping the Joint Enhanced Casework Team’s (JECT) operations under close review and is continuing to develop and improve its processes. This includes oversight of JECT to ensure that the range of interventions available are effectively managing individual cases. Oversight is through the CONTEST Board which is a senior officials board that meets monthly to monitor the implementation of CONTEST and ensures that we maintain collective decision-making and effective co-ordination across government. It brings together senior operational and policy leaders from each of the government departments included in CONTEST, Counter Terrorism Policing Headquarters (CTPHQ) and the security and intelligence agencies. As well as being part of regular discussions in the monthly CONTEST board structure, every six months JECT’s performance is considered as one part of CONTEST’s wider performance review.

The failure to maintain and disseminate an adequate intelligence picture: Prevent2

The Home Office's Prevent directorate provides the strategic direction for Prevent, including Prevent relevant training to non-police Prevent statutory partners within local authorities. The police are responsible for managing the terrorism risk of individuals throughout all stages of the Prevent pathway, as well as the policy, assessment tools, and training of police officers and staff conducting these assessments. As all of KS’s referrals were closed at the initial assessment stage by Counter Terrorism Policing Prevent officers, the Home Office Channel programme did not manage the case. Therefore, effective monitoring of the operational Prevent issues raised in the Report is best addressed by CTPHQ.

However, as part of the Home Office’s efforts to improve the Prevent system, we are working with partners including CTPHQ on multiple projects. These aim to better manage risk and improve the quality of our data, to further enable robust monitoring of the effectiveness of Prevent. I have set out the developments and monitoring in place for the three areas of concern identified in the Report for Prevent, which are within the Home Office’s remit.

a) Overall failure to revisit and review the overall intelligence and risk assessment picture in light of newly acquired information

I understand that the Home Office and CTPHQ launched a new joint Prevent case management system in May 2024. In developing this system, I am told we have ensured that when a new Prevent referral is registered, any previous referrals are automatically flagged to ensure this information is fully considered during the initial assessment stage and throughout the individual’s Prevent pathway. I am concerned about the specific issue of repeat Prevent referrals falling below the threshold and am committed to look closely at this. This new case management system also provides CTPHQ and the Home Office access to data trends, which allows for consideration of any outliers in decision making. These outliers can be flagged for potential further action. This includes additional training for the Counter Terrorism Case Officers (CTCOs)3, who undertake the assessment of Prevent referrals, or the Channel panel, or further investment in the local area if the threat has increased.

2 Responding particularly to paragraphs 18-21 of Judge Coroner’s Report of 20 May 2024. 3 CTCOs are responsible for managing referrals and cases through the Channel process (including ensuring case information is kept up to date on the case management system), reviewing and amending the Prevent assessment framework, assessing any escalating risk, and transferring cases to police led partnership/Pursue where appropriate.

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As I understand Chief Constable will also be addressing in Thames Valley Police’s response to you from the operational perspective, the Home Office and CTPHQ have also worked with the national CT Assessment and Rehabilitation Centre (CT-ARC)4 to develop a new Prevent assessment framework (PAF). I understand that this replaces the Vulnerability assessment framework and is designed to ensure that the triaging of referrals into Prevent is consistent, rigorous, and proportionate. I am told the PAF, which has been independently endorsed, will ensure that thresholds and decision-making are implemented consistently across all ideological threats by creating a framework that is easily understood, easily completed, and supports CTCOs in their decision making. It covers referral details, indicators of concern, a susceptibility assessment, engagement factors, intent factors, capability factors, protective and risk mitigating factors, and support planning. The PAF also captures repeat referrals to ensure consideration is given to cumulative risk, which is an issue I am concerned about. I understand that this new tool is more reflective of current research and understanding of those vulnerable to being drawn into terrorism; it will identify referrals suitable for Prevent and the Channel process earlier and more accurately; and it will improve the quality and effectiveness of risk assessments of referrals adopted as cases.

The PAF is being rolled out in Autumn of 2024 to all regions. Prior to using it, CTCOs must attend an assessed training day to become familiar with the PAF, how to complete it, how it fits into current processes, and to practise completing it. During the training day there are three assessment points where attendees will be assessed as either ‘Ready’ or ‘Not Yet Ready’ to complete a PAF for live cases. If awarded ‘Not Ready’, attendees will be provided a further opportunity to complete the task training.

I understand that the PAF has been piloted since November 2023 in the South-West and Eastern regions. During this pilot stage, as well as receiving feedback on the PAF, I am told that CT-ARC have been quality assuring the PAF process monthly to assess the quality of use and completion by looking at how integrity to the guidance is upheld. We will continue to monitor the PAF with CT-ARC and CTPHQ to ensure it is robust, efficient, evidence- informed, operationally viable and well-integrated into the current system. Details of how longer-term quality assurance will be conducted will be finalised in August ahead of national PAF rollout later in autumn. However, this will include continuous and regular review of PAF use, as well as a longer-term evaluation. As the PAF is embedded into the Prevent pathway it will also feature within existing Home Office quality assurance systems, specifically quality assuring the PAF’s operational application by Channel panels in the assessment of risk and provision of support.

b) Failure by Prevent to correctly assess risk, by over emphasising mental health difficulties

Improving the quality of Prevent referrals

4 The CT Assessment and Rehabilitation Centre (CT-ARC) is a national HM Prison & Probation Service (HMPPS) body comprising a network of specialist psychologists, probation officers, and other staff who focus on standards for risk assessment, risk reduction and rehabilitation.

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In 2023 the Home Office updated the Prevent duty guidance (England and Wales)5 and the Channel duty guidance6. My understanding is that this is to better enable those sectors subject to the Prevent duty (such as local authorities, police, health, education, and prisons and probation) as well as those working on Channel panels, to be effective at understanding and mitigating terrorism risk, and to have structures in place that identify and support people vulnerable to radicalisation. The new guidance provides clearer advice on how to understand and manage risk, including by ensuring comprehensive training and risk assessments take place. It also introduces new tools for frontline practitioners to ensure that those meeting the Prevent threshold are progressed for Prevent specific support, with a focus on ideology as a determinant of Prevent thresholds. I outline relevant training packages on ideology later under the subheading of training.

Our updated guidance advises front-line staff to use the national Prevent referral form to submit their initial concerns. This single Prevent national referral form, while not mandatory, has been provided to all partners to promote consistency. I have been told that it has been designed to be completed by front-line staff who may not have specialist knowledge of radicalisation. It requests information around ideologies, behaviours and relevant factors, encouraging the person submitting the referral to provide as much relevant information as possible. This is to ensure specialist officers can make an effective assessment of risk, including in the PAF, and improve data recording. We have also updated the GOV.UK Prevent page7 to make clear that referrals should be made where there is a genuine concern of radicalisation, and that ideology should be a critical consideration.

We are using Prevent referral data (from the new case management system) and training data to identify where the quality of referrals is lower, or not in line with the risk in that area or sector. This has enabled us to better target Prevent outreach and training to improve the quality of referrals. Alongside this, a refreshed list of ideology categories has also been created for use in the new case management system, which will be accompanied by updated training and guidance for case officers to ensure accurate recording of data and evidence about ideology. We will review the ideology categories on an annual basis to ensure they are reflective of the wider ideological picture and routinely monitor Prevent data, carrying out dip sampling to provide assurance that there are no disparities in decision-making throughout the Prevent pathway.

Improving mental health management within Prevent cases

The relevance mental ill-health conditions play in the threat varies by case. Mental ill-health can contribute to the radicalisation of some individuals, acting as a risk factor, while in other cases it may act as an inhibitor.8 The majority of Prevent practitioners are not mental health professionals and anecdotal evidence from those practitioners indicates that they remain concerned about the incidence of diagnosed and undiagnosed mental health conditions within Prevent casework. That is why it is essential that there is multi-agency involvement in the Channel process so that Channel panels can pull on the professional expertise of mental health practitioners when progressing cases. This includes advice on the type of activities

5 England and Wales: https://www.gov.uk/government/publications/prevent-duty-guidance. Statutory guidance for Scotland was issued on 7 May 2024 under Section 29 of the Counter-Terrorism and Security Act 2015: https://www.gov.uk/government/publications/prevent-duty-guidance-for-specified-authorities-in- scotland. 6 The Channel duty guidance for England and Wales: https://www.gov.uk/government/publications/channel- and-prevent-multi-agency-panel-pmap-guidance. 7 https://www.gov.uk/guidance/get-help-if-youre-worried-about-someone-being-radicalised. 8 See p. 15, paragraph 27 of CONTEST 2023: https://www.gov.uk/government/publications/counter-terrorism- strategy-contest-2023.

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that should be included in a support package9, as well as attending panels to provide an update on the progress of support given.

The Clinical Consultancy Service (CCS)10 can also be drawn on to provide Prevent officers with advice, guidance and options to help manage the individuals in their casework with mental health needs. Through this service Prevent officers are given access to a multi- disciplinary team, including NHS mental health nurses, psychologists and psychiatrists. The Home Office are part of the oversight board of the CCS to monitor its effectiveness in helping to reduce the risk of those individuals vulnerable to being drawn into terrorism.

The PAF is used by Channel to guide decisions about whether someone needs support to address their radicalisation risk, and the nature of support that they need. PAF training makes clear that mental health concerns can be a potential indicator of concern or a safeguarding factor, directing that any mental health support being received may form part of the information gathering process on an individual who has been referred. Mental health and complex needs are also considered as potential engagement factors, so consideration must be given as to whether the existence of any mental health difficulties could contribute to make an individual more vulnerable to engaging with an extremist group, cause or ideology.

As a challenging area for research, we recognise the importance of ensuring that Prevent practitioners have up to date guidance which assists them in understanding how best to understand the relevance of mental health for an individual. The latest Channel duty guidance reinforces that having mental health issues does not exclude a person from being suitable for Prevent. Rather, any relevant mental health issue is one of several factors which should guide decisions about whether the individual needs support to address their risk of radicalisation, and the kind of support that they need. Several of the case studies within the guidance have mental health elements to illustrate this. The Home Office will continue in its guidance to be clear that for Prevent, cases should not be presented as a binary choice between mental health interventions or counter-terrorism ones. We keep our operational policy approach to Prevent under constant review, and we will continue to look at mental health issues and neurodiversity as part of this, to identify areas we can strengthen.

To further this point, we have written to all Channel Chairs to raise awareness of the concern in the report that KS’s risk assessment was incorrectly focused on his mental health difficulties, and to reinforce that the purpose of Channel is both to safeguard individuals and to manage the potential terrorist risk they may pose. Therefore, the existence of or need for wraparound mental health support for an individual does not negate the need for the person to receive Prevent support. We also reminded Channel Chairs that the CCS is available to provide Prevent officers with advice, guidance and options to help manage the individuals in their casework with mental health needs.

c) Failures of training, supervision and selection

Training

9 See paragraph 157 of the Channel duty guidance 2024 for examples on the type of support which could be offered: https://www.gov.uk/government/publications/channel-and-prevent-multi-agency-panel-pmap- guidance 10 The Clinical Consultancy Service (CCS) was launched by CTPHQ on 2 April 2024, (building on the Vulnerability Support Hub pilots which you heard from several witnesses on) to provide access to a nationally consistent service.

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The Home Office Prevent directorate is one small part of the Prevent system, which operates at a mainly strategic level. The successful delivery of Prevent is dependent on the engagement of national, regional and local partners across multiple sectors, including the community and voluntary sector. Public sector frontline staff have been identified as a key group that can make an important contribution to identifying and referring people who may be at risk of radicalisation. Likewise, the success of the Channel programme is dependent on the co-operation and co-ordinated activity of partners so that a wide network of support is brought together to reduce a person’s terrorism or radicalisation risk.

Prevent staff in the Home Office

In July 2023, I am told, we created and started implementing a Prevent Professionalisation Plan to upskill Home Office officials working on Prevent through compulsory training and a new induction programme. All directorate staff were mandated to complete the Prevent duty training (both the awareness course and the referral course, which are part of the e-learning package referred to below)11 by end of September 2023. All directorate staff must retake the awareness and referral courses every two years and complete the refresher course in the year between. All new starters must complete the awareness and referrals courses within three months of starting in role, as part of their wider Prevent induction. In addition, a specialist ideology training package was developed by the Commission for Countering Extremism (CCE), which provides the government with impartial and expert advice on terrorism and extremism matters. I understand that this was rolled out as face-to-face training for Prevent directorate staff by the CCE in March and April 2024, training approximately 88% of the directorate in post at the time. Future training requirements will be kept under review.

Frontline staff subject to the Prevent duty

I have been told that the Prevent duty e-learning training package was updated in August
2023. Each of the four courses12 has specific learning outcomes to support awareness of Prevent and radicalisation; making a referral; and the Channel programme. Following this refresh, we monitor training uptake monthly and publish monthly performance data13. Over
1.4 million people have completed the training since it went live in August 2022. The current process provides learners with a certificate at the end of the training which they keep for their own records and to use as evidence for completion of training. I have been told that some sectors have created a Prevent learning goal/objective on their internal performance or training systems, which requires completion of the Home Office e-learning, particularly for front line staff. Staff upload a copy of the learning completion certificate to the platform to demonstrate it has been completed. This has aided supervisors at a local level to have consistent oversight of training. The published monthly regional performance data14, provides an insight into the extent of training delivery at a regional level. Whilst this would not be suitable for individual local authorities to monitor training, it does provide insight into training uptake across different regions.

A new face-to-face training package to raise awareness of Prevent has also been developed and is being implemented. This is designed to help attendees understand what may make people vulnerable to radicalisation and understand more about the local context. This will enable specialist trainers to have more detailed discussions, including on how to make high quality referrals that are relevant to Prevent. It also enables training to be tailored to the

11 https://www.gov.uk/guidance/prevent-duty-training. 12 https://www.gov.uk/guidance/prevent-duty-training. 13 https://www.support-people-susceptible-to-radicalisation.service.gov.uk/service-performance. 14 https://www.support-people-susceptible-to-radicalisation.service.gov.uk/service-performance.

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specific sector, location or role. During the pilot waves we are testing the service with existing trainers, and new Prevent training leads across England, Scotland and Wales. I understand the pilots have been running since 20 May 2024, and are being run nationally across health, local authority and education sectors with the final pilot in early September. We are piloting this service until late autumn, with wider rollout to follow once any final changes and improvements have been made based on user feedback.

We are also developing a new ideology training course to include as part of our face-to-face and e-learning training packages. The course has been developed with experts from the CCE and other subject matter experts within the Home Office. The ideology course includes modules on Islamist ideology, Extreme Right-Wing ideology, antisemitism and other types of concern. It is being developed to support frontline staff under the Prevent duty to understand the ideological nature of terrorism and to enable them to make an informed referral where the ideology present is identified and known. This will provide learners with a basic understanding of extremist ideology and radicalisation. The training will outline factors to consider when making a referral, such as the importance of ideology, common narratives, and a reflection of the current threat picture. This increased understanding will support sectors in making more appropriate and relevant Prevent referrals that can progress to Channel. The ideology training course will be available across the education, health, police and local authority sectors in England, Scotland, and Wales. The intention is for suitable trainers from each of these sectors to deliver in-person or virtual sessions, with the training package available on our online platform for registered trainers to access and deliver. I have been told that user research sessions were delivered with trainers across four identified sectors for police, education, local authority and health during January to early February
2024. The training modules were allocated to regions in accordance with the risk and threat in the area to ensure it was relevant to the local audience. Sessions were delivered in both virtual and in-person settings to gather feedback and understand the impact of different methods. Final iterations were made in response to feedback from learners and trainers. The training will be piloted and rolled out alongside the face-to-face training package in late autumn.

Channel panel members

Alongside sector specific training, Channel panel members and partners should complete the previously mentioned Prevent duty training courses. The Channel course of the Prevent e-learning package has tailored content for Channel chairs and for those who are new to attending Channel panels. Channel chairs and deputy chairs are also required to complete mandatory ‘delivering Channel locally’ training within six months of starting these roles, which is centred on building understanding of the Channel duty guidance requirements and standards. The Home Office has also commissioned a range of additional training (including training on different ideologies, the online threat picture and neurodivergence) to meet the needs of Channel chairs, deputy chairs and panel members in fulfilling the requirements set out within this guidance and to understand the national risk and threat picture.

Supervision and assurance

Identifying and supporting those vulnerable to radicalisation helps to keep us safe and specified authorities play a vital and valued role in this. The Prevent duty guidance sets out best practice and expectations for each sector and, by following it, specified authorities will be well placed to comply with the duty, underpinned by the Counter-Terrorism and Security Act 2015 (CTSA 2015). The guidance details at Section 4 the monitoring and assurance arrangements for each sector subject to the Prevent duty. There are a range of existing

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powers available to encourage compliance15. However, where a specified body is not complying with the duty, the Secretary of State may use the power of direction under Section 30 of the CTSA 2015 to give directions. These directions may be enforced by court order. 

I have been told that in support of our role in supervising local delivery, in 2021 we established an expert network of region-based Home Office Prevent Advisers who work together with partners across England, Scotland and Wales to raise Prevent delivery standards and hold local authorities to account. Prevent Advisers also deliver an annual assurance exercise, which assesses the extent to which local authorities are meeting the Prevent duty. As part of the Prevent duty guidance refresh in 2023, I understand that the Home Office updated its assurance process to help ensure that local authorities are delivering their statutory Prevent duty in line with the Prevent duty guidance. The Prevent duty toolkit for local authorities16 outlines eight benchmarks that Prevent delivery is measured against and includes suggested examples of good and best practice. The Home Office has worked with all local authorities in England and Wales to complete a Prevent assurance exercise for FY23/24 against seven of the eight Prevent duty benchmarks17. This is the third year that we have assessed local authorities in this way. This exercise provides the Home Office with assurances that the Prevent duty is being met in proportion to the threat and risk in each area. It also helps to understand where there are gaps in Prevent delivery, to identify and share good practice, and to improve performance and standards, which often involves direct support from the Home Office.

Following the introduction of the Channel Quality Assurance Framework in 2021, we are introducing an improved and strengthened quality assurance process. This includes routine assessment of Channel panel performance and case management. We will also utilise the data trends drawn from the new case management system to identify areas (regional or thematic) to provide additional case assurance and direct improvements where needed. We will use this quality assurance process and performance monitoring to further drive-up standards of delivery. I have been informed that this process started in April 2024 and initial results are expected to be shared with Channel panels in April 2025.

Where serious case reviews, safeguarding adult reviews or domestic homicide reviews are triggered due to a serious incident or a death involving a person supported through Channel, input from local Prevent practitioners (including the Channel chair and CTPHQ) should be sought to support the identification of practice improvements and shared learning. The Home Office is currently working with relevant partners to raise awareness of this new process to ensure that the Home Office is notified in these instances. Report findings detailing recommendations and any identified learning should also be forwarded. Where terrorism offences or incidents of serious violence are committed by people with a Prevent history and a statutory review process is not triggered, a Prevent learning review may be undertaken to identify national learning and drive system improvement. Where these instances are assessed as high harm by the Home Office, Prevent learning reviews may run in tandem with statutory review processes. The focus of a Prevent learning review is not to apportion blame, but to use reviews to identify good practice and where improvements are

15 For example, for local authorities: if there are concerns about compliance, the Home Office may consider the appropriateness of using existing mechanisms such as appointing an inspector, requiring the local authority to undertake specific actions, requesting an inquiry, or issuing a direction. Powers under the Local Government Act 1999 or the Local Government and Elections (Wales) Act 2021 may be used. 16 https://www.gov.uk/government/publications/prevent-duty-toolkit-for-local-authorities. 17 An assurance of the eighth benchmark, Channel, was not completed, as this is subject to a separate process (i.e., the Channel Annual Assurance Statement).

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needed, which can inform and strengthen Prevent legislation, policy or practice at the national level.

A new independent Standards and Compliance Unit (StaCU) was established in February 2024 by the CCE. This provides a clear route for both the public and practitioners to raise concerns about Prevent activity and delivery18. The unit triages complaints to the relevant body for investigation and ensures these complaints are handled promptly, fairly and transparently. The unit monitors data trends and any trends are reported into the Prevent Ministerial Oversight Board19 (PMOB), where Ministers can instruct investigations into specified authorities where there is concern over a failure to discharge the Prevent duty. Prevent senior management will also consider the findings of StaCU outside of the PMOB meeting cycle. This acts as a quality assurance mechanism for the Prevent system to ensure any systemic issues are resolved quickly and that Prevent continuously improves.

Selection of support providers

Multi-agency involvement in the Channel process is essential to ensure that people at risk of radicalisation have access to a wide range of support, from specialist services to diversionary activities. As mentioned above, Channel panels can pull on the professional expertise of mental health practitioners when progressing cases. It also ensures the full range of information is accessible to the panel, so that ideological drivers, risk, vulnerabilities and support needs can be fully assessed. Therefore, the Channel panel chair is responsible for inviting the appropriate representatives to each meeting as panel members and for establishing effective relationships across partners of the panel to ensure effective co- operation, information sharing, attendance at panel meetings and delivery of support.

Where a Channel panel identifies that an individual would benefit from an Intervention Provider (IP), the Channel case officer20 is responsible for arranging the provision of that service. IPs are vital to Prevent and work directly with Channel and Desistance and Disengagement Programme participants to help reduce their risk, often challenging and supporting individuals with a wide range of complex needs. IPs are experienced in assessing ideological drivers, possess an expert understanding of radicalising extremist narratives, can counter these narratives, and receive comprehensive Home Office training to support their work. When commissioning an IP the priority will always be to match the specific IP skillsets to the requirements of the person receiving support, and so Channel case officers will present three potential IPs to the panel wherever possible.

IPs work on a one-to-one basis with people who are vulnerable and potentially dangerous, and they are therefore subject to a rigorous recruitment process and must receive ministerial approval to work on the programme. Strengthened due diligence processes for IPs have been in place since July 2020. Continued professional development and professionalisation of the network of IPs is essential. A comprehensive IP training programme (called the IP Professionalisation Programme) was introduced in 2019 in support of their roles, which includes a range of mandatory skills-based courses to improve consistency in delivery, and to increase their knowledge and understanding of key themes. A monthly operational update ensures IPs are regularly provided with a contemporaneous picture of online activism. This

18 Complaints about how the Prevent duty has been applied, including any problems with Prevent training, can be made online: https://www.gov.uk/guidance/make-a-complaint-about-prevent. 19 The Prevent Ministerial Oversight Board is chaired by the Security Minister and convenes bi-annually. The PMOB increases oversight of Prevent, enables a truly cross-government approach to Prevent and is a clear decision-making forum. 20 Any reference to the Channel case officer refers to either the police CTCO or the Home Office-funded Channel co-ordinator, employed by the local authority.

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is intended to assist IPs in maintaining their understanding of how their referrals may be using social media applications to connect with extremists, as well as their appreciation of the extremist content found on these platforms.

Immigration Status/Deportation Issues21

Immigration Enforcement is committed to continuous learning and improvement. It is a cause of utmost concern to me that, although you concluded the failings identified within Immigration Enforcement did not contribute directly to the deaths of James Furlong, Joseph Ritchie-Bennett and David Wails, you found that ‘in different circumstances [they] could have been of real significance’.

Your Prevention of Future Deaths Report recognises the significant systemic changes within the Home Office since KS’s case was handled by Immigration Enforcement, including the reintroduction of exit checks, the new workflow management system (Define), improvements to the Voluntary Returns Service and the introduction of the Detention Gatekeeper. These wide-ranging improvements were set out in the witness statements of to the inquest.

I elaborate in this response on the changes outlined by in relation to Foreign National Offenders Returns Command (FNORC) staff training; subsequent developments since the inquest; and, I outline the assurance review which is now underway to evaluate the impact and sufficiency of the full breadth of changes which have taken place since KS's case was handled in Immigration Enforcement.

The training requirements of Foreign National Offenders Returns Command staff

The FNORC People Strategy and the FNORC Learning & Development Strategy set out the command’s high-level approach to training and staff development. The strategies were last refreshed in November 2022 and will be next revisited in November 2024. Under the current strategies, which were briefly touched upon in ’s witness statement of 15 November 2023 (paragraph 6), the command’s learning needs are met by a 14-person operational training team.

For new entrants, the training team delivers intensive initial casework training, initial administrative officer training and early in-role support. For existing staff, the team provides ongoing professional development. This includes refresher training, offered several times annually, for any staff who are changing role or who are returning to work after a significant period of absence. The training team also provides role-specific training, such as line- manager training, to meet demand, and targeted topical training where further learning needs are identified or where legislative, policy or process changes necessitate staff updates. The team also ensures staff are compliant with their mandatory learning requirements, including participation in courses introduced in response to the Windrush Lessons Learnt review.

Since June 2023, I am told that the training team has included an innovative ‘mobile mentoring’ unit of geographically mobile staff with significant casework experience, deployed to provide consistent, face-to-face support to new caseworkers. I understand that the approach was initially piloted between June 2023 and March 2024 to meet the needs of a large intake of new staff. During this period, 237 staff received mentoring support, and the pilot was subject to an internal evaluation in March 2024.

21 Responding to paragraphs 47-51 of Judge Coroner’s report of 20 May 2024.

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Following the internal evaluation, I am informed that Senior Civil Servant (SCS) approval was given on 1 April 2024 for the mobile mentoring unit’s work to be made permanent and to transition from being solely for new starters to include all staff, in line with business needs. The mentors’ remit now includes embedding and refreshing the skills of existing staff through a coaching-centred approach on live cases, based on thematic training needs identified through staff feedback and quality assurance. Current areas of focus include the duties of administrative grade staff, casework decision-making and the writing of release referrals. The unit remains flexible to shape its future offer to meet staff and business needs.

The current focus of the wider training team is the expansion of its learning and development support to non-traditional or non-casework functions within FNORC. This started with the design, in July 2024, of a casework overview package for staff working in the Electronic Monitoring (EM) Hub, to complement their existing functional training and ensure their understanding of the wider FNORC processes within which their work sits. The training package will be trialled in August and September 2024 before being made available to all relevant EM Hub staff. The training team will focus next on analysing and responding to the training needs of the Intake & Triage team (scheduled for Autumn 2024) and then those of the Criminality Assessment and Returns Unit (late 2024/early 2025).

In addition, since May 2024, I am told that an improved supervision offer has been introduced within FNORC and will be fully implemented across all sites by the end of 2024. The role of the Senior Caseworker (a Higher Executive Officer grade post) has been refocused on coaching and support, with the aim of maximising staff productivity, consistency and quality. There is a particular emphasis on reviewing staff work, both through the formal quality assurance framework and through informal responses to queries, providing constructive feedback and building teams’ technical expertise. Senior caseworkers also participate in a benchmarking cycle to review and grade the work of each casework decision maker on a quarterly basis and work with the individual’s line manager to address their development needs. These activities are underpinned by a newly produced Development Framework and Skills Matrix to help the Senior Caseworker identify and record staff learning and development needs, and where trends appear across units, they take a role in collaborating with other units, including the learning and development team, to ensure that these needs are addressed.

Assurance review

In response to the Regulation 28 Report to Prevent Future Deaths, FNORC has commissioned an assurance review of the reforms introduced since KS' case was handled by the department and which were outlined by at the inquest.

The assurance review was commissioned in June 2024 and is being conducted by the Immigration Enforcement Assurance, Integrity, Risk and Resilience (IE AIRR) Team.

IE AIRR sits in the Strategic Services and Transformation directorate within Home Office Immigration Enforcement. The assurance team offers bespoke, independent assurance reviews across teams in Immigration Enforcement to interrogate best practice and highlight areas of risk. As part of any final report issued by IE AIRR, actionable recommendations will be made in much the same way as external review bodies such as the Independent Chief Inspector of Borders and Immigration (ICIBI).

Assurance managers within IE AIRR are specialist trained staff and are accredited by the Institute of Internal Audit and Assurance. The postholder within the team with responsibility

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for recommendations also holds the internal auditors’ qualification from the Chartered Institute of Internal Auditors.

The review will be overseen by as the Senior Responsible Officer given her insight into the issues which concerned the inquest. The terms of reference and problem definition statement for the review have been agreed at Senior Civil Servant level and set out that the review will address the following questions:

1. Are adequate systems in place to ensure that all appropriate information is before the relevant Grade 7 when considering discontinuance of impending prosecutions?

2. Have the relevant Grade 7s received appropriate training to assess the prospects of removal when considering the discontinuance of impending prosecutions?

3. Has the implementation & reintroduction of new systems, including exit checks, workflow management tools, the triage system – ‘Define’, changes to the Voluntary Returns Scheme (VRS) & the detention gatekeeper addressed the issues raised by Judge Coroner?

4. Have the training requirements of FNORC staff been adequately met?

The review will provide an independent assessment of the changes made by FNORC and whether they are sufficient to mitigate a recurrence of the failures noted by at the inquest and reflected in your factual findings. If appropriate, the review will also highlight where further improvements can be made.

To assess the effectiveness of the introduction, re-introduction and/or improvement of systems and processes made by FNORC, IE AIRR is assessing the controls that have been implemented. Methods include ‘dip sampling’ (a random review of a sample) of FNORC cases to evaluate whether the systems are being correctly implemented, staff observation, and staff and stakeholder engagement. The latter is being used in particular in response to the fourth research question, to assess caseworkers’ self-assessment of training received, their understanding of their role and any concerns they may have.

The fieldwork for the assurance review is currently underway and is due to report by 11 October 2024. The report will detail key findings in response to the questions outlined in the problem definition statement and will make recommendations where there is scope for further improvement. Both will be backed by relevant data and guidance extracts.

Prior to final sign off, the assurance report will go through several levels of quality assurance and governance to ensure accuracy before the findings and recommendations are presented to . Once agreed, the recommendations will be logged on both the local FNORC recommendation register and the central IE recommendation register. Progress against the recommendations will be monitored on a regular basis by IE AIRR to ensure timely implementation. I am also personally committed to ensuring the proper implementation of any recommendations that will be made following completion of the review.

Discontinuance of Proceedings

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I understand that ’s witness statement of 15 November 2023 (paragraphs 13-22) also outlined the significant changes made to the processes by which the discontinuance of an impending prosecution can be requested. Most notably, junior FNORC casework staff can only request updates from the police and Crown Prosecution Service, as opposed to requesting discontinuance. Precautions have been designed into the process so that Grade 7 authority to request discontinuance of the prosecution must be sought and recorded in all cases, through amended documentation. These changes minimise risks of an inappropriate discontinuance request being made, or of the omission of the required authorisation. These changes are supported by improved recording via the Atlas casework system, to which FNORC fully transitioned on 19 October 2022 (i.e., the date on which FNORC ceased use of the legacy casework system).

The implementation and sufficiency of these changes form part of the IE AIRR assurance exercise and are the focus of two of the four questions which the review seeks to address:

1. Are adequate systems in place to ensure that all appropriate information is before the relevant Grade 7 when considering discontinuance of impending prosecutions?

2. Have the relevant Grade 7s received appropriate training to assess the prospects of removal when considering the discontinuance of impending prosecutions?

In addition to the general methodology outlined above for the assurance review, the review manager is conducting focused activity to assure the training, process and risks associated with the discontinuance of impending prosecutions. This includes interviewing the Grade 7s who have received the relevant training to assess their understanding, and analysing the process, particularly the origin of the required information and how it is received. To understand pressures that risk compromising the process being operationalised as intended, Grade 7s will also be interviewed about their expected levels of work and conflicting priorities.

Conclusion

I hope that my response to your Report has provided reassurance that the Home Office has fully considered your findings and concerns and that we intend to do all we can to prevent such tragic loss of lives in the future. This is both through ensuring our immigration processes are fit for purpose, and that we intervene early to stop people from becoming terrorists or supporting terrorism. I am committed to treat any failures with the utmost seriousness and oversee the proper implementation of recommendations and commitments. I will be extending an invitation to the families of James Furlong, Joseph Ritchie-Bennett and David Wails, should they wish to discuss the findings in relation to the Home Office or my response.

Home Secretary