Michaela Hall

Dear Sir, Inquest Touching the Death of Michaela Anne Hall Thank you for your Regulation 28 Report of 27th March 2024, following the Inquest into the death of Michaela Hall. You kindly extended the time for the issue of this response to the 8th June 2024. I know that you will share a copy of this response with Michaela Hall’s family, and I would like to take this opportunity to express my condolences for their loss. In your Report, you raised the following concerns specifically in relation to the Probation Service The practice of PSOs (or probation staff generally) self-allocating files to themselves, in particular, where they are under-qualified and insufficiently experienced to do the work required. You may feel an express policy provision mandating that managers allocate files/reports is required. Probation Instruction PI 04/2016 Determining Pre-Sentence Reports (last updated 12th January
2024) includes at para 1.21 that Probation Service managers must ensure that the delivery of pre-sentence reports (‘PSRs’) is undertaken by staff with suitable qualifications and/or levels of competence in line with the Probation Professional Register Interim Policy Framework (re-issued 28th March 2024). To support the allocation process in the future, a new guidance document has been created which clarifies when Probation Officers (POs) or Probation Services Officers (PSOs) should be allocated to prepare a pre-sentence report and this guidance is currently out for consultation, prior to publication. This guidance will provide greater clarity on the types of pre-sentence reports

which are, subject to manager discretion, appropriate for preparation by PO and PSO grades. It aims to ensure that Probation court staff can confidently understand when they may undertake the preparation of a pre-sentence report dependent on their grade and the circumstances of the case. A need to ensure that domestic abuse cases are allocated to officers with the appropriate expertise; Probation Instruction PI 05/2014 sets out the basis for Case Allocation and is now supported by supplementary Guidance on the Case Allocation Process. A new digital tool has now been implemented that enables a streamlined approach to allocation notifications and recording from courts for community cases. The tool provides information on the case for allocation, including risk of serious harm, risk of reoffending and risk registrations, and individual workloads to support the Senior Probation Officer making an informed and defensible allocation decision. As the information and the allocation activity are completed within the same tool, this requires access to fewer separate systems making it simpler to access/find the necessary information. The completion of OASys risk assessments and SARAs contrary to relevant guidance – you may feel this reflects a training issue; We have reviewed the current Risk and OASys training material, including Spousal Assault Risk Assessments (‘SARA’s) which has been re-developed into a blended learning product for new entrants. This strengthens the existing face-to-face component and provides a suite of digital resources focused upon the fundamental principles of risk assessment and management practice. This new product was launched from March 2023 and the suite of digital resources are available to all learners, to visit and revisit as and when required. All PQIPs (those training to become Probation Officers) and new entrant PSOs are mandated to complete this learning and this is assured through management oversight of the competency based framework that underpins development and pay progression. We have also launched a new safeguarding and domestic abuse blended learning package, incorporating a a live training event delivered virtually, providing reflective practice opportunities, digital tools and accessible learning resources. These are available at the point of need, to embed practice and improve performance outcomes. Every PQIP completes the new blended learning package following completion of the mandatory Safeguarding e-learning and Domestic Abuse e-learning, which is a requirement for all Probation Service staff. The Domestic Abuse e- learning has been updated to reflect the latest e-learning techniques as well as up to date evidence on domestic abuse. A national rollout plan has ensured learning placements are prioritised and based on role and identified need, with training having commenced in April 2022. PQIP learners and new entrant PSOs have been prioritised, and all staff are to have completed the new training package by April
2025.

Within the South West Region specifically, a rolling package of training for practitioners is currently being delivered which includes:
- Assess Confidently and Manage Effectively;
- Completion of OASys Sections 1-13 (which identifies factors linked to offending);
- OASys Risk of Serious Harm assessment/Risk Management Planning;
- OASys Sentence Planning;
- Professional Curiosity Harnessing Professional Judgement;
- Touch Points Model for Senior POs; and
- Quality Management for Senior POs. Monthly Protected Development Days have also been introduced across the Region since January 2023. These development days provide protected time during which staff are expected and encouraged to complete mandatory training and/or other identified learning and development activities, including those detailed above. Whether 15 days for completion of a comprehensive risk assessment is too long where, in a domestic abuse setting, with the perpetrator and victim living together, the level of risk can change very quickly; Risk assessment and management is an ongoing process reliant on gaining information from multiple sources and agencies. There are points where assessment is made using both dynamic and actuarial tools. OASys includes a sentence plan that can only be finalised once particular elements are in place or referrals completed, for example securing accommodation or receiving fuller information from partner agencies. The OASys assessment is a point of time record of that fuller information and does not prevent risk management action from being taken. OASys and Risk of Harm Guidance provides staff with an understanding of risk escalation and the need to be alert to change, responding swiftly. It is important relevant assessments are updated accordingly, however this may follow the required management actions being undertaken. Adherence to such practice is monitored through management oversight of cases which in further detailed in guidance. A risk assessment takes place when writing a pre-sentence report (and in the absence of a PSR an allocation risk assessment is completed). Historically, a shorter period of time for completion of a comprehensive risk assessment was not achievable and compromised the fullness of information on which it was based. In light of the concerns you have raised in your Report, this is something that will be considered as part of the development of a replacement to OASys which is currently taking place. A need effectively to ‘join up’ probation with other agencies. It was noteworthy here that probation was represented at MARAC (by definition, meaning the victim was considered to be high risk) yet both the OASys risk assessment and SARA assessed the perpetrator as medium risk – a contradiction that you may feel should have been apparent immediately; The Probation Service recognises the need to work closely with other agencies in order to share relevant information and work collaboratively to effectively manage the risk posed. We routinely

engage with Multi Agency Risk Assessment Conference (‘MARAC’) panels, whose focus is upon the perspective and protection of the victim. Because of this, the assessment tools and risk definitions used to calculate risk differs from those used by the Probation Service, so on occasion the risk level outcomes may vary, particularly if risk reducing restrictions to limit the perpetrator re-offending are in place. That said, it would be reasonable to expect that where risk to a victim is identified as high this would be mirrored in the OASys and SARA or clarity provided as to the relevant difference. It is acknowledged, however, that the development and maintenance of these close working relationships with other agencies, including information sharing arrangements, is of paramount importance and careful consideration is now being given to how this can be improved. We will continue to work to enhance the service provided, working with our partner agencies, to safeguard and protect victims of domestic abuse. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address these matters.

Cornwall Council |

Information Classification: CONFIDENTIAL Mr Andrew Cox Senior Coroner for Cornwall and the Isles of Scilly Cornwall Coroners' Service Pydar House Pydar Street Truro TR1 1XU

14 June 2024

Dr Mr. Cox,

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

On behalf of Cornwall Council We would like to express our sincere condolences to Michaela’s family. We are continuing to work with colleagues through the Domestic Homicide Review process to identify actions stemming from the Senior Coroner’s proposed recommendations.

In the regulation 28 report provided to the Council by the Senior Coroner, the following matters of concern and recommendations are recorded in respect of the death of Michaela Hall:

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1. Do not delineate rigidly between adults and children but consider the family as a whole. Where appropriate and permitted in law, share information between services;
2. Record in writing a rationale for reaching a view that there are no eligible care and support needs;
3. Record in writing why a safeguarding (s42) enquiry may not be progressed on a statutory footing but on a non-statutory basis instead;
4. When considering a victim of domestic abuse, complete a needs assessment even when consent is not forthcoming;
5. If no eligible care and support needs are identified, take a step back and consider the exercise of discretion;
6. When relevant information is shared from a family member or health-related information is received, ensure this is acted upon and shared appropriately between Council services and wider agencies.
7. Be curious. There were multiple examples of potential mental impairment – a diagnosis of OCD, mentions of suicidality and depression, the Acton email, yet no health-related enquiries appear to have been undertaken.

This report is a response to the Senior Coroner in respect of these matters. For ease of reference, we have responded to each concern in order, with the exception of points 4 & 7 which have been considered together.

1. Do not delineate rigidly between adults and children but consider the family as a whole. Where appropriate and permitted in law, share information between services;

There are mechanisms for information sharing between Together For Families (TFF), made up of children’s and families services, and Adult Social Care (ASC). This includes an awareness of respective safeguarding arrangements and referral routes – the adult Multi Agency Safeguarding Hub (MASH) and the Children’s Multi Agency Referral Unit (MARU) as well as ongoing work between practitioners.

Information Classification: CONFIDENTIAL The purpose of the MASH is to discuss with wider agency partners referrals which Adult Social Care receive. This enables swift multi agency information sharing. The MARU is the Multi Agency Referral Unit. This is the referral for mechanism for concerns in respect of children. Following the inquest and the Senior Coroner’s findings we have taken the opportunity to reinforce to team managers and practitioners within ASC, the need to share concerns and information with colleagues in TFF. The ASC practice framework references the whole family approach as a key tenet of our practice in Cornwall, identifying our awareness of the importance of considering individuals in the context of their families.

The whole family approach identifies a best practice approach for practitioners working within ASC to consider the needs of the whole family when carrying out assessments and developing care and support plans. The whole family approach encourages Local Authorities to take a holistic view of the individuals needs and consider this in the context of both their support network and wider community and how these could contribute towards the individual achieving their identified outcomes. In conjunction with this, Local Authorities must also consider how any identified needs of the individual are impacting on the family members or others in their support network. The guidance highlights that in order to make whole family approaches a reality in practice, four key steps are required which are to
1. Think family: this involves identifying the impact of the individuals care needs on the family.
2. Get the whole picture, which includes assessing the needs of the person and their carers' needs for support.
3.Make a plan that works for everyone.
4.Check that it is working for the whole family by carrying out an outcomes-focused review In Cornwall, we encourage our practitioners to use the whole family approach, supported and underpinned by our Strengths Based and Person-Centred approaches and training offers. We also have a specific commissioned support for both Adult Carers and Young Carers. In addition, all of our practitioners receive regular safeguarding training which supports them to identify and raise any issues or concerns which may relate to both children and adults appropriately. Following the inquest and the Senior Coroner’s findings, we have taken the opportunity to remind and reinforce with all Children’s Services managers and practitioners about existing arrangements in place to seek

Information Classification: CONFIDENTIAL support for victims of domestic abuse; the MARAC referral process; and the Safer Futures advice line, which is available to provide professional advice and support around domestic abuse. We have asked all practitioners across Children’s Services to consider carefully, and discuss with their managers, whether any additional adult safeguarding referral, and/or MARAC referrals, are appropriate for any adults they are working with. We now ensure that we have dedicated representatives from Adult Social Care at MARAC. Lunch and Learn events have been held to increase the awareness and knowledge of MARAC within the directorate.

As part of our commitment to increasing the confidence and capabilities of Children’s Services practitioners to take a whole family approach and recognise and respond effectively to domestic abuse and its impact upon children, we have invested in a full time Family Domestic Abuse Support Advisor (Family DASA) for each of our nine Family Assessment and Support teams, in partnership with First Light, a specialist domestic abuse provider. Family DASAs provide specialist advice, consultation and direct interventions with families where a risk of domestic abuse is identified in children’s social care referrals and/or social work assessments. In addition to the main Safer Futures advice line, this means that children’s services practitioners have the option of talking through any worries or concerns with our Family DASAs.

In children’s services assessments and planning, all children are considered as being part of a family, acknowledging the complexity of the families and communities we support and their potential to be part of other groups. Increasingly the wider (extended) family is incorporated into assessments and planning. All Early Help and social worker assessments are family assessments. Most plans are family plans, with the exception of Child in Care plans and Pathway Plans, which related to individual children in line with statutory guidance for children in care and care leavers.

2. Record in writing a rationale for reaching a view that there are no eligible care and support needs and record in writing why a safeguarding enquiry may not be progressed on a statutory footing but on a non statutory basis instead We have produced practice guidance for managers and assessing staff as to the level of information around an individual’s needs to make a decision on eligibility under the Care Act and

Information Classification: CONFIDENTIAL how this is to be recorded on documentation. Similarly, we have developed a template for staff working within the safeguarding triage function to ensure that they correctly record their rationale for decision making.

As discussed during the inquest there were issues with the accuracy of record keeping within the safeguarding concern in respect of the threshold decision making. We are satisfied that these were down to the mis-selection of radial buttons rather than a misunderstanding of the member of staff in regard to the legislation and decision making. However, we have taken this opportunity as recorded above to ensure that staff within safeguarding triage use the decision-making template to demonstrate their rationale for decision making within safeguarding concerns.

Equally, MARAC actions are now recorded on Halo for auditing and flagged to the MARAC chair when not competed.

3. & 7 When considering a victim of domestic abuse, complete a needs assessment even when consent is not forthcoming, and be curious in its undertaking

We accept the threshold to assess a person’s needs is a low one and there is a further duty under S.11 to assess those at risk of abuse or neglect regardless of consent for those who are unable to safeguard themselves. However, the areas of assessment are clearly set out within Regulationsi and are around general social care needs including nutrition, personal care, home environment and access to the community.

Given the limitation of the assessment, the burden of increased needs assessments may not provide any notable improvement for those subject to domestic abuse and, in view of the limited resources of the local authority, may divert precious resources from service provision. The Council commissions specialist domestic abuse services which are not reliant on eligibility under the Care Act for access.

Information Classification: CONFIDENTIAL Safeguarding triage has been receiving an ever-increasing volume of referrals over the past 4 years. The service now often receives between 900 and 1000 concerns a month. Whether or not a Care Act assessment is indicated is a key role of the safeguarding triage function and, if indicated, this recommendation would be passed to the locality teams.

Nevertheless, the Council accepts the finding of the Senior Coroner, that a Section 11 assessment should be considered in all cases where we are aware of domestic abuse and that the rationale for assessing or not assessing should form part of the social care record particularly in relation to the appearance of need and the ability of the individual to safeguard themselves. In this regard we have contained within the practice guidance referenced above, the importance of including a clear rationale for decision making within assessment documents if an assessment is not progressing for any reason.

Understanding coercive control and the impact of domestic abuse upon an individual’s capacity to consent or participate is key to such an assessment and decision. An emerging area of evidence, knowledge, understanding and skills that professionals have yet to be adequately informed about. Government strategy recognises that tackling domestic abuse is a cross–departmental and multi- agency responsibility. The Care Act statutory guidance on safeguarding includes coercive control. This means that a Local Authority’s duty to make (or ask others to make) safeguarding enquires and determine what action is needed is triggered by ‘reasonable cause to suspect’ that an adult with care and support needs is experiencing coercive control (where their needs prevent them from protecting themselves). Not all practitioners may recognise coercive control when responding to safeguarding concerns, particularly in domestic abuse situations. There is a need to apply professional curiosity, and consider inherent jurisdiction, in such circumstances by asking relevant questions to ascertain what the adult is actually experiencing in order to ensure they are able to access the right support. It is important for professionals to understand that controlling and coercive behaviour is not separate to violence, but that violence or fear of use of violence is a tactic used by the perpetrator to control the victim. It is also important to understand that the impact of coercive and controlling behaviour on victims can and will affect their own behaviours. Family members may notice a change in their daily activities, how they dress, whether they socialise. The impact of the domestic

Information Classification: CONFIDENTIAL abuse may also affect the victim’s usual decision-making processes, for example they may make decisions to pacify the perpetrator to avoid further abuse. These decisions may appear confusing and irrational to family members and professionals. Professionals should consider the impact of coercive and controlling behaviours on a victim in terms of their decision-making processes and any potential impact on their capacity to make safe decisions for themselves. This should be recorded in case notes and any rationale for undertaking (or not undertaking) an assessment. A practice guidance note has been written to support practitioners with their understanding and awareness of coercive control. We now audit 30 cases a month within ASC as an additional assurance in respect of the quality of our practice to ensure that the guidance and training we produce is producing anticipated improvements in practice. Similarly, we are evolving our understanding of how multiple, co- occurring conditions can impact ability to consent and participate (in this instance Compulsive Obsessive Disorder, depression and suicidality). In Safeguarding terms, the cumulative impact of these should be considered, alongside coercive control and other forms of domestic abuse, as having cumulative impacts upon capacity, the ability to engage and consent, rather than seen as separate issues. We have recently completed our Practice Framework within Adult Social Care. It instructs workers to be holistic, collaborative and enquiring in their practice to ensure that they are responsible for drawing out the information they require rather than passive receivers of information. This would include making enquiries with other agencies it was believed to have been in touch with individuals. Within the structure of our teams there are multiple opportunities for social workers and social work practitioners to discuss the individuals they are working with the peers and managers. This provides a blend of both formal and peer reflective supervision which is a key social work tenant.
5. If no eligible care and support needs are identified, take a step back and consider the exercise of discretion;

Where an adult is not identified as having care and support needs there is no legal duty to provide for those needs under section 18 of the Care Act 2014. The Council nonetheless has a power to meet an adult’s needs for care and support: section 19(1) of the Care Act 2014. That power can be exercised prior to any needs and section 13 eligibility assessment having

Information Classification: CONFIDENTIAL been undertaken if the Council considers that an adult’s suspected needs for care and support appear to be urgent (s.19(3) Care Act 2014).

Cornwall Council commissions services for adults who have needs for care and support which do not rely on an assessment of eligibility under the Care Act. These include the provision of specialist domestic abuse services. Within Cornwall this service is provided by Safer Futures, who provide a single point of contact for anyone in Cornwall or the Isles of Scilly who has experienced domestic abuse and requires support. This support includes advice, education, recovery and behaviour change programmes for people affected by domestic abuse and sexual violence.

Since Michaela’s death a Domestic Abuse outreach team has been commissioned. This team works intensively with people who traditional service provision often struggles to engage. This includes those with multiple vulnerabilities. The outreach team have deliberately low caseloads so they can offer flexible support in a way that meets the needs of the individuals. We are working to bring together the domestic abuse, drugs and alcohol, and homelessness outreach teams as one system, to enable one trusted professional to progress the relationship with the individual (such as Family Domestic Abuse Support Advisor and Independent Domestic Violence Advocates). This is part of an ongoing culture shift to ensure that organisations feel confident to work together as one team and is a focus of commissioned services in Cornwall. Currently, all professionals try to engage with an individual and offer support from their service area. There is a level of coordination at MARAC and via information sharing between agencies. The team-around-the-professional approach will allow one lead professional to coordinate and deliver integrated support to the individual. The trusted professional will work in a team-around-the-professional approach to safety plan and also to ensure the voice of the victim is heard through the professional with whom the victim is engaging.

6. When relevant information is shared from a family member or health-related information is received, ensure this is acted upon and shared appropriately between Council services and wider agencies.

We are aware of our ability to receive and record information about individuals. Under safeguarding legislation we are able to share information with relevant partners in certain

Information Classification: CONFIDENTIAL circumstances. We have taken this opportunity to remind operational managers and staff of the need to consider all the information available when commencing work with an individual and that safeguarding takes precedence over information sharing concerns. Since Michaela’s death MARAC have implemented the following with an aim to improve engagement with victims, and to better capture vital information known to families;

Adjustments are being made to improve the information gathered for MARAC cases via the MARAC case management system to more formally capture the voice of the victim and family. There are additional text boxes being added to the MARAC Research Form that captures wishes and feelings of the abused.

The commissioned domestic abuse service (Safer Futures) is currently reviewing their practices around family involvement and looking at ways to improve how they approach consent and employ curiosity around service users' more comprehensive support networks. When the review has been completed recommendations will be identified and implemented. Where there is consent, the Information Commissioners Office (“ICO”) and General Data Protection Regulation (“GDPR”) guidance will be utilised to show that the information gathered and recorded from the family is captured on a lawful basis. This information will then be fed into the safety planning process through MARAC. The victims expressed wishes would be listened too and considered alongside risk.

It is the aim of the MARAC to empower victims to have a voice and some control over the process, after so many have often lost control in many aspects of their lives due to the domestic abuse they have experienced.

Safer Cornwall, with Safer Futures, are exploring a pilot around ‘affected others’ groups which would provide support to family members of those impacted by domestic abuse. This is in its infancy and an evaluation would sit alongside the pilot, but it is hoped this would provide much needed information and advice to family members to enable them to feel more confident in supporting their loved ones. We will also be looking at whether information for families can be accessed via the Safer Futures website to enable them to gain information and advice on how to support their family members.

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Finally, 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 all our partners to support the residents of Cornwall.