West Midlands Police
Police / Law Enforcement
Action Taken
West Midlands Police have updated their systems with prompts to improve the identification of those at increased risk and will work with MAPPA partners to ensure the coordinator role and new policy are understood and cascaded to relevant staff. (AI summary)
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Dear Mrs Hunt,
Prevention of Future Deaths report dated 13 March 2024
I write in response to the Prevention of Future Deaths report dated the 13 March 2024 which followed on from the inquest concerning the death of Mr Jacob Billington. The report identified four key areas of concern, namely:
1. Management of release and lack of interagency working. The management of the perpetrators release was not coordinated and there was inadequate communication between relevant agencies. In effect agencies worked in silos. Critical information is not being shared and agencies work in different IT systems meaning there is no one place where information is collated and hence a comprehensive account of matters known to each agency is not easily available to those professionals who may need to know a high-risk prisoner’s whereabouts on release. This concern was reinforced by evidence heard during the inquest that changes made since Jacob's death did not include resettlement information being given to Mental Health In reach teams in the prison. The failure to share information leads to a concern of future deaths as high risk seriously unwell prisoners may be released without key agencies knowing where they are meaning they are not traced and treated assertively in the community.
2. Systmone. Details of the perpetrator’s GP and local CMHT were not recorded in an easily accessible format. The format in which key information is recorded has now been amended at HMP Swansea to ensure the prisoner’s GP details and their CMHT’s details (if a person is an existing patient under a CMHT) are highlighted on a front screen/page. I was informed that this change in information management and presentation within Systmone is unique to HMP Swansea and is not the practice in other prisons. I am concerned that there remains a risk that staff treating patients in prison may not have easy access to (and so overlook) this key information.
Keeping our Communities Safe and Reassured
Working in partnership, making communities safer STAFFORDSHIRE AND WEST MIDLANDS POLICE JOINT LEGAL SERVICES
Director of Legal Services
Your Ref:
Our Ref:
Email:
Date: 8 May, 2024
3. Cross agency guidance regarding release of high-risk prisoners with mental health difficulties at their sentence end date. There are no provisions available nor any cross-agency guidance in place for when a high-risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community.
4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
This letter is the response on behalf of the Chief Constable of West Midlands Police. Given the issues identified within the report, in preparing this response West Midlands Police have liaised with HM Prisons and Probation Service (HMPPS). As the lead agency for the Multi-Agency Public Protection Arrangements (MAPPA), I understand HMPPS will also provide a response.
Management of release and lack of interagency working
MAPPA is a national framework to assess and manage the risk posed by serious and violent offenders. It is not a statutory body in itself but is a mechanism through which agencies can better discharge their statutory responsibilities and protect the public in a co-ordinated manner. Agencies at all times retain their full statutory responsibilities and obligations. They need to ensure that these are not compromised by MAPPA. In particular, no agency should feel pressured to agree to a course of action which they consider is in conflict with their statutory obligations and wider responsibility for public protection.
West Midlands Police are fully engaged at all levels of MAPPA, including attendance at the Strategic Management Board (SMB), which is the means by which the partnership fulfils its duties to keep the MAPPA arrangements under review. The SMB monitors the effectiveness of MAPPA, making any changes that appear necessary or expedient. The SMB is therefore responsible for managing MAPPA activity in its area. This includes reviewing its operations for quality, and effectiveness and planning how to accommodate any changes as a result of legislative changes, national guidance or wider criminal justice changes. The SMB are responsible for the implementation of the MAPPA Guidance in their area, in line with local initiatives and priorities. WMP will ensure a senior leader is present at SMB, this will be at least a Chief Superintendent and, where possible, other senior leaders and the Assistant Chief Constable with responsibility for MAPPA will also attend. We will ensure that all offenders subject to notification requirements:
• Register as required.
• Are assessed in accordance with a nationally approved risk assessment and management system.
• Are visited at their registered address in line with the approved Risk Management Plan (RMP) and national guidance.
• Are managed in line with approved professional practice.
• Are entered on ViSOR and have their ViSOR records maintained in accordance with national ViSOR standards. The vast majority of MAPPA offenders will be managed through the ordinary management of one agency, although this will usually involve the sharing of information with other relevant agencies. The structural basis for the discussion of MAPPA offenders who need active inter-agency management, including their risk assessment and risk management, is the MAPPA meeting. The Responsible Authority agencies and the MAPPA Co-ordinator are permanent members of these meetings. Other agencies are invited to attend for any offender in respect of whom they can provide additional support and management. The frequency of meetings depends on the level of management deemed appropriate for each offender.
West Midlands Police will attend all Level 2 and 3 meetings. The officer attending the meetings will be senior enough in rank to allocate police resources. Best practice involves attendance from an Inspector at all Level 2 meetings and Chief Inspector at all Level 3 meetings. However, a lower-ranking officer may attend where necessary if they have experience of the MAPPA process and delegated authority to allocate police resources at the appropriate level.
Visor is the shared IT system accessible to numerous agencies. West Midlands Police will ensure we continue to update Visor records for each individual to ensure information can be shared across agencies.
We will work with all agencies to understand key roles and systems to better share information, manage individuals and protect the public.
Finally, as explained in evidence during the inquest: West Midlands Police’s approach to visiting managed offenders has changed since Mr Billington’s death. The position now is that a West Midlands Police officer will try to visit a managed offender when they are released from prison, regardless of the status of the MAPPA process.
Systmone
As Systmone is an IT system used by healthcare professionals, West Midlands Police did not (and do not) have access to this system.
Cross agency guidance regarding release of high-risk prisoners with mental health difficulties at their sentence end date
This issue will be addressed by HMPPS, however we will ensure we provide support from a policing perspective to partners in relation to high-risk prisoners with mental health difficulties at their sentence end date. From a policing perspective, it is important to note that the IT systems now in place (as described in evidence during the inquest) have changed meaning that there are now better opportunities to identify someone if they have been assessed as being at an increased risk to themselves or others.
West Midlands MAPPA has a prison discharge coordinator role
The issue will be addressed by the partners who manage the prisoner coordinator role and who amend the new policy. West Midlands Police will work with our MAPPA partners to ensure both the role and policy are both understood and cascaded to all staff within the police MAPPA teams.
If WMP can be of further assistance in relation to this matter, please do not hesitate to contact me.
Prevention of Future Deaths report dated 13 March 2024
I write in response to the Prevention of Future Deaths report dated the 13 March 2024 which followed on from the inquest concerning the death of Mr Jacob Billington. The report identified four key areas of concern, namely:
1. Management of release and lack of interagency working. The management of the perpetrators release was not coordinated and there was inadequate communication between relevant agencies. In effect agencies worked in silos. Critical information is not being shared and agencies work in different IT systems meaning there is no one place where information is collated and hence a comprehensive account of matters known to each agency is not easily available to those professionals who may need to know a high-risk prisoner’s whereabouts on release. This concern was reinforced by evidence heard during the inquest that changes made since Jacob's death did not include resettlement information being given to Mental Health In reach teams in the prison. The failure to share information leads to a concern of future deaths as high risk seriously unwell prisoners may be released without key agencies knowing where they are meaning they are not traced and treated assertively in the community.
2. Systmone. Details of the perpetrator’s GP and local CMHT were not recorded in an easily accessible format. The format in which key information is recorded has now been amended at HMP Swansea to ensure the prisoner’s GP details and their CMHT’s details (if a person is an existing patient under a CMHT) are highlighted on a front screen/page. I was informed that this change in information management and presentation within Systmone is unique to HMP Swansea and is not the practice in other prisons. I am concerned that there remains a risk that staff treating patients in prison may not have easy access to (and so overlook) this key information.
Keeping our Communities Safe and Reassured
Working in partnership, making communities safer STAFFORDSHIRE AND WEST MIDLANDS POLICE JOINT LEGAL SERVICES
Director of Legal Services
Your Ref:
Our Ref:
Email:
Date: 8 May, 2024
3. Cross agency guidance regarding release of high-risk prisoners with mental health difficulties at their sentence end date. There are no provisions available nor any cross-agency guidance in place for when a high-risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community.
4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
This letter is the response on behalf of the Chief Constable of West Midlands Police. Given the issues identified within the report, in preparing this response West Midlands Police have liaised with HM Prisons and Probation Service (HMPPS). As the lead agency for the Multi-Agency Public Protection Arrangements (MAPPA), I understand HMPPS will also provide a response.
Management of release and lack of interagency working
MAPPA is a national framework to assess and manage the risk posed by serious and violent offenders. It is not a statutory body in itself but is a mechanism through which agencies can better discharge their statutory responsibilities and protect the public in a co-ordinated manner. Agencies at all times retain their full statutory responsibilities and obligations. They need to ensure that these are not compromised by MAPPA. In particular, no agency should feel pressured to agree to a course of action which they consider is in conflict with their statutory obligations and wider responsibility for public protection.
West Midlands Police are fully engaged at all levels of MAPPA, including attendance at the Strategic Management Board (SMB), which is the means by which the partnership fulfils its duties to keep the MAPPA arrangements under review. The SMB monitors the effectiveness of MAPPA, making any changes that appear necessary or expedient. The SMB is therefore responsible for managing MAPPA activity in its area. This includes reviewing its operations for quality, and effectiveness and planning how to accommodate any changes as a result of legislative changes, national guidance or wider criminal justice changes. The SMB are responsible for the implementation of the MAPPA Guidance in their area, in line with local initiatives and priorities. WMP will ensure a senior leader is present at SMB, this will be at least a Chief Superintendent and, where possible, other senior leaders and the Assistant Chief Constable with responsibility for MAPPA will also attend. We will ensure that all offenders subject to notification requirements:
• Register as required.
• Are assessed in accordance with a nationally approved risk assessment and management system.
• Are visited at their registered address in line with the approved Risk Management Plan (RMP) and national guidance.
• Are managed in line with approved professional practice.
• Are entered on ViSOR and have their ViSOR records maintained in accordance with national ViSOR standards. The vast majority of MAPPA offenders will be managed through the ordinary management of one agency, although this will usually involve the sharing of information with other relevant agencies. The structural basis for the discussion of MAPPA offenders who need active inter-agency management, including their risk assessment and risk management, is the MAPPA meeting. The Responsible Authority agencies and the MAPPA Co-ordinator are permanent members of these meetings. Other agencies are invited to attend for any offender in respect of whom they can provide additional support and management. The frequency of meetings depends on the level of management deemed appropriate for each offender.
West Midlands Police will attend all Level 2 and 3 meetings. The officer attending the meetings will be senior enough in rank to allocate police resources. Best practice involves attendance from an Inspector at all Level 2 meetings and Chief Inspector at all Level 3 meetings. However, a lower-ranking officer may attend where necessary if they have experience of the MAPPA process and delegated authority to allocate police resources at the appropriate level.
Visor is the shared IT system accessible to numerous agencies. West Midlands Police will ensure we continue to update Visor records for each individual to ensure information can be shared across agencies.
We will work with all agencies to understand key roles and systems to better share information, manage individuals and protect the public.
Finally, as explained in evidence during the inquest: West Midlands Police’s approach to visiting managed offenders has changed since Mr Billington’s death. The position now is that a West Midlands Police officer will try to visit a managed offender when they are released from prison, regardless of the status of the MAPPA process.
Systmone
As Systmone is an IT system used by healthcare professionals, West Midlands Police did not (and do not) have access to this system.
Cross agency guidance regarding release of high-risk prisoners with mental health difficulties at their sentence end date
This issue will be addressed by HMPPS, however we will ensure we provide support from a policing perspective to partners in relation to high-risk prisoners with mental health difficulties at their sentence end date. From a policing perspective, it is important to note that the IT systems now in place (as described in evidence during the inquest) have changed meaning that there are now better opportunities to identify someone if they have been assessed as being at an increased risk to themselves or others.
West Midlands MAPPA has a prison discharge coordinator role
The issue will be addressed by the partners who manage the prisoner coordinator role and who amend the new policy. West Midlands Police will work with our MAPPA partners to ensure both the role and policy are both understood and cascaded to all staff within the police MAPPA teams.
If WMP can be of further assistance in relation to this matter, please do not hesitate to contact me.