Source · Prevention of Future Deaths

Alex Malcolm

Ref: 2019-0344 Date: 15 Oct 2019 Coroner: Andrew Harris Area: London Inner (South) Responses identified: 1 / 3 View PDF

Insufficient Approved Premises, delays in making MARACs statutory, and difficulties recruiting probation officers due to low pay are systemic issues hindering efforts to prevent future deaths.

Date 15 Oct 2019

56-day deadline 12 Jan 2020 est.

Responses identified 1 of 3

Child Death (from 2015)

Coroner's concerns

AI summary

Insufficient Approved Premises, delays in making MARACs statutory, and difficulties recruiting probation officers due to low pay are systemic issues hindering efforts to prevent future deaths.

View full coroner's concerns

In the circumstances it is my statutory to report to you: 1. Asenior NPS divisional head said that providing more Approved Premises places would potentially save lives. It is understood the matter is under review but details of what steps have since been taken were not heard by the coroner
2. The Chair of the Serious Case Review subgroup of Lambeth Safeguarding Children Board said that strengthening any arrangements around domestic violence, including putting MARACs on a statutory basis had the potential to save The senior Coroner raised this issue in a Prevention of Future Deaths Report to the Secretary of State for Health earlier this year, triggered by the chair of a domestic homicide review into the death of Donna Williamson. Her evidence was clear that there were arguments for MARAC and other bodies to be put on a statutory footing and for the system to be reviewed: The response from the ministry did not specifically address the issue
3.Asenior NPS divisional head said that there were still difficulties in recruitment and retention of probation officers, one factor in which was low pay It is understood the matter is under review but details of what steps have since been taken and their adequacy were not heard by the coroner: duty lives

Responses

1 respondent

HM Prison and Probation Service Central Government

PDF

Action Taken

HMPPS introduced a new pay structure in April 2018 for the National Probation Service, including a two-year pensionable pay award and a London Allowance and Market Forces Allowance to address recruitment and retention issues. (AI summary)

View full response

Taxk 4 13-(2 HM Prison & Probation Service HM Prison and Probation Service Post Point 14.05 Southern House Wellesley Grove Croydon Mr Andrew Harris CRO 1XN Senior Coroner Inner South District Greater London Southwark Coroner's Court 1, Tennis Street Southwark SE1 1YD December 2019 Loner INQUEST INTO THE DEATH OF ALEX MALCOLM Thank you for your letter of 16 October to the Chief Executive Officer; following the into the death of Alex Malcolm. inquest Her Majesty's Prison & Probation Service (HMPPS) is grateful for the observations in your report on the issues surrounding Alex's tragic death: You refer to difficulties in recruiting and retaining probation oificers and the steps being taken to address these; HMPPS introduced a new pay structure with effect from April 2018 for the National Probation Service (NPS) to recognise the professional nature of the work of its staff and the significant contribution make. As part of this process, pay for the NPS was compared against other public sector employment; to ensure that it was competitive NPS Modernisation included a two-vear pensionable pay award (2018-19 and 2019-20) for all staff. Approximately 9,500 staff received a minimum pay award of 3 per cent in each year (instead of a contractual per cent pay award if the pay reforms had not been implemented) The new pay structures also recognised staff at maximum for their and provide a framework for pay progression for all staff through a grade framework New arrangements, fuctres sionore benericiairpagton-poomotoncotasede also introduced to support career progression and to assist the policy, were of vacancies on a temporary and permanent basis, NPS staff based in London also receive a London Allowance of E3,889 addition, a 'Market Forces Allowance' of E1,100 to E3,100 i6 per annum: In currently paid to bchs RAJ they Pay the filling being

Probation Support Officers, Probation Officers and Senior Probation Officers in specific locations to address local recruitment and retention issues. HMPPS continues to monitor recruitment and retention, and to assess the implementation of the new pay structure hope that the measures have described above demonstrate the continued work being done in this area_ Ya^ 0" (AnA hobv HM Prison & Probation Service RECEIVED: nr41

Report sections

Investigation and inquest

On Ist December 2016, opened an inquest into the death of Master Alex Malcolm 5 (died 22.11.16) case ref: 03101-2016 (JB) and suspended it under Coroners Justice Act 2009 Sch 1(2) at the request of the police: The medical cause of death was reported as la Head A perpetrator was found guilty of murder on Zlst July 2017. On 12th July 2018 after hearing lengthy submissions and seeking his counsel's opinion, the Senior Coroner decided that there was an breach of Article 2 of the European Convention on Human Rights by the National Probation Service (NPS), on the application of Osman and resumed the inquest; a decision accepted by NPS at inquest: It was heard before a jury and concluded on 2nd September 2019. The jury concluded that she was unlawfully killed and delivered narrative conclusion.

Circumstances of the death

Matters recorded by the jury as contributing to the death included: 1, The perpetrator wrongly classified as MAPPA Category 2 Level 1 before release from prison 2, Failure to identify the perpetrator'$ relationship with the deceased' s mother 3, Failure to share information with relevant agencies who could have notified the deceased's mother of the perpetrator's history of violent offending and put in place safeguarding measures
4. Allocation of a high risk offender to & newly qualified probation officer_without_ Hon aged Injury: arguable being adequate supervision 5 . Failure to refer the perpetrator for a place in Approved premises
6. Failure of relevant agencies to identify, request and share relevant information 7 . Failure to adequately challenge Or to take action to recall the perpetrator in response to his failures to comply with licence conditions Defects in the system were found which contributed to the death and included:
1. Changes to the NPS in 2014 leading to higher case workloads
2. NPS understaffing 3 . Significant shortages of places in Approved Premises
4. Poor partnership working between prison and NPS and shortage of offender supervisors in prison Significant steps have been taken and action plans implemented to reduce the chance of future preventable deaths_

Action should be taken

In my opinion action should be taken to prevent future deaths I believe that the following organizations would wish to learn of the circumstances of this death and are in a position to mitigate O prevent future deaths: The Ministry of Justice with regard to concern The Secretary of State for Health and Social Care with regard to concern 2 The National Probation Service with regard to concern 3_ The full Record and detailed Domestic Homicide Review can be made available to Ministers if this is of assistance.

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Report details

Reference: 2019-0344
Date of report: 15 October 2019
Coroner: Andrew Harris
Coroner area: London Inner (South)

Responses identified

Responses identified 1 of 3

2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Jan 2020 (estimated).

Sent to

Department of Health and Social Care

HM Prison & Probation Service

MOJ

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.