Source · Prevention of Future Deaths

Michael Hoolickin

Ref: 2019-0292 Date: 29 Aug 2019 Coroner: Joanne Kearsley Area: Manchester (North) Responses identified: 4 / 5 View PDF

The coroner is reporting to prevent future serious further offence reviews following a death.

Date 29 Aug 2019
56-day deadline 20 Dec 2019 est.
Responses identified 4 of 5
Other related deaths

Coroner's concerns

AI summary
The coroner is reporting to prevent future serious further offence reviews following a death.
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_ In the circumstances it is being being 24th May July Bury during my statutory duty to report to you. For Everyone Serious_Further_Offence_Reviews Following the death of Michael Hoolickin the NPS conducted a single agency Serious Further Offence Review. No internal investigation review was conducted by GMP The ability to prevent future deaths is predicated on the recognition of issues or failures from which lessons can be learnt_ Despite the fact this was high risk offender who was jointly managed within a multi-agency integrated team there was no multi-agency review: The Court did not consider the involvement of any other agencies such as the offenders GP , drug and alcohol services or Social Services (he was leaving care young adult) as these were not within the scope ofthe Inquest: Some of these agencies were also supposed to be part of the IOM cohort The failure to undertake multi-agency review in cases where a high risk offender subject to multi-agency management has gone on to take someone's life means both organisational and individual failings are not identified and there is a missed opportunity to learn lessons in order to prevent future deaths_ For_the_Secretary of State for Justice and the_National Probation Service Transforming Rehabilitation The Court heard evidence as to the catastrophic impact the Transforming Rehabilitation Programme had had o the staffing levels within the NPS. In addition of the immense difficulties placed on the service in implementing new procedures, policies, working practices and training staff in the new service Of note this programme caused particular difficulties in certain parts of the country; the Rochdale, Oldham and cluster being one such area_ The Court was satisfied this, in part; contributed to the failure to implement PI 30/2014. The Court heard evidence of the planned move away from Transforming Rehabilitation and the plan to reintegrate the current divided service (NPS and CRCs) into one service which is due to come into force in the future. The Court has concerns as to the planning and preparation required for the amalgamation of any new service in order to alleviate the evidenced problems which occurred as a direct result of the previous Transforming Rehabilitation programme. N-Delius Case_management System: The Court heard evidence in respect of the difficulties of utilising the case management system N-Delius. One Senior NPS witness confirmed, it could be argued this system needs complete revision. Numerous witnesses evidence as to the difficulties in accessing this system, its design and the time it takes to access the different parts which hold pertinent information about an offender, describing this as prohibitive. For example for Offender managers trying to read through the file to obtain current information there is nowhere which would easily show the most up to date curfew or the most up to date position as to how often testing is being conducted. All such matters may be subject to revision during an offenders licence period. The last Offender Manager completely missed the fact that the offender was subject to hence no tests were conducted, bar one by the trainee OM, from 21st August testing October 2016. The Court was extremely concerned as to whether this system is fit for purpose, particularly when attempting to capture all relevant, recent information about high risk offender in order to reach an informed decision such as recalling them to prison Moreover the decision to initiate recall is the responsibility of an Assistant Chief Officer (ACO): The Court heard their decision is based solely on the information provided to them by the Offender Manager (OM) usually via Senior Probation Officer (SPO) who would have been consulted in the first instance. The decision therefore to deprive someone of their liberty and recall them to prison is totally reliant on the OM accessing the case management system (described above) and forwarding all relevant information. There is no expectation for an ACO to access an offenders records on the case management system in order to inform themselves or to consider whether there is any further relevant information_ There may not even be any direct contact between the OM and the ACO. In this case the Court_heard_evidence_of_the_complete_lack_of "professional_curiosity" from number of Bury gave drug drug drug witnesses which in conjunction with no expectation to read or access the information meant crucial information was not known to the ACO who ultimately responsible for the decision on recall; Drug_Testing the Court found there was an ineffective national system in use in 2016 (N Delius) for which there had been no training on hOw to access test results. As a result individual offices had implemented their own systems for storing test results_ However there is no induction training, information available to staff in individual offices by way of office procedures which informs staff of local practices. This is particularly pertinent if staff transfer from other offices_ ACQ_and_SPO_warnings During the course of the Inquest the Court heard differing opinion from the ACO and the expert as to whether an ACO is a final warning: In this case the offender received a SPO warning, an ACO warning and then a further SPO warning within 9 week period. National Standards suggest an ACO warning is a "final" warning: The ACO told the Court that there is no reason why a further SPO warning cannot be issued following an ACO warning: The expert suggested this was incorrect and that the guidance is clear that an ACO warning is a final ie last warning: The Court found there is a lack of clarity and specific instructions to the NPS on this point: Record Keeping The Court heard evidence as to the record keeping by NPS witnesses in this case The Court had serious concerns as to the poor records or complete lack of records particularly by SPOs and the ACOs OASYS _Assessments At no stage after March 2016 was the offenders OASYS risk assessment updated: Moreover the lack of formal supervision meant this was not addressed. Cross Referencing Intelligence_of Offenders_subject to Licence and Management During the course of the Inquest questions were raised around the ability of the NPS to cross reference intelligence received in respect of different offenders. In addition whether there was capacity to cross reference intelligence held by other agencies such as the Youth Offending Team. For example the offender was arrested on the 10th with PPO nominal who was known to YOT. It is not known whether YOT received any further information about the incident or whether held information which may have assisted the NPS For National Police Chief Council Greater _Manchester Police and National Probation Service Curfew Requirements The Court was satisfied from the evidence that there is no clear understanding as to the initiation of curfew checks It was clear to the Court there was confusion as to whether an offender on a curfew will automatically be subject to curfew checks carried out by the Police or whether such checks will only be conducted following a specific request by the NPS: As result in this case the offender was only subject to 2 curfew checks in 8 months In addition there was a lack of clarity as to whether the Police would only report a curfew check if the offender was not present at the time of the check Police_National Computer & Licence Conditions The Court heard that an offenders' licence conditions are not held on the Police National Computer database_ Hence if an offender is arrested by a different force they are unlikely to know whether the offender may be in breach of their licence. Hence it is not clear how any potential breaches would ever be shared effectively with the NPS. Integrated Working The evidence before the Court was there are no Standard Operating procedures or formal processes in place for the sharing of information when teams are integrated: As indicated above in this case the Court found this led to a culture of more informal discussions and means of sharing information. Integrated Offender_Management Cohort Meetings_ The evidence before the Court was that in respect_of_the_multi-agency IOM meetings_there was no_formal_agenda; no formal Drug drug May they minutes, no accurate record kept of these meetings by either GMP or the NPS and no way of ascertaining who had attended these meetings Of note these meetings are to discuss the ongoing management of high risk offenders managed in the community and is an opportunity to discuss how effective the management plan is_ There is no national guidance to forces or agencies on how these meetings should be structured or recorded. For Greater_Manchester Police and Lancashire Constabulary Information_Sharing The importance of ensuring accurate detailed information is shared between police forces is vital. Both offenders arrested on the were PPO nominals_ There was a complete breakdown of communication and information sharing between GMP and Lancashire Constabulary which lead to only information about one of the two offenders passed on. More importantly there was confusion between the forces as to which offender was being discussed. The impact of this goes directly to decisions made by the NPS on matters such as recall.

Responses

4 respondents
the National Police Chiefs Council Police / Law Enforcement
18 Nov 2019 PDF
Noted

The NPCC acknowledges the concerns and explains its role in encouraging collaboration between forces, stating that it will share the report and IOM guidance with chief constables across the country, but does not have the authority to direct action. (AI summary)

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Dear Ms Kearsley,

Prevent Future Deaths Report for Michael Hoolickin (Deceased) Thank you for your correspondence of 29 August 2019 in relation to the Inquest into the death of Michael Hoolickin, along with the Regulation 28 Report to Prevent Future Deaths.

I was not previously aware of this incident, and I am very sorry to learn of the tragic circumstances surrounding the death of Mr Hoolickin. You will appreciate that I am unable to comment on the specific facts of this case, but I can address your concerns regarding policing practice more generally. I understand that you have made contact with the chief constables of Greater Manchester Police and Lancashire Constabulary, both whom will no doubt wish to respond separately in addressing the issues you have raised with specific reference to the actions of their respective forces.

It is important to understand the distinct role of the National Police Chiefs’ Council (NPCC). As you know, each chief constable is ultimately responsible for operational matters within their own force area, which includes all of those issues referred to within the matters of concern you have raised. Whilst the NPCC seeks to encourage chief constables to work collaboratively in the national interest (for example, the way in which forces implement policies or practice), the NPCC does not have the authority to direct a chief constable to take (or not to take) a specific course of action. That said, we do recognise the need for consistency across forces whenever possible, which we know can lead to better outcomes for the public. The way the NPCC A.15

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National Police Chiefs’ Council (NPCC) 1st Floor, 10 Victoria Street, London SW1H 0NN - 020 3276 3795

achieves this is by allocating specific areas of national responsibility to different chief officers in various forces across the country. These chief officers act as the NPCC’s national lead on specific matters of policy and practice on behalf of their colleagues across all forces.

Your report raises a number of very important matters of concern:

1. Serious Further Offence Reviews
2. Curfew Requirements
3. Police National Computer and Licence Conditions
4. Integrated Working
5. Integrated Offender Management Cohort Meetings

In order to provide a useful response to the matters of concern you have raised, it has been necessary for me to consult with a number of national leads across several portfolios. I am unfortunately not able to provide you with a full response to all of your concerns today because some of those I have consulted with are still in the process of considering the matters of concern, and no doubt further consulting with subject matter experts. However, I hope you are willing to accept this letter in part response to the issues raised.

I have discussed the matters of Integrated working (concern 4) and Integrated Offender Management (concern 5) with the national lead for this area, Deputy Chief Constable Jon Stratford of Gloucestershire Constabulary. DCC Stratford advises me that unlike Multi-Agency Public Protection Arrangements (MAPPA), Integrated Offender Management (IOM) operates on a non-statutory basis. The agencies involved commit to joint working voluntarily in furtherance of their individual aims and because it is in the public interest for them to do so. This means that the precise nature of each IOM scheme is very much a function of the local partnership landscape, circumstances and priorities. The resultant diverse range of ways of working does not lend itself to strict codification at a national level, however IOM guidance does exist, and I have attached to this letter two “IOM Key Principles” guidance documents that have been designed to provide best practice guidance within which local schemes can operate.

The guidance documents attached do specify the need for effective information sharing. For example, paragraph 1.6 of the 2015 document states that “all necessary Information Sharing Agreements (ISAs), protocols and processes are in place to ensure swift and appropriate real time sharing of information and intelligence”. However, the precise ISA and ways of working must be built around the needs and ways of working of each individual scheme, which is impractical to provide at a national level. The guidance also describes cohort selection in detail, again emphasising the requirement for this to be tailored to meet local needs.

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National Police Chiefs’ Council (NPCC) 1st Floor, 10 Victoria Street, London SW1H 0NN - 020 3276 3795

Being statutory in nature, MAPPA arrangements will always have primacy over IOM schemes although, as set out in the Key Principle documentation, IOM working can be useful in complementing the measures agreed in MAPPA.

I am therefore content that sufficient IOM guidance does exist to support forces alongside the statutory requirements of MAPPA, but as I described earlier, it is a matter for each chief constable to ensure that appropriate arrangements are in place within their force. In order to encourage learning from this Inquest, it is my intention to share your report, this response and the IOM guidance with chief constable colleagues in all forces across the country, in case there are areas of practice within their own force which they feel may benefit from review.

I am sorry that at this stage I have been unable to provide you with a response to matters of concern 1, 2 and 3. I assure you these are being carefully considered by subject matter experts, and I will endeavour to provide a full response to these recommendations in the coming days.

Thank you for providing me with the opportunity to comment on the areas of concern you have identified. Please do not hesitate to get in touch if you have any further queries about the content of this letter.
HM Prison and Probation Service Central Government
9 Dec 2019 PDF
Action Planned

The Probation Service acknowledges the need for learning and improvement. The Greater Manchester IOM Framework is currently subject to review and your concerns will be considered as part of this review. Where deemed necessary further guidance or clarification including templates such as draft agenda, minutes and action logs will be included. (AI summary)

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Dear Ms Kearsley

Inquest into the death of Mr Michael Hoolickin

Thank you for your Regulation 28 Report, issued following the Inquest into the death of Mr. Hoolickin. I am replying as the Director General of Probation and Wales, part of Her Majesty’s Prison & Probation Service (HMPPS) on behalf of the Secretary of State for Justice and Ms Hamilton of the National Probation Service North West Division.

I know that you will share a copy of this response with the family and I would first like to express my sincere condolences that they were victims of such a terrible crime. The implementation of learning from this case is my absolute priority. We are grateful for your comments and recommendations for improvement, which we have considered in detail.

I set out below the responses to the matters you have raised giving rise to concern.

The failure to undertake a multi-agency review in cases where a high-risk offender subject to multi- agency management has gone on to take someone’s life means both organisational and individual failings are not identified and there is a missed opportunity to learn lessons in order to prevent future deaths.

There are arrangements in place for undertaking Serious Case Reviews on a multi-agency basis in a range of circumstances, including for certain offenders managed under Multi Agency Public Protection Arrangements (MAPPA) and for cases of Domestic Homicide. These reviews support organisational learning across agencies. The management of the perpetrator in this case was not captured under these arrangements as he was managed as MAPPA level 1 and under the current statutory guidance, his management did not meet the criteria for a mandatory MAPPA Serious Case Review. The MAPPA Guidance is statutory guidance issued by the Secretary of State for Justice under the Criminal Justice Act (CJA) 2003, to help the relevant agencies in dealing with MAPPA offenders. We will review the MAPPA guidance on which cases should be subject to a mandatory Serious Case Review. As part of the process we will consult with partners, including the Home Office and police, on strengthening the guidance on undertaking Serious Case Reviews where high risk MAPPA offenders have been convicted of Murder. A.55

The Court has concerns as to the planning and preparation required for the amalgamation of any new service in order to alleviate the evidenced problems which occurred as a direct result of the previous Transforming Rehabilitation programme.

The Department is determined to ensure a smooth transition to future probation arrangements which minimises disruption for staff and service users. We are working closely with the Community Rehabilitation Companies to ensure we get the transition to the new system right. Extensive planning for the transition is underway within HMPPS, drawing on lessons learned from Transforming Rehabilitation and from our experience in Wales, where offender management functions transfer over to the National Probation Service (NPS) in December 2019 ahead of Divisions in England.

The Court was extremely concerned as to whether the N Delius case management system is fit for purpose, particularly when attempting to capture all relevant, recent information about a high-risk offender in order to reach an informed decision such as recalling them to prison

HMPPS is engaged on a programme of work to modernise tools available to probation practitioners in their management of offenders. Those responsible for this work closely with operational staff in NPS to ensure that changes we make reflect their priorities and support front line staff in the way that they work. The team will look at the issues raised in this case as soon as possible, and establish what improvements can be made quickly. The team will consult front line staff to ensure any solutions developed reflect practitioners’ needs. Updated Guidance on professional judgment decision making and recording on NDelius has already been added to the EQUIP database.

There is no induction training, information available to staff in individual offices by way of office procedures which informs staff of local practices. This is particularly pertinent if staff transfer from other offices.

It is fully accepted that where there are local office practices in place there must be effective communication of such local practices to staff new to an office. I have therefore taken immediate steps to ensure that the National Induction Pack is updated so that it makes clear that specific induction on local practice and processes must be completed both for staff new to the organisation and for staff moving offices. We will also put in place a mechanism to record that this has taken place.

Lack of clarity and specific instructions to the NPS on the system of SPO and ACO warnings issued to offenders and serious concerns as to the poor records or complete lack of records particularly by SPOs and the ACOs.

The requirement for recording evidence of professional judgment has always been an essential element of record keeping in individual cases. In April 2019, HMPPS strengthened guidance by publication of the ‘Compliance and Engagement on Licence’ document. This paper outlines evidence based best practice guidance that encompasses several critical areas of management of offenders on licence from pre-release engagement to licence variation and recall thresholds. There is a chapter which provides specific guidance and outlines expectations relating to recording of and accountability for all decisions taken.

At no stage after March 2016 was the offender’s OASYS risk assessment updated. Moreover, the lack of formal supervision meant this was not addressed.

The Probation Instruction on sentence planning sets out the expectation that Offender Managers review OASys assessments and update the risk management plan in response to changes of circumstance and, in particular, changes which may impact on risk. The assessment and risk management plan should have been reviewed and updated in this case. The fact that that this had not A.56

been done should have been picked up through management oversight and our supervisory arrangements.

We have developed a new National Supervisory and Line Management Framework to better support front line probation staff in their role which is being rolled out across the NPS Divisions. This Framework is designed to ensure a consistent and appropriate level of management oversight through practice supervision sessions and observation of practice as well as review of cases. Through observation of practice, senior probation officers will be able to see whether staff are being sufficiently challenging and adopting a properly investigative approach in their face to face supervision of the offender. There is a minimum requirement of four practice supervision meetings and two practice observations per annum for all probation officers with their Senior Probation Officer/line manager. Within this framework, Senior Probation Officers with line management responsibility will ensure that work is undertaken in line with expected standards and that decision making is being properly recorded.

Questions were raised around the ability of the NPS to cross reference intelligence received in respect of different offenders. In addition, whether there was capacity to cross reference intelligence held by other agencies such as the Youth Offending Team.

We recognise the importance of sharing information about offenders both within teams and our own organisation and with partner agencies, including YOT. In March, HMPPS published a new Policy Framework on Intelligence Collection, Analysis and Dissemination and recently updated the policy in October. Its purpose is to ensure staff within HMPPS adopt consistent approaches to the collecting, handling, analysis and dissemination of intelligence. Its stated aims include that staff are confident in submitting and collecting intelligence to combat ongoing criminality. Staff are required to share intelligence appropriately within HMPPS or disseminate it to other agencies, so that through the proactive use of intelligence to identify potential risks, the public are protected as far as possible from the threat of harm. In addition, it is a clear principle of Integrated Offender Management (IOM) that all partners manage offenders effectively together, which means agreeing the means to share information and intelligence as a basis for multi-agency problem solving. This is set out in HMPPS guidance on IOM.

There is no clear understanding as to the initiation of curfew checks. It was clear to the Court there was confusion as to whether an offender on a curfew will automatically be subject to curfew checks carried out by the Police or whether such checks will only be conducted following a specific request by the NPS. As a result, in this case the offender was only subject to 2 curfew checks in 8 months. In addition, there was a lack of clarity as to whether the Police would only report a curfew check if the offender was not present at the time of the check.

The process for undertaking curfew checks should be set out in the risk management plan, stating clearly who is responsible for what, and in cases such as this it should be agreed at multi-agency IOM meetings. I have set out further below the arrangements that have now been put in place to strengthen IOM arrangements in Greater Manchester. You may also be interested to know that electronic monitoring is also available to monitor curfews for certain offenders, as is location monitoring, which allows an offender manager to request retrospective information about a subject’s whereabouts at any time during the lifetime of their supervision.

An offenders’ licence conditions are not held on the Police National Computer database. Hence if an offender is arrested by a different force they are unlikely to know whether the offender may be in breach of their licence. Hence it is not clear how any potential breaches would ever be shared effectively with the NPS. There is an established process for prisons to inform the police about an offender’s release on licence and a specialist central unit uploads information on to the Police National Computer (PNC). The A.57

system is owned and operated by the police and sits under the Home Office. HMPPS works collaboratively with the PNC Bureau to keep the process under review and ensure that we are providing them licence information in the most effective manner and will continue to do so.

There were no Standard Operating procedures or formal processes in place for the sharing of information when teams are integrated. The Court found this led to a culture of more informal discussions and means of sharing information.

The Greater Manchester Combined Authority Integrated Offender Management Framework was launched in August 2018 which established a clear governance structure for Greater Manchester IOM schemes. The Framework establishes steering groups, exit/entry meetings, and regular case discussion/tasking meetings for IOM cohorts and specifies the need to record and circulate minutes and actions and timescales for doing this. It identifies key cohorts and their criteria as well as the IOM offer. It provides clear guidance regarding the sharing, reviewing and recording by IOM partners of criminogenic and risk information relating to nominals.

In respect of the multi-agency IOM meetings there was no formal agenda, no formal minutes, no accurate record kept of these meetings by either GMP or the NPS and no way of ascertaining who had attended these meetings. Of note these meetings are to discuss the ongoing management of high risk offenders being managed in the community and is an opportunity to discuss how effective the management plan is. There is no national guidance to forces or agencies on how these meetings should be structured or recorded.

The Home Office has set out the key principles for IOM, one of which is that it delivers a local response to local problems. While we have issued national guidance for NPS staff on IOM, we think it is right that detailed arrangements should be agreed locally. The Greater Manchester Combined Authority IOM Framework establishes tasking meetings for all Greater Manchester IOM schemes. These meetings cover specific tasking, sequencing of delegated tasks, reviewing and concluding on outcomes. Partnership attendance is voluntary, but intelligence sharing is mandatory. These meetings provide an opportunity to review individual action plans, emerging intelligence, set priorities for action, enabling risk management planning to be implemented and contingency plans to be reviewed. The Framework requires the sharing of minutes from these meetings in a timely manner. It also requires these meetings to be held a minimum of three times per week.

The Greater Manchester IOM Framework is currently subject to review and your concerns will be considered as part of this review. Where deemed necessary further guidance or clarification including templates such as draft agenda, minutes and action logs will be included.

Thank you again for bringing these matters of concern to my attention. Please be assured that learning from the circumstances of this tragic death will also be shared more widely with colleagues across the NPS Divisions.
Greater Manchester Police Police / Law Enforcement
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Lancashire Constabulary. Police / Law Enforcement
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Report sections

Investigation and inquest
On the 8th November 2016 commenced an investigation into death of Michael Hoolickin who died on the 17/h October 2016 at the Manchester Royal Infirmary: The Inquest concluded on the 16h August 2019. The details as to how Michael's death occurred were recorded as follows: Michael Hoolickin died on the 17th October 2016 at the Manchester Royal Infirmary: He had been attacked and stabbed in an unprovoked assault on the 14th October 2016. The perpetrator of the attack was subject to licence conditions and management by the National Probation Service having been released from prison in February 2016. Organisational failures and failures in the management of the perpetrator, including the lack of implementation of PI 30/2014, lack of organisational knowledge on how to access drug test results and a failure to provide or seek out all relevant pertinent information meant there was a missed opportunity to initiate recall of the perpetrator on the 3"d August 2016, which whilst not causative of the attack on Michael, on the balance of probabilities, probably contributed to his death: The conclusion of the Inquest was that Michael Hoolickin was unlawfully killed. During the course of the Inquest the Court heard evidence from a number of witnesses including Offender Managers (OM), Senior Probation Officers (SPO) and Assistance Chief Officers (NPS): GMP officers from the Spotlight Team and also from an independent expert instructed to consider aspects of the NPS involvement.
Circumstances of the death
As indicated above on the 14th October Michael_Hoolickin was stabbed by an offender in an unprovoked attack: The offender Timothy Deakin (TD) had been released from prison in February 2016 having previously received 56 month sentence for an assault during which he had bitten someone's ear off. He was released half way through his sentence as he was a determinate sentence prisoner and was therefore managed by the NPS. He was subject to number of additional licence conditions, in particular: testing for class A and class B drugs. (The Court heard this was required to be undertaken weekly): Curfew and residence requirements. JThe Court heard evidence his curfew requirements the Drug at times were varied but for the majority of his time on licence he was subject to curfew which required him to be home in the evening from differing times): Non-association with his co-defendant His OASYS assessment in March 2016 had concluded he was a high risk of serious harm to adult males. His nature of the risk he presented was recorded as associated with extreme violence , with propensity to use instant violence when faced with confrontation and a concern was noted as to the offenders nonchalance to the violence he perpetrated. Of importance was the fact that the offenders risk of violence was recognised as linked to his use of cocaine. In addition he was classed as Prolific and Priority Offender (PPO) so was managed jointly with GMP as part of the Integrated Offender Management Unit (IOM): The Court heard evidence as to the offenders behaviour during the time whilst he was being managed on licence. He had a period of time where he resided in Approved Premises before returning to live at his Mother's address in Rochdale in April 2017. During his time on licence the offender had three OMs and whilst the Court found there were significant individual failings on the part of 2 of the OMs there were also numerous organisational failures_ One of the most significant organisational failures which will be dealt with below was in relation to drug testing, which meant throughout the entire licence period there was a failure by a trainee Probation Officer, 2 OMs, 3 SPOs and an ACO to realise the offender was testing positive for cocaine. Hence no referral to treatment services was ever made. During the offenders time on licence there were and significant events during the following time periods: May 2016 In the early hours of the 2nd the offender was arrested and was charged with no licence, no insurance and failing to stop for a PC (following a police pursuit, him crashing his vehicle and being chased and apprehended by a police dog) Following a RAMA meeting on the 3r May there was a failure by the SPO to recognise the fact there had been police pursuit and to pass this information onto the ACO for her information when considering the level of enforcement action: A managers warning was issued on the 4th May 2016. 10/h 2016 On the 10th May 2016 the offender was arrested by Lancashire Constabulary: The information provided by GMP to the NPS was that the offender had been arrested in possession of a tin of drugs (believed to be cannabis) which were in his under garments and he had been arrested for intention to supply: During the course of the Inquest it became clear that there was a discrepancy in the evidence from Lancashire Constabulary and GMP_ The Officer from Lancashire Constabulary gave a statement to the Court in which he clearly believed he was contacting GMP in relation to the person with whom the offender was arrested (DC): GMP had believed the call related to the offender Timothy Deakin; The result was the NPS were provided with incorrect information. However based on the information had been provided with, the case was reviewed by an SPO who considered recall was appropriate subject to a decision by the ACO. At no stage during the course of this offenders involvement with the NPS was there any attempt to clarify any information with GMP or to request evidence in order to support any of the shared intelligence or information_ The Court heard the ACO was contacted by the SPO and due to the fact the offender was in custody, deferred any recall decision until the morning: The following morning ACO did meet with the OM in the Rochdale Office but there was a failure to have a proper discussion with the OM about the offender who had now been arrested twice within week and within three weeks of leaving the Approved Premises. There was also a failure at this stage by the OM to provide all relevant information to the SPO and ACO in order for them to make an informed decision. As it transpired the offender was not charged with any offences by Lancashire (although clarity as to why not was never_requested bY the_NPS)and therefore decision was taken to issue an ACO being being drug key = 2-4th May Max they ' the warning: No discussion took place between the ACO and the SPO to explain the rationale for this decision and nowhere was there a documented rationale for the issuing of an ACO warning as opposed to recall: 21st June On the 21s June a member of the GMP Spotlight (IOM) team forwarded an email to the OM expressing her concerns about the offender. The Court heard there was close working relationship between the IOM and NPS witnesses. A number of GMP officers gave evidence to the Court as to their escalating concerns about the offender and the fact were of the opinion his risk of serious harm (and his risk to was increasing: were also of the opinion such views were shared with the NPS OM and trainee: Upon receipt of this email the OM had a telephone discussion with a SPO as to how to respond to GMP. Again the Court was not satisfied with the quality and quantity of the information provided by the OM to the SPO about the case. 22nd_-23rd June On the 23rd June NPS were forwarded an email by the GMP IOM officers which provided details of an incident which had occurred on the 22nd June. This intelligence report detailed an incident in which the offender and his CO-accused from whom he was subject to licence conditions not to associate with, were believed to have attended a property with knives. The officer who attended this incident gave credible evidence to the Court that whilst the people at the house would not provide statement, he believed the incident involved the offender_ At this stage, the evidence from GMP was in their opinion the offender by now be recalled, as felt the ability to manage his risk within the community was such that he could not be managed. Whilst it was accepted the decision to recall lies with the NPS the opinion of the Police in circumstances where have joint management responsibilities is clearly a relevant factor. This information was forwarded by the OM to the SPO however there was a failure by the SPO to respond and there was a failure by the OM then to escalate this significant information. GMP IOMNPS Integrated Working significant finding from this Inquest was the fact that in all likelihood the close integrated working led to significant failure to pass on concerns in a recorded and appropriate format: The Court found culture and practice had developed of expressing concerns through informal conversations, telephone calls none of which were recorded. Hence the informal nature of such discussions meant that the rationale for such concerns and the recording and documenting of concerns was lost. Moreover it meant information was not then provided in a structured way to SPOs and the ACO. It was clear to the Court that the IOM officers had significant concerns about the offender throughout the time he was on licence. Despite these concerns there was a failure to escalate their concerns to Senior Management: June 2016 During the period the 16th 2016 _ 23rd June 2016 the Court found there were failures by both GMP and the NPS in the management of this offender: During this time he was subject to one drug test, 2 curfew checks, and only 4 home visits which all occurred in the week commencing the 13th June and in which he was seen on only one occasion. 11th July 2016 On the 11t July the OM escalated the case to the SPO for advice this was following intelligence from GMP to suggest the offender had been at a festival for the weekend_ This led to a discussion between the SPO and the ACO. There was a failure by the OM and the SPO to provide full and detailed information including the OMs genuinely held belief by this time that consideration should be given to recalling the offender: A decision was taken to issue a further SPO warning to the offender they life) They they they Max May =13th

3d August 2016 On the 3rd August the offenders case was escalated by the OM to the ACO. The reason for the escalation was due to threats made by the offender to specific individual (linked to his family). This was the first time the ACO had been made aware of the intelligence from the 22nd June of the offender potentially involved in an incident with knives. Given the passage of time and the fact this had not been raised previously with her it was wrongly assumed this incident had been considered and clarification sought from GMP_ No information was soughtlprovided with regards to his drug test results despite the ACO aware he was subject to weekly Class A and Class B drug testing: No information was soughtiprovided with regards to the outcome of any curfew checks. On the basis of the information provided the ACO met with the offender to reinforce his licence conditions The Court found as a matter of fact that had all relevant information which was available been provided to the ACO on the 3rd August then on the balance of probabilities it is more likely than not recall would have been initiated_ Had recall been initiated the Court was satisfied from the evidence, it was more likely than not the offender would have been in custody on the 14lh October 2016 when he attacked Michael Hoolickin. 25" August 14th October A third OM took over the responsibility for the management of the offender during this period of time. During this entire period there was a lack of drug testing and a failure by the OM to have clear understanding of the offenders licence conditions and therefore a failure to enforce those licence conditions_ Handover_and Allocation_or_Work The Court heard evidence as to the quality of the handover provided to the third OM who was newly qualified OM (and new to the Rochdale office): The Court questioned the allocation of this offender to this OM which was done on an ad-hoc uninformed way: In addition the handover provided was inadequate. During the course of the Inquest the Court received evidence on a number of generic matters which are relevant throughout the time of the offenders management: Drug_Testing The failure to implement PI2014 which should have been implemented by November 2014 meant the Rochdale NPS office were not using instant drug testing which would have shown the offender was testing positive for cocaine. As it was, in 2016 Rochdale NPS were still using laboratory drug testing methods Frequency of_testing despite the offender being subject to weekly testing there were significant periods of time when no testing was undertaken: Particularly from the 2016 4th 2016 and from the 21s August 2016 _ 14h October 2016. Drug test results due to a failure nationally to realise that the case management system did not 'pull through' drug test results which had been requested by way of a "tick box" (ie the drug tested for), there was a failure to realise the offender was testing positive for cocaine on 9 occasions from the 4th May 2016. Staffing_shortages The court heard there were significant staffing shortages in the Rochdale, Oldham and cluster, in part due to Transforming Rehabilitation although other reasons also impacted such as sickness As result OMs had an excessive workload which the Court is satisfied in part contributed to the lack of effective management in this case. In addition a severe lack of SPOs (in part due to sickness) meant that there was ineffective oversight and formal management of cases this period of time_ The Court does recognise some attempts were made to minimise this issue.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe each of you respectively have the power to take such action:

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Report details

Reference
2019-0292
Date of report
29 August 2019
Coroner
Joanne Kearsley
Coroner area
Manchester (North)

Responses identified

Responses identified 4 of 5
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 Dec 2019 (estimated).

Sent to

Greater Manchester Police
Lancashire Constabulary
Ministry of Justice
National Police Chiefs’ Council
National Probation Service

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