Independent review of the care and treatment received by JW prior to an incident of homicide in December 2020

All agencies involved in this investigation should ensure that they have an appropriate plan in place to identify an individual’s serious escalating behaviour at an early stage to enable effective multi-agency oversight and co-ordination. The Safeguarding Adult Board, who have responsibility for holding statutory partners to account, should ensure that this is in place and satisfy themselves that relevant partners understand that perpetrators who pose a risk to the public may have care and support needs themselves.

Statutory organisations who receive public protection notices (PPN) need to undertake a review of how they effectively consider the information contained within PPNs so that they take appropriate steps in respect of the person who is the subject of the report.

The local criminal justice board (LCJB) should satisfy itself that all statutory agencies understand the information sharing agreements that are in place with partner agencies, and that a culture of proactive, lawful information sharing is developed to address both the needs of the service user and to minimise risk to the wider public.

Consideration should be given to developing an information sharing process that could establish multi-agency meetings where an offender in prison is on short-term remand and considered to be considered at significant risk to the public but are not currently a MAPPA subject.

The healthcare provider in the prison should ensure that it has robust systems and processes in place to ensure that timely and appropriate information is shared with known relevant health services for a prisoner due to be released, so that the right treatment and support can continue to be delivered effectively.

To enable offenders to be managed safely in the community, the criminal justice system should review release planning arrangements for those remand prisoners released suddenly from court to enable offenders to be managed safely in the community.

Where local police are acting as the lead agency for a MAPPA subject, they should ensure that police offender managers understand the need proactively to take reasonable steps to seek relevant information from known agencies to inform the risk assessment process and subsequent risk management plan.

Operational staff and supervisors within Sexual or Violent Offender Manager (MOSOVO) units should understand the College of Policing guidance on third-party disclosure, recognise when it is required, and be confident in using it appropriately.

The local police should ensure that the risk management process for persons under MAPPA is conducted at the earliest opportunity in order to identify the risks to the public, staff and the nominal themselves.

The local police should encourage and support the use of the dynamic ARMS risk assessment, particularly where mental health issues, violence and escalating behaviours are identified.

Recognising the complexities involved in arranging care and support for vulnerable prisoners released suddenly from custody, the Ministry of Justice should consider convening a multi-agency group comprising senior representatives from all relevant agencies to undertake a review to improve safeguarding and safety planning within national release pathways. This should include, but not be limited to, the specific consideration of the needs of those with mental health, or neuro-diverse issues and those who are to be released to no fixed abode.

NHS England Health and Justice must ensure their monitoring arrangements identify any lapses in compliance with standards and plans to rectify them are put in place.

The healthcare service in the prison should actively implement the care programme approach (CPA) or the Community Framework for all prisoners who present with complex mental health needs. This will provide a well-established framework to ensure continuity of care, joint working and effective information sharing takes place.

The healthcare service in the prison should ensure that their clinical staff understand their responsibilities under their respective codes of practice, and that systems are in place for compliance with their codes to be monitored through clinical supervision and managerial challenge.

NHS England need to ensure their quality assurance visits to prisons provide clear recommendations and when relevant are shared with the relevant Integrated Care System. Also, sharing relevant information with health and justice commissioners to enable them to monitor and ensure the healthcare service in the prison deliver high quality and safe care and that any emerging risks are identified and acted upon.

NHS England’s Health and Justice team need to gain robust assurance from the healthcare service in the prison that it has the governance, performance systems and processes in place to ensure it is delivering high quality and safe care.

NHS England’s Health and Justice Team should work with all healthcare provider agencies to ensure that SystmOne functionality is maximised to promote appropriately accessible sharing of important information between prisons and community services when a patient transfers in and out of secure and detained settings. It must be ensured that within this due consideration is given to NHS England plans for Accelerating Citizen Access to GP Data (1 November 2022).