REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 11. RtHonourable Robert Buckland MP, Secretary of Stat for Justice 2, KEE ational Probation Service North West NPS) 3. Chief Constable, Greater Manchester Police (GMP) 4 IB 12° 0: Navona rier Potce counci (wecc) '5._Chief Constable, Lancashire Constabul ‘CORONER | am Josnne Kearsey, Senior Coroner forthe Coroner area of Manchester North ‘CORONER'S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner's and Justice Act 2009 and Regulations 28 and 29 of the Coroners Investigations) Regulatons 2013, INVESTIGATION and INQUEST On the 6” November 2016 | commenced an investigation ino the death of Michael Hoolickin who ‘ied on the 17" October 2016 at the Manchester Royal Infirary. The Inquest concluded on the 416" August 2019, The detals as to how Michae's death occurred were recorded as follows: Michael Hoolickin died ‘onthe 17” October 2016 atthe Manchoster Royal Infirmary. He had been attacked and stabbed in 3 unprovoked assault on the 14" Ociober 2016. The perpetrator of the attack was subject to licence conditons and management by the National Probation Service having been released fom prison in February 2016. Organisational falures and flues in he management ofthe perpelrator, Including the lack of implementation of Pl 30/2014, lack of oxgansational knowledge on how t0 ‘access drug test results anda failure to provide or soek out al elevant pertinent information meant there was a missed opportunity to Inilate recall ofthe perpetrator on the 3” August 2016, which lst not causative ofthe attack on Michael, on the balanes o probabil, probably contouted to hie doath ‘The conclusion ofthe inquest was that Michael Hooicin was unawlly killed, During the course ofthe inquest the Court heard evidence from @ number of winasses including fender Mangers (OM), Senior Probation Officers (SPO) and Assistance Chief Officers (NPS). | GNP oficers ram the Spatight Team and also from an independent expert insted fo cander epee of he NPS involvement CIRCUMSTANCES OF DEATH [As indicated above on the 14" October Michael Hoolckin 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 a $6 month sentence for an aseault during which he had biten someone's ear off. He was released half way through his senfence as he was a determinate ‘sentence prisoner and was therefore managed by the NPS. He was subject to a number of ‘adaitoralleance canons n particular © Drug testing for cass A and class B drugs. (The Court heard this was required to be undertaken week), ‘©_Curfew and residence requirements. )The Court heard evidence his curfew requirementsat tines wore varied but forthe majority of his Ume on Heence he was subject to curfew ‘which require him tobe home inthe evening trom dfering times). 9 Nomassocaton with his co-defendant His OASYS assessment in March 2016 had concluded he was.a high risk of serous harm to aduit males. His nature of the risk he presented was recorded as being associated with exiome violence, with a propensity fo use instant violence when faced with confotaion and a concern \Was noted as tothe offenders nonchalance tothe violence he perpetrated. Of importance was the {act hat the offenders risk of violence was recognised as being inked to his use of cocaine. In addition he was classed as a Proc and Proity Offender |PPO) so was managed jointly with GMP as part ofthe Integrated Offender Management Unit (ION), The Court heard evidence as 2 the offenders behaviour during the time whilst he was being managed on cence. He had period ‘of time were he resided in Approved Premises before returning fo ve at his Mother's address in Rochdale in Api 2017, ‘bunng nis tme on cence the offender had three OMS and whist the Cour found there were significant indvidval falings on the part of 2 ofthe OMS there were also numerous organisational fares. (One of the most signicant organisational alures which wil be dealt with below was in relation to rug testing, which meant throughout the entre cence peried thera was a failure by a trainee Probation Officer, 2 OMs, 3 SPOs and an ACO to realise th offender was testing postive for cocaine. Hence no referral to drug treatment services was ever made, During the offenders time on lconce there were key and significant events during the folowing time periods: 2eathaay 2006 In the early hours of the 2% May the offender was arrested and was charged wih no eence, no insurance and faling to stop fora PC (folowing a police pursuit him crashing his vahile and boing ‘chased and apprehended by a police dog). Folowing @ RAMA nesting onthe 3 May there was fallire by the SPO to recognise the fact there had been 2 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 4” May 2016, 0" May 2016 (On the 10” May 2016 the offender was arrested by Lancastire Constabulary. The information provided by GMP to the NPS was thatthe offender had been arrested in possession of a tin of ‘rugs (beleved fo be cannabis) which were in his under garments and he had been arrested for Intention o supply During te cars fhe Ingest became rh hare wasa dsepary in ho evidence rom {nase Contry and CaP Tha tia fom Lancashfe Conary gave 9 statment 1 te Gout nwhcn he cary beloved he was cota GM int fs te person With | som te tender wae aenod (00) CME ha botoved ie sal rato eto afrcer Tina | Deskin “The result was the NPS were provided wi incor onan. However based on he | tomaton oy hasbeen proved wt cava was eae y an SPO wh cones reel wan apropate subject oo daceon bye ACO. ‘tno stage ring th course of hs tener invohement wth to NPS was there any atempt to Gey ay ttomoton sh CMP oro request Concert suport any ofthe shat iielgence or nermaton Te Court ear the ACO was contacted bythe SPO and duo to the fc th oflener was in Custody, dtored any recat econ unl he mong. The cloning meng te NCO tht mest ‘inte OMin he Roce ce ut are wa feo hoe a pope dosnt he On About the afder who hadnow been sresed tice win week and wan vee weak of Isang the Approves Proms. Thar was aco fase a is stan by he OM to pro Tier nono fo the S20 and ACO tn efor to ak an tered deco, ‘Ast wonspired th offender wasnt charged wih any offences by Lancashire (though day as {vy at was never requests byt NES) and arte 8 don ash obo ot ACOecision and nowhere was there a documented rationale for the issuing of an ACO waming a warring. No discussion Gok place between the ACO andthe SPO to explain th ralonale fortis | ‘opposed to recall, | 21 June On the 21" June a member of the GMP Spotight (IOM) team forwarded an emall to the OM expressing her concerns about the offender, The Court heard there was close working felationship between the IOM and NPS witnesses. A number of GMP officers gave evidence to the Court as to ther escalating concems about the offender and the fact they were of the opinion his Fisk of serous harm (and is risk to if) was increasing. They were also of the opinion such views ‘were shared with the NPS OM and trainee. Upon receipt of his email the OM had a telephone ‘discussion with a SPO as to how to respond to GMP. Again the Court was not saisted with the ‘quality and quantity of the information provided by the OM tothe SPO about the cas, 22nd 23° June (On the 29 June NPS were forwarded an email by the GMP ICM officers which provided detals of ‘an incident which had occurred on the 22” June. This inteligence report detaled an incident in \which the offender and his co-accused from whom he was subject lo licence conditions not 10 associate with, were believed to have atlanded a property with knives. The offlcor who attended this incident gave credible evidence to the Court that whist he poopie at the house woud not provide a statement, he beleved the incident involved the offander. A this stage, the evidence {rom GMP was in their opinion the offender by now be recalos, as they fot the ably fo manage his isk within the community was such that he could not be managed. Whit it was accepted the ‘decision to recall es withthe NPS the opinion ofthe Police in areumstances where thay have joint management responsbiltes fs cleaiy a relevant factor. This lyormation was forwarded by the OM to the SPO however there was a falure by the SPO to respond and there was a alu by the OM then to escalate tis significant formation. GMP IOMINPS Integrated Working ‘A significant ding from this Inquest was the fact that in al ikethood the close integrated working led to a significant faure to pass on concerns in a recorded and appropriate format. The Court found a culture and practice had developed of expressing “concems through informal Conversations, telephone. calls none of which were recorded, Hence the informal nature of such iscussions meant that the rationale for such concems and the recording ané documenting of ‘concoms was lost. Moreover it meant information was not then provided ina structured way to ‘SPOS and the ACO. It-was clear to the Court that the IOM officers had signifzant concems about the offender throughout the time he was on icence. Despite these concems hore was a faiuie to escalate hei ‘cancers to Senior Management May-June 2016 ‘During tho period the 16% May 2016 - 23" June 2016 the Cout found there were failures by both [GMP and the NPS in the management of iis offender. During this time he was subject to one drug test, 2 curfew checks, and only 4 home visits whic all oczured in the week commencing the 19" June and in which he was seen on only one occasion, 11%-19" July 2016, (On the 11" July the OM escalated the case to the SPO for advice this was following inteligence from GMP to suggest the offender had been at a festival for the weskend. This lod to discussion ‘between the SPO and the ACO. There was a failure by the OM and the SPO to provide full and ‘etal information including the OMs genuinely held belie by this time that consideration should be alven to recaling the offender. A decision was taken to sue a further SPO waming to the offenderAugust 2016 On the 3 August the offenders case was escalated by the OM to the ACO. The reason forthe ‘escalation was due to threats made by the offender to a specific Individual (inked to his fami) “This was the frst ime the ACO had been made aware ofthe itligence from the 22" June ofthe ‘offender potentially being 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 vas soughlprovided with regards to his drug test results despite the ACO being aware he was subject to weekly Class A and Class B ‘rug testing, No information was soughlprovided with regards to the outcome of any curow ‘checks. On the basis ofthe 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 3 August than on the balance of probabites i fs more tkely than not oeall would have been inilated.” Had recall been Initiated the Court was satsied from the ‘evidence twas more likely than not the offender would have been in custody on the 14" October 2016 when he attacked Michael Hoolckn. 25" Avaust = 14" October A thi OM took over the responsibly for the management cf the offender during this period of time. During this entire period there was a lack of crug testing and a failure by the OM to have & ‘deer understanding of the offenders cence conditions and therefore a fallure to enforce those ‘ioence conditions Handover and Allocation or Work — The Court heard evidence a8 tothe qualty of the handover provided fo the thd OM who was a newly qualified OM (and naw to the Rochdale office). The ‘Court questioned the allocation of this offender to this ON which was done on an adhoc ‘uninformed way. n addton the handover provided was inadequate. During the course of the Inquest the Court received evidence on a number of ganerle matters which are relevant throughout the time of the offenders management: Drug Testing - The failure to implement PV2014 which should have been implemented by [November 2014 meant the Rochdale NPS office were not usieg instant drug testing which would hhave shown the offender was testing postive for cocaine. Ast was, in 2016 Rochdale NPS were stil using laboratory drug testing methods. Frequency of testing ~ despite the offender being subject to weekly testing there were significant Periods of tiie when no testing was undertaken. Particularly from the 24° May 2016 — 4 July 2016 and fom the 21% August 2016 ~ 14" October 2016. ‘Doug test resus ~ due toa failure nationally to realise thatthe case management systom di not ‘pul through’ drug test results which had been requested by way of @ "ick Box” (i the drug tested for, there was a failure to realise the offender was testing posite for cocaine on 9 occasions from the 4" May 2016 | Staffing shortages ~ The court heard thore were signifcant staffing shortages inthe Rochdale, | (Oldham and Bury cluster, in part due to Transforming Rehabilaion although other reasons also | impacted such 38 sickness. As a result OMs had an excessive workioed wich the Cout is Salsfed in part contributed lo the lack of effecive management in ts ease, In adeton a severe lack of SPOs (in part due to sickness) meant that thore was ineffective oversight and formal ‘management of cases during this period of time. The Court does recognise some attempts were ‘made fo minimise this issue. | ‘5 | CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my pinion there is a risk that future deaths wil occur unless actions taken, In the ccumstances iis[| Statutory duty to report you ‘Tho MATTERS OF CONCERN areas fllows:- For Everyone + Serious Further Offence Reviews - Following the death of Michae! Hoolickin the NPS: ‘conducted 8 single agency Serious Further Offence Review, No intemal investigation ‘eve was conducted by GMP. “The abiily to prevent future deaths is predicated on the recognition of issues or failures from which lessons can be learnt. Despite the fact this was a figh ik offender who was Jpinly managed wither a mult-agency iniograted team there was no mui-agency reviow. ‘The Court did not consider the involvement of any other agencies euch ae the offenders GP, drug and alcohol services or Social Services (ne was a leaving care young adult) a= ‘hate wore nat within the scope of the Inquest. Same of thoes agentiog wore. aloo supposed to be part ofthe IOM cohort ‘The fale fo undertake @ multi-agency review in cases where a high sk oflender subject to multhagency management “has gone onto lake someone's Ie means. both ‘rganisational and individual falings are not identied end there is a missed opportunty to leam lessons inorder o prevent future deaths, or the Secretary of Stale for Justice and the National Probation Service ‘+ Transtoming Rehabiltaon. The Court heard evidence as to the catastrophic impact the ‘Transforming Rehabiltation Programme had had on the staffing levels within the NPS. In _ckiton of the immense dificlles placed on the sence in implementing new procedures, polices, working practices and traning staff in the new serdoe. OF note ths programme | caused particular diftcules in certain parts of the county, the Rochdale, Oldham and Bury ‘Guster being one such area. The Court was satistied tie, in part contributed fo the failure {implement PI 30/2014, The Court heard evidence of the planned move away from ‘Transforming Rehabilitation and the plan to reintogate the curent divided service (NPS. and GRCs) ilo one service whichis duo to came into force in the future The Court has ‘concems as to the planning and preparation required fr the amalgamation of any new service in order to alleviate the evidenced problems which occured a8 a direct reso! the previous Transforming Rehabittation programme, + N-Dellus Case management System. The Court heard evidence in respec of the dificuties ‘of ulising the case management system N-Delius. One Senior NPS witness confirmed, it ‘could be argued this system needs @ completo revision” Numerous witnesses. gave evidence as to the dificules in accessing this system, its design and the time it takes to ‘access the diferent parts which hold pertinent information about an offender, describing this as prohibitive. For example for Offender managers tying to read through the fle 10 ‘obtain current information there is nowhere which woud easiy show the most up to date curfew ofthe most upto date positon as to how often drug testing Is being conducted. All such matters may be subject to revision during an clfenders ieence period. The last Offender Manager completly missed te fact hat the ofender was subject to drug testing hence no drug tests were conducted, bar one by the tiainee OM, rom 21 August ~ 14 October 2016. The Court was extremely concernod as to whether tis systom i fi for purpose, particularly when attempting fo capture all relevant, recent information about @ high risk offender in order o reach an informed decision such as recaling them to prison + Moreover the decision to inate recall isthe responsbitly of an Assistant Chief Officer (ACO), The Court heard their decision is based solely en the infomation provided to them by the Ofender Manager (OM) usualy via @ Senior Frobation Ofica (SPO) who would hhave been consuited inthe fst instance. The decision therefore to deprive someone of their tery and recall them to prison is totally relart on the OM accessing the case ‘management system (described above) and forwarding al relevant information. There fs no expectation for ]an ACO to access an offenders records onthe case management system in bert inform themselves o to consider whathor thre any further relevant information. ‘There may not even be any direct contact Between the OM and the ACO, In this case the L Court heard evidence of the complete lack of “professional curlosly” rom a. number ofwitnesses which in conjunction wih ne expectation fo read oF access the Information meant] Crucial information was not known tothe ACO who ullmately responsible forthe decision ‘on recall + Doug Testing ~ the Court found there was an ineffective national system in use in 2016 (N Dols) for which there had been no taining on how to access Orug fst resulls, As a result Individual offces had implemented their own systoms for storing drug tet reeuits, However there isn induction training, information avaliable to ea in individual offices by way of office procedures which informs staff of local practices. This is pareulaty pertinent staf transfer rom other offices. + ACO and SPO wamings - During the course of the Inquest the Court heard difering ‘pinion from ths ACO and the expert as to whether an ACO isa final warming In this case. the offender received a SPO warning, an ACO waming and then @ further SPO waming within a9 week period. ‘National Standards suggest an ACO warning i 4 “fal” wating “The ACO fold the Court that there is no reason why a further SPO waning cannot be Issued folowing an ACO warning. The expert suggested this was incorect and that the ‘guidance is clear that an ACO warning isa final o last warring. The Court found there is 2 lack of cary and speci instructions tothe NPS on this point. “+ lecord Keaping - The Court heard evidence as tothe record keeping by NPS witnesses in ‘his caso. The Court had serious concems a6 to the poor records or completa lack of records particulary by SPOs and the ACOs. + OASYS Assessments ~ At no slage afer March 2016 was the offenders OASYS risk ‘assessment updated. Moreover the lack of formal supervision meant this was not | addressed: ‘+ Gross Referencing Ineligence of Offenders subiect to Licence and Management ~ During ‘he course of the Inquest questions were raised around the ablity of the NPS to cross ‘ference intligence received in respect of diferent dfenders. In addition whether there. was capacty 10 cross reference intsligonce held by other agencies such as the Youth ‘Offending Team. For example the offender was arrested on the 10" May with @ PPO. ‘nominal who was known to YOT. I is not known whether YOT roclved any further Information about the incident or whether they held information which may have assisted the NPS, For National Police Chie! Council, Greater Manchester Police and National Probation Service + Curfew Requirements, The Court was satisfied from fhe evidence that there is no clear Understanding as to the inition 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 caried out by the Police or whether such checks wil only be conducted fllowing a specific request by the NPS. As a result n tis case the offender was only subject to 2 Curfew checks in & months. in adtion there was a lack of carly as to whether the Police would only report a curfew check if the offender was notpresent atthe time ofthe check Police National Computer & Licence Conaitions The Court heard that an offenders licence Cconcitons ars not held on the Police National Computer database. Hence if an offender Is arrested by a diferent force they are unlkely to know whether the offender may be in breach of their cence. Hence itis not clear how any potential breaches would ever be shared effectively withthe NPS. + Integrated Working The evidence before the Court was there are no Standard Operating | procedures or formal processes in place forthe sharng of information when teams are Integrated. As indicated above in this case the Court ound this led fo @ culture of more Informal dscussions and means of sharing information. ‘+ Intearated Ottender Management Cohort Mectings. The evidence before the Court was that in respect of the mult-agency IOM meetings there was no formal agenda, no formalTminule, no Bocurate record Kept of those mostings by stier GMP or the NPS and no way ‘of ascertaining who had attended these meetings. Of nate these meetings are to discuss the ongoing management of high risk offenders being ranaged inthe community and isan ‘opportunity to discuss how effective the management plan is. There i no national guidance to forces or agencies on how these meetings should be structured or recorded Fe Police and Lancashi ‘+ Infomation Sharing - The importance of ensuring accurate deilod information is ehared | between poice forces is vital. Both offenders arrested cn the 2” May were PPO nominal, “There was a compete breakdown of communication ard information sharing between GMP ‘and Lancashire Constabulary which lead te only information about one of the two offenders being passed on. More importantly there was confusion between the forces ao t0 which offender was being diecuczed. Tha impact ofthe goos drostly to docisions made by the [NPS on matters such as recall. [ACTION SHOULD BE TAKEN In my opinion action should be taken to provent future deaths and | believe each of you respectively have the power to take such action. ‘YOUR RESPONSE ‘You are under a duty to respond to this report within $6 days o the date of tis report, namely 24” ‘October 2018. | the Coroner, may extend the period ‘Your response must contain details of action taken or proposed to be taken, sang out the timetable for acton. Otherwise you must explain why no actionis proposed, ‘COPIES and PUBLICATION | have sent 2 copy of my report to the Chief Coroner and tothe following Interested Persons namely = The famly of Michael Hooickin and ther legal representatives * Greater Manchester Police and ther legal representatives {= Natonal Probation Sena and thir legal representatives : and her legal representative : ni his legal representative | Lam also under a duty to send the Chief Coroner a copy of yourresponse, ‘The Chiet Coroner may publish ether or both na complate or redacted or summary from, He may send a copy of this report to any person who he believes may fod it useful or af Interest” You may ‘make representations to me the coroner atthe time of your response, about the release oF the publication of your response by the Chief Coroner. Date: 28th August 2019 Siar