Prevention of Future Deaths reports · 2018

Jacqueline Oakes

Regulation 28 report to prevent future deaths, reference 2018-0419, written 16 Oct 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report16 Oct 2018
Reference2018-0419
DeceasedJacqueline Oakes
CoronerLouise Hunt
Coroner areaBirmingham and Solihull
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Rt Hon David Gauke MP – Ministry of Justice
Home office
1 CORONER
I am Mrs Louise Hunt HM Senior Coroner for Birmingham and Solihull
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations
28 and 29 of the Coroners (Investigations) Regulations 2013.
3 INVESTIGATION and INQUEST
On 22/01/2014 I commenced an investigation into the death of Jacqueline Oakes. The investigation
concluded at the end of an inquest on 11 October 2018. The conclusion of the inquest by the jury was
“To conclude, the victim was killed unlawfully. However the victim was also a vulnerable lady which was
a factor in her making a number of naive decisions, despite knowing the offenders history.
Following the inappropriate placement of the offender in the same property as the victim, a relationship
between the 2 developed.
The offender committed numerous offences which failed to lead to any prosecution.
The support that the victim needed was available although Domestic Abuse (where identified) and
mental health sufferers need extra attention due to their sensitivity and complexity and this wasn't
always provided.”
4 CIRCUMSTANCES OF THE DEATH
Jacqueline Oakes suffered from mental health difficulties and was vulnerable and at the end of 2012 she
became homeless and moved into supported living accommodation in January 2013. It was there that
she met who had recently been released from prison for a serious offence against his
previous partner. had been sentenced to 30 months in custody with extended licence
for 24 months. He had been released on parole on 12/11/09 but was recalled to prison several days later
on 14/12/09 as he had missed his curfew and failed to attend a meeting with his probation officer. After
his return to prison he was refused further parole and was released on 11/02/13 at the end of his
sentence. His last Oasys assessment had confirmed him to be a high risk to future partners and a medium
risk to the public. He was MAPPA Cat 2 level 1. As he had served his full sentence no agencies were
notified about his release. met Jacqueline at the beginning of April 2013.
was abusive to Jacqueline and frequently assaulted her. He was arrested and charged with 3
counts of assault and harassment (fear of violence) in June 2013 but Jacqueline later retracted her
statement and he was released. Further assaults occurred in September 2013 and he was again arrested
and charged with assault. He was released on 04/11/13 as Jacqueline had provided a retraction
statement and a victimless prosecution was unsuccessful. There were further assaults in December 2013
and January 2014 and was arrested on 08/01/14 but later bailed pending further
enquiries. On 14/01/14 Jacqueline’s body was found in the flat where she was staying and
was convicted of her murder on 15/07/14 and sentenced to a minimum term on 18 Years in
prison.
Following a post mortem/Based on information from the Deceased’s treating clinicians the medical cause
of death was determined to be:
1a. MULTIPLE INJURIES
5 CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion
there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory
duty to report to you.
The MATTERS OF CONCERN are as follows. –
1. When an offender is released having completed their full sentence who is known to be a high
risk to others there is no mechanism for any other agencies to be alerted to that person’s
release. Had an alert been provided to other agencies that came into contact with Jacqueline
and it would have meant they were better able to manage the risks he posed.
Consideration should be given to whether such alerts can be provided.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have the power to take
such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
11 December 2018. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for
action. Otherwise you must explain why no action is proposed.
8 COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
Family
Probation service
Birmingham and Solihull Mental Health trust
Birmingham City Council
Police Federation
Swanswell
Sustain
West Midlands Police
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a
copy of this report to any person who he believes may find it useful or of interest. You may make
representations to me, the coroner, at the time of your response, about the release or the publication of
your response by the Chief Coroner.
9 16/10/2018
Signature
Mrs Louise Hunt HM Senior Coroner Birmingham and Solihull

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Hm Prison and Probation Service (PDF)
Her Majesty’s Prison and Probation Service 
                            Public Protection Partnerships Section 
Public Protection Group 
8th Floor 
102 Petty France 
London 
                                                                        SW1H 9AJ 

Telephone: 0203 334 0450 

Mrs Louise Hunt 
HM Senior Coroner 
Birmingham & Solihull Areas 
50 Newton Street 
Birmingham 
B4 6NE 

7 December 2018 
                                                                     Your ref: 97368 – JACQUELINE OAKES (LH/RP) 

Dear Mrs Hunt  

Thank you for your letter of 16th October 2018, enclosing your Regulation 28 Report following 
the inquest into the death of Jacqueline Oakes.  

We are grateful for your comments and recommendation for improvement, which we have 
considered in detail. You recommended that: 

When an offender is released having completed their full sentence who is known to be a high 
risk to others there is no mechanism for any other agencies to be alerted to that person’s 
release. Had an alert been provided to other agencies that came into contact with Jacqueline 
and 
posed. Consideration should be given to whether such alerts can be provided. 

 it would have meant they were better able to manage the risks he 

In response I have identified the current arrangements that are in place to ensure risk 
information is shared to partner agencies when a high risk offender comes to the end of their 
sentence and will no longer be under the statutory supervision of the Probation Service. I 
have also outlined the steps that are already underway to strengthen this area of public 
protection practice. 

Offender Management policy requires that offenders assessed as high or very high risk of 
harm remain the responsibility of the National Probation Service until the end of their 
sentence, regardless of whether or not they will be released from custody on licence or at 
sentence end date.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Multi-Agency  Public  Protection  Arrangements,  or  MAPPA,  are  framework  of  statutory 
arrangements operated by criminal justice and social care agencies that seek to manage and 
reduce the risk presented by sexual and violent offenders in order to reduce re-offending and 
protect  the  public.  This  is  done  by  sharing  information  and  establishing  a  coordinated  risk 
management plan that will allow offenders to be effectively managed.  

In line with current MAPPA Guidance, the National Probation Service (NPS) must review all 
MAPPA  offenders  at least  six  months  prior  to  release in  order  to  assess  the  risk  they  pose 
and  determine  the level  of  MAPPA  management  at  which  an  offender  should be  managed. 
Where  they  are  assessed  as  meeting  the  appropriate  criteria,  an  offender  would  then  be 
referred  to  MAPPA  level  2  or  3.  This  is  a  priority  in  cases  where  the  individual  is  released 
without a license at the point of sentence expiry.  

ViSOR is a secure, shared MAPPA database.  It provides a central store for up-to-date risk 
related  information  about  offenders  that  can  be  accessed  and  updated  by  the  three 
Responsible  Authority  agencies  (NPS,  HMPS  and  Police).    It  is  classified  as  Official 
(Sensitive)  and  enables  the  prompt  sharing  of  risk  assessment  and  risk  management 
information  on  individual  offenders  who  are  deemed  to  pose  a  risk  of  serious  harm  to  the 
public and members of staff.  It improves capacity to share intelligence and  enhances public 
protection measures by improving the safe transfer of key information when these offenders 
move between areas and establishments. 

Under current arrangements ViSOR is the primary tool for communicating the release of all 
registered sexual offenders (Category 1) and those most concerning violent offenders 
(Category 2) who meet the criteria for management at MAPPA Level 2 or 3. It is a mandatory 
requirement for police and probation respectively to create a ViSOR record which allows 
them to store and share risk related information on the offender during and after their 
sentence. The presence of a ViSOR record is flagged on the front screen of an offender’s 
record on the Police National Computer (PNC).  

Violent offenders who did not meet the criteria for level 2 or 3 MAPPA management are the 
only cohort of MAPPA offenders who have not routinely had records created on ViSOR. This 
identified gap in public protection provision is being addressed by a significant programme of 
change which will see the NPS increase staff access to ViSOR. It will be available to 
probation officers on their laptop computers for the first time and NPS will create ViSOR 
records for all MAPPA eligible violent offenders. Training is being scheduled and NPS will 
adopt a phased approach ensuring all relevant eligible offenders have a ViSOR record, 
starting with newly sentenced offenders, those already in the community or due for release 
and working back to those with longer to serve in custody. This will commence in February 
2019. 

 
 
 
 
 
 In the case of 
, a Category 2 Level 1 offender, it must be remembered that 
the Police were aware that he had been released from prison, as they arrested him a number 
of times. However, the new ViSOR arrangements will allow relevant risk information, 
gathered throughout his sentence to be recorded centrally and available nationally so that 
police officers can more readily access it.  

Further measures are available, outlined within the MAPPA Guidance and HMPS Public 
Protection Manual (PPM), to enable information sharing in relevant cases to enable public 
protection concerns to be managed post sentence by relevant agencies.  

All Category 1 and 2 offenders managed at Level 2 or 3 who are coming to the end of their 
notification requirements or period of licence must be reviewed and considered for 
registration as a Category 3 offender. Registration as a Category 3 offender should only 
occur if the offender meets the criteria and continue to require active multi-agency 
management.  

Additionally, the most recent update to the Guidance has included further advice on specific 
offenders who are not automatically eligible for management under MAPPA, to be referred 
into MAPPA. This includes those sentenced for offences of “Controlling or Coercive 
Behaviour in an Intimate or Family Relationship” and serial domestic abuse perpetrators.  
Where the lead agency deems that these offenders pose a risk of serious harm that requires 
active multi-agency management, they should consider referral into Category 3. 

The latest PPM requires prisons to notify Children’s Services of the release date of all 
offenders identified as presenting a risk to children at least six weeks before they are 
discharged from custody and to copy the notifications to the Police, and the probation or 
youth offending team.  

The PPM also sets out harassment public protection measures which require case by case 
consideration to be given to notifying the Police on discharge of any prisoner who is under 
harassment measures or subject to no-contact requests, if the information is not being 
shared under MAPPA. This should particularly be considered when dealing with persistent 
offenders. The notification of release will allow the Police time to consider whether any 
additional mechanisms are needed to enhance the victim’s safety in the community. 

Offenders are assessed throughout their sentence and plans are developed to manage 
identified risk of harm presented by the offender. The plan must indicate which agencies are 
involved with the case and the role of each agency in managing the risk. Those responsible 
for implementing any aspect of the plan should be provided with a copy of it. If NPS or HMPS 
refer anyone to an accommodation provider they are expected to pass on all relevant risk 
information to inform the providers’ decision on the offender’s suitability for the 
accommodation and to inform their on-going relationship with the offender. 

  
 
 
 
 
 
 At termination of the sentence, whether the offender is in custody or the community probation 
officers are required to review the assessment and plan for high risk prisoners. This is to 
ensure that any available risk management strategies are identified and can be used to 
support any agency providing ongoing resettlement services, albeit without the controls which 
are available through a licence. During this process it is essential that probation practitioners 
identify any further concerns that would require the Police, local authority or other agency to 
be informed prior to the release of an offender and the plan should be clear what support or 
control measures might remain in place once probation supervision has ended. Relevant 
agencies that have been, or will continue to be involved post sentence, should be informed 
about the final plan and also notified that Probation will no longer be responsible for 
managing the sentence of the court and do not have any further powers in relation to the 
offender.   If there are concerns in relation to a known child (or children) probation providers 
have a duty to report these concerns to the Local Authority, following local referral 
procedures.  

Where an offender is not in contact with any other organisations at the end of sentence, it is 
clearly not possible to pass information on at the point the offender will no longer be subject 
to monitoring or supervision by the NPS. However, Probation will contribute to any ongoing 
MAPPA management under Category 3, Multi Agency Risk Assessment Conferences for 
high risk victims of domestic abuse and can provide relevant and proportionate information to 
supplement that provided by the police on offenders they have previously managed.  

The NPS also contribute to information sharing and safeguarding decisions of known or 
previously known offenders as part of their duty to safeguard children as set out in Section 11 
of the Children Act 2004. This is through engagement with Multi Agency Safeguarding Hubs 
(MASH). MASH is a structure that exists in most of the 152 Local Authority areas, aiming to 
improve the safeguarding response for children by facilitating information sharing and 
decision making on a multi-agency basis. Often, though not always, the MASH includes the 
co-location of staff from the local authority, health agencies and police and sometimes also 
from education, probation providers and Youth Offending Service. There are different names 
for this multi-agency safeguarding structure within some Local Authorities (e.g. MACE, 
MAST) and although the MASH were primarily established to safeguard children, increasingly 
areas are integrating safeguarding adults and in some areas sharing information in relation to 
domestic abuse. 

The level and specific model of NPS engagement in MASH is determined at divisional 
management team level and ranges from identifying a single point of contact for the MASH, 
providing a virtual link through access to shared systems/emails or by providing seconded 
staff. This allows for the relevant sharing of risk information even after an offender is no 
longer subject to supervision, where proportionate and necessary, to safeguard children 
and/or adults at risk. The NPS engagement with the MASH is set out in the National 
Partnership Framework for England dated August 2016. 

 
 
 
 
 In all other situations, the Police already have access to the information regarding the 
offending history, the sentence and licence and are able to consider disclosure of any 
pertinent risk information to any relevant agencies where they consider it appropriate to do 
so. This information will be supplemented by the additional information stored on ViSOR.   

Guidance on activity that is required at termination of sentence is currently being written as 
part of the HMPPS transition to a new model for managing offenders in custody. This will set 
out a clear expectation that plans are shared with other agencies involved with the offender in 
line with lawful information sharing practice.    

Yours Sincerely  

Gordon Davison  
Deputy Director  
Public Protection Group

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