Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0344, written 15 Oct 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Oct 2019 |
|---|---|
| Reference | 2019-0344 |
| Deceased | Alex Malcolm |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Rt. Hon Robert Buckland QC MP, Lord Chancellor and Secretary of State for Justice, House of Commons, London, SW1A 0AA 2. The Rt. Hon Matt Hancock, Secretary of State for Health and Social Care, Richmond House, 79 Whitehall, London SW1A 2NS 3. Ms Jo Farrar, Chief Executive Officer, HM Prison & Probation Service (HMPPS), HM Prison Service, 102 Petty France, London SW1H 9EX CORONER I am Andrew Harris, Senior Coroner, London Inner South jurisdiction CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, Coronets and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INQUEST On 1* December 2016, | opened an inquest into the death of Master Alex Malcolm aged 5 (died 22.11.16) case ref: 03101-2016 JB) and suspended it under Coroners & Justice Act 2009 Sch 1(2) at the request of the police. The medical cause of death was reported as la Head Injury. A perpetrator was found guilty of murder on 2 ist July 2017. On 12" July 2018 after hearing lengthy submissions and seeking his counsel’s opinion, the Senior Coroner decided that there was an arguable breach of Article 2 of the European Convention on Human Rights by the National Probation Service (NPS), on the application of Osman, and resumed the inquest, a decision accepted by NPS at inquest. It was heard before a jury and concluded on 2™ September 2019. The jury concluded that she was unlawfully killed and delivered a narrative conclusion. CIRCUMSTANCES OF THE DEATH Matters recorded by the jury as contributing to the death included: 1. The perpetrator being wrongly classified as MAPPA Category 2 Level 1 before release from prison 2. Failure to identify the perpetrator’s relationship with the deceased’s mother 3. Failure to share information with relevant agencies who could have notified the deceased’s mother of the perpetrator’s history of violent offending and put in place safeguarding measures 4. Allocation of a high risk offender to a newly qualified probation officer without adequate supervision 5. Failure to refer the perpetrator for a place in Approved premises 6. Failure of relevant agencies to identify, request and share relevant information 7. Failure to adequately challenge or to take action to recall the perpetrator in response to his failures to comply with licence conditions. Defects in the system were found which contributed to the death and included: 1. Changes to the NPS in 2014 leading to higher case workloads 2. NPS understaffing 3. Significant shortages of places in Approved Premises 4. Poor partnership working between prison and NPS and shortage of offender supervisors in prison Significant steps have been taken and action plans implemented to reduce the chance of future preventable deaths. CORONER’S CONCERNS During the course of the inquest, the evidence revealed matters giving rise to concern that in my opinion means that there is still 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. A senior NPS divisional head said that providing more Approved Premises places would potentially save lives. It is understood the matter is under review but details of what steps have since been taken were not heard by the coroner. 2. The Chair of the Serious Case Review subgroup of Lambeth Safeguarding Children Board said that strengthening any arrangements around domestic violence, including putting MARACs on a statutory basis had the potential to save lives. The senior Coroner raised this issue in a Prevention of Future Deaths Report to the Secretary of State for Health earlier this year, triggered by the chair of a domestic homicide review into the death of Donna Williamson. Her evidence was clear that there were arguments for MARAC and other bodies to be put on a statutory footing and for the system to be reviewed. The response from the ministry did not specifically address the issue. 3. Asenior NPS divisional head said that there were still difficulties in recruitment and retention of probation officers, one factor in which was low pay. It is understood the matter is under review but details of what steps have since been taken and their adequacy were not heard by the coroner. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths. I believe that the following organizations would wish to learn of the circumstances of this death and are in a position to mitigate or prevent future deaths: The Ministry of Justice with regard to concern 1 The Secretary of State for Health and Social Care with regard to concern 2 The National Probation Service with regard to concern 3. The full Record and detailed Domestic Homicide Review can be made available to Ministers if this is of assistance. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Wednesday, 11" December 2019. 1, 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. If you require any further information ot assistance about the case, please contact the case officer, COPIES and PUBLICATION [have sent a copy of my report to the following Interested Persons: Mother) Father) ‘ounsel for The National Probation Service The Probation Service Case Officer Tam also sending this report to the following, who may have an interest, or as prevention may involve their organizations: the charity Safelives, the Local Government Association, Lambeth Child Safeguarding. fam 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 ot 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 oe [DATE] . ae IGNED BY CORONER] (sot oe ®
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.
| Fees Bt é3-lz. HM Prison & . HM Prison and Probation Service Probation Service Post Point 14.05 Southern House Wellesley Grove Croydon Mr Andrew Harris CRO 1XN Senior Coroner Inner South District Greater London Southwark Coroner's Court 1, Tennis Street Southwark SE1 1YD i i | | | i y) December 2019 Deas Coroner , INQUEST INTO THE DEATH OF ALEX MALCOLM Thank you for your letter of 16 October to the Chief Executive Officer, following the inquest into the death of Alex Malcolm. Her Majesty's Prison & Probation Service (HMPPS) is grateful for the observations in your report on the issues surrounding Alex's tragic death. You refer to difficulties in recruiting and retaining probation officers and the steps being / taken to address these. HMPPS introduced a new pay structure with effect from 1 April 2018 for the National Probation Service (NPS) to recognise the professional nature of the work of its staff and the significant contribution they make. As part of this process, pay for the NPS was compared against other public sector employment, to ensure that it was competitive. NPS Pay Modernisation included a two-year pensionable pay award (2018-19 and 2019-20) for all staff. Approximately 9,500 staff received a minimum pay award of 3 per cent in each year (instead of a contractual 4 per cent pay award if the pay reforms had not been implemented). The new pay structures also recognised staff at the maximum for their grade and provide a framework for Pay progression for all staff through a competency-based framework. New arrangements, such as a more beneficial pay-on-promotion policy, were also introduced to support career progression and to assist the filling of vacancies ona temporary and permanent basis. NPS staff based in London aiso receive a London Allowance of £3,889 per annum. In addition, a ‘Market Forces Allowance’ of £1,100 to £3,100 is currently being paid to i i Probation Support Officers, Probation Officers and Senior Probation Officers in specific locations to address local recruitment and retention issues. HMPPS continues to monitor recruitment and retention, and to assess the implementation of the new pay structure. | hope that the measures | have described above demonstrate the continued work being done in this area. Yan 6 d FC H M Prison & Probation Service
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