Sobhia Khan

19 April 2024 
Sent via email 

Dear HH Goldstone KC 

I write in response to your Report to Prevent Future Deaths (hereafter “PDF”) dated 
16 February 2024 concerning the death of Sobhia Tabasim Khan on 28 May 2017. In 
advance of responding to the specific concerns raised in your Report, on behalf of 
Cygnet Health Care, I would like to express my deep condolences to Ms Khan’s 
family and loved ones. 

To reassure you and Ms Khan’s family that the concerns raised in your PFD have 
been listened to and reflected upon, the following steps have been taken: 
1. The PFD action plan was reviewed at Clinical Governance meetings on 22 March 
2024. It is listed to be an agenda item every month until September 2024 and 
provided that all actions are embedded at that point, it will be closed. 

2. The action plan has been shared with the Senior Management Team for, and the 
Multi-Disciplinary Team  (MDT) and all staff involved in Mr Mustafa’s care at, Cygnet 
Hospital Derby. 

3. The action plan is included in Cygnet Derby Overarching Local Action Plan 
(OLAP) and reviewed bi-monthly by the General Manager, Hospital Manager, and 
Clinical Manager to ensure completion and embedding of the actions. 

4. The action plan was discussed and agreed at Medical Advisory Committee 
(MAC) (8 March 2024). 

5. To ensure ‘Ward to Board’ learning and dissemination a presentation on learning 
points and actions from the PFD has been, and will be presented, at the following 
meetings: Regional Governance for East and West Midlands Managers (13 March 
2024) and Secure Services steering group (30 April 2024), Regional Governance 
Medical Leads (9 July 2024). 

6. The action plan will also be disseminated to NHS IMPACT Contract meeting for 
Commissioner scrutiny and openness of process (23 May 2024). 

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 Cygnet Health Care responds to your PFD concerns as follows: 

Concern 1: Clinicians should be provided with full reports when considering 
discharge: Those recommending discharge were not provided with the full Spousal 
Assault Risk Assessment, but only a summary. Given 
catastrophic consequences that were liable to result from him being pre-emptively 
discharged, and that discharge was being recommended without recourse to the 
Tribunal, it was essential that the s.117 meeting was informed by detailed reports 
which, had they been properly considered, would have indicated a need for 
circumspection. 

risk profile, and the 

Response: 

1. Spousal Assault Risk Assessment (SARA) document are provided in full in 
professionals CPA meeting/s.117 meeting report packs. There document will be sent 
as a full document to the Ministry of Justice when applying for section 17 leave 
permissions from the MOJ. It will be indicated on the Request for Discharge that it is 
available for the MoJ to view (as the request for discharge form does not allow for 
attachments). 

2. A yearly service audit to be conducted by the psychology team at Cygnet 
Derby, to have as its focus in 2024, the delivery and evidence base of service users’ 
understanding and implementation of skills taught in sex offender, violent offender, 
and arson treatments. 

Concern 2: Over-reliance on self-reporting: It was recognised that Mustafa was 
narcissistic and manipulative but he was nonetheless relied upon to provide 
updates as to his mental health, his travel plans and the reasons for them, and – 
critically - whether or not he was in a relationship. Mustafa’s risk arose primarily in 
the context of relationships and he was not somebody that could be relied upon to 
disclose them. On the contrary, he had shown himself willing and adept at 
concealing them. This underlined why his self-reporting could not be relied upon 
and this was something that should have featured in his management throughout, 
and flagged at the point of discharge. 

Response: 

The MDT may be vulnerable to manipulation by service users and team  ‘splitting’ 
can occur which can lead to poor decision making on risk factors and discharges. 

1. The manipulation measurement tool, currently used for females, to be added as 
an addendum to the HCR-20 (a Secure Services Standard Risk Assessment tool for 
baseline risk assessment) and used for males going forward. 

2 

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 2. Potential Manipulation and Measurement tool to reviewed at CPA/s.117 
meetings 

To be completed by audit on 31 May 2024. 

3. A second opinion of a medical specialist, such as a neuropsychiatry specialist, to 
be sought in cases of high risk, or where the need for a speciality outside the remit 
of the MDT is identified. 

The need to consider the need for a second opinion will be added to the CPA 
checklist along with the relevant actions indicated if the need for a second opinion 
is identified. This will be monitored via MHAA audit. 

Concern 3: Record-keeping: This was a thread that ran through the case and 
applied both to the clinical notes but also the notes of meetings, such as MAPPA, 
which are necessarily a summary but which did not always include sufficient 
information to enable those reviewing them to understand what had been discussed 
and what actions taken. In terms of clinical records, whilst basic, mundane matters 
such as his sleeping habits and appetite were recorded, much of what mattered 
was not. The paucity of records and the poverty of their quality meant that Dr Kumar 
was not aware of the history of manipulation and the other factors which indicated 
an ample need for reassessment. In terms of the SOTP, whereas there was a conflict 
of evidence as to why the group programme was not available at Cygnet hospital, 
the keeping of proper records would have ensured that there was a ready answer if 
needed. The discharge meetings were poorly recorded, with the spousal assault risk 
assessment not having featured at all. There were repeated instances of witnesses 
not being able to remember, understandably, what had happened with respect to 
certain events. There was no excuse for professional witnesses to be put in this 
embarrassing position. The MoJ are reliant on what they are told in writing, but given 
that there is a culture of poor record-keeping, until and unless that record-keeping 
is improved to an acceptable level, they have to be more pro-active and more 
prepared to question things. 

1. All staff complete a report writing and record keeping developmental Skill 
workbook as part of their Cygnet induction. 

2. Cygnet audits on triangulation of records completed 3 monthly to ensure cross 
referencing of information in different streams of records. 

3. Section 117 and transfer of care meetings are monitored and audited at Cygnet 
Derby to ensure up to date reports or addendums are submitted, and detailed 
minutes recorded, the main focus being on MoJ , MAPPA, and high profile service 
user discharges. 

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 Kind regards 

Executive Director of Nursing 
Cygnet 

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21

HM ASSISTANT CORONER HIS HONOUR 
CLEMENT GOLDSTONE KC 

Date 

08/04/2024 

Dear Sir 

Re: Response Regulation 28: REPORT TO PREVENT FUTURE DEATHS 

This is Derby City Council's response to your report made under paragraph 7, Schedule 5, of the 
Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) 
Regulations 2013, dated 16 February 2024, following the tragic and unlawful killing of Sobhia 
Tabasim Khan on 27 May 2017. 

Thank you for your conduct of the inquest and for your identification of a number of matters of 
concern, which are set out in the report. The Local Authority accepts your findings. 

Since the tragic events Derby City Council has made significant changes to the way we manage 
mentally disordered offenders subject to conditional discharge from a s.37 hospital order with s.41 
restrictions under the Mental Health Act 1983, and support to staff discharging their role as Social 
Supervisors. This has been informed by internal and external reviews of systems and practice. 

With particular reference to the Coroner's concern, 5b, in July 2019 Derbyshire Healthcare NHS 
Foundation Trust secured funding for the creation of a Forensic Community Mental Health Team. 
The Local Authority has been working alongside the team to support supervision of mentally 
disordered offenders under a forensic pathway. 

Derbyshire Health Care NHS Foundation Trust and Derby City Council are at the next stage of the 
implementation of the forensic pathway and are finalizing a Memorandum of Understanding 
between the two organisations in order to employ a Senior Social Work Practitioner, with lead 
responsibilities for Forensic Mental Health. The post is designed to work across both 
organisations. To enable cohesive working across both social care and healthcare, and to maintain 
clear social work links and social work identity, it is agreed that the post is co-located cross the site 
of both agencies. 

The Council House, Corporation Street, Derby, DE1 2FS
derby.gov.uk 

To view Derby City Council Privacy Notices please visit derby.gov.uk/privacy-notice 
Please recycle this letter 

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 The role shall provide a social work contribution and responsibility to those that ordinarily receive 
services in Derby City engaged with the Forensic Division and/or under Part 3 of the Mental Health 
Act 1983. This specifically refers to the statutory duties of the Local Authority under Care Act 2014, 
Mental Health Act 1983 and associated legislation and policy. The Senior Social Work Practitioner 
will maintain all statutory responsibilities and professional governance will be in accordance with 
the standards set out by Social Work England, and the Department of Health Forensic Mental 
Health Social Work: Capabilities Framework 2016. 

In addition to this, the role will work on key aspects of service and practice development by: 

•  Sharing good practice and learning from case work 
•  Sharing knowledge, resources, and expertise 
•  Setting standards, expectations, and consistency around the Social Supervisor Role 
•  Process and discussion around best practice in relation to recall. 
•  Develop a centralised training agenda across organisations. 
•  Share developments from ADASS (Association of Directors of Adult Social Services) 

forensic network 

•  Maintain the Social Supervisor Register.  
•  Develop a countywide Social Supervisor Network, facilitating thematic reflective 

discussions. 

•  Develop a mentoring and buddying system across forensic work. 

The recruitment for this role will commence by July 2024 and a full workplan detailing the service 
developments above will be in place by end of December 2024. 

The Council has also introduced training for social supervisors funded jointly by health and social 
care; previously this was provided on an "ad hoc" basis and was agency specific.  Broadly 
covering all of the matters of concern, in September 2019 Derby City Council in conjunction with 
Derbyshire County Council commissioned regular training for social supervisors. There is a two 
day introduction to Part 3 Mental Health Act 1983 and the role of the Social Supervisor and a one 
day annual refresher. 

The course includes: 

•  Overview of the role of the Social Supervisor. 
•  The responsibilities associated with the role. 
•  Exploration of the multi-disciplinary approach to the role of Social Supervisor. 
•  Discharge planning and information sharing. 
•  Reflections on local policy and Code of Practice guidance, underpinning this work. 
•  Exploring conditional discharge under Part III MHA and reference guide, including Mental 

Health Tribunals. 

•  Good practice regarding record keeping, writing reports, recall, supervision and good liaison 

with the Ministry of Justice. 

Derby City Council currently holds a register of trained Social Supervisors across Derbyshire 
including their training record. 

With particular reference to the Coroner's concern, 5i, Derby City Council have introduced a rolling 
programme of Unconscious Bias training in relation to developing cultural competence. 

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 Sobhia’s death shocked the services involved, system wide. The loss of Sobhia, and the 
circumstances surrounding that, have had a profound effect on the local system and professionals 
involved. Our hearts go out to her family and friends. She remains in our thoughts, and we offer 
our sincerest condolences to her family. 

Yours sincerely 

Service Director of Adult Social Care, People Directorate 

14

Date: 

. 
11th April 2024 

HHJ Goldstone 
Derby and Derbyshire Coroners Court 

Via email only 

Dear HHJ Goldstone 

I  am  writing  in  response  to  the  Regulation  28:  Report  to  Prevent  Future  Deaths  dated  16th 
February 2024 following the inquest into the death of Sobhia Tabasim Khan on 27th  May 2017 
in Derbyshire. 

Sobhia’s death was a tragic incident that robbed her loved ones of a much-loved daughter, sister 
and friend. At the conclusion of the inquest, Assistant Chief Constable 
 offered in 
the media a sincere and unreserved apology to Sobhia’s family and friends for any failings of 
the force, and I would like to take the opportunity to offer my own sincere apology to them at this 
time. 

The Khan family have shown immense dignity since Sobhia’s death, and I hope our response 
shows how the force has worked to improve the management of sexual and violent offenders 
since  2017  as  well  as  other  actions  we  have  taken  to  protect  victims  and  improve  officers’ 
cultural awareness. 

In your report, you highlight nine areas of concern (A-I). The areas we understand to be relevant 
to Derbyshire Constabulary are stated and addressed below: 

C)  Police  power  to  arrest  where  there  is  a  reason  to  believe  a  person  is  at  risk  of 
death/serious injury 

There is no specific order or power of arrest where there is reason to believe that a person is at 
risk of death/serious injury, and this is something that requires national consideration. A letter 
explaining the circumstances of this case and the context concerning this recommendation has 
been sent to Assistant Chief Constable 
 national policing lead for the Management of 
Sexual Offenders and Violent Offenders (MOSOVO), for his consideration. 

However, the force does have powers where there are risks to a known victim, and we have 
made significant progress in how we protect vulnerable people from harm by strengthening the 
protection that we can offer. Civil orders such as Domestic Violence Protection Orders (DVPO) 
and  Stalking  Protection  Orders  (SPO)  have  powers  of  arrest  attached  to  them  so  that  a 
perpetrator  can  be  arrested  if  the  conditions  are  breached.  The  introduction  of  dedicated 

Derbyshire Constabulary, Headquarters, Butterley Hall, Ripley, Derbyshire, DE5 3RS 
Incoming telephone calls and communications may be monitored and recorded 

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 2 

operational  teams  in  January  2023  strengthened  our  capacity  to  proactively  manage  the 
perpetrators who pose the greatest risk of harm. The performance of these teams is monitored 
through internal governance structures that focus on compliance and quality. 

G) Over-reliance on self-reporting 

This issue was also highlighted in the Domestic Homicide Review (DHR) into this case that took 
place in 2017, where the following recommendation was made to all agencies involved: 

‘To be aware of and receive information and guidance on manipulation by offenders linking to 
the broader notion of disguised compliance, enabling staff to make further assessment of the 
behaviours and intention of individuals in an effort to identify and mitigate any such intentions.’ 

Since the recommendations from the DHR were received, the force has made several changes 
with both training and compliance. We have invested in additional training to upskill our officers 
and staff and equip them with the skills and knowledge to enable them to effectively manage 
self-reporting and  disguised  compliance.  All  officers  and staff  working  in  the Management  of 
Sexual  and  Violent  Offenders  (MOSOVO)  team  have  completed  the  College  of  Policing 
MOSOVO training course. 

Several changes have been made within the MOSOVO team to ensure compliance with national 
guidelines and Authorised Professional Practice (APP). We have strengthened our supervisory 
capability  by  investing  in  an  additional  Detective  Sergeant  within  MOSOVO,  increasing  the 
number  from  three  to  four.  This  has  improved  the  supervision  of  the  work  conducted  by the 
Offender  Managers.  In  addition,  the  MOSOVO  Detective  Inspector  conducts  10  quality 
assurance checks each month to monitor compliance with our Standard Operating Procedures. 

At the end of 2023, several officers and staff members were trained to deliver  the College of 
Policing MOSOVO training course so that new people joining the team could be trained in-house 
and  equipped  with  the  skills  and  knowledge  from  the  outset.  Continuing  Professional 
Development  (CPD)  events  are  held  throughout  the  year  in  order  to  refresh  the  skills  of  our 
officers and staff and so that they can share best practice. On a wider level, Vulnerability training 
was delivered to all frontline officers and staff during 2023 and 2024 and this has included the 
topics of controlling and coercive behaviour and disguised compliance. 

The Offender Managers generally conduct unannounced home visits to perpetrators, double-
crewed, as this is recognised best practice to minimise the risk of disguised compliance. We can 
report that our compliance rates in the last six months are 86% for unannounced visits and 84% 
for double-crewed attendance. On the occasions of non-compliance, a supervisor will ratify the 
decision with supporting rationale. In May 2023, we recruited a Digital Media Investigator (DMI) 
into the MOSOVO team to further strengthen our capability to manage and monitor compliance. 
The  DMI  accompanies  the  Offender  Manager  on  unannounced  home  visits  to  proactively 
conduct  checks  of  digital  devices,  such  as  laptops,  mobile  phones  and  tablets,  to  ensure 
compliance with any conditions of a licence or other order. 

H) Record keeping 

To record our interactions with offenders within the MOSOVO department, we use a national 
system called Violent and Sex Offender Register (ViSOR). This provides a national database 
for the Police and Probation Service to jointly register, risk assess and manage sex, dangerous 
and violent offenders. ViSOR catalogues an offender’s previous risk assessment reports and 
provides a link to the Police National Computer (PNC), which allows access to an offender’s full 

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 3 

criminal  record.  All  officers  and  staff  attend  a  training  course  prior  to  being  given  access  to 
ViSOR and are expected to adhere to ViSOR operating standards. 

Following  feedback  from  His  Majesty’s  Inspectorate  of  Constabulary  and  Fire  and  Rescue 
Services  (HMICFRS),  we  have  recently  reviewed  how  we  comply  with  the  national  ViSOR 
operating standards in recording Active Risk Management System (ARMS) assessments. We 
have reviewed our processes in response and adapted our Standard Operating Procedures to 
ensure that we are compliant and have rectified those that had been incorrectly recorded. The 
minutes of all Multi-Agency Public Protection Arrangements (MAPPA) meetings are recorded 
and are subject to scrutiny during the learning reviews conducted by the MAPPA partnership 
every  six  months.  Additionally,  we  work  with  other  forces  in  the  region  to  peer  review  and 
scrutinise each other’s minutes from MAPPA meetings. 

Improving investigations is a key strategic priority and we have a comprehensive programme of 
activity  to raise  standards  and  improve  record  keeping,  led  by our  Head  of  Crime,  Detective 
Chief Superintendent 
. The importance of record keeping has been reiterated as 
part  of  key  messaging  to  frontline  officers,  staff,  and  supervisors  through  their  senior 
management teams and force wide communications. 

I) Familiarisation of professionals with cultural issues 

All officers and staff embarking on a career in Derbyshire Constabulary now receive training on 
many cultural aspects, including diversity, equality and inclusion, human rights, the history of 
policing, the Police Race Action Plan, hate crime, forced marriage, honour-based abuse, and 
community  policing.  The  force  also  has  a  page  on  our  internal  intranet  site  entitled  ‘Cultural 
Competence’  which  has  been  produced  by  our  Head  of  Equality,  Diversity  and  Inclusion.  It 
signposts officers and staff to ways in which they can communicate effectively with people and 
be  aware  of  the  cultural  differences  that  may  impact  their  communication  with  people  within 
those communities. 

We have recently revised our Neighbourhood Profiles so that Safer Neighbourhood Teams can 
capture vital cultural information to enable them to understand the needs of the community and 
improve their engagement. The profiles outline the demographics of the area and identify key 
community groups and religious establishments, as well as identifying significant persons within 
them such as religious leaders, Councillors, headteachers and community workers. 

The  work  and  recommendations  noted  within  this  report  will  continue  to  be  progressed  and 
monitored by Detective Chief Superintendent 
 to ensure that we provide the very 
best possible service to our many and varied communities and cultures in Derbyshire. 

I hope the above response provides you with the necessary assurance of the actions we have 
taken, and continue to take, since Sobhia’s tragic death. 

Yours sincerely 

Chief Constable 

11

Corporate Services 
Ashbourne Centre 
Kingsway Site 
Kingsway 
DERBY 
DE22 3LZ 

26 March 2024 

HH Clement Goldstone KC 
Assistant Coroner sitting in the Coroners’ Areas of Derbyshire 

Dear Sir 

Re: Regulation 28 response: an inquest touching the death of Sobhia Khan 

May I first begin on behalf of the Trust by conveying my deepest condolences to the 
family of Ms Khan for their loss, which is most tragic, and our thoughts are with them. 

The  Trust  notes  that  the  Prevention  of  Future  Death  Report  is  wide  ranging  and 
encompasses  different  areas,  some  of  which  are  out  of  the  control  of  the  Trust  as 
they would require legislative changes. In answering below, the Trust has focused on 
those matters that are under its control as an organisation. 

Scrutiny of s. 41 cases by the Mental Health Review Tribunal (“MHRT”) 

Whilst it is acknowledged that 
Party to the inquest (namely Cygnet) the Trust does operate a low secure male unit 
within its healthcare portfolio and would like to offer assurance that it seeks to utilise 
the tribunal process as the norm for discharges of patients subject to s. 41 MHA 
restrictions. 

 was discharged by another Interested 

The Trust’s standard practice for discharge is to engage the receiving community 
service approximately 6 months prior to discharge. To ensure that the patient is 
ready for discharge the Trust utilises the Assertive Transition Service from IMPACT 
(see below for an explanation of what IMPACT is) during the patient’s leave prior to 
discharge. To allow for oversight at a collective level, the IMPACT Case Manager for 
the patient will routinely be invited to MDT, CPA meetings and 117 meetings. They 
are also kept informed of discharge plans. 

Ensuring that s.41 restricted patients are supervised under a forensic pathway 

With the support of commissioners, the Trust has invested into a Forensic 
Community Mental Health Team (“FCMHT”) over a 4-year period. The sum invested 
is £2.7 million. The monies provided have created a full multi-disciplinary team which 
provides care to the patients of Derbyshire. The approach taken by the FCMHT is 
guided by evidence from The Royal College of Psychiatrists and NHS England. The 
Trust is mindful of the complex nature of those patients who are under the care of 
the FCMHT and as such seeks only to recruit experienced clinicians. 

Trust Headquarters, Ashbourne Centre, Kingsway Hospital, Derby DE22 3LZ 

15 

 
 
 
 
 
 
 
 
 The Trust still has a small number of patients subject to s. 41 restrictions who are not 
under the care of the FCMHT. This approach is based on clinical need and the 
progress to recovery each patient has made; balancing the potential benefit of being 
supported by a FCMHT against the potential for a new clinical team in destabilising 
their recovery. Where clinicians do hold a restricted s. 41 patient on their caseload, 
they are mandated to receive forensic clinical supervision from the FCMHT. More 
broadly the FCMHT reviews any s. 41 restricted patient who are not under the care 
of the FCMHT to ensure they are receiving the appropriate level of care, support and 
supervision as would be expected of a patient subject to restrictions. 

In addition to the above, the Trust is an active member of IMPACT – the East 
Midlands Provider Collaborative made up of nine NHS and independent sector 
organisations that jointly provide specialised mental health services for patients. 

Clinicians should be provided with full reports when considering discharge 

The Trust is conscious that clinical teams, the Ministry of Justice and the MHRT rely 
on the information that is provided to them to consider risk and understand their own 
role in a patient’s care. To that end the Trust’s FCMHT has been provided with 
training on report writing to ensure that the information contained within the reports 
that it writes (to other clinicians, to MHRT and the MoJ) are of the standards 
associated with a FCMHT. 

Further, and in addition, specific training has been completed with those that 
undertake the social supervision role so that it is clear what standards and 
expectations are required. Any report written by a social supervisor employed by the 
Trust is scrutinised by a senior member of the FCMHT prior to being submitted. 

Where required and appropriate to the clinical discussion the MoJ is invited to attend 
and contribute to MDT meetings. 

Over-reliance on self-reporting 

The initial assessment of a patient before they are accepted into the FCMHT will be 
conducted by two staff members followed by a full MDT discussion – the purpose of 
this approach is to reduce the possibility of having a subjective view of a patient’s 
need and risks. The FCMHT are trained in conducting structured risk assessments to 
assess the level of risk posed and structured diagnostic assessments to support 
diagnosis. These tools are used to augment subjective clinical decision making with 
objective measures of assessment. Examples of the tools used: the Psychopathy 
Checklist and International Personality Disorder Examination Assessment. 

Employees working in the FCMHT have received external clinical supervision from 
an expert within Forensic Services to assist with analysing and understanding risk. 
The FCMHT has also accessed specific training around the management of patients 
subject to s.41 restrictions provided by the MoJ. 
The forensic pathway (both the FCMHT and inpatient teams) meet on a weekly basis 
to enable additional clinical discussion and scrutiny of cases that are causing clinical 
concern. 

The aforementioned Forensic Supervision offered by FCMHT for clinicians in CMHT 
provides safeguards against over-reliance on self-reporting as the risk based 

16 

 
 approach would foster clinical curiosity. 

Record keeping 

 was under the care of the Trust it transitioned from 

During the time 
hardcopy records to an electronic patient record, PARIS. Since that time, the Trust 
has now adopted Systm1 as its electronic patient record system across all its 
services. This enables all services to see what information is inputted by other 
services within the Trust. In addition, Trust clinicians can see information inputted by 
GPs and colleagues from the local community Trust enabling better, more holistic, 
care. 

The Trust conducts ongoing record keeping audits of the medical records of all 
patients who are subject to a s.37/41 to ensure that they meet the standards 
required. This audit process is reinforced by a robust supervision process for all 
nurses / AHPs working with those patients. 

Familiarisation of professionals with cultural issues 

The Trust recognises the importance of caring for an individual holistically and 
considering all facts that are relevant to a bio-psycho-social model of care. 

The FCMHT has undertaken shared cultural awareness training with the police and 
probation to explore unconscious bias, family loyalty etc. A gap analysis of all staff 
training is being conducted to further understand what areas are already strong and 
which areas are to be improved, this analysis will include whether there is a need for 
further cultural awareness training. 

More widely throughout the Trust, it has employed an Equality, Diversity and 
Inclusion Lead who offers support to employees when needed to help navigate 
challenging cultural normal within specific cases. 

I hope that this information reassures you and the family of Ms Khan that steps have 
already  been  taken  to  address  the  issues  raised  in  the  Prevention  of  Future  Death 
report  however  if  I,  or  the  Trust,  can  be  of  any  more  assistance,  please  do  not 
hesitate to contact me. 

Yours sincerely 

CHIEF EXECUTIVE 

17

ae Rt Hon Edward Argar MP
Ministry Minister of State for Justice

of Justice

His Honour Clement Goldstone KC

“
16 Apri 2024

RESPONSE TO REGULATION 28: PREVENTION OF FUTURE DEATHS REPORT

Thank you for your Regulation 28: Prevention of future Deaths (PFD) report dated 16 February 2024
following the inquest into the death of Sobhia Tabasim Khan who died on 28 May 2017 at 68 Peartree
Crescent, Derby.

| anticipate that you will share a copy of this response with Ms Khan’s family so | shall take this
opportunity to offer my sincerest condolences to them all including Ms Khan's brother, who
was present at the inquest and I have been told showed great fortitude throughout. The pain and anguish
of losing a family member in such terrible circumstances must be an immense burden and | understand
why Ms Khan’s family may have many questions about how it was able to happen, especially given Ataul
Mustafa’s previous offending, and why they will be interested in what the authorities will do to try to
prevent any similar tragedies happening.

Following evidence heard at the inquest you have identified a number of concerns, some of which are
relevant to the Ministry of Justice, namely, the scrutiny of restricted patients by the Mental Health
Tribunal, the Secretary of State’s use of recall powers, travel overseas for section 41 restricted patients
and supervision under a forensic pathway.

The Mental Health Casework Section (MHCS) in HMPPS exercises the Secretary of State’s statutory
powers under the Mental Health Act 1983 (MHA 1983), whilst the day to day supervision of conditionally
discharged patients is the responsibility of the care team in the community.

A common theme during the inquest and in the areas of concern in the PFD report was that the Ministry of
Justice was not furnished with a complete picture of [EEE presentation whitst detained in hospital
or discharged into the community. EEE was discharged into the community in 2015 by MHCS on
behalf of the Secretary of State and he murdered Ms Khan in May 2017. Since this tragic event, a number
of improvements have been made to the way the MHCS and care teams interact.

In March 2022 MHCS updated application forms for community leave and discharge applications requiring
increased detail around MAPPA engagement and victims with the aim of improving the quality and
completeness of the information submitted to the MHCS.

In July 2023 MHCS published guidance for those supervising conditionally discharged patients in the
community’. The guidance aims to support the supervision and reporting requirements for discharged

1 https://assets. publishing.service.gov.uk/media/64b016148bc29f000d2ccd1 5/Guidance-
_Conditionally_Discharged_patients_-_supervision_and_reporting_Final.pdf

E https://contact-moj.service.justice.gov.uk/

T +4420 3334 3555 ,
www.gov.uk/moj

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patients, it covers all aspects of a patient’s discharge into the community. At the same time, the reporting
tool that is used to keep the Secretary of State updated with regards to a restricted patient’s progress in
the community was also refreshed and improved.

One of your concerns centred on the fact that (was allowed to travel to Pakistan soon after his
discharge into the community. Under the MHA 1983, there is no statutory bar to overseas travel for
conditionally discharged patients and no mechanism for the Secretary of State to impose a blanket ban on
all overseas travel. However, guidance published in July 2023 underlines the following expectations:

“(T)he primary contact with the patient should be face to face’; and

“(W)here a patient has left the country for more than a short holiday, the Secretary of State does not
consider effective supervision possible and consideration will be given to recalling the patient for an
urgent assessment at the point of their return to the United Kingdom. It would not be acceptable for
telephone contact or supervision to be continued on the basis that the patient is in the community whilst
they remain outside the jurisdiction of the 1983 Act...’

Also among your concerns was the fact that [had an overall lack of forensic input, namely the
lack of a forensic psychiatric evaluation in advance of the request for discharge compounded by there
being no community forensic supervision. Although it is not within the legislative powers of the Ministry of
Justice to ensure that restricted patients are supervised under a forensic pathway, MHCS continues to
work with partner agencies in support of delivering a comprehensive approach to supervision of
discharged patients. The Government’s White Paper Reforming the Mental Health Act (January 2021) set
out aspirations to strengthen and further develop the role of the social supervisor. Health Education
England commissioned a project to develop a Social Supervision Quality Framework, training materials
and tools for social supervisors and their line managers aligned with the MHCS guidance, which my
department published in 2023. Further products from this joint work will be launched later in 2024.

The Framework and resources will better support social supervisors and clinical supervisors who must
submit regular progress reports to the MHCS for previously detained patients who remain liable for recall
to hospital from the community as part of their conditional discharge. You may also wish to note the
recently published DHSC guidance, Discharge from mental health inpatient settings’, it aims to share best
practice in relation to how NHS bodies and local authorities can work closely together to support the
discharge process and ensure the right support in the community. It includes a section on forensic mental
health forensic inpatient settings covering restrictedpatients.

You suggested it would have been more appropriate for the discharge decision to have been put before a
Tribunal instead of it being taken by the MHCS on behalf of the Secretary fo State. Parliament entrusted
to the Secretary of State a power to discharge restricted patients, and unlike the Tribunal, which must
reach a decision on discharge entirely on the statutory criteria in section 73 of the Act, the Secretary of
State has a broad discretion to order discharge where deemed safe to do so. The MHA 1983 has been
subject to intense public scrutiny since 2017, when the then Prime Minister, Theresa May, commissioned
an Independent Review of the Act. In response, the Government published a White Paper and public
consultation in 2021. The Draft Mental Health Bill (MH Bill) was published in June 2022 and made subject
to Pre-Legislative Scrutiny. Given this high level of independent scrutiny of the legislative provisions, | do
not consider the discharge process requires any changes.

When considering recall, MHCS guidance?’ is clear that ‘(T)here is no need for the patient's mental health
to have necessarily deteriorated in order to justify recall.’ MHCS can and do recall restricted patients
where there is an increased risk to others in order to protect the public. My officials regularly updats
guidance for those working with restricted patients including the publication of guidance on s42 discharge
in March 2022 and shall consider whether any changes to the recall guidance are necessary.

2 Discharge from mental health inpatient settings - GOV.UK (www.gov.uk)
3 Recall of conditionally discharged restricted patients - GOV.UK (www.gov.uk)

In 2024, MHCS introduced a new system in order to identify cases where domestic violence has taken
place, whether as part of the index offence or in the patient’s history. Once identified, the issue of domesic
violence will be highlighted to decision makers at all stages of a patient's movement through the hospital
system and prompt them to to ask further, specific questions around domestic violence to ensure that this
aspect of the risk is properly considered and mitigated.

Record-keeping was a thread that ran through the case and applied both to the clinical notes but also the
notes of meetings, such as MAPPA, which are necessarily a summary but which did not always include
sufficient information to enable those reviewing them to understand what had been discussed and what
actions taken. The National MAPPA Team in the Ministry of Justice has sought to improve the quality of
MAPPA meetings and the recording of decisions. Specifically, in May 2022 updated Statutory Guidance
was published on the conduct and recording of MAPPA meetings, including attendance, a clear focus on
decisions relating to risk assessment and management, and that actions are clearly recorded and
followed up. The Guidance is supported by a revised minutes template and an aide-memoire for MAPPA
Chairs. Furthermore, in April 2023 The National MAPPA Team published learning resources for MAPPA
Chairs and administrators with the aim of building confidence in ensuring that meetings are focused on
risk and that that all agencies are clear about their contribution to risk management planning and are
accountable for agreed actions.

| am confident that the above changes and updated guidance documents, designed to ensure that MHCS
are furnished with all relevant information in order to discharge responsibilities under the MHA 1983, and
that professionals supervising patients in the community continue to use their profession curiosity has led
to an improved overall system. MHCS continue to identify opportunities to enhance our guidance and
share knowledge with stakeholders.

Thank you for bringing these concerns to my attention. | trust that this response provides assurance that
action has been and is being taken to address the matters you have raised.

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RT HON EDWARD ARGAR MP