Zara Aleena

Miss N Persaud,  
His Majesty’s Area Coroner, 
East London Coroner's Court,  
124 Queens Road, 
Walthamstow,        
E17 8QP.  

By email only to: 

9th October 2024 

Dear Madam, 

Inquest Touching the Death of Zara Aleena 

Thank you for your Regulation 28 Report of 26th July 2024, following the Inquest into the death 
of Zara Aleena. As Chief Probation Officer, I am responding to the Report also on behalf of the 
Lord Chancellor and Secretary of State for Justice.  I know that you will share a copy of this 
response with Ms Aleena’s family, and I would like to take this opportunity to express afresh 
my deepest condolences to them for their loss.  

In  your  Report,  you  raised  the  following  concerns  specifically  in  relation  to  the  Probation 
Service:  

1.  The probation delivery unit responsible for the offender was understaffed at the time 
of relevant oversight. The staffing levels were 61% in 2022. The staffing levels at the 
time of the inquest in June 2024 were 58%. The inquest heard that this is a national 
problem and that there are other probation delivery units that have even lower levels 
of  staffing.  The  low  staffing  level  had  an  impact  upon  quality  and  depth  of 
assessments;  quality  of  supervision  of  junior  staff  (supervision  was  wholly 
reactive);  excessively  high  workloads  for  probation  officers  and  senior  probation 
officers;  lack  of  cover  during  annual  leave  for  probation  officers  and  poor  record 
keeping. 

1.1.  We  accept  that  the  Probation  Delivery  Unit  (PDU)  responsible  for  Jordan 
McSweeney  was  understaffed  at  the  time.  Whilst  at  a  national  level,  the  staffing 
position of the Probation Service is improving, I acknowledge that raising staffing in 
this PDU to its full complement remains a significant challenge. Therefore, until such 
time as the situation improves, in this PDU and others with acute pressure remaining, 
staff  will  follow  a  Prioritisation  Framework  which  we  first  implemented  in  January 
2022.  Those  PDUs  will  also  benefit  from  wider  national  workload  relief  through 
Probation  Reset  (see  below  at  1.4)  as  reflected  in  a  refreshed  Prioritisation 
Framework published in May 2024. 

 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 1.2.  We continue to prioritise recruitment to put the Service on a sustainable footing and 
ensure  sufficient  Probation  Practitioner  staffing  (Probation  Officers  and  Probation 
Service Officers). As of 30 June 2024, the staffing level of Probation Officers working 
across  the  Probation  Service  was  70%,  with  5,136  Full  Time  Equivalent  (FTE) 
Probation Officers in post. This number shows a considerable  increase relative to 
June  2021  (when  Community  Rehabilitation  Companies  were  dissolved,  and  the 
Probation Service was unified) when we had 4,517 FTE Probation Officers in post. 
London  had  the  highest  vacancy  rate  of  all  regions  as  of  30  June  2024  with  a 
vacancy rate of 41%. 

1.3.  Across  HMPPS,  4,582  new  Trainee  Probation  Officers  have  started  their  training 
since April 2020 (1,007 in 2020/21, 1,518 in 2021/2022, 1,514 in 2022/23 and 543 
in 2023/24). Many of these trainees have already qualified and taken up Probation 
Officer posts, and we expect the remainder to qualify by the end of 2025, taking on 
Probation  Officer  caseloads.  We  are  beginning  to  see  large  numbers  of  newly 
qualified officers coming through and continue to run national recruitment for Trainee 
Probation Officers to meet the Lord Chancellor’s commitment to bringing in at least 
1,000 new Trainee Probation Officers by the end of March 2025 so that we continue 
to have a pipeline of qualified Probation Officers.  

1.4.  As well as the focus on recruitment, in response to the additional demands placed 
on the Probation Service as a result of measures to address prison capacity, since 
July  2024  we  have  implemented  a  set  of  measures  known  as  Probation  Reset. 
These measures involve prioritising early engagement at the point where offenders 
are most likely to breach the requirements of their licence or community sentence 
and,  in  eligible  cases,  end  active  supervision  of  offenders  after  two-thirds  of  the 
licence or community order period. In turn, this ensures that staff can maximise the 
amount  of  available  supervision  time  on  the  most  serious  offenders.    Early 
indications  show  that  Probation  Reset  has  brought  capacity  into  the  system  and 
workloads to more manageable levels. 

1.5. 

Internal assurance alongside the findings of His Majesty’s Inspectorate of Probation 
shows that there is still some way to go before assessments consistently reach an 
acceptable  standard  of  quality.  Whilst  Probation  Reset  has  provided  us  with  a 
workload  reduction, the need  to  prioritise  and make  effective decisions  remains a 
critical  ask  of  staff.  The  Prioritisation  Framework,  introduced  in  2022,  remains  in 
place.  When a  PDU  has  reduced  staffing  capacity, they  can  re-prioritise  tasks for 
frontline  staff  to  ensure  staff  workloads  are  controlled  and  high  priority  work  is 
delivered.  

1.6.  HMPPS recognises the pressure upon Senior Probation Officers (SPOs) and how 
this can affect their supervision of junior staff. The number of SPOs has increased 
by 249 nationally since June 2022, whilst initiatives continue to strengthen the SPO 
role, including a review of the Management Oversight Policy Framework and roll out 
of  the  revised  Management  Oversight  model  by  December  2024,  to  ensure  the 
approach to staff supervision is consistent and effective. HMPPS has invested in a 
suite of capability options for SPOs to further develop their skills, continual learning, 
and  additional  support  from  dedicated  case  administration  officers  to  reduce  the 
demand on SPOs in relation to administrative tasks.  

2.  There were no systems in place devised to assist the staff working in these stretched 
circumstances, such as easy reference checklists for supervising key decisions.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2.1.  HMPPS accepts that we have to do more to help probation staff understand how to 
prioritise  and  make  informed  decisions  in  their  roles,  which  can  be  complex  and 
challenging.  

2.2.  As outlined in response to concern (1), whilst Probation Reset has provided us with 
a  workload  reduction,  the  need  to  prioritise  work  and  make  effective  decisions 
remain  central  to  what  we  require  of  probation  staff.  In  accordance  with  the 
Prioritisation  Framework,  Probation  Regions  are  assigned  a  red,  amber,  or  green 
categorisation depending upon the degree of prioritisation required. This Framework 
was  reviewed  in  June  2024  to  reflect  Probation  Reset,  given  the  implications  for 
operational delivery. London Probation moved to the Prioritisation Framework at its 
outset in 2022.  London is operating within red/amber site status, which is regularly 
reviewed. Alongside this, there is a specific project being run by the London Area 
Executive Director to review processes and practices alongside operating models. 
The aim of this is to identify a more refined approach to manage the acute challenges 
in  London  and  ensure  caseloads  are  manageable.  An  example  of  this  would  be 
expansion of remote support provided by an administration hub outside of London 
where  we  can  recruit  and  retain  staff  while  retaining  the  local  focus  on  the  good 
management of cases. 

2.3.  To assist with everyday operational process and procedure, Probation Practitioners 
have access to a comprehensive system known as EQUiP (Excellence & Quality in 
Process),  which contains  guidance  and  process  maps for  most of the  operational 
decision-making and is continuously updated to reflect changes to policy, tasks and 
timings.  Alongside this, HMPPS continues to develop a range of tools to support 
risk management practice.    

2.4.  Our work on Human Factors recognises the broader components of decision making 
and the importance of creating an environment that enables individuals and the wider 
organisation to learn from error. Human Factors aims to reduce the frequency and 
severity of mistakes by using mechanical or digital overrides or prompts and/or by 
introducing tools and techniques such as checklists as preventative measures.  Work 
in Wales Probation (2022-2024), based on Human Factors, tested a model designed 
to  assist  practitioners  (which  can  include  Probation  Service  Officers,  Trainee 
Probation Officers and qualified Probation Officers), Senior Probation Officers and 
operational  leaders  with  managing  priorities  and  decision  making,  with  a  key 
emphasis on risk. This model is now being implemented in two further regions; the 
work  will  be  evaluated  on  completion  and,  as  we  progress,  both  the  model  and 
products  will  continue  to  be  reviewed.  We  are  committed  to  considering  national 
implementation, with a view to providing staff with systems and processes to practise 
effectively and efficiently under stretched circumstances.   

3.  The understanding around risk assessment was poor, at all levels of staffing.  The 
practical application of risk assessment was poor at all levels of staffing.  Risk was 
not assessed at appropriate times, and the assessment of risk was not accompanied 
by  a  complementary  risk  management  plan.  Risk  management plans  were  on 
occasion prepared before risk was fully assessed (as occurred with the setting of 
licence conditions). One practitioner was advised to set a risk level to match other 
completed  documents  (without  analysis  of  risk  itself).  Practitioners  did  not 
holistically assess risk and take account of potential indicators of serious harm, to 
include  use  of  weapons;  attitudes  supportive  of violence;  callousness  and  high 
increased frequency of lower-level violence.  

3.1.  We accept that the understanding and application of risk assessment did not meet 
expected  standards  in  this  case.  Any  advice  given  to  the  practitioner  to set  a risk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 level without analysing the risk was in contravention of the content of the HMPPS 
Risk of Serious Harm (RoSH) Guidance, which sets out the process which Probation 
Practitioners must follow for assessing an offender’s risk of harm to others.   

3.2.  HMPPS plays a vital role in protecting the public from people who have offended, 
and we cannot do this effectively without understanding the risks presented by those 
being  managed.  Indeed,  ensuring  that  an  offender’s  risks  are  fully  understood  as 
part of a comprehensive risk assessment is vital for the formulation of a robust and 
comprehensive risk management plan. We know there is more to do to ensure that 
every risk assessment is undertaken at the right time, considers all the relevant risk 
factors and takes account of information from all relevant sources.  

3.3.  As set out in our response to His Majesty’s Inspectorate of Probation Serious Further 
Offence  Review,  the  RoSH  Guidance  is  based  on  the  right  evidence,  including 
learning from Serious Further Offence Reviews and Domestic Homicide Reviews, 
but there are ongoing organisational challenges in its implementation. We are taking 
steps to address the barriers to its effectiveness, but we know there is more to do, 
and we will publish a new HMPPS Public Protection Strategy by the end of March 
2025.  We  have  already  made  changes  to  the  suite  of  risk  training  which  all  new 
learners  on  the  Probation  qualification  route  and  new  Probation  Service  Officers 
complete. This ensures they understand the importance of actuarial tools, the need 
to  actively  monitor  changing  risk  and  how  this  should  inform  plans  and  action  to 
manage risk, and we will introduce new training for experienced staff (see response 
to concern 4). 

3.4.  The  structured  process  of  risk  assessment  as  set  out  in  the  RoSH  Guidance,  if 
followed, supports staff to think about an individual’s behaviour holistically, not just 
the index offence; and make reflective, logical, and informed decisions about risk. 
The section on risk management provides a structure to produce risk management 
plans that address the identified risks and set actions to protect people at risk.  

3.5.  This approach has informed the newly developed risk training for new practitioners. 
For experienced Probation Practitioners, HMPPS delivered webinars in Spring 2024, 
promoting the four steps of risk assessment as set out in the RoSH Guidance, and 
the importance of actuarial tools to 91% of  Practitioners in Court undertaking pre-
sentence report writing.   Further events for all Probation Practitioners responsible 
for managing individuals in the community will be held by November 2024, to ensure 
they are also aware of the importance of the use of actuarial risk predictor tools and 
the RoSH guidance and its value, to support them in assessing and managing risk.   

3.6. 

In 2023, London rolled out the Skills Improvement Programme with specific modules 
on  risk  of  harm  for  both  Probation  Practitioners  and  Senior  Probation  Officers. 
Probation Officer training within this Programme included “Risk including the 4-step 
risk assessment process and the 4 pillars of risk management” and Senior Probation 
Officer training included “Risk and Counter-signing framework”.   

4.  Risk assessment training is not part of the mandatory training framework within the 

Probation Service. Risk assessment training is not refreshed.   

4.1.  Whilst  we  recognise  that  in  this  case  risk  assessment  practice  was  not  at  the 
expected standard, risk assessment training has always formed part of the required 
learning and ongoing development for Probation Practitioners, and I am sorry that 
this was not clear from the evidence we have already provided to you.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4.2.  For  clarity,  ‘mandatory  learning’  refers  to the  learning  that  all  probation staff must 
complete  for  pay  progression  under  the  competency-based  pay  progression 
framework (CBF), whilst ‘required learning’ has been assessed as necessary for a 
particular  role.  Each  role  will,  therefore,  have  specific  ‘required  for  role’  learning 
products which are not optional. 

4.3.  Risk assessment is required learning for all Probation Practitioners, either as part of 
the  Probation  Officer  Qualification  pathway  or  the  Probation  Service  Officer 
Pathway. Risk training is reviewed to ensure it remains up to date. In March 2023, a 
suite of new learning products designed for new entrant practitioners was launched, 
drawing upon research and best practice to provide strong foundational knowledge 
of risk assessment, risk management and sentence planning, and incorporating an 
improved understanding of actuarial predictor tools. This blended learning comprises 
digital resources, which can be revisited at point of need, in addition to facilitated live 
sessions.   

4.4.  Experienced  Probation  Practitioners  are  required  to  revisit  and  complete  their 
training in relation to Child Safeguarding and Domestic Abuse on a three-year cycle. 
Knowledge  and  understanding  of  risk  assessment  and  management  are  further 
developed through experience of the work and its supervision. However, historically 
there has not been a requirement to attend further formal training on risk assessment 
and  management.  Having  recognised  that  risk  practice  is  not  consistently  at  a 
sufficient  standard, 
in  December  2023  a  new  Continuing  Professional 
Development risk learning product was commissioned to address this gap. This is 
intended to enable experienced practitioners to explore in-depth concepts related to 
risk assessment and to ensure their practice knowledge is up to date. This product 
is now being developed and is currently anticipated to be available to all practitioners 
from February 2025.    

5.  There  were  no  checks  to  ensure  the  provision  of  up  to  date  and  accurate  risk 

assessments to partner agencies (such as the housing team).  

5.1.  We  accept  that  in  this  case  up  to  date  and  accurate  assessments  of 

’s  risk  were  not  shared  with  partner  agencies.  We  are  committed  to 
improving  professional  standards  of  practice  and  have  introduced  mandatory 
professional  registration  for  Probation  Officers,  which  aims  to  sharpen  focus  on 
Continuous  Professional  Development  and  drive  improved  performance  and 
personal  accountability  to  deliver  public  protection.  Whilst  managers  do  oversee 
Probation Officer work, we would not expect them to check every referral before it is 
made.  The  professional  standards  will,  alongside  increased  staffing  levels  and 
improved  digital  checks/safeguards,  ensure  that  Probation  Officers  do  all  that  is 
required  of  them,  including  the  sharing  of  risk  information  with  partner  agencies, 
whose contribution is vital to the efficacy of risk management plans. 

5.2.  Effective risk assessment and management is a clear HMPPS priority and is assured 
at both local and national levels.  Locally, risk assessment and management practice 
is assured within teams and PDUs using the approved case audit tool. Nationally, 
the HMPPS internal Performance Assurance and Risk Group  (PARG) undertakes 
an annual sentence management audit, a key component of which is the quality of 
risk  management  practice.  The  results  of  this  audit  are  shared  with  regions  and 
recommendations given, which are incorporated into their local improvement plans. 

5.3.  Local  contract  teams  assure  quality  of  referrals  to  partner  agencies  using  an 
approved  audit  tool.  Nationally  PARG  delivers  annual  assurance on the  quality  of 
referrals  to  partner  agencies  across  some  of  the  suppliers,  who  provide  services 

 
 
 
 
 
 
 
 
 
 
 
 
 
 which  HMPPS  commission.  This  includes  an  assessment  of  whether  the  risk 
information included in the referral is clear, accurate, up to date, consistent with that 
contained in other internal records, and relevant to the Provider.   We have issued 
recommendations to Probation Regions on how to improve their performance. 

6.  There  was  a  lack  of  professional  curiosity  and  a  lack  of  sufficient  probing  into 

information relevant to risk.  

6.1.  We accept that there was a lack of professional curiosity and probing of risk-related 
information in this case. Professional curiosity is an essential part of the assessment 
and management  of risk  and is  a golden  thread throughout  the  new  Risk  training 
material.  It  will  also feature  in  the  new  Continuing  Professional  Development risk 
learning product, which is currently being developed by HMPPS in conjunction with 
subject  matter  experts.  This  product  will  be  piloted  with  Probation  Practitioners 
towards the end of this year before being launched from February 2025. The need 
to  demonstrate  professional  curiosity  is  also  woven  into  several  other  learning 
products,  most  notably  Skills 
for  Effective  Engagement  Development  and 
Supervision (SEEDS2) for practitioners (launched June 2022) and middle managers 
(originally  launched  2019,  paused  delivery  during  COVID  and  then  reviewed, 
updated and relaunched in 2022). In recognition of the importance of these products 
SEEDS2 has been identified as a now strategic learning priority for 2024-2025 with 
Probation Officers required to complete the learning by September 2025 as part of 
their Continuing Professional Development requirement 

6.2.  Reflective  Practice  supervision  (a  key  aspect  of  the  SEEDS2  approach)  plays  a 
crucial role in fostering professional curiosity by creating a supportive environment 
where practitioners  reflect  on  casework  and practice issues  by  critically  analysing 
and evaluating their experiences. It encourages practitioners to question their own 
practice, assumptions and decisions in concert with their line manager, who provides 
feedback based on observations and other sources. 

6.3.  Probation  Practitioners  also  have  access  to  the  HM  Inspectorate  of  Probation 
Effective Practice Guide on Professional Curiosity, published in October 2022, and 
are  encouraged  to  use  this  as  a  reference  document  to  support  continuous 
professional development and apply professional curiosity in their practice. 

7.  The  OASYS  risk  assessment  tool  is  unwieldy  and  difficult  to  navigate.  It  was 
challenging  to  extract  the  most  relevant  material.  The  content  of  the  OASYS 
assessment was so dense that the probation officers seemed to get lost in the detail 
and  failed  to  pull  together  and  formulate/analyse  key  risk  areas.    One  senior 
probation officer stated that she would not look at the OASYS when allocating cases, 
because OASYS assessments were “not always accurate and up to date”. It is noted 
that a new risk assessment tool within the probation service is a work in progress. 
It is envisioned that the new tool will take into account the above concerns.   

7.1.  We recognise that OASys (Offender Assessment System) is a complex tool for staff 
to  use  effectively,  which  is  why  we  are  replacing  it  with  a  modern  digital  tool  for 
identifying, managing and communicating risk.  

7.2.  The ‘Allocate a Person on Probation’ digital tool has been implemented in London 
and is subject to ongoing reviews. This presents OASys information in terms of risk 
of  harm  level  /  risk  predictor  tool  scores,  RSR  (Risk  of  Serious  Recidivism)  and 
OGRS  (Offender  Group  Reconviction  Scale),  and  active  risk  registrations  to  the 

 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
  
  
 allocating Senior Probation Officer. There is also a prompt for the allocating Senior 
Probation Officer to check OASys.   

7.3.  The  ’Allocate  a  Person  on  Probation’  tool,  from  September  2024,  also  supports 
recording of management oversight for allocation of a case. This includes any notes 
relating to the case, as well as the allocation suitability. This management oversight 
is required for all cases. On completion of the allocation of the case, this oversight is 
automatically recorded as a contact in the nDelius case management system. 

7.4.  More broadly, we are investing in the Assessing Risks, Needs and Strengths (ARNS) 
project,  the  replacement  for  OASys  to  be  used  in  prisons  and  by  the  Probation 
Service.  The project  aims  to  deliver  a  transformational  change  in  how  we  assess 
offenders,  using  the  latest  international  evidence,  including  that  on  criminal 
desistance. In  addition  to  a  new  enabling  digital  service  for  assessment  and 
sentence planning, there is a comprehensive new learning and development offer to 
support staff to adapt and enhance their practice. The roll-out of ARNS is scheduled 
to begin in the third quarter of 2025 and be in place fully by the third quarter of 2026. 

7.5.  HMPPS will be working to ensure risk assessment is undertaken throughout the time 
HMPPS is responsible for the management of the sentence, and regularly updated, 
to support the practitioner in understanding changing levels of risk accurately.  

7.6.  The ARNS project is focused on making the assessment and planning process more 
efficient by reducing duplication and making it easy to update.  Development work 
on  the  risk  section  within  ARNS  will  ensure that  relevant  information  is presented 
together  to  support  staff  to  analyse  key  areas  of  risk  holistically.  The  interaction 
between the new risk and sentence plan sections will support staff to translate their 
assessment of risk into comprehensive plans that both effectively manage risk and 
focus rehabilitation efforts to reduce risk. 

7.7.  ARNS is one of a number of tools being developed across HMPPS and the Criminal 
Justice System (CJS) to the current shared government digital standards which will, 
in time, allow better flow of information from one to another and therefore will support 
better information sharing. We are prioritising digital resource for the development 
of ARNS.  However, ahead of its full roll out, HMPPS will work in partnership with 
Ministry of Justice digital colleagues to streamline the current OASys tool where it is 
possible to do so efficiently and in a way that supports, rather than detracts, from the 
development of ARNS. 

8.  The  globe  system  and  alert  systems  did  not  work  effectively  in  this  case.  A 
restraining  order  had  been  put  in  place  against  the  offender,  but  this  was  not 
highlighted, as it should have been. Key staff involved in assessing and managing 
the offender were unaware of the restraining order.  

8.1.  We  recognise  the  importance  of  probation  staff  being  aware  of  restraining  orders 
and they are expected to record them in a globe in the case record system (i.e., an 
alert) with the start and end date, with explanatory notes. We also recognise that the 
globe system requires staff to look for and record relevant information.   To ensure 
that staff are prompted to consider whether there is a restraining order and to use 
the information to inform the management of the case, in April 2023 HMPPS made 
a  change  to  the  OASys  tool  to  prompt  assessors  to  state  if  people  under  their 
supervision are subject to Civil Orders. This means that practitioners are supported 
to  include  behaviours  which  have  resulted  in  the  courts  imposing  a  Civil  Order  in 
their  risk  assessment  even  if  they  were  not  convicted  of  an  offence.  It  will  also 
support them to ensure risk management concords with the aim of the Civil Order. 

 
 
 
 
 
 
 
 
 
 
   
 
 
 
  
  
 8.2.  To  further  strengthen  practice  and  ensure  that  practitioners  do  not  miss  the 
significance of a restraining order or any other Civil Order, in May 2024 we released 
a new Civil Order e-learning package to provide HMPPS staff with an overview and 
awareness  of  Civil  and  ancillary  Orders  and  why  they  are  important  in  probation 
work. Our target is that all staff in relevant roles will have completed this by the end 
of March 2025.  

8.3.  We  will  review  practice  guidance  by  December  2024,  including  when  to  add  and 
remove  a  globe to  ensure that  HMPPS  staff  are  clear  on  the  need  to  record  Civil 
Orders.  We are also committed to a review of the globe system by March 2025 with 
the purpose streamlining and to make information more accessible to staff. We are 
committed to identifying whether digital solutions are available to improve the review, 
updating and termination of information on the globe system. However, this will have 
multi-system  impacts  and  will  need  to  be  embedded  alongside  other  changes  as 
systems are developed, rather than be progressed in isolation. This will impact on 
timescales for this aspect of the solution. 

9.  There  may  be  obstacles  to  increasing  risk  levels.  The  inquest  heard  that  senior 
probation  staff  would  have  to  approve  increases  in  risk.  As  staffing  levels  are  so 
stretched, there may be reticence of junior probation officers to trouble the senior 
team. The risk assessment policy also includes a statement that staff “should not 
use  risk  levels  to  inflate  risk  because  of  anxiety  or  to  access  resources”.  It  is  a 
concern that this provision may inhibit decisions to increase risk.   

9.1.  We do not have any evidence of a widespread problem of Probation Officers being 
reluctant  to  ask  SPOs  to  approve  formal  increases  in  assessed  risk,  or  that  this 
particular statement in policy is inhibiting staff from raising their assessment of an 
offender’s risk level, where that would be justified based on the available evidence. 
The percentage of those assessed as  ‘high risk of serious harm’ has increased in 
recent  years  from  19.9%  in  2018  to  25%  in  2022.  PARG's  annual  sentence 
management audit confirms agreement with the risk level in most assessments. To 
avoid any misinterpretation, this statement will be removed in the next review, due 
by November. 

9.2.  The RoSH Guidance sets out helpful information to support practitioners undertaking 
assessments determine an overall risk level, ensuring they have taken all relevant 
information  into  account.  It  also  provides  prompts  for  “thresholding”  where 
practitioners  may  be  undecided  between  two  levels  such  as  medium  and  high. 
Additionally,  it  encourages  staff  to  consider  escalating  risk  factors  and  provides 
learning from Serious Further Offences in relation to the types of circumstances that 
most often indicate escalating risk.   

9.3. 

In response to an HMIP Thematic Report on The Role of the Senior Probation Officer 
and  Management  Oversight  published  in  January  2024,  a  number  of  initiatives 
across the Probation Service are underway exploring the role of the Senior Probation 
Officer and aiming to improve capacity and capability to undertake that role. As part 
of this, by December 2024, HMPPS will put in place a clear Policy Framework for 
Management Oversight and first-tier assurance. This will meet the demands of the 
probation caseload and ensure that effective management oversight arrangements 
are in place at the regional and Probation Delivery Unit level to assure the quality of 
work to protect the public by February 2025.  

9.4.  The new national framework for newly qualified officers (NQOs) was rolled out at the 
end  of  July  2024.    The  framework  builds  upon  already  established  processes  to 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 support NQOs in their first-year post-qualification, setting out the expectations and 
enablers  which  regions  should  follow  to  provide  consistency  in  their  approach  to 
transitioning and supporting NQOs in their development post qualification.   

10. The evidence revealed a difference of opinion and understanding around when an 
emergency  recall  should  be  requested.  A  senior  probation  officer  and  probation 
services  officer  erroneously  believed  that  an  emergency  recall  could  only  be 
requested out of hours.  

10.1.  We  accept  that  there  was  an  inconsistency  in  understanding  of  emergency  recall 
processes  in  this  case.  All  London  Probation  staff  have  been  reminded  of  the 
availability of the emergency recall process during normal working hours. Another 
reminder  was  given  to  all  staff  in  preparation  for  SDS40  (the  recent  changes  to 
standard determinate sentences, announced in July and implemented in September 
2024). 

10.2.  The  Recall  Policy  Framework  clearly  deals  with  Emergency  Recalls  at  sections 
4.3.13 - 4.3.15 and out of hours recalls at sections 4.6 and 6.5.  Guidance is available 
to all probation staff on EQUiP for emergency recalls during normal working hours, 
as well as standard recalls during normal working hours and out of hours recalls.  Our 
internal figures for recent months (from May to July 2024) evidence that there has 
been regular use of emergency recalls during normal working hours for individuals 
serving a determinate sentence. Recalls for those serving a life sentence are always 
dealt  with  as  emergency  recalls.  These  figures  evidence  the  regular  use  of 
emergency recalls during normal working hours.  These figures do not include recalls 
for those serving a life sentence which are always dealt with as emergency recalls.    

11. The  role  of  the  prison  offender  manager  is  to  gather  evidence  to  assist  with  the 
formulation of risk. Prison offender managers do not however receive focussed risk 
assessment training. Neither of the prison offender managers in this case gathered 
evidence to assist with the formulation of risk.  There were multiple intelligence logs 
and records that should have been obtained by them. The logs included findings of 
possession of weapons, drug taking, threats to harm others and a sustained assault 
on a servery worker using an improvised weapon. This information was not gathered 
and shared appropriately.  

11.1.  We agree that the role of the Prison Offender Manager (POM) is to gather evidence 
to assist with the formulation of risk. With this in mind, there is a designated modular 
training package specifically for POMs. We are sorry if our evidence did not make it 
clear  that,  as  well  as  risk  assessment  being  examined  in  all  modules,  there  is  a 
designated  module  focusing  on  risk  assessment,  planning  and  management.  In 
addition to this, all POMs receive OASys training. This is a four-day training event 
that  focuses  on all  aspects  of  the OASys  assessment,  including  risk  assessment, 
risk management and the sentence plan. POMs cannot receive an OASys account 
to complete an assessment until OASys training has been completed.   

11.2.  POMs are expected to complete OASys assessments on those prisoners who are 
serving more than ten months from point of sentence, as they are responsible for the 
supervision of these individuals.   

11.3.  For longer term sentenced prisoners there is an agreed process to share information 
via  the  POM-COM  (Community  Offender  Manager)  handover.  There  was  no  set 
agreed process  for those prisoners  serving  10 months  and less.  To  rectify this,  a 
mandated Information Sharing Form was introduced in November 2023. This form 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
     
 
 examines  custodial  contact  and  behaviour  and  must  include  information  that  is 
available  within  the  custodial  setting  that  would  not  be  easily  accessible  to 
community  colleagues.  This  was  introduced  to  standardised  information  sharing 
practices between prison and community.  

12. There  was  no  evidence  that  the  prison  offender  manager  from  February  2021  to 
October 2021 paid any attention to the sentence plan in place for the offender. They 
did not attempt to facilitate any rehabilitative interventions. There was no evidence 
of supervision for the prison offender manager. 

12.1.  Whilst recognising there was an ongoing staff shortage at the time due to recovering 
from  the  COVID  pandemic,  we  accept  that  mistakes  were  made  and  as  such  we 
have taken steps to rectify these.  

12.2.  HMPPS  sets  national  standards  and  operating  models  centrally,  but  it  is  down  to 
areas/regions/prisons  to  oversee  practice  and  ensure  that  POMs  are  carrying  out 
their duties and tasks accordingly. 

12.3.  In April 2022, the SPO Line Management Framework was introduced.  SPOs, also 
known as Heads of Offender Management Delivery (HOMDs) based in the Offender 
Management Unit (OMU) in prisons, are line managed by the Governors, who are 
responsible and accountable for the  delivery  of  case  management  in their  prison. 
The SPOs are responsible for line managing both Probation and Prison POMs and 
are required to undertake regular supervision (although the frequency is not currently 
stipulated) to improve the quality of Offender Management in Custody (OMiC) work 
and outcomes for  prisoners,  offering  greater  consistency  in approach to sentence 
management within a prison setting. HOMDs are also required to countersign work 
undertaken by POMs within the OMU. 

12.4.  The  training  referred  to  in  (11)  is  designed  to  give  POMs  the  necessary  skills  to 
undertake risk management and risk planning, and to deliver the sentence plan in 
custody. A new learning programme ‘Leading and Managing as an SPO (Sentence 
Management, Court and OMiC)’ was launched in May 2024 and covers leadership 
and management development specifically within the context of probation work. This 
programme includes sessions on management of risk of harm as a manager and on 
supporting staff to perform effectively.  

12.5.  More broadly, HMPPS launched the SPO Hub on the internal intranet in June 2024 
as  a  single,  accessible  resource  to  support  Senior  Probation  Officers  (including 
HOMDs).  The  Hub  includes  updates  on  relevant  inspections,  audits  and  action 
plans,  learning  and  development  pathways,  continuous  professional  development 
and resources such as current guidance on the staff supervision process. The Hub 
is being continually developed and specific consideration to the needs of HOMDs 
will  be  made  in  later  iterations.  The  Hub  also  provides  regular  progress  on  key 
projects  such  as  the  review  of  the  Management  Oversight  policy  framework 
mentioned  in response to concerns (1)  and  (9). Whilst the framework  has  to-date 
focused on community responsible cases, the planned changes in the forthcoming 
review will enable the framework to be applicable to both the community and custody 
setting. 

13. There was no system in place to alert the prison offender manager to handover an 
offender to the community offender manager when a period of sentence ended and 
where the offender remained in prison, on remand. 

 
 
 
 
 
 
 
 
   
 
 
  
 
 
 
   
  
 
 13.1.  If  a  prisoner’s  status  is  remand  only,  there  is  no  statutory  responsibility  for 
supervision as the prisoner is unsentenced.  If a prisoner is subject to both remand 
and recall, they are subject to statutory supervision only to the point of the Sentence 
Expiry  Date.  All  recalled  prisoners  remain  the  responsibility  of  the  Community 
Offender  Manager  (COM).  The  Prison  Offender  Manager  is  not  expected  to 
handover the supervision of the case, as the COM is responsible throughout. It is 
the responsibility of the COM to monitor sentence expiry dates, as they will need to 
complete a termination OASys and close the record.  

14. The system in place for sharing risk information between the Probation Service and 
the MPS was unclear. Only very limited intelligence was shared with the MPS. There 
was no explanation as to why that information was shared, when  more concerning 
risk related information was not shared.   

14.1.  There is a published Joint National Protocol  (JNP) - Recall Process for Offenders 
Subject  to  Licence, which  sets  out  the  high-level  roles  and  responsibilities  for  all 
stakeholders/agencies involved in the recall process.  

14.2.  The JNP places a responsibility on the Probation Service to provide the local police 
force  with  any  available  information  and  intelligence  about  the  offender’s 
whereabouts  in  order  to  assist  the  police  force  in  apprehending  the  offender  as 
quickly  as  possible.  This  includes  up-to-date  information  regarding  the  offender’s 
behaviour whilst on licence, to assist the police force in identifying any threat to the 
public  or  specified  individuals  and  any  risk  to  police  officers  when  seeking  to 
apprehend the offender.  

14.3.  There  is  also  the  Recall,  Review  and  Re-Release  of  Recalled  Prisoners  Policy 
Framework  which  stipulates  in  paragraphs  4.2.13  and  4.3.19  that  Probation 
Practitioners must ensure that all available information, which might assist the police 
in  locating  and  safely  apprehending  the  individual,  is  detailed  in  the  Part  A  recall 
report sent to Public Protection Casework Section (PPCS) in HMPPS HQ. PPCS is 
responsible for revoking an offender’s licence on behalf of the Secretary of State and 
then forwarding the revocation order to the Police National Computer Bureau and 
the local police force. 

14.4.  We  have  provided  further  detail  on  information  from  Prisons  being  fed  into  the 
offender management process below (in response to concern 15) and in response 
to concern (11) above.  

15. The  Integrated  Offender  Management  meetings  did  not  receive  the  necessary 
intelligence  from  the  prison  setting.  There  was  no  system  in  place  to  ensure  that 
either the prison offender manager was invited to attend, or that the prison offender 
incidents. 
manager  was  asked  to  provide  written 

information  around  risk 

15.1.  We  acknowledge  that  prison  staff  did  not  share  intelligence  about 

  with  their  colleagues  in  the  Probation  Service.  We  have  agreed 
processes in place to ensure that prisons communicate information to the COM for 
sentenced prisoners, but these processes did not function properly in this case, as 
explained in the SFO review. For long-term prisoners, information sharing from the 
POM to the COM occurs at point of handover. In November 2023, we standardised 
expectations for those prisoners serving a short-term custodial sentence. 

15.2.  To  ensure  that  all  appropriate  agencies  involved  in  an  Integrated  Offender 
Management  (IOM)  case  are  included  in  any  pre-release  work,  the  National  IOM 

 
 
 
 
 
 
   
  
  
 
 
 
  
 
 
 
 guidance  has  been  updated to  state  explicitly that the  POM must  be  invited to  all 
multiagency case conferences in preparation for release.  The guidance goes on to 
say that if the POM is unable to attend, a written update should be provided.  The 
latest version of the guidance (V4.1) went live on 30 August 2024. All IOM regional 
leads across England and Wales have received this updated guidance and will brief 
their local IOM teams within region. It has also been uploaded onto EQUiP, which is 
a library of resources for operational staff.  This case has been explicitly referenced 
on  page  25  of  that  guidance  to  stress  the  importance  of  such  communication 
between POM and COM when managing IOM cases, and to strengthen the learning 
from this tragic case.  

Thank  you  again  for  bringing  your  concerns  to  my  attention.  I  would  like  to  reassert  my 
condolences  to  the  family  and  all  those  who  have  been  affected  by  this  tragic  and  terrible 
event.. The probation service is committed to acting on the learning from this case.    

Yours faithfully, 

Chief Probation Officer

His Majesty’s Coroner Ms Nadia Persaud 
East London Coroners Court  
124 Queens Road 
Walthamstow 
E17 8QP 

Home Secretary 

2 Marsham Street 
London SW1P 4DF 
www.gov.uk/home-office 

19 September 2024 

Dear Ms Persaud,  

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

Thank you for your Report to Prevent Future Deaths on 26 July 2024 regarding the 
unlawful killing of Zara Natasha Aleena. 

I would like to start by recognising that at the heart of this tragic inquest is Zara Aleena and 
I extend my deepest condolences to her family and loved ones for their devastating loss 
and extend my gratitude to them for their persistence on change for the future. 

I would also like to thank you for your diligence and the detailed consideration of the 
failings you identified in your report.  These failings are shocking, and I am clear that the 
lessons must be learned across Government and beyond.  

Tackling violence against women and girls is a top priority for this Government and we will 
treat it as the national emergency that it is. This Government’s mission is to halve levels of 
violence against women and girls within a decade, using every lever available to us. The 
Home Office is working closely with other departments and stakeholders in developing 
plans to achieve this mission. The findings you outline make it crystal clear that lessons 
must be learned. I will ensure that these are acted upon, not only as we build upon the 
existing work I outline below, but also within our future work. However, I want to be clear 
that this will take time – we must deliver it effectively, and we must get it right. Too often 
piecemeal changes have failed to change systems which are fit for the future, and we are 
determined not to make those mistakes.  

The Home Office’s response to your report focuses on two matters of concern raised, 

specifically concerns 20 and 21. 

Matter of concern 21 

At least two other members of the public were followed by the offender before he attacked 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Zara Aleena.  The members of the public appear to have seen the offender and appear to 
be aware that he was following them. This was not brought to the attention of the 
emergency services. I am concerned that there is a societal acceptance that such conduct 
does not need to be reported.   

In your report, you highlight that other members of the public were followed by the offender 
before he attacked Zara Aleena and that this was not brought to the attention of the 
emergency services.  I recognise these failings and share your concern that there is a 
societal acceptance of such conduct which can mean that those subject to it may not feel it 
should be reported.  I also recognise that women may not report as they do not have 
confidence that they will receive a robust response.  Everyone has the right to live in 
freedom from fear, yet women and girls are still facing threats of violence, abuse and 
death.  

The Home Office has funded a range of interventions to help tackle violence against 
women and girls in public spaces, including within the night-time economy. These 
interventions have included capable guardianship initiatives such as Street Angels or 
Street Pastors and educational programmes with a focus on changing attitudes and 
perceptions and raising awareness on these issues, as well as active bystander training, 
which was targeted at night-time economy staff and other members of the community.  The 
independent evaluations of educational programmes have shown that they can have a 
positive influence on training beneficiaries’, including improvements in their awareness and 
understanding of these crimes, likelihood to report VAWG and improvements in confidence 
in their ability to support victims and ability to intervene in incidents. 

While we welcome this activity, it is clear that this does not go far enough and we must do 
more.  For far too long women and girls like Zara have been failed.  This is why this 
Government will treat VAWG as the national emergency it is.  We will go further, using 
every available tool to target perpetrators and address the causes of abuse and violence.  
The Home Office will use the learnings from these initiatives to help inform future policy 
interventions.  Universal education and prevention models aimed at the general public 
which centre around the acceptability of these crimes will be at the heart of this 
governments’ mission. 

Matter of concern 22  

Business owners were aware of the offender’s concerning conduct on the night of Zara 
Aleena’s murder.  For example, a public house had refused to provide more drinks to him. 
It is not clear whether business owners are encouraged to report such concerning 
behaviour to the authorities or whether they are offered any training to assist them and 
their staff to recognise sexualised or predatory behaviour.  

I would also like to respond to concerns relating to business owners not doing enough to 
report sexualised and predatory behaviour, and concerns relating to staff training.  All 
business owners are encouraged to report such concerning behaviour to the authorities. 
Additionally, the licensed sector often provides training to assist staff to recognise 
sexualised or predatory behaviour and to take the necessary action.  However, your report 
illustrates clearly that there were failings and that much more work needs to be done to 
ensure this is happening in practice.  I have asked my officials to consider how we can go 
further to encourage business owners and staff to report such predatory behaviour.  As a 

 
 
  
 
 
 
 part of this mission, we will work across government to ensure these responsibilities are 
understood, and pathways are created.   

Thank you for raising these important issues in your report.  I hope that this response has 
been helpful in setting out that, as a new Government, we are fully prepared to use every 
available lever and resource to better safeguard victims and prevent devastating cases like 
this from occurring.    

Home Secretary

28/08/2024, 11:40:40

Subject:     [SUSPICIOUS MESSAGE] RE: In the matter of Zara Natasha Aleena (ref: 18941988)
Sent:    
From:     Chief Executive<
To:    
Cc:    

>

This Message contains suspicious characteristics and has originated outside of Waltham Forest Council. If you are unsure please
contact the ICT Service Desk on Extension 4444.

Dear 

Please see the response below for the Coroner.

Dear Ms Persaud,

Further to your email of Friday July 26th attaching a Regulation 28 Report following the inquest touching upon the death
of Ms Zara Natasha Aleena, I can confirm that the London Borough of Redbridge has considered your findings and
includes a response to each of the relevant questions below, setting out action already being taken by the Council to
address these matters:

 (19) The details of training for CCTV operators includes “training on sexual harassment”, but it is not clear
whether this includes identifying sexual predators and stalking type behaviour.

The training for CCTV operators encompasses modules that cover behavioural body language training and are
specifically designed to detect behaviours that would fall under the remit of ‘suspicious’.  The training is based on
established principles and techniques outlined in Tavcom training programs – suspicious behaviours can include
gestures, mannerisms, alone or in a group, time, location, how someone is acting (i.e. drunk/disorientated), approaching
people, being aggressive etc.  The training given to all LBR CCTV officers to assist them in making inferences regarding
suspicious behaviours that lend themselves to multiple situations (including drug dealing, knife attacks, theft, robbery,
stalking, sexual harassment and intimidation).

These modules are essential in equipping operators with the skills to identify various forms of inappropriate and
potentially criminal behaviours, which includes but is not limited to, behaviours that could be interpreted by an operator
as being predatory.   The goal of this training is to ensure that CCTV operators are not only capable of identifying sexual
harassment but are also proficient in recognising and responding to broader patterns of suspicious behaviours. 

(20) I am unclear from the evidence provided, whether LBR have a system for checking that training provided to
CCTV operators is fully understood, or whether refresher training is provided to them.

LBR ensures that the training provided to CCTV operators is fully comprehensive and regularly reinforced through
evaluation and ongoing professional development.  After completing the Tavcom training, all operators must pass an
exam to obtain their SIA (Security Industry Authority) licence, confirming their understanding of the training content.
Additionally, LBR implements a performance management system, including mentoring from experienced operators and
regular audits of work to identify any gaps in knowledge or performance. These audits inform whether additional training
or guidance is needed, ensuring operators maintain high proficiency standards. Once operatives have had official
training, they are regularly audited on their CCTV viewing footage and any further training needs are picked up and
implemented on a case by case basis.  LBR will however, further to your findings, introduce a new annual mandatory
refresher training programme for all operatives, to include suspicious behaviour (so that in the event that suspicious
behaviour is observed by an operative during their patrols, we can formally demonstrate that they know the correct
action to take).

Operatives’ line managers are regularly based within the CCTV control room so are able to directly observe behaviour
and working practices during shifts, with regular communication and feedback.  This is in addition to regular,
documented 1:1s with each staff member and regular appraisals following LBR’s One Brilliant You appraisal process
which set and review operational and personal training and development objectives. All CCTV team One Brilliant You
conversations are up to date and logged in the Council’s itrent HR system.

Any incidents whereby an operative closely monitors a member of the public who is behaving suspiciously must be
carefully recorded in line with LBR CCTV protocols as previously supplied in LBR’s evidence.  Where this monitoring
leads to action such as an arrest, this is included within performance metrics for the service which feed into regular
briefings provided to management and the Cabinet Member.

I trust that this response sufficiently addresses the questions within your report, but please do ask for any clarification, if
required.

Yours sincerely,

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Corporate Director of People and Interim Chief Executive
People Directorate
London Borough of Redbridge
Lynton House, 255-259 High Road, Ilford, IG1 1NN

Web: www.redbridge.gov.uk
Twitter: @redbridgelive
Facebook: www.facebook.com/redbridgelive
Save time, go online: www.redbridge.gov.uk

 <

From: 
Sent: Friday, July 26, 2024 3:05 PM
To: 
Cc: 

>

Subject: In the matter of Zara Natasha Aleena (ref: 18941988)

Dear Mr Loades,

Please see attached a Regulation 28 (Preventing Future Deaths) Report served by His Majesty’s Coroner Ms Nadia Persaud
following the Inquest touching upon the death of Ms Zara Natasha Aleena.

Would you kindly acknowledge receipt and note the response time.

Kind regards

Senior Business Support Officer
East London Coroners Court
124 Queens Road
Walthamstow
E17 8qp
Direct number:  
Email: 
Alternative contact: 

Culture and Workforce Development and Business Support /Chief Executive Directorate

CONFIDENTIALITY NOTICE: The information contained in this e-mail is intended only for the addressee(s). It
may contain privileged and confidential information and, if you are not the intended recipient, you must not
read, copy or distribute it, nor take any action in reliance upon it. If you have received this e-mail in error,
please inform the sender as soon as possible and delete the e-mail from your computer. Any information
contained in this email or in attachments to this email that relates to an identified or identifiable living
individual is subject to the provisions of the Data Protection Act 2018 (DPA 2018). The intended recipient of

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 this email, together with any attachments therein must process (as defined by the General Data Protection
Regulation) the information in accordance with the DPA 2018.’ E-mail may be corrupted or altered during or
after transmission. We accept no responsibility for changes made to this e-mail after it was sent. Whilst we
take reasonable steps to identify software viruses, any attachments to this email may contain viruses which
our anti-virus software has failed to identify. No liability is accepted for such viruses, and we therefore
recommend that you carry out your own anti-virus checks before opening any attachments. Information
contained in this e-mail may be subject to public disclosure under the Freedom of Information Act 2000 or the
Environmental Information Regulations 2004.

LONDON BOROUGH OF REDBRIDGE DISCLAIMER

This email contains proprietary confidential information some or all of which may be legally privileged and/or subject to the provisions of privacy
legislation. It is intended solely for the addressee.

If you are not the intended recipient, an addressing or transmission error has misdirected this e-mail; you must not use, disclose, copy, print or
disseminate the information contained within this e-mail.

Please notify the author immediately by replying to this email. Any views expressed in this email are those of the individual sender, except
where the sender specifically states these to be the views of the London Borough of Redbridge.

This email has been scanned for all viruses and all reasonable precautions have been taken to ensure that no viruses are present.

The London Borough of Redbridge cannot accept responsibility for any loss or damage arising from the use of this email or attachments.

Our ref: 

Miss N Persaud 
His Majesty’s Area Coroner 
East London 
Coroner’s Court 
124 Queens Road 
Walthamstow 
London  E17 8QP  

By email: 

Dear Miss Persaud 

Deputy Assistant Commisioner 
Metropolitan Police Service 
New Scotland Yard 
Victoria Embankment 
London 
SW1A 2JL 

Email:

16 September 2024 

On behalf of the Commissioner of Police of the Metropolis, I write to provide the response to the matters 

of  concern  addressed  to  the  Metropolitan  Police  Service  (“MPS”)  in  your  Report  to  Prevent  Future 

Deaths, dated 26 July 2024, following the inquest into the tragic death of Zara Natasha Aleena.  

On behalf of the MPS, may I first express my sincere condolences to the family and friends of Zara 

Natasha Aleena, our thoughts and sympathies are very much with them. 

The MPS has acknowledged and reviewed all the matters of concern raised in your Regulation 28 Report 

and responds as follows. 

The Coroner’s “Matters of Concern 16 and 17” 

“I am concerned about the lack of rigour, detail and independence of the MPS investigation into this 

case. The unit involved in this case was the East Area BCU. An independent, rapid investigation (Fast 

Time Review) was carried out by the Directorate of Professional Standards. Despite the very limited 

time to complete the review, the DPS officer reached clear and valuable findings. The findings of the 

DPS  investigator  were  however  rejected  by  more  senior  officers  within  the  MPS.  The  officers  who 

rejected  the  findings  were  not  independent  and  all  worked  within  the  East  Area  BCU.  This  lack  of 

independence is of concern”.  

“The Fast Time Review did not probe into sufficient detail into the systems of the local intelligence team 

and  the  Computer  Aided  Dispatch  process.  A  more  detailed,  independent  review  should  have  been 

carried out”.  

 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 MPS Response 

The MPS accepts that the reviews of this case lacked sufficient rigour and detail and that the review 

process was not sufficiently comprehensive to identify all the potential learning arising from the police 

response.  

The findings of the Directorate of Professional Standards (“DPS”) fast time review identified learning, 

some of which was accepted and was covered in the witness statement of Chief Superintendent 

, 

submitted to inquest.  In addition to this review, the local East Area Basic Command Unit (“BCU”) also 

carried  out  a  review  and  identified  a  number  of  additional  learning  points  which  were  actioned.  

Importantly, learning and improvements required in relation to “recalls to prison” processes have been 

shared and informed a revised Offender Management policy, which is due to be implemented later in 

2024.  

The DPS fast time review following the murder of Zara Aleena was carried out in 2022.  Since then the 

MPS has made a number of changes to our professional standards operating model and a new Gateway 

Team, within DPS, are now responsible for undertaking most reviews of this nature.  This includes cases 

where  DPS  are  asked for  a  conduct  review (where there  isn’t a  public complaint).    Importantly, the 

outcomes  of such  reviews are  no  longer  considered  by  the  Appropriate  Authority  (as  defined  in the 

Police  Conduct  Regulations)  within  the  BCU.    I  discuss  the  role  of  the  Appropriate  Authority  and 

independence in decision making later in this response. 

If there are allegations of recordable police conduct or a public complaint, there is an existing avenue 

for independent investigation through a referral to the Independent Office for Police Conduct (“IOPC”).  

There are a number of mandatory criteria, which require the MPS to refer matters to the IOPC, the most 

applicable being a death or serious injury following police contact, consideration can also be given to a 

voluntary referral.   In 2022, the MPS considered the circumstances and decided this case did not meet 

the criteria for referral to the IOPC.   

The MPS has the capability to undertake reviews and investigations, which are independent of the BCU 

who responded to, or investigated, a particular case or incident.  The MPS Specialist Crime Review 

Group  (“SCRG”)  is  a  specialist  function  that  has  the  capability  to  undertake  internal  reviews  of 

incidents,  independently  of  operational  units  or  teams  responsible  for  crimes  and  other  incidents.  

Review officers and staff are experienced and subject to national specialist training and professional 

development. 

The SCRG conduct reviews on behalf of the MPS such as Domestic Homicide Reviews, Serious Case 

Reviews, Vulnerable Adult Reviews and reviews of undetected homicides.  They also undertake fast 

time reviews of critical incidents and other bespoke reviews as directed by the MPS.  Critical incident 

 
 
 
 
  
 
 
 reviews  can  be  conducted  at  any  time,  where  the  effectiveness  of  the  police  response  could  have  a 

significant impact on the confidence of victims, their families or the public. 

The  SCRG  have  been  commissioned  to  undertake  a  thematic  assessment  of  the  MPS  approach  to 

statutory and non-statutory post death reviews.  This will consider: 

•  The  options  currently  available  for  reviews  of  incidents  within  the  MPS,  including  SCRG 

critical incident reviews, DPS death or serious injury reviews and independent reviews by other 

police forces. 

•  Whether MPS internal review processes (including SCRG and DPS reviews) are sufficiently 

robust. 

•  Whether the policy and guidance for gold (strategic oversight) groups is sufficiently defined to 

assist gold commanders to consider all internal review options. 

The outcome of this thematic review is due in October 2024 and is expected to identify how operational 

reviews, such as the one following the murder of Zara Aleena, could be improved with appropriate levels 

of independence. 

The outcome and learning from the MPS fast time review into the circumstances surrounding the murder 

of Zara Aleena in 2022, were considered by the Appropriate Authority within East Area BCU.  Under 

the  Police  Conduct  Regulations,  the  Appropriate  Authority  is  an  officer,  of  sufficient  seniority, 

delegated by the Commissioner to make decisions relating to matters of police conduct.  Whilst the 

decision  maker  in  2022  had  no  direct  involvement  in  the  case,  the  MPS  accepts  that  there  was  an 

opportunity for greater independence in decision making if the review outcomes had been considered 

by a senior leader who was not part of East Area BCU. 

Since  2022,  the  MPS  has  transformed  its  professional  standards  operating  model  within  BCU,  such 

Appropriate Authority decision are no longer made by a member of the BCU’s senior leadership team.  

This responsibility has been transferred to the MPS Directorate of Professional Standards, who now 

undertake the role of Appropriate Authority in considering the outcomes of such reviews, independently 

of the BCU involved. 

Following critical incidents the MPS will often introduce a clear command structure, with associated 

independence  of  decision  making  and  oversight.    A  strategic  commander,  also  known  as  the  gold 

commander, can be appointed with oversight and responsibility for the MPS response.  This leader may 

be the Chief Superintendent responsible for the geographic area where the critical incident occurred.  

Dependent on the nature of the critical incident and / or its implications for London, a chief officer of 

Commander rank or above, may be appointed as the gold commander.  This introduces further levels of 

independence from those directly involved in the operational response. 

 
 
 
 
 
 
 The gold commander will decide if a review of the police response is required.  Having sought expert 

advice they would make the decision if a review is required and how it would be undertaken.  They 

would also inform a decision on whether there should be a mandatory or voluntary referral to the IOPC. 

The Coroner’s “Matter of Concern 18” 

“There were clearly learning points for the police constables, police sergeants and the local intelligence 

team. The MPS rejected the DPS recommendation for reflective learning, “as there was no failing in 

performance or conduct”. It is of concern that the threshold for reflective practice is set too high”.  

MPS Response 

The MPS is committed to identifying and responding to individual and organisational learning arising 

from awful cases such as this.  The inquest concluded there was learning for individual officers that may 

have been suitable for feedback and reflection that were not actioned. The MPS accepts that not all 

possible learning identified from the reviews surrounding the death of Zara Aleena were fully acted 

upon.    

The  Reflective  Practice  Review  Process  (“RPRP”)  is  the  process  for  handling  Practice  Requiring 

Improvement (“PRI”), which is defined as “underperformance or conduct not amounting to misconduct 

or gross misconduct, which falls short of the expectations of the public and the police service as set out 

in  the  policing  Code  of  Ethics  (Reg.3(1),  Police  Conduct  Regulations  2020)”.    The  definition  of 

misconduct  is  ‘a  breach  of  the  Standards  of  Professional  Behaviour  that  is  so  serious  as  to  justify 

disciplinary action (written warning or above)’.  RPRP is used to address lower-level breaches of the 

Standards of  Professional Behaviour,  or  underperformance  that  does  not  warrant  formal  misconduct 

proceedings.   

When the threshold of RPRP is not met, the MPS supports Learning Through Reflection (“LTR”).  LTR 

is aligned with guidance laid down by the Home Office and College of Policing on the wider use of 

reflective practice within the police service.  It is not part of legislated police conduct or performance 

processes, but is a scheme to improve police conduct and deal with low-level concerns by supportive 

line managers though a culture of reflection and learning.   

The MPS recognises the Coroner’s concern about the threshold that is applied to RPRP.  Since RPRP is 

subject to statutory guidance, the MPS is unable to make unilateral changes.  In this case, it was assessed 

by the Appropriate Authority that learning for officers and staff did not meet the threshold for RPRP.  

As discussed above, the MPS has made changes since 2022 and the Appropriate Authority for such 

decisions is now independent of BCUs.  They are aware that if they consider the threshold for RPRP is 

not met, Learning Through Reflection could be used and all MPS officers and staff have responsibilities 

towards continual learning and professional development. 

 
 
 
 
 
 
 
 The Coroner’s “Matter of Concern 14” 

“The  system  in  place  for  sharing  risk  information  between  the  probation  service  and  the  MPS  was 

unclear. Only very limited intelligence was shared with the MPS. There was no explanation as to why 

that information was shared, when more concerning risk related information was not shared.”  

MPS Response 

Whilst this matter of concern is directed towards the Probation Service, the MPS considers the following 

information about changes to our processes and systems, may assist. 

Since the tragic murder of Zara Aleena there have been a number of changes to the Integrated Offender 

Management (“IOM”) process.  The Mayor’s Office for Policing and Crime (“MOPAC”) have funded 

the Empowering Communities with Integrated Network Systems (“ECINS”).  ECINS is a web-based 

information sharing and case management software, which provide a multi-agency information sharing 

platform.    This  improves  the  sharing  of  IOM  information  and  allows  the  allocation  of  actions  and 

responses from the Multi-Agency Case Conferences.  This tool is available to all IOM partners that are 

signatories of the IOM Data Sharing Agreement. 

Since  2022,  the  MPS  has  introduced  CONNECT,  a  large-scale  technology  system  for  crime  and 

intelligence reporting and record keeping.  This has provided police offender managers with access to a 

feature called Proactive Managements Plans (“PMP”).  PMPs are now the primary police record for 

IOM offender management.  PMPs allow IOM records to be searchable, linked with other police records 

and readily available to all MPS staff.  HM Prison & Probation Service do not have direct access to 

these records, but PMPs create a permanent record of what has been shared between the MPS and its 

partners.  

Following inquest, the MPS has reflected on the sufficiency of information sharing from the HM Prison 

& Probation Service and the need for clarity around recalls to prison.  The MPS has developed a new 

process map, which provides clarity and guidance for Police Offender Managers to ask HM Prison & 

Probation Service a broad range of questions, with the intention to increase the likelihood of all relevant 

information being shared with IOM partners.  The new process highlights and clarifies the actions to be 

undertaken by Police Offender Managers and their supervisors, both before and after prison releases, 

including the recording of informed risk management decisions. 

The MPS is determined to continually improve and build confidence in our policing response to tackle 

violence against women and girls.  The murder of Zara Aleena and the subsequent inquest show the 

 
 
 
 
 
 
 
 
 
 importance of different organisations and agencies effectively working together to prevent future deaths 

and to keep people safe. 

Please do not hesitate to contact me should you require further information from the MPS. 

Yours sincerely,