Prevention of Future Deaths reports · 2024

Barrie Forster

Regulation 28 report to prevent future deaths, reference 2024-0603, written 5 Nov 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report5 Nov 2024
Reference2024-0603
DeceasedBarrie Forster
CoronerAndrew Cox
Coroner areaCornwall and the Isles of Scilly
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Information Classification: CONTROLLED 

NOTE: This form is to be used after an inquest. 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1. 
Communities, and Local Government  

Secretary of State for Housing, 

2. 

1  CORONER 

 Secretary of State for Justice 

I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall 
and the Isles of Scilly. 

2  CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and 
Justice Act 2009 and regulations 28 and 29 of the Coroners 
(Investigations) Regulations 2013. 

3 

INVESTIGATION and INQUEST 
On 5/11/24, I concluded the inquest into the death of Barrie Forster. 

I recorded the cause of death as: 
1a) Multi-organ failure; 
1b) Acute Upper Gastro-Intestinal Haemorrhage in a Man with Ischaemic 
Heart Disease and on Treatment with Apixaban; Craniofacial Trauma 
Necessitating Surgical Repair (Operation 21/11/2020). 

I recorded a conclusion that Barrie was unlawfully killed. In the event 
proper assessments had been made of the risk the perpetrator posed to 
Barrie and/or of the suitability of Barrie's address as somewhere for the 
perpetrator to live, it is more likely than not that the perpetrator would not 
have been permitted to live at Barrie's address upon release from custody 
and the assault would not have occurred when it did. 

4  CIRCUMSTANCES OF THE DEATH 

Barrie was assaulted on 20/11/20. The perpetrator, 
been released from custody two days earlier. 
three spells in custody the last two sentences having been imposed after 
offences committed against his sister who had the protection of a 
Restraining Order.  
The risk 
by the Probation Service particularly in light of a complaint of sexual 
assault by Barrie Forster against another family member and in the 

 posed to Barrie had not been assessed properly or at all 

 had recently had 

, had 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Information Classification: CONTROLLED 

context of recent assaults by 
Additionally, no, or no adequate, assessment had been made by the 
Probation Service of the suitability of Barrie's address as a place at which 

 against other members of the family.  

 could reside after his release from custody. 

After an earlier release from custody 
approved premises where he had stayed for six months. Thereafter, he 
had stayed in two B&Bs in another county before returning to Cornwall 
where he was homeless for a period, living in a tent at different locations. 

 had been found a bed in 

After his most recent custodial sentence, a formal application for a bed at 
approved premises had not been made but, informally, members of the 
Probation Service had been told one was not available. Discussions were 
ongoing with the Council’s homelessness team, but accommodation had 
not been secured. 
Probation Service had thought 
Travelodge or similar. 

 had earlier convictions for arson. The 

 would be found a room at a 

In the event, on the day of his release from custody, it was brought to the 
attention of the Probation Service that 
 intended to sleep on a sofa 
at his father’s address. The suitability of this accommodation was not 
considered. The risk 
this been done, I found it was more likely that not 
been permitted to live with his father and the assault would not have 
occurred when it did. 

 presented to Barrie was not assessed. Had 
 would not have 

5  CORONER’S CONCERNS  

During the course of these inquests, the evidence has revealed matters 
giving rise to concern. In my opinion there is a risk that future deaths will 
occur unless action is taken. In the circumstances it is my statutory duty 
to report to you. 

The MATTERS OF CONCERN are as follows.   

There is a lack of accommodation available to the Probation Service in 
which prisoners released from custody may properly be placed. This 
includes both Approved Premises (which I understand to be the 
responsibility of the MoJ) and more generally through the local authority 
to avoid homelessness. As a consequence, some prisoners are released 
and become effectively homeless (with increased difficulties in 
supervision) while others are accommodated at unsuitable premises, as 
happened in this instance. 

6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I 
believe you [AND/OR your organisation] have the power to take such 
action.  

2 

 
 
 
 
 
 
 
 
 
 
 
 
 Information Classification: CONTROLLED 

7  YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date 
of this report, namely by 5 January 2025. I, the coroner, may extend the 
period. 

Your response must contain details of action taken or proposed to be 
taken, setting out the timetable for action. Otherwise, you must explain 
why no action is proposed. 

8  COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following 
Interested Persons: 

- 
-  Probation Service 

 (sister)  

I am also under a duty to send the Chief Coroner a copy of your 
response.  

The Chief Coroner may publish either or both in a complete or redacted 
or summary form. He may send a copy of this report to any person who 
he believes may find it useful or of interest. You may make 
representations to me, the coroner, at the time of your response, about 
the release or the publication of your response by the Chief Coroner. 

9 

[DATE]                                              [SIGNED BY CORONER] 

5.11.24                                            

3

Responses

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

Response from Hmpps Moj and Mhclg (PDF)
Chief Probation Officer 
HM Prison and Probation Service 
8th Floor Ministry of Justice 
102 Petty France 
London 
SW1H 9AJ 

Email:dgoperationshmpps@justice.gov.uk 

31st December 2024 

HM Senior Coroner Andrew J Cox 
Cornwall Coroner's Court 
The New Lodge 
Newquay Road 
Penmount 
Truro TR4 9AA 

By email only to:  

Dear Sir, 

Inquest Touching the Death of Barrie Forster 

Thank you for your Regulation 28 Report of the 5th November 2024 issued following the conclusion 
of the Inquest into the death of Barrie Forster.   This response has been prepared in collaboration 
with 
provided on behalf of the Secretary of State for Justice.  

the  Ministry  of  Housing,  Communities  and  Local  Government  (MHCLG)  and 

is                                                 

I know that you will share a copy of this response with Barrie Forster’s family, and I would like to 
take this opportunity to express my condolences for their loss.  

In your Report, you raised the following concern:- 

There  is  a  lack  of  accommodation  available  to  the  Probation  Service  in  which  prisoners 
released  from  custody  may  properly  be  placed.  This  includes  both  Approved  Premises 
(which  I  understand  to  be  the  responsibility  of  the  MoJ)  and  more  generally  through  the 
local authority to avoid homelessness. As a consequence, some prisoners are released and 
become  effectively  homeless  (with  increased  difficulties  in  supervision)  while  others  are 
accommodated at unsuitable premises, as happened in this instance.  

His Majesty’s Prison & Probation Service provides an accommodation service in specific 
circumstances,  via  Homelessness  Prevention  Teams,  Strategic  Housing  Specialists  and 
Commissioned Rehabilitative Services (CRS).  The Probation Service manages a three-tier 
structure of temporary accommodation known as the Community Accommodation Service 
(CAS):  CAS1  (accommodation  with  a  public  protection  focus  for  higher-risk  offenders, 
known as Approved Premises), CAS2 (low to medium risk offenders on Home Detention 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Curfew or bail) and CAS3 (up to 12 weeks basic accommodation for prison leavers at risk 
of homelessness). 

in  developing  and 

Homelessness  Prevention  Teams  are  embedded  in  all  probation  regions  and  play  a 
to 
leading 
significant  role 
reducing homelessness  for  People  on  Probation,  transitioning  from  custody  to  the 
community.   They are tasked to choreograph local activity between the Probation Service 
and  a  range  of  strategic  partners,  including  Local  Authorities,  Housing Providers,  Police, 
Health, Strategic Housing Specialists (SHS), CRS providers and the Voluntary/Community 
Sector. This joint working helps to embed and expand housing options for prison leavers. 

the  regional  probation  response 

Across  our  prisons  49  full  time  equivalent  Strategic  Housing  Specialists  (SHS)  operate 
working to clusters of geographically close prisons across England and Wales. Their key 
responsibilities  include  Identifying,  developing,  and  delivering  a  range  of  solutions  that 
remove barriers to accommodation, including solutions to logistical barriers. They develop 
and deliver training products to upskill prison staff on accommodation pathways and act as 
subject matter experts on housing and homelessness for prison senior leaders and regional 
prison structures. They work in partnership to improve regional responses to homelessness 
amongst prison leavers and lead Local Authority Pre-Release Homelessness Panels which 
are  multi-agency  meetings  that  aim  to  identify  the  most  appropriate  accommodation 
pathway for individuals who would otherwise be homeless. In turn, this supports other areas 
of  resettlement  work  such  as  ensuring  the  continuation  of  healthcare  or  securing 
employment in the correct area. 

Additionally Commissioned Rehabilitative Service (CRS) provision exists in all regions of 
England  and  Wales.  Providers  have  specialist  knowledge  to  give  support  in  obtaining 
accommodation, including securing social or supported housing, securing a tenancy in the 
private  rented  sector,  help  to  sustain  existing  accommodation  and  help  to  close  down  a 
tenancy at the start of a long sentence. Accommodation CRS provision for women is part 
of the women's holistic CRS offer and not accessed via the region’s CRS Accommodation 
provider (for men) but from the CRS Women’s Services contract provider. 

There are currently 2339 Approved Premises bed placements across England and Wales. 
The Approved Premises Expansion programme concluded in March 2023, delivering 169 
additional spaces, 115 male and 54 female. This has enabled us to have the capacity for 
those  presenting  the  very  highest  risks,  to  stay  in  Approved  Premises  (AP)  for  up  to  12 
months.  We  have  also  expanded  provision  for  women  by  over  30%,  increasing  the 
opportunities for  women  to  have  a  place  in  an AP  after  release,  as  part  of  a community 
order or as a bail placement. The closure report for the expansion project concluded that 
there are now an additional 40 bed space placements in the Southwest South-Central Area.  

CAS2 provides suitable gender specific accommodation for Bailees and prisoners eligible 
for Home Detention Curfew (HDC), who might be remanded or not released due to lack of 
suitable accommodation. Additionally, they provide accommodation in some circumstances 
for  those  who  lose  their  accommodation  whilst  subject  to  licence  in  the  community,  all 
individual  placements  receive  weekly  support  sessions  to  help  ensure  successful 
completion of their residency. CAS2 currently has c850 bed spaces in over 275 properties 
across  England  and  Wales.  This  is  an  increase  from  550  at  the  commencement  of  the 
current contract in October 2022. CAS2 continues to increase capacity, working towards 
1350 spaces in the next year.  

CAS3 provides transitional accommodation for up to 84 nights for prison leavers and those 
moving on from CAS1 and CAS2, subject to probation supervision who would otherwise be 
homeless,  with  basic  floating  support  to  move  on  into  settled  accommodation.  All  prison 

Page 2 of 4 

 
 
 
 
 
 
 
 leavers  who  are  at  risk  of  being  released  from  prison  homeless  and  will  be  subject  to 
probation  supervision  upon  release,  will  be  offered  accommodation  through  our  CAS3 
provision;  however,  this  is  a  consent-based  arrangement  and  not  all  prison  leavers  will 
accept. The service is delivered by regional Homelessness Prevention Teams working in 
collaboration  with  contracted  accommodation  suppliers  in  10  probation  regions,  and  via 
grant funded arrangements in partnership with Local Authorities in Greater Manchester and 
Wales.   

CAS3 supported over 6,000 people last year (April 2023-March 2024) and the service which 
currently  provides  2603  bedspaces  is  expanding  to  support  more  people  at  risk  of 
homelessness each year.  

This provision provides a critical stabilising environment for people on release from prison 
from  which  they  can  address  other  aspects  of  their  behaviour  linked  to  their  risk  of  re-
offending.  

In  the  case  of  prison  leavers  not  placed  in  Approved  Premises,  who  are  at  risk  of 
homelessness, it is essential that services work together to fulfil their respective roles so 
that risk is effectively identified and appropriate accommodation is provided. 

Local  Authorities  have  statutory  duties to  assist people  who  are  homeless  or  threatened 
with homelessness.  They work in partnership with HMPPS to ensure those placed in CAS 
temporary accommodation have the move-on accommodation which is appropriate to any 
identified risks.   

In 2021 MHCLG, working closely with MoJ, launched the Accommodation for Ex Offenders 
(AfEO) scheme, which provides funding to local authorities to support ex-offenders to move 
to  settled  accommodation  in  the  private  rented  sector.  Since  2021,  approximately  thirty 
three  million  pounds  has  been  awarded  to  local  authorities  for  this  purpose  and  5,988 
individuals have been supported to access tenancies.   

Evidence shows that these programmes have enabled occupants to access and remain in 
accommodation.   However, more action is needed to ensure all prison leavers are able to 
access  accommodation.    MoJ  and  MHCLG  are  continuing  to  work  closely  together  to 
identify and implement what is needed.   

This work is part of cross-government work led by the Deputy Prime Minister to end all forms 
of homelessness.  The Deputy Prime Minister is chairing a dedicated Inter-Ministerial Group 
which brings together ministers from across government to develop a long term strategy, 
which will include action to avoid risk of homelessness for individuals leaving institutions, 
including prison.  It is expected that the strategy will be published next year following the 
conclusion of the next spending review.   In the meantime, as announced at budget, funding 
for homelessness services is increasing next year by £233 million.  This includes support 
for areas to maintain and develop pathways for prison leavers into settled accommodation. 
The  MHCLG  Homelessness  Advice  and  Support  Team  will  continue  to  work  with  local 
authorities  to  promote  a  partnership  approach  to  the  statutory  referral  mechanism  and 
improve quality of information sharing to promote better assessments and convening events 
to share best practice.    

The  Minister  of  State  for  Prisons,  Probation  and  Reducing  Reoffending,  Lord  James 
Timpson,  will  lead  on  driving  forward  the  Department’s  priority  to  reduce  the  number  of 
people leaving prison homeless and ensuring that there is appropriate accommodation to 
support those offenders who have higher support needs. 

Page 3 of 4 

 
 
 
 
 
 
 
 
 
 
 Thank  you  again  for  bringing  your  concerns  to  our  attention.  I  trust  that  this  response  provides 
assurance that action is being taken to address this matter. 

Yours sincerely, 

Chief Probation Officer 

Page 4 of 4

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