Kirsten Hocking

Date of report	11 Nov 2024
Reference	2024-0617
Deceased	Kirsten Hocking
Coroner	Nick Armstrong
Coroner area	West Sussex, Brighton & Hove
Category	State Custody related deaths
Source	judiciary.uk record · original PDF
Responses published	2

The report

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

_________________________________________________________________________________

WEST SUSSEX, BRIGHTON & HOVE CORONER’S COURT

INQUEST INTO THE DEATH OF KIRSTEN HOCKING

FINDINGS AND CONCLUSIONS 8 NOVEMBER 2024

NICK ARMSTRONG KC (ASSISTANT CORONER)

Findings of fact

1. Kirsten Hocking was born on 12 November 1991 and so was 31 at the time of her death on 24

May 2023.

2. She had a history of significant and multiple traumas throughout her life including sexual abuse
and the trauma of losing her son to adoption. The various diagnoses to which her mental health
team were working included one of complex post-traumatic stress disorder.

3. Kirsten had always managed her trauma with substance abuse, and she had a history of mostly
acquisitive offending which supported that. She had never worked. Kirsten also had a long history
of self-harm, usually in the form of cutting though she occasionally also tied ligatures.

4. In 2021 she was sentenced to 20 months for offences including shoplifting, abusive words and

behaviour and breach of an earlier order.

5. In 2022 she was released but recalled to prison in less than a week. She was held in HMP

Bronzefield. She was transferred to HMP Downview on 30 June 2022.

6. At this stage, Kirsten was very unwell, and at significant risk to herself. She was almost always on
the prison’s suicide and self-harming assessment system (ACCT), and she was often the subject of
constant supervision. By the autumn, however, Kirsten had established good relationships with
staff, and was beginning to show a new determination to turn her life around.

7. A further and important development was that Kirsten’s efforts to get in touch with her adopted
son, now aged eight, began to bear fruit. She had written to him for the first time. Later, she would
receive a reply. All this gave her a new hope. Those around Kirsten also began to feel a new
optimism for her prospects.

8. All agreed that Kirsten required a specialist rehabilitation placement. Her assessed risk to others
was medium, which meant that she would almost certainly not be able to access Approved
Premises (“AP”) provided by the probation service. That was the understanding of her probation
officer, and it was an understanding shared by others including, I note, the Prisons and Probation

Ombudsman. In fact, it appears that unlike men, medium risk women can sometimes access an
AP. However, the scarcity of that kind of accommodation, the waiting time, issues such as the
likely distance to the nearest one, as well as Kirsten’s particular risk profile, means that an AP was
almost certainly never a realistic option.

9. The problem, however, is that specialist rehabilitation accommodation is also very scarce, and it is
almost non-existent for women like Kirsten, who self-harm. This was variously described in the
evidence as a “hole” in the cover, or a “hiatus” in it. For this particular cohort, whose primary risk
is to themselves rather than to others, the picture is bleak. There is almost no such accommodation
available to this group, and what there is can only be accessed if someone is prepared to take a risk
and offer a chance.

10. That is what happened here. On 24 March 2023 a small charity offered Kirsten a place on condition
that she was fully abstinent from drugs and that she did not self-harm. Kirsten began to work on
the first condition, entering a methadone detoxification programme. She worked hard, and she
was successful. She completed the programme on 20 April 2023.

11. Unfortunately, the second condition, concerning self-harm, was not properly communicated and
was not properly understood by Kirsten and the staff who worked with her. This was a small
charity operating with a degree of informality in its arrangements. There was no written articulation
of the self-harm condition. Staff at the prison understood, and told Kirsten, that all self-harm had
to be communicated to the charity but they also believed that there was some flexibility and not
all self-harm would result in the offer of the placement being withdrawn. That seems to have been
correct, but there was little or no understanding that certain things had to be avoided, and what
they were. The position appears to be that for some at the charity any self-harm after the date of
the offer would have triggered withdrawal of the placement. Others took the view that it depended
on the number of incidents, or the severity of individual incidents.

12. The problem for the charity, and for others who provide this rehabilitation accommodation, is
that self-harm may require medical attention at a time when there are no staff on the premises.
Further, incidents can be distressing, and so destabilise other vulnerable residents. The other side
of this, of course, is that self-harm is particularly common in complex, vulnerable, women
prisoners. There does therefore appear to be a clear gap in provision. The evidence is that in the
community it may be possible to spend time working with someone to bring down their self-
harming to a manageable level. However, that may be harder in a prison case, where there is the
hard stop of a release date. The result is that despite the time and investment and optimism spent
in prison, it can all unravel very quicky on release for want of (it may be noted, much cheaper than
prison) accommodation.

13. In this case, more clarity and better communication might have produced a different outcome. It
might have meant that Kirsten worked on her self-harming with the same energy she brought to
her detoxification with the result that she kept the placement. Alternatively, it might have led to
people realising that Kirsten would not realistically be able to keep this placement, with the result
that another placement was found. Even if that was not a specialist rehabilitation placement, there
would have been more time to build a network of support around whatever was made available.

14. Instead, Kirsten continued to self-harm and at least one incident, on 11 April 2023, was serious.
That appears to have been a spike caused by her detoxification. Tragically, Kirsten’s self-harming
was reported on 20 April which was the same day as she came off the detoxification programme.
After that she started to re-stabilise. By then, however, it was too late. Despite being asked to
reconsider by staff at the prison, the charity now regarded her as too risky for them.

15. There began a scramble for an alternative placement. I had some concerns about the system for
finding a replacement specialist placement at speed, and its reliance on the energy and personal

knowledge of individuals. There was reference at one stage to frantic Googling. That is no real
system. However, the reality is that it had to go via the local authority commissioned system, and
that was always going to take a little time. In any event, I can see no causative consequences from
any of this. The wider market scarcity meant that there was almost certainly not going to be another
rehabilitation placement found in the time available. In the event, all the efforts could produce was
an interview about three or four weeks post release.

16. For a time it looked like Kirsten might be released with no accommodation at all. Fortunately,
Community Accommodation Service Tier 3 (“CAS3”) accommodation was found, but only the
day before Kirsten’s release, and in Chertsey, well away from her usual home areas. There were
advantages to that distance, but it also meant that support networks were not in place. The fact
that Kirsten was released on a Friday did not help. She was going from a very high level of support,
to almost nothing for a period of at least several days. Her consultant psychiatrist assessed Kirsten’s
risk to herself at the point of release as high.

17. The evidence is that it might have been possible to investigate an alternative specialist placement
earlier and in parallel to the one that had been granted. Given the state of the market, and the fact
that at that stage Kirsten already had a placement, it must be doubted whether that was ever going
to produce anything. That shows, however, that there was a missed opportunity to seek the CAS3
accommodation earlier, build a better network of support around that, and prepare Kirsten for it.
Once the specialist placement collapsed it should have been obvious that realistically CAS3 was
the only option. There should therefore have been an earlier focus on that route. In the event the
application for CAS3 accommodation was not made until 17 May 2023, two days prior to release.

18. Exceptionally, and reflecting once again the quality of those working with her as well as the level
of their concern, Kirsten was taken personally to the CAS3 flat by the prison officer who was her
key worker. The flat was found to be well presented, but by then the uncertainty had destabilised
Kirsten and the type of accommodation meant that she was exposed to unhelpful influences, again
without the support to help her navigate that. Kirsten had a drink with another resident shortly
after arriving there that night, and she took recreational drugs. She then engaged in a series of
desperate and regretful calls and text-messages with her sister, an officer at the prison with whom
she had become close, and her probation officer. She used a telephone that she had promised not
to use because it had drugs line numbers on it. The officer at the prison called the police, but the
police – and no-one criticised this decision; the officers who attended in the early hours of Saturday
morning showed proper care and thoroughness – could not find a basis for intervening. Kirsten,
still with the other resident, reassured them that she was fine.

19. There is no evidence about how Kirsten spent the remainder of that night, nor most of Saturday.
However, at some point on that Saturday, 20 April 2023, she obtained heroin. She injected it in a
public toilet in Worthing in the late afternoon. The amounts used suggest Kirsten did not intend
to die. Instead, it is more likely that she misjudged her tolerances having been in prison for more
than a year and having detoxed from methadone a month earlier. She was a highly distressed
woman seeking to soften her pain in the way she habitually had.

20. An ambulance was called at 17:11 and the police were called at 17:20. She was taken to Worthing

Hospital where she died at 16:45 pm on 24 May 2023.

21. There is no dispute about the medical cause of death. It will be recorded as follows:

1a Hypoxic brain injury
1b Out of hospital cardiac arrest
1c Drug overdose

Box 3

Kirsten Hocking was 31 years old when she died as a result of a heroin overdose. She had been released
from prison on 19 May 2023, and found in a public toilet in Worthing on 20 May 2023. She was taken to
Worthing Hospital where she died at 16:45 on 24 May 2023.

Box 4

Kirsten Hocking was a complex and vulnerable young woman with a history of trauma, substance misuse
and self-harm. She was to be released from prison on Friday 19 May 2023. All agreed that she needed a
specialist rehabilitation placement and with that, there were grounds for optimism. Kirsten had worked
hard on getting clean, and she had recently re-established contact with her son. For women like Kirsten,
who self-harm, rehabilitation accommodation is very scarce. She was a part of a cohort for whom there is
a real gap in provision. In this case, Kirsten was lucky. She able to secure a specialist placement. However,
the offer was fragile and the extent of that fragility was not properly communicated and understood. There
was therefore insufficient focus on Kirsten’s need to reduce her self-harming. The placement was
withdrawn, just a month prior to release. There was then insufficient focus on the reality that another
specialist placement was unlikely to be found and so non-specialist accommodation would need to be
identified with a network of support built around that. In the end, alternative non-specialist
accommodation was sought and found, but only a day prior to release, and with little support in place, and
none over that first weekend. Kirsten had by then been seriously destabilised. She drank and took cocaine
on the Friday night. She immediately regretted that, contacting her sister and others into the early hours.
On Saturday 20 May 2023 she travelled to Worthing and obtained heroin. At approximately 5 pm she
overdosed on it in a public toilet. That was probably an accident, caused by her reduced tolerances. Kirsten
was taken to Worthing Hospital where she died on 24 May 2023.

Also filed under 2024-0617: Kirsten-Hocking-Prevention-of-Future-Deaths-Report-2024-0617.pdf

Regulation 28: REPORT TO PREVENT FUTURE DEATHS

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

REGULATION 28 REPORT TO PREVENT DEATHS

THIS REPORT IS BEING SENT TO:

1 Probation Service
2 Steps2Recovery

CORONER

I am Nick ARMSTRONG, Assistant Coroner for the coroner area of West Sussex, Brighton
and Hove

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.

INVESTIGATION and INQUEST

On 01 June 2023 I commenced an investigation into the death of Kirsten HOCKING aged
31. The investigation concluded at the end of the inquest on 08 November 2024. The
conclusion of the inquest was that:

Kirsten Hocking was 31 years old when she died as a result of a heroin overdose. She had
been released from prison on 19 May 2023, and found in a public toilet in Worthing on 20
May 2023. She was taken to Worthing Hospital where she died at 16:45 on 24 May 2023.

CIRCUMSTANCES OF THE DEATH

Kirsten Hocking was 31 years old when she died as a result of a heroin overdose. She had
been released from prison on 19 May 2023, and found in a public toilet in Worthing on 20
May 2023. She was taken to Worthing Hospital where she died at 16:45 on 24 May 2023.

CORONER’S CONCERNS

During the course of the investigation my inquiries revealed matters giving rise to concern.
In my opinion there is a risk that future deaths could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows:
(brief summary of matters of concern)

Please also refer to the findings of fact, which accompany this report and set out the
circumstances of Kirsten Hocking’s death and Box 4 of the Record of Inquest (the narrative
conclusion). I have three concerns about future risks, two of which are for the Probation
Service (and/or the Ministry of Justice (“MOJ”). The other is for the charity Steps to
Recovery (“S2R”):

TO THE PROBATION SERVICE/MOJ:

Concern (1) is that there was and remains a real lack of specialist rehabilitation for women,
and in particular, women who represent only a low or medium risk of harm to others, but a
high risk of self-harm. This cohort are for the most part shut out from Approved Premises
(“AP”) (it appears that it is possible for medium risk women to be admitted to an AP but
that possibility is not well understood and the reality is that it is not available; that kind of
accommodation being very over-subscribed in any event). This means there is little or no
effective system of rehabilitative provision for that cohort. This is a cohort in which the
state has invested a great deal of time and money (in imprisoning and rehabilitative work)
only, the evidence suggests, for that investment to be at risk of being squandered on
release. It also means that provision can become dependant on small charities and related

Regulation 28 – After Inquest

Template Updated 15/10//2024 TG

acts of individual generosity, which is patchwork and may bring problems of unclear access
and unclear criteria (as happened here). The evidence was that this was being looked at by
the Probation Service, which does not generally provide specialist rehabilitation
accommodation itself but which has an obvious interest in it being available and so is
monitoring the situation. However the evidence was also that the situation is getting worse
not better, particularly for women (who tend to have higher levels of self-harm), and this is
despite things like the Corston review in 2007 and the case of Coll v SSJ ten years later,
which found discrimination because of the gender disparity with respect to the availability
of APs. There is now a similar lack, and apparent gender impact, with regard to specialist
rehabilitation accommodation too. The circumstances creating the risk of other deaths
therefore subsist, and might benefit from some renewed focus.

Concern (2) is linked to the first, in that the probation officers, who have primary
responsibility for finding accommodation and building release plans, need to understand
what accommodation is and is not available. This case showed that no-one, including the
relevant officer, realised that an AP might in theory have been available. It also showed a
failure to appreciate that once the first specialist placement fell through, a second was very
unlikely to be found and so CAS3 accommodation was realistically the only option. That
therefore needed finding quickly, so that a support plan could be built around it. There does
therefore seem to be a training need.

TO S2R:

S2R started providing this kind of specialist accommodation because there was such a
pressing need for more of it. They are to be welcomed for having done so. However, like
many small organisations which have grown, it appears that their systems have not always
grown with them. Work is already being done, but there remains a continuing risk.
Placement offers and the conditions and expectations which attach to them are too unclear.
The recording of decisions around offers, withdrawal, and reconsideration, also needs to be
better, not just to ensure that decisions are recorded, but also to ensure that decision-
making is properly structured and takes all relevant matters into account. Withdrawing
accommodation offers without first speaking to the requesting organisation (in this case
staff at the prison) also gives rise to risks. As this case shows, these are critically important
decisions, and great care is required.

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.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by January 05, 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.
COPIES and PUBLICATION

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

Change Grow Live (West Sussex)

Forward Trust

I have also sent it to

Regulation 28 – After Inquest

Template Updated 15/10//2024 TG

who may find it useful or of interest.

I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.

I may also send a copy of your response to any person who I believe may find it useful or
of interest.

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.

Dated: 11/11/2024

Nick ARMSTRONG KC
Assistant Coroner for
West Sussex, Brighton and Hove

Regulation 28 – After Inquest

Template Updated 15/10//2024 TG

Responses

2 responses 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 (PDF)

Nick Armstrong,

HM Assistant Coroner for the coroner area of West Sussex, Brighton and Hove

By email only to:

Dear Sir,

30th June 2025

Inquest Touching the Death of Kirsten Hocking

I refer to your Regulation 28 Report following the Inquest into the death of Kirsten Hocking and am
issuing this response on behalf of the Probation Service.

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

You expressed a concern that there was and remains a real lack of specialist rehabilitation for women,
and in particular, women who represent only a low or medium risk of harm to others, but a high risk
of self-harm. This cohort are for the most part shut out from Approved Premises (“AP”) (it appears
that it is possible for medium risk women to be admitted to an AP but that possibility is not well
understood and the reality is that it is not available; that kind of accommodation being very over-
subscribed in any event). This means there is little or no effective system of rehabilitative provision
for that cohort. This is a cohort in which the state has invested a great deal of time and money (in
imprisoning and rehabilitative work) only, the evidence suggests, for that investment to be at risk of
being squandered on release. It also means that provision can become dependent on small charities
and acts of individual generosity, which is patchwork and may bring problems of unclear access and
unclear criteria (as happened here). The evidence was that this was being looked at by the Probation
Service, which does not generally provide specialist rehabilitation accommodation itself but which has
an obvious interest in it being available and so is monitoring the situation. However the evidence was
also that the situation is getting worse not better, particularly for women (who tend to have higher
levels of self-harm), and this is despite things like the Corston review in 2007 and the case of Coll v
SSJ ten years later, which found discrimination because of the gender disparity with respect to the
availability of APs. There is now a similar lack, and apparent gender impact, with regard to specialist
rehabilitation accommodation too. The circumstances creating the risk of other deaths therefore
subsist and might benefit from some renewed focus.

From the start of this year, new initiatives have been launched by Government to improve outcomes
for women in custody and on probation. These include the creation of the Women’s Justice Board
and the introduction of The Women’s Policy Framework and accompanying operational guidance
which was developed with over 250 probation practitioners and subject matter experts. This supports

HMPPS staff across custody and in the community to deliver consistent practice which is gender-
specific and trauma informed and includes mandatory actions for working with women. The
expectation is that this new oversight from the Women’s Justice Board will renew focus on the
accommodation requirements for women who find themselves in the criminal justice system.

With specific reference to the female Approved Premises estate, the need to accommodate women
with a wide range of needs is recognised and the estate does aim to accommodate women with
complex needs who may pose a medium risk of harm. There is a new Central Referral Process which
is managed by a dedicated Female Central Referral Unit Manager who has experience of such cases
and can best assess the need for an AP space. Such spaces are also available for women who are
subject to a community-based disposal, not just for those on licence release.

Linked to your first concern, you commented that probation officers, who have primary responsibility
for finding accommodation and building release plans, need to understand what accommodation is
and is not available. This case showed that no-one, including the relevant officer, realised that an AP
might in theory have been available. It also showed a failure to appreciate that once the first specialist
placement fell through, a second was very unlikely to be found and so CAS3 accommodation was
realistically the only option. That therefore needed finding quickly, so that a support plan could be
built around it. There does therefore seem to be a training need.

The Central Approved Premises Team are currently promoting the use of community disposals with
Probation Court Teams across the county – which prevent the loss of accommodation due to a period
in custody. They are also engaging with regional females leads (senior probation officers) to promote
the availability of placements in an Approved Premises for women with complex needs who pose a
medium risk of harm. From September this year, there will be Female AP briefings for all practitioners
where this exact point will be emphasised.

Thank you again for bringing your concerns to my attention. I trust that this response provides
assurance that action is being taken to address the issues you raised.

Yours faithfully,

Head of Operations

Response from Steps2recovery (PDF)

Lexham House
28 St Charles Square
LONDON W10 6EE

4TH January 2025

To: Mr Nick Armstrong KC, Assistant Coroner to the West Sussex, Brighton & Hove
Coroner’s Service.

Response to the Regulation 28 Report following the Inquest into the Death of Kirsten
Hocking

Steps2Recovery (S2R) acknowledges the findings and conclusions outlined in the Coroner’s
report regarding the sad death of Kirsten Hocking and the concerns raised and herein
responds to the concern directed to S2R. We would like again to send our condolences to
Kirsten’s family. We remain committed to learning from these events and ensuring that every
possible action is taken to address the issues raised. Our organization is dedicated to
improving our processes, strengthening communication, and refining our approach to
supporting vulnerable individuals in need of rehabilitation.
The concern raised was as follows:- “S2R started providing this kind of specialist
accommodation because there was such a pressing need for more of it. They are to be
welcomed for having done so. However, like many small organisations which have grown, it
appears that their systems have not always grown with them. Work is already being done,
but there remains a continuing risk. Placement offers and the conditions and expectations
which attach to them are too unclear. The recording of decisions around offers, withdrawal,
and reconsideration, also needs to be better, not just to ensure that decisions are recorded,
but also to ensure that decision making is properly structured and takes all relevant matters
into account. Withdrawing accommodation offers without first speaking to the requesting
organisation (in this case staff at the prison) also gives rise to risks. As this case shows,
these are critically important decisions, and great care is required.”

In response to this, we have reviewed the findings in detail and have implemented the
following measures to address the concern raised and more:

1.

 Clarity in Communication with Potential Admissions

o All potential admissions are informed during the assessment process that

they are required to remain fully abstinent from drugs and alcohol.
Additionally, it will now include clearer parameters relating to issues such
as, but not limited to; self-harm, suicide, prescribed medication,
criminality, mobility and physical health. Any changes in these
circumstances may lead to a re-evaluation of their application by a

 multidisciplinary team, which may include third-party input and may result
in the withdrawal of their offer. This information will always be provided in
writing in clear and unambiguous terms, as well as communicated
verbally. We have implemented a new ‘Offer/Acceptance’ document that
details the offer, on which any conditions placed on our offers will be
clearly communicated in written form and sent to the main point of
contact and where appropriate cc’d to other involved parties. This single
document can then be accessed by other involved parties and eliminates
any confusion as to what is required to fulfil a successful placement. As
part of the review of our case management system ‘Lamplight’, this form
will be available on clients’ individual files.

2.

                  Obligations of Referring Services

o Referring services, such as Probation Services, HMP Services and

substance misuse commissioning agents, will now be explicitly informed
during the assessment stage that they must notify S2R, in a timely
manner, of any changes in the circumstances of prospective clients. This
includes, but not limited to, updates related to mental health, physical
health, self-harm, suicide risk, drug or alcohol use, or any other
significant issue. We will, whenever possible, recommend to referring
services that alternative placements should be considered as a
precaution, in case conditions change and the place offered by us is at
risk.

3.

                   Documentation of Communication & Decision Making.

o To provide further robustness and transparency all communications,

discussions, and decisions, with regards to the prospective client, will be
recorded on Lamplight, and regularly audited by our new senior
management team. This ensures robust documentation and
accountability of decision making.

4.

                   Pre-Arrival Updates from Referring Services

o In addition to our normal application process, and to ensure

preparedness, S2R will contact the referring service two weeks prior to
the client’s arrival to confirm there have been no changes in
circumstances. If circumstances have changed, which may lead to the
withdrawal of the offer, the referring service will be contacted and have
input into the final decision before it is made.

5.                    Leadership Experience.

We have appointed new executive team members, with a new Head of
Therapy and CEO to further develop the delivery of our services. We have

 also expanded our board of Trustees to include someone with extensive
experience in clinical management.

6.

                   Policy and Procedure Review

o S2R has engaged an external consultant to conduct a comprehensive
review of all policies and procedures, including but not limited to:

 Referrals
 Assessment and Admissions
 Self-Harm and Suicide Risk
 Planned and Unplanned Discharges

o The reviewed policies will now incorporate all the aforementioned

processes and actions, ensuring a robust framework moving forward.

        7.                    Staff Training

o S2R provides mandatory continuous training to ensure all staff are fully

trained on the updated processes, recording of decision-making, policies
and procedures.

  8.                    Enhancements to Case Management System

o S2R has undertaken a thorough review of its case management system,
Lamplight, and is collaborating with Lamplight to ensure the system
operates at its most efficient and effective configuration.

o Comprehensive further staff training on the Lamplight system will then be

provided to ensure its optimal use and accuracy in documentation.

We remain committed to continuous improvement and to providing the highest level of care
and support for the individuals we serve. We continue to take all necessary steps to
minimise risk and ensure a more robust service to the vulnerable individuals who rely on
Steps2recovery.

Yours faithfully,

 – Trustee

On behalf of the Trustees and Management of Steps2Recovery
Charity No.  1138353

The report

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