SFO Lessons To Learn

A long read, but an extremely comprehensive report from the West Country by Carl Eve in the Express and Echo:- 

Two years after Devon murder, a family is still waiting for answers

Two years ago, Tanis Bhandari was brutally murdered outside a Devon pub. On the anniversary of his murder his family are still searching for the answers they need. Crime reporter Carl Eve investigates whether his death could have been prevented.

Two internal investigations into the sequence of events which led to the killing of Tanis Bhandari has revealed a catalogue of systemic failures, delays, computer inadequacies and human errors.

The investigation has found that "there was a chance" that Donald Pemberton – serving a life sentence for the joint murder of the 27-year-old builder on New Years' Day – "would not have been at liberty on that night" had key information been available to police and his probation officer when he was arrested for threatening a group of men with two meat cleavers two weeks earlier.

The investigation found that the circumstances which led to the builder's death could be repeated not just in Devon and Cornwall, but in any force area of the country. The family of Tanis Bhandari are now calling up on the Government to take immediate action, noting the police's internal report concluded there was "every chance incidents similar to this case will recur" if no changes were made to current processes.

Mr Bhandari, a builder from Tamerton Foliot, Devon, was stabbed to death in the early hours of New Year's Day in 2015. Donald Pemberton and Ryan Williams were arrested shortly after and jointly charged with his murder. The pair were also jointly charged with causing grievous bodily harm with intent to Jamie Healy, Sean Cordon and George Walker and causing actual bodily harm to Matthew Dawe.

Pemberton, aged 20 at the time and Williams, aged 21, pleaded not guilty. A few days into their trial, Williams changed his plea, admitting his guilt. Pemberton continued to deny the offence, claiming he never stabbed anyone. He was found guilty of each count on a majority jury verdict of 11 to 1.

A Serious Further Offence review was carried by the Probation Service out in the wake of the murder after it was recognised that Pemberton was on licence at the time of the offence. Pemberton had only served two months of a four month sentence – for having a sharp article in a public place – and had been released from prison in mid-November 2014.

His licence terms stated he was "to be well behaved, not commit any offence and not do anything which could undermine the purpose of your supervision, which is to protect the public, prevent you from reoffending and help you to resettle successfully into the community".

A Victim Summary Report of the Serious Further Offence review would be prepared – but only if it had been requested by the families of those affected by Pemberton's actions. Tanis' mother, Andrea Sharpe, has now revealed that they were eventually contacted by the DDC Probation CRC.

In addition, the grieving family were contacted by Devon and Cornwall Police who revealed they were conducting an internal review of Pemberton's arrest on December 15, the information available on the police national computer (PNC) regarding his licence details, who was contacted as a result of PNC checks and an assessment of Pemberton in the police cells by a mental health nurse.

The questions that won't be answered

Riana Taylor, head of operations at the Dorset, Devon and Cornwall CRC – run by Working Links which took over part of the Probation Service's role – met with the family on May 18 this year, following it up with a letter on May 31 and a copy of the "victim summary report".

In answer to the family's questions at the meeting, she revealed that the probation case manager received a message from the mental health team on December 22 – seven days after his arrest – saying that a mental health assessment would be done on Pemberton "for having been arrested and potentially having a weapon in his possession".

The following day, December 23, the case manager contacted the mental health team and the police to find out more about the December 15 incident. She learned of Pemberton's arrest and bail until February 9. Tanis' family were told she began to prepare information to lay a summons before the court "in line with the breach procedure for a YOI licence". The summons was laid at the court on December 24 with a court date of January 16, 2015.

The five-page Serious Further Offence review "victim summary report" was written by the assistant chief officer of the Bristol, Gloucester, Somerset and Wiltshire CRC, which is also operated by Working Links. The report gave an explanation of the case history and put forward findings into how Pemberton's licence was managed. Tanis's family say they have asked for more details about the findings but have been told it goes against the Data Protection Act.

The report suggests the case manager made "persistent attempts" to obtain and share information with other agencies, including the police and mental health services. Tanis's family have asked for, and been refused, evidence of those attempts.

The report reveals that the National Probation Service (NPS) allocated the supervision of Pemberton's licence after he was released "to a staff member who was newly appointed to the role of case manager (Probation Service Officer – PSO)".

The report stated this case manager was "an experienced staff member" who had worked "for a few years in probation in another role". Again, Tanis' family were refused information as to what role this case manager previously held in the Probation Service.

The report noted how the DDC CRC's practice was to "provide training for newly appointed case managers … through a designated PSA development programme". It was found there was a "delay in getting the case manager onto this training programme."

The report also found that "in this case the formal risk assess documents were not completed at the right time" and that while it was claimed risk management plans were made by the case manager, these were "not formally recorded". The DDC CRC refused to explain to Tanis' family why they were not recorded, citing the Data Protection Act.

The report also accepts "there were delays in the CRC receiving key information from other agencies". It stated: "The review highlighted areas where information sharing between agencies was inconsistent and there appeared to be a lack of interagency approach to reduce risk and address Donald Pemberton's apparent mental health issues."

The report claimed there was "ample evidence on record which indicated that the case manager persistently pursued information from other agencies and to ensure that Donal Pemberton accessed the appropriate treatment for his mental health issues". Again, the CRC has refused Tanis's family's request for that evidence.

In its recommendation section, the CRC claimed that "although no one could have foreseen the offence" it was "committed to identifying learning and improving practice." Areas of improvement were identified including that cases were allocated and "case details are recorded accurately throughout the supervision period."

Gavin Bhandari, Tanis's brother, responded to this recommendation: "That shouldn't be a recommendation – it should have been standard practice."

The CRC also recommended that "core training for new case managers" should be prioritised to "ensure it takes place as soon as possible after the person has come into post." In response Tanis's family feel the training should take place before new case managers take up their post.

Another recommendation is that CRC's should "develop guidance for all team managers on the allocation of appropriate cases to new staff and level of training require to hold specific types of cases and appropriate oversight of their work", which has led Tanis' family to question whether the new case manager was properly guided by senior staff and properly qualified. Again, the CRC has refused to expand upon the matter, citing the Data Protection Act.

Two more recommendations raise questions over current practices. The report said its "action plan" should "monitor completion of formal risk assessments and risk reviews through individual staff supervision and the CRC's staff observation policy". Again, Tanis's family say this should be standard practice, not something that is being recommended.

Finally, the family say they have concerns that one of the recommendations is to "agree a protocol with the police public protection team regarding access to intelligence and escalation of concerns", as it suggests that no such protocol already exists.

How Pemberton's licence was not on police records

A far more detailed, and revealing, report was released to Tanis's family by investigators from Devon and Cornwall Police's Professional Standards Department, dated September 9, 2016. The aim of the investigation was to "establish facts, the sequence of events and their consequences" and revealed a worrying gap in the computer systems police rely on, not just in Devon and Cornwall, but across the whole of England and Wales.

It also revealed a series of delays and omissions resulted in a slow response, and ultimately a drift in the handling of Pemberton's increasingly worrying behaviour.

The investigating officer, a detective constable, notes how Pemberton was released from the Young Offenders Institution (HMPYOI) Portland on October 31, 2014 after receiving a four month prison sentence on September 2 for having a bladed article in public. It also notes the incident in the early hours of December 15 at King Street where Pemberton was seen on CCTV brandishing two meat cleavers. The report reveals that Pemberton was arrested and interviewed later the same day and bailed to February 9, 2015.

The detective said he obtained a copy of Pemberton's signed notice of supervision, given to the 20-year-old on his release from the YOI. It stated that he was to be supervised by an officer from the Probation Service between October 31, 2014 and January 30, 2015. He was to report to the service's office at St Catherine's House in Notte Street on November 3. His supervising officer was appointed at a later stage.

After arrest he was booked into custody at Charles Cross police station at 11.47am. The report notes: "The custody record confirms Mr Pemberton saw the Health Care Professional (HCP) while he was in custody. They deemed a Mental Health Assessment was not required. This was discussed with the Community Psychiatric Nurse (CPN) who said they would inform the Insight Mental Health Team [that] they would "need to see Mr Pemberton as soon as possible in the community."

The police investigator carried out more inquiries and discovered Pemberton's probation case manager was not made aware of his arrest until she was left a note on her office desk on December 23, 2014 asking her to call a member of the Insight Mental Health Team. She called police and learned Pemberton had been arrested "as part of a large group passing around meat cleavers".

In the course of his inquiry, the police investigator reported how the Probation Service's supervising officer had been called by a doctor on November 21 who had seen Pemberton "who said he was paranoid and was afraid of his father and was now keeping an axe under his bed". The supervising officer called police as she was advised action under Section 136 of the Mental Health Act was required. However, after calling 101 and waiting for 15 minutes, her supervisor told her to "hang up and call 999". She informed the police investigator she was told by the call handler the matter was not an emergency and she should go back to the 101 number. When she called the 101 number again she was told he was "back at home and no longer a risk".

The probation officer's concern, the investigator noted, was how Pemberton "had been presenting himself as a paranoid recluse" and if he was on the streets with others they knew very little about him. The investigator noted how "as he was a youth prisoner, the breach process involved putting the matter to a court for the recall to prison to be issued. This was initiated, but was hindered by the time of year and it was not completed before the New Year."

The investigator also noted how the relatively new probation manager "had never received contact from the custody unit before when someone under supervision had been arrested. The Probation Service would usually hear about it when the person was at the court with the CPS paperwork".

The investigator found Pemberton had been interviewed by police and explained he had gone with others to give someone – allegedly forcing a young girl to do things of a sexual nature – a "beating". CCTV footage was examined and Pemberton admitted he was the person holding the meat cleavers.

A Detective Sergeant was told about the case and studied the CCTV footage. He then authorised Pemberton's police bail at 9.43pm that same day for further inquiries, later telling the PSD investigator he was "unaware Pemberton was subject of a licence release from prison".

However, an audit of the police computer revealed Pemberton's PNC (Police National Computer) record had been accessed by a police constable, a resource deployment officer in the control room and a custody police sergeant, on the day. The PSD investigator stated in his report how he contacted the PNC Bureau of the Metropolitan Police to determine exactly what was on Pemberton's record in December 2014 and whether it reflected his release from the Youth Offending Institute (YOI) and his licence.

He also contacted a specialist PNC advisor at Scotland Yard who explained how in December 2014 "only prisoners released on a licence with supervision from a sentence of 12 months or more would have had their licence details sent to the PNC bureau.

The investigator also contacted YOI Portland to determine what had been sent to the PNC Bureau regarding Pemberton's release. The prison's offender management unit who explained it was "not routine for licences to be sent to them [the police] unless the person concerned comes under the Multi-Agency Public Protection Arrangements (MAPPA), is a Prolific or Other Priority Offender (PPO) or is released on Home Detention Curfew (HDC), in which case the licence would be sent to the PNC Bureau. As Mr Pemberton was not in any of those categories, a copy of the licence would have been provided to Mr Pemberton on his release and to the Probation Service only; the licence details were not sent to the PNC Bureau."

In a damning observation, the investigator noted: "A search of the archive of prison licences held on Devon and Cornwall Police's computer system also revealed no record relating to Mr Pemberton." The investigator concluded that "to draw conclusions in this case requires the consideration of two discreet issues which are the crux of the matter" – the first being why Pemberton was bailed and secondly the "absence of the details of his supervision licence from his police records" following his released from prison.

The PNC audit found "none of the investigation team, including the [detective sergeant] accessed the PNC record of Mr Pemberton". This meant his "disposal history, which would have shown his recent conviction and release for a similar offence, was not taken into consideration when the decision to bail him was made".

However, most damning of all, was the PSD investigators discovery that there was "no doubt the details of Mr Pemberton's supervision was not on his PNC record". In addition, the investigator found the sending of licence details of all prisoners released on licence to the PNC Bureau "is not happening, at least at that institution".

Another shocking revelation was that Devon and Cornwall Police computer system, does not extract a suspect's Custody History screen, meaning custody officers "would not see any licence details held on a prisoner in custody as the data would not be available via the interface".

The PSD report admits "this presents a clear drawback to the custody system.; even if prisoner licence details were recorded in accordance with the new guidelines by the [specialist PNC advisor at the Metropolitan Police's PNC Bureau], the custody officer would be unaware of it."

The investigator notes that as the ultimate bailing or charging decision is made by the custody officer, it was "imperative" they were able to view all the relevant information. The investigator said this issue "needs to be addressed as a matter of priority".

They noted how the current process of arrest sheets being sent "once per week" by Charles Cross custody centre to Plymouth's Probation Service was "inadequate to address the problems highlighted by this case".

They added: "It is of little use for the Probation Service to receive information about a supervised prisoner six days after they were in custody. Common sense dictates they should be made aware of the detention while the prisoner is still in custody so any recall can be considered, and initiated and completed, ideally before their release."

The report's damning conclusion

For the family of Tanis Bhandari, there is one devastating conclusion written in the report notes. It notes that while there was no "causal link" between the police's actions on December 15, 2014 and the tragic events of January 1, 2015 "there was a chance Mr Pemberton would not have been at liberty on that night, had his supervised released been reflected on his PNC record, and a recall to prison been issued for him, as a result of his behaviour on 15th December".

"There was a chance Mr Pemberton would not have been at liberty on that night"

The investigator also noted that had Pemberton been charged on that night, he may well have been at liberty on January 1, adding: "There is no way of knowing for certain whether or not he would have been in custody on 1st January even if the licence breach had been recognised, and acted upon, at the time, or if he had been charged with offences."

Their report also noted that it would have been "correct and diligent" for the affray investigating officers to have check Pemberton's PNC record as it "could have influenced the briefing they gave to" the detective sergeant.

What lessons were learned?

In the section headed Lessons Learned, the investigator noted key action needed to be taken to "prevent a repetition of it".

The PSD investigator highlights firstly the process of prisons informing the Metropolitan Police PNC Bureau of prisoners released on licence. The second is the manner in which licence and supervision information is present on the PNC and third the "fallibility of a custody system interface which does not extract relevant date from PNC".

As HMPYOI Portland confirmed it would not have sent details of Pemberton's release to the PNC Bureau, as he was not considered a prolific offender or subject of home curfew or MAPPA, The investigator suggested it would "seem only logical that the licence and supervision details of all [the investigator's italics] prisoners released, who are subject to them, should be sent to the PNC Bureau so they can be placed on PNC."

They noted how as police were the "most likely" to come into contact with prisoners on licence, if officers were left unaware of their licence and supervision situation this "will have a detrimental effect on public safety as the police are unable to deal with them appropriately".

The investigator warned: "The concern is that Prisons, nationwide are adopting different criteria for sending, or not sending, prisoner licence details to the PNC Bureau. While this practice continues, and until all prisoner licence details are sent to the PNC Bureau, there is every chance incidents similar to this case will recur." There needs to be an established working practice, on a national level, between the National Offender Management Service (NOMS) the Probation Service and the police to ensure the correct information is provided to the PNC Bureau to reflect the licence status on the individuals PNC record."

They said that licence information needed to be "immediately obvious to anyone viewing the record" as it was, in some cases, "contained in a body of many lines of text and could be missed".

One of the investigator's findings, which has shocked the family of Tanis Bhandari, is that more than a third of all PNC records may not show the licence details of convicts who have been released by prisons. In an effort to determine the scale of the problem, the investigator reported how a "dip-sample of 11 PNC records of people on licence within Devon and Cornwall showed that in four cases their licence was not reflected on PNC in any way".

The investigator suggested: "Having licence information in a readily identifiable and accessible format on PNC would make the fact the subject of the check is currently on licence immediately obvious to the person viewing the report, such as the custody officer or the investigating officer.

"In turn this should prompt the investigating officer to contact the relevant Probation Officer, while the subject is in custody, so that consideration could be given to seeking a recall to prison for the individual. If a prisoner is identified as being on licence, contact with the Probation Service should form part of the prisoner process followed by the investigation officer, and a note of that contact should be made on the custody record."

The investigator noted how Devon and Cornwall Police's UNIFI system interface "does not extract the CU [custody history] screen information from PNC." As such, they recognised that "even if licence information was sent to the PNC Bureau… it would still not be visible to the custody officer making the check."

In a final damning paragraph, the investigating officer insisted: "This needs to be changed with immediate effect so the CU screen data is captured and available to them."

Hinting that this was a problem across all forces, they added: "Although UNIFI is the system used in this force area, other forces use the same, and other similar systems. All forces should check the interface used to ensure the CU screen is being extracted by it from PNC."

It should be noted the investigating officer from Devon and Cornwall Police Professional Standards Department is a Detective Constable and has no power whatsoever to enact any of the suggestions they have put forward in their report.

Tragedy is not the first of its kind

Tanis's family have examined a similar case in South Wales highlighted in January this year. In 2015 a successful petition was launched to demand the full Serious Further Offence review into the monitoring of David Braddon, of Caerphilly, South Wales be made public. Conner Marshall, aged 18, was murdered by Braddon in March 2014. At the time Braddon was under probation's supervision for assaulting a police officer and drug offences.

The summary report released to Mr Marshall's parents claimed that there was "nothing the offender manager could have done which would have predicted or prevented the offence". Mr Marshall's parents launched a petition to be allowed access to the full report and after thousands signed it, they were told by the Ministry of Justice the full report would be released to them.

Mr Marshall's family said there were "missed opportunities" to prevent their son's death but the Wales Community Rehabilitation Company (CRC) – also run by Working Links who run the Dorset Devon and Cornwall CRC which oversaw Pemberton's case – stated that Conner's death was "not predictable or preventable". As a result Mr Marshall's family launched a crowdfund appeal to cover the cost of lawyers to pursue legal action against the privatised probation organisation.

In October 2015 figures released by the Ministry of Justice showed the number of serious crimes committed by violent and sex offenders being monitored after leaving prison rose more than 28 percent. Some 222 offenders under supervision in the community were charged with crimes including murders, manslaughters or sexual offences in 2014/15. More than 68,000 sexual and violent offenders were under such arrangements at the time.

While the Ministry of Justice said such reoffending remained rare, the probation union NAPO blamed the privatisation of the service.

At the time, Tania Bassett, national officer for the probation union NAPO, said: "We are starting to see the Mappa process falling apart in some areas, partly due to the privatisation of probation, which means the exchange in information between agencies is not quick enough."

Tanis's family still want answers

Andrea Sharpe, Tanis' mother, said their family has been left with many unanswered questions. She said: "Reading the report from the Probation – or rather the private part of the Probation Service – it's just dreadful. It's just a sham. It's incomplete. It doesn't tell us anything and it's really quite worrying.

"What's worse is they are just not answerable and they get to keep it all to themselves, saying they're a private firm."

Gavin Bhandari, Tanis's brother, said: "We were told by Working Links that if we have any questions we have to go back to the Ministry of Justice. Basically, they're saying 'we've learned lessons, and besides, they're inside now'.

"I've studied the Government websites and I've learned that three letters are sent by the prison when someone is released on licence. The information about the licence should be printed off and sent to the local police force.

"The CRC claimed that a YOT licence was not subject to a recall to prison. So what's the point in having it then? That you can breach again and again and not be sent back to prison to safeguard the public?"

He added: "When he breached his licence, what action can be taken? From what I've read the Government's website state he could have been recalled. He could have been brought back before the magistrates. Even if it was a just a telling off in front of a magistrates it could have curbed any future offending.

"As for the Probation Service, we asked them a series of questions – like where is the evidence that Pemberton's case worker tried to contact other agencies. And if they were newly appointed who were they supervised by and how closely were they supervised. Why did they delay her training for what is clearly such an important position."

The National Offender Management Service's "Supervision of Young Offenders" protocols state that Young Offenders serving sentences of less than 12 months "must be supervised for three months following their release".

The protocol notes how if a young offender fails to comply with the conditions of the supervision notice, they can be taken to court. The supervising officers "must provide information about the breach to the court" and if satisfied there has been a breach, the "court may order the offender to be detained (in prison or youth detention accommodation) for up to a maximum of 30 days".

Gavin said: "As far as our family are concerned the Probation Service has not told us the truth. We know from The Herald's reporting that it has been part-privatised and the organisation now running the Plymouth probation claimed they were not subject to Freedom of Information requests."

Andrea said perhaps the only way her family would get to see the full Probation report was to copy the efforts of Connor Marshall's family in South Wales. She said: "Reading about the Welsh case, perhaps our next step is also to get a petition up to get the full information.

The police report showed there was a catalogue of disasters. Admittedly, they were more open, much more than the Probation Service. But you realise there was stuff that should have happened and didn't and stuff they should have done, and didn't.

"What incredible is if you stop someone for a road traffic violation, they can check all this information, like your road tax, your insurance, your driving licence details, the driver's history. They can have your car taken off you straight away if they need.

"You're more likely to be checked up on accurately for a driving offence. There's more surveillance and information on you available to the police if you're a driver than an armed criminal.

"This is now a national issue. The Ministry of Justice need to wake up and shake up their act. What's worse for us is we don't know who is responsible for fixing it. The police have put forward these recommendations and we don't know who it has gone to.

"Who acts on this? Because they need to start doing something and take action now before someone else is hurt or worse.

"Nothing is going to change our loss. This investigation by the police won't change the result of that night. But it would be nice to know that people are acting on advice to prevent it happening again to another poor family."

Gavin said: "As far as our family concern the Probation Service has not told us the truth. We know from the Herald's reporting that it has been part-privatised and the organisation now running the Plymouth probation claimed they were not subject to Freedom of Information requests."

The police response

A spokesman for Devon and Cornwall Police said: "Following the death of Tanis Bhandari and subsequent conviction of Donald Pemberton for Mr Bhandari's murder, there has been a review from Devon and Cornwall Police's Professional Standards Department looking at any lessons which could have been learned from this tragic death.

The matter was initially referred to the IPCC, but referred back to Devon and Cornwall Police for investigation. At no point has there been any suggestion of any wrong doing of any Devon and Cornwall Police officers or staff.

One of the main areas identified by the review is how information and intelligence on a prisoner being released from custody is placed on the Police National Computer by the National Offender Management Service. This is not an issue isolated to Devon and Cornwall, but something identified as a matter of process and policy nationally."

The Probation/Working Links response

In January 2016, Working Links – who run the Dorset, Devon and Cornwall CRC – said all decisions "were made and supervised by fully-qualified and experienced probation workers".

At that time they did not reveal that the case manager was awaiting further training.

The spokesman for Working Links also said that the Community Rehabilitation Company had "rigorously reviewed the specific issues identified in the case and are implementing a plan of action" adding: "we have worked with the National Probation Service, police and other partners to review and enhance our robust processes."

The spokesman said Working Links had "improved communication with partner agencies and we are working with police to improve access to intelligence to help us monitor offenders better and further provide timely, relevant services tailored to their situation".

In its final line, the spokesman said that "as part of Transforming Rehabilitation reforms, our service delivery and subsequent results are now more transparent than ever, ensuring the government and taxpayers can hold us to account".

Responding to another media outlet's recent question, a spokesman for Working Links said Pemberton's management had not been linked to the crime committed and "processes were being followed to tackle the offender's behaviour".