Lessons Not Being Learnt

Right from the start when Chris Grayling and the coalition government began to impose their omnishambolic 'Transforming Rehabilitation' on a gold-standard service, there were repeated warnings that it would lead to an increase in Serious Further Offences, and so it transpired. As a consequence, the deeply cynical amongst us have long suspected that the whole SFO investigation and reporting system has been the subject of deliberate obfuscation for political ends. Too often it's also felt as an opportunity to simply 'throw staff under the bus' rather than look at systemic failings.  

Here we have HM Chief Inspector of Probation Justin Russell with a press release introducing his latest report on the subject and unambiguously calling for an independent body to oversee the whole process in order to help restore public and professional confidence in a currently deeply-flawed system:-

Probation system ‘not doing enough to learn from past mistakes

The probation system is not doing enough to learn lessons from serious crimes committed by offenders under supervision, according to inspectors.

Nearly a quarter of a million people are on probation in England and Wales. Around 0.2 per cent of these individuals are charged with serious further offences each year while under supervision. These crimes include murder, rape, and other violent and dangerous offences.

HM Inspectorate of Probation examined the way probation services review and learn lessons in these cases. Inspectors also looked at how HM Prison and Probation Service (HMPPS) quality assure those reviews, and use information to improve national policies and practice. Victims and their families were asked about their experiences too.

Chief Inspector of Probation Justin Russell said: “Serious further offences have a devastating impact on victims and their families. The review process must examine the period leading up to the offence and how the probation service managed the risk of serious harm.

“Our inspection found that individual reviews were good in parts, but a fifth (22 per cent) of those we inspected failed to give a clear judgment as to whether all reasonable steps had been taken to manage the risk of serious harm. At a national level, more needs to be done to identify trends and themes to drive changes to probation policies and guidance.

“Until this work is done, the government and probation services are not doing enough to learn from past mistakes. Lessons must be learnt to prevent more tragedies in the future.”

Probation services in England and Wales are delivered by a mix of providers. The National Probation Service (NPS) supervises high risk offenders in the community, while 21 Community Rehabilitation Companies (CRC) supervise low and medium risk offenders.

When an individual who is on probation commits a serious further offence, a manager in the relevant NPS division or CRC conducts an internal review.

Inspectors found:

• Serious Further Offence reviews often set out the timeline of events, but are less effective at explaining why the offence took place. Reviews should draw clear conclusions on failures of probation practice.
• Serious Further Offence reviews focus solely on probation practice, unlike reviews conducted in other parts of the criminal justice system, such as those following domestic homicides. Offenders are usually known to other agencies, so these interactions are not explored and important opportunities for joint learning are being missed. Inspectors recommend external agencies that have been involved in the case, such as the police and children’s services, should be involved in the Serious Further Offence review. Consideration should also be given to whether this should be mandatory for all homicide cases not currently covered by other multi-agency procedures. There should be a requirement for SFO reviews that include findings on the actions of other agencies to be shared with those agencies.
• Individual probation officers involved in cases are interviewed by the Serious Further Offence review teams, but often do not see the final reports and have limited opportunities to question the findings. Some staff view the process negatively and believe its primary focus is to attribute blame. The Inspectorate concluded this ‘culture of fear’ undermines the ability of organisations to learn from the process.

Relatively few victims or their families ask to see the Serious Further Offence review and take up of this offer is not monitored centrally. More effort needs to be made to increase the uptake of this offer.

Victims and their families that do ask to see the review found the process open and honest about failings, and appreciated the chance to discuss the case with a senior manager.

The Inspectorate found the content and length of the reviews would be difficult for some victims and family members to digest. Inspectors also urged greater consideration to individual circumstances before disclosing reviews, for example to ensure vulnerable victims have proper support.

HMPPS is responsible for quality assuring Serious Further Offence reviews and providing feedback to probation services.

Inspectors found:

• Reviews are not analysed nationally to identify themes, which could improve policy and practice.
• Staff shortages have led to backlogs and unacceptable delays – the HMPPS quality assurance process should take 20 days but takes six months on average.
• There is a lack of independent oversight and transparency in the process with HMPPS auditing the quality of its own work.

Mr Russell said: “Significant resources are rightly invested in the Serious Further Offence review process. In our view, the current arrangements are inefficient and lack independence and transparency.

“We recommend an independent agency should get involved in quality assuring this vital work. The agency should look at a proportion of completed reviews each year and publish its findings on a regular basis. This will help to increase public confidence in the process.

“Following our inspection, we have made a number of recommendations to the Ministry of Justice and HMPPS. These aim to refocus the Serious Further Offence review process on learning lessons, improving probation policies and practice, and increasing access for victims and their families.”

Earlier this year, the Secretary of State for Justice asked Mr Russell to conduct an independent review into the case of Joseph McCann, who committed a series of serious further offences while under probation supervision. The first part of that report will be published in June 2020.

--oo00oo--

Foreword 

Serious Further Offences (SFOs) are committed by a small proportion of the probation caseload. For the victims and families involved, however, the consequences are devastating and often life changing. It is therefore essential that probation providers are accountable for the work undertaken and that the learning from such events results in improved service delivery. 

This is the primary purpose of the SFO review process, which was first introduced in 2003 to ensure rigorous scrutiny when serious offences are committed by service users subject to probation supervision. A revised process was implemented in April 2018. This was the focus of our inspection. 

A priority for the new process is to ensure increased transparency for victims and family members, and to some extent this has been achieved in that they now have access to the full review document. The reviews, however, are often long and complex documents that examine probation practice in detail, sometimes over many years. Although probation providers have ensured that the disclosure of reviews to victims is handled sensitively, it can still be confusing and overwhelming. Very few take up the offer of full disclosure, and further work is needed to better understand the reasons for this and to take full account of victims’ individual circumstances and needs. 

At the heart of the SFO review process is the aim that learning from SFO reviews should improve the management and supervision of service users. We found a mixed picture. At a national level, SFO reviews are not analysed to identify themes, inform policy and improve practice. At a local level, probation providers have procedures in place to identify learning from the reviews that they have undertaken. The fear and concern that the process provokes in operational staff, however, undermines the ability of organisations to learn from the process. Their perception is that the review focuses on individual and not organisational responsibilities, and our findings confirm this. 

SFO review cases are frequently complex, with many agencies involved. Most SFO cases, however, are not the subject of multi-agency reviews and the current process focuses solely on probation practice. Valuable learning is therefore lost. A multi-agency contribution would help victims and family members to have an improved understanding of the management of the case. 

The HM Prison and Probation Service (HMPPS) SFO review team is responsible for the central quality assurance of the SFO reviews and providing feedback to local areas. There have been unacceptable delays in this process, with probation providers and individual staff members waiting an average of six months for feedback on their reviews. 

In contrast to the process for other serious case reviews, such as Domestic Homicide Reviews or MAPPA serious case reviews, the current SFO process lacks independent oversight and transparency. Although we don’t recommend that an independent body should take on the reviews themselves, we do recommend that there should be independent oversight of the quality assurance process, by an independent body scrutinising the quality of a sample of reviews on a regular basis and reporting publicly on what they find. This would also allow the overstretched central HMPPS SFO review team to focus its efforts on drawing together the lessons learned from SFO reviews and promising practice identified across England and Wales. This in turn should be used to inform national policy and drive improvements in practice. 

Significant resources are rightly invested in the SFO review process. In our view, the current arrangements are inefficient. The potential improvements to the management of service users and increased accessibility for victims and family members are not fully realised. We make a number of recommendations to improve the efficiency and the overall impact of the SFO review process.

Justin Russell HM Chief Inspector of Probation