Report Highlights Structural Failings

Press release issued today:-

Independent serious further offence review of Damien Bendall

Background

Damien Bendall murdered Terri Harris (aged 35), John Paul Bennett (aged 13), Lacey Bennett (aged 11) and Connie Gent (aged 11). He also raped Lacey. These crimes took place in September 2021 in Killamarsh, Derbyshire. He pleaded guilty in December 2022 and was later sentenced to a whole-life prison term.

Bendall was on probation when he committed these offences. The Lord Chancellor and Secretary of State for Justice the Rt Hon Dominic Raab asked HM Chief Inspector of Probation Justin Russell to conduct an independent review into this case. This review was completed in January 2022 and can now be published following the completion of the criminal proceedings.

Statement

HM Chief Inspector of Probation Justin Russell has made this statement:

“This was a deeply concerning case. The Probation Service’s assessment and management of Bendall at every stage, from initial court report to his supervision in the community, was of an unacceptable standard and fell far below what was required.

“Bendall had previously committed violent offences. His records show a former partner had made allegations of domestic abuse against him and a police child sexual exploitation unit had made enquiries about him with the Probation Service. Probation practitioners should take account of this sort of intelligence when assessing potential risks of serious harm. But this does not appear to have happened in this case.

“Bendall committed arson in May 2020. A member of the probation service’s court team interviewed him in June 2021 in order to prepare a report with sentencing options for the judge. The report author noted Bendall was suitable for a curfew requirement at the home of Terri Harris. They came to this wholly inappropriate conclusion without speaking to Ms Harris, visiting the property, conducting domestic abuse enquiries, or taking into account past domestic abuse claims.

“The court report author assessed Bendall as posing a medium risk of serious harm to the public and posing a low risk of serious harm to partners and children. We do not agree with this risk assessment; they under-estimated the risks Bendall posed and this had serious consequences.

“Probation managers and practitioners took the risk assessment from the court report as a given, and missed several opportunities to scrutinise and change it. If Bendall had been assessed as presenting a higher risk of serious harm – which would have been appropriate – it is unlikely a curfew order would have been deemed suitable and he would have been assigned to more experienced and confident probation officers.

“Instead, Bendall’s case was transferred to the East Midlands in the summer of 2021, and he was supervised by insufficiently qualified and experienced probation practitioners. The safety of Ms Harris and her children was not given due consideration. This was especially troubling as Bendall had started drinking alcohol and smoking cannabis again, which is likely to have increased the risk of serious harm.

“Probation services must strike the right balance between protecting the public and supporting individuals to move towards crime-free lives. Sadly, in this case, the balance was out of kilter.

“In January 2022, we published a separate thematic report on electronically monitored curfews which questioned why domestic abuse and child safeguarding enquiries are not mandatory before court ordered curfews. The Bendall case demonstrates clearly why these checks are so important.

“This review also highlights common issues that we have found in previous and recent inspections of probation services: the lack of qualified probation officers and managers with too many responsibilities to provide effective oversight for less experienced staff.

“The Probation Service must tackle these workforce issues. Probation practitioners must have the right knowledge, skills and experience to manage their assigned cases – and appropriate support and oversight from managers.

“We want to see probation practitioners and managers scrutinising case files and past criminal behaviour properly and developing a deeper understanding of the people they manage. We did not see enough ‘professional curiosity’ in this case – Bendall’s words and assertions were often taken at face value. Probation practitioners should be interrogating and verifying claims to build up a complete picture of the individual.

“As a result of this review, I made 17 recommendations for improvement to the Ministry of Justice, HM Prison and Probation Service and His Majesty’s Courts and Tribunals Service. They have accepted all these recommendations and responded with an action plan for implementing them. While this is welcome, over the past year in our local and national probation inspections we have continued to raise deep concerns about the quality of probation practice we find more generally in relation to the assessment and management of risk of harm. This is a subject I have raised repeated concerns about since becoming Chief Inspector. It is vital that this time lessons are learnt from this awful case.

--oo00oo--

Extracts from the full report:-

1. Foreword 

In September 2021, Damien Bendall was charged with the murders of Connie Gent (aged 11), Lacey Bennett (aged 11), John Paul Bennett (aged 13) and Terri Harris (aged 35), who was pregnant, and with raping Lacey. These shocking crimes have devastated families, friends, and the local community in Killamarsh, Derbyshire and beyond. In December 2022, the courts imposed a whole life sentence. 

Damien Bendall was on probation when he committed these crimes. The Probation Service typically conducts a Serious Further Offence (SFO) review when an individual on probation commits a serious violent or sexual offence. However, in this case, the Secretary of State for Justice asked me, as Chief Inspector of Probation, to conduct an independent SFO review into the Probation Service’s management of Damien Bendall. 

This report sets out the findings of that independent review. My inspectors found that the Probation Service’s assessment and management of Mr Bendall at each stage of the process from initial court report to his supervision in the community were of an unacceptable standard and fell far below what was required. 

Vital information about the serious risks posed by Mr Bendall to those he lived with, and the public, was not included in the Probation Service’s report and recommendations to the judge when he was sentenced for an arson offence in June 2021. As a result, he was sentenced to an entirely inappropriate curfew condition to reside with Ms Harris and her children. This was then compounded by a failure to allocate his case to an appropriately experienced and trained probation officer who could have managed him at the higher risk of serious harm level his past history certainly warranted. Several opportunities to correct these mistakes and amend his risk of harm classification and reallocate Mr Bendall’s supervision to an appropriate practitioner were missed in the period from June to September 2021. 

Inspectors found successive probation practitioners missed opportunities to ensure vital information known about Damien Bendall was included in assessments and plans to manage and address the risk of serious harm he posed to both women and children. Practitioners did not carry out safeguarding enquiries when he was sentenced for his most recent offence of arson. The impact of unmanageable workloads at both the probation practitioner and senior probation officer levels resulted in reduced oversight of new or struggling staff, frequent role changes and sickness absence. This made consistency and continuity of practice challenging. In this case, there was an increasing reliance on unqualified and trainee staff to manage workloads; this contributed to emerging factors linked to risk of harm not being recognised and escalated appropriately. 

This is a deeply concerning case that raises serious issues around the Probation Service’s assessment and management of risks of harm. This is a subject that has been of repeated concern to us in our local inspections and on which I have commented in my annual reports and in relation to other SFOs, 1 including that of Joseph McCann, 2 on which we reported in 2020. 

As a result of our findings, we make 17 recommendations for improvements to His Majesty’s Prison and Probation Service, His Majesty’s Courts and Tribunals Service and the Ministry of Justice regarding safeguarding and risk assessment practice and procedures, which I expect the service to respond to as a matter of urgency. It is vital that key lessons are learned from this awful case. 

Justin Russell

HM Chief Inspector of Probation

5. Executive summary 

Inspectors found that, at every stage of probation involvement, from the pre-sentence report provided to the court on 08 June 2021 to the commission of the SFOs in September 2021, the Probation Service’s assessment and supervision of DB fell well below the necessary standard. A failure to assign the correct risk of harm level to DB (which should have been ‘high’ risk of serious harm given his past history) meant that the court was missing vital information when reaching its sentencing decision. It is possible that, had a holistic assessment been provided to court (including his pattern of offending against Asian men, use of callous and organised violence against prison staff, an analysis of previous noncompliance and the most recent high risk of serious harm assessments), an immediate, rather than suspended, prison sentence might have been imposed. 

As it was, the court imposed a suspended prison sentence, which included an entirely inappropriate curfew condition to reside with Ms Harris and her children. The case was then allocated for community supervision to an inexperienced and inappropriate practitioner. 

There were then subsequent failures by supervising managers and new practitioners to adequately read the case and amend the initial, incorrect ‘medium risk of serious harm’ to ‘high risk of serious harm’. 

Had DB’s risk of serious harm to the public and children been correctly assessed as high, and had his risk of serious harm to partners been correctly assessed as medium, the court may not have curfewed him to an address with Ms Harris and her children. He would have been allocated to an experienced probation practitioner. This would have led to enforced weekly face-to-face appointments and improved communication with partner agencies, and assertions lacking evidence would not have been relied upon and repeated in future assessments. 

In sections 7 to 11 of this report, we analyse the management of DB during his two most recent sentences, the first a prison sentence with probation licence supervision imposed on 29 January 2017 and the second a suspended sentence order managed in the community imposed on 09 June 2021. In this summary we focus on our key lines of enquiry and summarise why, in our view, the following deficiencies occurred. 

Process for recommending curfew requirements 

The Criminal Justice Act 2003 requires that, ‘before making a relevant order imposing a curfew requirement, the court must obtain and consider information about the place proposed to be specified in the order (including information as to the attitude of persons likely to be affected by the enforced presence there of the offender)’. The current court process requires that court officers undertake domestic safeguarding enquiries ‘in order to assess risk of harm and suitability for sentencing options in all offences involving domestic abuse’,  which DB’s index offence did not. 

HM Inspectorate of Probation recently published a thematic inspection on electronic monitoring, including its use for curfews. In this report, we recommended that HMPPS: 

• mandate the requirement to make domestic abuse and safeguarding checks before recommending a sentence or release on electronically monitored curfew 

• work with the police and children’s social care at a national level to ensure that probation practitioners in every region are provided with domestic abuse and safeguarding checks in a timely manner.  

Before DB’s sentencing for arson, the court officer did not carry out domestic abuse enquiries on the address, find out whether Ms Harris’s children were known to children’s services or speak directly to Ms Harris to ensure she consented to her home being used as a curfew address by DB. The Sentencing Act 2020 requires courts to have sight of this information before imposing a curfew order. However, it appears that courts do not have a mechanism to ensure this information is seen in every case. In this instance, important checks were not carried out and the court proceeded to issue a curfew order without them. 

Child safeguarding 

Inspectors found that probation practitioners in this case based their risk of harm assessments on whether DB had convictions against children or for domestic abuse, or if children’s services were involved with the family. These are highly relevant factors, but probation practitioners should delve deeper to explore the broader attitudes and behaviours of the person under supervision, including their impact on the children in their lives. DB did not have a history of offending against children. However, we found that insufficient consideration was given to whether his racist, manipulative and controlling attitudes and his violent and unpredictable behaviour would have a negative impact on the wellbeing and safety of children. 

We did not find evidence of sufficient professional curiosity about the nature and level of the role he played in the lives of the children of his partners. 

Intelligence was available to the Probation Service from Wiltshire police’s child sexual exploitation team regarding DB’s risk of serious sexual harm to girls. However, this information was not explored or recorded sufficiently to inform the risk of serious harm assessment and plans to keep children safe. 

The probation practitioner who prepared the court report following DB’s arson conviction took his account and version of events in relation to his offending and circumstances at face value. This included DB’s assertion that he played an important part in taking care of Lacey and John Paul Bennett. This information was not checked with their mother. There were no checks to find out if children’s services were currently working with the family or had previously done so. Most egregiously, the report stated that DB was ‘suitable’ for a curfew at Terri Harris’s address. When considering a curfew in the home of children, the attitudes of the people in that home8 and the best interests of the child should be given weight. 

At the start of the most recent order, in June 2021, there was again a failure to be professionally curious about the children living with DB. To probation practitioners, DB presented himself as a father figure to the children of Terri Harris and this was accepted without challenge. No contact was made with the children’s parents. When DB admitted to using drugs and alcohol this was not escalated to a manager and a children’s safeguarding referral was not completed. We found that the risk of serious harm to children was inaccurately assessed and seriously underestimated. 

It is our view that there should be a section of the offender assessment system (OASys) that solely considers the wellbeing and safety of the children – actual and potential – in the life of the person on probation. This would separate children from assessments of broader familial and intimate relationships, and specific prompts should be used to facilitate a more rigorous and defensible assessment of the impact on a child’s ability to thrive. 

Domestic abuse 

During previous orders, DB’s relationships with his mother and grandmother were not explored appropriately. Probation practitioners did not demonstrate sufficient professional curiosity, did not conduct safeguarding enquires, and took information from DB, again, at face value. 

Inspectors found that key information on risk from prison and from DB’s ex-partner and her current partner was not given due consideration and was not recorded appropriately. The impact of this failure was significant, as successive probation practitioners did not recognise that DB posed a risk of serious harm within relationships. 

Probation at court appeared to take DB’s word without verification. The author of the court report noted that a curfew would be ‘suitable’; they did this without undertaking safeguarding enquiries on the address or communicating with the owner/lead tenant of the property. This loophole in the mandated checks required before a curfew recommendation needs addressing urgently. 

Probation practitioners should have explored DB’s relationship with Ms Harris in greater depth, including whether he was coercively controlling her. DB was open about the fact that he had very limited income and that Ms Harris was paying for his accommodation, bills and food. Inspectors conclude that contact with Ms Harris by the Probation Service before sentencing, and at key assessment stages and when there was evidence of increasing risk, would have been appropriate.

Inspectors found that the risk of serious harm to known adults, including partners, was underestimated. There was no focus on safeguarding in this case and, as a result, DB was sentenced to an inappropriate curfew requirement that may have exacerbated the risk of harm to Ms Harris and her children. 

Fast delivery report 

The use of a short format report in this case, rather than a standard delivery report, was incorrect. Mr Bendall’s criminal history was complex and as such met the threshold for a suitable adjournment period to allow for a thorough read of his case to inform the completion of a more detailed report. This case met HMPPS’s own criteria for a standard delivery report as ‘additional assessment, professional discussion and multiple enquiries [were] required to aid risk assessment’ and ‘liaison where medical report [was] unavailable on the day’.

Senior probation officer workload 

Inspectors found that high workloads and staff shortages in the Swindon office impacted on the ability of probation practitioners to undertake high-quality work. Inspectors heard that this was a long-standing issue that they had experienced since the changes introduced with Transforming Rehabilitation. 

HM Inspectorate of Probation has often found that the span of line management control for senior probation officers (SPOs) is concerning. SPOs increasingly deal with complex staffing and human resources issues, for which some feel unequipped. This also reduces the time they have available to provide effective professional oversight of the work of the practitioners they line manage with individual cases. HM Inspectorate of Probation has previously found that SPOs do not have enough time to supervise all members of their teams to the standard they would wish, and when they do hold supervision sessions, there is often a focus on managing volumes of work rather than improving quality. This case highlighted this issue on two specific occasions. 

Firstly, there was insufficient oversight of a member of the probation court team, which led to a poor-quality fast delivery report being presented to the court. This was due to SPO sickness and a lack of resources to cover the absence. 

Secondly, SPO3, who managed the probation practitioner responsible for DB after sentencing from June 2021, was unable to engage with the case fully. SPO3 managed a large number of staff. She directly managed 16, but when covering for colleagues she had oversight of up to 30 PQiPs. This is far in excess of the line management span recommended by HMPPS, of 10 full-time equivalent posts for SPOs. This prevented her reading DB’s case at the allocation stage and from providing the necessary oversight. 

Inspectors found that the SPOs were also not given meaningful, regular and effective supervision and support. 

Professional qualification in probation and probation services officer training and oversight

The probation practitioners who managed DB from June to September 2021 were inexperienced, unqualified and had insufficient support to understand and recognise the risks and needs in the case. We conclude that they should not have been exposed to cases such as DB at this stage in their careers. Following the unification of probation services, new guidance on allocations has been published, and this is welcomed. This guidance sets out clearly that ‘some case allocation decisions will rely on the judgement of the operational manager to decide whether a case is suitable to be managed by a probation officer or a probation services officer (PSO). This decision will be based on individual circumstances of the case, and the skills, ability and experience of the individual officers.’ 

Inspectors heard concerns about the efficacy of online training, especially for key learning on domestic abuse and child safeguarding, from all grades of staff, not just professional qualification in probation (PQiP) and PSO staff. There had been an understandable reliance on this method during the period of Covid-19 restrictions; however, some staff noted that prior to the pandemic there had been a trend towards self-reliant e-learning and development. Practitioners said that such self-selective training and development suffered when staff spent their hours ‘firefighting’ with excessive caseloads. DB’s case was one of 10 being managed by a staff member who had yet to complete basic safeguarding training.

6. Recommendations 

We have directed the recommendations to HMMPS and the Ministry of Justice to ensure national learning. HMPPS should: 

Court work and curfew requirements 

1. ensure that domestic abuse enquiries are carried out on everyone sentenced so that accurate risk assessments can be made and safe proposals are made in court reports 

2. ensure that child safeguarding enquiries are made in all cases where the person being sentenced lives with, is responsible for, has access to, or is likely to have a negative impact on the wellbeing or safety of a child 

3. develop a mechanism and reliable processes with relevant agencies to allow sufficient safeguarding enquiries to be completed, to verify information and therefore reduce reliance on self-disclosure 

4. ensure that sufficient safeguarding enquiries with relevant agencies are always carried out before finding a curfew requirement suitable, and that policy/practice guidance clarifies that assessment of suitability post-sentence should be ongoing. 

5. quality-assure risk assessments and proposals to the courts for accuracy and suitability 

6. introduce a process to contact relevant adult residents of the proposed curfew address and obtain their prior consent to a curfew condition at their address to assess whether the address is suitable for an electronically monitored curfew 

7. ensure that court reports provide a sufficient analysis of the person’s circumstances, including analysis of risk of harm, to provide safe sentencing options. 

Child safeguarding 

8. include a specific section in OASys that is dedicated to assessing and planning for the safety of children, and ensure that the nature of contact and impact the person on probation has in the life of the child have been considered on both current and future children in the person’s life 

9. ensure that the impact on children’s safety and wellbeing is sufficiently considered in every case. 

Risk management plans 

10. ensure that probation practitioners contact partners, family or other key adults in the lives of the person under supervision to determine and discuss their inclusion in risk management plans. 

Training and support 

11. consider the suitability and efficacy of online training, particularly on domestic abuse, child safeguarding and other key training required to correctly assess and robustly manage risk of serious harm 

12. ensure that each PQiP has access to a mentor who has at least two years’ experience as a qualified probation practitioner. 

13. dedicate time for probation practitioners to engage in reflective discussions with colleagues and the line manager regarding cases. 

Allocation practice 

14. ensure that NDelius entries for ‘management oversight – allocation’ include evidence that the manager has considered the complexity of the case and the capabilities and capacity of the probation practitioner receiving the case. 

Oversight of SPOs 

15. review and monitor SPO workloads to ensure that sufficient line management and management oversight of case work can be provided effectively 

16. review the line management responsibilities and supervision of SPOs responsible for PQiPs to ensure the standard of PQiP management and oversight is appropriately robust, including the suitability of the cases allocated to them. 

Ministry of Justice should: 

17. amend legislation to be more prescriptive of the information that should be obtained and considered by the court, to assure themselves of the safety of other household members at a proposed curfew address before they impose an electronically monitored curfew. 

Until this can be actioned HMCTS should issue guidance to court staff requiring them to satisfy themselves that relevant checks have been undertaken by the probation courts team.