Another Graphic Illustration of Failings

With quite astonishing testimony coming in on the state of probation, including cocaine use and 90% of the job being work on the laptop, one cannot escape the conclusion that fundamental restructuring cannot be far off. As the latest SFO review from the new HM Chief Inspector confirms, the present state of affairs is untenable. Here's the press release:-  

Independent serious further offence review of Joshua Jacques

Background:

On 25 April 2022 police forced entry to a property in Bermondsey, London, where the bodies of Denton Burke (aged 68), Dolet Hill (aged 64), Tanysha (Raquel) Ofori-Akuffo (aged 45), and Samantha Drummonds (aged 27) were found. All four victims had suffered stab wounds and lacerations. Joshua Jacques was charged with these murders.

In June 2022, the Lord Chancellor and Secretary of State asked the Chief Inspector of Probation to undertake an independent review into how the Probation Service managed Joshua Jacques, as he was under probation supervision when he was arrested for these offences. This review was completed in November 2022 and can now be published following the completion of criminal proceedings.

Statement:

Chief Inspector of Probation Martin Jones CBE stated:

“There were serious failings in the supervision of Joshua Jacques. Despite concerns about repeated non-compliance with his licence conditions, enforcement practice was inconsistent and opportunities to recall Jacques to custody were missed.

“Joshua Jacques was incorrectly allocated to a newly qualified probation officer who had only finished their training three months before being assigned the case. Under guidelines by HM Prison and Probation Service (HMPPS), Jacques should have been allocated to an experienced, qualified probation officer. The probation practitioners in this case lacked the required experience to respond adequately to the complexity of the case. The management oversight of the probation practitioners involved in this case was also insufficient. Probation staff reported a lack of confidence in decisions made by their line manager, contributing to a reluctance to seek out further management oversight.

“There was a lack of professional curiosity in all areas of probation practice in this case. This meant several events, such as an arrest for further offences, disclosure of declining mental health, problematic behaviour towards neighbours, a new relationship, and the unpermitted use of social media, were not responded to or explored sufficiently.

“Joshua Jacques was appropriately assessed as posing a high risk of serious harm to the public prior to his release from custody. However, his risk in other categories, including to staff or potential partners was underestimated. No risk assessment was completed for Jacques following his release which resulted in no risk management plan or sentence plan in the community being completed.

“Probation practitioners were aware of Jacques’ mental health history, including that he had been sectioned in 2018 and that he had behaved violently during a period when his mental health was not stable. Jacques had also reported that random aggression could be a symptom of declining mental health. In February 2022, Jacques disclosed to probation court staff that he was experiencing a decline in his mental health; however, no action was taken. Inspectors found during this review that probation staff felt ill equipped to understand and respond to mental health concerns, with limited training and support being available to them.

“The case records show that Jacques was routinely using cannabis whilst on probation, and his licence contained a condition to engage in a drug abuse intervention on release from prison. No such intervention was organised by the Probation Service and our inspection found no evidence of a referral to a drugs agency.

“Sadly, this case is symptomatic of the issues we have observed across the probation service in recent years. A reliance on an inexperienced cohort of probation staff, a lack of support for mental health and substance misuse issues alongside insufficient management oversight are concerns which have been highlighted repeatedly. As a result of this review, eight recommendations were made to HMPPS. They have accepted all these recommendations and responded with an action plan for implementing them.”

The following extracts are from the full report and although lengthy, give a graphic illustration of the fundamental flaws in how the probation service as simply not fit for purpose as part of HMPPS and under civil service control.  

1. Foreword 

In April 2022, Joshua Jacques was charged with the murders of a family of four: Denton Burke, Dolet Hill, Tanysha Ofori-Akuffo, and Samantha Drummonds. On 21 December 2023 he was found guilty of murder following trial. 

Joshua Jacques was under probation supervision when he was arrested for these offences, having been released from prison on licence in November 2021. Ordinarily, the Probation Service would conduct a review of the management of the case, in the form of a Serious Further Offence (SFO) review. In this case, the Secretary of State for Justice asked HM Inspectorate of Probation to complete an independent review into how the Probation Service managed Joshua Jacques. 

The impact of these shocking crimes cannot be underestimated and will have had a profound impact on their family and the wider community. We offer our sincere and heartfelt condolences and recognise that the family need information about how Joshua Jacques was supervised in the community and answers as to whether there were failings in this practice.

This report presents the findings of our independent review and sets out that the practice in this case fell below the expected standards. 

As a result of recent recruitment drives and of experienced staff leaving the Probation Service, many probation teams now have large numbers of newly qualified officers (NQO) or recently qualified officers. In the Southwark Probation Delivery Unit (PDU), this situation impacted on the level of experience in the teams available to manage high risk and complex cases, something our core inspections have also routinely found. 

We found Joshua Jacques’ case was incorrectly allocated to an NQO, and the lack of good quality management oversight of this member of staff impacted on the quality of decisions made. There was a notable absence of professional curiosity1 across all areas of probation practice from court through to sentence management, and a failure of the probation practitioners overseeing the case and their manager to meet fully their expected responsibilities. As a result, several significant events, such as an arrest for further offences, disclosure of declining mental health, problematic behaviour towards neighbours, a new relationship and use of social media when not permitted to do so, were not responded to sufficiently. 

While appropriate referrals were made to Multi Agency Public Protection Arrangements (MAPPA) and to Approved Premises (AP) by the probation practitioner, these critical elements of increased supervision did not fulfil their potential in supporting the management of risk of serious harm posed by Joshua Jacques. An initial OASys assessment was not completed upon his release, which meant that his management in the community was not supported by a robust risk management plan, nor a sentence plan to inform his supervision on licence. The pace and level of engagement of Joshua Jacques with his licence was seemingly determined by him, rather than the probation practitioners, who viewed his engagement and progress too optimistically.

There were concerns Joshua Jacques was not complying with the conditions of his licence and, though this happened repeatedly, they were each dealt with in isolation. Practitioners did not see the bigger picture and missed opportunities to respond sufficiently to his concerning behaviours, for example through a recall to prison. 

Many of the findings of this review mirror those of our thematic and regional probation inspections. This review makes eight recommendations to His Majesty’s Prison and Probation Service which we require implementation of as a matter of urgency to ensure learning is implemented quickly and nationally, not just in the PDU where this case was supervised.

Martin Jones CBE 

HM Chief Inspector of Probation

5. Summary of Key findings 

JJ’s supervision was characterised by several practice deficits and missed opportunities which impacted on how JJ was managed on licence. Nine key themes identified from the independent review are outlined below. 

Risk of serious harm assessment 

In custody, two OASys assessments were completed which concluded that JJ posed a high risk of serious harm to the public, specifically identifying the public to be drug users and peers operating in drug supply. This was an appropriate assessment, however it failed to identify all factors that were linked to the risk of serious harm such as his mental health, substance misuse and current accommodation. JJ was assessed as posing a low risk of serious harm in all other categories, which was an underestimation of the level of risk he posed. 

An initial OASys assessment was commenced upon release, however, this was never fully completed and remained an incomplete document. This was poor practice and was not in line with organisational expectations. 

The failure to complete an OASys assessment on release resulted in no assessment of risk of serious harm and no risk management plan in the community to inform how the risk posed should be safely managed while on licence. Additionally, there were no sentence plan objectives to support and inform the supervision appointments, which should have been targeted to address those factors most likely to contribute towards further offending. Further reviewing did not take place following MAPPA meetings, nor in response to changes of circumstances and significant events. Completing a review would have enabled the probation practitioner to consider the significance of new information, and review the sentence and risk management plans accordingly, to ensure the necessary arrangements were in place to protect the public. 

The pre-sentence report prepared for court, and the OASys completed following sentence to the suspended sentence order, both replicated the pre-release assessment and did not take the opportunity to consider all available information to support an updated and holistic assessment. 

MAPPA meetings considered the level of risk of serious harm posed by JJ; however, this did not negate the need for an OASys assessment to be completed. This is essential probation practice to ensure that the management of each case is supported by a robust and defensible assessment of risk of serious harm and need. In the absence of a formal assessment using the OASys tool, inspectors would have expected to see other evidence of assessment and planning within case management records. However, there were no such records to satisfy us that a clear understanding of how to manage the risks posed were in place. 

Professional curiosity and optimism bias 

PO1 and PO2 put a strong focus on addressing JJ’s needs, such as accommodation and employment. Though these were important factors and progress was made, the supervision sessions were not underpinned by a sentence plan and there was no evidence of interventions which focused on offender behaviour being delivered. Inspectors found that this strong emphasis on relationship building and addressing JJ’s needs was not balanced against the need to manage risk of serious harm. 

Probation practitioners viewed JJ’s behaviour on licence through an over optimistic lens and did not fully understand the expectations on them to be professionally curious and proactive. As a result, they did not adequately explore issues such as why he had purchased a vehicle, or his problematic behaviour in his accommodation and they failed to inform police of a second breach of the criminal behaviour order (CBO). 

These skills of professional curiosity grow and develop with practitioner confidence and experience, and with the effective support and oversight from peers and managers. There was a lack of experience within the probation practitioner staff group at Southwark PDU and lack of robust management oversight further contributed to this. Where a workforce has limited experience, they need guidance from those with a more established level of knowledge to provide support and oversight to aid their development. 

Enforcement 

Good probation practice seeks to motivate people on probation to comply and engage positively with the requirements of their sentence. While this should include a focus on desistance from further offending, it should also include appropriate enforcement action being taken when required. Instances of non-compliance should be responded to in a proportionate, fair, and transparent manner.

Enforcement practice in this case was inconsistent, with instances of non-compliance considered in isolation rather than seen in the round. Opportunities to escalate and consult with the delivery unit head (HOS1) were not sought. There was a failure to act upon a pre-release assessment that identified that swift enforcement of the CBO and licence were required to manage the risk of serious harm posed by JJ. Enforcement guidance issued in October 2021 was not followed. Our inspectors felt the decision not to recall JJ following his arrest for further offences was defensible. However, in making the decision, senior manager oversight should have been sought by SPO1 and the failure to do so was against expected practice. The enforcement practice in this case did not analyse the behaviour being displayed by JJ, nor did it explore whether additional supportive or restrictive measures short of recall were needed to manage his licence. 

Resourcing and workload 

Southwark PDU had been operating under ‘green’ status under the national prioritising probation framework but had several vacancies, particularly at probation officer and probation service officer grade. Many staff within the PDU were at early stages of their career and there were limited numbers of experienced staff available. The probation practitioners in this case lacked the required experience to respond adequately to the complexity of the case and behaviours being presented. In addition, the pace and volume of work impacted on the quality of work undertaken in this case. 

HMPPS’s Tiering framework and case allocation guidance was not followed, and JJ’s case should have been allocated to a more experienced probation practitioner. The allocated probation practitioner in this case was within their newly qualified probation officer (NQO) period and in allocating the case, the SPO should have been assured that PO1 had the required knowledge, skill, and experience to manage the case effectively. JJ’s tier increased following the initial MAPPA meeting and this should have prompted re-allocation of practitioner in line with the expected practice for NQOs. 

Management oversight 

Management oversight was of an insufficient standard. Staff reported a lack of confidence in decisions made by their line manager, contributing to a reluctance to seek out further management oversight. When sought, decisions made by the probation practitioners would generally be approved without the necessary discussion or scrutiny needed to ensure that the most appropriate course of action was being taken. Opportunities to escalate to HOS1 were also missed. 

Similar to the findings from the Inspectorate’s broader local inspection programme, the workload, and responsibilities of line managers in this Probation Delivery Unit were found to be concerning. SPOs were managing large teams and were expected to provide support and oversight of their staff and manage human resource issues, as well as provide oversight and scrutiny of each probation practitioner’s caseload. SPOs also have additional lead responsibilities, such as MAPPA, which impact on their ability to perform their role to the expected standards. 

Inspectors also found insufficient processes in place to manage staff absence. PO1 was absent from work for a period of three months. While during this time PO2 had maintained contact with JJ on their own initiative, the process for caseload reallocation during an absence was not clear, which resulted in a lack of clear ownership of this case and many of PO1’s other cases during this period. 

Multi Agency Public Protection Arrangements (MAPPA) 

JJ’s index offence (the last set of criminal actions that brought him into contact with the criminal justice system) meant that he was not automatically eligible for management under multi agency public protection arrangements (MAPPA). Therefore, it was good practice for JJ to have been referred to MAPPA as a Level 2, Category 3 case. However, there was insufficient evidence that this MAPPA referral positively impacted upon the management of the case. 

The MAPPA referral for JJ was completed late, only one month prior to release. To allow effective coordination this should have been done six months prior. In recognition of the complexity of the case and imminency of need, it was positive to see that JJ was listed promptly for discussion once he had been referred. However, the initial delay in referral resulted in little time for MAPPA to effectively contribute to the pre-release planning, with PO1 having already set licence conditions with the prison, without a contribution from the MAPPA panel. 

The minutes from each of the four the MAPPA meetings held to discuss JJ were of an insufficient standard, providing limited evidence that partner agencies were active in supporting the management of risk of serious harm he presented. 

There were missed opportunities for meaningful actions to be set in response to new information, and a lack of oversight of outstanding actions. JJ was de-registered from MAPPA oversight without an adequate rationale, whilst two actions which had already been carried forward remained outstanding. 

Approved Premises 

The Approved Premises (AP) placement was an opportunity to positively contribute to the management of JJ’s risk of serious harm. Key work sessions were held by AP staff which were appropriately focused, with structured sessions on the immediate needs of JJ; exploring issues such as registration with a GP, finance, and education, training, and employment (ETE), which supported his resettlement into the community. However, professional curiosity was not applied during AP staff interactions with JJ. There is no evidence that there was sufficient exploration of his behaviour and movements, which would have aided the probation practitioner’s understanding of how JJ was spending his time away from the AP. 

AP staff should play a significant role, both in providing relevant risk information to the probation practitioner and in contributing to effective risk management. It is essential that they understand the risk of serious harm presented, are actively involved in the delivery of the risk management plan and are part of MAPPA meetings. An AP representative was not able to engage in pre-release planning due to the delayed referral, and subsequently did not attend the MAPPA meetings held, which impacted on pre-release planning, information exchange and the effective risk management of the case.

Mental health 

JJ had been sectioned previously in 2018 and had informed probation practitioners that feelings of anxiety and paranoia were normal for him. Prior to release, JJ’s mental health was described to be stable, and probation practitioners stated that there were no obvious signs of a mental health decline upon release into the community. 

However, he was described by PO1 as presenting as ‘low’ on occasion, which was attributed to boredom and need for structure in the community. Days prior to the SFO, JJ was described as talkative and going off on irrelevant tangents in his conversations with probation staff. Furthermore, JJ informed PSR1 that when committing the further offences on licence, he had been experiencing poor mental health. This was not explored further and there was a lack of significance given to this statement, resulting in no analysis or action. 

Probation practitioners were aware of JJ’s mental health history but lacked any detailed information. They were also aware that he had behaved violently during a period when his mental health was not stable, and JJ himself had reported that random aggression could be a sign of his mental health declining. However, this was not identified as a factor linked to risk of serious harm within OASys assessments. Additionally, the correlation between his continued use of illegal substances and his mental health was not sufficiently explored or responded to. Prior to JJ’s release from custody, information on JJ’s mental health was sent by the prison mental health in-reach team to his registered GP, however they were not aware that the GP had retired. Upon registration with a new GP, this prior information on JJ’s mental ill health was not passed to them. 

There was a reliance on JJ recognising and self-reporting a decline in his mental health and on the one occasion he disclosed such concerns no action was taken. Probation practitioners stated that there was a gap in services available to support those with mental health, particularly if there were also substance misuse concerns. As emphasised by the report published in 2021, A joint thematic inspection of the criminal justice journey for individuals with mental health needs and disorders, mental health can present significant challenges for probation practitioners, and is often characterised by insufficient information exchange and the need for better training and support. Inspectors found during this review that staff felt ill equipped to understand and respond to mental health concerns, with limited training and support being available. 

Substance misuse 

JJ had used cannabis since he was a child and was described to be lacking insight into the harmful effects of his substance misuse. Probation records and a psychiatrist’s assessment indicate a link between JJ’s substance misuse use and mental health, and that JJ’s sectioning in 2018 had been preceded by the consumption of medication, alcohol, and cannabis. Additionally, much of JJ’s offending was linked to substance misuse. 

Probation case records show that JJ was routinely using cannabis while on licence. He had completed substance misuse intervention programmes in custody and his licence contained a condition to engage in a drug abuse intervention on release from prison. However, such an intervention was not organised by probation practitioners, and we could find no evidence of a referral to a drugs agency. 

Inspectors found that probation practitioners did not explore the underlying reasons for JJ’s substance misuse, and minimised and tolerated regular use while he was on licence. This was underpinned by a failure to adequately analyse the impact of substance misuse to the risk of serious harm he posed.