“The inquest heard evidence that the probation staff were carrying significant caseloads”

The coroner’s concerns

– 1. The inquest heard evidence that the probation staff were carrying significant caseloads. This was due to challenges in recruiting sufficient staff. The evidence was that there is still a national 3 shortage of probation officers. Steps have been taken to recruit and train further probation officers which provides some assistance but means that overall, a significant number of probation officers are young in service and experience. 2. The evidence before the inquest was that it was important that newly qualified probation staff were closely supervised and supported by their managers. Without that supervision performance issues identified by the trackers were not being tackled. Ensuring this had been and was challenging as the number of staff line managed by senior probation officers had been too high. This was being addressed but was only achievable if sufficient senior staff were retained. 3. Evidence before the inquest was that if probation referred clients under supervision to places such as the Health and Wellbeing College this would, if not implemented effectively pose a significant risk to vulnerable users of such institutions. If referrals were made without a protocol being in place that dealt with managing risk then the risk posed increased further. 4. Clear Information Sharing protocols between Probation and such groups as drug and alcohol services were limited. Without clear agreements understood by both sides there was a significant risk that crucial information that impacted risk assessments would not be shared. 5. The inquest was told that nationally a significant number of police forces were struggling to adequately staff their Sexual Offender Management Units. As a consequence, the level of supervision of sex offenders in the community was being risk managed posing a risk to communities. 6. In the case of Greater Manchester Police, the staffing issues had been known by senior managers for a number of years (many years before Covid) and a decision taken to risk mange far below the appropriate staffing numbers taken. The consequence was that the staff in the unit could not effectively manage their caseloads that were far in excess of the recommended level. The numbers in the unit were increasing but the caseloads were still high. 7. The GMP investigation into their role in relation to Elizabeth’s death was poor in quality and there was no evidence that any 4 senior officer had considered the report. The inquest was told that the quality and lack of referral upwards of a report was not unique to Elizabeth’s case. 8. There was no evidence before the inquest of any professional curiosity by senior GMP officers as to the role of GMP and if lessons could be learnt. It was unclear as to why senior officers were unsighted. 9. It was accepted that there needed to be a level of professional curiosity by staff dealing with high-risk offenders such as in this case and that training for probation officers and police staff needed to reinforce that. 10. The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place. There was also a need for effective information sharing protocols and effective well understood safeguarding provisions. 11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2024-0288

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0