Lack of clear information sharing protocols between probation and other agencies
Ministry of Justice received 2 coroners' reports about this hazard between 29 May 2024 and 22 Jan 2025.
They came from 1 coroner. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“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.”
Original on judiciary.uk ↗ Ministry of Justice responded, stating 3 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“The Trust recognises that, at the time of the incident the College did not have a clear written protocol in place to manage risk. As an educational establishment the College did not have plans or processes in place to communicate effectively with other teams within the Trust such as the clinical teams or externally to organisations such as the Probation Service about the risk of harm occurring to others. The College is bound by Trust policies in relation to safeguarding and the College team did”
“the Head of Public Protection at Greater Manchester Police and the Head of Public Protection at Greater Manchester Probation service commenced monthly meetings in 2023.”
Stated timescale: 2023
1 more stated action in the Promises tab.
- 8 months laterClosely relatedConfidence 0.90 · high
“Evidence from Probation and Prison staff showed a lack of understanding of how the prison system could update the probation system and where that information could be found.”
Original on judiciary.uk ↗ Repeated from the earlier report:Probationinformation
Ministry of Justice responded, stating 1 specific action.Response (PDF) ↗
“The Barricade Guidance referred to in evidence given at the Inquest hearing has now been finalised and is going through the final stages of sign off prior to issue to all approved premises staff on 1st August 2025. This guidance will form part of the Safe Working Practice document and staff will be required to acknowledge receipt and their understanding by the end of September 2025. This will be overseen by all Approved Premises Managers.”
Stated timescale: 1st August 2025 and end of September 2025
- All reports to Ministry of Justice
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2024 → 2025Nathan Shepherd8 months after Elizabeth McCann · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight failures in information sharing between probation and other agencies, leading to incomplete risk assessments. The earlier report cites missing protocols with drug/alcohol services, while the later notes staff misunderstanding of prison-to-probation updates.
Elizabeth McCann · 29 May 2024
“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.”
Original on judiciary.uk ↗ Nathan Shepherd · 22 Jan 2025
“Evidence from Probation and Prison staff showed a lack of understanding of how the prison system could update the probation system and where that information could be found.”
Original on judiciary.uk ↗
Stated action
“The Trust recognises that, at the time of the incident the College did not have a clear written protocol in place to manage risk. As an educational establishment the College did not have plans or processes in place to communicate effectively with other teams within the Trust such as the clinical teams or externally to organisations such as the Probation Service about the risk of harm occurring to others. The College is bound by Trust policies in relation to safeguarding and the College team did”
Stated action · timescale: 2023
“the Head of Public Protection at Greater Manchester Police and the Head of Public Protection at Greater Manchester Probation service commenced monthly meetings in 2023.”
Stated action · timescale: 30 June 2024
“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”
Stated action · timescale: 1st August 2025 and end of September 2025
“The Barricade Guidance referred to in evidence given at the Inquest hearing has now been finalised and is going through the final stages of sign off prior to issue to all approved premises staff on 1st August 2025. This guidance will form part of the Safe Working Practice document and staff will be required to acknowledge receipt and their understanding by the end of September 2025. This will be overseen by all Approved Premises Managers.”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Ministry of Justice at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2024 → 2025 | 0.74 | 0.14 | Closely related · 0.90 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.