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recurance

Terri Harris, John-Paul Bennett, Lacey Bennett and Connie Gent

7 Nov 2023 · Coroner Peter Nieto · Derby and Derbyshire

The coroner's concerns

  1. 1. inadequate offender records and documents

    “Probation Service (PS) offender records and documents”
  2. 2. insufficient or absent domestic abuse and child safeguarding checks

    “PS domestic abuse (DA) and child safeguarding (SG) checks”
  3. 3. failure to report potential risk comments by offenders

    “Reporting concerns to the PS by the Electronic Monitoring Service (EMS)”
  4. 4. non-notification of missed substance misuse appointments

    “Notification of missed substance misuse appointments to the PS”

Responses

2023-0467-Response-from-Derbyshire-Healthcare-NHS-Foundation-Trust.pdf ↗· Derbyshire Healthcare NHS Foundation Trust

Stated action

“any attendance by an individual open to probation will be via the Probation Feedback Form within 48 hours of attended appointments and 24 hours of a failed appointment; a failed appointment being when an individual does not attend the planned appointment for whatever reason. For failed appointments the Feedback Form will include the efforts made to establish contact with the individual.”

2023-0467-Response-from-HM-Prison-and-Probation-Service.pdf ↗· Derbyshire Healthcare NHS Foundation Trust

Stated action · April 2024

“We will issue new guidance for practitioners on NDelius recording of closed cases.”

Stated action · April 2024

“We will update existing guidance in relation to recording, handling sensitive information and OASys help-text to address risk information received on closed cases.”

Stated action · April 2024

“We will finalise and promote a new Senior Probation Officer (SPO) learning and development package, currently in development, to include support for SPOs on advising practitioners on handling sensitive information.”

Stated action

“We will conduct a review of Information Security Policy Framework to address closed cases.”

Stated action · Summer/Autumn 2024

“The new assessment service will continue to be designed as an open document, whilst facilitating a separate section for recording non-disclosable information. Current timelines aim for the 'Needs analysis' and 'Offence analysis' and sentence plan sections of the new service being available to pilot groups of staff by Summer/Autumn 2024.”

Stated action

“we will add to existing guidance for practitioners and court report writers on 'where to find risk related information on case records,' covering both OASys and NDELIUS.”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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