The Plymouth Safeguarding Adults Board (PSAB) on the 4th March 2020 published the findings of a Safeguarding Adult Review regarding Donald Pemberton, one of two men convicted of the murder of local man Tanis Bhandari in 2015.
The review was commissioned by the board in 2018 following a referral from Devon and Cornwall Police and has involved local, regional and national agencies including the Police, as well as National Probation Service (NPS); Dorset, Devon and Cornwall Community Rehabilitation Company (CRC); HM Prison and Probation Service (HMPPS); Livewell Southwest; The Zone; University Hospital Plymouth NHS Trust; Mayflower Medical Group and HMP Portland.
While several single-agency reviews had been conducted following the incident, the Safeguarding Adults Review focussed on how the various agencies in contact with Mr Pemberton and his family in the months prior to the murder worked together, including how they managed the risks he presented to himself and others.
Areas of learning that were identified in the review
- How the police are notified by the prison service when someone is released on licence
- Information sharing between the police and probation services
- Timely application by probation for an arrest warrant when risks escalate
- Using information available on the PNC to inform bail decisions
- Holistic multi agency assessment and management of risk
- Awareness of partner agency roles and responsibilities
Recommendations from the review
- That Devon and Cornwall Police ensure all relevant staff know how to access licence information from the PNC, appreciate the potential value of this information and the need to promptly notify NPS teams of relevant arrests
- That Devon and Cornwall Police ensure these issues are fully addressed in the training of new staff
- That Devon and Cornwall Police ensure arrest notifications are made when they are required and without delay
- That Devon and Cornwall Police, the NPS and CRC ensure the ‘Direct Access’ system is successfully implemented and that anticipated improvements are made in sharing information on offenders
- That the NPS and CRC ensure warrants are sought in order to expedite breach proceedings when appropriate
- That Devon and Cornwall Police ensure they consider wider public safety, including a review of the suspect’s PNC record, when making a decision to grant bail or release them under investigation
- That Devon and Cornwall Police ensure they adopt a balanced approach to complying with the ‘necessity to arrest’ principle, that a suspect’s PNC record always informs arrest decisions and that public protection considerations will always inform decisions to arrest or not
- That Livewell Southwest (Community Mental Health Teams) and the Zone ensure safety plans for patients supported in the community are reviewed when circumstances change
- That Livewell Southwest (Community Mental Health Teams) and the Zone ensure the capacity of family members to contribute to the safety plan is assessed and support provided to family members where necessary
Action has already been taken to address these recommendations and the Plymouth Safeguarding Adults Board continue to monitor progress and ensure all learning is embedded into practice.
A Board Partner has been nominated to provide oversight on progress towards achieving the recommendations and embedding into practice. Areas of progress include:
- A Prison Licence page has been added to the force intranet site, where officers and staff can access full license conditions and details for the relevant probation staff member.
- Introduced the Direct Access programme which has given access to police IT systems to probation services. These two new introductions to police processes have aided information sharing between colleagues and partner agencies.
- Custody Officers undergo comprehensive training and covers all the requirements to undertake PNC checks and to use this information when considering the release of a detainee. They are also trained extensively in the application of the law around bail and risk assessments on the release of a detainee; which includes public and victim safety. Custody officers are tested through work place assessments which are required to prove their competency. This also includes scrutiny over their considerations when releasing a detainee.
- The Direct Access system is currently working well with NPS, staff access the daily intelligence report and where there is a known service user the offender manager is contacted. The CRC are in the process of setting this up.
- CRC Quality Development Officers have now been recruited across the area from July 2020 to work with staff on developing quality and effectiveness of practice.
- The First Response Service provides a single point of contact for people experiencing a mental health crisis, as well as their families and their carers. It also provides advice and information to other agencies and organisations. It aims to meet people’s urgent mental health needs using a holistic health and social care approach, as far as possible in their communities or in people’s own homes, offering alternatives to attending hospital and a safe place for enhanced brief psychological intervention and support with mental wellbeing and problem solving.
- The First Response Service is designed in response to national policy and guidance (e.g. the NHS Long Term Plan) calling for 24/7 mental health crisis response services, and expedited most recently due to the directive for the ‘immediate establishment of 24/7 urgent NHS mental health telephone support, advice and triage as a priority’ in the context of Covid-19. Livewell Southwest’s First Response Service launched 24/7 on 1 May 2020.