The Plymouth Safeguarding Adults Board (PSAB) has 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.
Andy Bickley, Independent Chair of the Board, said: “The board would like to express sincere condolences to the family and friends of Mr Bhandari and deepest sympathies to the surviving victims of the attack in which he lost his life. We know the incident has deeply affected many people, particularly the bereaved family.
“If there is one thing this case highlights it is the importance of agencies sharing information and working together effectively to make sure that those who most need our help get it and that risks to themselves or others are properly managed. There were clearly fundamental failings in this case.
“The organisations involved had already made a number of improvements before this review got underway and have since, for example; positive changes have been made to the police records system to indicate where an individual has a probation supervision requirement, with direct access now being made available for probation staff to view police records.
“A new licence management system for prisons to share comprehensive information with the Police National Computer (PNC) Bureau and local police is now in place, along with improved multi-agency risk assessment and management arrangements.”
A number of areas of learning were identified in the review, including:
- 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 include:
- 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 will continue to monitor progress and ensure all learning is embedded into practice.