Elizabeth McCann

1. 1. significant caseloads of probation officers

   “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 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. 2. lack of clear information sharing protocols

   “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.”

3. 3. insufficient staffing of Sexual Offender Management Units

   “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.”

4. 4. poor quality GMP investigation and lack of senior officer consideration

   “The GMP investigation into their role in relation to [the deceased]'s death was poor in quality and there was no evidence that any 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 [the deceased]'s case.”

5. 5. poor quality investigation and missing risk management systems

   “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.”

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