James Furlong, Joseph Ritchie-Bennett and David Wails
20 May 2024 · Coroner Sir Adrian Fulford · Central Criminal Court
The coroner's concerns
1. inadequate mental healthcare provision
“material; and d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison”
2. intelligence dissemination failure
“The failure to maintain and disseminate an adequate intelligence picture”
3. information siloing with MI5
“a failure by CTPSE to share relevant information with MI5 - see”
4. process failure in risk management schemes
“The failure to handle the intelligence concerning KS appropriately had a notable impact on the Prevent, Pathfinder and MAPPA processes”
Responses
2024-0276-Response-from-Berkshire-Healthcare.pdf ↗· Berkshire Healthcare NHS Foundation Trust
2024-0276-Response-from-Midlands-Partnership-NHS.pdf ↗· Midlands Partnership University NHS Foundation Trust
2024-0276-Response-from-Ministry-of-Justice.pdf ↗· Ministry for Justice
2024-0276-Response-from-NHS-England.pdf ↗· NHS England
2024-0276-Response-from-Oxford-Health.pdf ↗· Oxford Health NHS Foundation Trust
Stated action · July 2024
“OHFT currently provide psychological services for HMP Bullingdon and HMP Huntercombe as part of the integrated mental health team. The evidence based psychological interventions are delivered based on clinical need and sentence length, in line with the NHS Stepped Care Model and National Institute of Clinical Excellence guidance. These include psychotherapy, cognitive behavioural therapy [CBT], trauma focussed-CBT, and eye movement desensitisation and re-processing.”
2024-0276-Response-from-Thames-Valley-Police.pdf ↗· Thames Valley Police
Stated action · end of the year
“CTPSE initiated this review (the CTPSE FIMU review) in response to the issues canvassed in these Inquests. It is being carried out by CTPSE's Head of Intelligence, an officer of Detective Superintendent rank.”
2024-0276-Response-from-the-Home-Office.pdf ↗· Home Office