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1. Introduction

1.1 In July 2004, James Campbell, aged 19, abducted a two-year-old child from her home and sexually assaulted her with intent to rape. Following his conviction he received a sentence of life imprisonment. At the time of this offence the offender was under the supervision of North Lanarkshire Council Social Work Department on an Extended Sentence licence following his release from a three-year prison sentence in May of the same year for an offence of a similar nature against a 91-year-old woman.

1.2 Because of the deep concerns raised by this case, the Minister for Justice asked the Social Work Inspection Agency to undertake an investigation into North Lanarkshire Council's handling of the post-release arrangements and any related issues. The scope of the investigation was to examine the arrangements the Council made for the offender's release, the suitability of the accommodation provided to him after release, and also to review the level of supervision and support provided by the Social Work Department. The investigation was to highlight if there were any broader issues about the management of extended sentence prisoners.

1.3 Managing the risks posed by sexual offenders living in the community is a complex task cutting across the organisational boundaries between local authorities, police, prisons, housing and health services. There are important connections between the post-release handling of this case and the offender's history during his first prison sentence and before. We have therefore reviewed these antecedent periods as a part of this investigation.

1.4 This report outlines the sequence of key events for the offender, from his initial contacts with North Lanarkshire Social Work Department when he was a 15 year old through to the point where he committed his second attempted rape. It analyses these events and draws from them key recommendations and learning points for the future handling of such cases.

1.5 In completing this report we were mindful that those who have committed very serious sexual or violent crime will often continue to pose serious risk, even after completing a prison sentence or participating in the best available rehabilitation programmes. It is the job of prisons, social work services, police and other agencies to do everything possible to assess risk and take the best possible steps to protect the public insofar as they can do this. It is important to recognise that even the most accurate forms of risk assessment will be wrong in a percentage of cases, and even the most diligent supervision package will not guarantee that a determined offender will not offend. It is never possible to eliminate risk altogether.

1.6 Managing high-risk offenders in the community requires a major investment of time and resources and a high degree of professional skill. As the level of risk increases so too does the requirement on all agencies to invest increasing levels of resources to address and manage it. No agency has infinite resources and expertise to draw on, and all carry wider responsibilities for many other high-risk offenders living in the community. Agencies have to strike the right balance between resource pressures and the need to do the best possible professional job. These are important factors to bear in mind when considering the actions of the agencies in handling this case.

1.7 To carry out this investigation, inspectors interviewed key members of staff who were involved with the offender through his periods of contact with social work and education in the community and prison, key prison staff and managers who worked with him and managed the prison regime he was subject to, and police personnel who registered him as a sex offender. In addition, we read social work case files from the community and prison and from the school he attended. We also reviewed relevant protocols and procedures underpinning sex offender management in North Lanarkshire.

1.8 The SWIA team comprised Jo Knox, Depute Chief Social Work Inspector and Gerard Hart, Social Work Inspector. Dr Caroline Logan, Chartered Clinical and Chartered Forensic Psychologist provided expert advice on certain aspects.

2 Summary of Key Events

2.1 In carrying out this investigation, we reviewed all available evidence to produce a detailed account of the facts of the case. All of the agencies involved have agreed the accuracy of this factual account. What follows is a summarised version of the key facts from the full account.

2.2 Between November 2000 and April 2001, when he was 15 years old, the offender had a brief period of voluntary contact with North Lanarkshire social work services.

2.3 The offender did not come to the attention of the social work department again until after he had committed an assault with intent to rape and housebreaking against a 91-year-old woman on 1st November 2002. Following his conviction for that offence on 24th February 2003, the court requested assessment reports from a chartered clinical and chartered forensic psychologist and from social work in North Lanarkshire. After considering these reports the court sentenced him to three years' imprisonment with a two-year extended sentence on 19th March 2003.

The custodial sentence: 19th March 2003 until 4th May 2004

2.4 The prison where the offender served his sentence runs a group sex offender treatment programme ( SOTP), but he arrived after a group had commenced, and was not in custody long enough to participate in the next one. As a result, he did not receive any sex offender groupwork while in prison. Nor did he receive any individual treatment to address his sexual offending.

2.5 On 25th March 2003, the prison social work unit wrote to North Lanarkshire Council requesting a supervising officer for the offender. North Lanarkshire did not respond to this request. A prison social worker interviewed him in April and May 2003, and noted in the prison case file that the offender was high-risk, but was willing to examine his offending behaviour. This social worker left the prison during the summer of 2003. In October of that year the prison social work unit responded to a request made by members of his family and allocated another prison social worker to work with the offender.

2.6 In December 2003, North Lanarkshire Council and the prison social work unit completed separate assessment reports to help the Parole Board to decide on the conditions that should apply to the offender's release licence. The prison social worker and the community-based social worker met on 26th November 2003 as part of the process of completing their reports. On 4th December 2003 the prison social work unit wrote to North Lanarkshire a second time asking them to identify a supervising officer. On 15th December 2003 police and social work officials in North Lanarkshire discussed the offender's pending release at the regular monthly 'multi-agency monitoring meeting' ¹ at which they share information about sex offenders in North Lanarkshire.

2.7 In January 2004, members of the offender's family expressed their concern to both the prison and North Lanarkshire social work services that he should not return to live in his previous home area due to the possibility of community reprisals. On 12th January 2004 the prison social worker completed a risk assessment that concluded that the offender posed a high risk of reconviction and a high risk of harm to the public. The assessment stated that he posed a risk to 'women of all ages' and that although he had not targeted a child 'the possible risk to children should be taken into account'. On 29th January 2004, a North Lanarkshire social work manager entered a supervision note in the case file that the offender was a high-risk offender who required a full case conference chaired by the police closer to his date of liberation. The case note also stated that he could not return to live in his previous home area.

2.8 On 2nd February 2004 there was another 'multi-agency monitoring meeting'. This again discussed the offender's imminent release.

2.9 On 2nd March 2004, the Parole Board set the following conditions for the offender's extended sentence licence: that he must reside only in accommodation approved by his supervising officer; undertake an addiction assessment and any subsequent counselling his social worker directed him to attend; undertake offence-focused work to address his sexual offending; and not accept work of any kind without informing his social worker. He was also required to stay out of trouble and do his best to find suitable work. On 22nd March, the North Lanarkshire social worker who was then dealing with the case confirmed to the housing department and other social work colleagues that the offender's release date was to be 4th May 2004.

2.10 A pre-release meeting took place in the prison, attended by the offender's supervising social worker, a housing representative and a social worker from the authority's high-risk offender team. The prison senior social worker also attended. The social worker who had until then managed the pre-release arrangements from North Lanarkshire did not attend the meeting having handed the case over to the supervising officer in the days before 8th April. The meeting focused on accommodation issues and plans for offering sex offender groupwork.

2.11 Between 14th April and 4th May 2004, North Lanarkshire's housing department and social work service unsuccessfully attempted to secure suitable accommodation for the offender. The process started with the housing department sending their social work colleagues a list of 51 available properties. Social work staff checked those properties that were potentially suitable on their computerised social work information system.
This showed the proximity of the property to known vulnerable people. They also checked whether a property was close to homes for the elderly or primary schools.
On 29th April 2004 social work specified one suitable property but it transpired that the housing department had by then allocated this flat to another tenant.

The period in the community on supervision

2.12 On his release from prison on 4th May 2004, the offender registered immediately with the police as a sex offender. He moved into the only available accommodation _ a homeless persons' unit. This unit had a number of self-contained flats, a 24-hour concierge service and CCTV coverage. At the monthly multi-agency monitoring meeting on 10th May 2004, the police stated that they were unhappy with the offender's placement in this unit as its occupancy changed regularly and it was possible that vulnerable people could be living there. Social work and housing officers were still attempting to secure more permanent accommodation.

2.13 Between 4th May and 8th July 2004 weekly ² contact took place between the offender and his supervising officer. Although this initially focused on practical and welfare issues, towards the end of May the supervising officer commenced a series of written exercises to prepare him for the sex offender group programme. During June 2004, the supervising officer visited the offender in the homeless unit on five occasions. The supervising officer completed two different risk assessment exercises and continued to deliver the groupwork preparation exercises along with discussions about ongoing accommodation and college issues. During this time the offender also had contact with the housing support worker and saw his family on a regular basis. The staff at the homeless unit had no concerns about his behaviour in the hostel.

2.14 On 17th May 2004 the police completed their assessment about how likely the offender was to re-offend. They decided that he posed a 'medium' risk of reconviction. This assessment required three-monthly review and contact with the offender once in six months. The police did not see the offender again after he registered on 4th May.

2.15 North Lanarkshire housing service and the social work department continued to seek suitable permanent accommodation for the offender while he was living in the homeless unit. In mid-May 2004, he indicated that he had changed his mind about where he wanted to live, and this delayed the process of finding suitable accommodation. By 30th June 2004, the social work department had identified suitable properties in an area where the offender then preferred to live. He offended again before any of these properties became available for letting.

2.16 On 8th July 2004, the supervising officer interviewed the offender for the last time before his offence. At this interview there was further discussion about the lack of confirmed accommodation and he reported that his college bursary was in place. He said he had forgotten to do the work on the preparation exercise for the groupwork programme. The supervisor explained that he would be on annual leave for one week from 12th July and the offender was to continue to work on this exercise during his absence.

2.17 On 10th July 2004, the offender committed an offence of abduction and attempted rape of a 2-year-old child.

3 Analysis

Introduction

3.1 The Sex Offenders Act 1997 sets out the requirements for those convicted of certain sex offences to register their name and address and to keep the police notified of any changes for a set period of years. In the same year SWSI published 'A Commitment to Protect', setting out the essential ingredients for the co-ordinated management of sex offenders in the community, followed in 2000 by 'Managing the Risk: an inspection of the management of sex offender cases in the community'. Also in 2000 the Scottish Executive published guidance for agencies on their roles and responsibilities in implementing the Sex Offenders Act. ³ The important theme in all of these documents is the need for coherent interagency co-operation to channel information properly and to provide a framework for agencies to work together to help protect communities from the risks posed by sex offenders.

3.2 The handling of the offender's case by the various agencies raises a number of important issues about the management of high-risk offenders. This chapter analyses the key aspects of this. This analysis includes the extent of the adherence to national and local procedures, and how the services undertook risk assessment and management tasks. There are key points about how agencies interact and communicate and about how well the respective roles of police, social work and accommodation services contributed to the shared challenge of providing coherent and effective risk management and supervision.

Early Involvement with Social Work Services

3.3 In late 2000, and early 2001, the offender had a brief period of contact with the social work department to deal with behavioural issues. There is no evidence that at that time he showed any signs of sexual aggression or violence against vulnerable people.

Managing the Extended Sentence

3.4 National guidelines for extended sentence prisoners require the allocation of a social worker from the start of the sentence. This is to ensure that the prisoner maintains an active link to his home area and that the community-based social worker knows the offender and has sound up-to-date information upon which to plan for release. The prison social work unit wrote to North Lanarkshire shortly after the offender arrived at the prison on 19th March 2003, prompting them to allocate a supervising officer for him. However, North Lanarkshire did not respond to this request and did not allocate a social worker. There appears to have been an oversight in the management systems within the social work area team as the senior social worker to whom the letter was passed told us that he did not receive it. Taken together, these delays and oversights meant that purposeful work did not commence with a young man who had recently committed a very serious sexual offence.

3.5 There were also gaps in the prison social work unit's handling of the offender's extended sentence. National procedures indicate that they must interview an extended sentence prisoner within two days of notification of the prisoner's status ⁴ but this did not happen for almost a month after his arrival in the prison where he was to serve his sentence. Evidence suggests that the prison social work unit's administrative arrangements were efficient given that they wrote to North Lanarkshire Council requesting a supervising officer on 25th March 2003 _ six days after the offender arrived at the prison.

3.6 Procedures for Extended Sentence prisoners set out that the prison social work unit should offer contact and assistance to the prisoner during the sentence ⁵ in order to build a working relationship with them and to support the efforts of the community-based supervising officer. The allocated prison social worker interviewed the offender once, and did not see him again before leaving his post in summer 2003. He noted in the case file that the offender was willing to work on his offending but there was to be a gap of six months before the prison social work service reallocated the case.

3.7 During the majority of the offender's sentence there was a considerable degree of staff turnover and sickness in the prison social work unit. A temporary senior social worker was in post for much of 2003, a period where there was also a sharp upturn in prisoner numbers. This placed additional pressures on the prison social work unit. The intermittent nature of the contact by the prison social work service meant that no-one got to know the offender over a sustained period during his sentence. If they had done so, they might have more quickly followed up the lack of an allocated supervising officer, and built a fuller working alliance with community-based colleagues.

Family Contact

3.8 Families have an important contribution to make in helping offenders to avoid reoffending. ⁶ Part of the role of the community-based supervising officer in extended sentence cases is to contact the offender's family (where possible) to begin the process of preparing them to contribute during the sentence and to prepare for the eventual release. ⁷ Members of the offender's family clearly showed that they wished to be involved during the prison sentence and afterward. They approached a prison social worker in October 2003 and asked her to identify a prison social worker for the offender. In January 2004, family members visited the author of the home background report in the social work office to communicate their concerns about the available accommodation options. After release, the family saw the offender very frequently, but the evidence does not indicate that there was any working alliance between family members and the social work department. North Lanarkshire's failure to allocate a community-based supervising officer from the outset of the custodial sentence, or to correct this later, meant that there was no connection between the key partners, prison, community and family, to work together in supporting the offender's release.

Pre-Release Preparations

3.9 The author of the home background report was the allocated officer for the case although did not appear to see himself as the offender's supervising officer. He visited him in prison, met with the prison social worker, and wrote the home background report. He went on to make the arrangements for the pre-release meeting in conjunction with the prison-based social worker.

3.10 This worker had one contact with the offender's family in early January 2004 (at their instigation). There is no doubt that of all of the North Lanarkshire staff, this worker knew the most about him. Yet days before the pre-release meeting was due to take place on 8th April 2004, this worker agreed with the senior social worker for the new throughcare team that someone else would take immediate responsibility for the case, and promptly withdrew from attending the meeting. This meant that nobody with a specific knowledge of the offender attended the meeting. In every sense, this situation is precisely opposite to the policy intention which is that prisoners subject to extended sentences should receive a continuity of social work involvement throughout their custodial term and beyond, with close liaison and information sharing with the Scottish Prison Service.

3.11 The author of the home background report worked in the area social work team holding responsibility for the offender's case, and there was temporarily no criminal justice senior social worker for that team. Another senior social worker from a different social work discipline was 'covering' the absence. As with the prison social work unit, staff sickness issues and a lack of focused attention to the case possibly contributed to the ad hoc character of the transfer of the offender's case between workers.

3.12 In the period before the release of the offender from prison, North Lanarkshire Council was setting up its new 'Justice Throughcare' social work team as part of the Scottish Executive initiative to enhance throughcare services for those prisoners subject to mandatory supervision after release. Their plan was that the team would maintain contact with these prisoners during their sentence and also supervise them for three months after release. After that, the responsibility to supervise the prisoner for the remainder of the licence would lie with the local area social work team covering their permanent home area. The senior social worker for the throughcare team took up post in December 2003, and two social workers joined by February 2004. In March 2004, there was one remaining vacancy in the team _ the authority later recruited the social worker that would become the offender's supervising officer to this post. The establishment of the justice throughcare team and the pressures this created appears to have caused a hiatus during the period of transition, and that allowed the transfer of this case between workers to occur in an unplanned manner.

Accommodation Issues

3.13 Although the police voiced a number of very reasonable concerns about the decision to place the offender in a homeless person's unit, and social work also were keen that he should quickly move on to other accommodation, it is evident that his placement there was an emergency decision made on the day of his release because there was no alternative accommodation available. In certain cases, emergency housing placements are unavoidable, but in this case there does seem to have been an opportunity for a more planned outcome. The author of the home background report advised the housing department about the offender's situation in January 2004, yet joint work did not commence to identify suitable accommodation until after the pre-release meeting on 8th April 2004.

3.14 Between 8th April and 4th May 2004, the housing department and the community-based supervising officer attempted to secure suitable accommodation for the offender. This was a laborious and complicated process because the social work department had to sift each possible option for suitability before notifying housing of the short list of suitable properties. The onerous nature of this process, carried out by a middle manager with other duties, delayed the process considerably and their tardiness in finalising the choice, which required prompting from the supported accommodation manager, meant that the housing department had by then allocated the property to another tenant.

3.15 It appeared that social work and housing staff held different understandings about their powers and obligations when housing sex offenders. Social work operated on the understanding that the housing service could not allocate and hold property in advance of an individual's release from prison. Senior social work managers said that they have developed new procedures since the offender's release from prison to ensure that housing will now remove from the available stock any address agreed as suitable for a sex offender prior to the release of that offender from prison. However, housing have said that they have always been able to do this and that the problem in the the offender case was length of time it took social work to narrow three potentially suitable properties down to one definitely suitable one. The procedures between housing and social work for refining the potential lists of available properties are complex and cumbersome, and require everyone to be able to work with a degree of urgency that is difficult to achieve amidst the pressure of other clients with similar demands. The housing service told us that at the time they were trying to house the offender there were 11 other offenders in the high-risk category also requiring accommodation.

Case Recording and Procedures

3.16 Given the assessed risk posed by the offender we considered that the supervising officer should have kept much better records of the case. The notes often consist of only a few lines, and it is impossible to get an impression of the quality or content of the interactions with the offender. In a case of this seriousness, it is important to keep a full and clear record of all information on the offender and any interaction with third party agencies or individuals relevant to the case. The North Lanarkshire sex offenders' protocol document sets out that a senior social worker will sign case records on sex offenders at two-weekly intervals. There is no evidence in the case file that the senior social worker in the Justice Throughcare team did this.

Risk Assessment

3.17 A key issue at the heart of the management of this case is the degree of risk that individuals and agencies thought the offender posed on his release from prison and how this, in turn, informed their actions in managing the risk in the community. To assess risk fully it is necessary to consider two dimensions _ the probability of a person offending again and, if they do, the likely degree of harm that they may cause. The assessment also needs to consider what the specific risk is and to whom and the circumstances that might precipitate a further offence.

3.18 Prior to sentencing the offender in March 2003, the High Court obtained social work and psychology reports. The social worker's report set out a range of key factors and concerns in relation to the offence although it did not come to a conclusion about the level of future risk. The psychologist's report concluded that the offender posed a moderate risk of repeat conviction and that he would be a suitable candidate for a
sex-offender treatment programme.

3.19 During the custodial sentence the prison social worker undertook a careful assessment using a structured clinical framework, based on a series of five interviews with the offender. This assessed him as a high risk of re-offending with a high risk of causing harm and identified women of any age as potential victims and also highlighted the importance of not overlooking the potential risk to children. A key aspect of purposeful high-risk offender management is the effective sharing of information within and across agency boundaries. It is of concern that those responsible for supervising the offender on release did not see this well set out assessment, although the evidence indicated that North Lanarkshire Social Work Department did receive it on or before 7th May 2004. However, although this assessment would have added to the information about the offender and potentially highlighted broader concerns about the potential range of victims, it is clear that from the outset social workers and managers involved with this case considered him as a high-risk offender. The central issue is what the individuals and agencies involved interpreted 'high-risk' to mean, and how this informed the action that they then took to manage the risk.

3.20 The guidance on the Sex Offender Act places considerable responsibility on the police to assess the risk posed to children or vulnerable adults. The guidance notes that where the police consider that the offender is likely to pose a medium to high risk, they should carry out a full assessment and collaborate with social work services, housing and other agencies (where relevant) to consider how best to manage the risk. Following his release from prison and registration as a sex offender, the police undertook a structured risk assessment using records they held, but without consultation with social work colleagues. They had a discussion with the offender and a member of his family. Together with their own records and intelligence, these discussions were the basis for their risk assessment, which was that he presented a medium risk of re-offending which required three-monthly follow-up assessment and at least one contact every six months.

3.21 Risk assessment using actuarial methods calculates the likelihood of re-offending by comparing key factors about the offender with the statistical frequency of re-offending in a sample of offenders with the same characteristics. Another form of risk assessment uses structured clinical judgement informed by up-to-date research on the strongest factors for predicting risk. Experts often disagree on what is the best method, although many support a combination of actuarial assessment with structured clinical judgement. It is most helpful to use structured tools designed to assist with risk assessment, but not every such tool has had the rigorous testing needed to validate its predictive accuracy. Even when tools have had such validation they are subject to in-built levels of error and are certainly not fail-safe.

3.22 Those involved in making assessments of the risk posed by the offender used a variety of tools to assist them. The psychologist who prepared the risk assessment before his sentencing on 19th March 2003 used well-known, internationally-validated tools developed for use with adult offenders. It is of some concern that the offender was only 17 at the time of the assessment. The prison-based social worker undertook a creditable assessment based on a structured clinical approach. ⁸ She was untrained in using this approach but drew on her considerable experience as a social worker. The police used a non-validated tool, used by all Scottish forces, which required considerable clinical judgement to complete. They had, however, received training to use the tool according to police policy. There is no suggestion that they used the tool incorrectly with respect to the training that they received.

3.23 The supervising officer also completed two risk-assessment exercises in the course of his contact with the offender, one non-validated tool which indicated moderate risk and the other a validated tool which indicated high risk. Although he was also an experienced social worker, he had not had training in the use of either of the risk assessment instruments he used.

Perception of Factors Lowering Risk

3.24 Risk is not static _ it varies over time and as circumstances change in the offender's life and environment. Risk assessment has to be a dynamic and ongoing process that monitors these changes and their impact, so as not to miss the critical point at which a situation moves from one of routine to one of concern. Agencies appear to have held a perception that certain aspects of the case reduced the level of risk. The supervising officer said that he set weekly contact with the offender, as opposed to more frequently, because the homeless unit had security cameras and 24-hour concierge staff. The offender also had a housing support officer visiting him regularly to help him to settle into the homeless unit. Because these protective factors provided a check on his behaviour they encouraged a reduced frequency of contact. Separately, the police told us that they saw the offender's positive family relationships as a significant factor to alleviate his risk of reoffending. They based this on the initial meeting with a family member when the offender attended to register as a sex offender.

3.25 There are a number of observations to make about how the supervising officer and the police weighed factors that they thought lowered the level of risk. The homeless unit where the offender lived after release has 'around-the-clock' staffing and closed circuit television cameras. However, it is not a dedicated unit for housing high-risk offenders, and the members of staff there were unaware that he was a sex offender. There would be no expectation that they would scrutinise his behaviour at the level of intensity that would be appropriate for a high-risk offender. This lack of knowledge also applied to the tenancy support officer assigned by housing to work with him. It is therefore questionable whether the supervising officer should have relied on these factors to the extent that he did. For example, the offender admitted to his supervising officer in June that he had met someone in the pub who had offered him work laying slabs. The supervising officer told us that he was not concerned about the offender being in the pub because had he been intoxicated the homeless unit staff would have picked this up.

3.26 It is noteworthy that the offender had an unfulfilled condition on his release licence to undertake an addiction assessment. Intoxication was a major factor in his first serious offence, but because he had completed a 21-hour drug awareness course in prison the supervising officer elected not to pursue the assessment requirement at that time. Information that he had been drinking was therefore potentially highly significant in terms of risk amplification, but this warning information had less influence than the perceived protection offered by Campbell living in a staffed and monitored unit.

3.27 The decision of the police to regard positive family supports as a protective factor in dealing with sex offenders is reasonable as there is research evidence to suggest that the lack of positive family relationships increases the risk of sexual violence. ⁹ There is no evidence in the file that the offender's family were ever anything other than a positive influence on him. However, none of the agencies had established a working relationship with the family and therefore had no way of knowing what he was doing when he was with his family, who he was in contact with, or even if he was telling the truth about his whereabouts when he said he was with his family. The approach of family members to the prison social work unit in 2003, and to the author of the home background report in January 2004, suggests that they may indeed have proved to be willing partners in working with the authorities had they been given the opportunity. In our view, the lack of contact the agencies had with his family, and their failure to engage them as partners in the process of managing risk, meant that vesting confidence in them as protective agents was over-optimistic.

Sex Offender Treatment

3.28 An important element in reducing the risk posed by sex offenders is to undertake interventions designed to reduce the offender's denial of the offence; to assist them in understanding how their thinking patterns draw them into a cycle of offending; to help them understand the impact of their offending on victims; and to help them to develop ways of controlling their thinking and behaviour to avoid future offending. Groupwork is the most common method used in Scottish prisons to address sexual offending.

3.29 The offender was serving a relatively short time as a convicted prisoner because he spent some months on remand before sentencing. When he arrived at the prison where he would serve his sentence he had just missed the start of a sex offender group and did not have enough time left in prison to complete the next one. A senior member of prison service staff at the institution told us that having sufficient numbers of sex offenders at any one time to run a group can be difficult in that establishment. The infrequent running of the group militates against sex offenders subject to shorter-term sentences getting access to the Sex Offender Treatment Programme ( SOTP) run by SPS. The offender left prison without having received any focused input to address his sex offending or for those in authority to learn more about it.

3.30 The North Lanarkshire plan was that, on his release from prison, the offender would participate in their recently established sex offender programme. This is a programme designed for adults over the age of 21 years. Managers in North Lanarkshire's social work department decided to include him in the programme despite his age because of the lack of other options and a view that he showed sufficient maturity. This would have been subject to fuller assessment as part of the initial stages of the programme. The high-risk offender social worker said that they were able to include someone of the offender's age on the programme as, at the time, it had appeared unlikely that it would run to an accredited standard. When the programme did start, it did in fact satisfy accreditation requirements and this would probably have precluded the offender from participating because of his age. However, he re-offended before the programme commenced.

Multi-Agency Risk Management

3.31 Strathclyde Police and North Lanarkshire Council have a joint protocol that sets out agency responsibilities when managing a registered or suspected sex offender. They reviewed and updated this protocol in September 2003. It emphasises the importance to effective risk management of clear communication and inter-agency collaboration. It sets out how a referral about a sex offender should progress between the agencies and sets out four levels of meeting. The first of these is the 'information gathering meeting' which any of the agencies may convene for the purpose of sharing information about an individual offender, and to decide whether there should be a more formal 'risk assessment meeting'. The 'risk assessment meeting' is the second tier, arranged, chaired and minuted by the police. It should result in an agreed multi-agency action plan for the management of the offender. At the third level is the 'multi-agency monitoring meeting' which meets monthly to consider the whole range of sex offenders of concern to both the police and social work across the authority area. Finally, there is a quarterly Implementation Group with a responsibility to monitor and ensure the implementation of the protocol. The multi-agency principles contained in the protocol are fully in line with current thinking on effective risk management of sex offenders.

3.32 North Lanarkshire social work staff concerned with the offender undoubtedly saw him as a high-risk offender both before and after his release. A file note made by the senior social worker for the area team holding his case on 29th January 2004 stated that all agencies considered him to be a high-risk offender requiring an intensive supervision package with twice-weekly visits. It noted further that the police would need to convene a full 'case conference' before the release date, and that housing services would need to be involved to identify suitable housing away from the area where Campbell had previously lived. However, this manager was temporarily absent and took no part when the case transferred from the author of the home background report to the supervising officer.

3.33 The note of 29th January contained a blueprint for a very comprehensive strategy to handle risk and envisaged much interagency co-operation to achieve it. The actual practice of agencies fell substantially short of this vision. The involvement of housing services in looking for accommodation did not commence until after the pre-release meeting in April, the police did not convene any case conference or risk-assessment meeting, and the level of contact between the offender and the supervising officer was not twice per week. The perception of risk held by the agencies does not seem to have translated into effective and co-ordinated action to address the risk.

3.34 The social work criminal justice service and the police did not follow their own agreed procedures for the management of sex offenders in the community. There were monthly information sharing meetings that discussed the offender, along with other sex offenders, before and after his release, but there should also have been a 'Risk Assessment Meeting' convened and chaired by the police to specifically discuss him ¹⁰ and establish a joint action plan for his management in the community. No such Risk Assessment Meeting took pace, and as a result there was no co-ordinated action plan.

3.35 The police officers who dealt with the registration and risk assessment of the offender were unsure about what a 'Risk Assessment Meeting' was and when it should have happened. Both the supervising social worker and the police officers confirmed that they did not communicate with each other at any stage following the offender's registration as a sex offender on the day of his release from prison.

3.36 It seemed clear to us that North Lanarkshire and Strathclyde Police did not adhere to the terms of their sex offenders' protocol when managing the offender in the community. The protocol aims to promote the 'active management' of offenders but what actually took place does not reflect this. Targets for individual agencies set out in the protocol, for example that the pre-release meeting would take place three months before release, ¹¹ went unmet while targets for multi-agency collaboration, like having a risk-assessment meeting, also failed to occur. These weaknesses in delivering the terms of the protocol translate in practice to a systemic breakdown between police, social work, and prison. The protocol document is lengthy and complex, and perhaps this was a factor in preventing those who ought to have been familiar with it from actually becoming so.

4 Conclusions and Recommendations

4.1 Managing high-risk offenders is a complex task _ no two offenders are exactly similar, and each presents a range of risks and needs that require a tailored response. Each agency has a role that ideally complements those of its partners, and the challenge is to strike the right balance to deliver supervision that reduces risk and meets need. Where a high-risk offender commits a further serious offence, despite the efforts of those who are supervising him, it is right to examine and reflect on the specific circumstances of the case and identify appropriate lessons to assist others in the handling of such cases in the future. There is much to learn from this case, and this chapter sets out the key learning points for all agencies. Our analysis of this case highlights the complexity of the interplay between the key agencies and underlines that each has an essential role. In our opinion, the weaknesses in managing this case occurred across all of the agencies and at all stages through the prison sentence and back to the community. They were wholly systemic in nature.

4.2 It is important to recognise that the offender misled many individuals when he was living in the homeless unit. He gave every impression that he was progressing well and living a crime-free life. Even if the agencies had managed this case to an optimal standard it is still entirely possible that the offence would have taken place as risk can never be eliminated altogether. Because risk is inherently unpredictable it is incumbent upon organisations to do what they can to mitigate it. The weaknesses we have identified in this report mean that the agencies involved fell short of doing everything possible to reduce risk. Acting to remedy the areas of weakness is a challenge for the agencies who were directly involved in managing this case, but the lessons learned are equally relevant to all agencies across Scotland working with high-risk sex offenders.

4.3 The SWIA ongoing performance inspection programme of criminal justice social work services has already examined the procedures for high-risk offender management in 11 of Scotland's 32 local authorities, ¹² and has found considerable variation in practices between authorities. This is an area of work which requires clarity of definition and purpose and consistency in practice. We feel that to a large extent all agencies involved in this very challenging work should carefully consider the learning from this case. We have therefore, for the most part, set out our recommendations in broad terms as we feel that they have general applicability and may help agencies to reflect on current practice and build consistency. This is in line with ministerial intentions that this report should highlight if this case identifies any broader lessons about the management of extended sentence prisoners.

Adherence to Extended Sentence Procedures

4.4 The Scottish Executive has issued guidance to local authorities on extended sentences. This spells out that extended sentence prisoners must receive an enhanced level of supervision to reflect their risk. In this case, North Lanarkshire Council and the prison social work unit did not fulfil all the requirements set out in the extended sentence guidance. Whilst the sum total of activity in the case was not significantly below the minimum standards of service for contact, we do not feel that it satisfied the spirit of extended sentence provisions which is to enhance the quality of practice with offenders on extended sentences because of the typically serious nature of their offending. We accept that because extended sentences are relatively rare it may be the case that their implications are less well known. However, recent policy and guidance to enhance the throughcare arrangements makes it clear that agencies should manage all statutory licences in the same way as an extended sentence, recognising the importance of early contact with prisoners and their families to ensure meaningful and appropriate arrangements are in place at the appropriate time.

4.5 The offender was 19 years old when he came out of prison having spent 18 months in custody. He was living alone for the first time in his life, had no job, and could not re-establish links with his earlier peer group and neighbourhood because of the nature of his offence. The review of this case highlights the missed opportunity to engage with his family as part of the network of support that could have worked collaboratively together both to monitor his activity and provide assistance for his safe resettlement. It is in order to achieve this that the extended sentence guidance stresses the importance of family contact by the supervising social worker. Instead, the authorities provided limited oversight but otherwise left the offender mainly to his own devices.

Staff Sickness and Business Continuity

4.6 A recurrent issue is the impact that staff turnover and sickness had on the ability of the agencies to deliver an effective service. During 2003, there were significant staffing difficulties in the prison social work unit as a result of staff shortages and sickness coupled with a sharp rise in the prison population at the establishment. This period coincided with the late allocation of a prison social worker to conduct an initial assessment of the offender and the failure to reallocate the case to another worker after the first one left in May 2003. Staffing issues in the prison social work team during 2004 meant that it was a manager with limited knowledge of the case who represented the prison-based social work unit at the pre-release meeting.

4.7 In North Lanarkshire, the senior social worker responsible for the area criminal justice social work team holding responsibility for the offender's case during the pre-release period was intermittently absent during 2003 and 2004, and this absence may have been a factor in the ad hoc manner of the case transfer from the author of the home background report to the eventual supervising officer. It was this senior who wrote a comprehensive risk management action plan in a case note on 29th January 2004 flagging up the need for a risk assessment meeting with the police. Unexpected staff absence is an unfortunate reality in day-to-day practice, but it is essential to maintain continuity of service delivery, especially for offenders such as this who commit very serious offences and have the potential to cause a high level of harm.

4.8 We accept that the high level of sickness both in the prison social work unit and within North Lanarkshire Social Work Department, together with the changes in the arrangements for delivering throughcare services in North Lanarkshire had a significant impact on the handling of this case. Resource constraints will always provide tensions about service provision and provide a considerable challenge for managers. However, it is our view that cases assessed as high risk must have the highest priority and other services managed accordingly.

Accommodation Issues

4.9 The process of finding stable accommodation for the offender on his release from prison was laborious. The housing team that endeavoured to find appropriate accommodation had a range of other work to progress as well as 11 other high-risk offenders to accommodate. Social work also had a vital and time-consuming role in the process. It appeared to us that at an operational level, social work and housing staff were confused about the procedures in place for allocating accommodation to prisoners not yet released from custody.

4.10 This case demonstrates that finding accommodation for high-risk offenders is a complex task requiring careful planning between agencies. The working arrangement between the social work team and the housing service meant that they passed information backwards and forwards rather than sitting down together to find a suitable property for the offender. Had they done this it may have added value to the work to locate and set aside a suitable property.

4.11 Finding the right accommodation for sex offenders is a vital component of effective risk management. It contributes both to the effective protection of the public and to the personal safety of the offender. It is important to recognise that, for the most part, knowing where a sex offender is and being able to monitor and manage them effectively is one of the strongest safeguards for the public. Where an offender is under the threat of community reprisals, they may flee the area and the authorities may lose track of their whereabouts. This is a very dangerous situation. In dense urban areas it is very difficult to find housing for offenders that is remote from vulnerable people and which also provides the degree of public anonymity necessary for safe risk management in the community. 'Reducing the Risk: Improving the response to sex offending; The Report by the Expert Panel on Sex Offending' ¹³ did not consider hostel accommodation to be an appropriate way of dealing with the accommodation needs of most sex offenders. It expressed the concern that placing numbers of sex offenders together in one location presented serious dangers.

4.12 The Expert Panel report noted the importance of appropriate housing of sex offenders in order to best manage the risks they pose. The report makes the following recommendations:

• That the Scottish Executive, Scottish Homes (New Communities Scotland) and local authorities and the Scottish Federation of Housing Associations should develop a national accommodation strategy to assist the management of offenders in the community based on Chartered Institute of Housing (Scotland) guidance.
• The Homelessness task force to ensure that new guidance relating to the Housing Bill and the provision of guidance on homelessness take account of the need to house sex offenders and the challenges this presents.

4.13 We are aware that all those with responsibility in these areas have given much consideration to these issues in the intervening time since the publication of 'The Report of the Expert Panel on Sex Offending'. In many areas, housing services work very closely with their social work colleagues to manage the dilemmas and difficulties posed by cases such as this. Nevertheless, the absence of national guidance means that agencies struggle to find their own solutions. There are no simple solutions to this problem and local areas will always need to find solutions that best meet their local conditions. However, it seems to us that given the considerable difficulties in providing appropriate housing for sex offenders that advice and support in the form of a national strategy would be a significant and helpful step forward.

Communication and Information Sharing

4.14 Previous investigations into high-profile cases where things have gone wrong have documented poor communication as a factor. Communication between individuals and across agencies is also a recurrent theme in the handling of this case. We have already highlighted our concern that the staff directly involved in the offender's supervision did not see the risk assessment undertaken by the prison based social worker and forwarded to North Lanarkshire Council. We have not found the reason for this and recommend that managers in North Lanarkshire follow up this matter.

4.15 In addition to this matter there were a range of other oversights which evidenced poor communication in this case. The unanswered requests from the prison for a supervising officer; the failure in the operational communication between police and social work front-line staff, and the poor case records in North Lanarkshire's social work file that do not effectively communicate the handling or content of practice are all examples of poor communication.

Use of Risk Assessment Tools

4.16 Accurate risk assessment is a vital component of offender management. The psychologist used assessment tools developed for adults and did not take account of the age the offender was at that time. Although the psychologist prepared the report at the time of sentence, it was subsequently on file and an expert report at this stage could have been invaluable to those practitioners who later assumed responsibility for this case. Given the notable qualifications of its author, the report may have had some bearing on how those involved with the offender's management after release viewed his level of risk. This is a matter of concern that requires follow-up. The prison-based social worker and the supervising officer in North Lanarkshire acted in good faith when they used risk-assessment tools to assess the offender, but their use of these tools without the relevant training is not defensible practice. The risk assessments that the supervising officer completed were not part of a systematic process, and they did not significantly influence his subsequent management of the offender. This suggests that there was a lack of clarity among staff about North Lanarkshire's expectations with regards to risk assessment and how this was to inform risk management. These are important areas where clarity is essential.

4.17 Using clinical judgement to assess the likelihood of repeat sex offending is a complex and demanding task. The best assessments are those which combine all available information about an offender with the skills, knowledge and expertise of the different agencies into a judgement based on an internationally-recognised framework for risk assessment. As part of this process, different agencies may have different roles, for example the police might complete an initial risk-assessment based on static historical factors about an offender, but also may contribute a wealth of key data and intelligence to assist others with more sophisticated risk assessment tasks to aid risk management. In this case, the police officers undertook a complex assessment on their own. Clinical judgements require significant training, and it is likely that the risk-assessment tool used by the police was too complex for effective use by two police officers without other support.

4.18 We are aware that the police and criminal justice social work across Scotland are currently in the process of adopting an internationally-recognised assessment tool and that a national programme of joint training has now commenced. This is a welcome step that will ensure a high level of consistency in assessment processes. However, it is important that all agencies recognise the importance of proper application of the tool and this will require ongoing monitoring. Further assessment measures to support risk management strategies are also under consideration.

Sex Offender Treatment

4.19 As well as assessing risk, a crucial element in managing high-risk sex offenders is to provide appropriate intervention focused on their offending. The prison service did not undertake a risk assessment on the offender nor offer any intervention to address his sex offending. He missed the start of a group programme and was not in prison long enough to undertake and complete the next one. Between 19th March 2003 and 4th May 2004 there was enough time for him to complete the 9-month ' SOTP programme', and therefore presumably enough time for a one-to-one treatment package. It seems unfortunate that because his period of custody did not coincide with timescales for the SOTP programme the prison service did not assess and offer offence focused intervention to a young person who had recently committed a very serious sexual offence. This observation echoes recommendation 28 of the Report of the Expert Panel on Sex Offending, which is that SPS should provide treatment for all sex offenders regardless of the length of their sentence. ¹⁴

4.20 There are important distinctions emerging in the literature between adult sexual offenders and adolescents who display sexually aggressive behaviours, ¹⁵ and it does not necessarily follow that including the offender in North Lanarkshire's adult sex offender group was the right option in preference to other treatments delivered in partnership with multi-agency monitoring and supervision. ¹⁶

Sex Offenders Protocol and Interagency Relationships

4.21 The police, the housing service and the social work department have produced a comprehensive sex offender protocol document for North Lanarkshire. This document provides a framework for information to flow between the agencies and attempts to provide structures to assess and manage the specific risks posed by individuals as well as the impact of these factors on the overall strategy for the delivery of services to manage high-risk offenders across the local authority area. We recognise that this has provided a major catalyst for promoting the strong inter-agency links in North Lanarkshire. However, the evidence in the case of the offender shows clearly that the agencies did not follow their protocol in practice; important meetings did not happen and the agencies were not working to a joint action plan. The protocol did not provide a straightforward blueprint for action that practitioners could easily follow. It is important that protocols readily translate into practice, and we felt that the North Lanarkshire and Strathclyde Police document would benefit from greater simplicity. It is our view from the SWIA inspections in other local authority areas that there are significant variations between areas in the processes used for sex-offender management. We believe that this is another area where a national approach would provide much needed consistency and result in greater clarity for all those agencies involved in this complex process. Any national approach should of course be flexible enough to adapt to specific local circumstances.

4.22 We are conscious that the Scottish Executive has progressed, over a period of time, the recommendations contained in the 'Report of the Expert Panel on Sex Offending'. As a result of the work of the Information Sharing Steering Group chaired by the Solicitor General, the Management of Offenders etc. (Scotland) Bill now before Parliament contains provision for responsible authorities in a local authority area to jointly establish arrangements for assessing and managing the risks posed by certain offenders, including sex offenders. The legislation also provides for Scottish Ministers to issue guidance on how agencies should carry out this function. It seems likely that this provision will provide the means to satisfy our concern for a consistent and joined up approach to this complex area of work.

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