Independent report

Report 10: offensive weapons homicide review, West Midlands (accessible)

Published 13 January 2026

Name of Relevant Review Partners: Coventry City Council, West Midlands Police and NHS Coventry & Warwickshire Integrated Care Board.

The review has been co-ordinated by Birmingham Community Safety Partnership, on behalf of the Relevant Review Partners.

The review panel consisted of: Coventry & Warwickshire Partnership NHS Trust, West Midlands Police, Home Office Immigration Enforcement, Birmingham Local Authority, Coventry Local Authority, West Midlands Ambulance Service, University Hospitals Coventry & Warwickshire, NHS Coventry & Warwickshire Integrated Care Board, Coventry Probation Services, Warwickshire Police, and Bedfordshire Probation Services.

Case Reference Number: West Midlands OWHR 009

Pseudonym 1: Victim Michael

Pseudonym 2: Perpetrator Malik

Pseudonym 3: Perpetrator Scott

Pseudonym 4: Perpetrator Jacob

Date of the incident which led to the Review: August 2023

Date of death, where applicable: August 2023

Review’s start date (commissioned): October 2023

Review completion date (approved and signed off): 25/08/2025

Publication date: Week of 12/01/2026

Explain any reasons for delay in completion (this should include any additional delays other than due to a criminal trial).

There have been significant delays in completing this report, primarily due to difficulties in engaging with regional local authorities and services outside the pilot areas. Once collaboration began, the information shared proved to be insightful.

Brief Outline of Circumstances Resulting in the Review

In August 2023, West Midlands Ambulance Service received a 999 call about a male found in an area of Coventry with wounds to his chest and right leg. When the ambulance crew arrived, they found Michael on the floor and unresponsive. They assessed him and located a stab wound in the central chest area. Michael was treated and taken to University Hospital Coventry & Warwickshire, where he received theatre care, before hospital staff transferred Michael to critical care.

Michael died at the age of 47 in August 2023. Jacob, 34, Malik, 22, and Scott, 21, were arrested in August 2023.

Following a six-week trial at the Crown Court, Malik and Scott were found guilty and received minimum life sentences of 26 and 27 years, respectively, for the murder of Michael and the supply of Class A drugs. Jacob was found guilty and received an 11-year custodial sentence for the manslaughter of Michael and conspiracy to supply Class A drugs.

Details of the Decision to Undertake a Review and Notification

Offensive Weapon Homicide Reviews (OWHRs) were introduced through the Police, Crime, Sentencing and Courts Act 2022 and require the Police, Integrated Care Boards and Local Authorities in England to review the circumstances of certain homicides where the victim was aged 18 or over, and the events surrounding their death involved, or were likely to have involved, the use of an offensive weapon.

OWHRs allow local partners to collaborate and share any lessons learned, highlighting outcomes to improve national and regional understanding of the causes of homicide and serious violence.

OWHRs are currently being piloted in parts of London, the West Midlands, and South Wales and subject to further evaluation, the process may be adopted nationally across England and Wales.

West Midlands Police, an OWHR-relevant review partner, informed Birmingham Community Safety Partnership in August 2023 that a homicide had occurred in Coventry. Several alleged perpetrators were believed responsible for using an offensive weapon, which had led to the death of a male aged over 18 years old.

Birmingham Community Safety Partnership met with Relevant Review Partners in October 2023 to assess if the homicide circumstances met the criteria required to progress to an Offensive Weapon Homicide Review.

In accordance with the OWHR Statutory Guidance, Birmingham Community Safety Partnership commissioned an OWHR. The criteria for this review were met under section 24 (6) of the Police, Crime, Sentencing and Courts Act 2022 and the accompanying Regulations. Namely:

• a. the death occurred in England
• b. the person was aged 18 or over
• c. the death involved the use of an offensive weapon
• d. the body has been located
• e. the identities of both victim and perpetrator have been recorded
• f. one or more of the review partners has information about the victim, and
• g. this is not a ‘death or serious injury matter’ within the meaning of section 12(2A) of the Police Reform Act 2002

Birmingham Community Safety Partnership, under sections 24(1) and (6) of the Police, Crime, Sentencing and Courts Act 2022, sent a formal written notification to the Home Office that the circumstances of the homicide met the criteria for progressing to an OWHR.

Offensive Weapon Homicide Review Panel Members

The list below sets out the organisations that contributed to the homicide review. It includes frontline and specialist representatives from key service areas that had prior contact with Michael, Malik, Scott, and Jacob individually.

• Birmingham Community Safety Team
• West Midlands Police
• Coventry City Council
• NHS Coventry and Warwickshire ICB
• Immigration Enforcement
• Coventry & Warwickshire NHS Trust
• Coventry Probation
• Bedfordshire Probation

Once established, the panel held its first meeting in November 2023, followed by a second in February 2024, and culminating in January 2025 when the panel considered a final set of recommendations. Alongside those meetings, collaboration was also undertaken with partners who engaged later in the process, ensuring their perspectives were reflected in the review.

Terms of Reference (TOR)

The Offensive Weapon Homicide Review panel is the local oversight group for the review. During the first panel meeting, the chair outlined:

• The purpose of the review and methodology.
• A review period of two years preceding Michael’s death, with flexibility to extend if necessary.
• Birmingham Community Safety Partnership shared a revised TOR in November 2023.

Panel members were:

• Independent of any staff line management involved in the case.
• Sufficiently senior to have the authority to commit their agency to actions and decisions.

The OWHR Tactical Steering Group meets monthly, following an initial biweekly schedule. The Strategic Group is coordinated through the West Midlands Violence Reduction Unit, which has agency management oversight of OWHRs. The group reviews and completes quality assurance reports, including signing off on recommendations

Scoping Document

• Based on Independent Management Reviews (IMRs) from selected services.
• IMRs built the chronology of agency contact and individual histories.
• Complied with statutory guidance to support comprehensive analysis.

Methodology

• The chair analysed events leading to the homicide of Michael.
• Prompted professional curiosity and encouraged deeper questioning of agencies.
• Reviewed IMRs, court documents, open-source material and agency policies.
• The focus was on understanding the drivers of violence and the effectiveness of any previous interventions experienced by Michael, Malik, Scott, and Jacob.

Synopsis

The chair has turned to public source documents to understand as clearly as possible the events which led to the death of Michael. A criminal trial concluded in 2024, and the chair sought context and facts within the presiding trial judge’s summing-up comments, sentencing remarks, and admissions made by Jacob, Scott, and Malik.

Information from West Midlands Police indicates that Michael, Malik, Jacob, and Scott were associated, but it is unclear how long they knew each other or how they met.

Malik, Jacob and Scott were part of a drug network dealing in Class A drugs. They had a vested interest in the effective delivery of drugs in a geographical area of Coventry. Michael is said to have recently joined the operation and been a part of the delivery of drugs in the local area. A current and common way to distribute illegal drugs to customers is by bicycle. An unknown thief stole the bicycle used by people within Jacob, Scott and Malik’s network from a multi-occupancy dwelling in August 2023.

However, Jacob, Malik and Scott incorrectly accused Michael of having stolen the bicycle, which they considered a drug-dealing asset and believed that the loss of that asset would impact the effective delivery of drugs. Michael was initially assaulted outside of the multi-occupancy address by Malik and Scott, before evidence used by the prosecution suggests he was lured to a park a short time later by Jacob, and Michael’s homicide took place.

Key Lines of Enquiry relating to Michael

Previous Local Authority Involvement: Does a local authority outside the pilot areas hold key information about Michael?

Agency awareness: Were any local agencies or national agency offices within that authority previously aware of Michael? Was Michael’s information recorded or flagged on national systems accessible across regions?

Service engagement history: Is there evidence of prior engagement with services such as housing, health services, social care, education, or health services?

Relocation to Coventry: When Michael moved to Coventry, was there a formal transfer of information between the local authorities involved? Were any services transferred, paused, or re-initiated upon his relocation? Were local agencies in Coventry made aware of any historical concerns, risks, or needs?

Relocation Motivated by Safety Concerns: Was Michael’s relocation prompted by safety concerns (e.g. threats, exploitation, gang involvement)? If so, were appropriate safeguarding protocols followed to ensure continuity of support and protection?

Key Lines of Enquiry relating to Jacob

Initial Police Response: Following Jacob’s caution for possession of a lock knife at Heathrow Airport, did the Metropolitan Police formally interview Jacob? Was an intelligence report generated regarding the arrest and linked to Jacob at a local or national level?

Intervention and Follow-Up: Was Jacob offered any structured intervention (e.g. education, diversion, or support programmes)? Were any referrals made to relevant services?

Contextual Consideration: Given that laws and police policy around offensive weapons have evolved since 2012, how would such an incident be managed under current legislation and policy? Is there any retrospective learning that could inform current practice?

Key Lines of Enquiry relating to Scott

Conviction and FNO Identification: In 2020, Scott was convicted of an offence involving an offensive weapon and sentenced to 54 months in prison. Following this, he was identified as a Foreign National Offender (FNO) and became of interest to Home Office Immigration Enforcement (HOIE).

Agency Collaboration and Case Management: How effective was the multi-agency collaboration between: HOIE, HM Prison and Probation Service (HMPPS), Police Integrated Offender Management (IOM) units?

Clear and coordinated process for: Managing Scott’s release, requesting, receiving, and acting on relevant intelligence and sharing risk-related information post-release.

Intelligence Coordination: Were any barriers identified in accessing or using intelligence from different agencies? Were risk management procedures consistent with public protection responsibilities?

Key Lines of Enquiry relating to Malik

Threats to Kill Allegation: In April 2021, Malik’s stepbrother reported to West Midlands Police that Malik had made a threat to kill and was allegedly affiliated with a gang in Coventry.

Police Response and Investigation: Did West Midlands Police attempt to verify the claim of gang involvement and visit Malik to assess the situation, gather further intelligence, and consider the potential safeguarding or risk-related implications?

Complainant and Case Closure: After discovering the complainant had left the country, was the decision to close the case reviewed, considering the seriousness of the allegation? Could further efforts have been made to substantiate or refute the intelligence?

Use of Intelligence Systems: Despite no previous police history found for Malik, were intelligence sources or community links explored for corroborating or disproving the gang affiliation claim? Were there missed opportunities for preventative engagement?

Equality and Diversity

Public Sector Equality Duty (PSED) under the Equality Act 2010 requires public authorities to consider the impact of their decisions on people with protected characteristics. This includes considering how their policies, programmes, and services affect people with protected characteristics. The chair and review panel have found it challenging to evaluate the impact of such decisions due to the limited information gathered, despite the efforts of BCSP and the chair.

Michael	Findings of Impact
Age 47 years	Not Known
Disability	Not Known
Gender Reassignment	Not Known
Pregnancy & Maternity	Not Applicable
Race	Not Known
Religion or Belief	Not Known
Sex	Male
Sexual Orientation	Not Known
Marriage & Civil Partnership	Not Known
Socio-Economic Disadvantage	Not Known

Jacob	Findings of Impact
Age 32 years	Not Known
Disability	Not Known
Gender Reassignment	Not Known
Pregnancy & Maternity	Not Applicable
Race	Self-Defined Black African
Religion or Belief	Not Known
Sex	Male
Sexual Orientation	Not Known
Marriage & Civil Partnership	Not Known
Socio-Economic Disadvantage	Not Known

Malik	Findings of Impact
Age 22 years	Not Known
Disability	Not Known
Gender Reassignment	Not Known
Pregnancy & Maternity	Not Applicable
Race	Self-Defined Black African
Religion or Belief	Not Known
Sex	Male
Sexual Orientation	Not Known
Marriage & Civil Partnership	Not Known
Socio-Economic Disadvantage	Not Known

Scott	Findings of Impact
Age 21 years	Not Known
Disability	Not Known
Gender Reassignment	Not Known
Pregnancy & Maternity	Not Applicable
Race	Self-Defined Black Italian
Religion or Belief	Not Known
Sex	Male
Sexual Orientation	Not Known
Marriage & Civil Partnership	Not Known
Socio-Economic Disadvantage	Not Known

Involvement of family/next of kin and other relevant persons

In December 2023, a West Midlands Police family liaison officer visited Michael’s father and sisters and provided them with a letter from the chair, along with documentation from Birmingham Community Safety Partnership, including an OWHR leaflet. At that time, Michael’s family wished to wait until after the trial before considering whether to support the OWHR. In September 2024, a police family liaison officer confirmed that Michael’s family did not wish to engage with the process. The family has indicated that the reviewing author may choose whether to use pseudonyms within the report.

Please indicate which family member declined involvement:

Michael’s sister, speaking on behalf of the whole family.

In May 2024, BCSP emailed three letters, written by the chair, to the perpetrators’ solicitors, requesting that family and/or friends engage with the OWHR. In July 2024, the chair spoke with three solicitors and/or clerks who had represented Malik, Jacob, and Scott and followed up with an email requesting their engagement. In September 2024, the chair sent three individual letters offering OWHR engagement to Malik, Jacob, and Scott while they were in prison. The prison liaison office was engaged to facilitate contact with serving prisoners and to support their participation in the author’s work. To date, neither the OWHR chair nor BCSP has received any response to the above requests.

Family History and/or Contextual Information

The chair and review panel members have been unable to obtain Michael’s family history and meaningful contextual information. We do know and recognise that Michael was a much-loved son, brother, friend and father and that his death has devastated those who knew and loved him.

Agency Timeline

Michael

Michael lived in a one-bedroom flat, but the panel is unaware of how he accessed that accommodation and how long he had been living there; review partners have been unable to gather that information.

Michael had strong links to the Bedfordshire area, and Bedfordshire Probation held key information about Michael beyond the time parameters agreed by the panel. Members of Michael’s family believe that Michael may have relocated to Coventry after he was the victim of a machete attack in June 2022. Michael was unable to assist local Bedfordshire police officers with their enquiries about the attack, and they were unable to ascertain why Michael would be subject to such violence. NHS Coventry and Warwickshire Integrated Care Board (CWICB) will say that Michael received care at Luton and Dunstable University Hospital in June 2022, and this corresponds with a knife injury police report.

Bedfordshire Probation reported that Michael had been a client of their services from 1994 to 2023. Throughout this period, Michael exhibited a pattern of regular drug use, committed offences for financial gain, and had a lifestyle and associates that may have posed a risk to him. There is evidence, extending beyond the two years before Michael’s death, that he expressed a wish to adopt healthier behaviours, improve his relationships, and move away from environments he recognised as unhelpful to his wellbeing. As a result of the personal and social challenges that Michael was managing, his access to and uptake of support services were inconsistent, with periods of engagement interspersed with episodes of disengagement.

In mid-2022, Michael disclosed to his probation officer that he had been a victim of a machete attack in Bedfordshire, a significant safeguarding event that required further investigation. However, Michael’s probation officer did not explore the disclosure further, nor did they share the information with other relevant agencies responsible for supporting Michael and managing any threat, harm or risk relating to Michael. The information disclosed was not recorded accurately or promptly, and therefore, appropriate risk assessments and multi-agency or cross-boundary collaboration did not take place.

Michael was released from prison in early 2023 after serving a short sentence for burglary and fraud.

Malik

NHS Coventry and Warwickshire Integrated Care Board (CWICB) reports that Malik was not registered with a GP in the Coventry area and had only attended Coventry A&E twice for minor medical issues. At the time of the homicide, Malik reported that he was a university student outside of Coventry. Based on the information available at the time, enquiries were made, but Malik was not recognised as a student at the university or elsewhere in the geographical area. Checks also revealed that he had not accessed NHS services during that time or in the area described. At some stage, Malik returned to his home in Coventry and began drug dealing. Malik had no prior criminal convictions before his 2024 conviction; in one instance, he was a victim of motor vehicle theft. Information indicated that Malik did not access local authority child or adult services.

No information was disclosed during the review process, indicating that Malik had accessed local authority services during the relevant period.

However, in April 2021, a report of Threats to Kill was made to West Midlands Police against Malik by his stepbrother. The latter told the police that Malik was part of a gang in Coventry. West Midlands Police attempted contact with the complainant, but they had left the country, so the investigation was closed. While West Midlands Police conducted intelligence checks concerning Malik and found no evidence of offending, they did not speak to Malik, nor did they report and share the intelligence that Malik was part of a gang with a local gang unit.

When Malik was arrested in August 2023 and taken into local police custody, the Coventry and Warwickshire Partnership Trust and the Liaison and Diversion Service spoke with him. The service provides support to individuals in police custody and, if necessary, refers them to forensic mental health services. Although Malik was anxious, he did not require a referral to treatment.

Scott

Scott lived locally in Coventry. NHS Coventry and Warwickshire Integrated Care Board (CWICB) reports that he registered with a local GP from September 2014 to September 2023 and last contacted them in 2017. He last attended a hospital in 2018 following an injury to his shoulder.

West Midlands Police stated that between 2017 and 2023, Scott was both a victim of crime and a perpetrator. As a juvenile, he was a victim of theft and fraud, and he had received educational advice concerning the inappropriate use of social media, the circumstances of which were shared with Coventry Social Care for information only.

No information was disclosed during the review process to indicate that Scott had accessed local support services during the relevant time, nor as a child or young adult.

In February 2020, Scott was found guilty of committing a robbery during which he had shown a machete to the victim so that they surrendered property and was sentenced to 54 months upon first conviction. Key factors which would have influenced the sentence include the aggravated nature of the offence, given that an edged weapon (machete) was produced/seen, and the victim was approached as he entered the communal area of his own place of residence.

In August 2020, Warwickshire Police submitted an entry to the Police National Database, associating Scott with a County Lines operation established in the West Midlands.

In January 2021, while in prison, Home Office Immigration Enforcement (HOIE) served Scott with a Deportation Decision Notice, Stage One, and a Stage Two letter eighteen months later, in December 2022.

Scott appealed in January 2023, and in February 2023, Scott was subject to a conditional custodial release from prison and moved to an Immigration Removal Centre (IRC). At this stage, Coventry Probation had engaged with Scott before his release and informed him that he would be subject to Probation Licence conditions if he successfully appealed for bail at a future date.

Scott requested a bail hearing with an immigration judge. Coventry Probation Services shared information about Scott with Home Office Immigration Enforcement using OASys, a tool used by His Majesty’s Prison Service and the National Probation Service (HMPPS) to assess the risk level of offenders. Sharing a risk assessment was intended to support Immigration Enforcement’s proposal to challenge bail. Coventry Probation Services determined that Scott’s level of risk to the public was high, specifically to male peers whom Scott may target to commit a crime against or during conflict between peer groups.

In February 2023, the probation practitioner acknowledged a County Lines risk registration flag linked to Scott. Scott’s police offender manager did not access this single strand of intelligence, nor was it the subject of any discussion between partners.

In February 2023, a Multi-Agency Public Protection Arrangement (MAPPA) form was circulated and signed by relevant review partners, confirming that Scott was considered suitable for level one management.

A First-tier Tribunal judge granted Scott bail, subject to conditions of electronic monitoring, residence, and weekly reporting to an Immigration Officer. In March 2023, Scott was released from the Immigration Removal Centre.

The West Midlands Police Integrated Offender Management Unit and Coventry Probation collaborated to share available information and intelligence, aiming to prevent Scott from reoffending and offer supportive interventions.

In April 2023, Scott’s probation practitioner referred him to a Problem-Solving intervention and a Drug Recovery Service after Scott disclosed that he was using Cannabis. The probation practitioner shared the information with the police offender manager practitioner. A joint probation and police offender management visit occurred later in the same month. Scott was considered engaging, and they recommended that Scott no longer register with Integrated Offender Management.

Between March 2023 and August 2023, Scott allowed his electronic tag to run out of power on approximately 20 separate occasions, thereby failing to comply with his conditions of immigration bail and technically breaching them. Neither Scott’s probation practitioner nor offender manager was aware of this.

In July 2023, Electronic Monitoring Services visited Scott and provided him with a new tag after receiving an automated notification indicating that the tag was no longer in use. Scott stated that the tag had fallen off when he had fallen off his bicycle.

The Home Office or Electronic Monitoring Services do not actively monitor the movement of individuals subject to electronic monitoring unless specifically requested to do so or as part of an individual’s immigration bail conditions.

Instead, trail data is collected and stored until an interested party requests access. Access request reasons can include breaches of immigration conditions and requests from external agencies. Home Office Immigration Enforcement typically does not act against individuals who allow their batteries to run down but then charge them soon after, given the high volume of such cases and the need to manage resources effectively. “Soon after” is not defined; however, Home Office Immigration Enforcement officers would act if a device were out of contact for 24 hours to 3 days or more for high-harm individuals and 7 days or more for low-harm individuals.

In August 2023, Scott’s probation practitioner reduced Scott’s risk to the public from High to Medium based on their knowledge of Scott’s compliance.

In August 2023, Scott failed a drug test for Cocaine use.

In August 2023, after the murder of Michael, Scott was stopped by police in a car while sitting in the passenger seat. Scott had a Samurai sword in his waistband and another on the passenger seat floor.

Jacob

NHS Coventry and Warwickshire Integrated Care Board (CWICB) has indicated that Jacob has been registered with a local GP practice since July 2023 but never contacted them. Previously, his GP care was in London.

At the time of his arrest, Jacob was staying at a local hotel. Review partners have been unable to ascertain whether Jacob placed himself at the hotel or was referred there by a local authority outside of Coventry.

Jacob was known to several police services, including the Metropolitan Police, West Midlands Police, Thames Valley Police, and Cambridgeshire Police.

The Metropolitan Police held five crime reports between 2011 and 2013. Two of these are for Shoplifting, two for Possession of Controlled Drugs, and one for Possession of a Weapon from 2012, when he had a lock knife at Heathrow Airport. Jacob received a caution for this offence. Requests for information relating to Jacob carrying a knife did not yield any further results, acknowledging that over the last 13 years, PNC and PND systems have matured. The Metropolitan Police has evolved since 2012, establishing policies and processes to tackle knife crime, with a focus on education, enforcement, and engagement.

Cambridgeshire holds one custody record from 2008, which relates to Fraud. Thames Valley Police also have one custody record from 2010 for Failure to Comply with Section 27 of the Bail Act 1976.

West Midlands Police have stated that Jacob’s first interaction with their police service was in August 2023, when he reported that he was a victim of blackmail. A friend had stolen his passport and demanded money in return. Police officers offered Jacob access to victim care services, and his friend returned his passport. The police then concluded their investigation.

When Jacob was arrested for the murder of Michael and charged, the Criminal Justice Liaison and Diversion team spoke to Jacob. He agreed to participate in a mental health assessment, which took place in September 2023, and they found no evidence of any acute mental illness. Jacob revealed that whilst in custody, he had become a father. Children’s services discussed the child at a Multi-Agency Safeguarding Hub meeting due to concerns relating to Jacob’s arrest and criminal charges.

Good Practice

Whilst in police custody and HMP, Malik and Jacob received support from the Coventry & Warwickshire Partnership NHS Trust Liaison and Diversion Service Mental Health team. The timely intervention of trained practitioners and the sharing of information to inform risk assessments between custody and prison are examples of effective practice.

Improving Systems and Practice (National, Regional and Local)

Following a report prepared for a Serious Further Offence (SFO) review, West Midlands Probation Service has implemented an action plan spanning internal, local, and regional levels. The review identified several shortfalls in risk assessment, case management, and management oversight. Several organisational and individual actions have been identified to strengthen practice and oversight.

Recommendations 1 and 4 should be implemented locally, in Coventry and Bedfordshire, respectively. Recommendations 2 and 3 should be applied nationally.

Recommendations

1. West Midlands Police should ensure that officers in Coventry are fully aware of their responsibilities to submit intelligence concerning individuals with suspected gang affiliations and complete thorough research across intelligence systems when managing individuals with gang connections or vulnerability to criminal exploitation to inform safeguarding and investigative activity. The Lead Responsible Officer (LRO) for Coventry Police should communicate expectations accordingly to support other training and CPD linked to managing intelligence. In this review, officers from two different areas of frontline policing did not proactively assess or research available intelligence that linked Scott and Malik to criminality. Having taken those steps, the officers may have had opportunities to test the veracity of the intelligence, engage with Malik and Scott, and add value to understanding risk levels and the required partnership intervention.

2. Clear practice guidelines are essential for the management and supervision of foreign national offenders as part of a joined-up partnership service. Agencies within this review have policies and procedures that support practitioners in specific roles when assessing and managing risk within individual organisations. However, there is an identifiable lack of collective responsibility, collaboration and governance across some agencies within the review. Highlighting red flags enables agencies to assess and manage risk proactively, thereby promoting accountability across significant partnerships. It is not best practice to expect or assume that a single agency can identify and manage all indicators of violence and vulnerability relating to Scott. Senior contract managers from the Home Office Immigration Enforcement (HOIE) and the Ministry of Justice’s Electronic Monitoring Services (MOJ EMS) should meet to address the existing gap between breaches of Home Office EMS and alerts to criminal justice partners.

3. Home Office Immigration Enforcement (HOIE) to provide sensitive partnership guidance on the tolerance level HOIE applies when a high-risk individual breaches immigration bail conditions. During this review, key agencies were unaware of HOIE’s role in managing Scott’s immigration bail conditions, the recourse when bail is breached, and overall governance.

4. Bedfordshire Probation Services should consider the consistency of standards among practitioners, particularly in terms of identifying vulnerabilities of people on probation and the subsequent assessment and management of risk to keep them safe. When Michael disclosed that he had been a victim of a machete attack, this was a red flag; the practitioner did not explore this further with Michael. Had the practitioner done so, they may have added meaningful detail to the risk assessment, engaged with Michael and collaborated with partners to manage the risk to Michael. Leaders responsible for training should consider using professional development days to assess current understanding, advance identified learning, and support the processes already embedded within Bedfordshire Probation Services.

Dissemination

List of recipients who will receive copies of the Review

Date circulated to relevant policy leads: 26/06/2025

Organisation	Yes / No	Reason
West Midlands Police	Yes	Relevant Review Partner
Coventry Probation Services	Yes	Relevant Review Partner
Coventry & Warwickshire Integrated Care Board	Yes	Relevant Review Partner
Birmingham Community Safety Partnership	Yes	Relevant Review Partner
Immigration Enforcement	Yes	Relevant Review Partner
Bedfordshire Probation Services	Yes	Relevant Review Partner

OWHR Process Summary

Independent Management Reviews were collected from October 2023 to January 2025.

Review Panel Members met as a group in November 2023, February 2024 and January 2025.

E-mails and letters from the chair to FLO requesting contact with Michael’s family. December 2023 and April to July 2024.

E-mails between the chair and Birmingham Community Safety Partnership, facilitating letters from the chair to the solicitors who represented Malik, Jacob and Scott. May-June 2024.

E-mails and calls from the chair to solicitors who represented Malik, Jacob and Scott. June 2024 Oct 2024

Draft report sent to Birmingham Community Safety Partnership in July 2024 and returned with comments from Birmingham Community Safety Partnership and West Midlands Police in August 2024.

E-mails and calls from the Birmingham Community Safety Partnership and the OWHR chair to a local authority outside the pilot area, aimed at encouraging engagement with the OWHR process, from October 2023 to January 2025.

E-mails and meetings between the chair and the Immigration Enforcement and Policy Team were held from May 2024 to January 2025 to better understand their process for engaging with partners.

E-mails and meetings with probation partners to complete IMRs and update the draft report from December 24 to May 2025.

Updated draft report to Birmingham Community Safety Partnership, September 2024.

Updated draft report to Birmingham Community Safety Partnership, January 2025.

Final draft report to Birmingham Community Safety Partnership, June 2025

Final confidence check

This Report has been checked to ensure that the OWHR process has been followed correctly and that the Report has been completed as set out in the statutory guidance. I can confirm that this Report section is at a standard ready for publication. [confirmed]

Once completed, this report needs to be sent to the Secretary of State for the Home Office. Tick to confirm this has been completed. [confirmed]

Statements of Independence

Statement of Independence by Chair

Please read and sign the following statement. Consider the section on independence in the OWHR Statutory Guidance before completing.

Chair 1: Helen Lyons

Statement of independence from the case:

I make the following statement that before my involvement with this review:

• I have not been directly involved in the case or any management or oversight of the case.
• I have the appropriate recognised knowledge, experience and training to undertake the review. Therefore, I meet the criteria for an Independent Chair.
• The review was conducted appropriately and was rigorous in its analysis and evaluation of the issues as set out in the Terms of Reference. I recognise that the purpose of this is to identify learning from the case, not to attribute blame to practitioners or agencies.
• I have read and understood the equality and diversity considerations and will apply them accordingly.

Please set out below how you meet paragraphs 3.14 – 3.19 of the OWHR guidance.

The independent chair has a history of working at both tactical and strategic levels in policing, offering a depth of skills balanced with breadth of experience. They have a deep understanding of violence against women and girls (VAWG) and preventing harm to vulnerable groups within society. They have received Home Office training specifically designed for independent chairs and OWHRs.

The relevant review partners delegated responsibility for this OWHR to the independent chair, and the reporting framework adheres to statutory requirements. The chair has no connection with the relevant review partners or local oversight process for this review.

Signature: H Lyons

Name: Helen Lyons

Date: 4th June 2025

To be completed by the Home Office:

Please tick here to confirm that the Chair was appointed from the Independent Chairs List held by the Home Office: [confirmed]

If the Chair is not a member of the Independent Chairs List, then please give detail to confirm how the alternative Chair fully meets the Competencies set out in the OWHR guidance.