Independent report

Report 11: offensive weapons homicide review, Harrow (accessible)

Published 5 February 2026

1. Name of Relevant Review Partners

• Harrow Council
• Metropolitan Police Service (North West Area)

• North West London Integrated Care Board

• Barnet Council

2. Case Reference Number

OWHRWL23

2.1 The Pseudonym has been chosen on behalf of the family by the report Author at their request.

Victim 1: Michael

Perpetrator 1: Not Applicable

3. Date of incident which led to the Review

July 2023

4. Date of death where applicable

July 2023

5. Review’s start date (commissioned)

04/04/2023

5.1 Review completion date (approved and signed off): 08/07/2025

5.2 Publication date: 05/02/2026

5.3 There were significant delays in completion of this report. The Chair and Author was not formally instructed until March 2024 and the scoping and terms of reference meeting took place in early April 2024.

5.4 The trial was set for late June 2024 and therefore, due to the closeness of that date, the decision was taken that the Individual Management Reviews (IMR’s) would not be fully required until early July 2024.

5.5 The first formal Panel Meeting was timetabled for the 23rd July 2024. However, only 4 Panel members attended. A second Panel Meeting was scheduled for 20th August 2024. This was postponed as, once again, the number of confirmed attendees was significantly lower than required for a meaningful meeting. The second Panel meeting took place on 9th October 2024.

5.6 It should also be noted that at the trial, the charged perpetrator was found not guilty. As a result, it has not been possible to pursue any direct enquiries with those involved in the fatal death of Michael. The Chair did approach the perpetrator’s solicitors to invite them to take part, but they refused.

6. Outline of circumstances resulting in the Review

6.1 Offensive Weapon Homicide Reviews were introduced under the Police Crime Sentencing and Courts Act 2022^{[footnote 1]}

6.2 Section 24(1) of the act states that an Offensive Weapon Homicide Review must take place when a review partner considers that-

• (a) the death of a person was, or is likely to have been, a qualifying homicide,
• (b) the death occurred, or is likely to have occurred, in England or Wales,
• (c) such other conditions as the Secretary of State may specify by regulations are satisfied, including, for example, conditions relating to—
  • (i) the circumstances of or relating to the death,
  • (ii) the circumstances or history of the person who died, or
  • (iii) the circumstances or history of other persons with a connection to the death, and
• (d) the review partner is one of the relevant review partners in respect of the death.

6.3 The relevant review partners are:

• The Local Authority
• The Police
• The local Health Board or Integrated Care Board.

6.4 The above review partners are required to meet along with other partner agencies who are relevant, to review the person’s death, to confirm if the criteria for an Offensive Weapon Homicide Review is met.

6.5 The criteria, set out in the legislation, confirms that for a homicide to be considered for an OWHR the victim must be over 18. An alleged perpetrator can be included in a review at any age, including under 18.

6.6 Synopsis of the incident

6.7 In the early hours of the morning in late July 2023, Michael was driving in his car in the northwest area of London. He made several stops during the early hours indicating that he was dealing drugs.

6.8 At a similar time a group of 6 males left an address in an area of Barnet. The address was a flat in a block owned and managed by a housing association. The address was described by the Senior Investigating Officer as a “free house”; the adult tenant being regularly away and leaving their teenage daughter in occupation.

6.9 The group took a short tube ride an Underground Station, close to where the incident took place.

6.10 CCTV evidence gathered from the vicinity shows Michael’s car pulling up and 5 of the 6 males approaching it. One male leant into the front passenger door for just under a minute. There is no concrete evidence of what happened during this altercation, however the perpetrator pulled out, what is described as, a large knife, or machete and inflicted a single stab wound to the chest of Michael. The weapon used was not recovered.

6.11 Michael was in possession of a knife but during the investigation it was found sheathed under the driver’s car seat.

6.12 Michael drove at speed for a short distance after he had been stabbed. Michael stopped and got out of his car. He approached another car parked nearby and pleaded for help. The occupant recalls Michael saying “I just got stabbed. Help me”, or words to that effect. The driver of the other vehicle telephoned the emergency services and requested the attendance of paramedics.

6.13 Michael collapsed on the ground by the driver’s door of this car and remained there until the emergency services arrived. Despite their best efforts, Michael ultimately died at the scene, from the stab wound.

6.14 The perpetrator: Of the 6 individuals, one person was charged with the murder of Michael. However, the outcome of the trial was that he was found not guilty of murder and manslaughter. The defence case was that it was self-defence on the basis that the perpetrator was in fear of being harmed by Michael. He was convicted of being in possession of an offensive weapon and received a 6 months imprisonment sentence for possession of a offensive weapon. As he was on remand for longer than this time it was deemed he had served the sentence and was released at conclusion of the trial.

6.15 Following the incident the below Review Partners, led by Harrow Council, met on the 5th September 2023 to assess if the circumstances of the Homicide met the definition for an Offensive Weapon Homicide Review, as set out above. The Review Partners were:

• Harrow Council
• Metropolitan Police Service Northwest Area (MPSNW)
• Northwest London Integrated Care Board
• National Probation Service

6.16 In summary, the above Relevant Review Partners commissioned an OWHR for the death, in accordance with the OWHR Statutory Guidance.

6.17 Section 24(6) of the Police Crime Sentencing and Courts Act 2022, sets out that the homicide is a qualifying homicide for an Offensive Weapon Homicide Review (OWHR) if: -

• a. the person was aged 18 or over, and
• b. the death, or the events surrounding it, involved the use of an offensive weapon.

6.18 The criteria for this Review are met under: Section 24(6) of the Police Crime Sentencing and Courts Act 2022. The homicide is a qualifying homicide for an Offensive Weapon Homicide Review due to the fact that:

• The victim is over 18 years of age.
• The weapon was identified by the Pathologist’s report as a double- bladed knife or small machete. The weapon has not been recovered.

6.19 Review Panel Members and local oversight process

6.20 On the 12th September 2023, Harrow Council formally notified the Secretary of State that the criteria had been met and an Offensive Weapon Homicide Review would be commenced.

6.21 On the 25th January 2024, Jonathon Toy, was formally appointed as Independent Chair and report author to undertake the Offensive Weapon Homicide Review.

6.22 An Offensive Weapon Review Panel was established. The first meeting took place on the 4th April 2024. The following Table (Table 1) sets out the Panel members, their roles, and the organisations that they represent.

6.23 The Panel acts as the local oversight process for this review.

Table 1 - Offensive Weapon Homicide Review Panel Members

Organisation	Position
Harrow Council	Deputy Community Safety Manager
Harrow Council	Head of Community Safety
Harrow Council	Head of Youth Justice Service
Barnet Council	Community Safety Partnership Officer
Metropolitan Police Service North West Area	Review Officer - Specialist Crime Review Group (SCRG)
Metropolitan Police Service North West Area	Superintendent
Central and North West London NHS Foundation Trust	Director of Quality
Probation Service	Head of Service, Harrow and Barnet London Probation Service

7. Terms of Reference

7.1 Terms of Reference were drafted by the Independent Chair, who is also the author of the final report and approved at the first Panel hearing on the 4th April 2024. A redacted version of the Terms of Reference is attached (Appendix 1).

7.2 The Terms of Reference included 4 Key Lines of Enquiry (KLOE) which are relevant to the timeline set out in section 7.3 below. These formed the focus on the review process and were as follows:

• KLOE 1 - What are the background contextual factors that brought the 6 members of the group together who were at the scene of the homicide? Consideration should be given to females connected to the group at the time leading up to the homicide.

• KLOE 2 - Are there dynamics in relation to culture and/or identity that create interrelationships or conflict between individuals or groups in the area?

• KLOE 3 - Does status and respect feature in the dynamics within and between those involved in, or associated to, the victim or perpetrator?

• KLOE 4 - Do geographical boundaries impact on the operational structures, sharing of information, or resources that could assess risks of violence and vulnerabilities associated with personal or group conflict who travel across local authority boundaries?

7.3 Additional Considerations – The following additional considerations were agreed by partner agencies as part of the Terms of Reference.

• How was the weapon used in the homicide obtained?

• Are there any other links that relate to the other homicides in the local area that should be considered or explored?

7.4 The agreed time period of the review is 1st February 2020 up to and including the date of the incident in July 2023. The reason is that it is believed that the victim Michael came to the notice of local partner organisations.

7.5 Methodology for the review

7.6 The methodology was a review of the circumstances of the incidents, a review of the Individual Management Reviews supplied by key agencies, interviews with lead officers, including the Senior Investigating Officers, Youth Justice Managers and case officers, Metropolitan Police Service (Northwest) senior officers and Multi Agency Safeguarding Hub workers, St Giles Mentor, and the Registered Housing Provider lead officer.

7.7 Key documents reviewed were in relation to policies and procedures related to child safeguarding and risk and vulnerability meetings, enforcement policies and the local safer Harrow Serious Violence Strategy 2024-2027.

7.8 The following Table (Table 2) sets out the documents reviewed and dates of the interviews that took place in collating this report and its findings.

Table 2: Details of Individual Management Reviews

Full Individual Management Reviews

Agency	Submission date	Representing	Author (by role)
Probation Service	July 2024	Probation Service	Head of Service Probation Officer
Central and North West London NHS Foundation Trust (CNWL)	July 2024	CNWL	Named Professional for Safeguarding Adults
Pathologist’s Report	June 2024	N/A	N/A
Metropolitan Police Service NW	June 2024	MPSNW	Review Officer, Specialist Crime Review Group (SCRG)

Short reports

Agency	Submission date	Representing	Author (by role)
Data Protection Act return – Barnet Homes	August 2024	Barnet Homes	Community Safety Officer
Multi Agency Child Exploitation Panel minutes x 2 (Sept 2020 and December 2020	September 2024	Harrow Council	Safeguarding Team Manager
Exploitation Risk Assessment	September 2024	Harrow Council	Deputy Head of Community Safety/ Safeguarding Team Manager
Harrow Council Violence and Vulnerability Daily meeting Terms of Reference.	September 2024	Harrow Council	Deputy Head of Community Safety
Harrow Council Violence and Vulnerability Daily meeting notes	September 2024	Harrow Council	Deputy Head of Community Safety
Child In Need Plan minutes October 2021	September 2024	Harrow Council	Team Manager

121/ group interviews

Agency	Submission date	Representing	Author (by role)
MPSNW	July 2024	MPSNW	Senior Investigating Officer
Harrow Youth Justice Service	August 2024	Harrow Youth Justice Service	YJS Manager and Case Worker
Barnet Council	August 2024	Barnet Children and Families Service (Safeguarding leads)	Team manager
St Giles Trust	August 2024	St Giles Trust	Mentor
MPSNW	September 2024	MPSNW	Public Protection
Sage Homes Limited	October 2024	Sage Homes	Quality and Performance Manager

Key additional documents

Agency	Submission date	Representing	Author (by role)
Rex v XX – Prosecution opening statement	August 2024	MPSNW	Senior Investigating Officer
Carson Kaye	October 2024	Carson Kaye Solicitors	Stefan Sutherland Defendant’s Solicitors
London Borough of Brent Enforcement Policy	January 2025	London Borough of Brent	Trading Standard
Operation Dakota intelligence checks through data protection requests.	November 2024 and January and February 2025	London Borough of Barnet	Assurance and Public Protection

8. Equality and Diversity

8.1 This section addresses the nine protected characteristics under the Equality Act 2010^{[footnote 2]} to the Review. It includes examining barriers to accessing services in addition to wider consideration as to whether service delivery was impacted.

8.2 Section 149 of the Equality Act 2010 introduced a public sector duty which is incumbent upon all organisations participating in this review, namely to:

• eliminate discrimination, harassment, victimisation, and any other conduct that is prohibited by or under this Act.
• advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it.
• foster good relations between persons who share a relevant protected characteristic and persons who do not share it.

8.3 The review gave due consideration to all the Protected Characteristics under the which are: age, disability, gender reassignment, marriage and civil partnerships, pregnancy and maternity, race, religion or belief, sex, and sexual orientation.

8.4 The following information has been used to assess if there were any barriers in accessing services. In this case this assessment is solely made for the perpetrator.

8.5 Michael was a white male and at the time of the incident he was 19 years of age. He had no defined disability prior to the incident.

8.6 Michael was born in Romania. His mother and family have a close Romanian heritage. He lived with his mother and stepfather, until they separated in late 2019, when his stepfather left the family home.

8.7 He had close family members in the Northwest London area as well as in Romania, which his family frequently visit.

8.8 Whilst Michael had close support of his family at their home address in the Harrow area, his accommodation was best described as fluid. He shared rented accommodation in 2022 and he had a period of unstable accommodation until his death in July 2023.

8.9 In summary, there was nothing to specifically indicate that there was any discrimination in this case that was contrary to the Equalities Act 2010.

8.10 The author has considered the intersectionality of Michael’s age, race and cultural beliefs of Michael and his family. There are elements of this intersectionality which impacted on his decision making, but these are not directly related to discrimination. Michael’s family have raised their concerns that their treatment by agencies, specifically those in the criminal justice system was discriminatory, due to their Romanian Heritage. This is explored in more detail in the key learning points and recommendations set out below.

9. Involvement of family/next of kin and other relevant persons

9.1 Michael’s family were contacted about the OWHR process following the first panel meeting on the 4th April 2024.

9.2 The chair initially contacted the Family Liaison Officers in early April. A meeting with Michael’s mother, the Family Liaison Officer and the Chair took place in April 2024. Due to the fact that Michael’s mother primarily spoke Romanian and her understanding of English was limited, an on-line interpreter was present. In addition, a family member, Michael’s sister-in-law was also on-line to support Michael’s mother.

9.3 The Chair further met with Michael’s mother in July 2024. Michael’s sister-in-law was on-line to provide support with translation. The family raised their concerns that agencies did not see the same risks in relation Michael, particularly the threats made towards him, that they had and were experiencing. This has been reflected within the relevant KLOE.

9.4 The Chair also met with the family on the 7th February 2025 to talk through the findings of the report and the recommendations set out below.

9.5 During these meetings it was very clear just how much the family are still grieving the loss of their son, brother, brother-in-law, cousin, and uncle. They shared photographs of Michael at Christmas, wrestling with his older brother and with his niece who adored him. They shared stories, like when Michael would hold his niece upside down so her feet were on the ceiling and she could walk upside down. They shared cherished text messages from Michael saying “Love U”, a painful reminder that they can no longer hear those words from him.

9.6 The following are the words from Michael’s sister, which they wrote when they attended the trial and which the family have kindly shared for his report.

As I sit in this courtroom exposing my vulnerability and reliving every emotion, I felt that day for the loss of my big brother- (Micheal). The day you recklessly killed him and left him all alone. You have not only ended is life by ended hi dreams, his hopes, his whole future, his ability of raising his own family and being at peace. The night I found out one of the worse news of my life will forever haunt me. You have not only taken his life but you have ruined mine forever. I will never smile again without feeling guilty. The feeling of loneliness haunts me every single day. Coming home and being all alone not able to knock on his door and talk, never seeing his smile which lit the whole room and his contagious laugh. Michael was joyful and loving, in-fact he was the funniest person I have ever met. I have funny stories like when it was snowing and he made us all go out in the garden a covered me in snow, or when he sat on my school computer by accident and we tried hiding it. Whenever he saw me upset, he tried his best to make me happy and it always worked.

Everyday, since xx July, his face on the news, I wake up with only memories left of him. Every day I wake up hoping miraculously he would be in the room next to me. Every day it hits me that it’s not possible. Not today, not tomorrow, not in 10 years’ time. He was smart with lots of potential for his future that you have taken away. I hope the guilt haunts you just how the pain haunts me and everyone who loved Michael. He was only 19 years, which his 20th birthday only 2 months away. I remember his birthday exactly, not being able to give him a hug, a gift, a birthday wish yet instead having to look at his old birthday pictures from when we were little, that adorable innocent smile, not knowing in a few years that he will ever be able to smile again. In fact pictures and videos are all I have now. My brother was like my best friend, by father figure and my protector all in one. Unfortunately, that’s not the case anymore. You get to live but with that night embedded in your mind for the rest of your life.

I don’t know if you feel guilty, but I wonder if you ever thought to turn around and help him. The thought of him lying cold in his own blood alone kills me every single day. I wish I could say I don’t carry anger in my heart but hat would simply be a lie. You and I both know the word of self-defence is a lie. How dare you, just imagine it was you and the pain you brought to our family happened to yours. I almost a whole year of grieving it has robbed me of my ability to fee joy and continue doing even simple talks. Sometimes I don’t know if I want to heal as the pain in the last link I have with him. Every day I wish I could go back and have one last day with Michael. Do you wish you could go back and change what you have done? Every day I wish I didn’t take the moments in our childhood for granted. Unfortunately, no one can bring my brother back ever but I’ve made my wish in life to live for him make him proud and serve him justice.

9.7 These words should be at the forefront of partner agencies in delivering the recommendations set out below, to ensure that his sister feels proud that meaningful change has happened, for her and her brother Michael.

9.8 The Family Liaison Officer lead has provided exceptional support and advocacy on behalf of family members. The chair would like to personally thank and recognise his compassion and kindness which was seen first-hand during the visit and subsequent conversations.

10. The family alleged perpetrator declined involvement

Not Applicable

11. Contact with the perpetrator and/or family members

11.1 The chair of the review wrote to the perpetrator’s solicitors on the 29th September 2024. The correspondence provided the identified perpetrator and their family an opportunity to be involved in the reviews.

11.2 On the 2nd October 2024 the Chair received a reply from the solicitors stating they had passed on the request to the family and were awaiting a reply.

11.3 On the 4th October 2024 a further correspondence was sent by the solicitors stating “We have spoken with our client and his family about the below. They are not willing to partake in the review.”

12. Family History and/or Contextual Information

12.1 The contextual information in relation to Michael is that he was born in Romania but grew up in England. His mother is Romanian and came to the United Kingdom as an EU citizen for economic reasons.

12.2 His biological father lived in Romania was not involved with Michael. Michael he did not know his birth father or have any contact with him.

12.3 Michael’s mother remarried. However, they were subsequently divorced in November 2019. His mother speaks limited English although she has a good understanding of the spoken language. She is in full time employment, working shifts.

12.4 Michael has two siblings, an older brother who is married and a younger sister. He came from a family who are hard working and have a very clear cultural identity linked to their cultural heritage.

12.5 Although it is difficult to fully evidence, there are strong indications that Michael’s own Identity, formed by his, cultural experiences particularly within his friendship and peer groups and own experiences growing up in North West London created tensions within the family. These tensions centres around the lifestyle choices Michael was seen to making by the family and which were different from their expectations. This was exacerbated during the Covid lockdown periods, particularly between March and July 2020, when Michael was 16 years of age.

12.6 The contextual considerations are explored in depth through the report, Key Learning Points and Recommendations.

12.7 In terms of the group of 6 males who were together leading up to the stabbing of Michael, they come from a variety of backgrounds, cultures and faiths. There is evidence that a number of the group experienced violence in the family home and family breakdown. Whilst it cannot be evidenced, this may have caused members of the group to gravitate towards each other.

12.8 Their contextual connections as a loose group of friends, is that there was a link to education, the local environment that they frequented and importantly, the flat that they regularly visited in the Colindale area in the weeks prior to the fatal incident.

12.9 The perpetrator who fatally stabbed Michael was born in the UK. His parents are from the Middle East and Africa. The family are practicing Muslims and are Arabic speaking. The perpetrator is the eldest of 2 siblings. His relationship with his young brother has been described as strong. His parents are separated but they co parent the children.

12.10 The perpetrator attended a local school where he established links with some of the other individuals involved in the events on the evening leading up to fatal stabbing. It is recorded he was bullied at school and had witnessed a stabbing in childhood years. His educational experience had been described as chaotic which resulted in limited attendance and truancy. He also spent periods of his childhood accessing support services both as a day patient and inpatient due to an eating disorder. Concerns were noted regarding his aggression towards family members, his need to exercise and adhere to boundaries particularly around eating plans being put in place and actioned by parents. Early Help support was offered to the family.

12.11 At age 17, Social Care was alerted to his involvement with the police which included several incidents including theft of a motor vehicle, getting involved in fights, thefts, robberies which is said to involve carrying a knife. Following assessment, he was stepped up to the Reach Team, a service which works closely with criminally and sexually exploited children. He was opened to Youth Justice Service and was subjected to a 6-month referral order and a Child in Need plan. A National Referral Mechanism was also opened for him. He had a pattern of non-engagement at times during interventions.

12.13 In summary, there is contextual information for both Michael, the perpetrator and the identified group. This is covered as part of the learning points as set out in response to the Key Lines of Enquiry below.

13. Agency Timeline

13.1 NOTE – It is important to note that in this case, there has been no defined connection, or involvement, between the victim and those involved in his fatal stabbing. There is no evidence that indicates that the incident was in relation to any personal conflict between the victim, members of the group or connected associates. The closest explanation is that this was a chance encounter, possibly in connection to a drug related interaction or robbery that quickly escalated and resulted in the fatal stabbing of Michael.

13.2 The timeline is based on the agreed timeframe set out in the Terms of Reference being February 2020 and July 2023. This includes contact with family members by agencies or professionals during, or prior to, this period.

13.3 Key events

13.4 The following Table sets out the key events and timeline, a short commentary of the events and contact between Michael and agencies.

Year	Date	Agency	Comments
2019	Nov	Child Safeguarding	Michael’s mother and stepfather separate.
2020	Feb	Violence Vulnerability and Exploitation Minutes	10/02/20 – Michael is involved in an incident at police cadets.
2020	Feb	Violence Vulnerability and Exploitation minutes	Michael comes to the notice of partner agencies, due to a missing episode. He advised Violence Vulnerability and Exploitation Social Worker that he was in Ashford, Kent.
2020	Feb	Violence Vulnerability and Exploitation minutes	During a Police Stop and Search Michael is identified as part of a group pointed out by a member of the public as being involved in a fight with weapons.
2020	April	Violence, Vulnerability and Exploitation minutes	Police Stop and Search carried out in an area known for drug dealing. Michael was identified as part of a group who appeared to be involved in a drug exchange.
2020	May - July	Multi Agency Child Exploitation (MACE) minutes	The family seek to get Michael to accept rules to prevent tension from escalating. He left the family home and stayed away for 6 weeks.
2020	July	Violence Vulnerability and Exploitation minutes	Michael was the subject of a stop and search by the Police. He was seen the previous day with a group after a robbery (where a knife was mentioned). He was with two other males known for drug dealing, hanging around an alleyway known as an escape route for robbers.
2020	July	Violence Vulnerability and Exploitation minutes	Michael was found with an iPhone that was stolen during a robbery.
2020	Aug	Metropolitan Police Service (Merlin report)	Michael was arrested for stealing a moped and an iPhone. Michael appears to be known to the Police for other offences listed on the merlin list. Merlin is a Police system used to record details of vulnerable people to enable safeguarding teams to assess risks of harm.
2020	Aug	Metropolitan Police Service	Michael is reported missing for two nights.
2020	Aug	Metropolitan Police Service	Michael goes missing for two nights.
2020	Aug	Reported by mother to the Police on 26th August	Michael goes missing for two nights.
2020	Sept	Metropolitan Police Service	Michael goes missing for one night.
2020	Sept	Metropolitan Police Service	Michael stopped by Police in the early morning for theft of a motor vehicle (two Counts).
2020	Sept	Strategy meeting	Multi Agency Child Exploitation Panel meeting held to discuss Michael.
2020	Dec	Youth Justice Service	Michael is excluded from Stanmore College, which he started at in September 2020.
2020	8th Oct		Michael turns 17.
2020	Oct	Harrow Youth Justice Service	Youth Justice Service Referral Order for theft of motor vehicles in September.
2020	Nov	Harrow Youth Justice Service	Referral Order Panel meeting – 4 month Referral Order commenced from this date.
2020	Dec	Strategy meeting	Multi Agency Child Exploitation Panel meeting held.
2021	Jan	Harrow Youth Justice Service	Michael advises Youth Justice Service case worker that he has rented a place in Kent. He returns a few days later to avoid a breach of his Referral Order.
2021	Jan	Violence and Vulnerability minutes	Michael was one of three males stopped and searched following an attempted Robbery.
2021	Jan	Exploitation Risk Assessment	Multi Agency Exploitation Risk Assessment is completed for Michael. The Risk level is assessed as Medium.
2021	Feb	St Giles Trust	Michael is referred to Rescue and Response Service. St Giles Trust case worker makes a home visit to get Michael to engage. Michael is not home. Case Worker sends a text to Michael.
2021	Early Feb	Metropolitan Police Service	Michael stopped and arrested for burglary with three other suspects. Youth Justice Service records indicate that the address was “smashed up” No further action taken by the Police.
2021	Late Feb	Metropolitan Police Service	3 young boys attack a car at the same address as the previous incident. Michael is identified as one of them.
2021	Late Feb	Metropolitan Police Service	Michael found naked outside an address in Neasden - Michael said he met three males who had robbed him and taken his clothes. Youth Justice Service record notes indicate that the motive was for the burglary offence earlier in the month.
2021	March	Youth Justice Service	Michael was in hospital following the above assault. Youth Justice Service records indicate that Michael was aware that there was a “hit against his name”.  He stated that he kept a kitchen knife in his room and tried to stay in.
2021	March	General Practice Surgery	Received a report from local Hospital that Michael has received a blunt trauma to the head following an assault in a park. A referral was made to social services.
2021	Mid March	Youth Justice Service	There was a partnership strategy meeting. Police put a Call Aided Dispatch CAD marker on the home address. Michael has advised his Youth Justice Service Social worker the locations where he feels safe/unsafe. Professionals at the meeting were concerned about his safety.
2021	Mid March	Youth Justice Service	Youth Justice Referral Order came to an end.
2021	Late April – Late May	St Giles Trust	St Giles worker still had not managed to engage Michael and had still not met him. St Giles noted that Michael may have been working.
2021	Mid May	General Practice Surgery	Several attempts were made to call in Michael for a review. A letter was also sent to the home address but there was no response.
2021	Late May	St Giles Trust	St Giles Worker puts Michael on watching brief.
2021	Early June	St Giles Trust	St Giles worker sends a text message to Michael to see if the work place was verified.
2021	Early June	St Giles Trust	St Giles receive confirmation that Michael is working at a car wash at Potters Bar. Text message from social worker and Compass (young person substance misuse agency) stating they have closed the case due to lack of engagement.
2021	Mid June	St Giles Trust	St Giles closes the case due to non-engagement.
2021	Mid August	Metropolitan Police Service	Arrested and charged with being in possession of a Psychoactive substance (Nitrous Oxide).
2021	Sept	Metropolitan Police Service	National Referral Mechanism Referral made.
2021	Oct	Child In Need meeting	Just before Michael’s 18th Birthday a Child in Need (CIN) meeting took place, between his allocated Social Worker and representatives from Turning Point and Prospects.
2021	8th Oct		Michael turns 18
2021		Child In Need meeting	Child in Need plan closed as Michael has turned 18.
2021	Early Dec	Metropolitan Police Service	Michael arrested for Possession with intent to supply a controlled class C drug (Cannabis) and driving a motor vehicle without a licence or third party insurance.
2022	Jan 2022	Probation Service	Michael received a 12 month Suspended Sentence Order for using a Motor Vehicle Uninsured against third party risks.
2022	June	Metropolitan Police Service	A group of males break into Michael’s family home searching for him. Michael hid in the bathroom. Police called and attended the address.
2022	June	Metropolitan Police Service	Metropolitan Police Service offer special schemes and panic alarms. These are declined. Family advise MPS that Michael had gone to stay with his brother. The address was flagged on the Computer-Aided Dispatch (CAD) system, for an urgent response to calls.
2022	June	Family decision	Family immediately move home by exchanging addresses with a close relative.
2022	8th Oct		Michael turns 19.
2022	Late Nov	Probation Service	Michael receives a 12 month Community Order for offences under the Psychoactive Act 2016 and he was referred to a Probation Practitioner.
2022	Nov -Dec	Probation Service	Weekly Supervision and Surveillance Order. (This then became monthly until the time of his death.)
2022	Dec	Probation Service	Community Order commences, with 40 hours unpaid work which Michael completes.
2022	Dec	Probation Service	Home visit arranged, and enquiries to Integrated Offender Management team, Serious Group Offending and Serious Violence Panel were made by his Probation Practitioner.
2023	Early 2023	Probation Service	Probation make referral to Police Serious Group Offending (SGO). Probation noted that the Police Serious Group Offending were not taking referrals at that time.
2023	Early 2023	Probation Service	Probation make referral to Street Link as Michael is at serious risk of becoming homeless.
2023	July	Probation Service	Michael was staying odd nights at different places, ‘sofa surfing’, or sleeping in his car.
2023	Late July	Metropolitan Police Service	Michael is fatally stabbed.

13.5 Summary of Michael’s Agency Timeline

13.6 In early February 2020 Michael started to come to the notice of police and partner agencies as part of a group that were becoming involved in robberies, thefts and weapon carrying.

13.7 There were concerns raised by partner agencies about Michael and a missing episode. He advised a Social Worker that he was in Ashford, Kent. The notes in the Violence and Vulnerability summary document states that he was “doing County Lines activity and also linked with Elders in Queensbury, Belmont, Stanmore, and Edgware area’

13.8 Between this period and into the early summer there were emerging tensions within the family home. Michael had started to stay out late. During a later interview with his Social Worker, which took place in the Autumn of that year, he reflected that he was bored at home.

13.9 In May tensions escalated as the family did their best to manage Michael. They came to a head later that month and ultimately he was asked to leave the family home. He stayed away for a period of around 6 weeks. The minutes of the Multi Agency Child Exploitation meeting which took place in October state that during this period and until his return in July “…he stayed with older men in Queensbury/Kingsbury High Street. He started stealing food and drinks from Morrisons around this period and funded himself by stealing things during this period.”

13.10 Harrow Council co-ordinate a daily Violence, Vulnerability and Exploitation meeting. The purpose of the meeting is to share and encourage the sharing of fast-time information with regards to youth-related violence, vulnerability and exploitation.

13.11 Michael, aged 16, was first discussed at the meeting in August 2020 as Michael’s name had been linked to a number of incidents, dating back to February of that year. These are set out in the above timeline.

13.12 Between late August and mid September Michael had a series of missing episodes. There are 4 periods totaling 7 nights.

13.13 On the 10th of September Michael was arrested by the Police for the theft of a motor vehicle.

13.14 A strategy meeting was held on the 21st September where there were concerns that Michael was at risk of criminal child exploitation. These concerns were minuted in the Multi Agency Child Exploitation meeting which took place in October 2020.

13.15 Both Michael’s Social Worker and the Harrow Violence Vulnerability and Exploitation (VVE) Manager felt that Michael was at risk of criminal exploitation and that he was part of the Queensbury Gang. Information shared by the Violence Vulnerability and Exploitation worker indicates that Michael had sold cannabis frequently and was at the stage where he could source it for others to enable them to sell it for themselves. 

13.16 During this meeting there are recorded notes that state that the representative Police Officer shared there is “no CCE (Child Criminal Exploitation) Strategy meeting as there is not enough evidence for criminal exploitation, its more vulnerability and the dynamics at home which are concerning.”

13.17 The recorded minutes go on to state “Exploitation risk assessment has been completed, from Children Service perspective we felt Michael was at risk of CCE (Child Criminal Exploitation), but we have different threshold to the police.”

13.18 Following the arrests in September, for Motor Vehicle Offences, Michael is referred to the Harrow Youth Justice Service, to consider him for a Referral Order. The Referral Panel met in November and approved the Referral Order for a 4-month period, which commenced on 24th November.

13.19 The notes recorded by the YJS Social Worker highlighted concerns about his peer group, the missing episodes and that Michael was “Searching for a sense of belonging”.

13.20 The YJS Social Worker recorded Michael’s risk levels at the beginning of the Referral Order as:-

• Risk of serious harm – Medium
• Risk of reoffending – Medium
• Own safety and well being- High

13.21 In September Michael was discussed at length at the Multi Agency Child Exploitation (MACE) Panel meeting. The outcome of the meeting recorded that Michael was at medium risk and his case would be brought back in 2 months.

13.22 In early December a further Multi Agency Child Exploitation meeting was held. It was recorded that “Michael’s attendance at college has also slightly improved and self-reports he is now up to at least 35%.”

13.23 The minutes record that Michael’s risk level is assessed as Medium.

13.24 Based on the notes there appears to be a contrary view of Michael’s risks. There is a statement in the minutes that reads, “There are concerns in respect of Michael’s arrests - indicative of exploitation, and his associates are known to the VVE. (Violence and Vulnerability Exploitation)”. In a following paragraph “No CCE (Child Criminal Exploitation) concerns and is not open to the police. Michael is engaging well with YOT, the problems are more around family dynamics.”

13.25 The decision of the Panel is that as Michael is open to the Youth Justice Service the case would be “Closed to MACE (Multi Agency Child Exploitation) be discussed at Safety, Wellbeing and Risk Management Panel (SWARM).

13.26 In December 2020 Michael is excluded from Stanmore College, due to low attendance, truancy, and failure to submit work.

13.27 In January 2021 the Youth Justice Service Social Worker contacted Michael due to concerns about his engagement in his Referral Order. It is recorded on the Youth Justice Service notes that he struggled with compliance and attendance. Michael notified the social worker that he has rented a place in Kent with some friends and is working. He was informed that he was at risk of breaching his Order and Michael returned.

13.28 An Exploitation Risk Assessment was completed by Michael’s allocated Social Worker. The Risk Assessment forms part of the Harrow Violence and Vulnerability Assessment process. There is a section of the Assessment titled “Young Persons View of Risk”. This section is not completed.

13.29 There is a further section titled “Parent or carers view of risk”. This section is scored out of 10 with 0 being the highest level of risk and 10 being “problem is sorted as much as it can be”. This section is scored at 1 with the following statement. “(Michael’s mother) … has expressed significant concerns around Michael’s behaviour, however, also appears to have almost given up on him, waiting for him to turn 18 and leave the house. There is a clear breakdown in their relationship which is perhaps part of the reason Michael does not stay at home.”

13.30 The risk level is identified as Medium with the following concerns noted: -

• “Michael coming to harm due to his risk-taking behaviour-
• Michael potentially being incarcerated should he continue to come to police attention-
• Michael is at significant risk of being exploited-
• Michael is currently not in education, training or employment. –
• There appears to have been a breakdown in his relationship with his mother, meaning that he appears to spend more time out of the home than in.”

13.31 The notes confirm that the case is closed to the MACE Panel.

13.32 During January and February Michael is linked to a series of robberies and other offences with his peer group. His is referred to the Rescue and Response Team for mentoring support. The Rescue and Response Team was established across Brent, Barnet and Harrow to provide support to young people up to the age of 18 who go missing and are at risk of exploitation. The service offers mentoring support delivered by St Giles Trust.  A mentor was allocated to Michael. On receipt of the referral the appointed mentor made a home visit. Michael was not at home, but the mentor spoke to his mother and younger sister about the support offered.

13.33 The following are the notes taken and recorded by the St Giles Rescue and Response Mentor. They are verbatim notes provided by the mentor (grammatical errors have been included for accuracy): -

“Michael is a 16 year old boy of Romanian ethnicity. He lives with his mother and sister following his mother’s divorce from his stepfather. Since the divorce, there are concerns about Michael’s activities- coming home late, behavioural issues at home, whereabouts unkown and being found by Police with othe rpeople known for crimila actiivities or found in places known for drug dealing. He was missing for around 6 weeks from May 2020, and this was not reporetd to Police. Michael says that he was living with an older man/males in Queensbury area at this time but teh details of this older men are not known. He has had three more missing episodes for two nights each, agian his whereabouts are not known. Michael has said that he is involved in selling cannabis frequently and is involved in theft of mopeds. He has been arrested for theft of mopeds twice recently. Due to these, there are concerns around Michael being groomed and being criminally exploited. There are concerns around his missing episodes and his associations with other peers who are known for criminal activities”

13.34 On the 2nd February Michael was discussed again at the Violence, Vulnerability and Exploitation meeting. The concluding notes are as follows: -

“There are escalating concerns in terms of Michael’s offending behaviours and exploitation. He was involved in County Lines last week whilst he was missing in the Kent area. Rescue & Response have been informed. The CCE Unit (Child Criminal Exploitation) have not engaged with a strategy meeting as YOT (Youth Offending Team) are involved and he is on a CIN  (Child in Need) plan so they don’t feel there is anything they could offer further. XX advised that there was not currently enough in respect of potential CBO (Criminal Behaviour Order), but this may need to be considered in the future if things continue to escalate, XX outlined that he is a victim and exploited first though.”

13.35 In February 2021. Michael’s mother applied for European Union settlement for Michael.

13.36 In late February, Michael, along with a group of young people, was arrested in relation to a residential burglary. It was noted that the address was “smashed up”. Michael tried to evade arrest by fleeing over roof tops.

13.37 There was a further incident at the same address as the above burglary where Michael had been involved. A car outside of the property was vandalised.

13.38 A few days later, following a call from a member of the public, Michael was found by Police Officers naked outside an address in Neasden. He claimed that he had been robbed and told officers that it related to the burglary that he was involved in, earlier in the month.

13.39 Subsequently, Michael provided a statement to the Police. The Youth Justice Social Worker stated he was nervous about giving a statement and very reluctant to have police involved. He told his Youth Justice Social Worker that there was snap chat information about his belongings and offering money to harm him.

13.40 A strategy meeting was held in March between the Youth Justice Service, Police and with input from the Violence and Vulnerability Exploitation Team. A flag was put on the home address on the Police Control Aided Dispatch system to ensure that any 999 calls related to the address received an urgent response. The Violence and Vulnerability Team provided a commentary on where Michael felt safe and unsafe, and it was noted that professionals were concerned about his safety.

13.41 On the same day the Youth Justice Worker contacted the Multi Agency Safeguarding Hub (MASH). A Multi Agency Safeguarding Hub is a team of professionals from different organisations such as the Police and children services who come together to protect young people and children from harm. The Police advised that there was no report of a threat to harm so the Officer in Charge had not put the details on the Multi Agency Safeguarding Hub data system. However, this appears to be contradicted by a Merlin report that is recorded on the data system indicating that there was an open case allocated to Harrow Children’s Service. The notes go on to state that in “accordance with MASH instructions, guidance and policy, this Merlin will now be Forwarded to Children’s Services. No checks will be completed”

13.42 Michael’s Referral Order with the Youth Justice Service (YJS) came to an end in mid-March. It was noted by the Youth Justice Social Worker, that Michael’s risk level would have been Medium/High by the end of his involvement with the service.

13.43 Between March and the end of April, the St Giles mentor attempted to make contact with and meet Michael, through telephone and text messages.

13.44 In May St Giles placed Michael on a “watching brief” due to lack of contact.

13.45 Michaels General Practice Surgery made several attempts via letter to call him in for a medical review. However there was no response from Michael.

13.46 In June, St Giles became aware that Michael may be working in a car wash in Potters Bar. They attempted to verify this by contacting Michael via text.  St Giles received a confirmation from a Social Worker verifying that Michael was working. St Giles formally close the case due to lack of engagement.

13.47 In the same month, Michael’s settled status was confirmed by the Home Office.

13.48 In August 2021 Michael was arrested and charged for possession of a Psychoactive substance, Nitrous Oxide.

13.49 The Police subsequently made a National Referral Mechanism Referral and concerns were discussed at a multi-agency strategy meeting. The Police identified this as an opportunity to implement safety planning, with the focus being on Michael as a victim.

13.50 The General Practice Surgery received a risk assessment for Michael from Hammersmith Custody Suite. However it is recorded that there was no attempt to call Michael for a follow up.

13.51 In October 2021 Michael turned 18 years of age. A Child in Need review meeting was held just prior to his 18th Birthday. In attendance were Michael’s allocated Social Worker and representatives from Turning Point, a Drug and Alcohol support service and Prospects who support people into vocational and employment opportunities. Neither Michael, nor his mother, were in attendance.

13.52 At the meeting, it was recorded that Michael was referred by professionals to both Turning Point and Prospects. However, it was noted that Michael was struggling to be engaged by professionals, or his mother. Both agencies recognised that Michael was about to turn 18. Agencies indicated their willingness to keep the support network around Michael and once engagement has improved between these services then referrals to other agencies could then be explored.

13.53 There was also a clear recognition in the meeting that there remained contextual risks and references to the likely court outcome of recent offences, including the prospect of a Rehabilitation or Community Order. However, the notes of the meeting also state “It was agreed at the meeting that no new significant incidents have come to light involving (Michael), since his arrest on the 11/ 12th August 2020”

13.54 A number of actions were agreed prior to the case being closed. These actions fall into three categories: -

• Providing information to Michael or his mother on support services,
• Providing key information on housing and benefit support,
• Practical support in relation to Michael’s legal status and relevant documentation.

13.55 The action plan was agreed by those present at the meeting and the Child in Need Plan was closed as Michael was defined as an adult.

13.56 In early December Michael was arrested for Possession with intent to supply a controlled class C drug (Cannabis) and driving a motor vehicle without a licence, or third party insurance.

13.57 In January 2022 Michael received a 12 month Suspended Sentence. This related to an incident involving motor vehicle offences committed in December 2021. The lead agency was the Probation Service as Michael was then over the age of 18. The assessment was considered as low for all categories. A Sentencing Plan was not completed.

13.58 In June 2022 Michael’s family home was broken into by a group of males seeking Michael. Michael was alone in the house at the time. He hid in the bathroom and called his family and the Police. The Police attended as the group fled the property. The Police offered panic alarms and special schemes for the address, but the family declined. (It should be noted that the family dispute this offer being made). A flag was placed on the police Call Aided Dispatch (CAD) system in relation to the address. The intention was to highlight the address as requiring an urgent response should a call be received.

13.59 Within days, in order to protect Michael, the family move home, swapping their address with a relative. The Police do not appear to have a record of this swap of address taking place.

13.60 In November 2022 Michael received a 12 month Community Order for possession of psychoactive substances in August 2021. The substance is recorded as nitrous oxide on the National Probation Service case system, called OASys.

13.61 The Community Order commenced in December 2022 and comprised 40 hours unpaid work which Michael completes. The Probation Service carried out a risk assessment which was completed in December along with a Sentencing Plan. The Risk Assessment considered a number of factors related to an individual which either protect them or which increases their risk of reoffending. The Risk Assessment highlighted a number of risks including medium to high scores for the following three categories, “Thinking & Behaviour”, “Attitudes” and, “Life styles & Behaviour”. He had very low scores for accommodation and relationships (1 for both). His overall risk assessment was recorded as Medium.

13.62 During this period, Michael’s case was allocated to a Probation Practitioner. A home visit was arranged, and enquiries to the Integrated Offender Management Team, Serious Group Offending and Serious Violence Panel were made by his Probation Practitioner.

13.63 The referral to the Police Serious Group Offending (SGO) was made in February 2023, but it was noted that this was not successful. The Probation Practitioner stated that they believed the Police Serious Group Offending (SGO) was not taking referrals at that point.

13.64 It should be noted that the Probation Delivery Unit was classed as a Red Site. A Red Site is where a prioritisation model is implemented to manage the caseloads.  This meant some cases were managed by phone and meant engagement was limited.

13.65 The Probation Practitioner continued to make contact with Michael as part of his 12 month order and Michael’s case remained with them up until the time of his death. However, the attempts to offer support were hampered by the Probation Practitioner not being able to engage Michael and he refused to sign the Intervention Document. This meant that the Probation Practitioner was not able to make referrals to other support agencies.

13.66 Michael did inform his Probation Practitioner that he had tried to contact Drug Treatment and Referral services in Harrow, however he had to wait for hours on the phone to get through.

13.67 Michael returned to the family home in early 2023 and it was noted on the Probation recording system that he was living there or with a relative.

13.68 Later in 2023, the Probation Practitioner made a referral to Street Link due to Michael being evicted and becoming homeless. The Probation Service notes made reference to Street link having Michael’s details and were attempting to make contact.

13.69 In early July, Michael was no longer living at the family home. It is believed he was sofa surfing or on occasions, sleeping in his car.

13.70 The fatal incident occurred in July.

14. Practice and organisational learning

14.1 The Terms of Reference for this case identified four Key Lines of Enquiries which have continued to form the basis of this review.

14.2 Each of the Key Lines of Enquiries (KLOE) have been set out below with the associated Key Learning Points that have arisen through the review process.

14.3 KLOE 1: - What are the background, contextual factors that brought the 6 members of the group together who were at the scene of the homicide. Consideration should be given to females connected to the group at the time leading up to the homicide incident.

14.4 The author has taken the opportunity to undertake 1-2-1 interviews with the Senior Investigations Officer, lead Child Safeguarding Officers in Barnet, Educational leads and Housing representatives from the borough. There is little information on the contextual background that brought the group together. The only clear determining factors are: -

• There are members of the group that live in the nearby area.
• There is a connection between some of the group through school or college, but not all.
• The flat where the group met beforehand was a “Free House” which was frequented by young people. The description “Free House” is the terminology used by the Senior Investigating Officer due to the fact that, as part of the investigation, it was evident that the property had been regularly used by young people, including members of the group, to meet, drink alcohol and smoke drugs.

14.5 There were other contextual factors that were noted in the history of some of the 6 males and 2 females. This included references to domestic abuse in the family home, school exclusion and contact with Children Services. These were not consistent across all 8 of the young people and there is not sufficient evidence that these were contributing factors which drew them together.

14.6 The flat is in a residential housing block close to an Underground Station in the Borough of Barnet.

14.7 It is evident that the flat had been used as a “free house” for some time. The description was given as it was clear through the investigation that the premises had been used by young people and there was no adult supervision.

14.8 The occupant was a 15 year old female, the daughter of the named tenant and her 17 year old female friend. The named tenant appears to have been absent from the property for periods of time, including several weeks, leaving the 15-year-old daughter responsible for the property.

14.9 There has been reference to there being complaints associated with anti-social behaviour in the block of flats, including smoking in the lift. However, the review could find no recorded evidence from Barnet Homes or the Barnet Anti-Social Behaviour Teams which directly relates to the flat.

14.10 The block of Flats is owned by Sage Homes Limited, a Registered Housing provider. In 2023, the block was managed by Places for People. The organisation had the management responsibilities for both the tenancies and overall repairs and maintenance of the building. This function was taken back in-house by Sage Homes in January 2024 in order to have greater control over their properties.

14.11 There has been a long-term Police and Partnership operation on a nearby Housing Estate. The operation, referred to as Operation Dakota, is part of the National Police Chiefs Council’s programme called Clear Hold Build, which aims to tackle organised criminality in local areas. Record checks carried out by the Police and Barnet Council’s Community Safety Team have not identified any of the individuals involved in the fatal stabbing of Michael, as part of Operation Dakota. The only time that any of the individuals are referenced within Operation Dakota, is when 3 members of the group have been arrested for the murder of Michael. Two of the group live within close proximity to each other, whilst the third does not live in either Barnet or Harrow.

14.12 There are a series of forums in Barnet that bring together Registered Housing Providers to discuss issues around crime or anti-social behaviour. These forums include the Community Safety Multi Agency Risk Assessment Conference, which focuses on complex Anti-Social behaviour cases, and an Adult Risk Panel for high harm non-anti-social behaviour cases. There is also a governance structure for the Clear Hold Build programme which is jointly overseen by the Metropolitan Police and Barnet Council.

14.13 The Barnet Community Safety Multi Agency Risk Assessment Conference meets 6 weekly. The meeting brings together partner agencies to discuss and resolve complex, high risk anti-social behaviour cases. The address was not brought to the attention of the conference as there were no incidents that warranted it being referred.

14.14 Places for People and Sage Homes did not attend these meetings and would have only been invited by Barnet Council if there was a relevant case. It is understood from lead officers in Barnet Council that other registered housing providers use these panels for high risk or complex cases. 

14.15 Exploring opportunities to attend multi agency partnership meetings, such as the Multi Agency Risk Assessment Conference, was specifically raised by senior managers within Sage Homes during the 1-2-1 interview process.  It has been highlighted by managers within Barnet Council that there are a significant number of Registered Social Landlords in the area, and it would be challenging to involve them all unless there are specific cases or locations that involve a Registered Social Landlord.

14.16 Key Learning point 1 – There are no clear contextual factors that brought the members of the group together. None of the group were arrested during the Clear Hold Build Enforcement programme, referred to as Operation Dakota. The evidence indicates that the key link between the group and the two females was the flat which had no adult oversight and was, for all intent and purposes, a free house. It is noted that as part of their investigations following the death of Michael, Police recovered two knives from the premises. There are clear safeguarding issues in relation to the occupant and those frequenting the address.

14.17 Summary - The only identified link between the group of 6 males and 2 females was the address that was frequented on the evening of the fatal stabbing of Michael and the weeks beforehand.  There is very limited information on the activity taking place in the flat and there was no adult oversight.

14.18 The key partnership learning is to explore the opportunities of greater engagement with Registered Housing Providers on key interventions of programmes that help to address local priorities, including serious violent crime and anti-social behaviour. This should include multi-agency programmes to tackle anti-social behaviour or organised criminality in local areas, such as the Council led Multi Agency Risk Management conferences and other local partnership governance arrangements.

14.19 KLOE 2 - Are there dynamics in relation to culture and/or Identity that create interrelationships or conflict between individuals or groups in the area?

14.20 The 6 individuals who were at the scene when Michael was fatally stabbed come from a variety of cultural and religious backgrounds. In fact, based on the evidence provided, this was not a formed group per se and certainly not a group that could be described as having conflict between other groups in the area.

14.21 The best description of the 6 males and 2 connected females is that they were drawn together by the opportunity of an unregulated address. Their links through schools or the local proximity were tenuous and created associations rather than any sense of group dynamics. This is evidenced through the 1-2-1 interviews but also based on the local Police and partner agencies mapping of named groups in the area. The 6 males and 2 females, or any combination of this group do not feature in any partnership forums or intelligence related to group conflict.

14.22 Learning Point – There are no learning points from this KLOE.

14.23 Summary – There are no cultural or identity connections that can be drawn from the dynamics of the individuals who are loosely associated and not a formed, or defined, group.

14.24 KLOE 3 - Does status and respect feature in the dynamics within and between those involved with or associated to the victim or perpetrator.

14.25 There is no direct evidence that status or respect featured in the dynamics between Michael and those connected to the peer group of 6 who were present at the scene of Michael’s fatal stabbing..

14.26 There is evidence that there was an issue of respect between Michael and the families who associated him with crimes carried out by Michael and his peer group in early 2021. Michael recognised this as a concern and even referenced that people were “out to kill” him. It is unclear how much this conflict extended to those that exploited him, particularly those involved in the drug supply market that he was engaged in.

14.27 However, through 2021 and into 2022, Michael appears to have withdrawn from his previous peer group and, based on the evidence, appears to have become more isolated. He clearly felt he was at risk and informed his key workers that he carried a knife as a form of protection. This is evidenced in the Child in Need Plan notes of October 2021 where it is stated that “In the past Michael has mentioned sometimes keeping a knife on him when he has felt vulnerable.”

14.28 It is less clear if agencies fully understood, or explored, these risks and concerns with Michael. This is covered in more detail within KLOE 4 below.

14.29 Turning to the group of 6 males who travelled together to Edgeware and who were at the scene of the fatal stabbing of Michael. As highlighted above this was not a fully formed group with any collective history of conflict.

14.30 However, there were members of the group who were beginning to develop a notoriety. Two members of the group were becoming involved in a number of offences with other named associates. The severity of the offences were increasing, from robbery and violent offences in 2022 to drug related violence and an armed robbery in 2023.

14.31 This evidence supports the theory held by the Senior Investigating Officer and Barnet Safeguarding leads that at least one, if not two members of the group were seeking status and respect within their peer group and are likely to have been more dominant figures. There is evidence that supports this theory. Two of the members of the group were related to each other and as stated above their offending, particularly their severity of offending, had been escalating. The author, senior investigating officer and the panel are in agreement that status and respect are key factors in considering why the one member of the group went towards Michael’s car.  

14.32 I strongly believe that this is also supported by the circumstances related to the “Free House” and events on the evening leading up to the fatal stabbing of Michael. It is noted that only one member of the group approached Michael’s vehicle and one person inflicted the fatal stab wound. This is evidenced through the CCTV camera and an eyewitness to the incident, both of which highlight one male approaching Michael’s car. The male then runs away from the car followed by all but one of the group of 6.

14.33 Learning Point 3 – Focusing on the group of 6 males who were at the scene of the fatal stabbing there is supporting evidence that at least one of the group was developing a growing notoriety where respect and status, personally and across his peer group, would have been a determining factor.

14.34 The Ministry of Justice publication “Understanding the psychology of gang violence: Implications for designing effective violence interventions” references the relevance of status and respect  as key motivational factors for both joining and maintaining involvement in a group or gang. Whilst the publication was some years ago, it still has relevance to the current day.^{[footnote 3]}

14.35 From a partner agency perspective, it would be difficult to identify how this risk could have been assessed within this group. However, it would be valuable for both Barnet and Harrow Community Safety Partnerships and Child and Adult Safeguarding Partnerships, to review their risk assessment processes to see whether Identity, Status and Respect, are defined risk factors, within their contextual safeguarding processes.

14.36 KLOE 4 - Do geographical boundaries impact on the operational structures, sharing of information, or resources that could assess risks of violence and vulnerabilities associated with personal or group conflict who travel across local authority boundaries? Addendum – Following the meeting with the family of Michael the KLOE has been amended to include: Did the agencies engaged with Michael recognise the risks through the same lens that the family saw?

14.37 There is evidence that there is a good dialogue between Harrow, Barnet and Brent that enables information to be shared on risks between individuals, groups or organised crime gangs. The author has seen evidence of cross border partnership mapping, and there are daily Violence, Vulnerability and Exploitation meetings held by Harrow Council, which enable sharing of intelligence and information with neighbouring boroughs. This is referenced in the Harrow Council Violence and Vulnerability Daily meeting Terms of Reference.

14.38 There are learning opportunities that would improve this meeting however, the concept should be considered as good practice.

14.39 However, what is evident from the information gathered, is that partner agencies involved with Michael since 2020 to the time of his death, did not assess risk in the same way and there were differences of opinion of the risk posed to and from Michael.

14.40 The minutes of Violence, Vulnerability and Exploitation Meetings, Child in Need minutes, MACE meetings, Youth Justice meetings, the Exploitation Risk Assessment and Probation Risk Assessment all provide clear evidence that support this. These are set out in Michael’s agency timeline which is detailed above.

14.41 It is also evident that agencies did not consider the views of Michael’s family in terms of the risks that they perceived. This was directly raised by the family and evidenced in the Child in Need Plan minutes of October 2021 and Multi Agency Child Exploitation minutes which either did not include the family’s views, or their views were not reflected in the final risk assessment. Where the family’s views are highlighted, such as in the Exploitation Risk Assessment, the risk assessment was assessed as Medium.

14.42 It is very clear that there are two different narratives in relation to Michael, his background, risk and offending behaviour.

• Narrative 1 – Michael came to the attention of partner agencies due to concerns that he was at risk of harm through exploitation. His level of offending increased and his lack of compliance with orders and failure to engage with support agencies meant it was impossible to achieve meaningful progress. There were family dynamics which caused the missing episodes rather than Michael being at risk of harm caused by exploitation from people outside of the family home.

• Narrative 2 – Michael came to the attention of partner agencies due to concerns that he was at risk of harm through exploitation. This was at a time just after Michael’s mother and stepfather separated. It was also during the first weeks of Covid lockdown, which caused a significant strain on the family dynamics. During and leading up to this period, Michael was developing an Identity based on his cultural experiences, which differed from those of his close family. This created increasing tensions within the family dynamics.

His vulnerabilities did not decrease and his lack of stable accommodation and any access to money resulted in his making a series of choices that consistently added to his vulnerability. He became aware that those who were his peers, or those he came into conflict with, were making threats to his life and he had little trust in the agencies who offered support, particularly after he provided a statement in 2021 and when his home was broken into in 2022. Michael had a lack of a sense of belonging and expressed this to his social workers. This lack of belonging, at home, in his peer group, through disengagement with education and constantly moving to different areas, increased up to the point of his death.

14.43 Whilst there are crossovers between the two narratives, as author, I am firmly of the opinion that, based on the evidence, the second narrative is a more accurate reflection of Michael and Michael’s journey during this period of his life. In order to demonstrate this the following table summarises the contextual risk factors that relate to Michael. All of these factors are evidenced in the Individual Management Reviews, minutes of meetings or supporting documentation.

Contextual Risk Factors	Evidence
Individual	Michael was of Romanian heritage. He had been in the UK from a young age which directly influenced his individual culture and identity. This created conflict within his family, which was exacerbated during the Covid lockdown period, particularly between March to June 2020. When he left the home, he was known to be living with older men which was a significant vulnerability. He had regular periods of moving from different addresses, or working and living away from home, from the age of 16. He had no stable accommodation from the age of 17. He stole food, committed robberies and began selling drugs to earn money and he had no other means of financial support. He had no legal EU status until the summer of 2021 which meant he could not apply for a driving licence, which he saw as an opportunity to earn money.
Family	Michael’s mother and stepfather had recently separated which affected Michael. There was growing conflict between Michael and his mother as well as his older family members Michael’s mother worked and there was an expectation that Michael would take care of his younger sister. This added to the tensions within the family.
Peer Group	Michael’s peer group were involved in criminal activity including burglaries, robberies and use of weapons. The relationship with his peer group changed after Michael gave evidence and threats were made against him.
School	Michael’s education was severely affected during the periods of Covid lockdown which took place in his GCSE year. Whilst he signed on at Stanmore College in the Autumn 2020, by December his placement was terminated due to a lack of attendance and non-completion of work.
Community	Michael stated he felt he had no sense of belonging. Michael spent periods of time living in different areas of London, Kent and Essex. Michael had no stable employment or defined career pathway.

14.44 Both the narrative of Michael combined with the contextual risk factors highly indicate that Michael had been impacted by a number of traumatic events, starting with the separation of his mother and stepfather, quickly compounded by the Covid lockdown.

14.45 There is a significant body of evidence relating to the impact of trauma in childhood and adolescence trauma is a key risk factor. As highlighted by Young Minds, the interrelationship between trauma and identity can affect mental wellbeing in adolescence ^{[footnote 4]}. This adds further weight to the importance for agencies to recognise Status, Identity, alongside Trauma, as key risk factor considerations, as part of any contextual safeguarding risk assessment process.

14.46 There are a number of key learning points for partner agencies to consider. These are set out below.

14.47 Learning Point 4 – Consistency of partner agencies contextual risk assessment.

14.48 The Review clearly highlights that there are very differing views of contextual risks, based on the perspective of each partner agency. As a result, assessments were not consistent with the actual risks posed and did not always consider all the factors of the agencies that had been, or were, engaged with Michael, his family or peer group. For example:

• Police leads did not consider that Michael was vulnerable to exploitation but saw the issues as related to family dynamics.
• Despite a Multi Agency Strategy meeting led by Youth Justice in 2021, in relation to the growing vulnerability of Michael, the Police MASH team advised that there was no report of a threat to harm so the Officer in Charge had not put the details on the Multi Agency Safeguarding Hub data system.
• The Probation Practitioner did not review the Child in Need plan for Michael when carrying out the risk assessment.
• The Child in Need meetings do not appear to have included other key agencies such as Youth Justice, the St Giles mentor or education leads to fully explore all of the contextual factors. As a result, decisions were taken with the anticipation that Michael was working with key agencies or providers, when in fact, they had not engaged with him.
• The GP surgery received a Risk Assessment for Michael from Hammersmith Custody Suite in August 2021 but made no attempt to call him for a follow up.
• There does not appear to have been any formal risk assessment following the incident in June 2022 when a group broke into the family home looking for Michael.
• The lack of contact or access to support by Michael was not viewed as a risk in its own right, or as a pattern which increased his isolation and vulnerability, by multiple panels.

14.49 It should also be highlighted that whilst Identity, Status and Respect are well documented contextual considerations, as highlighted in Learning Point 3 above, this does not appear to feature in any of the risk assessment processes provided. It should also be highlighted that Identity and trauma should also been considered within the contextual considerations, particularly where the cultural experiences of the child differ from the experiences of their family or guardian.

14.50 It is noted that concerns in the way that the Metropolitan Police Service assessed the risks associated with child exploitation were highlighted in His Majesty’s Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) inspection report into the Metropolitan Police Service’s handling of sexual and criminal child exploitation of children. ^{[footnote 5]}

14.51 The findings included the following serious concerns:

• The presence of victim-blaming language among officers and staff;

failing to identify exploitation, or to understand the links between missing children and exploitation.

• When children go missing regularly, the force’s response is frequently poor, with officers and staff simply waiting for them to turn up;
• The force often using officers and staff to investigate child exploitation who don’t have the skills or knowledge to do this effectively, with supervisors also lacking the right knowledge and experience; and
• Delays in starting and progressing investigations, and many missed opportunities to identify suspects and disrupt their activity, leaving children exposed to risk.

14.52 Summary – Agencies did not fully recognise the cumulative risks that were impacting on Michael’s decision making. As a result, non-engagement, which was a constant theme across agencies interaction, was seen as a reason to close down engagement rather than as an accumulation of the contextual factors affecting Michael. 

14.53 Based on the evidence gathered, Michael was not “hidden” to services, rather the agencies who were given responsibility to provide support, or an intervention, did not find ways to engage with him.

14.54 There is a clear opportunity for partner agencies, children and adult safeguarding leads to review the existing contextual safeguarding risk assessment processes to improve the consistency of approach. Status, Respect, Identity and Trauma should feature within the contextual risk assessment considerations.

14.55 Learning Point 5 – Dynamic Reviews of Contextual Safeguarding Risk Assessment

14.56 There is very limited information of any formal process where the contextual safeguarding risk assessments carried out through partnership agencies were being reviewed. The only concrete evidence of this taking place was through the Youth Justice Social Worker where Michael’s risk was assessed at the beginning and end of his Referral Order.

14.55 Whilst there were two MACE panel meetings in September and December 2020, the contextual risk factors were not fully reviewed and the case closed on the basis that Michael was in education and being managed by the YJS.

14.57 The Child in Need Plan was reviewed in October 2021 but closed as Michael had turned 18. However, his risk levels were not fully considered as part of this process and neither Michael nor his relatives were present.

14.58 The Daily Violence, Vulnerability and Exploitation Meeting reviews all daily incidents highlighting any high risks of harm and is a referral pathway to relevant services such as the Multi Agency Safeguarding Hub, Multi Agency Child Exploitation meeting, Mental Health, or Social Services. The daily meeting does not currently score or rescore outside any Exploitation Risk Assessment Form. 

14.59 It should be highlighted that other local authority areas have developed more dynamic contextual Safeguarding Risk Assessment processes. The Birmingham Children’s Trust has adopted this approach as part of its Empower U safeguarding approach to exploitation and vulnerability. Further advice and information on how Birmingham Children’s Trust are using the process, can be found through EMPOWERU EMPOWERU@birminghamchildrenstrust.co.uk

14.60 These processes are designed to enable partner agencies to regularly review the changing risk level using a simple scoring matrix. The matrix includes:

• The contextual Safeguarding headings

• Whether the risk is
  • Emerging – beginning to come to the attention of agencies,
  • Experiencing – in an existing risk factor,
  • Significant – it places the individual at significant risk of harm,
  • Each of the above are scored on a Red, Green or Amber basis.
• An Escalation Assessment – The assessment enables partner agencies the opportunity to identify if the risk is decreasing, increasing or remaining stable. Stable includes the assessment that there has been no material change.

14.61 The dynamic system enables partners to review the contextual factors and supporting them in understanding both the increasing prevalence of risk, but also which contextual factor is the more dominant. The following grid is an illustration of the scoring process, based on Michael’s Contextual Safeguarding Factors prior to his fatal stabbing.

Contextual Safeguarding Heading	Comments	Risk	Escalation assessment
Individual	[blank]	Significant	Increasing
Family	[blank]	Experiencing	Stable
Peer	[blank]	Experiencing	Increasing
School	[blank]	Experiencing	Decreasing
Community	[blank]	Experiencing	Stable

14.62 The process is designed in such a way that it enables partners to carry out a swift review and trigger a more in depth assessment, or referral to partnerships panels.

14.63 Summary - In order to achieve a more dynamic, universally recognised risk process both Harrow and Barnet Community Safety Partnerships should explore best practice in simple, dynamic risk assessment processes which can be applied universally in any violence and vulnerability forums.

14.64 Learning 6 – Violence, Vulnerability and Exploitation Daily Meeting – Risk Assessment

14.65 The Violence, Vulnerability and Exploitation Daily Meeting is run by Harrow Council to share fast time information with regards to youth related violence, vulnerability and exploitation.

14.66 The Impact of the meeting is stated in the Terms of Reference as follows:

“The meeting has proven effective in enabling all relevant agencies to make prompt and informed decisions, and initiate action to be taken to minimise risk of harm or of potential incidents.  All incidents and actions are recorded, tracked and disseminated and help to develop a strategic response to Violence Vulnerability and Exploitation.”

14.67 The meeting is an effective way of assessing both emerging and current risks related to both individuals or groups and should be considered as good practice.

14.68 There are opportunities to improve the meeting by considering the introduction of a dynamic risk assessment as highlighted in Learning Point 5 above.

14.69 There is also a connected Exploitation Risk Assessment Form which enables partnership agencies to make referrals to the meeting and onwards to other agencies such as the Multi Agency Safeguarding Hub or the Multi Agency Child Exploitation Panel.

14.70 The form is detailed and provides a useful opportunity for practitioners to consider a number of key factors. However, it does not follow a Contextual Safeguarding Framework.

14.71 Summary - The Violence, Vulnerability and Exploitation meeting should be recognised as good practice. The meeting could improve its overall impact by including a Contextual Safeguarding risk assessment process, particularly where cases are brought to the meeting on multiple occasions (on three or more occasions).

14.72 Learning Point 7 – Reflecting the view of relatives or guardians or close friends.

14.73 During the interview process Michael’s family highlighted their concerns that partner agencies did not perceive the same level of risk that the family saw between early 2020 and the Summer of 2023.

14.74 Based on the evidence reviewed through the minutes of safeguarding meetings and 121 interviews, there is evidence that supports that view. As referred to above, Michael and his family were not present at the Child in Need meeting in October 2021 prior to the case being closed and the Exploitation Risk Assessment Form includes a small section relating to the view of his mother but no comments from Michael.

14.75 It should be added that there were consistent challenges with services engagement with Michael, which are documented within the Individual Management Reviews, panel minutes and 1-2-1 interviews. This is also recognised by Michael’s family.

14.76 Despite this there were opportunities to better engage with Michael and his family particularly at key reachable moments such as when he was robbed in 2021, when the house was broken into by males searching for Michael in 2022, during his Referral Order and his Community Order.

14.77 There were a number of reasons why this did not happen: -

• Covid was cited as a significant factor in how agencies engaged with criminal justice agencies and hampered direct contact,
• That Probation Service had implemented a prioritisation model to manage the caseloads,
• Less experienced staff were allocated to the case,
• That Michael had turned 18 and was classified as an adult.

14.78 There were also times when Michael’s responses were not fully explored and certainly not cross referenced with his family. There were times that he said he was working, that he had accommodation and was back at college, all of which were not verified. As a result, services were stopped or handed over to other agencies, but Michaels contextual risks had not reduced.

14.79 Michael’s family also raised a question to whether Michael was discriminated by both local and criminal justice agencies due to his Romanian Heritage. They have expressed an opinion that they sensed a greater level of negative sentiment due to the increased government and media focus on immigration.

14.80 The family have provided email evidence with the Professional Standards Unit, Central Specialist Crime from July to October 2022, following the arrest of Michael, where they raise their concerns of discrimination felt by the whole family stating that they were “all treated with disrespect, rudeness, arrogance and discrimination”. (email correspondence with the family dated July 2022). The family also highlighted concerns following the arrest of Michael which took place a few weeks after unknown males broke into the family home in June 2022. 

14.81 During meetings with them and subsequent emails and text conversations, that raised concerns that, in their opinion, unsubstantiated allegations were made against Michael which were subsequently not pursued. The family have expressed that concerns were not fully addressed during this period, when Michael was later arrested in October 2022 and through the criminal justice process.

14.81 The family also raised concerns about Michael’s treatment whilst in custody. He was 18 years of age at the time and as clearly evidenced was still a vulnerable young person due to a series of traumatic incidents including, at the time, people breaking into his family home looking to harm him. Despite this, the response to the complaint made by Michael’s family on his behalf, was “Regarding xx in custody, if he wishes to make a complaint he will have to himself, as per the same procedure you have, unfortunately you can’t make a complaint on someone else’s behalf”. (email correspondence with the family by the Professional Standards Unit August 2022)

14.82 There is national research that highlights the challenges that Roma communities face in terms of their view of government bodies and their cultural heritage, particularly post Brexit.^{[footnote 6]} The views of Michael’s family, combined with national research, strengthen the key learning and recommendations that Culture and Identity should be key consideration as part of any multi agency contextual risk assessment process and embedded in the training programmes for practitioners, front line officers and agencies.

14.83 Summary - The view of family, close relatives, or guardians and the individual should be a fundamental part of any risk assessment. Harrow Children’s and Adults Safeguarding Partnership should consider how the views of individual, parents, relatives or guardians can be obtained. The aim of this approach is to better inform the contextual safeguarding risk factors, including Culture and Identity, so they reflect the full extent of risk, through the eyes of both professionals and those closest to the person at risk. Embedding a greater understanding of Culture and Identity with training programmes for front line officers and agencies will help to reduce perceptions of discrimination felt by diverse communities.

14.84 – Learning Point 8 – Adultification

14.85 – Adultification is best defined as “…when notions of innocence and vulnerability are not afforded to certain children. This is determined by people and institutions who hold power over them. When adultification occurs outside of the home it is always founded within discrimination and bias”.^{[footnote 7]}

14.86 The definition of adultification relates to a child’s personal characteristics, socio-economic influences and/or lived experiences. Regardless of the context in which adultification takes place, the impact results in children’s rights being either diminished or not upheld. This results in adultification bias which is contrary to child safeguarding legislation and guidance.

14.87 In terms of Michael, the evidence clearly indicates that agencies engaged with Michael did not apply the notions of innocence and vulnerability. When Michael did engage with agencies between the ages of 16 and prior to him turning 18, the vulnerabilities were evident, such as leaving home, living with older people, renting accommodation in Kent or taking low paid work. However, agencies treated these “choices” as if they were being taken by an adult, rather than a child.

14.88 Summary - Partner agencies need to be more aware of adultification and the potential for adultification bias, particularly in terms of children in adolescence. Improving partner agencies understanding of adultification and recognising adultification bias is highlighted as a key learning point.

14.89 Learning point 9 – Quality Assurance of Risk Assessment

14.90 Based on the above learning points the author feels that partner agencies, including the Police, Probation Service, Children and Adults Safeguarding, community safety professionals and commissioned partner agencies should consider how risk assessment processes are quality assured. This would improve the overall decision making in terms of the level of risk posed to, and from, the individual across the contextual safeguarding headings.

14.91 It is noted that Probation Services Senior Managers have highlighted this in their individual agency learning as set out below. However, partner agencies may wish to consider developing a multi partnership Quality Assurance Process to train senior managers, or supervisors, with the aim of achieving greater consistency of assessment.

14.92 Learning Point 9 – Post 18 provision and Support

14.93 One of the most troubling elements of this case relates to how service provision fundamentally changed for Michael once he became 18 years of age.

14.94 Once Michael’s Child in Need Plan was closed, his access to support services became limited. Other than engagement with his Probation Practitioner, his contact with other agencies stopped. It is noted that both Prospects and Turning Point were willing to continue to offer support until Michael was 19.

14.95 It was noted in the Child in Need minutes that unless someone actively pursued Michael, it was well documented that he was unlikely to seek support. However, information in career opportunities, drug support services or housing application processes were emailed to Michael or sent to the home address. There is a clear challenge to agencies, who had the best of intentions, in whether the ways they engaged with Michael were appropriate based on their knowledge of Michael.

14.96 However, despite turning 18, none of Michael’s vulnerabilities had reduced. It could be argued that between the late Autumn of 2021 and Summer of 2023, his risks increased. He was charged and convicted of offences, his house was broken into with threats to harm made towards Michael, and he had no stable accommodation. His relationship with his family remained fractious.

14.97 It is worrying that Michael should have been considered an adult with the ability to make adult choices. There is currently no multi-agency panel that captures those vulnerable adults transitioning to adulthood. This has been highlighted as a concern by Metropolitan Police Service lead officers and forms part of the recommendations below.

14.98 It is vital that Harrow Safeguarding Partnership Boards undertake a review on how support is continued past the age of 18 for a young adult who has recognised contextual risks.

14.99 In the past 10 years there has been a greater understanding on the development of the adolescent brain. There are numerous articles and publications that highlight that the parts of the brain that regulate our impulses continue maturing until our early 20s. ^{[footnote 8]}

14.100 It is also worth noting that the Metropolitan Police Service new crime recording system called Connect came into force in the Autumn of 2024. The formal measures of “Serious Youth Violence” and “Teen Violence” have been replaced by “Youth Violence”. “Youth Violence” is defined as “a count of victims aged between 10 and 24 years of any offence of Homicide, Lethal Barrelled Discharge, Knife Crime Robbery or Violence with Injury”.

14.101 In light of this recent research, there is now a strong body of evidence that defines adolescence up to and including the age of 19 years. The World Health Organisation defines adolescence at 10 to 19 years of age. The Organisation’s fact sheet on adolescent mental health provides good evidence of the importance in recognising the vulnerabilities that exist across this age range.^{[footnote 9]}

14.102 Key learning from this review and the academic research undertaken, highlights the importance for National Government to review the different definition of child, young person, adolescent and young adult to better align how vulnerability is considered. The aim of the review is to reduce the current cliff edge of support that exists at the age of 18 where services are reduced or withdrawn based only on age.

14.103 Learning Point 10 – Meaningful engagement and interventions

14.104   There was a wide range of services offered to Michael however, his engagement was limited. It is disappointing to read that a number of agencies considered the lack of engagement as a decision to close the case.

14.105 The manner in which Michael was approached was not consistent with his risk factors or lifestyle. Face to Face contact was not a regular feature of engagement. Whilst Covid was a factor in 2020 and early 2021, the evidence does highlight that, although the interventions were aimed at meeting the needs, as assessed by professionals; drug and alcohol support, accommodation advice, mentoring, employment support; there does not appear to be a level of consistency that better engaged Michael. As a result, Michael’s risks did not diminish.

14.106 A good example is the learning highlighted by Michael’s General Practice Surgery. Despite writing to Michael and calling him on several occasions between March 2021 and August 2021, he did not attend any of the review meetings. The Practice have recognised this as a missed opportunity to discuss emotional wellbeing or substance misuse issues.

14.107 A key learning point is how the role of Domestic Violence or Sexual Violence Advocates support vulnerable clients at risk of abuse. They provide practical, social and emotional support to keep the client safe, advice on the criminal justice process, and to develop pathways to safely move on.  They provide a different role to mentors.

14.108 Harrow should use the findings of the review to look at the range of interventions and redefine meaningful engagement to focus on Face to Face contacts and activities that support their emotional, social and vocational development with vulnerable adolescents and young adults.

14.109 In addition, the partnership should review external 1-2-1 support and consider if developing Serious Violence Independent Advocates would result in a better outcome for vulnerable individuals or their parents/guardians, such as in Michael’s case. The decision on how and when the advocacy role is applied should align with the contextual safeguarding risk assessment process, as set out in the above learning points.

14.110 Additional considerations for learning – The weapon used in the Homicide.

14.111 The weapon used in the fatal stabbing of Michael has not been recovered. However, the Pathologist report dated February 2024 describes the weapon as a bladed article with two cutting surfaces. It inflicted a wound to Michael’s chest of approximately 9cm in depth and an incised wound to the right wrist in keeping with a defensive injury.

14.112 The opening statements in the trial Rex v XX refer to the weapon as a large knife or small machete.

14.113 The London Borough of Brent provides the Trading Standards Service on a joint consortium basis for the London Borough of Harrow with the London Borough of Brent being the lead authority. The consortium has been in place for over 50 years. This means that the Trading Standards service has the responsibility to enforce legislation across both boroughs.

14.114 Taking into account the National challenges for the Trading Standards profession in training qualified professionals and the additional financial pressures within local authorities, such an approach should be recognised as good practice.

14.115 Trading Standards have provided information on their approach to tackling underage knife sales.

• Between January 2020 and August 2023 Harrow Trading Standards carried out 10 age restricted test purchase operations for knives. On 9 occasions there were no sales.

• With regards to the one sale, both the company and seller received a letter of warning.

• During this period, Harrow Trading Standards carried out no online test purchase operations.

14.116 Trading Standards advised that their team proactively visit businesses and provide age-restricted advice to businesses and this also includes the sale of knives.

14.117 The purpose of these visits is to advise and ensure that the business is storing and displaying knives safely and securely so they could not be stolen or used as a weapon against staff or someone else and to check what steps they have in place to ensure they do not sell knives to a person under the age of 18.

14.118 The author has reviewed the Regulatory Enforcement Policy provided by Brent & Harrow Trading Standards Service. The policy provided was titled “Brent Enforcement Policy”, rather than a joint policy. The current policy is dated 2019 and requires updating. There is no reference to age restricted sales or online sales in the Policy

14.119 Trading Standards do not have a specific enforcement policy that highlights our approach to underage sales however they have advised that they adhere to the Home office guidance.^{[footnote 10]}

14.120 Key Learning Point

14.121 The availability of knives, particularly large knives and machetes such as those used in the fatal stabbing of Michael, is a significant concern nationally. The Offensive Weapons Act 2019 introduced legislation in relation to remote sales of certain bladed articles. Despite this, on line purchases remain a significant concern to front line agencies working to prevent knife crime.

14.122 As the current enforcement Policy requires updating, this provides an opportunity for Brent & Harrow Trading Standards to include a focus on age restricted sales including on line test purchases.

14.123   Individual Agency Learning

14.124 As part of the Review process the following section sets out the learning that has been identified by Individual agencies who were engaged with Michael or his family, or those charged with the homicide. Agencies have agreed to take this learning forward through their management and oversight processes.

14.125   National Probation Service

• There appeared to be a lack of professional curiosity by Probation Practitioners in this case. The case was assessed as low risk and due diligence was not used to check information provided by Michael.
• There needed to be a swifter Housing response when Michael became Homeless particularly as his request for Housing support services was the only provision that he took up.
• More details were required by Probation from safeguarding leads on their concerns regarding Michael, including the reasons which led him to being a Child in Need.
• There should have been a greater emphasis on carrying out a Maturity Assessment and adopting a trauma informed approach to inform the assessment and management of his case.

14.126 Metropolitan Police Service Northwest Area

14.127 The Approved Professional Practice for the investigation of violent crime could include the approach taken in Domestic Abuse investigations where there is a requirement for officers to complete checks on the past 5 years intelligence held within Metropolitan Police Service systems to inform investigative strategy and drive professional curiosity.

14.128 Senior Officers should ensure that there is an Action Plan in place for the Metropolitan Police Service North West Area in relation to the findings of His Majesty’s Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) inspection report into the Metropolitan Police Service’s handling of sexual and criminal child exploitation of children. This Action Plan should be presented to the Safeguarding Children’s Partnership with an agreed timeframe for updates on progress.

14.128 General Practice Surgery

14.129 The Surgery has identified the importance of holding more regular Adult Safeguarding meetings, particularly for regular non-attendance cases, or where Risk Assessments are received from partner agencies. The Practice Manager should seek to hold quarterly review meetings as a minimum.

15. Improving Systems and Practice (National, Regional and Local)

15.1 Purpose of OWHRs

“OWHRs should act to empower professionals to explore the way their organisation and the wider system they operate in could be improved to protect people from serious violence. Innovation in investigative methods and approaches, and the ability to challenge existing narratives, practice, and policy will be required to ensure a meaningful OWHR.”^{[footnote 11]}

15.2 The below recommendations aim to meet this purpose and the objectives of Offensive Weapon Homicide Reviews, to “identify what can be done differently at an agency and system level to prevent future homicides and reduce serious violence” (section 1.23 of the above guidance). 

15.3 National Recommendations

15.4 Recommendation 1 – For the Government, led by the Department for Education to review, amend and formally adopt the following definitions and age ranges for the terminology of a Child, a “Young Person”, an “Adolescent”

• Child – a person up to the age of 18
• Adolescent – a person between the age ranges of 10-19 - This would align with the definition of an adolescence as set out by the World Health Organisation^{[footnote 9]} and the Chief Medical Officer Demography report^{[footnote 12]} although the statistics in the latter report should be treated as historic the description set out under the section  “Why does adolescence matter” is still relevant.
• Young Person – a person between the ages of 10-25

15.5 Recommendation 2 - It is recommended that a clear definition of a young adult, being 18-24 years of age is formally adopted across government departments as set out in the Parole Board report Young Adults Member Guidance.^{[footnote 13]}

15.6 Recommendation 3 – That relevant Central Government Departments, led by the Department for Education, urgently reviews the safeguarding responsibilities of partner agencies for a young adult between the ages of 18-24, where there are recognised latent vulnerabilities, to ensure they receive the same level of support and protection as if they were under the age of 18. This will ensure that the level of support is not diminished due to an age-based “cliff age”, which is so evident in this case.

15.7 This approach will better align with the greater understanding of the scientific research in terms of brain development and emotional maturity which takes place in the early 20s, in order to prevent vulnerable individuals having key support withdrawn, due solely to the determination of their age.^{[footnote 6][footnote 7][footnote 8]}

15.8  The above recommendations align with the direction of travel set out in the government White Paper “Keeping Children Safe, Helping Families Thrive Breaking down barriers to opportunity” (November 2024).^{[footnote 14]} The vision set out in the White Paper is “… for children’s social care reflects our child-centred approach across government, where children come first and services are designed around the support they need to be safe, to be healthy and to flourish in life”. The above Recommendations should be considered by the Department for Education in any future changes to the law or steps to strengthen multi agency child protection as set out in the White Paper.

15.9 Partnership Recommendations

15.10 Recommendation 1 – Engagement with Social Housing Providers - Barnet Council, Barnet Homes and community safety leads, should consider how they formally engage with Registered Housing Providers on local issues such as crime and anti-social behaviour, long term enforcement or regeneration programmes. The aim is to maximise the opportunities to improve the flow of information and intelligence and, where appropriate, share resources. This should also be a consideration for Harrow Council and the Metropolitan Police Service Command area, covering Harrow and Barnet.

15.11 Recommendation 2 – Status, Respect and Identity – The cross borough daily Violence and Vulnerability meeting, Child and Adult Safeguarding Partnerships and multi-agency risk meetings, should review their risk assessment processes to ensure that Status, Respect and Identity, including cultural identity, are defined risk factors within their contextual safeguarding processes. Status, Respect and Identity should feature within the contextual considerations and be included in both the process and training on contextual safeguarding.

15.12 Recommendation 3 - Partnership review of Contextual Safeguarding Risk assessment processes - For partner agencies, children and adult safeguarding leads, to review the current contextual safeguarding risk assessment processes, carried out by the Child in Need Assessment, Multi Agency Safeguarding Panels, Youth Justice and Probation Panels, Violence Vulnerability and Exploitation daily meetings, the Exploitation Risk Assessment Form and with externally commissioned agencies. The aim of the review should be to improve the consistency of approach of assessing the contextual risk including the cumulative risk. This should include risks pre and post the age of 18 years.

15.13 It is acknowledged that the Terms of Reference for the Violence and Vulnerability Exploitation daily meeting is currently being reviewed and will consider and seek to incorporate recommendations from this report as appropriate.

15.14 Recommendation 4 – Introduction of dynamic risk assessment tool – Both Harrow and Barnet Community Safety Partnership should explore best practice in simple risk assessment processes which can be applied universally in any violence and vulnerability forums.

15.15 As part of this recommendation it is proposed that Harrow Council take the opportunity to consider how risk is assessed through the Violence, Vulnerability and Exploitation meeting, including the opportunities of using a dynamic risk assessment tool, particularly where individuals or groups are discussed on several occasions.

15.16 Recommendation 5 - Greater involvement of the individual and family voice as part of the formal risk assessment process - Harrow Children’s and Adults Safeguarding Partnerships should consider how the views of parents can be obtained to better inform the contextual safeguarding risk factors so they reflect the full extent of risk through the eyes of both professionals and those closest to the at-risk person. This should include strengthening the multi-agency, restorative practice approach,^{[footnote 15]} recognising the cultural challenges that certain migrant communities face when interacting with government agencies and the criminal justice system. Developing such an approach will benefit other Children and Adults Safeguarding Partnerships, both Pan-London and Nationally.

15.17 Recommendation 6 – Partnership training – Harrow Community Safety Partnership, Safeguarding Adults Board and Children’s Partnership leads should work together to develop a training programme on: -

• Adultification,
• The use of language, specifically victim blaming language in reports and risk management processes
• The relevance of Status, Respect, Identity, including Cultural Identity, in the risk assessment process and in engaging with individuals and families, from ethnic and culturally diverse backgrounds and communities.

15.18 The training should be multi partnership and include voluntary and community agencies who are commissioned to deliver interventions. Consideration should be given to the benefits of expanding this to cover partner agencies across the Northwest Borough Command Unit. This recommendation should be aligned with the review of the contextual safeguarding risk assessment process and a dynamic risk assessment tool as set out in Recommendations 4 and 5 above.

15.19 Recommendation 7 – Quality Assurance and learning from Risk Assessments – Police, Probation Service, Children’s Partnerships and Adults Safeguarding Board, community safety professionals and commissioned partner agencies should consider developing a Multi Partnership Quality Assurance Process for Risk Assessments. Senior Managers or Supervisors across key partners should be trained on the process, with the aim of achieving a greater consistency of assessment.

15.20 Recommendation 8 – Introduction of a post 18 provision - Harrow Community Safety Partnership and Harrow Adults Safeguarding Board to work together to establish a multi-agency panel that captures and supports vulnerable young people transitioning to adulthood (18-24 year olds). The panel is to consider cases of young adults who remained at high risk of contextual harm including a clear understanding of the importance of Identity and Culture. The panel should aim to deliver interventions that support young adults, practically, emotionally and socially to reduce the risk and make positive choices by providing 1-2-1 advocacy support. Michael’s family have specifically highlighted this recommendation as a crucial improvement that would support them in their determination to “make him proud and serve him justice” (see 9.5 and 9.6 above).

15.21 Recommendation 9 – Defining support and interventions, including advocacy - Harrow Community Safety Partner agencies should use the findings of the review to look at the range of interventions for those identified as being at risk to exploitation and/or group conflict, and redefine meaningful engagement to focus on Face to Face contacts with vulnerable young people and young adults. This should include clear evidence that the intervention includes engagement in activities which progress the persons progress in moving away from exploitation, or group conflict.

15.22 In addition, the partnership should review external 1-2-1 support and consider developing Serious Violence Independent Advocates to improve better outcomes for vulnerable individuals or their parents/guardians. The decision on how and when the advocacy role is applied should align with the contextual safeguarding risk assessment process as set out in the above Recommendations.

15.23 Recommendation 10 – Harrow Enforcement Policy and on-line Test Purchases

15.24 Brent & Harrow Trading Standards to update the current Enforcement Policy so that it clearly covers both local authorities and includes a section which focuses on age restricted sales and on-line Test Purchases.

15.25 Recommendation 11 – Metropolitan Police Service

15.26 It is recommended that the Metropolitan Police Service Lead Responsible Officer for violence against the person considers effecting a change to the current Metropolitan Police Service violence against the person investigation policy to include extended mandatory intelligence checks in offensive weapon related criminal investigations.

15.27 This is already subject to a recommendation made by another Offensive Weapon Homicide Review as highlighted by Metropolitan Police Service lead officers.

15.28 Recommendation 12 – Harrow and Barnet Probation Service

15.29 To use learning and development opportunities to improve practitioner’s ability to be professionally curious and thinking in a more trauma informed way when conducting risk assessments.

15.30 Recommendation 13 – General Practice Surgery

15.31 To hold regular Safeguarding Adults meetings focused on regular no attendance cases, or where partnership Risk Assessments have been received. The aim is to ensure these have been acted upon and any communication or contact is appropriate for the patient, based on both their contextual risks and cultural background.

15.30 Good Practice

15.31 The Violence and Vulnerability and Exploitation daily meeting held, by Harrow Community Safety partners should be considered as best practice. The recommendations in relation to this meeting are aimed at building on, rather than impacting, the effectiveness of the meeting.

15.32 The work of the Youth Justice Social Worker should be highlighted. Between November 2020 and March 2021 was one of the rare times that Michael was willing to engage with services. The Social Worker should be commended for their support, despite the challenges that Covid restrictions imposed.

15.33 The Metropolitan Police Service North West area lead officer has highlighted the opportunities taken by the Police for sharing information with key partner agencies to help identify risk at the earliest opportunity to improve safeguarding procedures.

15.34 Since the publication of the His Majesty’s Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) inspection report into the Metropolitan Police Service’s handling of sexual and criminal child exploitation of children the Police have made a number of improvements in how such cases are handled, processed and reviewed. The Metropolitan Police Service North West area should provide Child and Adult Safeguarding Boards with an Annual Update on the process and its impact.

15.35 The support provided by the Family Liaison Officer to Michael’s family has been outstanding and the author of the report has witnessed this first hand. Despite the significant challenges of the case and the criminal justice outcome the Officer has continued to support the family which they have personally acknowledged.

16. Dissemination

Date circulated to relevant policy leads: 10/06/2025

Organisation	Yes or No	Reason
Harrow Council	Yes	Relevant Review Partner
MPS NW	Yes	Relevant Review Partner
North West London Integrated Care Board	Yes	Relevant Review Partner
Barnet Council	Yes	Relevant Review Partner
Probation Service	Yes	Appropriate Body

17. OWHR process

The process that was followed can be summarised as follows:

• The first panel meeting to set the terms of reference, scope and Key Lines of Enquiry took place on the 4th April 2024. Due to the fact that the trial into the murder of Michael was due to take place in late June/early July, the panel agreed to delay the next panel meeting until after that date.
• The Chair met Michael’s family in late April to talk through the review process and next steps.
• Collation and submission of Individual Management Reviews were requested for the 1st July 2024.
• The Chair met the family again in mid July to talk through the Key Lines of Enquiry and gain their insights. This was reflected back to panel members and the Key Lines of Enquiry amended.
• The first Panel meeting was set for the 22nd July. However, this and one subsequent meeting was postponed due to the lack of sufficient partner attendance.
• Series of individual agency interviews from July-October 2024 with lead officers across the relevant review partners, housing leads and commissioned service providers, to gather information and understand the process followed in relation to agencies involvement with Michael and the perpetrator.
• The second panel meeting took place on 9th October where the first draft of the report was presented to the panel members.
• A further panel meeting took place on 17th December 2024.
• The final panel meeting took place on the 4th February 2025.
• The Chair met with Michael’s family on the 7th February 2025 and had further correspondence with them on 18th and 19th April. Their comments and amendments have been reflected in the final report.
• The report presented and approved for submission to the Quality Assurance Board, namely the Harrow Community Safety Partnership.

18. Final confidence check

18.1 This Report has been checked to ensure that the OWHR process has been followed correctly and the Report completed as set out in the statutory guidance.

18.2 I can confirm that this Report section is at a standard ready for publication.

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

19. Statement of Independence by Chair

Chair: Jonathon Toy

20. Statement of independence from the case

20.1 I make the following statement that prior to 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 have met the criteria of 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 accordingly.

20.2 Jonathon has been working in the field of community safety and enforcement for the past 25 years with experience in four London boroughs, including 10 years as Head of Community Safety for Southwark Council.

20.3 He is recognised as a national lead in violence prevention. Jonathon has specialist knowledge in working with young people and families, schools and local communities affected by violence. He has developed innovative programmes to address violent crime and gang related violence. Over the past 20 years he has directly supported vulnerable individuals and families impacted by serious violent homicides. He continues to provide mentoring support for individuals and families in schools and local communities.

20.4 Jonathon worked with the Home Office in 2011 following the Summer Riots, advising on programmes to address gang and weapon violence and in the drafting of the “Ending Gang and Youth Violence Report” He was a member of the government’s national Ending Gang and Youth Violence Team, developing multi-agency approaches at a local level to address serious violent crime.

20.5 He was the lead consultant for Croydon Council in developing and adopting a Public Health Approach for Violence Reduction. Jonathon has provided support for the Ben Kinsella Trust and joined Thames Valley Violence Reduction Unit to shape a long-term approach to address the underlying causes of violence in the area.

20.6 Between January 2020 and April 2024, Jonathon was the lead officer for the development and adoption of the Safer Warwickshire Partnership Serious Violence Prevention Strategy. This includes ensuring all the statutory partners meet their requirements under the Serious Violence Duty and has been acclaimed for developing a Whole School’s Approach to violence prevention. Jonathon was also supporting colleagues across West Midlands in embedding a contextual safeguarding framework for violence prevention programmes. In addition, Jonathon oversaw Warwickshire’s Domestic Homicide Review (DHR) process, from the adoption to publication of DHR’s.

20.7 In April 2024, Jonathon joined Enfield Council as Head of Community Safety. He has strategic responsibility for delivering the Serious Violence Duty, working with the London Violence Reduction Unit of specific violence prevention programmes and has the lead responsibility for all Domestic Homicide Reviews.

20.8 Jonathon has published a number of articles and papers on gangs and serious youth violence, most notably a practitioner report in 2009 titled “Die another Day”, articles for Safer Communities (Pier Professional Ltd) and more recently published a highly acclaimed book “Silent Voices” – based on real life stories from people affected by gang violence.

20.9 Jonathon completed the Home Office training for Offensive Weapon Homicide Reviews in April 2024 and has attended 100% of the quarterly update session and network meetings held by the Home Office since the pilot programme began.

Signature: [signed]

Name: Jonathon Toy
Date: 08/07/2025

21. To be completed by the Home Office

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

1. Police, Crime, Sentencing and Courts Act 2022 commencement schedule - GOV.UK ↩

2. Equality Act 2010. Equality Act 2010 (legislation.gov.uk) ↩

3. Understanding the psychology of gang violence: implications for designing effective violence interventions (publishing.service.gov.uk) ↩

4. Cultural Identity & Mental Health - Family Pressures - YoungMinds ↩

5. The Metropolitan Police Service’s handling of the sexual and criminal exploitation of children - His Majesty’s Inspectorate of Constabulary and Fire & Rescue Services (justiceinspectorates.gov.uk) ↩

6. RomaCommunityPerspectivesonMigrationtotheUK.pdf ↩ ↩²

7. https://www.justiceinspectorates.gov.uk/hmiprobation/wp-content/uploads/sites/5/2022/06/Academic-Insights-Adultification-bias-within-child-protection-and-safeguarding.pdf ↩ ↩²

8. Neuroscience and brain development: Mentally Healthy Schools ↩ ↩²

9. Mental health of adolescents ↩ ↩²

10. Code of practice: age restricted products and services - GOV.UK ↩

11. Offensive weapons homicide reviews - GOV.UK ↩

12. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/252658/33571_2901304_CMO_Chapter_8.pdf#:~:text=Young%20people%20aged%2010%E2%80%9319%20years%2C%20defined%20by%20the,adolescence%20understood%20as%20the%20healthiest%20period%20of%20life. ↩

13. Guidance for Parole Board Members on Young Adult Prisoners - GOV.UK ↩

14. Keeping children safe, helping families thrive - GOV.UK ↩

15. Restorative Practice includes a range activities used to engage those affected by harm and conflict to communicate effectively about the impact of behaviour, explore relationships and mutually agree the steps that need to be taken to acknowledge and where possible repair the harm that has been caused. https://restorativejustice.org.uk ↩