Independent report

Report 13: offensive weapons homicide review, West Midlands (accessible)

Published 2 March 2026

1. Name of Relevant Review Partners

Birmingham Community Safety Partnership

West Midlands Police

NHS Coventry and Warwickshire

Coventry City Council

2. Case Reference Number

WMP COWHR010

2.1 The families of the victims have chosen the Pseudonyms.

Victim 1

Charlie

Victim 2

Shaun

Pseudonym 1:

Perpetrator 1

Saban

3. Date of incident which led to the Review

September 2023

4. Date of death where applicable

September 2023

5. Review’s start date (commissioned)

10/10/2023

5.1 Review completion date (approved and signed off):

5.2 Publication date: 02/03/2026

5.3 There are no significant delays in completion of this report. There were delays in engaging Immigration Enforcement Competent Authority (IECA) in gathering key evidence, pertinent to the learning points and recommendations. It was not until the first draft report was completed that full engagement commenced. This did result in the delay of the first draft and subsequent panel meetings.

5.4  It should also be noted that Saban was in a secure psychiatric unit.  At the date of completing this report, he continued to be assessed for his mental capacity to be charged. As a result, it has not been possible to speak to him.

5.5  Subsequently to the completion of the report, Saban was brought to trial in early summer of 2025 and was found guilty of attempted murder and two counts of manslaughter. He was sentenced to life with a minimum term of nine years and four months and also given an indefinite hybrid order under the Mental Health Act 2005.

5.6  There was a further delay to the publication following the media coverage of the report and the challenges highlighted by members of Shaun’s family in relation to the Home Office Immigration Service.

5.7  The Chair and Author of the report met with a member of Shaun’s family in Late Autumn 2025 and discussed the report in full with them. The family were provide with an opportunity to comment on the findings and recommendations.

5.8  The family raised concerns that Shaun’s real name, rather than a pseudonym, should be included. However, after careful review, the Community Safety Partnership who commissioned the review, decided that real names would not be included in the report, based on fairness, consistency, and safeguarding concerns.

5.9  Whilst first names were considered, the potential impact on Charlie’s family included their young children was a significant factor and could affect them now and in the future.

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)^{[footnote 1]}

6.2  Section 24(6) of the above Act sets out 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.

6.3  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.

6.4 Synopsis of the incident

6.5 In the early hours of a  Sunday morning in late summer 2023, a fail to stop fatal Road Traffic Collison was reported in a street, Coventry. A male pedestrian identified as Shaun, was declared as deceased at the scene.  A second male, Charlie, suffered fatal injuries after being knocked off his bicycle in a nearby road. The investigation has revealed that the vehicle was driven intentionally at the victims.

6.6  The recorded cause of death for both Charlie and Shaun were fatal injuries which occurred due to being struck by a motor vehicle.

6.7  There was no relationship between the perpetrator and either Charlie or Shaun.

6.8  The perpetrator referred to as Saban, had a recorded home address in Coventry. He was arrested and has subsequently been sectioned following a mental health assessment. 

6.9  Following the above incident the below Relevant Review Partners, led by Birmingham Community Safety Partnership, met in early October 2023 to assess if the circumstances of the Homicide met the definition for an Offensive Weapon Homicide Review, as set out above.

• West Midlands Police
• Coventry City Council
• Coventry and Warwickshire Integrated Care Board

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

6.11  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:

• Both victims are over 18 years of age
• The perpetrator is over 18 years of age. Although the perpetrator has not been formally charged with the offence, it was agreed by West Midlands Police, Senior Investigations Officer, that there are sufficient grounds for a review to take place.
• In this case it has been determined, in consultation with the Home Office, that a motor vehicle, driven deliberately with the intention of causing serious harm, meets the criteria of an offensive weapon.

6.12 Review Panel Members and local oversight process

6.13 In the autumn of 2023 Birmingham Community Safety Partnership formally notified the Secretary of State that the criteria had been met and an Offensive Weapon Homicide Review would be commenced.

6.14  Subsequently, Jonathon Toy, was formally appointed as Independent Chair and report author to undertake the Offensive Weapon Homicide Review.

6.15  An Offensive Weapon Review Panel was established. The first meeting took place on the 7th November 2023. The following Table (Table 1) sets out the Panel members, their roles, and the organisations that they represent.

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

Table 1 - Offensive Weapon Homicide Review Panel Members

Organisation	Position
Coventry and Warwickshire Partnership NHS Trust	Head of Safeguarding
Coventry and Warwickshire Integrated Care Board	Deputy Designated Nurse Safeguarding Adults and Children
Birmingham Community Safety Partnership	Community Safety Partnership Officer
Birmingham Community Safety Partnership	Community Safety Partnership Officer
UK Immigration Compliance and Enforcement Service-West Midlands	Assistant Director Immigration Compliance and Enforcement
UK Immigration Compliance and Enforcement Service-West Midlands	A/HM Inspector
Immigration Enforcement Competent Authority (IECA)	Head of Operations IECA Operational Lead Technical Specialist Team Leader
West Midlands  Police	Head of Review for West Midlands Police
Coventry City Council	CCTV and Community Safety Manager Violence Prevention - Programme Manager (Shared Post between Coventry City Council and West Mids Police) Modern Slavery Lead - Community Safety Officer Project Manager (Migration Team)

7. Terms of Reference

A Terms of Reference was drafted by the Independent Chair and Author and approved at the first Panel hearing on the 7th of November 2023. A redacted version of the Terms of Reference is attached (Appendix 1).

7.1  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:- The Alleged perpetrator is an illegal immigrant who arrived in the UK at some time in early 2022. He was arrested on immigration offences in the Summer of 2022. KLOE:- Were there any agencies who had an interaction with the perpetrator between these periods? This would include the Single Competent Authority whose role it is to determine the status of the subject as well as the agency completing the National Referral Mechanism (NRM) and its use in collaboration with other partners in identifying and referring potential victims of modern slavery and ensuring they receive the appropriate support.

NOTE – This KLOE was drafted as part of the original Scoping and Terms of Reference meeting. IECA representatives where not in attendance at this initial meeting. Subsequently policy leads have proposed the following amendment to ensure that it is factually accurate. This amendment was agreed at the final panel meeting on the 13th May 2024:_

Amended KLOE 1 - The Alleged perpetrator is an illegal immigrant who arrived in the UK at some time in January 2022. He was arrested on immigration offenses in August 2022. KLOE:- Were there any agencies who had an interaction with the perpetrator between these periods. This would include designated First Responders whose role it is to identify potential victims of modern slavery and, where appropriate, refer them to the National Referral Mechanism (NRM) for onward consideration,   Immigration Enforcement Competent Authority, one of two Competent Authorities, whose role it is to make decisions on cases referred to the National Referral Mechanism (NRM) about whether they are recognised as victims of modern slavery,  and collaboration with other partners in ensuring potential victims receive the appropriate support.

• KLOE 2:- To identify if any agency had any knowledge or indication that the perpetrator had a mental health assessment or was diagnosed with mental health needs.
• KLOE 3:- Are there opportunities by agencies or between agencies, to better manage individuals who are determined as having an illegal immigration status and released on bail, to ensure that contact is maintained.
• KLOE 4:- To explore if there are opportunities within local communities to better understand the cultural dynamics for those individuals who have no legal immigration status so that they have access to support, including financial, housing, and wellbeing support.

7.3  The agreed time period of the review is 1st January 2022 up to and including the date of the incident in early September 2023. The reason is that it is believed that the perpetrator, Saban arrived in the United Kingdom around January of 2022. The exact date is uncertain due to the fact that he arrived illegally and therefore, there is no formal documentation that can confirm a date. The date in September is the date of the incident that resulted in the death of both Charlie and Shaun.

7.4 Methodology for the review

7.5   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, interviews with Immigration Lead Officers and Immigration Enforcement Competent Authority (IECA) leads and face to face meetings with the families of the victims.

7.6  Key documents reviewed were in relation to the National Referral Mechanism process and statistics, including review of the Reasonable Grounds and Conclusive Grounds Decisions made by IECA and the national policies relating to the determining whether someone is or is not a victim of trafficking, at the time of the homicide and how they have changed subsequently.

7.7  The following Table (Table 2) sets out the document’s 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)	Quality assured by
Coventry and Warwickshire Integrated Care Board (C&WICB)	22.12.2023	C&WICB	Deputy Designated Nurse Safeguarding Adults and Children	n/a
Coventry and Warwickshire Partnership NHS Trust (CWPT)	22.12.2023	Safeguarding Adults professionals for CWPT	Named Professional for Safeguarding Adults	Chief Nursing Officer
West Midlands Police, Force Review Team	22.12.2023	West Midlands Police	Detective Constable	Head of Review Team

Short reports:

Agency	Submission date	Representing	Author (by role)	Quality assured by
Immigration Compliance and  Enforcement Service	19.01.2024	Immigration Enforcement Service	A/HM Inspector	N/A

121 group interviews:

Agency	Submission date	Representing	Author (by role)	Quality assured by
Immigration Enforcement Competent Authority (IECA)	22.01.2024 16.02.2024	Immigration Enforcement Competent Authority (IECA)	SEO Technical Specialist Team Leader	N/A
Immigration Compliance and Enforcement Service	19.01.2024 22.01.2024 16.02.2024 12.03.2024 15.03.2024	Immigration Enforcement Service	Assistant Director and A/HM Inspector	N/A

Key additional documents:

Agency	Submission date	Representing	Author (by role)	Quality assured by
Immigration Enforcement Competent Authority (IECA)	02.04.2024	The Reasonable Grounds and Conclusive Grounds Decision’s summation and minutes	N/A	Head of Operations and Operational Lead IC
Coventry City Council	13.02.2024	Mental Health Assessment Report	N/A	N/A

8. Equality and diversity

8.1  This section addresses the nine protected characteristics under the Equality Act 2010 (Footnote 2)^{[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 Act.

8.4  The Protected Characteristics are: age, disability, gender reassignment, marriage and civil partnerships, pregnancy and maternity, race, religion or belief, sex, and sexual orientation.

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

8.6  Saban is a white male and at the time of the incident he was 33 years of age. He had no defined disability prior to the incident. However, a Mental Health Assessment was carried out in the days, following the tragic events. The assessment report states that Saban :-

“ …. is suffering from a mental disorder of a nature and degree which warrants his admission to hospital for the purpose of assessment and possible treatment, for at least a limited period of time. The nature of his disorder is indicative of a psychotic disorder; however, the full extent, chronicity and progress is unclear and needs further assessment.”

8.7  As a result it was recommended that he be detained under section 2 Mental Health Act 83, in secure provision. Saban remains within this provision at the time that this report was written.

8.8  Saban is Albanian and originates from Fier Patos in a rural part of Albania. He does not speak English and he may have been a victim of modern slavery and debt bondage. Although there is no conclusive evidence to confirm this, it is referenced in the National Referral Mechanism Reasonable Ground Decision and the Mental Health Assessment interview. He may have been a victim of modern slavery and debt bondage. Although it is noted that a referral to the National Referral Mechanism resulted in a negative Conclusive Grounds decision based on there being insufficient evidence to confirm his alleged exploitation.

8.9  It is also likely that he had no stable accommodation and it is likely that he was sofa surfing, adding to his socio-economic disadvantage. Once again there is no direct evidence to support this, but subsequent checks on his given home address give a strong indication that this was likely to be the case.

8.10  Whilst Coventry is recognised as a City of Sanctuary with a wide range of support services for both asylum seekers and illegal migrants, checks with local agencies indicate that Saban did not seek or was not known to any of the local providers. This includes the Central England Law Centre, the Anchor Centre, New Start for Life and Coventry Refugee and Migrant Centre.

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

8.12  Coventry has a large number of Albanian nationals seeking immigration status compared to other areas of the country. The Home Office provides information to Coventry City Council on the number of NRM’s submitted, broken down by country of origin. Data indicates that for 2023, there were 41 NRM’s submitted for Albanian Nationals out of an overall total of 154 submissions for the Coventry local authority area. This is the second highest country of origin for NRM submissions.

8.13  Based on national studies it is recognised that Albanian nationals are very well interconnected within their own communities and families but as a result are less connected to other services.

8.14  Shpresa, a national organisation established to support Albanian communities, published a report “Into the Arms of Traffickers” (Footnote 3).^{[footnote 3]} The report concludes that –

“.….. delays in trafficking and asylum decisions place young people at greater risk of trafficking within the UK, and specifically labour exploitation and criminal exploitation. Home Office delays are causing mental ill health, social isolation, poverty, and distrust of authority. These are the same vulnerabilities that traffickers’ prey upon when grooming their victims.”

8.15  Whilst the report is focused on young people, its findings are equally relevant in Saban’s case, as it is evident that he had no contact with GP, health services or any other local support agencies.

8.16  It should be noted that Coventry City Council officers have taken a lead role in gaining a greater understanding of the Albanian community in the area.  As part of their research, over 100 Albanian nationals were spoken to and a booklet developed for local agencies in the West Midlands, to better understand the social and cultural challenges. (Albanian-Culture-A-Guide-for-Frontline-Professionals.pdf (westmidlandsantislavery.org) (Footnote 4) ^{[footnote 4]} This should be highlighted as good practice both regionally and nationally.

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

9.1 Both families were contacted about the OWHR process following the first panel meeting on the 7th November 2023.

9.2 The chair initially contacted the Family Liaison Officers in early November. A meeting with the families, their representatives and Victim Support Homicide Team had already been organised for the 15th November by the Family Liaison Officers.

9.3 The chair was invited and attended the meeting to discuss the OWHR process, its intended outcomes and the involvement of the families, as they felt appropriate.

9.4 Following the meeting the chair provided letters and the OWHR information leaflet to the Family Liaison Officers, in order to discuss this further with the families.

9.5 On 22nd January 2023, email correspondence from the Family Liaison Officer to the OWHR chair advised that Shaun’s family did not want to be part of the OWHR process, due to the fact that they did not feel there would be any significant change from the review. However, the chair has continued to liaise with the Victim Support Homicide lead, offering the opportunity for further discussions should their decision change.

9.6 The chair continued to correspond with the Victim Support Homicide lead through text and email and arranged to meet with Charlie’s family on the 20th March to discuss the findings along with the Victim Support lead.

9.7 During the meeting the chair set out the Key Lines of Enquiry that form the basis for the review and talked through the findings and recommendations.

9.8 The draft report was shared through the Victim Support Homicide lead on the 19th June 2024. The chair met with them again on the 28th June 2024 to talk through the report. This was the preferred medium, due to the technical elements of the report and its findings.

9.9 The pseudonym of Charlie was chosen by his wife and she has provided the following words for the report:-

Charlie was my husband and father to our two children. We all love and miss him very dearly. Charlie was extremely caring, considerate and loving to everyone in his life. He loved to look after those around him and was always supportive to me. He was my rock and my best friend. We have the most amazing memories as a family. Charlie would love to take us away on trips and would always be up for fun. He would always make me laugh and everyone around him loved his bubbly character and big smile. Not only will I miss him but everyone who knew him will feel a deep grief, he was such a special person and such a huge loss in our lives. Charlie was a fantastic dad to the children, they will now have to grow up without their dad but have the fondest memories of him and will cherish those forever. Charlie loved to take photos everywhere we went and loved to have them printed. I will now treasure these and love to look back at the beautiful times we had together. Charlie loved to cook! He made some amazing dishes and tasty food. He also loved gardening. I will miss him coming home and going either straight to the kitchen or into the garden after work to make dinner or watering the plants. Charlie was always very active, he used to love exercise and walking. We used to go out as a family biking or walking. I will miss being able to do this with him by our side. A huge hole has been left in our lives and we miss him so very much. Our love for Charlie will last forever.

9.10 The Victim Support Homicide lead has provided exceptional support and advocacy on behalf of both families. The chair would like to personally thank and recognise her for her compassion and kindness which was seen first-hand during the visits.

10. Family declined involvement

10.1 During the group meeting on the 15th November 2023, members of Shaun’s family expressed their concerns that the review would not have any impact to result in any change.

10.2  On 22nd January 2023 email correspondence from the Family Liaison Officer to the OWHR chair advised that Shaun’s family did not want to be part of the OWHR process, due to the fact that they did not feel there would be any significant change from the review.

10.3  However, the chair has continued to liaise with the Victim Support Homicide lead, offering the opportunity for further discussions should their decision change.

10.4 The pseudonym of Shaun was agreed upon by the Victim Support Homicide lead following a conversation with his mother.

10.4 Based on early conversations with the Family Liaison Officers and the Victim Support Homicide lead, the following description of Shaun has been prepared:-

Shaun always lit up a room. He has been described as living life to the full. He travelled the world, was a Disc Jockey and played a role in one of the country’s most popular soaps.  He was the youngest of large close family and he lived with his mother who misses him every day. His family said that he didn’t like cars, in fact they would go so far as saying he was frightened of them. The circumstance of his tragic death is not lost of them.

Shaun touched so many lives is a positive way and those they knew him said you couldn’t help but feel his warmth. He loved the colour white and it is testimony to him that hundreds of people attended his funeral, Shaun in a white coffin, surrounded by those friends and family whose life has a big hole without him.

11. Contact with the perpetrator and/or family members

11.1 Following the incident the perpetrator was admitted to a secure provision. He has remained within this provision to date and continues to be assessed.

11.2  The author has asked for updates on 3 separate occasions, but due to his ongoing assessment, it has not been possible to involve him in the review process.

11.3  There is reference to a relative (cousin) who Saban was allegedly staying with. This person has declined to make a statement to police and has only provided very limited information to us about Saban and his life.

11.4  Police investigation officers have indicated that the information the relative could offer to the review is likely not to be accurate and it is highly unlikely that he will engage.

11.5  In light of this advice and the fact that Saban has not been formally interviewed by the Police at the time that the report was finalised, it has not been possible to involve any family members for the perpetrator in the review.

12. Family History and/or Contextual Information

12.1 There is no contextual information in relation to either victim which bears any relevance to this case. Neither victim was known to the perpetrator prior to the tragic events of in the late Summer of 2023.

12.2 In terms of the perpetrator, it has been difficult to obtain any information in relation to his family history.

12.3 It is known that Saban comes from a small rural area of Albania. Prior to his arrival in the United Kingdom, he appears to have spent some time in Calais. During his Mental Health Assessment interview on the following the tragic incident, Saban referred to being “not in the right frame of mind when he left Calais”.

12.4 However, checks carried out by West Midlands Police with authorities in Albania found no reference to Saban having any underlying mental health condition.  It should also be noted that the findings of the on-call duty consultant and duty consultant who carried out the Mental Health Assessment interview, found that Saban “appears delusional, paranoid, psychotic”. Accordingly, his references to his experiences in Calais cannot be relied on.

12.5 It is understood that Saban has referred to staying with a “cousin” when he came to reside in Coventry. It has not been possible to speak to this person, due to their reluctance to engage with either the police, as part of their investigations, or with the OWHR process. Based on the experience of Police, Immigration Officers, and local anti-slavery network leads, it is strongly suspected that this person is unlikely to be a direct relative.

12.6 In summary there is little contextual information for Saban that is relevant, outside of the scope of the agreed timeline for this review.

12.7 Note – At the time of drafting the final report, the Police had not been able to formally interview or charge the perpetrator, due to the current mental health assessment. As a result, the author has chosen not to make further requests with possible family members to minimise any risk of impact on further investigations.

13. Agency Timeline

13.1  NOTE – It is important to note that in this case, there was no prior connection, or involvement, between the victims, Shaun and Charlie and the perpetrator, Saban. As highlighted in the summary of the circumstances above, in early September 2023, Saban randomly drove a car at three persons who he did not know and had no connection with. Sadly, the injuries sustained by both Shaun and Charlie resulted in their tragic deaths.

13.2  In light of the above, the key events revolve around Saban and agencies’ engagement with him from the time of his arrival in the UK and when he came to the notice of authorities. The involvement of agencies with Shaun and Charlie bears no relevance for this case to the learning and has not been included.

13.3  The timeline is based on the agreed timeframe set out in the Terms of Reference being January 2022 and September 2023. There was no contact with family members by agencies, or professionals during or prior to this period. As a result, a genogram has not been included.

13.4 Key events

13.5  The following Table sets out the key events and timeline, a short commentary of the events and contact with Saban and agencies.

Year	Date	Agency	Comments
2022	Approx. January	West Midlands Police (WMP)	Saban left Albania in early January 2022 and entered the UK illegally. There are two differing accounts provided by Saban related to this timeframe. Firstly, he arrived illegally in the back of a lorry in January 2022. Secondly, he arrived in the UK around March or April 2022.
	August	WMP	Saban arrested by WMP following a vehicle stop in Coventry and detained at Perry Bar Police Station.
	August	West Midlands Immigration Compliance & Enforcement (ICE)	Saban Interviewed by Immigration Compliance and Enforcement Officers.
	August	West Midlands ICE	Saban was served immigration paperwork for illegal entry and detained within Harmondsworth Immigration Removal Centre
	Sept	NRM/ Home Office	National Referral Mechanism (NRM) referral. The NRM referral was made by the Home Office (detained casework team) at Harmondsworth detention centre.  The grounds included that Saban was a potential victim of trafficking on the basis of being forced to work in a car wash in London, not being paid and assaulted and for the purpose of labour exploitation.
	Sept	NRM/Home Office	Notification sent to the Metropolitan Police of Saban’s account of UK-based exploitation
	Sept	NHS Trust	Saban admitted to Hillingdon Hospital.
	Sept	NHS Trust	Saban tested positive for Covid 19.
	3rd October	Immigration Enforcement Competent Authority (IECA).	Positive Reasonable Grounds decision made. Decision was recorded by the decision maker as “I suspect but cannot prove” that the individual is a potential victim of modern slavery” (As recorded on the Reasonable Grounds Decision minutes)
	3rd October	Perpetrator	Saban applied for Immigration Bail. This was refused on the 7th October
	October	Metropolitan Police	Informed the Home Office that their investigation into potential exploitation had been closed due to insufficient information.
	20th October	Immigration Enforcement	Following the positive RG decision, it was determined that there was no immediate prospect of removal within a reasonable timeframe and Saba’s detention was therefore no longer appropriate. Saban was released on Immigration bail to an address of a stated relative in Coventry. Commencement of reporting was set as 5th December 2022. The bail requirements were that he report to ROM Solihull, Sandford House, 41 Homer Road, Solihull, West Midlands B91 3QJ, between 10 am and 3pm and weekly thereafter.
	5th Dec	ICE	Saban did not attend to report on bail and did not attend subsequently to any weekly reporting requirements. There was no known criminal history, mental health issues on the system. Other than being a potential victim of trafficking there was no identified risk.
2023	March	IECA	9th March 2023 – The Salvation Army contacted after Lexmark Solicitors requested support.
	March	IECA	IECA contact Lexmark Solicitors to request further information
	March	IECA	Lexmark Solicitors contact IECA stating they had not had any contact with Saban and had withdrawn representation.
	March and early April	IECA	Two letters sent by IECA to Saban’s home address requesting further information. No response received.
	12th April	IECA	Evidence gathering completed. Ready to be assigned to a decision maker for a Conclusive Grounds decision.
	September	WMP	Homicide of Shaun and Charlie and arrest of Saban.
	Sept	Coventry and Warwickshire Partnership NHS Trust (CWP NHS Trust)	Saban assessed by the Liaison and Diversion Team (LIDI) in Police custody. He was found to be presenting with symptoms of a mental illness which required further assessment in a safe hospital setting.  Saban was admitted to a Medium Secure hospital under Section 2 of the Mental Health Act for further assessment.
	4th Sept	IECA	Email to Immigration and Compliance Enforcement stating that they expect a Conclusive Grounds decision to be made before 17/10/2023.
	4th Sept		Series of contacts between IECA and WMP in relation to the arrest of Saban by WMP, specifically:- 4th September 2023 – Lexmark asking for decision to be expedited due to Saban previously allegedly having Appendicitis and stress due to delay since claim being filed. 6th September – contact between IECA and WMP 8th September – details of arrest from WMP 11th September – logged and contacted again by WMP
	27th Sept	IECA	27/09/2023 – negative conclusive grounds decision made by IECA.
2024	9th January	SWP NHS Trust	Secure Forensic Service continue to assess Saban’s mental capacity to be charged.

14. Practice and organisational learning

14.1  The Terms of Reference for this case identified four Key Lines of Enquiries which has 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  Amended KLOE 1:- The Alleged perpetrator is an illegal immigrant who arrived in the UK at some time in January 2022. He was arrested on immigration offences in August 2022. KLOE:- Were there any agencies who had an interaction with the perpetrator between these periods. This would include designated First Responders whose role it is to identify potential victims of modern slavery and, where appropriate, refer them to the National Referral Mechanism (NRM) for onward consideration, Immigration Enforcement Competent Authority, one of two Competent Authorities, whose role it is to make decisions on cases referred to the National Referral Mechanism (NRM) about whether they are recognised as victims of modern slavery,  and collaboration with other partners in ensuring potential victims receive the appropriate support.

14.4 There is no evidence that Saban encountered any agency or support organisation during the period January 2022 and August 2022.

14.5  However, it has become clear during the review process that a critical factor was his interaction through the National Referral Mechanism assessment process, following the NRM referral made on 13th September 2022, until the Negative Conclusive Grounds decision made by the Immigration Enforcement Competent Authority on the 27th of September 2023.

14.6  The focus therefore has been on:-

• Whether there is learning from this case, that highlights opportunities to improve the National Referral Mechanism (NRM) decision making process?
• Whether there are opportunities for greater collaboration with other partner agencies to support Competent Authorities and Immigration Compliance and Enforcement to identify individuals, known through the NRM process who have failed to comply, with conditions, or where the decision-making process is significantly delayed?
• Based on the above findings, to make recommendations that can better safeguard individuals who are subject to an NRM decision making process, in terms of their physical and mental wellbeing, but importantly to safeguard the wider community, recognising that both Charlie and Shaun were innocent victims.

14.7 Key Learning point 1 – National Referral Mechanism decision making process.

14.8  Key learning point 1 sets out the timeframes based on Modern Slavery: Statutory Guidance for England and Wales (under s49 of the Modern Slavery Act 2015) and Non-Statutory Guidance for Scotland and Northern Ireland (hereafter referred to as Modern Slavery Statutory Guidance) and the timeframe as it relates to Saban’s case. It includes key findings and the conclusions, based on the evidence gathered through the review process.

14.9 The National Referral Mechanism (NRM) is a framework for identifying and referring potential victims of modern slavery and ensuring they receive the appropriate support. (Footnote 5) ^{[footnote 5]}

14.10  A referral can be made by identified first responders who are named in the above guidance. A ‘first responder organisation’ is an authority that is authorised to refer a potential victim of modern slavery into the National Referral Mechanism (NRM). All referrals are made to the Home Office, In Saban’s case the referral was made by Immigration Enforcement whilst he was at Harmondsworth Detention Centre.

14.11  Once a referral has been submitted, the decisions on all NRM cases, irrespective of the immigration status, nationality, or status of individual, are made by a Competent Authority (SCA or IECA). In the case of Saban, the Competent Authority which oversaw the decision-making process was the Immigration Enforcement Competent Authority (IECA).

14.12  There are two stages of the NRM decision making process.

14.13 In addition there are a series of actions available following the arrest of an illegal migrant which enables Immigration Compliance and Enforcement to request that a person can be issued papers and place on a return flight to their home country.

14.14 An Official Correspondence Manager for the National Returns Progression Command has provided the following statement in relation to Saban’s case:-

“There are no set timescales for the removal of individuals once they are detained. Detention can however only take place if there is a realistic prospect of removal within a reasonable timescale. As circumstances of any case changes, detention is reviewed in light of these changes and release may then become the most appropriate option.

The Home Office deals with significant and complex challenges when seeking to return those who have no right to be in the UK to their country of origin or lawful place of return. These challenges can include travel documentation, late applications, late appeals and broader non-compliance with a lawful returns process. In this particular instance a complex legal issue was raised whilst the individual was detained and this meant that there was no immediate prospect of removal within a reasonable timescale. As a result, the individual was bailed from detention.”

14.15  The “complex legal issue” refers to the reasonable grounds application made in relation to Saban.

Stage One – Reasonable Grounds Decision.

14.16  The threshold for a Reasonable Grounds test at the time that the referral was made for Saban was that, based on the information available at the time, in the mind of the decision maker, there are reasonable grounds to suspect but cannot prove that the individual is a potential victim of human trafficking.

14.17  This threshold was raised in revised Modern Slavery Statutory Guidance issued on 30 January 2023 and further amended following litigation in July 2023. The revised wording is “reasonable grounds to believe that the person is a victim of modern slavery”. (Footnote 6)^{[footnote 6]}

14.18  Even with the revised wording, the ‘reasonable grounds’ test has a lower threshold than is required for prima facie evidence (which is legally sufficient evidence, that, if contested, would establish a fact, or raise a presumption of a fact).

14.19  It should be noted that the SCA or Immigration Enforcement Competent Authority (IECA), has five working days, where possible, from the receipt of the referral to make a decision on whether there are reasonable grounds to believe that the individual is a “potential victim of trafficking”.

14.20 Stage Two – Conclusive Grounds (CG) Decision

14.21  The current Modern Slavery Statutory Guidance (footnote 6) sets out that following a positive Reasonable Grounds decision, a victim will receive a  Recovery Period of at least 30 calendar days beginning on the date the decision is made.  At the time of Saban’s positive RG decision, the Recovery Period was 45 calendar days.  No CG decision is issued during the Recovery Period.  Before a CG decision can be taken, the competent authority will also make attempts to gather further information relating to the account of exploitation from the individual or their legal representative and other agencies if involved with the individual.

14.22  The Conclusive Grounds decision is based on whether, on the balance of probabilities, the person is more likely or not to be a victim of modern slavery.

14.23  The burden of proof is more stringent than the reasonable grounds decision. This means that more evidence may often be required before a decision can be made.

14.24 Annex E of the Modern Slavery Statutory Guidance sets out the guidance for the decision making process for Reasonable and Conclusive Grounds decisions. (Footnote 7) ^{[footnote 7]} Section 14.136 states in relation to the CG decision that

“In reaching their decision the relevant competent authority must weigh the balance of probabilities by considering the whole modern slavery process and the different and interrelated actions that need to have taken place. To make their decision, they must weigh the strength of the evidence presented, including the credibility of the claim, and use common sense and logic based on the particular circumstances of each case.”

14.25 Section 14.168 states that there are three potential outcomes for a case at the Conclusive Grounds Decision stage:

• the individual is recognised as a victim of modern slavery (human trafficking)
• the individual is recognised as a victim of modern slavery (slavery, servitude and forced or compulsory labour)
• there is insufficient evidence to recognise the individual as a victim of modern slavery.

14.26  Based on the most up to date statutory guidance published on the  22nd February 2024 (see footnote 6) there is no target to make a Conclusive Grounds decision within a specific timeframe. A decision can only be made fairly, and reasonably once sufficient information has been made available to the competent authority for it to complete the decision. (Section 14.124) (footnote 6).

14.27  Although there is no target date, the above statutory guidance also states that “When the relevant competent authority has received sufficient information for it to complete a decision, it should seek to do so as soon as possible but only once a minimum of 30-calendar days of the Recovery Period have passed, unless the relevant competent authority has received a Request to delay the decision.”

14.27  The timeframes for Saban’s NRM referral

The timeline for Saban’s referral process is as follows:-

• 13th September 2022 NRM referral made.
• 3rd October 2022 – Reasonable grounds threshold met on the basis that Saban was being forced to work in a car wash for no pay.
• Saban was granted a ‘recovery and reflection period’ of 45 days from 3rd October 2022 until 16th November 2022.
• 20th October 2022 – Saban was released from Harmondsworth Immigration Centre on bail due to there being no prospect of removal in a reasonable timeframe.
• 12th April 2023 The IECA have concluded the evidence gathering stage and the case is ready to be allocated to a decision maker for a CG decision to be made.
• Early September 2023 - date of the homicide incident.
• 27th September 2023 – Negative CG decision made by IECA on the basis that there was insufficient evidence to recognise the individual as a victim of modern slavery. In light of the decision the NRM referral was considered to be concluded and there were no further barriers to removal.

14.28  The author has had the opportunity to review the Conclusive Grounds Decision made by the IECA on the 27th September 2023.

14.29  In summary, the decision is based on the fact that the information available to consider is deemed to be insufficient for the account to meet the balance of probabilities.

14.30 The Decision is recorded in the following statement.

“Taken cumulatively there are not considered to be Conclusive Grounds to believe that you were subjected to modern day slavery (human trafficking and or slavery, servitude or forced/compulsory labour)”.

14.31 National Referral Mechanism Timeframe

14.33 Based on the Modern Slavery Statutory Guidance, under the National Referral Mechanism process at the time of Saban’s case:-

• The Reasonable Grounds decision should be made within 5 working days from the National Referral Mechanism referral, where possible.
• Conclusive Grounds decision to be made after the 45 day recovery and reflection period’ from 3rd October 2022 until 16th November 2022.

14.34  Based on this Guidance and the fact that no Request to Delay was received from Saban or his legal representatives, a decision should have been made “as soon as possible” after 12th April as this was the date where the IECA had completed evidence gathering. This is referred to as “decision ready”, where the evidence gathering is considered complete and the case is ready for allocation to a Conclusive Grounds decision maker.

14.35  It would not be an unreasonable assertion that “as soon as possible” would mean a period of weeks, not months.

14.36  The final decision however was not made until 27th September 2023, 3 weeks after the homicide of Shaun and Charlie by Saban.

14.37  Through the interview process, it is clear that had Saban’s Conclusive Grounds Decision been made (that he had negative grounds to stay), Immigration Compliance and Enforcement would have taken greater steps to identify and detain Saban.

14.38  It is impossible to ascertain the timescale for such action due to the fact that Saban may have taken steps to ensure that he did not come to the attention of authorities.

14.39 National Context

14.40  It is important to note the national picture for Modern Slavery National Referral Mechanism process during 2022. Modern Day Slavery National Referral Mechanism and Duty to Notify Statistics UK Quarter 2 2023, sets out the pressures on both the SCA and IECA during the time period that Saban’s NRM referral and decision-making process took place (Footnote 8)^{[footnote 8]}

14.41  Key facts that are included in the report and which are relevant to this review are as follows:-

• The period September – December 2022 (Q3) recorded the second highest level of National Referral Mechanism Referrals between April 2014 and end of June 2023. (See Figure 1 below). This is the period when Saban’s Reasonable Grounds Decision was made.
• The most common nationality referred was Albanian and this has been consistent since April 2022.
• The proportion of positive decisions had remained relatively stable in recent years, with around 9 out of every 10 referrals receiving a positive decision. However, since 30 January 2023, the threshold for a positive reasonable ground’s decision changed, which has led to a reduction in the proportion of positive decisions issued.
• From April to June 2023, 2,086 conclusive grounds decisions were issued. The number of conclusive grounds decisions issued this quarter is the second highest since the NRM began, following the increasing trend since the early months of 2021 due to the recruitment of additional decision makers by the competent authorities.
• The average time taken from referral to conclusive grounds decisions made from April to June 2023 across the competent authorities was 451 days, compared to 565 days from January to March 2023 For conclusive grounds decisions made by the IECA, the average time taken this quarter was 414 days.

14.42 Summary

14.43  It cannot be ignored that had the NRM decision making process been made in a timelier manner, even allowing for delays in the system, Saban would have had a greater attention by enforcement services, specifically Immigration Compliance and Enforcement

14.44  It is fully acknowledged that officers involved in the decision-making process were under significant pressure due to the number of NRM applications being made in 2022, the more flexible Reasonable Ground threshold at the time, as set out above and staffing resources, specifically in decision makers being able to review cases deemed “decision ready”. This resulted in delays in the decision-making process, specifically following the 12th of April 2023.

14.45 It is evident that there are opportunities to tighten the process from when a Conclusive Grounds decision is ready to be made, and the decision being completed. Tightening this process will require additional resources and the involvement of a wider range of partner agencies, as set out in the recommendations below (see Recommendations 1, 2 and 3 below)

14.46 KLOE 2:- To identify if any agency had any knowledge or indication that the perpetrator had a mental health assessment or was diagnosed with mental health needs.

14.47  There is no evidence that agencies had any knowledge that Saban had mental health needs. The Individual Management Reviews have no information relating to mental health needs and checks with Albanian Authorities, carried out by West Midlands Police, have provided no evidence that there were mental health issues, prior to leaving his home country.

14.48  At no point during his interaction with agencies, from the point that he was arrested in August 2022 to his release from Harmondsworth Detention Centre in October 2022, was there an indication of mental health concerns  and no mental health assessment was either requested or carried out.

14.49  In summary, there are no key learning points that have arisen from this Key Line of Enquiry.

14.50 KLOE 3:- Are there opportunities by agencies or between agencies, to better manage individuals who are determined as having an illegal immigration status and released on bail, to ensure that contact is maintained?

14.52 Saban was released from Harmondsworth Detention Centre under bail conditions to report to Sandford House, Solihull, on a weekly basis from  the 5th December 2022. He did not adhere to his bail conditions and failed to attend on any subsequent weeks.

14.53 There was no follow up to the breach of bail. No letters were sent, or visits made to his last known address by Immigration Enforcement Officers or the Police.  Part of the explanation for this was that the risk assessment at the time for Saban was low. The Police have also stated in their Individual Management Review they were not aware of the breaches of bail.

14.54 The author has made further enquires with West Midlands Police, in terms of the management of immigration bail from the Police perspective.

14.55 Lead officers have advised that:

• Breaches of immigration bail are not notified to the relevant police force, especially where immigration are the only agency involved with the person.  (This was the case in relation to Saban)
• The only time where forces are notified is when the breaching individual is flagged on the Police National Computer, either as request to locate/trace or they are wanted for an offence.
• Police Forces will not be requested to assist in locating an individual unless there is a criminal interest in that person. (At the time of the breach of bail Saban was assessed as low risk and there was no reference to criminal interest)

14.56  It should be highlighted that Police Forces conduct ACRO checks when making assessment of risk. ACRO Criminal Records Office (ACRO) is a national police unit working for safer communities (Footnote 9)^{[footnote 9]} This assessment provides a greater understanding of the risk that an individual is likely to pose. Immigration Compliance and Enforcement do not undertake similar risk assessments.

14.57 Whilst this does not relate directly to this case, West Midlands Police have highlighted this as an opportunity to improve and more closely align risk assessment processes across enforcement agencies.

14.58 However, the other explanation provided by Immigration Enforcement Officers during the interview process is that a breach of bail for immigration grounds has no authority. Even if a person in Saban’s circumstances is identified as being in breach of bail, the outcome is for new bail conditions to be issued. In addition, breaches of bail also have no bearing on the NRM decision making process. 

14.59  Summary - It appears that the sanctions for not adhering to bail, for immigration grounds, are inadequate for enforcement agencies and provides limited incentives for individuals to comply with them. (See Recommendation 4)

14.60 KLOE 4:- To explore if there are opportunities within local communities to better understand the cultural dynamics for those individuals who have no legal immigration status so that they have access to support, including financial, housing, and welling support.

14.61  Section 8 above sets out the range of support agencies and services that have been established in Coventry to support Asylum Seekers and illegal migrants. In addition, specific information has been developed to provide front line agencies with a greater insight into the Albanian community as evidenced by the Albanian Culture - A-Guide for Frontline Professionals developed by the West Midlands Anti-Slavery Network (see Footnote 4).

14.62  This approach is highlighted as good practice.

14.63  It has also been evident throughout the interviews and information gathering process, undertaken during this review, that there is a significant commitment amongst lead agencies to work together to identify and support individuals who are known to the immigration system and who are awaiting a determination of status. The author wishes to highlight the following:-

• The extensive experience held by lead Immigration Compliance and Enforcement Officers recognised through the interview process.
• The knowledge of members of the West Midlands Anti-Slavery Network and Modern Slavery leads in Coventry City Council.
• The development of a booklet for local agencies in the West Midlands, to better understand the social and cultural challenges of Albanian nationals. (See Footnote 4 above)
• The extensive investment in community and voluntary sector provision in Coventry to support asylum seekers and illegal migrants. (See 8.10)
• The recognised close partnership working arrangement between West Midlands Police and Immigration Compliance Enforcement Service to refer and assess cases of illegal migrants, evidenced for example when Saban was first arrested in August 2022.

14.64  The above services are all highlighted as good practice and both officers and organisations should be recognised for their commitment to support asylum seekers and illegal migrants.

Learning Point 3 – Maximising partnership resources

14.65  Despite this experience, knowledge, and willingness to work collaboratively, there were missed opportunities for partner agencies to be engaged in Saban’s case. These include:-

• Saban was released from Harmondsworth Detention Centre on the 20th October but was not due to report for Bail until 5th December 2022. A referral to local support agencies would have offered the opportunity for Saban to be engaged in local services between these time periods.
• Saban failed to report for his bail conditions on the 5th December 2022, or subsequently. However, no contact was made and there was no visit to the known home address. Local partner agencies and support services were not contacted, and the Police were not notified. Local agencies could have been engaged in undertaking local checks and visits on behalf of the and Immigration Compliance Enforcement where the breaches of bail were repeated.
• Subsequent checks post 3rd September 2023, on Saban’s home address, have identified that the property was highly likely to have been a false address and unoccupied for a considerable period of time. Had they been engaged, Coventry City Council could have undertaken system checks through housing and benefits data, or through officer visits to assess the property and its occupancy.
• Coventry City Council provide a range of regulatory services, with powers to assess business operators. These services are intelligence led and can provide an invaluable resource in carrying out checks on businesses, including those where illegal migrants may be engaged or, at risk of, modern day slavery.

14.66  It is recognised that Saban, or those connected to Saban would have taken steps to ensure he remained hidden from authorities. As such partnership engagement may have been unable to identify him.

14.67  However, there are clear opportunities to develop a structured partnership approach to illegal migrants who are awaiting determination of status.

14.68 The aim of this partnership approach should be to:-

• maximise knowledge and experience,
• increase the opportunities to support individuals, financially, practically, and emotionally.
• Ensure that safeguarding principles are applied, to support those individuals awaiting lengthy determination of status and the wider community. (See Recommendation 5)

14.69 Additional consideration for learning – The weapon used in the Homicide.

14.70  An offensive weapon is defined, for the purposes of an Offensive Weapon Homicide Review, an offensive weapon is defined under section 1 of the Prevention of Crime Act 1953 as: 

“Any article made or adapted for use for causing injury to the person or intended by the person having it with him for such use by him, or by some other person.” ^{[footnote 10]}

14.71  In this case, the weapon used in the homicide of Charlie and Shaun was a motor vehicle which was fatally driven deliberately at them and a third victim who suffered minor physical injuries, in three separate incidents in early September 2023.

14.72  In terms of the vehicle, it was not registered, or insured, by Saban. It is understood that registered keeper was not linked to Saban, by either association or address. The registered keeper has not been traced at the time that this report was completed.

14.73  However, it is also important to note that the vehicle was registered and was not reported stolen and there is no evidence to indicate that it was uninsured or unroadworthy.

14.74  Saban does not have a UK driving licence. At the time of writing the report, enquiries are being made as to whether he held an Albanian licence.

14.75 The author has given careful consideration as to whether there is any partnership learning on how the weapon (the car) was obtained.

14.76  Based on the facts, it is concluded that there were no reasonable steps or opportunities that can be identified for partner agencies that would have prevented Saban from accessing the vehicle, or to intervene in its use.

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

15.1 OWHR010 Recommendations Preface 

15.2  The following recommendations are made based on the key learning points, set out above.

15.3  It is well documented that at the time that Saban was identified by authorities as an illegal migrant, the National Referral System and enforcement processes were overwhelmed with cases.

15.4  In Quarter 3 of 2022, 4,586 potential victims of modern slavery were referred to the National Referral Mechanism, of which 25% (1,147) went to the Immigration Enforcement Competent Authority (IECA).  In 2022, The average time for a conclusive grounds decision to be made in the IECA was 217 days. This rose, in 2023, to 489 days. (Footnote 11) ^{[footnote 11]}

15.5 It is also well documented that illegal migrants are often hidden and go to great lengths to remain hidden. Statistics provided by Immigration Compliance and Enforcement have highlighted that there are nationally around 100 listed absconders per week. An absconder is defined as someone who has not attended their reporting requirement on 2, or more occasions. 

15.6  In summary, it cannot be said for certain that Saban would have been identified by agencies if his negative Conclusive Grounds decision had been made at an earlier time. 

15.7  However, if the assessment processes were tighter and decisions made swifter, it would have resulted in other agencies, specifically Immigration Compliance and Enforcement and West Midlands Police, being involved in trying to identify him.

15.8  In conclusion, the recommendations are based on three key areas: -  

• How the decision-making process can be tightened, particularly when a Conclusive Grounds decision can be made. 
• Increasing partnership scrutiny where cases are delayed, or requirements not adhered to and 
• How more agencies can be trained and engaged to support the identification of those individuals who Immigration Enforcement cannot identify with the aim to safeguard those individuals and the wider community. 

15.9  It is highlighted that the purpose of Offensive Weapon Homicide Reviews, as set out under Section 1.26 of the Statutory Guidance for OWHR’s published in June 2023 is stated as follows: -  “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 12) ^{[footnote 12]}

15.10  The below recommendations aim to meet this purpose and the objective 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). 

15.11 Recommendation 1 - Improving the efficiency of the referral and decision-making process.

15.12  At present, the Modern Slavery Statutory Guidance states that the Reasonable Grounds decision, made by the Competent Authority, is an objective one. (Footnote 13)^{[footnote 13]}

15.13  Section 14.54 of the above guidance states that it is open to the Competent Authority decision maker to give appropriate weight to relevant factors and balance them with the account provided by the First Responder (the party who has made the referral).

15.14 There is comprehensive published guidance, as set out above, to support the relevant Competent Authority decision makers in reaching a decision. The guidance clearly states under Section 14.6 that:-

“All competent authority staff must take account of any relevant factors set out in the working with Vulnerable people section (Footnote 14)^{[footnote 14]} when making a decision as this section outlines some of the challenges victims may face in providing a clear and consistent account of their experiences. Competent authority staff must take account of these reasons when considering the credibility of a claim in the round”.

15.15 This includes the impact of trauma of modern slavery, which may be a valid reason why aspects of a potential victim’s account are inconsistent or, lack sufficient detail.

15.16  It is noted that recent changes in the assessment criteria have tightened. Since July 2023, when the threshold for a positive reasonable ground’s decision changed, there has been a reduction in the proportion of positive decisions issued.

• Of the 3,635 reasonable grounds decisions issued in this quarter, the proportion of positive reasonable grounds decisions reduced to 25% for adults. (Footnote 8)
• Of the 4,548 reasonable grounds decisions issued in the period October-December 2022 (when Saban’s reasonable grounds decision was made), the proportion of positive reasonable grounds decisions was 84% for adult potential victims. (see Footnote 15) ^{[footnote 15]}
• At the time of writing the report, the most recent publication, covering January-March 2024, shows that of the 5,161 reasonable grounds decisions issued this quarter, the proportion of positive reasonable grounds decisions was 42% for adult potential victims. (See footnote 16).^{[footnote 16]}

15.17 If Saban had received a Negative Reasonable Grounds decision, he would not have received protection from removal from the UK under the protection of being a potential victim of modern slavery, and he would have needed to make further representations in order to remain in the UK.

15.18 The Reasonable Grounds threshold has increased since the time of Saban’s reasonable grounds decision, however, that is not to say that had Saban’s referral been received after the change in threshold, the outcome would have been different.

15.19  In light of the findings from this Offensive Weapon Homicide Review, it is recommended that there should be a review of the cross agency training opportunities that can improve the NRM decision making process.

15.20  The following will support the overarching recommendation:-

• It is vital to ensure that all elements of the referral process are as efficient as possible, from the first responder through to the decision-making process. This would be supported through greater understanding of the importance of the first responder duty and how this is discharged. Developing and delivering training which sets out both the roles and how each element of the process interrelates, which can be delivered across all agencies would support this greater understanding.
• Competent Authorities should ensure that decision makers have access to continued appropriate training to enable them to make effective decisions.
• Consideration should be given to both updating training material and making training mandatory for first responders. This should include a focus on the importance of providing relevant information to support the decision-making process.

15.21 Recommendation 2 – Monitoring impact of changes to the Modern-Day Slavery Statutory guidance

The changes to the threshold for the Reasonable Grounds, as set out in Modern Slavery Statutory Guidance, are closely monitored by Competent Authority senior policy leads over the next 6-month period to ensure greater scrutiny of referrals are maintained.

15.22 Recommendation 3 – Incorporating Timeframes for Conclusive Grounds Formal decisions

15.23 This recommendation relates to the timeframe from when sufficient evidence has been gathered to make a conclusive grounds decision and the completed file is allocated to a decision maker, in order to assess the case and make the conclusive grounds decision.

15.24  In relation to the timescale for making a Conclusive Grounds decision, the Modern Slavery Statutory Guidance currently states:

14.124. “There is no target to make a Conclusive Grounds decision within a specific timeframe.  A decision can only be made fairly and reasonably once sufficient information has been made available to the competent authority for it to complete the decision. When the relevant competent authority has received sufficient information for it to complete a decision it should seek to do so as soon as possible but only once a minimum of 30-calendar days of the Recovery Period have passed, unless the relevant competent authority has received a Request to delay the decision…”

15.25  Based on the findings of this review, it is recommended that the Timescale for Conclusive Grounds Formal decision section of the Modern Slavery Statutory Guidance is amended as follows:-

“Where a relevant competent authority has received sufficient information for it to complete a decision, it should seek to do so as soon as practicably possible but no longer than 45 calendar days (and only once a minimum of 30 calendar days of the Recovery Period have passed), unless the Competent Authority has received a request to delay the decision.”

15.26  This time frame would apply once sufficient information has been received for the Competent Authority to assess a case.

15.27  In addition, it is recommended that the 45 calendar day  timeframe is reduced to 28 calendar days, following the “decision ready” decision (once the 30 calendar days of the Recovery Period has passed)  as the current improvements to the decision-making process comes into effect.

15.28  Introducing a clear time frame, from when the information has been gathered and the case is ready to be assessed and a Conclusive Grounds decision being taken, will tighten up the decision making process and reduce the risks of lengthy delays, which in turn impacts on the wellbeing of those individuals awaiting a determination of status.

15.29  Increasing decision-maker capacity within the Competent Authority to address the backlog will be key to the implementation of this recommendation.

15.30 Recommendation 4 -  Introduction of an Assurance Process for outstanding Conclusive Grounds Decisions

15.31  If recommendation 3 is accepted and a timeframe agreed, it is recommended that the Home Office Single Competent Authority (SCA) and Immigration Enforcement Competent Authority (IECA), work towards establishing an Assurance process for all Conclusive Grounds decisions that are outstanding after an agreed time frame.

15.32  As part of this recommendation, it is proposed that the agreed timeframe for the Assurance process to commence would be 260 calendar days, or 9 months, including the 30-day Recovery Period.

15.33  It is acknowledged that this is considerably less than the current time period for Conclusive Grounds decisions, which is 414 days. However, it should be recognised that the current delays are having significant impact on the health and wellbeing of those awaiting a decision, such as in Saban’s case, which in turn, has the potential of impacting on the wider community. (see footnote 3 above)

15.34 It is recognised that, at present, introducing an Assurance process would impact on existing resources which are currently focused on the case assessment process.

15.35  However, it should be a strategic ambition to introduce an Assurance process. The process should be defined by a criterion agreed between IECA, ICE and local enforcement agencies, based on a combination of agreed risk indicators and the time frame for each case.

15.36  In addition partner agencies involved in the NRM decision making process should agree a series of trigger indicators  which can escalate a case for more urgent review. It is recommended that the IECA, ICE, Police,   local authorities and stakeholders work together to agree the trigger indicators and establish a process to request expedition of a case.  The agreed process to request expedition would form part of future Modern Slavery Statutory Guidance. This is addressed in Recommendation 5 below.

15.37 Recommendation 5 – Bail Conditions for Migrants awaiting a Conclusive Grounds Decision

15.38  It is recommended that there is a change in the national policy for breach of bail conditions for immigration cases, in order that breaches of bail have a greater ramification.

15.39  Throughout this Offensive Weapon Homicide review, partner agencies involved in the NRM assessment process and those front agencies offering support for migrants, have made a strong case that breaches of bail should not directly impact on the Conclusive Grounds decision making process.

15.40 The rationale is that such an approach would adversely impact on those individuals who are being exploited through modern slavery, with the result of more individuals becoming hidden. Accordingly, there will be a need to adopt a safeguarding approach at the heart of the changes, with consideration for safeguarding the individual and wider community.

15.41 It is recommended therefore, that policy makers, lead officers in Immigration, Compliance and Enforcement and representatives of Association of Chief Police Officers work together to agree appropriate changes for breach of bail conditions which can be formally implemented.

15.42 To support this, it is recommended that Immigration Compliance and Enforcement conduct ACRO checks when making assessment of risk. ACRO Criminal Records Office is a national police unit working for safer communities.(Footnote 17)^{[footnote 17]} This will align with Police Forces, who have already adopted this approach. It would provide a greater understanding of the risk that individual is likely to pose and achieve greater consistency across enforcement agencies in assessing risk.

15.43 Whilst it is recognised that this would not be directly relevant in this case, as the risk assessment made was low, it would afford the opportunity for partner agencies to review the risk level collaboratively, including where there are consistent breaches of bail.

15.44 Consistent breaches of bail should trigger a response from a wider range of partner agencies, other than Immigration Compliance and Enforcement, in order to undertake reasonable steps to identify the individual. This may include checks on the last known address or registered place of work. In Saban’s case it could also have included checks on the vehicle that he was known to have been driving.

15.45 Recommendation 6 - Maximising partnership resources

15.46  It is recommended that partner agencies involved in the NRM process, West Midlands Police, and local delivery agencies, establish a local case management meeting process to undertake the following functions:-

• Share information with local service providers on individuals who have had a NRM Reasonable Grounds Decision in order that the local provider agencies can offer support services.
• Review individuals known through the NRM’s system where they have failed to comply with their bail conditions. This will enable local service providers to undertake local checks and support the Immigration Enforcement Service in seeking to identify them, or in highlighting further risks.
• Review all cases where a Reasonable Grounds decision has been made, but the Conclusive Grounds decision remains outstanding after an agreed timeframe, as set out in 15.25 and 15.26 above. This will enable the IECA to work with local provider agencies to consider any risks and seek support to resolving cases in a timely manner. In addition, this approach will provide partnership resources to support the Quality Assurance procedure as set out in Recommendation 4 above.

15.47  The agencies involved should be respective subject matter leads from Coventry City Council, local housing providers, West Midlands Police, Immigration Enforcement lead officers, NRM SCA/IECA lead officers and local service providers.

15.48  A clear information sharing agreement will need to be established and the regularity of a case management meeting be determined by local agencies. However, the purpose of the meeting should be clearly articulated; “To support agencies involved in the NRM process to identify risks and reduce delays in decision making, through closer partnership working”.

15.49 Recommendation 7 – Full engagement of key partner agencies

15.50  This is a specific recommendation made by the author of this review.

15.51  The key learning of this case revolves around the National Referral Mechanism process and the agencies involved in both the decision making and enforcement process. However, it has been both challenging and frustrating to both those managing this review and the independent author to engage key officers from these agencies, particularly in the early stages of the review.

15.52  Once a suitable lead from Immigration Compliance and Enforcement has been identified in early December 2023, progress was made.

15.53 However, despite the best endeavours by the author, it was not until February 2024, after the first draft was written, that suitable policy leads from IECA became involved.

15.54  Whilst the author wishes to acknowledge the considerable support provided by those officers in shaping the report and its recommendations, it was very evident in the early stages of identifying the Appropriate Bodies to be part of the review, that these key agencies did not respond to, or acknowledge the significance of the review process. This is particularly concerning as the Immigration Service and the Offensive Weapon Homicide Review programme are part of the same Government Department.

15.55 In light of this, the author recommends that Central Government Departments are specifically named as Appropriate Bodies, as part of the Statutory Guidance for Offensive Weapon Homicide Reviews, should  they be formally adopted. Awareness raising across Whitehall will be required, including the role of senior policy makers and managers for delivering national services.

Good Practice

As referred to in 8.16 above, it was noted that Coventry City Council officers have taken a lead role in gaining a greater understanding of the Albanian community in the area.  A booklet has been developed for local agencies in the West Midlands, to better understand the social and cultural challenges. (Albanian-Culture-A-Guide-for-Frontline-Professionals.pdf (westmidlandsantislavery.org) This should be highlighted as good practice both regionally and nationally. (Footnote 4)

16. Dissemination

Date circulated to relevant policy leads: 01/03/2024

Organisation	Yes	No	Reason
West Midlands Police	√	☐	Relevant Review Partner
Coventry City Council	√	☐	Relevant Review Partner
Coventry and Warwickshire Integrated Care Board	√	☐	Relevant Review Partner
Coventry and Warwickshire Partnership NHS Trust	√		Relevant Review Partner
Immigration Compliance and Enforcement	√	☐	Appropriate Body
Immigration Enforcement Competent Authority	√	☐	Appropriate Body

17. OWHR process

The process that was followed can be summarised as follows:-

• Collation of Individual Management Review which were received by the 31st December 2022.
• Series of individual agency interviews from January-March 2024 with lead officers in Immigration Compliance and Enforcement (ICE) to gather information and understand the process followed in relation to both the agencies involvement with the perpetrator, the response to immigration bail and the response to absconders.
• Series of individual agency interviews with the OWHR chair and with lead officer of Immigration Enforcement Competent Authority (IECA) to understand the assessment process, the decision making process post a Reasonable Grounds Decision and, current challenges for Competent Authorities. These interviews took place between January 2024 and March 2024.
• 13th February 2024 - Joint information sharing session with local professional involved in managing immigration cases in the West Midlands area and representatives of the West Midlands Anti-Slavery Network
• There was a joint information sharing session with the chair and representatives on ICE, IECA and the OWHR chair to talk through key recommendations and cross reference process improvements aligned to the recommendation. The meeting took place on 15th  March 2024.
• Two panel meetings - to talk through the draft reports. The first meeting was on the 14th March 2024 and talked through the timetable, key learning points and recommendations.
• At the request of the panel a precis was drafted by the OWHR chair on 15th March and shared with relevant review partners. Comments were gathered and the section was added to the report.
• Key recommendations that related to specific organisations were updated by the OWHR chair and shared by email. Amendments were made and the agreed version of the recommendation were added to the final version of the report. This took place between 20th March and 2nd April 2024.
• 13th May 2024 Final Panel meeting, recommendations agreed by all parties. KLOE 1 amended by IECA for accuracy.
• 28th May 2024 Final Report and executive summary submitted to Coventry Community Safety Partnership lead officers

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, 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 led 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 the London Violence Reduction Unit of specific violence prevention programmes and has the lead 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 attend 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: 19/07/2024

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: √

22. Scope/Terms of Reference

22.1  The Scope and Terms Reference are set out in section 7 above, in line with the OWHR statutory guidance.

1. Footnote 1 -https://www.gov.uk/government/publications/police-crime-sentencing-and-courts-bill-2021-overarching-documents/police-crime-sentencing-and-courts-act-2022-commencement-schedule ↩

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

3.  Footnote 3 - Into the Arms of Traffickers https://shpresaprogramme.org/research/ ↩

4.   Footnote 4 Albanian-Culture-A-Guide-for-Frontline-Professionals.pdf (westmidlandsantislavery.org) ↩

5. Footnote 5 - https://www.gov.uk/government/publications/human-trafficking-victims-referral-and-assessment-forms/guidance-on-the-national-referral-mechanism-for-potential-adult-victims-of-modern-slavery-england-and-wales ↩

6. Footnote 6 - Modern Slavery: statutory guidance for England and Wales (under s49 of the Modern Slavery Act 2015) and non-statutory guidance for Scotland and Northern Ireland (accessible version) - GOV.UK (www.gov.uk) ↩

7. Footnote 7 Annex E – Guidance for competent authority staff on the NRM decision-making process (please note this annex applies for all cases referred UK-wide) ↩

8. Footnote 8 Modern Slavery: National Referral Mechanism and Duty to Notify statistics UK, Quarter 2 2023 – April to June - GOV.UK (www.gov.uk) ↩

9. Footnote 9 Home (acro.police.uk) ↩

10. Footnote 10 - https://assets.publishing.service.gov.uk/media/5a7a3bf740f0b66a2fc00dcd/Knives_and_offensive_weapons_information_GDS_FAQ.pdf ↩

11. Footnote 11 - Modern Slavery: National Referral Mechanism and Duty to Notify statistics UK, Quarter 3 2022 – July to September - GOV.UK (www.gov.uk); Modern Slavery: National Referral Mechanism and Duty to Notify statistics UK, end of year summary 2022 - GOV.UK (www.gov.uk); Modern Slavery: National Referral Mechanism and Duty to Notify statistics UK, end of year summary 2023 - GOV.UK (www.gov.uk) ↩

12. Footnote 12  https://www.gov.uk/government/publications/offensive-weapons-homicide-reviews/offensive-weapons-homicide-reviews-statutory-guidance-accessible-version ↩

13. Footnote 13 Section 14.52 Modern Slavery: statutory guidance for England and Wales (under s49 of the Modern Slavery Act 2015) and non-statutory guidance for Scotland and Northern Ireland (accessible version) - GOV.UK (www.gov.uk) ↩

14. Footnote 14 -  www.gov.uk/government/publications/modern-slavery-how-to-identify-and-support-victims/modern-slavery-statutory-guidance-for-england-and-wales-under-s49-of-the-modern-slavery-act-2015-and-non-statutory-guidance-for-scotland-and-northe#vulnerable ↩

15. Footnote 15 - Modern Slavery: National Referral Mechanism and Duty to Notify statistics UK, end of year summary 2022 - GOV.UK (www.gov.uk) ↩

16. Footnote 16 - Modern Slavery: NRM and DtN statistics, January to March 2024 - GOV.UK (www.gov.uk) ↩

17. Footnote 17 - https://acro.police.uk/s/ ↩