Independent report

Report 8: offensive weapons homicide review, Brent (accessible)

Published 15 October 2025

Safer Brent Partnership Offensive Weapons Homicide Review

Report into the lives and learning through service engagement with the homicide victim and the perpetrators

P1, P2 and P3

Allan Doherty
Independent Chair and Reviewer

The Safer Brent Partnership, Offensive Weapons Homicide Review team and the Independent Reviewer would like to express their deepest regret for the loss of the victim’s life; as well as extending their sympathy to their family, and to their friends for their loss.

The Partnership also recognises the considerable distress experienced by the families of the perpetrators and those who know them.

1. Brief Outline of Homicide

1.1. In September 2023 police were called to an incident where a male had suffered multiple stab wounds. Police discovered the victim (V) unresponsive, and officers commenced CPR. V was then conveyed to a nearby hospital. Sadly, despite medical intervention, V died.

1.2. A forensic post-mortem found the cause of death was multiple stab wounds to the chest. All injuries were consistent with sharp objects with at least moderate force used.

1.3. Following the death a coroner’s inquest was opened and adjourned. As a result of an ongoing police enquiry the inquest remains open and adjourned. The coroner has been made aware of the Offensive Weapon Homicide Review (OWHR) into this death.

2. Police Investigation and Court Proceedings

2.1. P1, P2 and P3 were identified as suspects and were arrested and charged with murder and possession of offensive weapons.

2.2. Following a trial at Crown Court in 2024, all three pleaded not guilty to all charges but were convicted of the murder. They were each sentenced to life in prison, P1 with a minimum sentence of 28 years, P2 with a minimum sentence of 25 years, and P3 with a minimum sentence of 24 years.

2.3. It is understood that V may have been in an altercation with an individual 11 days prior to his death. During this the individual was stabbed through the window of their vehicle and sustained a significant injury.

2.4. It is suspected that this individual may have been involved in the murder of V. However, this individual has not been arrested and therefore is not subject to this review.

2.5. This incident was later detailed in the criminal trial of P1, P2 and P3, and reported in the press as a possible motive for the murder of V.

3. The Purpose of an Offensive Weapon Homicide Review (OWHR)

3.1. OWHRs were introduced through the Police, Crime, Sentencing and Courts Act 2022 and require the police, Integrated Care Boards (ICBs) and Local Authorities (LAs) in England to review the circumstances of certain homicides where the victim was aged 4 18 or over, and where the events involved, or were likely to have involved the use of an offensive weapon.

3.2. These reviews are separate from any criminal investigations or criminal proceedings, and they are in addition to any inquest or other form of inquiry, if applicable.

3.3. The purpose of OWHRs is to identify any lessons that can be learnt in relation to the death, and to consider whether there is any action which should be taken to aid in preventing future homicides.^{[footnote 1]} The review brings together all the relevant local partners and bodies and examines their work to consider whether any changes need to be made in policies or practices to aid in preventing future homicides involving offensive weapons. The reviews are not designed to investigate the death, identify culpable parties or to be a disciplinary process.

3.4. OWHRs are currently being piloted in the five London boroughs of Brent, Barnet, Harrow, Lambeth, and Southwark along with areas in the West Midlands and South Wales, prior to a decision being made on whether they will be adopted nationally across England and Wales.

3.5. Members of the Safer Brent Partnership (which includes the Metropolitan Police Service (MPS), North West London Integrated Care Board and LA services), with reference to the statutory guidance, confirmed that V’s death met the legal criteria for an OWHR to be completed. The OWHR Strategic Group of the Safer Brent Partnership agreed that following a final review of information gathering returns, V had links to the NHS, police and the National Probation Service (NPS). The information gathering returns also found that P1 had links to Brent Housing Needs, MPS and NPS. P2 and P3 also had links to police. As there was sufficient information and links for V, P1, P2 and P3 to relevant partners, the OWHR Strategic Group agreed that there could be lessons to be learnt within the scope of the OWHR.

3.6. Families, friends and other people who knew the parties linked to the homicide are invited to take part in the review, and to have the opportunity to speak voluntarily to the Independent Reviewer (IR) who is the author of the report. Families and friends can help in providing wider context, and a level of understanding of the lives and experiences of individuals prior to the incident which would otherwise be lost.

3.7. An OWHR will normally be completed within about 12 months of the death.

3.8. This OWHR report has been anonymised in accordance with statutory guidance. The specific date of the homicide has been removed. Only the IR and represented services are named. All relevant information (including names and associated review documentation) is secured by London Borough of Brent on behalf of the Safer Brent Partnership. A glossary of terms can be found at page 29.

3.9. The following initials have been used in this review to protect the identities of the victim and the perpetrators.

Adopted initials

Initial	Applied to
V	Victim
P1	Perpetrator 1
P2	Perpetrator 2
P3	Perpetrator 3

3.10. In October 2023, the Safer Brent Partnership, having established that V’s death met the legal criteria for an OWHR in accordance with the statutory guidance, proceeded to commission an independent OWHR.

3.11. A process for recruiting a Home Office trained OWHR IR was begun, and the IR was appointed in December 2023.

3.12. The Brent OWHR Strategic Group appointed Allan Doherty. Allan is a retired Police Officer who served with West Yorkshire Police for 31 years and retired at the rank of Chief Superintendent. During his police service Allan performed several roles including, Divisional Commander, Senior Investigating Officer (SIO) and Head of the Major Crime Unit. After retiring from the police Allan was appointed as an independent chair, reviewing Home Office decisions regarding victims of modern slavery.

3.13. This OWHR outlines the review process, the findings and recommendations considered by the OWHR Strategic Group in considering the lessons learnt from events prior to the homicide of V.

4. Equality and Diversity

4.1. The 2021 census highlighted Brent had a population of 339,800 people and was among the top 5% most densely populated English local authority areas. It was also noted to be one of the most ethnically diverse areas in the United Kingdom. According to this data, Brent’s population includes a significant proportion of residents from various ethnic heritages, reflecting the borough’s rich cultural tapestry. Approximately 65% of the population is from Black, Asian, and Minority Ethnic backgrounds. Specifically, about 18.8% of the population identifies as Black, which includes both African and Caribbean communities, along with other Black identities. In 2021 6% of the population in Brent identified at Black Caribbean, the sixth highest rate nationally and 32.8% of Brent’s residents identified as Asian, Asian British, or Asian Welsh. Within this group, the Indian community is particularly prominent, accounting for 19% of the borough’s population. Other Asian groups, including Pakistani, Bangladeshi, Chinese, and other Asian backgrounds, make up the remaining 13.8%.

4.2. Consideration was given to V and P1, P2, and P3’s backgrounds, including all nine protected characteristics under the Equality Act 2010^{[footnote 2]}, age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation. While it is recognised that some of these characteristics can influence service responses and outcomes, there is no definitive evidence to suggest that they played a role in this case, or that any biases impacted professional involvement or intervention.

4.3. Sex: All individuals subject to this review were adult males.

4.4. Age: V was 25 years of age, P1 was 19 years of age, and both P2 and P3 were 20 years of age at the time of the murder.

4.5. Disability: V was diagnosed with dyslexia, TICs (a neurological condition) and Attention Deficit/Hyperactivity Disorder (ADHD) as a young person. V was referred to the Children and Adolescent Mental Health Service (CAMHS) following his ADHD diagnosis, where he was able to access support. P1 suffered from a sickle cell condition which is considered a disability in the UK.

4.6. Race: V was of Asian heritage. P1 is Black British and born in Nigeria, P2 is Black British and born in London. P3 is of Iraqi heritage.

4.7. Sexual orientation: Information suggests two of the individuals had heterosexual relationships and V was the father of a child.

4.8. Marriage and civil partnerships: None of the individuals were formally married or in a civil partnership.

4.9. Socio-economic status: V worked as a car salesman for two years. P3 worked as a delivery driver for a fast food chain.

4.10. Consideration was given to how agencies respond to requests for housing provision for known offenders and there was an assessment of the effectiveness of the multi-agency network in the management of ongoing risks including the effectiveness of risk assessment and intervention strategies.

5. Family History and/or Contextual Information

5.1. Efforts were made to engage with the family of V, as well as the close family members of P1, P2, and P3, as part of the review process. However, due to the sensitive and complex nature of the enquiry, opportunities for a meeting did not arise.

5.2. V’s Family History: V lived in stable accommodation in the London Borough of Harrow with his mother and his siblings since 2012. He appeared to be happy at the accommodation, he was well supported by his mother and close to his siblings. V’s parents were separated, and he did not have a relationship with his father.

5.2.1. V struggled with reading, writing and numeracy which made formal education difficult, he was diagnosed with dyslexia, TICs and ADHD as a young person, he was subject to temporary exclusions prior to him completing GCSEs, despite these barriers he managed to gain six GCSEs at school. Following this he attended college and was undertaking a BTEC in multimedia.

5.2.2. The exclusions occurred whilst he was at school and were outside the scope of this review.

5.2.3. V had a daughter with his ex-partner, he saw his child on an infrequent and informally arranged basis.

5.3. P1’s Family History: P1 lived in the London Borough of Brent with his mother and siblings.

5.3.1. P1 left full-time education with several GCSEs. He had no employment since leaving education but admitted during the trial to have been a drug runner.

5.3.2. P1 reported having several breakdowns when he was younger, however, he had no diagnosed mental health issues

5.4. P2’s Family History

5.4.1. P2 lived at home in the London Borough of Brent with his mother, father and sibling.

5.5. P3’s Family History

5.5.1. P3 lived in the London Borough of Brent with his mother and brother.

6. Methodology

6.1 An examination of the contacts between the persons subject to the review and the local statutory agencies revealed several interactions and key practice episodes (KPE). The vast majority had occurred within the two-year period preceding the homicide and therefore this period was considered appropriate to review, any significant events that occurred outside of this period were mentioned where appropriate, to ensure proper context was considered. The IR liaised on a regular basis with the police SIO and his deputy whilst conducting this review.

6.2. Review partners submitted information gathering returns in two phases. Firstly, to scope what interactions took place with partners. This information supported the development of the terms of reference and scoping documents. These documents were approved by the Brent OWHR Strategic Group.

6.3. The second information gathering phase consisted of further evaluation of the initial scope returns through a policy and procedure lens. This led to a series of case review meetings, led by the IR with each of the review partners to explore any further questions and to ensure clarity.

6.4. The returns revealed over 120 contacts between the key partner agencies and the four persons subject to the review, some of these were protracted and complex requiring detailed analysis. Amongst the 120 contacts, 106 KPEs were identified, these were used to create chronological agency timelines.

6.5. Separate chronologies were developed for each of the key agencies. (Section 7, page 8). These chronologies were presented to partners for review before completing an overview report. This was presented to the Brent OWHR Strategic Group for review and sign off.

6.6. The analysis considered the following:

• The level of engagement individuals had with local partners/bodies, both statutory and non-statutory; what support they received and what further opportunities there had been to support individuals
• What policy and procedure governed decision making and actions taken, and the resulting engagement with individuals
• What previous relevant information or history about the individuals involved was known and how this impacted assessment, planning, decision making and actions in respect of service users • What safeguarding processes were in place and how these considered any existing vulnerabilities.
• Collaborative working processes between agencies in supporting individual.
• Any challenges services faced in delivering support. This could include both organisational issues and other contextual issues.
• Whether actions were implemented effectively, monitored, and reviewed and whether all local partners/bodies contributed appropriately to the development and delivery of the multi-agency actions.
• Whether there are operational, policy or strategic improvements that could be made considering this incident.
• Identifying areas of good practice and successful interventions which could be incorporated into general processes and system responses.
• Whether improved data sharing could have had a positive effect on the case.
• The potential for identifying improvements to methods of preventing serious violence and the use of offensive weapons, or broadening understanding as to how to address serious violence from a systems perspective.

7. Chronology Insights

7.1. Prior to the period under review V was involved in offences of robbery, stealing from the person, and supplying controlled drugs. He had served custodial sentences and had been supervised by the NPS.

7.2. Access to ADHD Treatment – V

7.2.1. After his release from prison V visited his GP in May 2021 to obtain medication for his ADHD. He had received medication when he was younger, but due to several reasons he had missed appointments and was no longer receiving medication. Studies such as “ADHD and missed appointments in primary care settings” (Journal of ADHD Research, 2020) suggest individuals with ADHD are up to 60% to 90% more likely to miss appointments.^{[footnote 3]}

7.2.2. His GP was unable to prescribe the medication due to clinical practice guidelines, the GP referred V to the local ADHD service provider. V saw his GP on a further six occasions over the next two years regarding ADHD.

7.2.3. The GP was informed by the ADHD service that past referrals for V had not been received and therefore V was not on the waiting list which was 20 months.

7.2.4. Previous referrals made by V’s GP seem to have been ‘lost in the system’ resulting in a delay from May 2021 to January 2023, if the fault was that of the NHS rather than the patient, V should have been placed to a position on the list which reflected the original time of referral.

7.2.5. An attempt to gather more information regarding this issue from the ADHD service was made on behalf of this review but no reply was received.

7.2.6. The local ADHD service was commissioned to complete 441 assessments per year. The demand was so high, they had to close the service to new referrals with 5000 outstanding referrals and no further funding available. The waiting list for accepted ADHD assessment referrals is five years.

7.2.7. V’s GP and the local ICB have both acknowledged that leaving patients without treatment for ADHD for two years is unacceptable. The GP suggested that each practice should have at least one GP trained to prescribe and monitor for ADHD.

7.2.8. To address local ADHD waiting times, a business case has been developed for additional investment to reduce the backlog. The ICB is working to change the GP referral form so that greater visibility of referrals to all adult ADHD providers can be obtained which will inform future commissioning arrangements to ensure sufficient capacity.

7.2.9. The provision of ADHD services is in crisis nationally and the IR acknowledges the response in the form of a business case by Central and North West London NHS Foundation Trust to deal with this. Expanding ADHD specialist services in the NHS would improve access to timely diagnosis and care, offer holistic treatment options, reduce stigma through education and lower long-term costs by addressing unmet needs and preventing related health and social issues. The IR in collaboration with the OWHR Strategic Review Group considered this as a potential example of local good practice. However, it was concluded that it fell short of the necessary threshold.

7.2.10. The treatment V received for his ADHD fell outside the scope of this review, however, the IR sought information regarding the transitional arrangements for passing back care from prison healthcare to community GPs.

7.2.11. This process is called GP to GP - the prison contacts the patient’s community GP and advises them of the patient’s treatment, medication, diagnosis and hospital appointments. This will be dependent on the patient being registered with a GP. Patients are also given a summary of their care and treatment upon discharge. After their release, their records are passed on to their registered GP.

7.2.12. This process was not in place in 2020, V would have been provided with a summary upon his discharge for him to pass onto his GP, no record of this was found. V would have been de-registered from his GP and registered with the prison health service. He would have had to re-register with a GP practice on his release.

7.2.13. V was seeking help in managing his ADHD and despite his own and his GP’s efforts could not get the treatment/medication he needed due to a crisis with the ADHD services along with his referral not being properly dealt with. How the lack of treatment impacted on his behaviour is impossible to say, he continued to act in an anti-social manner, committing crime and engaging in violent behaviour. However, it is also true that V behaved in a similar way prior to the period under review when he was receiving ADHD treatment. The crisis in ADHD is being addressed locally and this is recognised by the IR.

7.3 Housing Support – V & P1

7.3.1 In September 2021 P1 approached his local authority housing provider seeking housing whilst disclosing problems at home. The housing provider and local safeguarding team assessed the case but were unable to offer housing as he did not meet the threshold for adult safeguarding. The safeguarding team acknowledged they could have signposted P1 to non-statutory services for support and could also have explored the local authority’s power to undertake a non-statutory safeguarding enquiry.

7.3.2 In June 2022 V made a homeless application to the local authority housing provider. The service was experiencing high demand and V was not offered an appointment for six weeks. Difficulty was experienced in contacting V due to an incorrect email address. V was assessed by phone and follow up checks were made with his GP to gather information regarding his medical history. No report was received from the GP. The GP holds no record of the requests. V reported difficulties at home and the housing officer spoke to his mother to confirm that he had left home the week before.

7.3.3 V disclosed to the housing authorities his previous offending behaviour and the fact that he was on probation. There had been several changes in the probation service staff, so he did not know the name of his current probation officer. The housing officer was unable to speak to V’s probation officer, despite this, V was accepted as eligible and was offered accommodation in a hostel. A letter was sent to V and several unsuccessful attempts to contact him by phone were made, in October the case was closed.

7.4 Probation Service Engagement – V

7.4.1. In October 2021 V’s period of probation ended, a week later he was sentenced again to custody for stealing from a person, after taking days spent on qualifying curfew into account he was released on the day of sentencing and commenced another period of supervision.

7.4.2. A risk assessment concluded that V was a low risk of serious harm. The probation service acknowledged that a previous conviction for robbery in 2016 should have been considered which may have resulted in a medium risk assessment. This was later changed. Liaison with the police around any known gang issues would also have been beneficial although V’s case did not meet the criteria for the MPS to return police intelligence checks.

7.4.3. V did not attend a scheduled probation appointment. He informed the PP that he was in hospital with a broken jaw following an assault the previous day. (No record of this was held by other contributors to this review). The probation service accepts that this event should have triggered actions to gather information from police and safeguarding services, however, no immediate action was taken which they identified as a gap in the management of the case.

7.4.4. V failed to attend subsequent scheduled probation appointments. He accrued unacceptable absences on two occasions in January 2022. Warnings were sent to him. This should have triggered a recall discussion with a manager as the licence period did not end until the end of January 2022. V did not attend until March 2022. The probation Service accepts that there were insufficient instructions given to obtain compliance, and appointments were not provided in line with expected standards. V did attend future appointments; the probation Service accepts there was little evidence of structured intervention work being delivered to support this frequency of appointment.

7.4.5. During May and June 2022 V was reallocated to another practitioner twice. Caseloads were being realigned and this impacted on the consistency of case management. He failed to attend some appointments, giving an excuse for one, the probation service accepts that insufficient professional curiosity was applied.

7.4.6. Information known about V’s potential vulnerability to serious group offending might have changed the decision not to offer further appointments. In October 2022 the post-sentence supervision period ended for V, the case/sentence was terminated.

7.4.7. Following his conviction at Sussex Magistrates’ Court V was under the supervision of the probation service. Prior to sentencing V was assessed as a medium risk of harm to the public through the targeting of individuals for acquisitive offences to be committed, with and without the use of weapons.

7.4.8. He missed his first two appointments, but these were recorded as acceptable absences as the probation officer gave V the benefit of the doubt as a means of engaging his compliance. V’s attendance continued to be sporadic at unpaid work and Rehabilitation Activity Requirement (RAR) appointments.

7.4.9. Having been convicted of a similar offence for which he had previously served a prison sentence and a period of probation, V continued to fail to attend his probation appointments. He was given the benefit of the doubt despite demonstrating similar non-compliant behaviour during his last period of probation. Whilst two letters were sent to V warning him of the consequences of his behaviour, it seems that V was not being sufficiently compelled to comply with the terms of his order and that sanctions should have been considered earlier.

7.4.10. In August and September 2023 V failed to attend all unpaid work appointments and he was suspended from the project. He also failed to attend all probation appointments with the PP on four further dates. A breach of the community order was initiated several days later but the breach information pack had not been submitted to court prior to his murder.

7.4.11. The breach pack was not submitted within the probation services guidelines, however had it been, the courts likely response would have been to communicate with V via written summons which would not have been received in sufficient time to affect his subsequent murder.

7.4.12. Given the instances above, V’s qualification for the Multi Agency Public Protection Arrangements^{[footnote 4]} (MAPPA) was considered by the IR and relevant review partners. V did not automatically qualify for MAPPA because he did not have a sentence for more than 12 months for a violent offence. If there had been sufficient concern in the case about the potential danger he posed to others, a referral to MAPPA under category 3^{[footnote 5]} could have been completed. This would ensure information sharing and a joint response to the risk management plan. No significant information was received during statutory supervision that would have triggered this.

7.5. Police Service Engagement – V

7.5.1. In October 2022 V was stopped and searched by police in company of a group of other males. Following information received from a member of the public that they had seen V and the others using drugs and NOS canisters. Officers noted a smell of cannabis and empty NOS canisters in the vicinity. The search was negative.

7.5.2. In late January 2023 V was a passenger in a car that was stopped by the police, V appeared under the influence of controlled drugs. When asked the reason for being in the area at 0130 hours V was slow to answer and provided inconsistent responses, a small quantity of balloons and nitrous oxide (NOS) were found in the car. No further action (NFA) was taken.

7.5.3. In March 2023 at 0218 hours police saw V and another male in a street in London. The second male was carrying a large NOS canister. V was stopped and searched. The search was negative. The second male was dealt with by the police.

7.5.4. In early November 2022 the first of a series of incidents occurred near a bar in London. In some of these incidents, victims handed over their mobile phones to a suspect who then either stole the phone or transferred money from the victims account into another account without the authority of the victim. In some of the incidents, property was snatched and violence was used. V was linked to these incidents although in most of them the victims were unwilling to support a police investigation as the banks had reimbursed the stolen money.

7.5.5. The first incident occurred in early November 2022 when the stolen money was found to have been transferred into V’s bank account. The victim was unwilling to support the police investigation and NFA was taken.

7.5.6. The second incident occurred in early February 2023, on this occasion V was stopped, searched and arrested by the police but no evidence was found. The victim was unwilling to support the police investigation and NFA was taken.

7.5.7. The third incident occurred in early March 2023, this incident was observed by CCTV operators and appeared to capture an attempted robbery. The police attended the scene and arrested V and another man who matched the description of the suspects. V was interviewed regarding the incident but made “no comment” to all questions, the victim was unwilling to support the police investigation and NFA was taken.

7.5.8. Two other incidents occurred in April and May 2023 at the same location. In the first incident, property was stolen from a person who was also assaulted. In the second incident a phone was snatched from a victim and a large sum of money was transferred into another account.

7.5.9. These incidents appeared to have a similar nature and used a similar modus operandi (MO). As a result, an investigation commenced which was complex and protracted. V was considered as a possible suspect but was not seen or spoken to in relation to these matters prior to his murder four months later.

7.5.10. In the middle of this series of incidents V was arrested in Brighton in March 2023 for stealing a mobile phone from a female adult victim. He was charged and bailed. V was sentenced at Magistrates’ Court at the end of May 2023 to a Community Order for 18 months with 120 hours Unpaid Work and Rehabilitation Activity Requirement of 15 days. V was the subject of a Community Order until November 2024.

7.5.11. This offence occurred in the Sussex police area, there does not appear to have been any proactive sharing of intelligence between the two police services other than an entry on the Police National computer (PNC) the police national database^{[footnote 6]} (PND). The information was recorded correctly on both systems and was available through a search. There is no mandatory requirement for Sussex police to share this with the MPS. The PND is a national information-sharing system that gives police services direct access to up-to-date information on crime, custody, intelligence, domestic abuse and child abuse held by other services.

7.5.12. The PND holds copies of records held by police services. It does not process these records and has no mechanism to identify updates, progress or subsequent case disposal. This information is recorded on PNC not PND. PND does not facilitate access to the actual records but provides a reference number and officer in the case details.

7.5.13. Access to PND is restricted and is not automatic and is subject to vetting and further training.

7.5.14. V was considered as a possible suspect and as such did not, at this time meet the threshold to be circulated on the PNC as being wanted /missing (WM). PNC markers are used on the PNC to identify where an individual may:

• pose a risk to themselves
• pose a risk to others
• be vulnerable
• be wanted in connection to an offence.

There was no PNC marker at this time in relation to V.

7.5.15. V had been convicted of an offence in Brighton which was similar in nature to the five other offences that he was potentially linked to in London. No mandatory requirement existed for the Sussex police to inform the MPS of offending by one of its residents in the Sussex area. This left the MPS potentially unaware of such offending and if so, this may have hampered V being identified as a possible threat to the public. Proactive communication between the two police services regarding V’s criminal activities may have been productive and may have assisted the MPS in their investigations into the offences committed in their area .Under the current arrangements there was no automatic notification made to make the MPS aware of the fact that a man who was a suspect in a series of theft/robbery offences in London had been arrested and convicted of a similar offence in the Sussex area. Whilst V was being considered as a possible suspect, he was not considered to meet the criteria to be ‘flagged’ (subject to a marker) on the PNC which would have resulted in a notification being made to them.

7.5.16. On the same day he was arrested in Brighton, V was involved in a disturbance in London, during which he was hit by a car and received injuries.

7.5.17. V later attended a physiotherapy appointment when he showed the physiotherapist a video of him being hit by the car. V did not share this information with the police. The investigation was closed due to a lack of information.

7.5.18. The internal sharing of information within different parts of the NHS appeared to be largely effective. However, there was no evidence of information being shared between the NHS and other partner agencies. While patient confidentiality is a key consideration, there are circumstances, such as when there is a clear public interest or safeguarding concern, where information can be lawfully shared without patient consent. Further insights are needed to assess whether greater collaboration and information sharing between health services and partner agencies could have improved outcomes, risk management or intervention opportunities and how existing protocols could be strengthened to ensure that critical information is shared appropriately moving forward.

7.5.19. Two victims were approached by V who took one of their phones and then gestured to his waistline in a way which suggested he was carrying a weapon. V was challenged by a group and returned the phone before leaving in a vehicle. Police arrested him shortly after. V was bailed with conditions not to enter the City of London and to sign on once a week at a local police station. He was bailed to allow for the obtaining of identification statements, phone and CCTV evidence, his return date was set for three months later but matter was dealt with as NFA due to his murder several days later.

7.6. Police Service Engagement – P1

7.6.1. In June 2022 P1 engaged with the police on three occasions. On the first occasion he was stopped and searched by police for drugs, he received a Community Resolution for possession of cannabis. The next day he was stopped and searched for weapons. A member of the public told the police he had seen three males, one was in possession of a knife. The informant identified P1 as one of them. The search was negative.

7.6.2. P1 was stopped and searched by police for drugs, he was seen with other males wearing full black clothing and a face mask. He tried to avoid police. He appeared to be holding something in his pocket and was nervous and uncooperative. The search was negative.

7.6.3. In early November 2022 P1 was stopped and searched for drugs by officers from British Transport Police (BTP), he was found in possession of a kitchen knife, and he was arrested. The Crown Prosecution Service (CPS) authorised a charge of possession of an offensive weapon. He was remanded in police custody to appear at magistrates’ court. A risk assessment was completed recognising the increased risk, due to the violent nature of the offence, it was necessary for his own safety and for the wider community to remand P1 in police custody.

7.6.4. He was bailed in early November 22 to appear back before court three weeks later, with conditions to live and sleep at his home address and co-operate with the NPS for the preparation of a pre-sentence report.

7.6.5. In late November 2022 P1 was sentenced to a Suspended Sentence Order (three months custody, suspended for 12 months) with two requirements: Rehabilitation Activity Requirement (15 days) and Unpaid Work (105 hours).

7.6.6. In mid December 2022 P1 was stopped and searched by police for stolen property he was with a group of other males paying close attention to members of the public. No items were found.

7.6.7. In January 2023 P1 rang the police about people knocking at his door armed with baseball bats, these people left, their identities were not established.

7.6.8. In February 2023 police on patrol stopped and searched P1 and a group of other males after they were seen to be smoking cannabis. The cannabis was seized, along with further herbal cannabis found inside P1’s pocket. P1 received a Community Resolution Order for drugs. Police acknowledged that P1 should have received a Penalty Notice for Disorder (PND). A Community Resolution Order would not constitute a breach of his probation order, the custodial element would only have been activated in the event of a further conviction through court or for not complying sufficiently with requirements of the order.

7.6.9. The NPS were not made aware of these incidents until they requested police checks to be made in April 2022. The probation service had a protocol in place with the MPS. The protocol only allowed for requests to be made on certain types of cases and only every six months. As a result, the information about the community resolution was not proactively shared with probation. This limited communication and the restrictive nature of the protocol hindered a more timely and effective exchange of critical information.

7.6.10. The police response to the probation service was ‘the male in question has been stopped and searched on a few occasions in different areas and arrested for drugs.

7.6.11. The police did not specifically mention the occasion in June 2022 when P1 was stopped and checked for weapons, however, as no weapons were found this may have been appropriate. P1’s probation order was for possession of a weapon in central London.

7.6.12. The probation service felt that the supervising PP should have responded to police to query further details around this information, such as dates and times of the arrests and any pending matters. The PP did question P1 about the information, he stated that it had happened on one occasion only and had not taken it further.

7.6.13. If there had been concerns regarding escalation in risk of harm or further involvement in serious violence, a consideration could have been made to referring P1 to MAPPA this would be under Category 3 as the sentence received did not qualify for MAPPA arrangements automatically. However, this did not appear necessary during his order.

7.6.14. The police are aware of the disproportionate numbers of young black males who are subject to street searches and are therefore concerned that such encounters with negative outcomes may not be appropriate to share. Negative stops are shared widely with partners and discussed at monthly S&S monitoring groups. The searches were negative. As there was no evidence of any criminality, the sharing of negative stop and search outcomes could be viewed as unnecessary criminalisation.

7.6.15. Whilst the IR accepts this is a reasonable position it is also true that such information could have prompted a fuller review by the probation service. Information might have been gathered that would have assisted in the management of P1’s case. Specifically, it would have given them an insight into the amount of time he was coming to notice by the police. It could have led them to question him on his lifestyle, how he was spending his time and with who he was associating. It would also have enabled the probation service to consider the impact on him from a diversity point of view and prompted them to give him support if required regarding the impact of searches on young black males.

7.6.16. In each London borough, Stop and Search Community Monitoring Groups (SSCMG) monitor all local stop and searches, including the numbers of stops, arrest rates, disproportionality, complaints and body worn video. SSCMG provide a local, borough-based mechanism to monitor police use of stop and search powers. In addition, the SSCMG is a forum for the local community to engage in discussion and debate on police use of stop and search, it’s outcomes and impact.

7.6.17. The day after P1 had been given conditional court bail for possession of an offensive weapon he was involved in a knife-point street robbery in central London. The allegation of robbery was made directly to BTP. The matter was investigated by the MPS. Due to the complexity of the case, it took eight months to identify and arrest all the suspects involved, P1 was the last to be identified. It was not possible to put P1 before the courts prior to the subsequent murder of V 10 months later.

7.6.18. The first suspect was arrested by officers at the scene. During interview he made “no comment” to all questions. He was bailed, pending CCTV enquiries and CPS advice with conditions not to enter the Borough of Westminster unless by written appointment, to live and sleep at an address in London and to observe a doorstep curfew.

7.6.19. The victim told police he did not know the three suspects but would recognise them if seen again. The police commenced enquires to identify the two outstanding suspects using the CCTV images that had been captured.

7.6.20. The second suspect was identified from the CCTV images in late November 2022 and arrested a few days later. The matter was submitted to the CPS who authorised a charge of robbery. He was remanded in police custody to appear at magistrates’ court in early December 2022. He pleaded guilty to the offence.

7.6.21. P1 remained at large but he was also identified from CCTV images in mid April 2023. He was arrested in June 2023, he made no comment to questions but agreed to take part in the identification process, this took place and in July 2023, he was formally identified by the victim who said P1 was “the one who said he would stab me if I did not give him the pouch”.

7.6.22. Once P1 had been identified and circulated as wanted for this robbery it took the police two months to locate and arrest him. During this time P1 was being supervised by the probation service in relation to the knife offence that he committed in November 2022. Police officers made several enquires to locate him and P1’s family contacted his probation officer in May 2023 regarding a visit the police had made to their home.

7.6.23. There is no evidence that the police shared information proactively with the probation service regarding the reason they wished to speak with P1 or asked the probation service to assist them in locating him until mid June 2023, the police arrested him three days later.

7.6.24. After P1 was positively identified by the witness as being involved in the robbery, the police were of the view there were insufficient grounds to object to bail and request an immediate charging decision from the CPS and remand P1 in custody.

7.6.25. Following P1’s arrest, intelligence research was conducted, which included his offending and arrest record on the PNC. This identified that P1 only had one previous arrest and subsequent charge and conviction for possession of an offensive weapon in early November 2022.

7.6.26. The Investigating Officer (IO) cannot recall if the PNC was checked for the sentence received in relation to that conviction. This check would also have revealed the bail history in relation to that matter and the fact that the robbery offence was committed whilst P1 was on court bail for possession of an offensive weapon.

7.6.27. There was no evidence to indicate an escalation of offending. In the previous six months, there had been no further arrests or convictions. The victim did not reside in the same area as P1 and was unknown to him. The victim told police he had not seen a knife and no weapons had been found during the search of P1’s home. P1 was released on bail pending CPS charging decision.

7.6.28. In late July 2022, five days after the identification of P1, the case was submitted to the Case Management Team (CMT) for submission to the CPS. This was returned to the IO 28 days later for further investigative actions to be completed. Actions were completed and the IO re-submitted the case file to the CMT in mid September 2023.

7.6.29. P1 remained on police bail until a date in September 2023 when a DI authorised him to be released under investigation. This was on the basis that the other suspect was no longer on bail, all relevant lines of enquiry had been completed and there was no evidence to indicate P1 had come to the attention of the MPS since his arrest. In addition, there was no known relationship between the victim and the suspects or that P1 had breached the bail conditions previously imposed, it was disproportionate to keep P1 on bail whilst awaiting a CPS charging decision.

7.6.30. In mid October 2023 the IO checked the progress of the submission and noted the case file had been closed in error by the CMT. It was re-opened by the CMT and submitted to the CPS.

7.6.31. The Police have identified individual learning regarding this issue.

7.6.32. In late December CPS authorised charges of robbery against P1 and suspect 1, to be dealt with by Postal Charge Requisition.

7.6.33. This proved to be the second occasion in this review that live investigation files had either been closed in error or not managed robustly enough to ensure a timely investigation. In both instances opportunities to intervene by the potential prosecution of persons subject to this review before the murder of V were missed. (see section 7.8.3)

7.6.34. This investigation was a difficult and very complex matter, the evidence against those involved came at different times. The IO showed great professionalism, perseverance and diligence over the six months it took to identify all those involved.

7.6.35. The guidance around charging and bail decisions relies on gathering information from many sources, including the PNC. The IR was able to view the PNC records relating to P1 and found navigating around the document time consuming and difficult. It is understandable that the officer dealing with this matter might have had difficulty in recognising the date P1 was given court bail for the possession of the knife in early November 2022 as that information is not immediately apparent when reading the PNC readout. Given that the officer would be working in a busy operational environment within tight timescales and high caseloads the IR takes the view that their task would have been made more difficult considering the disjointed and confusing format of the PNC readout.

7.6.36. The IR feels it is important to make clear that this should be viewed as a systems failure.

7.6.37. It is impossible to predict future offending behaviour which might result in offensive weapon related homicides. However, it may be appropriate to consider if persons arrested or convicted for possession of offensive weapons should be subject to enhanced levels of information sharing between the probation service, the police service, and other agencies.

7.7. Probation Service Engagement – P1

7.7.1. In December 2022 P1 attended the first of his appointments with the probation service. A pre-sentence report was completed for sentencing. The risk of serious harm was assessed as medium, which is defined as the offender having the potential to cause serious harm but is unlikely to do so unless there is a change of circumstances.

7.7.2. The pre-sentence report would have benefitted from additional exploration around P1’s potential involvement in serious group offending and police checks, which were not completed.

7.7.3. The risk of serious harm assessment may have gone into more detail around the potential impact of further access and use of weapons, however, based on P1’s lack of previous convictions and without further information indicating any more entrenched involvement in violence, the assessment was found to be sufficient.

7.7.4. Safeguarding checks had been requested when completing the initial assessment and sentence plan, but the response was either not received or not recorded. There were no police checks completed at the point of the assessment being completed. P1’s reporting frequency was reduced to monthly appointments.

7.7.5. In August 2023 P1’s compliance with the Unpaid Work Requirement reduced, he was arriving late or leaving early for various reasons. The PP made many of the non-compliance entries as acceptable rather than deciding to pursue a breach.

7.7.6. After P1 had been identified and circulated as wanted for the knife-point robbery that took place in early November 2022 it took the police two months to locate and arrest him. During this time P1 was being supervised by the probation service in relation to the knife offence that he committed also in early November 2022. Police officers made several enquires to locate him and P1’s family contacted his probation officer in May 2023 regarding a visit the police had made to their home. P1 was advised to go to the police station to find out what they wanted to speak to him about. P1 denied any knowledge of what this would be in relation to. The probation service have acknowledged that this information should have prompted the PP to go back to the police to make enquiries on the investigation matter, particularly in view of the result of the recent police checks. Individual learning was identified by the probation service.

7.7.7. There is no evidence that the police shared information proactively with the probation Service regarding the reason they wished to speak with P1 or asked the probation service to assist them in locating him until mid June 2023, the police arrested him three days later.

7.7.8. Had the probation Service contacted the police (or the police service contacted the probation service) they may have established that P1 was circulated as wanted for a knife-point robbery. In early May 2023 the probation officer having been made aware by P1’s family that the police had been looking for him advised him to attend a police station.

7.7.9. P1 saw a site supervisor in mid May 2023, a month after he had been circulated as wanted and a month before he was eventually arrested. He also saw his probation officer three days before he was arrested. A lack of professional curiosity may have resulted in P1 being arrested much later than he could have. An opportunity for better interagency working may have been missed resulting in a lack of cooperation and delay in arresting P1. Individual learning was identified by the probation service.

7.8. Police Service Engagement – P2 & P3

7.8.1. In April 2022 P3 was involved in a street fight, Police attended but during his arrest P3 assaulted a police officer causing a broken ankle. P3 was released under investigation and the matter was allocated to another officer to complete the required enquiries.

7.8.2. The original investigating officer transferred from the MPS to another police service. The investigation was passed between several officers and there were delays in obtaining necessary information and evidence. This was compounded by under resourcing and excessive workloads, the matter was submitted to the CPS in August 2023 and rejected. The matter was re-submitted to the CPS in December 2023 after P3 had been charged with the murder of V. A charging decision was made in February 2024.

7.8.3. The investigation and submission of a report to the CPS does not appear to have been dealt with in a timely manner. The delays in submitting a file for a CPS decision resulted in a delay of 22 months from the date of the offence to when a charging decision was made. This was the second time a live investigation file had not been dealt with properly. (see 7.6.33)

7.8.4. The MPS have identified individual learning from this incident.

7.8.5. As a result of this delay P3 did not face criminal proceedings for this matter prior to the murder of V. This may have been a missed opportunity to reduce the risk of future violence.

7.8.6. In early October 2022 police in central London noticed P3 with another male with inflated balloons and a large canister of NOS. P3 admitted to having another two large canisters in his backpack and a small amount of cannabis in his right-side jean pocket. P3 received an Adult Community Resolution.

7.8.7. In January 2023 P2 was arrested on suspicion of possession of cannabis. As police approached to speak with him and a group of males, they ran away. He was detained, they noted a strong smell of cannabis from him and found a parcel containing separate wraps of cannabis in a nearby bush. The parcel could not be attributed to P2, and no further action was taken.

7.9. Service Engagement During Transitions

7.9.1. The transition from adolescence to adulthood presents significant challenges, particularly for young adults who may be more vulnerable to impulsivity and risk-taking behaviours. Factors such as neurodevelopmental conditions, societal pressures and systemic barriers can further influence their pathways and interactions with support services. Key themes related to offending behaviour, including the impact of hyper-masculine norms, engagement with services and housing instability are considered. By exploring these issues through existing research and case-specific findings, the review highlights areas where improved interventions and systemic changes could lead to better outcomes.

7.9.2. Both V and P1 faced challenges accessing housing services, partly due to high demand and communication breakdowns. Housing instability often correlates with increased offending behaviour. Shelter UK’s report on housing and crime discusses the impact of homelessness on recidivism.

7.10. Socioeconomic Considerations

7.10.1. Economic deprivation significantly influenced the Victim’s and P1’s trajectories, affecting their ability to access stable housing and mental health services. Statistics from the Office for National Statistics (ONS) link economic instability with a 20% increase in reoffending rates.

7.10.2. V was seeking help in managing his ADHD but he could not get the treatment/medication he needed. This was due to a crisis with the ADHD services along with his referral not being properly dealt with.

7.10.3. The combined effects of race, economic deprivation and various factors created compounded vulnerabilities for V and P1. Addressing these requires holistic, intersectional approaches. Kimberlé Crenshaw’s foundational work on intersectionality (Crenshaw, 1989) provides a framework for understanding overlapping disadvantages. Health England (2022) reports that addressing intersectional vulnerabilities increases service engagement by 40%.

7.10.4. Young adults transitioning out of adolescence face unique challenges, including impulsivity and risk-taking behaviours often exacerbated by ADHD and other conditions. Research by the Youth Justice Board (2022) highlights tailored interventions reduce recidivism by 30% in individuals aged 18–24.

7.10.5. Male offenders often face societal pressures to conform to hyper-masculine norms, which may exacerbate involvement in violence and gang activities.^{[footnote 7]}

7.11. The Use of Stop and Search

7.11.1. The individuals reviewed in this case had all been subject to police stop-and-search interventions, with some found in possession of illegal substances such as cannabis, nitrous oxide, or both. In one instance, a person was found carrying an offensive weapon, resulting in a criminal conviction. Many young men spend considerable time in public spaces with groups of peers, which can appear intimidating to the public and often draws police attention. On several occasions, police encounters with individuals in this review stemmed from public reports of suspected criminal activity.

7.11.2. When sufficient evidence was available, the police applied appropriate sanctions, including seizing offensive weapons and illegal substances, thereby enhancing public safety. Although not all stop-and-search incidents resulted in positive outcomes, the IR assessed all cases documented in the agency timeline. This transparency was essential to evaluate the frequency of police contact with the young black and Asian males involved and to ensure the appropriateness of police actions. In all instances, the police were found to have exercised their stop-and-search powers lawfully, with at least one intervention preventing potential serious harm by removing an offensive weapon from the streets.

7.11.3. While the use of stop-and-search powers was appropriate, there was inconsistency in sharing outcomes with other agencies. This reflects broader systemic concerns about the effectiveness of such interventions. The Independent Office for Police Conduct (IOPC) has highlighted that inadequate follow-up communication undermines coordinated responses (IOPC Annual Report, 2023). The Home Office’s guidance on stop and search provides a framework to ensure lawful and effective practice.

7.11.4. The use of stop-and-search powers on young black and Asian males and such interactions can alienate individuals and reduce trust in authorities. (Equality and Human Rights Commission report on racial disproportionality in policing). The Lammy Review (2017) found black individuals were nine times more likely to be stopped and searched than white counterparts, with limited evidence of increased criminality. The Brent Community Action Plan (BCAP) was developed in response to the need for targeted support and empowerment of Brent’s black community. The plan articulates the council’s 10-year commitment to tackling inequalities experienced by the black community.

7.12. Police Drug Misuse Referral Arrangements

7.12.1. The individuals reviewed in this case had all been found in possession of illegal substances such as cannabis, nitrous oxide, or both. However, through the information gathered for this review there is no evidence of referrals for any of the individuals to a drug misuse support service. The IR raised this with partners and the Police and LA provided the following details on the current provision.

7.12.2. The MPS has established Project ADDER (Addiction, Diversion, Disruption, Enforcement, Recovery) in each Police Basic Command Unit (BCU) to bring together local policing, Specialist Crime strands and external partners to holistically tackle drug supply, associated exploitation, violence and robbery.

7.12.3. Project ADDER examines the MPS role in diverting people with substance misuse issues to treatment services, the associated benefits and how to improve service for communities. Early intervention, referral, and diversion are crucial to preventing long-term serious substance misuse. Each of London’s 32 boroughs has a substance misuse treatment service.

7.12.4. On 12th August 2024, Project Adder launched a voluntary referral process for officers and staff to refer adults they know who suffer substance misuse to local treatment.

7.12.5. The new voluntary referral process is a simple, easy-to-use tool that requires minimal data entry and no follow-up actions. Officers and staff must complete the form, obtain the person’s consent, and then submit it. Once submitted, the tool will automatically refer the person to the appropriate treatment service and provide the referred person with more information via email or text.

7.12.6. The process sits outside the criminal justice pathways and helps those who might not self-refer to treatment services on their own. As the referral is voluntary, it is more likely that the person who is being referred will engage with the treatment provider and more likely they will enter treatment.

7.12.7. Project Adder was not implemented in the areas where persons subject to this review were detained within the period of this review.

7.13. Local Substance Misuse Provision

7.13.1. Specialist drug and alcohol treatment and recovery services offer a wide range of interventions to support people to recover from drug and alcohol dependence. Locally services are commissioned by the public health team. Drug and alcohol services are provided through the VIA charity’s ‘New Beginnings Service’.

7.13.2. The New Beginnings Service covers two sites: Cobbold Road, which is the community hub, and Willesden Centre for Health and Care, where the majority of clinical services are provided. Services are open five days a week. In addition, outreach work takes place in the early morning and late evenings. At weekends Cobbold Road Treatment and Recovery Service is also open for the BSAFE (Brent Social Access for Everyone) service.

7.13.3. The service offered is tailored to individual health and social care needs with all service users having an individual care plan and a personal worker in a treatment and recovery model aimed at supporting people from addiction through to abstinence-based recovery pathways.

7.13.4. Services provided by New Beginnings include:

• Information, advice, support, assessment and drop-in
• One-to-one key working
• Needle exchange and harm reduction services
• Substitute prescribing
• Health assessments and blood born virus screening & vaccination
• Group work programmes (including abstinence and evening groups)
• Counselling and psychology
• Access to inpatient detoxification and residential rehabilitation
• Women-only groups
• Self-help and mutual aid groups
• Sexual health advice
• Smoking cessation
• Aftercare services
• Education, training and employment (ETE) support
• Reducing offending and gang affiliation
• Integrated Offender Management (IOM)
• Restrictions on Bail (RoB)
• Prison, Probation and court link work
• Family and carers’ support and advice
• A health and wellbeing service for people who use substances at lower levels, including alcohol, club drugs, cannabis and cocaine.

7.13.5. The service includes a shared care scheme where clients receive most of their care from primary care (GP) with clinical support and advice from New Beginnings. Clients on this scheme will usually be on stable substitute prescribing and often have other chronic conditions which are suited to primary care management.

7.13.6. VIA also provide an Individual Placement Support (IPS) service not only in Brent but across West London. The IPS service aims to achieve sustainable employment, to help reduce stigma, enrich lives, boost local economies, develop additional talents, and create workforces that reflect the diversity of their local communities. Brent’s employment specialist attends the Cobbold Road service up to three times per week and continues to develop and maintain strong relationships with the New Beginnings staff team, attending team meetings and service user groups including the B3 Recovery Champions course.

7.13.7. Young people have a specialist service - Young People VIA Elev8. This is delivered by VIA New Beginnings and provides specialist advice and support for young people directly impacted by substance misuse along with emotional health and well-being interventions. The service is available for young people who are under 25 and who live or study in Brent. It includes:

• advice and information around health and wellbeing
• private and confidential sessions with their own support worker (in person and online)
• help to make better decisions about an individual’s drinking or drug use
• help get other support that they may need.

7.13.8. The service can meet young people at a location that works for them, such as school, college, youth club or a safe space in their local community, and at a time that suits young people.

7.13.9. Cannabis is still the primary drug used by young people, with alcohol being the secondary substance. The service offers holistic interventions that looks to address issues as they impact on substance misuse and well-being such as:

• Anxiety
• Bullying
• Issues around body image / eating disorder.
• Vaping.

7.14. Service Engagement and Information Sharing

7.14.1. The lack of consistent engagement with probation services for V and, to a lesser extent, P1 indicates systemic inefficiencies. Professional curiosity and consistent case management could have improved outcomes.

7.14.2. In some cases, the correct procedures were followed but factors that made it harder for local professionals and organisations, working with the victim and alleged perpetrators and with each other were identified. In the main these issues concerned the sharing of information between different police services and with the probation service. The police shared all information appropriately and in accordance with policy, systems are in place to facilitate information sharing, where necessary and proportionate, PNC flags (markers) exist to alert across police boundaries. In this case no marker was in place in relation to V to alert those investigating the series of robberies/thefts in London of other police activity relating to him.

7.14.3. The failure to effectively share information across police forces and between police, probation and health services hindered early intervention efforts. The Serious Violence Duty introduced under the Police, Crime, Sentencing and Courts Act 2022 emphasises multi-agency approaches. Multi-agency safeguarding hubs (MASH) evaluations (University of Bedfordshire, 2021) report a 35% increase in successful interventions when agencies collaborate effectively.

7.14.4. No formal information sharing arrangements were in place to make the probation service aware of many of V’s activities as the case did not meet the threshold for formal information sharing arrangements between police and probation. Although V did not automatically qualify for MAPPA because he did not have a sentence for more than 12 months for a violent offence, if there had been sufficient concern in the case about the potential that he posed a danger to others, then a referral to MAPPA under category 3 could have been completed to ensure information sharing and a joint response to the risk management plan. No significant information was received during statutory supervision that would have generated this consideration.

7.14.5. The police were in possession of information regarding V and P1 that the probation service was unaware of until the probation service made a request. The information was brief and should have been followed up by the probation service. The sharing of more detail between the police and the probation service could have allowed the probation service to reassess the risks and the management plans for both V and P1. It may have raised sufficient concern to consider referring them both to the Multi Agency Public Protection Arrangements.

7.14.6. Whilst V’s possible involvement in offences in London were being investigated, he was arrested and convicted in another force area for a similar offence. No automatic notification was made to alert the MPS of this, all the information was recorded properly on the PNC and was accessible.

7.14.7. Furthermore only a few days before his murder V was arrested for another matter in another force area where he stole property and when doing so, he gestured to his waistline in a way which suggested he was carrying a weapon. it is not clear if the MPS were immediately aware of this arrest. Again, no automatic notification was made to alert the MPS, and the information was recorded properly on the PNC and was accessible.

7.14.8. Whilst all the information regarding V was properly recorded on the PNC and was accessible it is not clear which police service had the full picture of his suspected criminal activities. It is not clear which police service should have considered sharing information with the probation service. Better sharing of intelligence could have helped both the police and probation service to work more effectively.

7.14.9. At the time of his murder, V was subject to statutory probation supervision due to an offence of stealing from the person in another force area and was also on police bail for robbery. V may have been initially wrongly assessed as low rather than medium risk by the probation service. In addition, the probation service acknowledged gaps in their management of V, unacceptable missed appointments should have triggered either recall or later breach discussions. Instead, due to staffing and capacity difficulties at a national level the probation service had to make the decision to offer him no further appointments. Even if he had been breached in September 2023, he would still have been at liberty at the point he was sadly murdered.

7.14.10. During V’s second period of probation, he did not comply with his order and was eventually breached. This breach did not occur until a short time prior to his murder and no further court appearance would have been possible prior to his murder.

7.14.11. V came to the attention of the police on nine occasions as a suspect in the two-year period prior to his murder including being convicted of theft from the person in another force area. He was also on bail for robbery and had been arrested on two other occasions for theft from persons or robbery and linked by evidence to a further offence. Additionally, he had been stopped by the police twice in connection with nitrous oxide. The probation service was only aware of one conviction for theft from a person.

7.14.12. At the time P1 committed murder he was under a Suspended Sentence Order for an offence of possession of an offensive weapon and subject to statutory supervision by the probation service. He was also released under investigation by the police for a knife-point street robbery that he had been identified for by a witness five months before the murder. Once he had been identified as being involved in the street robbery a lack of liaison between the police and the probation service may have led to a delay in his arrest.

7.14.13. Following his arrest, the police did not identify that the offence had been committed whilst on court bail. This was one of the factors that led the police not to immediately to put the matter before the CPS and to release him whilst the case was prepared for a CPS charging decision.

7.14.14. This oversight may have contributed to a missed opportunity to charge P1 earlier and to remand him in custody or restrict his liberty by way of conditional bail. The failure to recognise he had committed an offence whilst on bail may have been in part caused by the disjointed and confusing format of the PNC readout forms which the police would have used to gather the relevant information.

7.14.15. During the two-year period leading up to the murder P1 came to the attention of the police on seven occasions as a suspect. These included conviction for possession of a knife, arrest for knife-point robbery and possession of cannabis on two occasions. In addition, he was stopped and searched by the police on the streets in the company of other groups of males on a further three occasions.

7.14.16. If there had been concerns regarding escalation to risk of harm or further involvement in serious violence, consideration could have been given to referring P1 to Multi Agency Public Protection Arrangements. This would be under Category 3 as the sentence received did not qualify for MAPPA arrangements automatically. No significant information was received during statutory supervision that would have generated this consideration.

7.14.17. At the time of the murder P3 had been released under investigation for assaulting a police officer for 17 months. The police accept the length of time it took to conclude this allegation was unacceptable. As a result of this delay P3 did not face criminal proceedings for this matter prior to the murder of V.

8. Conclusions

8.1. Despite numerous contacts with local statutory services in the weeks leading up to the murder it was not possible to predict or prevent the outcome.

8.2. Several opportunities may have been missed to prosecute some of those involved or apply other criminal justice interventions until after the murder had occurred. We cannot be sure that these opportunities would have resulted in criminal convictions, we cannot know what sanctions may have been imposed or how these may have affected those involved.

8.3. Where opportunities were missed, learning was identified and measures put in place to prevent recurrence. Where possible recommendations have been made to improve systems and practices to reduce the risk of violence in the future.

8.4. The incident which took place eleven days before V was murdered was mentioned in the court case of the perpetrators as the motive for the murder. The victim did not name V as the suspect, nor did he give a description which matched V. No other information or intelligence existed to link these two incidents. It was impossible for the police to link this incident to V or the other perpetrators subject to this review or to predict the outcome.

9. Recommendations

9.1. The National Health Service to review the systems in place to receive, administer and share ADHD referrals to ensure that all referrals are correctly monitored and responded to. This review should ensure that all referrals are correctly monitored, responded to in a timely manner and that relevant health information is effectively shared with appropriate stakeholders to improve coordinated care and decision-making.

9.2. The Metropolitan Police Service to review their force monitoring process and in particular the case management systems to ensure that safeguards are put in place to prevent case files being closed in error and avoidable delays being experienced. The Metropolitan Police service should examine its quality assurance processes, scrutiny or audit processes to identify the extent of error rates.

9.3. It is noted that the information sharing protocol between London Probation region and the MPS has recently been updated to allow for intelligence checks to be requested on all current Probation cases, moving away from a previous prioritisation criterion that had been applied by the Met. The NPS should ensure that police intelligence checks are routinely undertaken on those convicted for weapon related crimes and should consider whether referral to MAPPA under category 3 is appropriate dependent on intelligence information that is received.

9.4. Brent Probation Service and the Metropolitan Police Service to consider the sharing of information between statutory agencies regarding individuals who have been arrested for weapon offences that are already subject to statutory supervision.

9.5. The IR found on several occasions a lack of professional curiosity had occurred by agencies involved in this review, indeed this also extended to a lesser degree into the review itself. It is recommended that individuals working for all agencies involved in OWHRs be encouraged to go further, raise questions and to be more proactive in sharing information with wider partners.

9.6. The Home Office and Police Service to consider developing a process for an automatic PNC notification to go to the police area where an offender resides when they are arrested or convicted of a weapon related offence. This would result in better intelligence sharing and where applicable a joint response to any risk management plan. The Home Office are leading on the replacement of the PNC with Law Enforcement Data Service (LEDS) and the above recommendation should be brought to the attention of the implementation team. It is recognised that such a change could generate a high number of notifications which in turn could result in the system being potentially overwhelmed. In addition, a process would need to be developed to receive such notifications and to manage them. The IR cannot present a definitive solution to this problem but simply highlights a gap in the current situation, possible solutions could be developed around existing processes such as Threat to life processes, Threat, Harm, Risk, Investigation, Vulnerability and Engagement processes (THRIVE) or the Multi Agency Safeguarding Tracker (MAST) processes. This case highlighted how people arrested for weapons related offences took too long to be brought to justice and how intelligence derived from such arrests failed to be shared with the Probation Service resulting in missed opportunities for interventions.

Glossary

Abbreviation/Term	Meaning
CPR	Cardiopulmonary resuscitation
OWHR	Offensive Weapon Homicide Review
ICB	Integrated Care Board
LA	Local Authority
MPS	Metropolitan Police Service
NHS	National Health Service
NPS	National Probation Service
IR	Independent reviewer
ADHD	Attention deficit hyperactivity disorder
GCSE	General Certificate of Secondary Education
BTEC	Bachelor of Technology
CAHMS	Child and Adolescent Mental Health Services
KPE	Key practice episode
CLP	City of London Police
GP	General Practitioner
PP	Probation Practitioner
RUI	Released under investigation
CID	Criminal investigation department
CPS	Crown Prosecution Service
PPF	Prioritising Probation Framework
IT	Information technology
NOS	Nitrous oxide
BTP	British Transport Police
CCTV	Closed circuit Television
NFA	No further action
A&E	Accident and Emergency
CPW	Community Protection Warning
IIO	Initial investigating officer
DI	Detective inspector
CCC	Central Criminal Court
RAR	Rehabilitation Activity Requirement
MAPPA	Multi Agency Public Protection Arrangements
MO	Modus operandi
WM	Wanted/missing
IO	Investigating officer
CMT	Case Management Team
IOPC	Independent Office for Police Conduct
BCAP	Brent Community Action Plan
Project ADDER	Addiction, Diversion, Disruption, Enforcement, Recovery
BCU	Basic Command Unit
BSAFE	Brent Social Access for Everyone
ETE	Education, Training, Employment
IOM	Integrated Offender Management
RoB	Restriction on Bail
IPS	Individual Placement Support
MASH	Multi agency safeguarding hubs
HMPPS	His Majesty’s Prison and Probation Service
LEDS	Law Enforcement Data Services
SIO	Senior Investigating Officer
VVC	Violence and Vulnerability Coordinator
Tics	Fast, repetitive muscle movements that result in sudden and difficult to control body jolts or sounds.

Appendices

Appendix A

1. Governance and Structure of the Review Process

1.1. The Safer Brent Partnership serves as the statutory forum with overall responsibility for local oversight and the approval of the report. It is also tasked with ensuring the implementation of any recommendations resulting from the OWHR. Operational decision-making and report approval have been delegated to the Brent OWHR Strategic Group, which comprises representatives from each statutory review partner.

1.2. The London Borough of Brent is the lead agency for the partnership for OWHRs and has applied resources through the Violence and Vulnerability Coordinator (VVC) - OWHR lead role to engage with the Home Office, the MPS and the ICB and to support this and other active OWHRs.

1.3. The findings from this work are documented and presented to the Brent OWHR Strategic Group for review and scrutiny. The group considers and approves the final report and its recommendations before submitting them to the Safer Brent Partnership for endorsement and subsequent submission to the Home Office.

1.4. The Applied OWHR Process Governance Cycle:

• Brent Community Safety Partnership (Governance and Oversight)
• OWHR Strategic Group (Operational governance, Initiation, Briefings and Support)
• OWHR Case Review Meetings (Gather Data, Reflection and Insight)
• Family/Friends Engagement (Report Enrichment and Insight)
• Service Specific or Themed Meetings (Focus, Clarity and Challenge)
• Review and Reflection Meetings (Establish Learning and Develop Recommendations)
• OWHR Strategic Group (Consider, Challenge and Propose for Sign off)

2. Contributors to this Homicide Review

2.1. The Brent OWHR Strategic Group, is comprised of experienced senior representatives that meet regularly, usually on a fortnightly basis, to oversee and support active OWHRs:

OWHR Strategic Group Members:

• London Borough of Brent Community Safety Team
• Metropolitan Police (North West Basic Command Unit)
• Metropolitan Police (Specialist Crime Review Group) (support role)
• North West London Integrated Care Board - Brent (lead)
• North West London Integrated Care Board - Brent Safeguarding (support role)
• Brent Probation Service (non-decision-making standing member)
• NHS England - Mental Health (where applicable)

2.2. The OWHR Case Review Group, comprised of largely frontline and specialist representatives from key service areas where it had been established that contact had been had with either V, P1, P2 or P3 respectively:

• OWHR Case Review Group Members
• London Borough of Brent Community Safety Team
• Metropolitan Police (Specialist Crime Review Group)
• North West London Integrated Care Board - Brent Safeguarding
• Brent Probation Service
• Metropolitan Police Service
• London North West University Healthcare NHS Trust - Safeguarding
• London Borough of Brent Housing Needs Team
• Central and North West London NHS Foundation Trust - Safeguarding
• Brent Community Mental Health Team
• City of London Police Service
• GP Direct Welbeck Road
• Sussex Police
• Nottinghamshire Police
• London Borough of Brent (OWHR Lead) – (support role)

Appendix B

3. The Scope and Terms of the Reference of this Review

3.1. The terms of reference and OWHR scoping document for this review were considered and signed off by the OWHR Strategic Group in March 2024.

3.2. Under section 28(2) of the Police, Crime, Sentencing and Courts Act 2022 and in line with OWHR statutory guidelines, the terms of reference include the aim to develop and support new legislation, while shaping the content for evaluation during the Home Office’s pilot phase of introducing OWHRs. Additionally, the review should:

• Identify lessons learned from the death
• Assess whether any actions are appropriate in response to those lessons
• Highlight factors that may have hindered local professionals and organisations from working effectively with the victim, perpetrator(s), other connected individuals and each other to mitigate the risk of violence
• Recommend agency and system-level changes to prevent future homicides and reduce serious violence
• Identify examples of good practice and successful interventions for integration into standard processes and system responses
• Approve the draft OWHR report for review and final approval by the Safer Brent Partnership.

3.3. The scoping document was informed by the initial information returns received from key services shortly after the confirmation of the OWHR proceeding.

3.4. Requests for information were made to key service agencies which may have had a record of contact with V, P1, P2 and P3.

3.5. Through two phases of information gathering, it became clear the main focus of this review should lie with V and P1.

3.6. The key timeline of 24 months prior to September 2023 was reviewed given that V and P1 were not known to each other prior to the incident. A chronology of service engagement with V, P1, P2 and P3 was compiled, and background information provided.

Appendix C

4. V, P1, P2 & P3 Agency Timeline

4.1. December 2018 CITY OF LONDON POLICE (CLP)

V was arrested and charged with offences of robbery and offering to supply controlled drugs.

4.2. July and October 2020, January 2021 NATIONAL PROBATION SERVICE (NPS)

V was sentenced to 27 weeks custody for theft committed in March 2019, he was released in October 2020 having served 12 weeks, he was on licence until late January 2021.

4.3. May and June 2021 GP

V visited his GP to obtain ADHD medication. He said he was not feeling well and that he felt better and more focused when on medication. The GP referred V to the adult ADHD clinic.

4.4. September and October 2021,BRENT HOUSING P1 applied for accommodation due to problems at home. Following assessment, the LA made the decision that he did not meet the threshold for adult safeguarding and no accommodation was offered.

4.5. Late October 2021 (NPS)

V’s period of post-sentence supervision ended.

4.6. Late October 2021 (NPS)

V appeared at Nottingham Crown Court and was sentenced to six months custody for stealing from the person. His previous period of probation ended five days before. He was ‘released with time served’ on the day he was sentenced. V was instructed to attend Brent Probation Office. He was inducted and was allocated to the same probation practitioner (PP) who had managed his previous sentence. V was instructed to attend regular appointments.

4.7. November 2021, January 2022 (NPS)

V failed to attend scheduled probation appointments. He accrued absences. Warnings were sent to him. V did not attend until March 2022.

4.8. March 2022 (NPS)

V attended his probation appointment. He was instructed to attend monthly.

4.9. April 2022 (MPS)

Police were called to a location in London to reports of a group of youths fighting in the street. When approached, the group became aggressive, during which a police officer was assaulted by P3. The officer sustained a broken ankle. P3 was arrested and interviewed. P3 was ‘released under investigation’ (RUI) for further enquiries to be completed by the criminal investigation department (CID). The matter was submitted to the Crown Prosecution Service (CPS) in August 2023 and rejected. The matter was re-submitted to the CPS in December 2023 after P3 had been charged with the murder of V. A charging decision was made in February 2024.

4.10. April and May 2022 GP

V was seen by his GP. He reported poor memory and concentration. He had become very impulsive and developed sleep disturbance, low mood and anxiety. He had not heard from the ADHD clinic. He was issued a sick note due to his ADHD. In late May 2022 the GP emailed the local ADHD services to expedite V’s appointment.

4.11. May and June 2022 (NPS)

V was reallocated to another practitioner twice due to the first practitioner leaving. He failed to attend some appointments; one was deemed acceptable because he informed the PP that he had broken his foot by ‘falling into a ditch’.

4.12. June 2022 (MPS)

P1 was stopped and searched by police for drugs. P1 received a Community Resolution Order (CRO) for possession of cannabis^{[footnote 8]}.

4.13. June 2022 BRENT HOUSING

A homeless application was made by V. Due to high demand for the service, the automated appointment system issued an appointment for early August 2022. This was later brought forward to mid July 2022.

4.14. June 2022 (MPS)

P1 was stopped and searched by police for weapons. No weapons were found.

4.15. June 2022 GP

V reported to the urgent care centre at a local hospital that in mid June 2022 he injured his right foot and ankle because of getting stuck in a ditch.

4.16. June 2022 (MPS)

P1 was seen by police with two other males wearing full black clothing and a face mask, he was searched, and no items found.

4.17. July – October 2022 (NPS)

No further appointments were offered to V, due to a staffing and capacity crisis. The Probation Prioritisation Framework (PPF) permitted early cessation of contact with eligible cases due to capacity issues.

4.18. July 2022 GP

The GP called V three times regarding his universal credit with no reply, a week later V visited his GP to request urgent help due to getting into arguments with people and being unable to relax and focus. He was also fidgety. The GP rang the ADHD clinic without answer. The GP emailed the mental health service for V to be seen as soon as possible. The GP practice sent an email to North West London ICB, for approval for funding to treat V.

4.19. July 2022, 19/07/2022 BRENT HOUSING

Calls were made to V to complete his housing needs assessment; V did not answer or return the calls. His mother was contacted to see if she could assist, she advised he was unwell. The email address provided in the initial application was found to be incorrect.

4.20. July 2022 BRENT HOUSING

V was assessed by phone. He advised he had been excluded by his mother from the family home. Support needs were identified including, unconfirmed ADHD and offending behaviour. V advised he was known to the probation service. The IT system was updated with V’s correct contact details.

4.21. July 2022 BRENT HOUSING

V contacted Housing for an update, he was advised his case would be referred to management to be prioritised. Five days later a housing officer called V to obtain an update; without reply, an email was sent.

4.22. July 2022 BRENT HOUSING

V’s GP was contacted for a medical report to determine if V would meet the threshold for priority need and would require interim accommodation.

4.23. August 2022 BRENT HOUSING

No medical report was received, an email was sent to V’s GP.

4.24. September 2022 BRENT HOUSING

A call was made to V’s mother, she confirmed he had left home over a week ago.

4.25. September 2022 BRENT HOUSING

The council accepted V was eligible and homeless. He was referred to a local homeless hostel. This was a male only hostel. V was notified he was owed the relief duty^{[footnote 9]}. A housing assessment was sent to the hostel. The hostel tried to contact V without reply.

4.26. October 2022 BRENT HOUSING

Housing officers called V on several occasions to obtain an update with no reply, The relief duty owed to V had come to an end. V was notified by letter in mid October 2022. The case was closed the same day. V was referred to a suitable housing pathway.

4.27. October 2022 (MPS)

Police in central London saw P3 with inflated balloons and a large canister of nitrous oxide (NOS). He was detained. P3 admitted to having another two large canisters in his backpack and cannabis in his pocket. P3 received an Adult Community Resolution^{[footnote 10]}.

4.28. October 2022 (NPS)

The post-sentence supervision period ended for V; the case/sentence was terminated.

4.29. October /2022 (MPS)

Police stopped V with a group of other males after they had been seen using drugs and NOS canisters. Officers noted a smell of cannabis and empty canisters in the vicinity. The search was negative.

4.30. November 2022 BRITISH TRANSPORT POLICE (BTP)

P1 was stopped and searched for drugs, he was found in possession of a kitchen knife. Following his arrest the CPS authorised him to be charged with possession of an offensive weapon. He was remanded in police custody to appear at magistrates’ court. He was bailed in early November 22 to appear back before the court in late November 2022 on conditional bail.

4.31. November 2022 (NPS)

P1 appeared at magistrates’ court charged with possession of an offensive weapon. A pre-sentence report was requested.

4.32. November 2022 (MPS)

An allegation of robbery was made to police by a member of the public who stated they met the suspect in a bar in central London. They left the venue with the suspect, who asked to use his phone for entry of social media contacts. The complainant handed over their phone. The suspect began walking away. The complainant asked for the phone to be returned, the suspect punched them in the face and appeared to have transferred money to another account.

The complainant stated that they willingly handed their phone to the suspect. When the suspect returned the phone, the complainant realised that money had been transferred to another account. Financial enquiries identified the account the complainant’s money was transferred to as being in the name of V. CCTV enquiries were negative. The complainant was unwilling to support a police investigation as their money had been refunded by his bank. The case was closed with no further action taken (NFA).

4.33. November 2022 (MPS)

An allegation of robbery involving three suspects was made to BTP. The matter was investigated by the MPS. Due to the complexity of the case, it took eight months to identify all the suspects involved, one of which was found to be P1. It was not possible to put P1 before the courts prior to the subsequent murder of V 10 months later.

The first suspect (suspect one) was detained by officers at the scene. He was seen to discard the victim’s bag, this was seized. He was arrested, interviewed and bailed.

4.34. November 2022 GP

The practice received a report from the urgent care centre, at a local hospital stating that V had injured his shoulder in a local park.

4.35. November and December 2022 (MPS)

The second suspect for the knife-point robbery was identified from the CCTV images in late November 2022 and arrested a few days later. CPS authorised a charge of robbery. He was remanded in police custody to appear at magistrates’ court in early December 2022. He pleaded guilty to the offence. Bail was extended in relation to suspect one until early May 2023. One remaining suspect was yet to be identified (later to be identified as P1).

4.36. November 2022 (NPS)

P1 was sentenced to a Suspended Sentence Order (three months custody, suspended for 12 months) with two requirements: Rehabilitation Activity Requirement (15 days) and Unpaid Work (105 hours) for the offence of possession of an offensive weapon committed in November 2022.

4.37. December 2022 (NPS)

P1 attended his initial probation appointment. He was issued with appointments to attend on a weekly basis, he was also inducted to the unpaid work requirement.

4.38. December 2022 (MPS)

P1 was stopped and searched by police for stolen property, he was seen in a group with other males paying close attention to members of the public. No items were found.

4.39. December 2022 (NPS)

The initial sentence plan is completed by the PP following the first three appointments with P1.

4.40. January 2023 (MPS)

Police stopped P2 along with other males in an alleyway. As officers approached to speak with the males, they ran away. Officers detained P2 and one of the males. Officers noted a strong smell of cannabis from P2 and found a parcel containing separate wraps of cannabis in a nearby bush. P2 was arrested on suspicion of possession with intent to supply controlled drugs. Searches were made of his home address. There was insufficient evidence to attribute the drugs seized to P2, the case was closed with NFA taken.

4.41. January 2023 (MPS)

The police stopped a vehicle in which V was a passenger, he appeared under the influence of controlled drugs. When asked the reason for being in the area at 0130 hours, V was slow to answer and provided inconsistent responses. He was searched. A small quantity of balloons and NOS were found in the car^{[footnote 11]}. NFA was taken.

4.42. January 2023 (MPS)

P1 called police stating people with baseball bats were knocking at his door. He called back shortly afterwards stating they had left, and he no longer wanted police to attend. He was given personal safety advice and told to call back should they return. The suspects were unknown.

4.43. January 2023 GP

V visited his GP to follow up the ADHD clinic. He said that he had not heard from them since he was referred in 2021. The GP agreed to chase up the referral, he was prescribed medication to help him sleep. He was given a sick note from January 2023 to the end of April 2023 and blood tests were arranged. V told the GP that he was going to a local hospital A&E because he had been knocked down by a van, he had neck and back pain and wanted a full examination. The practice later received a report from A&E regarding this incident. V was kept in for observation and was discharged after 10 hours.

4.44. January 2023 and February 023 GP

The GP practice emailed the ADHD service indicating that V had been referred to them in 2021, with a reminder in 2022, without a response. The ADHD administration team replied that past referrals for V had not been received. The practice later received notification that V had been placed on the ADHD waiting list which was 20 months.

4.45. February 2023 (MPS)

A member of the public made an allegation of theft to police. She stated that after leaving the bar mentioned earlier in this report, she was approached by a group of males. She began talking with them and one asked to put their number in her phone. The complainant handed over her phone to the suspect who ran off. V was stopped and searched by officers in relation to the allegation. No stolen property was found. The victim told police V had not stolen her phone, but she believed he knew the suspect responsible. V denied any knowledge. The case was closed with NFA taken as the complainant was unwilling to support a police investigation.

4.46. February 2023 (MPS)

Police on patrol stopped and searched P1 and a group of four other males after they were seen to be smoking cannabis. The cannabis was seized, along with further herbal cannabis found inside P1’s jacket pocket. He admitted ownership of the cannabis. P1 received a Community Resolution Order for drugs.

4.47. February and March 2023 (NPS)

Safeguarding check completed/returned relating to P1, appeared to indicate that the family were known to adult safeguarding team. P1’s reporting frequency was reduced to monthly appointments with the PP.

4.48. March 2023 (MPS)

At 0300 hours CCTV operatives noticed an incident which appeared to be an attempted robbery on the street where the bar subject to previous incidents mentioned in this report is situated. A member of the public was attempting to get into a taxi and was surrounded by a group of males. When the member of the public got into the back right-side passenger seat of the taxi the suspects appeared to prevent them from closing the door and attempted to steal their bag. The member of the public prevented their bag being stolen and the taxi drove away. Officers attended the area and detained V and another suspect as matching the descriptions of those involved.

V and the second suspect were arrested on suspicion of attempted robbery. They were taken to a local police station where they were both interviewed during which they answered “no comment” to all questions. The complainant was unwilling to support the police investigation, and the case was closed with NFA taken.

4.49. March 2023 (MPS)

At 0218 hours police saw V and another male in a street in London. The second male was carrying a large NOS canister. V was stopped and searched. No items were found. The second male was found in possession of a large NOS canister and balloons for which he was issued with a Community Protection Warning (CPW).

4.50. March 2023 (MPS)

Anonymous information received via Crimestoppers suggesting that a person unknown, who lives at the address of one of the perpetrators, was supplying drugs.

4.51. March 2023 SUSSEX POLICE

At 0235 hours in late March 2023 V was arrested in Brighton for stealing a mobile phone from a female adult victim, he was charged and bailed.

4.52. March 2023 (MPS)

V was the victim of a serious assault where a vehicle had driven towards him and four other males at speed, causing injuries. Officers discovered V lying on the grass verge of the roundabout on his back conscious. He told the initial investigating officer (IIO) that a car had driven at him, causing pain all over his body. V told police that he had arrived at the venue in a taxi where he noticed a fight taking place which involved approximately 50 members of the travelling community with a lone Somali male. V stated that he tried to go over to assist this male. This continued for a short time until the suspect drove at speed towards V and a large group of people in the road, hitting V, lifting him over the bonnet of the car.

An investigation was conducted during which no suspects were identified. The windows of the suspect vehicle were tinted, and CCTV did not capture the driver. V was unwilling to provide a statement and support a police investigation. The case was closed with NFA taken.

4.53. March 2023 GP

V’s GP received a letter from the A&E unit at a local hospital regarding the incident where V had been hit by a car. Following treatment he was discharged. V had a telephone consultation with his GP who arranged a physiotherapist appointment in April 2023.

4.54. April 2023 GP

V was seen by the practice physiotherapist regarding the injuries he had received following the assault involving the car, V showed a video of the incident. He was lifted 1m in the air and thrown 3m away and the car drove off. The physiotherapist reported trauma of multiple joints. V was referred to the trauma and orthopaedic clinic.

4.55. April 2023 (MPS), April 2023 (NPS)

The NPS requested information regarding P1. The MPS response to the probation service was “the male in question has been stopped and searched on a few occasions in different areas and arrested for drugs”.

4.56. April 2023 (MPS)

Police were called to a location by a member of the public stating there were males removing panels from a vehicle. Police spoke to P3 and other males. They were unable to account for their presence at the location or provide proof of ownership. P3 was detained for the purpose of a search. No items were found.

4.57. April 2023 (NPS)

V appeared at Brighton Magistrates’ Court for an offence of stealing from the person committed in March 2023. The offence involved V taking a mobile phone out of the hand of a female victim. The court adjourned for a pre-sentence report to be prepared.

4.58. April 2023 GP

V was seen by his GP for a review of his ADHD. The GP wrote to the ADHD clinic to expedite the appointment and issued a sick note for one month.

4.59. April 2023 (MPS)

P1 was identified as a possible suspect for the knife-point robbery that occurred in November 2022 by intelligence from CCTV and he was circulated on the police national computer (PNC^{[footnote 12]}) as wanted for this offence.

4.60. April 2023 (MPS)

Police were approached by a member of the public, to report the theft of their mobile phone, gold bracelet and watch after leaving the bar mentioned previously in this report. The complainant told police that at around 0305 hours, he was approached by an unknown male selling NOS who persuaded him to take some. Shortly afterwards, he realised his phone, bracelet and watch were missing. When he and his friend demanded them back, his friend was assaulted by the suspect.

In early May 2023 police received an online allegation of theft. The victim reported that whilst waiting for an Uber in the SE1 area his mobile phone was snatched by an unknown male who ran off. Later that night there was usage on his account, the victim reported that after stealing his phone the suspect fraudulently took around £7000. V was mentioned as a possible suspect; he was believed to be involved in a theft of a mobile phone. V was not shown as a suspect as the victim did not respond to police and did not provide a statement to support the investigation. The case was closed with NFA taken.

4.61. May 2023 (NPS)

P1’s family called the probation service to inform them that the police had attended their address looking for P1. P1 was advised to go to the police station to find out what they wanted to speak to him about. P1 denied any knowledge of what this would be in relation to.

4.62. May 2023 (NPS)

P1 is instructed to commence the unpaid work requirement and is allocated to a project.

4.63. May 2023 (NPS)

V was sentenced at Sussex Central Magistrates’ Court for theft from the person to a Community Order for 18 months with 120 hours Unpaid Work and Rehabilitation Activity Requirement (RAR) of 15 days.

4.64. June 2023 (NPS)

P1 continued to attend appointments. He denied any ongoing police involvement. The police contacted the probation service on 16/06/2023 and advised that they wish to speak with him as part of an ongoing investigation. He was later arrested at his home address and bailed by police subject to further investigation. P1 was accepted on an apprenticeship course at college.

4.65. June 2023 (MPS)

Police arrested P1 at his home for the knife-point robbery that occurred in central London in early November 2022. He was interviewed at a police station during which he answered “no comment” to all questions, including CCTV evidence. He was bailed to return to a police station in mid August 2023 with conditions not to enter a location in central London or to contact the other suspects or any prosecution witness. He agreed to participate in identification procedures.

In July 2023 a positive identification was made, the witness confirmed that P1 was “the one who said he would stab me if I did not give him the pouch”. P1 was released on bail pending a CPS charging decision. The witness told the police that they had not seen a weapon.

P1 remained on police bail until September 2023, then with the appropriate authorisation of a detective inspector (DI) he was released under investigation (RUI). In December 2023 CPS authorised charges of robbery against P1 and suspect one, to be dealt with by Postal Charge Requisition^{[footnote 13]}. P1 was at this time remanded in custody for the murder of V.

4.66. August and September 2023 (NPS)

V failed to attend all unpaid work appointments and was suspended from the project. He also failed to attend four probation appointments in September 2023. A breach of the community order was initiated in early September 2023. The breach information pack had not been submitted to court by the time of V’s death.

4.67. August 2023 (NPS)

P1’s compliance with the Unpaid Work Requirement reduced, he was reported to be arriving late or leaving early for various reasons.

4.68. August 2023 (MPS)

P2 was stopped and searched for weapons at the Notting Hill carnival.

4.69. September 2023 (MPS)

An individual who may be connected to P1, P2 and P3 was involved in an altercation during which he sustained a significant injury. This incident was later detailed in the criminal trial of P1, P2 and P3 and reported in the local press as a possible motive for the murder of V.

4.70. September 2023 CITY OF LONDON POLICE (CLP)

Two victims were approached by V who took one of their phones off them and then gestured to his waistline in a way which suggested he was carrying a weapon. V was challenged by a group and returned the phone before leaving in a vehicle. Police arrested him shortly after. V was bailed with conditions not to enter the City of London and to sign on once a week at a local police station, he was bailed to allow for the obtaining of identification statements, phone enquiries and CCTV, his return date was mid December 2023 but the matter was dealt with as NFA due to his murder later in September 2023.

4.71. September 2023 (NPS)

Information was received after V’s death that he had been subject to police bail from mid September for an offence of robbery.

4.72. September 2023 (MPS), LONDON AMBULANCE SERVICE (LAS), LONDON NORTH WEST UNIVERSITY HOSPITAL

During the late evening police were called to a location in London by the LAS in relation to a fight where police discovered V, unresponsive. Officers and ambulance staff attempted CPR, V was conveyed to hospital, he had a traumatic cardiac arrest. His heartbeat was absent throughout the resuscitation. his life was later pronounced extinct. A forensic post-mortem examination established the cause of death was due to multiple stab wounds.

4.73. September 2023 GP

The GP practice received notification from the A&E Unit of V’s death from stab wounds.

4.74. September 2023 (MPS)

P1 and P2 were arrested on suspicion of murder. P2 was released on conditional police bail.

4.75. September 2023 (MPS)

In September 2023 P1 was charged with murder and possession of an offensive weapon. He was remanded in police custody to appear at the Central Criminal Court (CCC).

4.76. September 2023 (NPS)

P1 was arrested for the alleged murder of V, at the time he committed the murder he was under a probation order and subject to a three-month suspended prison sentence.

4.77. October 2023 (MPS)

P2 attended a police station in compliance with his bail conditions and because of new evidence, he was arrested, the CPS authorised P2 to be charged with murder and possession of an offensive weapon. He was remanded in custody to appear at magistrates’ court.

4.78. October 2023 (MPS)

P3 was arrested on suspicion of murder. The CPS authorised P3 to be charged with murder and possession of an offensive weapon. He was remanded in police custody to appear before magistrates’ court shortly after.

4.79. November /2023 (NPS)

P1’s Suspended Sentence Order (three months custody, suspended for 12 months) expires.

4.80. December 2023 (MPS)

CPS authorised charges of robbery against P1 committed in November 2022. As he was remanded in custody, the charges were to be dealt with by Postal Charge Requisition.

In December 2023 the file in relation to the assault on a police officer committed in April 2022 by P3 was submitted to the CPS. A charging decision was made in February 2024.

Dissemination

The list of recipients to receive copies of this Review Report (in line with guidance and due to the recommendations of this Report) are as follows:

• Brent Community Safety Team
• Metropolitan Police Borough Command Unit - Brent
• North West London Integrated Care Board – Brent
• Brent Probation
• Home Office
• Metropolitan Police Specialist Crime Review Group
• London North West University Healthcare NHS Trust - Safeguarding
• London Borough of Brent Housing Needs Team
• Central and North West London NHS Foundation Trust – Safeguarding
• Safer Brent Partnership
• Sussex Police
• Nottinghamshire Police
• City of London Police

Final Confidence Check

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.

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

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

Statements of Independence

Chair

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 of 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 ser 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.

Signature: Allan Doherty

Name: Allan Doherty

Date: August 2025

To be completed by the Home office:

☒ Please tick here to confirm thar the Chair was appointed from the Independent Chairs List held by the Home Office.

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

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

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

3. Access to ADHD treatment is critical, yet systemic barriers often lead to delayed or insufficient care. In this case, delays in the referral process, combined with under-resourced local ADHD services, exacerbated the victim’s condition, potentially influencing their behaviour. National Institute for Health and Care Excellence (NICE) guidelines on ADHD (NICE ADHD Guidelines) emphasise the need for timely assessment and treatment ↩

4. MAPPA is a set of arrangements which provides a common framework for the identification, assessment, and management of certain offenders in the community. Multi-agency public protection arrangements (MAPPA) guidance, Home Office 2024 ↩

5. Category 3: other dangerous offenders - who have been cautioned for/ or convicted of an offence which indicates that he or she is capable of causing serious harm, and which requires multi-agency management. Multi-agency public protection arrangements (MAPPA) (accessible version) - GOV.UK ↩

6. A national information management system that improves the ability of the police to manage and share intelligence and other operational information. The system aims to prevent and detect crime and make communities safer. (Police National Database (PND) - His Majesty’s Inspectorate of Constabulary and Fire & Rescue Services). ↩

7. Studies show that gender-specific interventions reduce violent behaviours by 25% (International Journal of Offender Therapy, 2021). ↩

8. Community Resolutions Guidance 2022, National Police Chief’s Council ↩

9. Local Authority Duty to Relieve Homelessness, Shelter 2022 ↩

10. Community Resolutions Guidance 2022, National Police Chief’s Council ↩

11. Nitrous oxide (NOS) is regulated under the Psychoactive Substances Act 2016, which prohibits the production, supply and possession with intent to supply of psychoactive substances if they are likely to be used for their psychoactive effects. However, simple possession of nitrous oxide is not an offense under this legislation unless it occurs in a custodial institution. This legal framework often results in cases being marked as “no further action” (NFA) where possession alone is identified, as enforcement focuses on supply rather than personal use. ↩

12. A computer system used by the police and other UK law enforcement organisations to access real time information of national and local significance. The PNC is used to carry out real-time checks, for example on a person’s criminal record, missing and wanted people, and vehicle registration checks (Police National Computer (PNC) - His Majesty’s Inspectorate of Constabulary and Fire & Rescue Services). ↩

13. A postal requisition is a legal document notifying you that a decision has been made to prosecute your offence(s) at court. Postal Requisitions, Avon & Somerset Police). ↩