Annual Report 2025: Serious Further Offences

Chief Inspector’s overview (Back to top)

This is our fourth annual report of our serious further offence (SFO) inspection work¹ since we commenced our independent oversight of reviews carried out by HM Prison and Probation Service (HMPPS).

This year’s findings highlight a consistent and concerning trend that the quality of SFO reviews produced by probation regions is not meeting the required standard.

We have quality assured 90 SFO reviews this year, with 53 per cent of these rated as ‘Requires improvement’. In contrast, just 46 per cent were rated as ‘Good’, and one per cent as ‘Outstanding’. Disappointingly, these findings show no improvement from the previous year.  

This year, we engaged directly with the families of victims impacted by serious further offences, both through survey responses and in-person meetings. We extend our gratitude to all who contributed by sharing their experiences of the SFO review process, which has provided valuable insights that inform this report. 

Our annual report details the findings from this engagement, showing consistent themes of poor communication, and a lack of transparency. Families consistently reported that engagement with the probation service was characterised by delays, was impersonal with a perceived lack of recognition of victim individuality, showed limited compassion towards the families, and was delivered as a formality from HMPPS that neither supported the process nor acknowledged the gravity of their loss.  

This has highlighted a clear opportunity for HMPPS to do more to engage meaningfully with victims and their families, and the powerful testimonies shared could play a vital role in shaping and improving victim engagement practice. Families consistently called for an SFO review process which is timely, transparent, person-centred, and trauma informed². In our experience families were rarely looking to apportion individual blame and instead keen to be assured that steps were being taken to learn lessons. They also expressed a willingness to share their experiences to support and benefit others in similar circumstances, who may need to navigate the process in future. 

This year we were also concerned to find that a significant backlog of SFO reviews has developed across probation regions. This must be addressed, while also ensuring that the standard of the reports is not further negatively impacted. 

In last year’s SFO annual report we made 11 recommendations, seven of which were repeated from the previous year’s’ SFO annual report. It is discouraging to note that while HMPPS have taken forward some activity against most of these recommendations, the outcomes and their impact is still not clear. 

This year, we have made seven recommendations, three of which are specifically aimed at improving the experiences of SFO victims and their families. We also include recommendations on the quality and timeliness of SFO reviews, and on addressing the backlog of overdue reviews.  I encourage HMPPS to engage fully with all these recommendations, with the hope that the necessary improvements, in particular those supporting a more transparent and compassionate approach to engagement with the families and victims of SFOs, may be put in place as soon as possible.

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Introduction (Back to top)

Serious further offences (SFO) are specific violent and sexual offences committed by people who are, or were very recently, under probation supervision at the time of the offence.

The SFO review process² begins when a person on probation has been charged and appears in court for an SFO qualifying offence. This alleged offence must have been committed while the person was under probation supervision or within 28 working days of their supervision period ending. Following the initial court appearance, a notification is completed and the SFO review is commissioned.

It is of concern that there has been a sustained increase in the number of notifications of an arrest and charge for an SFO over the last two years. In the period 2023/2024 the figure increased from 478 to 770, and in 2024/2025 it increased further by 13 per cent to 872³. While SFOs remain comparatively rare as a proportion of the overall caseload, the trends need to be monitored carefully, given our consistent inspection findings that the quality of public protection work needs to improve. If the service as a whole does not understand enough about the risk posed by those they are managing, there is an increased risk that things may go wrong and warning signs may be missed.

Although SFOs account for less than 0.5 per cent of the total probation caseload, their impact cannot be understated. As such, an SFO review is expected to provide assurance that there has been rigorous and transparent scrutiny of an individual case, and to identify where learning and improvements are needed to effect change at an individual, local, regional and national level where applicable.

An SFO review is automatically triggered and must be completed when:

• any eligible supervised individual is charged with murder, manslaughter, other specified offences causing death, rape or assault by penetration, a sexual offence against a child under 13 years of age, or qualifying offences under terrorism or anti-terrorism legislation during a period of management by probation. This includes ancillary and inchoate offences such as attempt, conspiracy to commit, incitement to commit and encouraging or assisting commission.

A review is conditionally triggered and must be completed when:

• any eligible supervised individual is charged with another offence on the SFO qualifying list committed during a period of management by Probation and who is or has at some point been assessed as high/very high risk of serious harm during the current sentence

• any eligible supervised individual is charged with another offence on the SFO qualifying list committed during a period of management by Probation, prior to completion of an initial risk assessment.

A case no longer qualifies for an SFO review if it subsequently falls outside the SFO eligibility criteria, because:

• the individual is found not guilty at court, other than for reasons of fitness to plead or by reason of insanity
• proceedings are discontinued, either before trial or at court
• the charge is reduced to one that falls outside the SFO eligibility criteria.

In these circumstances, the probation region can determine whether they wish to continue with a local review into the case.

The SFO procedures also stipulate that there may be other instances where the automatic or conditional eligibility is not met, but a review could still be completed on a discretionary basis, for example where there is significant media or ministerial interest or where there are reputational risks to the organisation.

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The SFO review process (Back to top)

⇩	A person subject, or recently subject, to probation is charged with a SFO.
⇩	Following the first court appearance the probation court team will complete the SFO notification, which is authorised by the probation region and submitted to the HMPPS central SFO team.
⇩	Probation regional SFO teams complete the SFO review.
⇩	The SFO review is assured and countersigned by the nominated staff members from the probation region and submitted to the HMPPS central SFO team for quality assurance.
⇩	Approximately 20 per cent of the submitted SFO reviews are allocated to HM Inspectorate of Probation to complete this quality assurance.
⇩	HM Inspectorate of Probation quality assure the SFO review and provide probation region with written feedback, including a rating for each standard, which forms a composite rating.
⇩	Following conviction, automatic review cases, the victim or their family members are notified that an SFO review has been completed. A meeting is offered to share the SFO review.
⇩	The victim or their family member can also opt to engage with the victim contact scheme for ongoing information on the sentence.

SFO reviews are completed by probation regions. Each region has a dedicated team of reviewing managers whose role it is to complete the SFO reviews, overseen by an SFO lead manager and a senior leader. In most probation regions, this is the head of performance and quality.

Regional probation directors have a responsibility to ensure that the SFO review is countersigned before it is submitted to the HMPPS central SFO team. In the main, SFO reviews are internally quality assured by the SFO lead manager. The regional probation director delegates countersigning of the review to a senior manager who is independent of the line management of the case.

When the SFO review is countersigned, the relevant probation manager confirms they are satisfied that it meets the required standard. Following the countersignature, the review is submitted to the HMPPS central SFO team for quality assurance. Approximately 20 per cent of these reviews are subject to quality assurance by His Majesty’s Inspectorate of Probation.

Our quality assurance findings have shown that the layered approach to the regional internal countersigning of SFO reviews is not providing the consistent level of quality and rigorous oversight required. We consider this further in our analysis of this year’s quality assurance data.

Sharing the SFO review with victims and their families

Following conviction the victim or their family members are formally informed that the case was being managed by the probation service when the offence was committed and has met the SFO criteria.

For automatic review cases, the victim liaison officer (VLO)⁴ should write to the victim or their family member on behalf of the head of the probation delivery unit (PDU) where the person on probation had been managed. This letter should explain clearly that they are entitled to information on the SFO review process, offer a meeting with a relevant senior manager (usually the head of the PDU) and state that they are eligible to receive a copy of the review.

The HMPPS policy framework does, however, set out the level of information that the victim or their family member will receive. For SFO notifications received:

• on or after 01 April 2018, a copy of the full review will be shared, and only information that cannot lawfully be shared will be redacted
• before 01 April 2018, a victim summary report (VSR) will be shared; requests to see the full review will be considered on a case-by-case basis, with a presumption to provide a redacted copy.

The victim or their family member can ask to see the SFO review at any point after the conviction. Our data shows that more requests to access a review are being made, some immediately after conviction and others months or years later.

When a meeting is arranged, the SFO policy framework⁵ stipulates that the VLO and PDU head should ensure the arrangements ‘meet the individual needs of the victim and in order that they can be aware of the victim’s circumstances and any particular sensitivities’. They should also consider who is to be offered disclosure of the SFO, and how to do this when there are multiple family members.

The meeting should be timely, held in an ‘appropriate venue’ and should only be confirmed when the SFO review has been quality assured and deemed ready for sharing.

Victims or their family members can also choose to engage with the victim contact scheme5 (VCS) following conviction, or at any point in the sentence. The VCS provides ongoing information on sentence progression and other key pieces of information while the person is in custody and following their release.

The role of HM Inspectorate of Probation in SFO quality assurance

Our role in the quality assurance of SFO reviews was established following publication of our Thematic inspection of the Serious Further Offences (SFO) investigation and review process⁶ in May 2020, when we were asked by the Secretary of State to assume a role in independently quality assuring SFO reviews completed by probation service regions. Since April 2021, we have been required to:

• examine and rate approximately 20 per cent of all submitted SFO reviews to drive improvement and increase public confidence in the quality of the reviews
• convene multi-agency learning panels to bring together agencies involved in specific cases to improve practice and strengthen partnership working
• provide an annual overview of this work.

The Secretary of State for Justice can also ask us to complete an independent review into a specific case or aspects of a case.

Our core probation inspections also consider the work of each of the regional SFO reviewing teams, the quality of the SFO reviews they produce, and whether the learning and action taken as a result of the SFO review has had a positive impact on the practice deficits identified across the probation region.

To underpin the quality assurance of SFO reviews, HM Inspectorate of Probation sets the standards against which the quality assurance activity is delivered.

These standards set out expectations that an SFO review will provide a robust and transparent analysis of practice, provide clear judgements on the sufficiency of that practice, identify areas for learning, and be written in an accessible way.⁷

This is our fourth SFO annual report. It sets out the findings of our quality assurance work between April 2024 and April 2025 and includes an overview of our engagement with victims’ families who have directly experienced an SFO.

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Recommendations (Back to top)

In last year’s SFO annual report we set a total of 11 recommendations. Seven of those had been set in the previous year’s report and were repeated, as we found insufficient evidence that progress had been made against them.

These recommendations and HMPPS’s responses to them are set out in the tables below.

Recommendation 1
Promptly review the SFO review document format to maximise the opportunity to produce high-quality and informative SFO reviews that meet the needs of victims and their families.
Action taken and impact	HMPPS have introduced a new approach to SFO reviews, which is set to continue.
Categorisation	Some progress.
Improvement still required?	Yes. The implementation and impact still need to be demonstrated, particularly given the need to address the backlog of SFO reviews that has formed.

Recommendation 2
Ensure that the learning identified is translated into meaningful and impactful actions.
Action taken and impact	HMPPS quality assures action plans as part of its quality assurance process. HMPPS also advised that it will begin a review of how the probation service identifies organisational weakness. A process will be developed to analyse the themes arising from SFO reviews findings.
Categorisation	Some progress.
Improvement still required?	Yes. The quality assurance activity is existing activity. The impact of this needs to be demonstrated. The progress and impact of the latter two elements need to be demonstrated.

Recommendation 3
Ensure that where applicable, all learning linked to the probation partnership working is identified and shared with the relevant agencies.
Action taken and impact	HMPPS will continue to quality assure SFO reviews. The revised approach will consider how actions are communicated with partners. HMPPS have advised that they now record learning that is being shared with partner agencies, or where feedback identifies the need for this.
Categorisation	No progress detailed.
Improvement still required?	Yes. The update provided does not address the recommendation and reflects existing activity. The findings and actions taken following the review of the SFO approach have not been shared.

Recommendation 4
Develop a process to ensure that learning from SFO reviews is fed back into the organisation to inform and shape developments within probation regions and more widely across HMPPS.
Action taken and impact	HMPPS will begin a review of how the probation service identifies organisational weakness. Learning will be centrally collated and analysed for significant national themes. Themes are shared on a quarterly basis at strategic performance and quality meetings. And the role of the SFO reference group has been strengthened to focus on such themes.
Categorisation	Some progress.
Improvement still required?	Yes, the implementation and impact still need to be demonstrated.

Recommendation 5
Ensure that robust and rigorous countersigning takes place on all SFO reviews before they are submitted for quality assurance.
Action taken and impact	HMPPS partially accepted this recommendation however the rationale for this is not clear. The HMPPS will continue to use the existing policy framework and a revised countersigning checklist will be used. Work to benchmark and engage with regional SFO leads will continue.
Categorisation	Some progress.
Improvement still required?	Yes, the implementation and impact still need to be demonstrated.

Recommendation 6
Put robust processes in place to ensure that, following quality assurance feedback, all required changes to the SFO review document are timely and made to a sufficient standard.
Action taken and impact	This was partly accepted for capacity and affordability reasons. HMPPS has an existing expectation that amendments are made within four weeks following quality assurance feedback. HMPPS requires reviewing managers to continue to prioritise prompt action to make amendments when a review is shared with victims, when there is significant public interest, and if following QA the review is rated as ‘Inadequate’. In other reviews which require improvement, probation regions will continue to prioritise feedback which indicates that changes to the action plan are required to ensure that opportunities to act on learning are not delayed.
Categorisation	Some progress.
Improvement still required?	Yes, this represents existing activity.

Recommendation 7
SFO reviews, particularly those of the most serious offences, should where possible be undertaken by a separate probation region to that responsible for supervising the case at the time of the SFO. And consideration should be given to raising the grade of SFO reviewers, particularly for the most serious or complex cases.
Action taken and impact	This was partially agreed for affordability reasons. HMPPS will consider alternative options to raise the quality of the SFO reviews. HMPPS will continue to work to the policy framework for separate probation regions to complete SFO reviews. HMPPS will allocate the most serious and complex cases to a separate probation region and have done so on two occasions.
Categorisation	Some progress.
Improvement still required?	Yes, the implementation and impact still need to be demonstrated.

Further recommendations 2023/2024

Recommendation 8
Introduce training and development for those working in SFO teams in a way that enables reviewing managers to undertake the role in a meaningful way and supports a shared learning culture among SFO reviewing teams and across probation regions.
Action taken and impact	This was partially agreed, as HMPPS determined that they already provide significant support to reviewing teams. HMPPS has reviewed the learning package. HM Inspectorate of Probation will continue be consulted on themes for engagement events with staff.
Categorisation	Some progress.
Improvement still required?	Yes. The implementation and impact still need to be demonstrated.

Recommendation 9
In conjunction with the SFO procedures being reviewed, specific focus is given to the transparency of the process and how the review findings are shared with those staff members who were involved in the management of the case
Action taken and impact	A task force has been established to promote an SFO learning culture and enhance staff support. HMPPS will consider the revised format of the SFO review and whether this supports greater sharing of the review.
Categorisation	Some progress.
Improvement still required?	Yes. The implementation and impact still need to be demonstrated.

Recommendation 10
Action is taken to ensure the resourcing of SFO reviewing teams can meet the requirements set out in the SFO policy framework, and that specific focus is given to addressing the backlog of SFO reviews and their ongoing completion in a timely manner.
Action taken and impact	HMPPS will review the current process to develop a model where this can be achieved within the available resources.
Categorisation	Some progress.
Improvement still required?	Action is taken to ensure the resourcing of SFO reviewing teams can meet the requirements set out in the SFO policy framework, and that specific focus is given to addressing the backlog of SFO reviews and their ongoing completion in a timely manner.

Recommendation 11
Review the effectiveness and impact of the SFO policy framework and approach to analysing practice when serious further offences occur to ensure meaningful learning is identified at the right level.
Action taken and impact	HMPPS will pilot a new approach to SFO reviews to inform a fundamental change to SFO policy.
Categorisation	Some progress.
Improvement still required?	Review the effectiveness and impact of the SFO policy framework and approach to analysing practice when serious further offences occur to ensure meaningful learning is identified at the right level.

HMPPS provided a written response to the recommendations set out in the previous annual report. Of the 11 recommendations set, four were partially accepted, with capacity and affordability cited as reasons for two of these.

In its response, HMPPS said it had already started work to develop a new approach to SFO reviews and would continue this work.

Part of the response outlined activity that HMPPS was already taking forward through existing routine work. It did not evidence any further developmental action being taken to meet the recommendations.

It is positive to see HMPPS commit to taking forward some new areas of work; however, the progress achieved to date was not made clear in its written response. Therefore, assurances are still required that this activity is happening and resulting in meaningful and impactful outcomes.

In response to action six, HMPPS set out their existing expectations that reviewing teams should make the required amendments within four weeks of the quality assurance feedback being sent. They also emphasised that there is a prioritisation framework applied when requests to share the review is received by the victim or their family, where there are significant quality issues and the review has been rated inadequate, and in cases of significant public interest. In other reviews which require improvement, HMPPS have advised that probation regions will continue to prioritise feedback where changes to the action plan are required to ensure that opportunities to act on learning are not delayed. Although it is encouraging that HMPPS are expecting amendments to be made, we have not received assurances that this is being applied as expected, or to the required standard, thus the progress made against the recommendation is not clear.

The response to action point eight reflects that the learning package has been reviewed. The HMPPS central SFO team have consulted with our SFO inspectors to seek input on recurring quality assurance themes and areas to address within forum meetings held with SFO teams. It is positive that an ongoing intention to consult with us is emphasised in their response, which we look forward to.

It is concerning to note that, although HMPPS’s area executive directors (AEDs)⁸have been provided with monthly data on the timeliness of SFO reviews, the backlog has continued to grow over this reporting year.

The taskforce that HMPPS has referenced is in principle a positive example of action taken. However, the conclusions of the taskforce have not been documented in HMPPS’s written response to us.

We make a further seven recommendations to ensure there is an ongoing focus on outstanding areas of work and based on this year’s report findings.

HMPPS should:

1. devise and implement an approach to engaging with victims and their families following an SFO, which is directly informed throughout by victims, their families and relevant interested parties
2. devise and implement a clear mechanism by which feedback from victims and their families can be collected, understood and acted on, following sharing of an SFO review
3. carry out a review of the support and training provided to staff that deliver SFO findings to victims and their family members, and act on the findings of that review
4. ensure that the process for countersigning of all SFO reviews is sufficiently robust to meet the required standard and that regional senior leaders are held to account for the quality and timeliness of SFO reviews
5. gather evidence that action plans are always being implemented, that recurring and thematic learning is identified to make improvements to practice, and that updates to action plans sufficiently reflect the progress and impact made
6. implement changes to ensure that all SFO reviews are timely and completed to a sufficient standard
7. monitor and publish information on completion of overdue SFO reviews, including the size of the backlog, progress made, the quality of reviews completed against the standards, and the impact of the process.

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Contextual data (Back to top)

The total number of SFO notifications received by the HMPPS central SFO team in 2024/2025 was 872.⁹

Concerningly, this number represents an increase of 13 per cent compared to the previous year and is the highest number recorded in the whole series of figures published by the Ministry of Justice.

Table 1: SFO data as at 30 September 2024 for England and Wales

244,209	Number of individuals under probation supervision as of 30 June 2025. This represents an increase of two per cent compared to the end of June 2024. Compared to June 2015, this represents an increase of seven per cent.
872	Number of SFO notifications received in 2024/2025, which is an increase of 13 per cent compared to 2023/2024, when 770 notifications were received.
770	Total number of SFO notifications received in 2023/2024. This represented a 33 per cent increase in the number of SFO notifications compared to the previous year.
488	By 30 September 2025, 488 reviews had been completed on the 872 notifications received.
357	Number of SFO convictions from the 579 notifications received in 2023/2024 as at 30 September 2025. Of these convictions, 56 were for murder and 107 were for rape and other serious sexual offences.
50%–60%	Proportion of SFO notifications that result in a conviction for an SFO in most years. In the remaining cases, charges are dropped, or the person is acquitted or convicted of a less serious offence.
56	Number of the 357 SFO convictions in 2023/2024 for murder, a decrease from 67 the previous year.
107	Number of the 357 SFO convictions in 2023/2024 for rape and other serious sexual offences, compared to 108 from the previous year.

Table 2: Conviction offences by notification period

SFO conviction	2021/2022	2022/2023	2023/2024
Murder	65	67	56
Attempted murder or conspiracy to commit murder	17	13	26
Manslaughter	22	24	19
Rape/assault by penetration of a child under 13/attempted rape/rape of a child under 13	77	108	107
Arson with intent to endanger life	21	23	30
Kidnapping/abduction/false imprisonment	22	18	22
Death involving driving/vehicle-taking	10	14	16
Other serious sexual/violent offending	67	45	81
Total	301	312	357

Table 3: Number of SFO convictions by the type of index sentence, as at 30 September 2025

Index sentence type	2021/2022	2022/2023	2023/2024
Community supervision	112	142	168
Prison sentence	168	155	179
Life sentence	8	6	4
Imprisonment for public protection	13	9	6
Total	301	312	357

Table 4: Number of SFO convictions for murder, by the type of sentence the person on probation was serving at the time         

Index sentence type	2021/2022	2022/2023	2023/2024
Community supervision	27	33	28
Prison sentence	36	30	27
Life sentence	2	3	0
Imprisonment for public protection	0	1	1
Total	65	67	56

These statistics demonstrate that, given the increase in SFO notifications, there is a need to ensure the timely completion of reviews, so that the existing backlog does not increase further. Although some SFO notifications will not result in a conviction, it is still a requirement that a review is completed following notification. It is therefore important that reviews begin in a timely manner and that they meet the expected standard. This will avoid amendments being required, which can have further implications for the regional SFO reviewing team’s workload. It is also relevant when considering the needs of victims and their families, as it ensures that a sufficient quality SFO review is available for them in a timely manner on request, which we will consider later in this report.

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What we found, April 2024 to April 2025 (Back to top)

During the period April 2024 to April 2025, we quality assured a random sample of 20 per cent of the SFO reviews undertaken by the Probation Service in England and Wales, which equated to 90 reviews.

Table 5: SFO reviews quality assured by HM Inspectorate of Probation, by offence type

Number	SFO offence
14	Murder
3	Attempted murder
4	Manslaughter
42	Rape
2	Attempted rape
7	Assault by penetration
4	Sexual assault of a child under 13
1	Arson with intent to endanger life
5	Attempting to cause/incite a child under 13 to engage in sexual activity
1	Engaging in sexual activity in the presence of a child under 13
6	Death by dangerous driving
1	Possession of a document of use for terrorism
90	Total

Of the 90 SFO reviews we quality assured, 46 per cent were subject to a community sentence and 54 per cent were subject to post-release supervision, via licence or post-sentence supervision.

Quality assurance by sentence type	#	%
A community sentence	41	46%
Post-release supervision	49	54%

Risk of serious harm category at the point the SFO was committed	#	%
Low	5	6%
Medium	47	52%
High	38	42%

Of the 90 SFO reviews that we quality assured this year, 42 per cent of those supervised had been assessed as posing a high risk of serious harm before the SFO was committed, 52 per cent were assessed as posing a medium risk of serious harm, and six per cent as low risk of serious harm.

Concerningly, we found in 91 per cent of the SFO reviews, the risk of serious harm categories assigned to the case by the probation service had been inaccurately assessed. This meant that in most cases the overall risk of serious harm level was incorrect, the relevant categories and those at risk were not adequately identified, and/or the nature of the risk of serious harm posed by the individual was not captured accurately in the assessment.

Our 2023/2024¹⁰ annual report included a focus on inaccurate risk assessments, and this year’s quality assurance findings demonstrate that this remains an ongoing concern. In that annual report, we cited several key factors that underpin this practice, which remain relevant. These include:

• inexperienced officers completing assessments
• lack of training, or insufficient training available
• information not being sought from available sources, for example domestic abuse or child safeguarding enquiries not being completed
• assessments not based on all available information, resulting in pertinent information not always being explored or used effectively to inform the risk assessment
• information taken at face value and not followed up or verified, demonstrating a lack of professional curiosity
• risk assessments not reviewed when new information about risk comes to light
• excessive workloads, which can result in assessments being completed quickly, late or by another practitioner who is not as familiar with the case – in some cases, review assessments are not completed
• a narrow view of the risk of serious harm is presented, for example a practitioner may focus on the most pertinent risk factors and not consider wider issues; this results in an assessment that is not holistic and does not consider all risk factors
• insufficient multi-agency working to inform risk assessments.

Quality assurance by MAPPA level at the point the SFO was committed	#	%
Level 1	20	91%
Level 2	2	9%

Of the 90 SFO reviews quality assured, 41 per cent were identified as being actively managed under Multi-Agency Public Protection Arrangements (MAPPA).¹¹

The diagram shows that of the 41 per cent of cases eligible for management under MAPPA, 91 per cent were registered at MAPPA Level 1 at the point the SFO was committed, and nine per cent at MAPPA Level 2. None of the cases quality assured were managed at Level 3 at the point the SFO was committed.

For those registered at MAPPA Level 1, we found mixed evidence on the quality of this oversight. The Level 1 framework was not being implemented at team and/or PDU level. Level 1 meetings were not being held at the expected frequency, and meetings that were held did not contribute meaningfully to the management of the case.

It is of further concern that we also found mixed evidence of how well practitioners and reviewing managers understood the practice guidance on individuals who were not automatically eligible for management under MAPPA but could be referred into these arrangements under category 3. This lack of understanding was particularly evident in high-risk domestic abuse cases that should have been considered for referral. 

In 48 per cent of the SFO reviews we quality assured this year, we found that MAPPA practice was not sufficiently considered by the reviewing manager, resulting in a gap in the quality of the analysis of practice and missed opportunities to consider how well MAPPA practices are delivered by the probation service.

Given that accurate risk assessments and effective MAPPA oversight are critical to public protection, these areas should continue to feature in SFO review action plans. We will consider how learning is identified and actioned later in this report.

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Quality assurance activity (Back to top)

The quality assurance of SFO reviews is underpinned by HM Inspectorate of Probation standards. These standards are supported by our rules and guidance, and our ratings characteristics. These documents are available on our website so that reviewing managers and SFO leads can use them to support their writing and countersigning of SFO reviews7.

Our standards have been agreed with HMPPS, and support both our quality assurance activity and that of the HMPPS central SFO team.

The standards have four elements:

• analysis of practice
• sufficient judgements
• learning
• victims and their families.

The SFO quality assurance standards set the expectation that each SFO review will:

• include a robust and transparent analysis of practice
• use an evidence base to provide clear and balanced judgements on the sufficiency of practice
• identify where there are opportunities to learn and drive practice improvements; where relevant, these should be across all levels of the organisation
• be written in sensitive and accessible manner so that it can be shared with the victim or their family.

Each individual standard is assigned a rating, and these are then combined to contribute to a composite rating of:

• ‘Outstanding’
• ‘Good’
• ‘Requires improvement’ or
• ‘Inadequate’.

Following quality assurance, written feedback on the SFO review is given to the probation region. This explains where the review met the required standard, whether improvements are required, and how these should be made.

The HMPPS central SFO team also use our quality standards when they are quality assuring SFO reviews. We work collaboratively with them, meeting quarterly and holding joint benchmarking sessions. This is an important element of our work, which further supports joint monitoring of how the standards are applied and promotes their consistent application.

Our quality assurance of SFO reviews is underpinned by continual internal dialogue and reflection. Internally, we hold quarterly benchmarking sessions between our SFO inspectors to support our ongoing assurance on the consistent application of the standards. This includes additional benchmarking sessions when there is an initial indication during the quality assurance process that the threshold of ‘Inadequate’ is being met. We also collectively consider an SFO review where a rating of ‘Outstanding’ is given, which enables us to identify the strengths of the review and share this learning more widely.

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Composite ratings (Back to top)

Of the 90 SFO reviews that we quality assured this year, 53 per cent received a composite rating of ‘Requires improvement’, 46 per cent a rating of ‘Good’ and one per cent a rating of ‘Outstanding’. No reviews received a composite rating of ‘Inadequate’. These findings are consistent with the previous year’s and show that no improvements in the quality of SFO reviews have been made this year, with most not meeting the required standard.

HM Inspectorate of Probation composite ratings 2024/2025	#	%
Outstanding	1	1%
Good	41	46%
Requires improvement	48	53%

HM Inspectorate of Probation composite ratings since 2021
Years	2021-2022	2022-2023	2023-2024	2024-2025
Outstanding	3	3	1	1
Good	66	49	46	46
Requires improvement	25	45	52	53
Inadequate	6	2	1	0

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Regional overview (Back to top)

The SFO reviews we quality assure are randomly allocated to us by the HMPPS central team. Although it is a random sample, we expect each of the probation regions to be represented over the course of the 12 months.

Therefore, the proportion of SFO reviews we quality assure per probation region can be affected by factors such as the number of SFO reviews completed by probation regions and the timing of these submissions for quality assurance.

Over the last two years, we have had increasing concerns about the time being taken to complete SFO reviews, with many probation regions routinely seeking to extend the submission deadline. These requests are made formally by the probation region to the HMPPS central SFO team, who review and approve the request.

Of the 90 SFO reviews we quality assured this year, 77 per cent had at least one approved request for an extension of the completion date, and some had multiple requests. The reasons for most of these requests related to the availability and workload of the reviewing manager; linked to this was the need to prioritise certain reports, for example those that were high profile or where there was an active request for the report from a victim or their family member. These extensions varied in length from weeks and months to a year. This figure is consistent with our findings from the previous reporting year, in which 76 per cent of the SFO reviews that we quality assured had an extension granted.

The impact of this cannot be underestimated. Delays in completing SFO reviews can hinder the probation service’s responsivity to the learning and practice needs identified as part of the SFO review and can result in delays in sharing the SFO review should there be a request for access by the victim or their family. Furthermore, the frequent requests for extensions have increased the number of SFO reviews waiting to be completed, contributing to a backlog of reviews that are overdue.

When we have spoken to probation regions it is apparent that they have differing views on the extent of the backlog, owing to how each region allocates work to reviewing managers, and how they determine the number of SFO reviews that remain outstanding for completion.

Regions report that several factors have caused delays in completing SFO reviews, including an increase in the number of SFO notifications and the volume of work increasing accordingly, and wider resourcing concerns among reviewing teams.

Additionally, regions have expressed the view that amending the reports following quality assurance feedback is contributing to an increased workload. We acknowledge that the quality assurance process will provide feedback on how to develop the standard of the SFO review, and reviews with a composite rating of ‘Requires improvement’ or ‘Inadequate’ will require larger amounts of work to improve the standard of the review. However, this emphasises the importance of probation regions ensuring that the internal quality assurance and countersignature process is of a sufficient standard, so that the SFO review meets the expected standard when it is first submitted for quality assurance. This will reduce the overall time taken to complete the reviews.

We are aware that, at the time of writing this annual report, HMPPS has introduced a revised SFO review process and template aimed at addressing the backlog. This is intended to be an interim measure, and it will evaluate the findings to further inform the longer-term review of the SFO procedures. We will report on the findings from this backlog recovery approach, and the quality assurance of the reviews written on the revised template, in our 2025/2026 annual report. We have also made recommendations this year that focus on the implementation of this approach, the internal countersigning of SFO reviews, and the strategic oversight of this by probation regions.

Composite ratings by each probation region between 2023/2024 and 2024/2025

Composite ratings 2023/2024 in bold

Composite ratings 2024/2025 in (brackets)

Probation Region	Outstanding	Good	Requires improvement	Inadequate
Yorkshire and the Humber		3 (5)	8 (9)	1
Greater Manchester		3 (5)	4
London		3 (10)	6 (8)
West Midlands		6 (2)	4 (5)
East Midlands		1 (1)	1 (0)
Wales		4 (2)	2 (2)
North West		3	3 (7)
Kent, Surrey, and Sussex		1 (5)	5 (1)
East of England	1 (1)	6 (5)	1 (4)
North East		3 (1)	4 (6)
South West		4 (2)	5 (4)
South Central		3 (3)	2 (2)

This table demonstrates the continued regional variation in composite ratings in the most recent reporting period, compared with the previous year.

In previous annual reports we have highlighted HMPPS’s intention to review the policy framework that supports the delivery of SFO reviews. In this reporting year the same framework has remained in place; however, a revised review template was introduced in January 2024. In last year’s annual report, we noted that HMPPS were encouraged by the quality of reviews being completed and anticipated that this revised format would help reviewing teams manage the pace and demand of workload

This year all but two of the 90 reviews that we quality assured were completed on this revised template. Our quality assurance findings showed that it has not had the positive impact on quality, pace or workload HMPPS originally anticipated.

To maintain our focus on the quality of SFO reviews, we have continued to engage with the probation regions, with the aim of supporting them to work to the SFO quality standards and thus improve the quality of their SFO reviews. We have held individual meetings with reviewing managers and SFO leads for the region, and benchmarking sessions. We value this work with SFO reviewing teams, which reflects our commitment to ongoing learning and driving improvement and quality.

The benchmarking sessions are delivered in two formats. First, there are sessions with the team of regional SFO reviewing managers, and then there are individual sessions with the regional SFO leads. The latter are delivered collaboratively with the HMPPS central SFO team. They focus on the SFO lead’s role in the internal quality assurance of an SFO review before it is submitted for quality assurance. It has been positive to work with the HMPPS central SFO team on these sessions, and these will continue to be delivered collectively over the forthcoming year.

We collect anonymous feedback after each of the benchmarking sessions, and this reflects an overwhelmingly positive response:

“It provided clarity regarding quality of reports and what is required to meet the QA standards. Use of the case study was helpful. Face to face delivery was excellent and very effective promoting more discussion and interest.”

“I thought that it was extremely informative and the practice advice and guidance given is something that I can apply to my reviews. It was also good to meet in person.”

“Significantly, it was really helpful to gain understanding and perspective from both sides, i.e. reviewers and HMIP QA’ers.”

“Really helpful session which allowed free flow of discussions in a relaxed setting to review a report together. The facilitators were both really effective in explaining the purpose.”

Benchmarking for SFO reviewing teams delivered by HM Inspectorate of Probation

“It was an extremely helpful/informative session, and i felt a lot more confident in QA’ing documents following this.”

“The session was really helpful for future QA of reviews as well as in relation to the specific case reviewed – helpful discussions in how to approach QA, and we also took away a lot of helpful learning and considerations for the team in writing reviews which will benefit the QA process. Positive that RM (reviewing manager) individual needs were also considered during the meeting in relation to their experience/knowledge at the point of writing the review, and any issues/developmental needs for consideration and how feedback was going to be provided to them. Also, positive that follow up conversations with both us or the RM was offered.”

Benchmarking for countersigning leads delivered jointly by HM Inspectorate of Probation and HMPPS central SFO team.

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Individual quality standards (Back to top)

Figure 6: Analysis of practice

Transparent analysis of assessing, planning, implementation and review

Investigative in its approach

Analyses whether all reasonable action was taken across all levels

Underpinning reasons for omissions in practice are explored and explained

Effective practice is identified where relevant

Analysis of practice
Outstanding	2%
Good	61%
Requires improvement	36%
Inadequate	1%

This year, we have seen improvements in the proportion of SFO reviews that had analysed practice to a ‘Good’ or ‘Outstanding’ standard, with 63 per cent meeting this standard compared with 56 per cent the previous year. This is a positive upward trend on last year’s findings.

Our SFO quality assurance found this year that there was sufficient consideration of whether all reasonable action was taken during the management of the case in 67 per cent of reviews. In 62 per cent, there was sufficient analysis of the missed opportunities in practice that had been identified.

Last year, it was positive to see that the key factors that underpinned the practice was analysed in 68 per cent of cases; however, this year we have found this has reduced to 59 per cent. It is important for reviewing managers to identify and analyse the reasons for any practice deficits/critical omissions, and to focus the learning and action planning accordingly. These underlying factors should be considered at all levels of the organisation so that the practice is understood at an individual, PDU, regional and national level where it is applicable.

This year, the proportion of reviews that considered the interface between the probation service and the relevant partner agencies involved in managing the case increased from 50 to 60 per cent. This is an important aspect to consider, given that often the management of cases will also involve working with agencies other than the probation service.

Last year, we commented that, with the introduction of the revised SFO review template, HMPPS set out expectations that the analysis of practice was to be contained to the six-month period immediately before the date of the SFO. We raised concerns that this approach could overlook significant aspects of practice that occurred in the earlier phases of the sentence management process, which may be critical to understanding the case in full. This could include the work of probation court teams, the period spent in custody by the person on probation, placements in approved premises and the initial period of sentence management.

The HMPPS guidance for reviewing managers on using this template is that there are few exceptions that will result in the boundary of the review being extended beyond the six-month point. However, if the parameters of the template were less prescriptive and reviewing teams were able to use their professional judgement to identify the parameters of the review, pertinent to each individual case, it would allow more breadth of analysis and understanding of all key areas of sentence management across all levels.

We have now seen this template used consistently across the reporting year, and our concerns remain. The fact that only 47 per cent of reviews have received a composite rating of ‘Good’ or ‘Outstanding’ indicates that the template is not capturing all relevant aspects of case management; therefore, it is unclear whether these critical elements of sentence management are understood. This in turn impacts on how well areas of learning are identified.

Figure 7: Sufficient judgements

Clear and balanced judgements on the sufficiency of practice which have a clear evidence base.

Explorative, investigative and all relevant interviews completed.

Provides judgements on systemic and procedural factors which underpinned practice.

Judgements provided on management oversight at all levels.

Judgements provided on probation’s contribution to partnership working.

Sufficient judgements
Outstanding	1%
Good	43%
Requires improvement	56%
Inadequate	0%

This year 44 per cent of SFO reviews reached the required standard of ‘Good’ or ‘Outstanding’. This is a slight decrease from last year, when 47 per cent received these ratings. There were no reviews where the sufficient judgements standard was rated as ‘Inadequate’.

The SFO quality assurance standards have both an ‘analysis of practice’ and a ‘sufficient judgements’ standard so that the SFO review not only considers how the case was managed but also provides clarity to the reader on whether this met practice requirements.

The standard requires SFO reviews to have clear, balanced and evidence-based judgements on the sufficiency of practice, which include assertions on what the relevant factors were that underpinned this practice. This should include judgements on practice at an individual level, and on the prevalence of the wider systemic and procedural factors where relevant.

Where practice deficits have been identified, the review should also provide clear judgements that determine the significance and impact of these, with a focus on their relevance to the SFO. This is particularly important where expected practice could have altered the course of the probation supervision. For example, clear judgements should be given if recall enforcement action should have been taken, supported by explanations on what this means and the implications of this, specific to the case, so that the reader can understand the impact this action could have had on the supervision before the SFO was committed.

We found that the significance and impact of deficiencies and missed opportunities in practice were sufficiently explained in 41 per cent of the SFO reviews we quality assured this year, indicating the need for significant improvements to be made.

In comparison to last year, we have seen consistency in the proportion of SFO reviews that were informed by relevant staff interviews (77 per cent of reviews). Improvements in the proportion of reviews that provided sufficient judgements on the practice of staff at all levels increased from 32 per cent to 59 per cent. There was also an increase, from 57 to 62 per cent, in the proportion of reviews that included sufficient judgements on the systemic and procedural factors that the reviewing manager determined to be relevant to the practice in the case.

Figure 8: Learning

All relevant learning is identified

The learning is translated into developmental actions.

The action plan addresses practice deficits at all levels where relevant.

Actions are SMART and clear about how the impact will be measured.

Effective countersigning  ensures the review identifies all learning opportunities.

Learning
Outstanding	1%
Good	46%
Requires improvement	52%
Inadequate	1%

We have seen a slight increase in the number of reviews that met the learning standard, with 47 per cent rated as ‘Good’ and ‘Outstanding, compared to 44 per cent in the previous year.

This standard focuses on whether learning opportunities are identified, and how these are incorporated into an action plan that accompanies the SFO review.

The action plan should include actions that are developmental and have clear measurements so that their progress and impact can be monitored and evaluated.

Areas for improvement for staff across all levels were sufficiently identified in 60 per cent of the reviews we quality assured, and 69 per cent identified these at a local team or PDU level. This figure reduced slightly when considering learning opportunities at a regional and national level, with 59 and 55 per cent of reviews identifying this where applicable.

In terms of action planning, our quality assurance found that 63 per cent of SFO review action plans contained sufficient developmental activity to support improvements in practice for staff involved in managing the case. However, further development was required in how this activity was measured, because we found that 53 per cent of SFO reviews did not contain effective measurements.

An action plan is devised following completion of an SFO review. This should include learning points for areas that the review has highlighted as needing development and/or improvement, to ensure lessons are learned from the case, where relevant.

Probation regions are responsible for implementing the actions set as part of the SFO review and monitoring their progression and impact.

Regions are required to provide an update on the progress made against each of the actions set. A formal written update should be provided to the HMPPS central SFO team six months after the review is submitted for quality assurance. HM Inspectorate of Probation is provided with the action plan updates for the reviews we have quality assured. We will comment further on action plan updates later in this report.

Figure 9: Victims and their families

The SFO review is accessible and inclusive with professional terminology explained.

The review is sensitive to the needs of the victim or their family.

It is transparent and provides balanced judgements.

The review focuses on pertinent issues which are most likely to be of concern.

Assurance is provided that all required learning has been identified and is translated into tangible actions.

Victims and their families
Outstanding	0%
Good	40%
Requires improvement	60%
Inadequate	0%

We found that of the 90 SFO reviews we quality assured, only 40 per cent met the ‘victims and their families’ standard, which is a decrease from 49 per cent last year. In turn, there has been an increase in the proportion rated ‘Required improvement’, from 56 per cent to 60 per cent. This raises significant concerns about the apparent lack of focus given to the victim standard when writing and countersigning the SFO review, and impact this has on its overall quality.

This year, our data shows that ‘victims and their families’ had the lowest proportion of SFO reviews that met the required standard. Concerningly, the fall in the proportion of reviews meeting this standard this year demonstrates that a significant amount of work is still needed to improve how reviews meet the needs of victims and their family members. The ‘victims and their families’ standard considers the way in which the review is written. It states that the review should be accessible, transparent and sensitive for a reader who is not familiar with the work of the probation service. It emphasises the importance of the review focusing on the pertinent issues and areas of practice, and on providing assurance that any learning required has been identified and taken forward in a tangible way.

The SFO review must be an accessible and informative document that can be readily shared with the victim or their family. Therefore, it is essential that the reviewing manager considers the language and tone used throughout the review. Our quality assurance feedback repeatedly emphasises the need for revisions to be made to SFO reviews to meet this standard; this feedback has included the need to:

• ensure that information such as dates and offence details is accurate
• correct any spelling and grammatical errors
• address any inappropriate or insensitive descriptions of offending behaviour – this can include the use of language and terms that may be factually accurate, but are unnecessarily detailed for inclusion in the review itself
• address any insensitive language about those deemed to be at risk of serious harm during the review period, particularly when the SFO was linked to domestic abuse and the victim of the SFO had also featured as a person at risk during the review
• amend any use of jargon and professional terminology that doesn’t include a clear explanation or reference to a glossary
• address statements that read as opinion or assumptions, as these should be underpinned by factual evidence to ensure that messages are clear and avoid any confusing or misleading statements.

Over the course of our involvement in the quality assurance of SFO reviews, we have seen a gradual increase in requests to access reviews by victims or their family members. This year we have been notified of 34 requests to access the SFO review, which is an increase from 24 in the previous reporting year. This is solely for the SFO reviews that we have quality assured; thus, it is reasonable to suggest that the HMPPS central SFO team have also received an increase in such requests.

This increase in requests to access reviews highlights the ongoing need to ensure the victim standard is met. The ‘Voices of SFO victims and their families’ section in this report considers issues raised by victims’ families when accessing SFO reviews, demonstrating the significance of the issues highlighted above.

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Other assurance activity (Back to top)

‘Requires improvement’ quality assurance

We randomly sample reviews rated as ‘Requires improvement’ to monitor how well the required changes are made to the review following quality assurance feedback. In these cases, the review does not receive a further rating, but the reviewing and countersigning managers are provided with written feedback against each of the four standards.

This year, of the nine SFO reviews sampled, we found mixed evidence that the quality assurance feedback had been applied to the SFO review. In most of the SFO reviews, the required changes following QA feedback had been partially and not fully applied across each of the four the standards.  

It is expected that, following initial feedback, the required changes will be made within four weeks. Probation regions are responsible for overseeing this and ensuring that the changes are made to a sufficient standard. This sampling activity demonstrates that, although detailed quality assurance feedback is provided, the required changes are not always made in the way they should be or within the expected timeframes.

Furthermore, this also emphasises that probation regions are not making the most of the quality assurance feedback to improve the quality of SFO reviews. The timely completion of amendments following quality assurance is important, not only to ensure that the SFO review is responsive to the learning needs identified as part of the SFO review, but also to support the probation region to respond in a timely manner to requests made by victims or their families to access the SFO review.

Action plan quality assurance

This year we have also randomly sampled six-month action plan updates on a quarterly basis, reviewing 11 action plan updates from 10 of the regions. Concerningly, we found that, in the action plans we sampled, there was often limited evidence that learning and improvements had been made sufficiently. As a result, we had little confidence that action plans were consistently leading to better practice or effectively improving public protection.

The action plan update should reflect the delivery of the actions and their impact. If the original quality assurance feedback identified that additions or changes were required to the SFO review in respect of learning and action planning, the sampling assurance also considers whether this has been applied.

To inform this activity, we consider four questions for which we respond either yes, partially or no, in respect of how far the plan has achieved its purpose.

• Has the action plan been updated as outlined in the original QA feedback, including any additional areas of learning identified?

Yes	Partially	No	N/A*	Total
1	3	6	1	11

*N/A denotes an action plan where no amendments were required following the original QA.

This demonstrates that in most cases, required amendments were not made to action plans following the original QA feedback. Of the 11 action plan updates sampled, one did not require updates or amendments to be made to the action plan following quality assurance feedback. The other 10 did require some form of amendment. Of these, only one was updated accordingly, and three were partially updated.

It is therefore apparent that, in many cases, the required amendments are not always being made to action plans following feedback. The impact of this is that the plan may not be sufficient to ensure relevant action is taken to improve practice, and that the progress and outcomes of any monitoring activity may not always be measured effectively.

• Is a sufficient level of detail provided in the action plan update?

Yes	Partially	No	Total
3	4	4	11

In respect of the action plan update submitted by the probation region, of the 11 action plans considered three had a sufficient level of detail on the actions that had been taken forward. An example of feedback for one plan that had a sufficient level of detail was:

‘The action plan update contains relevant detail on the activity that has occurred against each action set and is clear that evidence has been sought to confirm completion of the activity.’

However, the majority were either only partially sufficient or did not provide a sufficient level of detail. An example was:

‘For many of the learning points, there were multiple actions set. However, the update does not cross reference all this expected activity, therefore it is unclear if all the required action was taken forward. If any of these actions were subsequently determined to be unnecessary or were amended, it would be appropriate to specify this.’

• Is there evidence that the action has been taken forward as intended?

Yes	Partially	No	Total
4	5	2	11

There were more action plan updates that provided evidence of actions being taken forward as intended, compared with the other measures.

Examples of feedback are:

‘Activity regarding management oversight has been completed sufficiently and the impact stated.’

‘It is positive that the plan has noted where activity remains outstanding and when this will be completed. Where activity has been concluded, it is indicated that this has been sufficiently implemented.’

However, more of the updates gave only partial or no evidence for this question:

‘There are several gaps in the information provided, and the overall quality of the update does not match that of the initial action plan submitted.’

• Is there evidence of effective measurements being applied and do the updates reflect these measurements?

Yes	Partially	No	Total
2	6	3	11

Two of the plans evidenced that measurements had been effectively applied to monitor the progress made because of the action taken and the impact this had on the practice deficit identified.

One update which answered yes, stated:

‘There is a comprehensive update provided with regards to the AP (approved premises)¹² and purposeful activity. The impact of this is also stated, with the work supporting what is contained in risk management plans.’

However, most of the sample only partially demonstrated that measurements were being applied effectively, with three assessed as not containing any evidence of this. An example from an update that did not demonstrate effective measurements is:

‘In its current form the update has copied the intended measurements into the action undertaken column, and the detail is not provided. The ‘impact of action on practice’ also does not provide an understanding of whether the intended outcomes have been sufficiently reached or if there is a need for further action.’

What should an action plan update include?

As well as the points highlighted above, high-quality action plan updates should consider the following:

• The measurements undertaken to demonstrate impact, such as dip-sampling of case records, benchmarking, case discussions and auditing, should be consistently included in the action plan update. The narrative detail of the measurement activities can be streamlined to provide the reader with a clearer outline of what has taken place.
• Where activity has taken place over time, the impact column should present a clear overall judgement. This should reflect all available evidence and indicate if the objective has been sufficiently met.
• If there have been changes to the circumstances of those assigned actions, for example holding a different role in the organisation, the plan should reference whether the learning remains relevant or whether amendments to the action are required.
• Sufficient evidence should be provided for regional and national actions to demonstrate the progress that has been made on these.
• The update should aim to avoid active commentary or open questions, focusing instead on clear, evidence-based conclusions.
• The update should be countersigned, to evidence that assurance of any changes has taken place.
• The update should be legible and comprehensive, and ensure the updates correspond with the action required. The use of ‘working notes’ should be avoided.
• Any wider actions for the organisation, including assurance activity, should be appropriately noted and updated accordingly.

In conclusion, our sampling activity shows that quality assurance feedback is not being consistently applied as expected to SFO reviews.

We also found that that most of the six-month updates from the probation regions in this period were not adequately detailing the activity taken forward nor highlighting the impact the action has had.

We have delivered presentations and engaged with several regions focusing on the completion of high-quality action plan updates. The implementation and follow-up of action planning is also a focus of our core inspection work.

Given that learning from SFOs is a key part of the review process, more robust updates should be completed. This will not only assure the organisation that lessons have been learned from SFOs, but will also give assurances to victims and their families that HMPPS has taken learning forward and is addressing critical omissions and practice deficits, both on an individual and wider scale. As such, we have made a recommendation that reflects the need for HMPPS to take this area of work forward.

Voices of SFO victims and their families – understanding perspectives on the SFO review process (Back to top)

As part of our ongoing work to understand how victims and their families experience the SFO review process, this year we gathered feedback from the families of victims who engaged with us through a survey distributed via support charities, as well as from families who reached out to us directly. Their insights are reflected below, and provide a powerful account of their individual experiences, revealing the extent of the emotional impact of the process and elements that did not fully meet their needs. While in many cases it is impossible to remedy the harm and trauma caused by an SFO, this feedback is critical in shaping victim-focused practice and ensuring that the SFO review process is transparent, compassionate, and focused on learning and accountability at the correct level.

For this report, we have chosen to refer to the loved ones of those affected by SFOs as ‘victims’ families’ or ‘families of victims’. This is because we recognise that these individuals are victims in their own right, however, terms such as ‘secondary’ or ‘indirect’ victims can often feel diminishing to their experience, failing to reflect the profound impact of the offence on their lives. Our intention here is to use language that acknowledges family members’ experiences with sensitivity and respect while maintaining clarity throughout the report.

Awareness of process, initial contact and rights

Before receiving contact from the probation service, awareness of what constitutes an SFO was generally low. Most of the victims’ family members had no understanding of the term, until informed by a VLO. Similarly, communication about the review process itself was inconsistent, with only one individual confirming they had been informed that a review would take place and that they were entitled to receive this. Others stated that they had received no contact about the review or their rights to receive information.

One person suggested that the current approach may unintentionally exclude wider family members where communication is routed solely through one individual. Others who are impacted by the offence are then left feeling disconnected from the process, despite their close connection to the victim:

“As the victim was my sister, I was only made aware of the SFO via a parent (my sister’s next of kin). There was no indication I was able to be part of the process or kept informed, I had to rely on my parent. This would be exceptionally difficult in circumstances where family members who would like to know about an SFO will not be informed if they are out of contact with the next of kin.”

The families of victims also highlighted some of the hidden challenges in navigating contact with the probation service during the review process. That includes family members having to introduce themselves to reception staff at probation offices and needing to explain that the purpose of their call related to the death of a loved one. This was described as distressing and unnecessary, when it would be preferable instead to receive direct contact details for the appropriate point of contact. While it was acknowledged that such details may be included in initial correspondence, not all victims’ families had received this. Those who had recalled the difficulties in their capacity to retain and process information in the early stages, due to the overwhelming circumstances of their loved one’s death.

It was commonly expressed that the capacity to receive and act on information evolved over time, depending on emotional readiness, meaning victims’ families may not seek contact until a later time when they feel able to engage. Several families stressed the importance of a sensitive and flexible approach, enabling the probation service to respond to changing levels of readiness and allow re-engagement at a later stage, while still respecting earlier decisions to decline contact.

Communication, empathy and emotional support

Many reflections identified the importance of timely communication and action. There was a consistent view that communication lacked transparency, consistency and compassion. Family members expressed frustration at having to chase for information that they later learned they were entitled to and that should have been provided proactively. In some cases, delays in receiving the SFO review or the absence of a full report left the families of victims with more questions than answers and risked undermining their trust in the overall process.

Recollections indicated shared concerns about untimely communication, insufficient support, and a perception of defensive local engagement:

“No communication from probation. Limited access to information. Local probation units were particularly unhelpful and obstructive.”

“The initial disclosure was overwhelming, we needed time to absorb its lengthy contents and then follow up, but follow up, although promised, was not forthcoming.”

Perceptions of what would constitute a reasonable timeframe for disclosure of a review varied, and included suggestions such as ‘immediately’, ‘within 2 months of sentencing’, to six or 12 months. While expectations differed, there was a commonly expressed view that the timescale in which families had been provided the review was not acceptable, suggesting timeliness is critical.

“Fifteen months from sentencing to disclosure with no updates was far too long. The tone of the SFO was disrespectful in its trivialisation of the offences… then the lack of promised follow-up completely devalued my daughter’s life and our grief. There were no apologies for the mistakes made.”

One victim’s family recalled how they had first become aware of the serious failings in the management of the case via the inquest rather than the probation service. Learning of the missed opportunities and practice omissions in this context contributed to a perception that the probation service had not been transparent, with concerns raised about misleading information being presented during the inquest. The delay in receiving the SFO review in this case further compounded the family’s grief and reinforced their sense of being disregarded.

A commonly raised concern was that the process was disjointed and incomplete, with disclosure meetings perceived as a procedural formality rather than an opportunity for meaningful victim focussed engagement:

“My parent was handed the review, talked through some of it, and then left to try and make sense of it.” 

The process of engaging in review disclosure meetings was described by several families as retraumatising. The trauma of revisiting the offence, which some considered had been described in vivid terms, triggered intense psychological and emotional distress, even when this occurred many years later. It was highlighted that in these circumstances it should not be considered a ‘normal’ bereavement, meaning those involved in the disclosure of reviews need to recognise the impact of such events and adopt a trauma-informed approach throughout the process.

Personalisation and recognition of victim identity

A recurring theme was the need for personalised engagement. Families stressed that victims should not be treated as case numbers or peripheral to the main narrative. There was also a strong emphasis on the impact of language with terms such as ‘the murder’ or ‘the SFO’ used repeatedly by professionals without first asking how the family preferred the loss of their loved one to be referred to. This was experienced as dehumanising and distressing:

“The SFO report itself is cold, clinical and confusing. The victim is given absolutely no recognition or acknowledgement. Her death is a short sentence at the end that is simply referred to as ‘The SFO’. That is the most disrespectful thing of the whole experience.”

Testimonies emphasised the importance of reviews and interactions needing to have a ‘human element’. This includes asking families how their loved one should be referred to (for example by their full name or nickname) and acknowledging significant dates such as birthdays and anniversaries. They should also avoid making assumptions about the family’s preferences, which includes giving them meaningful choices about the time and location of meetings, beyond the clinical setting of a probation office or the privacy of their own home. Other small gestures, potentially interpreted as minimal but which to families were significant, included asking where individuals would feel comfortable to sit or offering a drink, to make the process feel more human and less procedural.

“The review did outline in great detail everything that happened leading up to her death and all the failings, which were generally acknowledged, which was important information for us. However, the complete alienating of my sister – her name, how she died, how her death was a consequence of the failings – was deeply disappointing.”

These reflections demonstrate that there is a valuable opportunity for HMPPS to work collaboratively with those impacted by SFOs, helping to minimise unintended distress.

Victims’ families’ experiences of engagement

Testimonies of those that had received disclosure of the SFO review revealed that compassionate and reassuring experiences were rare and that, in contrast, a common experience was to feel misunderstood, dismissed, and unsupported throughout their interactions with the probation service. This stemmed from communication that felt generic and impersonal, and which was at times attributable to the conduct of specific individuals that lacked professionalism and compassion, contributing to an overall sense of being unheard and invalidated.

“When we couldn’t get communication from the Probation Service after the SFO was given to us, we went to the media. The Probation Service would respond with copy and paste generic ‘sympathies’ and reassurance that practices had been reviewed (but not changed).”

“We as a family have felt unheard and misunderstood through the whole process – we are not trying to make the Probation Service feel defensive, just to acknowledge the huge, devastating consequences of their failures and genuine commitment to certain improvements so that no other family has to experience what we have been through because of the Probation Service’s failings.”

Findings and learning: accountability and change

Victims’ families often described the communication of findings as impersonal, detached, and lacking empathy or meaningful engagement. One family member who received a summary only said:

“We were given a brown envelope by a senior manager and told to take it home to read and contact our local offices with any questions!”

These experiences led to a perceived lack of transparency and inclusion, which contribute to feelings of alienation and mistrust.

While some family members acknowledged that practice deficiencies, missed opportunities, and failures were identified in the review, they felt these were minimised. This stemmed from explanations that were seen as lacking in depth and clarity, and the structure of the review, which was described as lengthy and disjointed. This made it difficult for victims’ families to grasp the narrative of failure and learning:

“The SFO was a huge 76-page report that was somewhat in chronological order but not all the way through. Practice deficiencies and missed opportunities were acknowledged frequently throughout – but the ‘learning outcomes’ from these were often unclear, or unacceptable.”

When asked whether the impact of practice failures was explained, families commonly expressed a sense of disconnection between the identification of failings and any meaningful accountability. Individual narratives expressed a powerful and profound loss of confidence in the actions taken to learn from failure, with victims’ families perceiving little evidence of systemic change. This revealed a belief that the gravity of the harm caused was dismissed, and that efforts to learn from mistakes were evasive or absent:

“They were mostly very mundane and specific (e.g. this particular element has been discussed with the officer, and they recognise the issue), generic (e.g. this training has been reviewed (no further action)) or completely ignored (e.g. practices have changed so don’t need reviewing, the officer has moved on so can’t be spoken to, etc.)”

“The sheer scale of the failures and evasive way they were addressed left us feeling that the issues (driving offences) were not taking seriously.”

“…for such a report to be meaningful, it should provide both acknowledgement of the severity and consequences of the failures (which it does not) and explicit reassurance and demonstrable follow ups that show genuine change has been or is being made as a result of the SFO.”

Accuracy and accessibility

Families of victims consistently indicated that reviews were not perceived as sufficiently accurate, clear or concise. Many described the review as confusing and emotionally detached. Several questioned the integrity of the content and highlighted a lack of transparency.

Factual errors, such as incorrect dates of the victim’s death, significantly undermined confidence in reviews, as inaccuracies led families to question the reliability of the entire document and exacerbated emotional distress.

A view commonly expressed was that the language used in the review was difficult to navigate and could be overly technical. The use of unexplained abbreviations, acronyms, excessive length and lack of corresponding glossary also created barriers to accessibility. The physical format and layout caused confusion and made it difficult to understand the messages being conveyed:

“The timeline was often unclear and moved around. The layout was confusing and difficult to understand. As just a paper copy it’s hard to make notes, go back and find key points, etc. The conclusion summary at the end was useful but again followed the theme of being very detached from the actual consequences of the failings.”

“It was accurate but not clear and concise. There were 76 pages of dense, convoluted language that I am still trying to make sense of 15 months later.”

While factual content was recognised and appreciated, a consistent and strongly expressed concern was that the reviews did not focus on what mattered most to victims and their families. This was because, despite being comprehensive, the reviews were perceived as emotionally detached and written in a tone that was considered to minimise the offender’s actions.

When exploring how well reviews acknowledged the impact that findings might have on victims, victims and their families highlighted an absence of personal or compassionate framing in the review. Powerful testimonies illustrate how language choices contribute to a sense of dehumanisation and minimisation of the gravity of the loss, compounding distress, retraumatising families and invalidating their experiences:

“There was no acknowledgement in the review. No cover note, no recognition that the findings were utterly devastating. No way of even knowing who the victim was. So very disappointing and painful.”

“…completely ignored as though his death did not exist. Disrespect to a level I did not know existed. Made to feel as though we were in the wrong.”

“Indifference to the driving offences was appalling, and the final sentence referred to the death of my precious daughter as an ‘incident’. It did not even mention her name, the indifference and dehumanisation of the review devastated me and made me feel like I had lost her all over again.”

“…the lack of acknowledgement of the true human cost of the offence was a slap in the face of our family.”

Accountability and apologies

A point that surfaced in several accounts was that even after serious failings were acknowledged, and while condolences were offered, many families did not receive a direct apology. This was considered essential, as a simple but powerful act of accountability.

One family member recalled how a senior manager had offered a verbal apology and agreed to follow this up in writing at their request. However, no such letter was received until the issue was raised again in a subsequent meeting. The initial response to this reminder was described as defensive, with the family member being told that an apology had already been given. When eventually provided this was meaningful to the family; however, the delay and manner in which it was provided contributed to their overall sense of frustration and disappointment.

Other victims’ families described their interactions with senior leaders as a ‘tick-box exercise’ and felt there was no genuine attempt to support or acknowledge what for them was a life-defining experience. Families also expressed particular concern about the role of the head of the PDU, whom they felt held significant accountability for failings but at times had deflected this onto others, particularly probation practitioners, which lacked moral integrity. This led to a sense of blame-shifting that created concerns that the probation service focused more on the organisation’s reputation than acknowledging its mistakes. Responses during disclosure meetings were described as repetitive and scripted, failing to address specific questions asked by family members and at times lacking in empathy and compassion. Use of the term ‘learning curve’ to describe one SFO that resulted in the death of a loved one was considered insensitive and a stark example of what many victims’ families described as a lack of humanisation.

The voice of victims’ families: key messages

In our engagement with the families of victims, serious concerns were raised about their experience of the SFO review process. Poor communication, lack of transparency, and a perceived absence of humanisation of the victim and compassion for families were highlighted as critical elements. Families reported that engagement with the probation service was often limited to delayed and formal interactions that failed to acknowledge the gravity of their loss. They emphasised the need for the overall process to embed timely, transparent, and trauma-informed communication at the earliest point of an SFO being identified followed by regular and reliable follow up.

Communication was flagged as needing to be accurate, humanised, and objective, and delivered by trained staff who understand the profound emotional impact of the loss of a loved one in such circumstances. Flexibility of contact over time was considered essential, to enable families to re-engage later if they initially decline, recognising their changing emotional capacity to receive information.

A recurring theme expressed to us was the need for victim-focused framing and systemic accountability within reviews. Victims’ families repeatedly shared the need for the victim to be referred to by name and to avoid reducing their death to a procedural term such as ‘the SFO’. Families also want clear, concise explanations of what happened, the failures that occurred, and the learning identified as necessary to prevent recurrence. There is also a strong desire for this to be accompanied by a sincere apology.

A strong theme from families who had received disclosure of the review (in all forms) was a call for training for staff, which is co-designed with victims and their families and prioritises empathy, compassion, and understanding of the human impact of organisational failures. Families also strongly advocate for a process that instils confidence in messaging and offers genuine accountability to ensure the process is transparent, respectful, and capable of driving meaningful learning and change.

In light of the experiences shared with us by the families of victims, there is a clear opportunity for HMPPS to strengthen the SFO review process to achieve a more inclusive, compassionate, and responsive approach. This is also supported by our findings on the victim and their families standard, which was the lowest-rated standard in this year’s data.

In recognition of this, we remain committed to improving victim-focused practice and make relevant recommendations in this year’s report.

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Conclusion (Back to top)

Our quality assurance findings have consistently shown that more is needed to improve the quality and timeliness of reviews.

Concerningly, this year our quality assurance data is consistent with the previous year’s findings, with 53 per cent of reviews not meeting the required standard. We continue to emphasise the importance of this work being done well. This is important not only to show that HMPPS responds in a transparent and robust manner to cases where there has been an SFO but also to ensure that the review and the associated process is sufficiently tailored to meet the needs of victims and their family members.

Over the course of this year, we have heard from those who have been directly affected by SFOs. This engagement has been incredibly valuable, and we are extremely grateful to all those who have taken the time to share their personal experiences.

This engagement highlighted that, along with improving the quality and timeliness of SFO reviews, there is a clear need to strengthen how the probation service engages with victims of SFOs, and their families, to ensure that reviews are undertaken in a meaningful and transparent way. Victims and their families bring valuable and impactful experiences that should actively shape and inform the way in which HMPPS engages with future victims and their family members.

We acknowledge these findings may not reflect the experiences of all SFO victims and their families, however, there is consistency in what has been shared with us. We have learned a great deal from this engagement and anticipate this will be the start of ongoing engagement with SFO victims and their families to further contribute to our understanding of the SFO process and its impact. We will continue to hear from victims and families and will highlight positive practice as well as sharing areas which can be developed with HMPPS. Our aim is to help shape future engagement, to ensure involvement with victims and families is as meaningful as possible.   

We have set seven recommendations for HMPPS, which aim to drive improvements in all the areas highlighted in this review. We will seek an update on progress made periodically throughout the following year, and work with the probation service to develop effective ways of working based on our ongoing engagement with victims and their families.  

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Annexe A (Back to top)

Comparison of data for each quality assurance standard. Please note that the data set has been merged from two data sets collected over the reporting years.

Figure 10: Analysis of practice standard data between 2021 and 2025 (percentages)

Analysis of Practice standard data between 2021 and 2025 (percentages)
Years	2021-2022	2022-2023	2023-2024	2024-2025
Outstanding	6	9	2	2
Good	58	56	54	61
Requires improvement	30	34	41	36
Inadequate	6	1	2	1

Figure 11: Sufficient judgements standard data between 2021 and 2025 (percentages)

Sufficient judgements standard data between 2021 and 2025 (percentages)
Years	2021-2022	2022-2023	2023-2024	2024-2025
Outstanding	6	9	1	1
Good	64	44	46	43
Requires improvement	25	44	53	56
Inadequate	5	2	0	0

Figure 12: Learning standard data 2021-2025 (percentages)

Learning standard data 2021-2025 (percentages)
Years	2021-2022	2022-2023	2023-2024	2024-2025
Outstanding	6	7	0	1
Good	59	43	44	46
Requires improvement	30	49	55	52
Inadequate	5	1	1	1

Figure 13: Victims and their families standard data 2021-2025 (percentages)

Victims and their families standard data 2021-2025 (percentages)
Years	2021-2022	2022-2023	2023-2024	2024-2025
Outstanding	8	2	1	0
Good	72	45	40	40
Requires improvement	14	50	56	60
Inadequate	6	2	2	0

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Footnotes (Back to top)

1. Our reports – HM Inspectorate of Probation ↩︎
2. Ministry of Justice and HMPPS. (2021). Probation Service serious further offence procedures policy framework. ↩︎
3. Ministry of Justice. (October 2025). Serious Further Offences (SFOs) 2025.
   ↩︎
4. The VCS is available to victims of serious violent or sexual offences where a custodial sentence of 12 months or more has been imposed. The probation service is responsible for delivering the VCS, and a VLO is assigned to each victim who has opted to engage. ↩︎
5. Ministry of Justice and HMPPS. (2021). Probation Service serious further offence procedures policy framework. ↩︎
6. HM Inspectorate of Probation (2020). A thematic inspection of the Serious Further Offences (SFO) investigation and review process. ↩︎
7. HM Inspectorate of Probation SFO webpage: Serious Further Offence reviews. ↩︎
8. AEDs are responsible for probation and prisons on a regional basis. ↩︎
9. Ministry of Justice and HMPPS. (2021). Probation Service serious further offence procedures policy framework. ↩︎
10. HM Inspectorate of Probation (2025). Annual report 2024: inspection of probation services. ↩︎
11. Multi-agency public protection arrangements are in place to support the management of those convicted of violent and sexual offences. MAPPA has three categories and three levels for managing offenders, with Level 3 being the highest management level. HMPPS (2024). Multi-agency public protection arrangements (MAPPA): Guidance. ↩︎
12. Approved premises are residential units providing a temporary placement in the community for people who are subject to probation supervision and pose a high risk of serious harm, requiring additional monitoring. ↩︎