Safeguarding adults at risk of harm supervised by the Probation Service in England: a thematic inspection

Published:

13 November 2025

Foreword (Back to top)

The probation caseload is complex and challenging. Probation staff work daily with people on probation whose lives are frequently in crisis and who pose serious risks to the public and, at times, to staff themselves. Managing these concerns requires considerable skill and judgement. While the primary focus of the Probation Service is the protection of victims and the public, it also has responsibilities for the welfare of the people it supervises, many of whom face acute personal risks. There is an inevitable risk that public protection is compromised when people on probation cannot access the services they need.

The findings from this inspection reveal the challenges and dilemmas that probation practitioners face in their supervision of people on probation. It highlights the complex vulnerabilities of the people on their caseloads, which include mental health needs, substance misuse, and risks of suicide and exploitation. While there is a clear strategic direction and an emerging policy framework to address these issues, the key challenge remains: ensuring that these ambitions are consistently translated into effective frontline delivery.

I am encouraged by the examples of innovation and dedication that we observed across regions. The development of suicide prevention forums, the piloting of GP registration on probation premises, and the integration of health and justice coordinators are all commendable steps forward. Equally, the emergence of Engaging People on Probation teams and bespoke services for women and young men demonstrate a commitment to tailoring support to individual needs.

However, this inspection also highlights areas requiring attention. Inconsistent access to adult social care and mental health services, limited use of safeguarding referrals, and apprehension from probation practitioners about the purpose of the death under supervision review process, all point to systemic barriers that must be addressed. As a result, probation practitioners are often left managing complex cases in isolation, without the necessary support from partner agencies.

The implementation of Probation Reset, while necessary to manage workloads, must be carefully monitored to ensure it does not inadvertently compromise safeguarding. Ending contact with individuals without proper planning or support risks undermining the core aims of rehabilitation and protection.

Keeping people on probation safe helps to keep the public safe and this report calls for a renewed focus on embedding safeguarding at the core of probation practice. It urges national leadership to support regional teams in translating policy into action, and to foster a culture where safeguarding is not viewed in isolation but as integral to public protection. Effective partnerships at both a national and local level are essential to build and sustain such a culture. It is vital that the risks to people on probation are recognised, and that the services needed to manage those risks are accessible. We have made eight recommendations that, if followed, are designed to further improve the Probation Service’s ability to safeguard people on probation.

Martin Jones CBE
HM Chief Inspector of Probation

Contextual facts (Back to top)

167,575 (90% men and 10% women)	Total probation caseload in the community, 30 June 2024¹
1,404	Total number of deaths among people on probation, 2023/2024²
392 (28%)	Number of deaths recorded as self-inflicted for people on probation, 2023/2024³
306 (22%)	Number of deaths recorded as drug related for people on probation, 2023/2024⁴
1,267 (1,136 men 90% and 131 women 10%)	Total number of suicides recorded for individuals under probation, 2011-2021⁵
Six times higher (11 times higher for women and four times higher for men)	Risk of suicide in the probation population compared to the general population, 2011-2021⁶
69% (34% attended five or more times)	Percentage of people on probation in one probation delivery unit having at least one emergency hospital department attendance between April 2022 and March 2025⁷
10,862 (6.3%)	Number of people on probation identified on nDelius as vulnerable
20%	Average percentage of women identified as vulnerable on nDelius in the six inspected probation delivery units
5%	Average percentage of men identified as vulnerable on nDelius in the six inspected probation delivery units

Executive summary (Back to top)

Context

The Care Act 2014 and the Social Services and Well-being (Wales) Act 2014 established statutory responsibilities for local authorities and relevant partners – including the Probation Service – to cooperate in protecting adults at risk. While the Probation Service necessarily prioritises public protection, it also has a responsibility to safeguard individuals under supervision who may be at risk of harm.

This thematic inspection explored whether the Probation Service maintains sufficient focus on adult safeguarding, alongside its public protection duties. It assessed the effectiveness of current policies, the quality of practice, and the outcomes for individuals identified as at risk, particularly in relation to suicide and self-harm.

Research evidence highlights the elevated risks to people on probation. They have significantly higher rates of suicide, homicide, and drug-related deaths compared to the general population. These findings underscore the importance of coordinated safeguarding responses and the need for robust multi-agency collaboration.

Methodology

The inspection team developed a bespoke methodology with HM Inspectorate of Probation’s research team. Ninety-nine cases were inspected remotely across six regions, focusing on safeguarding concerns, suicide risk, and links to reoffending and serious harm. Fieldwork included remote case reviews, on-site visits, and structured interviews with probation staff, partner agencies, and national leaders.

User Voice carried out surveys and interviews with people on probation, providing valuable insight into their lived experiences. In total, 268 people on probation gave their views on their experience of safeguarding while under probation supervision. The findings will be published in a separate report. A copy of the full User Voice report can be found here.

Policy, strategy and national leadership

Strategic responsibility for safeguarding individuals on probation is dispersed across HM Prison and Probation Service (HMPPS), with contributions from the Public Protection Group (PPG), the Rehabilitation Directorate, and the death under supervision team within the Security Directorate. Suicide prevention is overseen by a cross-directorate steering group, reflecting the complexity of the landscape. While the integration of safeguarding, health, and wellbeing into strategic frameworks is welcome, inspection findings reveal that this has been implemented unevenly. National leadership must continue to support regional delivery, ensuring that these elements are embedded as core components of public protection and rehabilitation, rather than treated as peripheral concerns.

The Probation Service has made some progress in developing strategic frameworks to support adult safeguarding. The updated Safeguarding Adults at Risk in the Community policy, issued in February 2025, sets out clear expectations for regional leadership and operational accountability. Each region is required to appoint a strategic safeguarding lead, with probation delivery unit (PDU) heads responsible for engaging with Safeguarding Adults Boards (SABs). While structural arrangements are broadly in place, we found that awareness and implementation of the policy varied across regions.

Integration of health and social care is a growing priority, supported by the National Partnership Agreement and the work of health and justice coordinators. There have been some positive initiatives, such as hepatitis C testing on probation premises, and there are plans to pilot more health-related activities, including GP registration in probation offices. We welcome the plans to work jointly with the health service to address health inequalities. However, access to adult social care remains inconsistent. Referral rates are low and probation practitioners (PP) have limited confidence in navigating thresholds and pathways.

The national drug and alcohol strategy promotes a recovery model, which includes consideration of the risks to people on probation who misuse substances. We identified some good practice, especially where services were co-located and contact was responsive to the often-immediate needs of the complex caseload. We saw contingency planning for drug-related risks, including overdose. The strategy’s emphasis on engagement must be balanced with proactive risk management.

Suicide prevention has emerged as a strategic priority, with regional forums and training initiatives gaining traction. Training from the Zero Suicide Alliance is a positive development, though completion rates are low and safety planning is underused. PPs require more robust support and training to manage the complex risks associated with suicide and self-harm.

The national death under supervision policy provides a framework for learning, but its implementation has raised concerns. Practitioners expressed apprehension about the review process, perceiving it as focused on individual failings rather than systemic improvement. The national death under supervision team’s analysis offers valuable insights, but the sharing of findings with partner agencies remains inconsistent.

Partnership working and local leadership

Probation representation on SABs is generally in line with policy, but the impact on service delivery is limited. Boards often prioritise older adults and care settings, with minimal focus on the probation caseload. Information-sharing and advocacy for probation-related safeguarding issues require strengthening.

Referral pathways into adult social care are inconsistently understood and applied. The EQUIP framework⁸ offers practice guidance, but referrals from the Probation Service are frequently rejected, and PPs are unclear about how to escalate these cases. Most PPs have completed the mandatory online adult safeguarding training but there was inconsistent understanding of when to make section 42 and section 9 referrals under the Care Act 2014. The lack of data and analysis of referral outcomes hinders the development of effective partnership working.

Multi-agency risk management meetings (MARMMs) and complex lives panels offer potential for coordinated responses to the risks people on probation face, but their use is patchy. The Probation Service relies on Multi-Agency Public Protection Arrangements (MAPPA) to secure agency involvement, which is not always appropriate and underscores the need for alternative mechanisms.

Access to mental health services is variable. Some PDUs have developed innovative pathways and escalation processes; however, referral criteria and long waiting lists can still prevent access to services and contact sometimes ends prematurely.

Engaging People on Probation (EPOP) teams are emerging as valuable assets that provide peer support and contribute to safeguarding. Their integration into PDU operations varies, and their potential in relation to identifying risks to people on probation should be further harnessed.

Safeguarding people on probation

Case inspections revealed strengths in PP engagement and sentence delivery with people on probation. PPs developed positive professional relationships with people on probation and provided them with tailored support. However, assessment and planning were inconsistent, and safeguarding risks were often overlooked or insufficiently addressed.

Gender disparities in vulnerability assessments suggest underlying assumptions, with women more likely to be identified as vulnerable. The term ‘vulnerability’, and how it is assessed, itself warrants review. The risks faced by people on probation should be integrated into the new probation assessment framework currently being developed.

Planning for safeguarding was an area for improvement. We saw limited evidence of PPs collaborating with people on probation, and safety plans were underused. Sentence delivery was significantly stronger, particularly for women and younger cohorts, where bespoke services and engagement strategies were in place.

Probation Reset, introduced to manage workloads, has important safeguarding implications. If proactive contact ends without adequate planning, individuals may be left unsupported. The Probation Service must therefore ensure that safeguarding considerations are central when preparing to end contact.

Recommendations (Back to top)

HM Prison and Probation service should:

develop a strategy to ensure the death under supervision process focuses on systemic learning and improvement. This should include sharing the analysis of death under supervision findings with the key regional strategic boards
ensure that referrals to adult social care are monitored and that escalation processes are in place at both regional and national level
ensure that trauma-informed practice is applied to men. This should include a review of assessment and engagement practices and take into consideration learning from other public sector organisations
ensure that the risks to people on probation are integrated into the assessment and planning framework for people on probation
review the use of the term ‘vulnerability’, and how it is assessed, in relation to people on probation
ensure that the assessment of vulnerability and the risks to men on probation are not influenced by assumptions about gender
review the number and use of risk registrations on nDelius to ensure they are accessible and assist probation practitioners in their supervision of people on probation
ensure suicide prevention is central to probation delivery and that training is mandatory.

1. Introduction (Back to top)

1.1. Why this thematic? (Back to top)

The Care Act 2014 and the Social Services and Well-being (Wales) Act 2014 set out the statutory framework for providing adult social care and adult safeguarding. This included establishing Safeguarding Adults Boards (SABs) in England, and Safeguarding Boards (SBs) in Wales. Both Acts emphasised the importance of cooperation and placed a reciprocal duty on local authorities and relevant partners to cooperate with each other in respect of their relevant care and support functions. Local authorities take the lead in adult safeguarding; however, multi-agency working with partners in health, social care, police, prisons, probation, housing services, and others is seen as critical to protecting adults at risk of harm. The Probation Service is named as a relevant partner. It therefore has a statutory responsibility to ensure that any adults under its supervision who have been identified as at risk of abuse or neglect, and who require support, receive the necessary safeguarding interventions.

The Probation Service has practice guidance in place both for adult safeguarding and for the prevention of suicides, but this is an area that has not previously been the subject of thematic inspection. The recent focus of probation practice has been on public protection. HM Inspectorate of Probation’s core adult inspection programme does not directly address the risks to people on probation. In relation to safeguarding, it focuses primarily on children, victims or potential victims. This inspection provided an opportunity to consider whether the Probation Service has also kept a necessary focus on adult safeguarding. We also considered the effectiveness of probation policies; current probation practice in this area; and the outcomes for people on probation identified as at risk of harm.

1.2. Background (Back to top)

People on probation frequently present with volatile behaviour and complex needs. These needs can include the risks they face in their own lives, which often require coordinated safeguarding responses. Probation policy and practice emphasise the Probation Service’s public protection priorities, but they have always recognised the risks to the people on probation themselves.

Research indicates that a significant proportion of the probation caseload may require adult safeguarding interventions. Individuals subject to probation supervision are six times more likely to die from suicide than the general population; the risk is four times greater for men and 11 times greater for women.⁹ The evidence also indicates that up to 32 per cent of people on probation have attempted suicide at some point in their lives. Between April 2023 and March 2024, there were 1,404 deaths of offenders in the community. Individuals subject to release on licence made up 43 per cent of this total, with 54 per cent of individuals being subject to a community sentence. Self-inflicted death accounted for 28 per cent (392) of these deaths and four per cent resulted from homicide. These figures show a small reduction on the figures for 2022/2023. However, this may be because data-gathering processes and classifications significantly improved following introduction of the Reporting and Reviewing Deaths Under Probation Supervision in the community policy in 2022.

Slade et al. (2024) analysed HMPPS data on deaths among people under probation supervision between 01 April 2019 and 31 March 2021, where the cause of death was confirmed. They found a significantly elevated risk of death from external causes for people on probation compared to the general population. Of the deaths recorded under probation supervision, they identified that 10 per cent were from suspected suicide, five per cent were from homicide and 26 per cent were drug related. Even accounting for differences in definitions, Slade et al. took the view that these rates far exceeded those in the general population, where the annual death rates identified by the Office for National Statistics are approximately one per 100,000 for homicide, 10 per 100,000 for suicide, and eight per 100,000 for drug poisoning.

Adverse childhood experiences and the probation caseload

Researchers have identified the impact of adverse childhood experiences (ACEs) in relation to abuse, neglect and trauma on adult involvement in criminal behaviour. Bellis et al. (2015) found that individuals who had experienced four or more ACEs were:

15 times more likely to have committed violence against another person in the previous 12 months
16 times more likely to have used crack cocaine or heroin
14 times more likely to have been a victim of violence over the last 12 months
20 times more likely to have been incarcerated at any point in their lifetime.

These findings emphasise the ongoing impact of ACEs on adult behaviour and are directly relevant to the probation caseload. Recent research has drawn attention to a particularly high-risk group within populations involved with the criminal justice system – individuals who engage both in self-harm and in violence towards others, often referred to as ‘dual harm’ (Carr et al., 2020). These individuals are disproportionately affected by extensive histories of trauma and adversity, with ACEs emerging as a significant predictor of later harmful behaviours. Carr et al.’s national cohort study in Denmark revealed that those with dual harm profiles were markedly more likely to have experienced multiple forms of childhood adversity, with nearly one in five exposed to five or more ACEs. This cumulative trauma was found to elevate the risk of dual harm far beyond that associated with either self-harm or violence alone.

The evidence suggests that specific adversities – such as parental criminality, substance misuse, and exposure to interpersonal violence – are particularly potent in shaping dual harm trajectories. For example, childhood hospitalisation due to assault was identified as a uniquely strong predictor of later dual harm, underscoring the cyclical nature of violence and victimisation. These findings are mirrored in forensic mental health settings, where individuals frequently present with complex trauma histories, psychiatric vulnerabilities, and overlapping patterns of self-injury and aggression (Stinson et al., 2021).

These findings have implications for both probation policy and practice. There is an evident need to identify and support individuals at risk of dual harm through integrated, trauma-informed approaches. This includes the routine screening of people on probation to identify those at risk and developing interventions that address both psychological distress and criminogenic needs. It also indicates the need to adopt a holistic approach that recognises the interconnected nature of self-harm and violence and seeks to address the underlying trauma that drives both.

Inspection reports

A series of thematic inspections by HM Inspectorate of Probation have provided insights into safeguarding practice. The 2024 inspection of services for young adults found that domestic abuse was a significant factor in many cases but was not consistently considered in risk assessments. It also revealed that safeguarding information from children’s social care was rarely requested, despite its relevance. The inspection recommended a relaunch of the young adult’s policy framework, with clearer guidance on information-sharing and trauma-informed practice.

The 2023 inspection on domestic abuse highlighted inconsistent knowledge of specialist services among practitioners and a lack of consideration for victims’ vulnerabilities. Similarly, a 2021 joint inspection with the Care Quality Commission on drug treatment found that safeguarding was not proactively addressed, and that high thresholds for adult social care intervention were preventing vulnerable individuals from getting support. Another 2021 joint inspection on mental health identified gaps in assessment and support, particularly in pre-sentence reports, and raised the inconsistent use of mental health flags within probation systems.

Earlier inspections have also shed light on longstanding challenges. A 2008 joint inspection with HMI Prisons reported insufficient support for individuals with learning disabilities, despite some positive engagement with local safeguarding boards. HM Inspectorate of Probation’s inspection of the probation service’s exceptional delivery model in response to the Covid-19 pandemic (2020) found that reduced access to support services had a detrimental impact on individuals assessed as vulnerable, although some innovative practices were noted.

Beyond probation-specific inspections, other reports have contributed to the discourse on safeguarding. The 2008 Commission for Social Care Inspection review emphasised the importance of designing safeguarding into services and identified key building blocks for prevention, including public awareness, advocacy, and a well-trained workforce. The 2018 inspection by the Independent Chief Inspector of Borders and Immigration criticised the fragmented approach to adult safeguarding within the Home Office and called for a coherent strategy and dynamic assessment processes.

Finally, learning from inquiries and serious case reviews has underscored recurring themes in safeguarding failures. The Department of Health (2011) identified issues such as poor early warning systems, lack of multi-agency collaboration, and failure to listen to service users and carers. Braye, Orr and Preston-Shoot (2014) found that safeguarding failures often stemmed from a lack of personalisation, with professionals focusing on problem behaviours rather than engaging with individuals as people with complex needs.

Preston-Shoot and Braye’s (2024) national analysis of safeguarding adults reviews (SARs),¹⁰ covering April 2019 to March 2023, examined 652 cases to identify recurring themes and systemic challenges in adult safeguarding across England. The analysis found that self-neglect was the most frequently reviewed concern, appearing in 60 per cent of cases, with notable increases in substance dependency. While some examples of good practice across all agencies were identified – particularly in risk management and person-centred approaches – serious shortcomings were widespread. These included poor risk assessment, inadequate consideration of mental capacity, and failures to recognise abuse or neglect. The report also highlighted significant issues in interagency collaboration, with frequent breakdowns in case coordination and information-sharing, often compounded by confusion over data protection and ineffective use of multi-agency meetings.

Taken together, these reviews reflect the central importance of safeguarding in probation practice. They highlight the need for robust partnerships, informed assessments, and a commitment to continuous learning to ensure that individuals at risk are protected and supported effectively.

1.3. Aims and objectives (Back to top)

The inspection sought to answer the following questions:

Does leadership support, promote and enable effective adult safeguarding practice for people supervised by the probation service?
How effective are the adult safeguarding arrangements at keeping people safe?
How well do practitioners support the adult safeguarding needs of people on probation?
Do the training and supervision of probation practitioners support the delivery of high-quality adult safeguarding practice?
Are arrangements with statutory partners and other agencies established, maintained and used effectively to respond to adult safeguarding concerns?

1.4. Report outline (Back to top)

Chapter	Content
Policy, strategy and national leadership	In this chapter, we consider the impact of policy, strategy and national leadership on the safeguarding of adults supervised by the probation service. We focus on policies that relate to safeguarding adults; health and social care; drugs and alcohol; suicide prevention; and death under supervision.
Partnership working and local leadership	In this chapter we consider the impact of local leadership and multi-agency arrangements on managing the risks faced by people on probation.
Safeguarding people on probation	In this chapter, we review our case inspection findings and consider how effectively sentence delivery focuses on safeguarding adults on probation. We examine the reports submitted to court and consider the assessment and planning of cases, and sentence delivery. We also consider the impact of Probation Reset on safeguarding adults on probation.

2. Policy, strategy and national leadership (Back to top)

In this chapter, we consider the impact of policy, strategy and national leadership on the safeguarding of adults supervised by the Probation Service. We focus on policies that relate to safeguarding adults; health and social care; drugs and alcohol; suicide prevention; and death under supervision.

2.1. Policy and strategy (Back to top)

The risks to people on probation inevitably span a wide range of service delivery areas, including safeguarding, drugs and alcohol, suicide prevention and sentence management. Responsibility for strategy and policy development in these areas is shared across different HMPPS directorates and strategic groups.

Safeguarding adults at risk in the community

The Public Protection Group (PPG) is responsible for the Probation Service’s safeguarding adults framework, reflecting its broader remit for safeguarding policy in respect of victims, potential victims and people on probation.

The Probation Instruction 06/2016: Adult Social Care was introduced in response to the statutory obligations set out in the Care Act 2014 and the Social Services and Well-being (Wales) Act 2014. These Acts redefined the responsibilities of local authorities and criminal justice agencies in relation to adult social care, establishing the principle of equivalence – that individuals in custody or under supervision should receive care and support that are on a par with those in the wider community. The instruction mandated PDUs to forge effective partnerships with local authorities, ensuring that the care and support needs of all service users are identified and addressed.

The Probation Service National Partnership Framework Safeguarding Adults Boards (2023) set out the parameters for the Probation Service’s relationship with SABs. In February 2025 the PPG issued an updated probation service policy statement, Safeguarding Adults at Risk in the Community. This sets out the framework for adult safeguarding practice. Each probation region is expected to appoint a senior manager to act as the strategic lead for safeguarding, ensuring clear lines of accountability and embedding safeguarding principles into local operational processes. The policy statement also sets out the responsibilities for PDU heads in relation to SABs and for senior probation officers in relation to PPs. It emphasises the importance of leadership, staff training, and the dissemination of learning from SARs, underlining the need to develop a vigilant and responsive operational culture.

In the inspected regions, knowledge of the safeguarding adults at risk policy statement varied. This should be seen in the context of the series of priority policies that have been implemented since May 2024, primarily focused on the expedited release of prisoners. Adult safeguarding arrangements in the regions were, however, in line with the policy statement. A senior manager, often the head of public protection, was identified as the regional lead for adult safeguarding, and PDU heads or their deputies were responsible for attending SABs. Regional and PDU heads are responsible for determining the level of contribution and probation-related information shared with SABs.

The safeguarding adults at risk in the community framework focuses on adults with care and support needs who may be at risk, including those who are on probation and those who may be at risk from people on probation. There is no specific unified guidance on responding to the wider needs of people on probation. However, given the PPG’s core responsibilities, much of the framework focuses on adults identified as at risk who are not on the probation caseload. There is no specific guidance for people on probation. Senior managers recognise that the Probation Service has a low profile at SABs. One senior manager described probation as the ‘forgotten about cousin’. Actions are being taken to address this. For example, strategic managers are meeting with representatives from the Department of Health and Social Care (DHSC) to improve their understanding of probation at a strategic level and to ensure a joint approach to the next update of the Care Act statutory guidance.

Health and social care

The recognition that the health of people on probation is fundamental to their wellbeing and rehabilitation, combined with the NHS’s drive to reduce health inequalities, resulted in the National Partnership Agreement for Health and Social Care for England. This agreement covers the period 2022-2025 and is being extended to 2027. It has the specific aim of improving the quality of services for people in prison and those subject to Probation Service supervision. The agreement is overseen by the Strategic Health and Justice Partnership Board, on which both HMPPS’s Rehabilitation Directorate and NHS England sit.

The health and wellbeing division is part of HMPPS’s Rehabilitation Directorate. The Health and Care Partnerships group includes the Health and Social Care Team, which is responsible for supporting staff across custody and community settings to consistently deliver access to health and substance misuse services to the highest standard. This is achieved through partnerships with health agencies and other government departments. In collaboration with NHS England, there is a dedicated joint role focused on leading policy and programme delivery to address health inequalities for people on probation. The Public Health Team’s work involves engaging and collaborating with the wider public health sector. The group plays a key role in the national strategy. The research into ACEs by Bellis et.al (2015) identified poor health outcomes for people on probation. As part of the NHS drive to address health inequalities, people on probation were a target population group in the Core20PLUS5 survey undertaken in 2023. The health and wellbeing division worked with the NHS to complete the survey. The survey focused on people on probation’s access to and experience of health and care services. This identified concerns in relation to health care needs, lifestyle and accessibility. A significant, positive, finding was that nearly half of the people on probation identified the service as helpful when they wanted to access community health services.

As part of the national plan, regional health and justice coordinators were introduced in each probation region in 2023. Their initial priority was to support Reconnect, an NHS service that focuses on improving continuity of care for people leaving prison. Their responsibilities have subsequently broadened to include access to health and social care services generally. The national plan recognises the role of the probation service in improving access to health services. Four areas have been identified to pilot GP registrations on probation premises. This greater focus on health and wellbeing has also led to GP registrations being recorded on the probation nDelius case management system. Alerts have also been set up on the same system to ensure that PPs are aware if there have been any concerns about self-harm in prison when a prisoner is released on licence. The vision for the shared approach is to develop a probation neighbourhood health service as part of the 10-year health plan for England (2025).

The National Social Care Board is attended by the DHSC and co-chaired by HMPPS. The board is also attended by a regional probation director, who acts as the national probation lead for health. The importance of an approach to people on probation that incorporates health and social care is recognised across this board. It has therefore been decided that all regional probation plans must now have a health section.

We saw some evidence that these partnership arrangements were having a direct impact on delivery in the regions. There was also evidence that the health and justice coordinators were helping to support Reconnect and to ensure that care and prescriptions continued for people leaving prison.

Good practice example

In Liverpool North PDU, health and justice coordinators have been involved in developing health pathways for men and women. This has included undertaking a health needs analysis based on a survey of 150 people on probation. Health and justice coordinators have worked with Mersey Care NHS Foundation Trust to ensure that women on probation are registered with a GP quickly, and to improve access to mental health services. Women on probation can now make direct referrals for talking therapies and there are plans for the joint employment of a female trauma worker on site at the Liverpool women’s service. It is recognised within the PDU that this bespoke wrap-around service is not consistently in place for men on probation, but health and justice coordinators in Liverpool have worked with the health service to provide health tests such as cholesterol, body mass index and hepatitis C on probation premises. As part of this initiative there are plans to install a portable NHS centre in the probation office car park.

We saw less evidence that the strategic focus on improving access to social care services was having an impact on delivery. Referrals to adult social care were made inconsistently. Both managers and PPs had little confidence in either the adult social care pathway or that the threshold for services was applied consistently. While there is a mechanism for recording referrals in nDelius, it does not follow a standard pattern seen in other types of referrals and does not appear to be well known, well used or well understood. As a result, there is minimal information on probation referral rates for adult social care. The information that was made available to the inspection team showed that few referrals were made and there were significant discrepancies in the level of referral between the regions. Although regions could escalate concerns about cases to the national team, this rarely happened.

The last Probation Service instruction in relation to Adult Social Care PI 06/2016 was jointly issued with the prison service instruction PSI 03/2016. This was before the reunification of the Probation Service in 2021. These instructions were primarily a response to the Care Act 2014. The focus of the instructions was on prisons and approved premises. People on probation outside of approved premises were not covered. National HMPPS leaders in health and social care recognise that the adult social care probation instruction requires review in line with the Safeguarding Adults at Risk in the Community probation policy statement. People on probation and their access to adult social care should be a strategic priority and central to the reissued guidance.

The strategy of adopting a more holistic approach to addressing the health and social care needs of people on probation, alongside the Probation Service’s primary responsibility of public protection, is appropriate. To manage risk of serious harm, the Probation Service needs to engage effectively with people on probation and address the causes of criminal behaviour. User Voice found that 65 per cent of people on probation responding to their survey, and 77 per cent of the people on probation they interviewed, linked their offending to vulnerabilities, often rooted in health and wellbeing. The data available on the health of people on probation is limited, but the Core20PLUS5 survey identified that many people on probation have limited trust in professionals and do not find health services accessible. An integrated approach to health and probation provides a basis for developing trust, accessing services, and improving engagement to manage the risk of serious harm more effectively.

Drugs and alcohol

The Office for National Statistics (2023) analysis of the 8,385 deaths under supervision between 2011 and 2021 found that 2,801 of these were drug related. Risks associated with drug and alcohol misuse were further highlighted by Slade et al. (2024), who found that the risk of a drug-related death was 26 per cent higher for people on probation than for the general population.

Responsibility for HMPPS’s drug and alcohol strategy sits with the drug and alcohol group, which is part of the Rehabilitation Directorate. The Probation Service delivers services for people on probation with addiction problems alongside services commissioned by the local authorities. The drug and alcohol group’s strategy promotes the recovery model for addiction. The guidance given to regions for developing an operational model identifies 10 objectives, which promote enabling recovery, reducing demand and restricting supply. The guidance issued to PPs is in line with these objectives. Community Sentence Treatment Requirements, Drug Rehabilitation Requirements (DDRs) and Alcohol Treatment Requirements are advocated for suitable cases.

Nationally, the number of treatment requirements made has been inconsistent and people on probation must give their consent to the making of a requirement. There have been some concerns about the inflexible approach of treatment providers in relation to enforcement. The recovery strategy recognises that many people with addiction problems will not be suitable for these requirements and that the commissioned services must meet the needs of these people. In the regions, we saw good examples of this flexibility of approach. In Liverpool North PDU, addiction services were co-located with the sentence management team and were prepared to meet with people on probation without them needing a pre-arranged appointment.

Services were also co-located in Coventry PDU. In recognition of the complexity of individuals with addiction problems, an enhanced Drug Rehabilitation Requirement (DRR) was being piloted in this PDU. This included additional peer support and social activities to support engagement with DRRs. A proactive response to enforcement of DRRs has also been introduced, whereby people on probation who breach the requirement are offered immediate one-to-one sessions with the co-located addiction service, to help them re-engage.

The risks to people on probation with addiction problems is recognised in the national strategy and the guidance to PPs. The main emphasis of the policy and guidance, however, is on progress, engagement and sharing information. Operational managers and PPs were aware that people on probation have a higher risk of drug-related death. Naloxone was available in offices in case a person on probation presented with drug overdose, and most operational staff had received training in administering it. However, service delivery did not routinely incorporate work to proactively address the risks of drug-related deaths. For example, in our inspection of cases we did not find any contingency plans that set out what staff should do if a person on probation experiences a drug overdose. Although some people on probation will be suitable for treatment, a significant proportion will be unmotivated and minimally compliant. The co-location of services and flexible delivery seen in some PDUs are positive steps, but greater emphasis on strategy and practice is needed to address risks to this group.

Suicide prevention

The Office for National Statistics (2023) analysis found that 15 per cent of deaths under supervision were self-inflicted. Slade et al. (2024) also highlighted the elevated risk of suicide among people on probation. Responsibility for oversight of the Probation Service suicide prevention plan 2023-2026 sits with the national probation suicide prevention steering group and the death under supervision working group. A national suicide prevention lead works alongside the groups to deliver the plan. The three priority objectives of the plan are to deliver service improvements for people on probation at risk of suicide; to use data and evidence to inform suicide prevention activities; and to work internally and externally to improve awareness and share learning. Actions include establishing regional suicide prevention forums to drive practice improvements, using death under supervision data to improve learning, and promoting suicide prevention training.

The impact of the suicide prevention plan varied in the inspected regions. In most regions, suicide prevention forums have been established, and the work was supported by a regional suicide prevention plan. In other regions, the forums were still being developed and senior managers reported they had so far had little impact. In the West Midlands probation region, the forum was attended by representatives from the NHS and the police, in addition to probation attendees. Its action plan included a focus on areas of practice such as indeterminate sentenced prisoners, safety planning and enforcement. The South West region had developed and promoted a suicide and self-harm prevention pack that highlighted the probation safety plan.

Good practice example

The Kent, Surrey and Sussex (KSS) suicide prevention forum identified that few PPs were using safety plans to prevent suicide. It set a key action to increase their use. The health and justice coordinator developed a briefing pack for PPs on the use of safety plans, which was piloted in one PDU. The initiative was supported by briefings from senior probation officers and psychologists. One of the pilot’s key aims was to take a proactive approach to addressing self-harm among people on probation, ensuring that safety planning became a routine part of supervision rather than something used only in times of crisis. In the piloted PDU the use of safety plans has subsequently increased significantly, and the initiative will be rolled out across KSS by December 2025.

A key feature of both the national prevention plan and the regional forums has been the completion by practitioners of the online suicide awareness training provided by Zero Suicide Alliance. This training was introduced at the end of 2024 and completion rates in the inspected PDUs are still below 50 per cent. This rate of completion is partly attributable to the fact the training is required (should be done) and not mandatory (must be done). It is also important to recognise that during 2024/2025, the Probation Service underwent significant operational changes around prison releases, which became the primary focus for sentence management teams. However, PPs are not confident in assessing self-harm and we found minimal use of safety plans in the cases inspected. Those who completed suicide awareness training found it helpful, but the training remains introductory. Given the complexity and instability of caseloads, PPs need more advanced training and support to meet the demands of working with people frequently in crisis.

The Improvement Support Group (ISG) issued a seven-minute briefing for PPs in 2024, prepared by the suicide prevention steering group. Entitled suicide prevention, this provides a comprehensive analysis of the key points in relation to the risks of suicide of the people on the probation caseload. It covers key areas such as high-risk behaviours, high-risk groups and higher-risk periods for suicide. It promotes probation plans and states that every person on probation should be asked about suicide as part of their assessment, as this does not raise the risk of harm. Accessing this practice guidance is the responsibility of PPs and in the PDUs we inspected, awareness of it was limited. In our view, this guidance should form the basis of mandatory training and induction for all PPs.

The development of suicide prevention forums and the introduction of suicide awareness training are welcome and demonstrate the probation service’s understanding of the risks and challenges faced by people on probation. The role of health and justice coordinators has underpinned these initiatives in the regions. However, as with health and social care, it is important that probation practice in relation to suicide prevention is integrated into service delivery and not viewed in isolation.

Death under supervision

In 2022, the Probation Service introduced a policy on reporting and reviewing deaths under supervision in the community. The primary purpose of the policy is to set out the actions to be taken following the death of an individual while under probation supervision. The policy sets out what information should be collated, recorded and shared. It emphasises that preventing death is not the main responsibility of PPs. The secondary purpose of the policy is to enable ‘learning from deaths to improve our service and our approach to preventing deaths’.

The national death under supervision team was set up in 2023, initially for two years. It reports to the safety group in HMPPS. Its role is to oversee and give guidance on the process. It also collates and analyses the regional findings to provide reports to the regions and to produce a national annual report.

The policy states that each region should identify a senior manager to act as a regional death under supervision lead. The policy for reporting and reviewing deaths directs that part one of the review form should be completed by the PP and part two by their line manager. In the East of England and KSS, the responsibility for part two had been moved to a regional team, who were also responsible for collating and reviewing the information. Reviews of deaths under supervision will inevitably be sensitive matters and, in our view, this was a good model.

The purpose of the death under supervision process is to ensure that findings are used for systemic learning. However, when cases are reviewed, findings about individual practice may be identified. It was evident during the inspection that PPs are apprehensive about the process and sceptical about its purpose. Line managers were praised for their supportive approach, but it was felt the process focused on individual practice failings. One PP stated:

“My manager was incredibly supportive, but the process doesn’t take account of our sensitivities – we have relationships with the individuals who have died. The focus of the questioning was on what I had done and my decision-making … there was no consideration of concerns about probation practice as a whole.“

The review of deaths under supervision has a delicate balance to strike. The policy rightly emphasises that preventing death is not the responsibility of PPs. However, when such an event occurs it is right that a case is reviewed. It is likely that only in exceptional circumstances will probation practice be causal in relation to the death. It should therefore be explicit that any practice shortcomings found will not be linked to the death. It is, however, important that findings from the process are used to review the effectiveness of probation policy and inform improvements in practice. The process and team are still in their relative infancy but there is some evidence of this starting to happen. In 2025, the Probation Service issued ‘Recalls – know the risk of self-harm and suicide (probation)’, a safety learning bulletin for PPs, which was informed by the analysis of the death under supervision team. At a regional level there was also some evidence of the death under supervision process resulting in practice improvement. In KSS, areas identified for improvement following findings from the process included enforcement, home visits and the use of safety plans.

The national team’s analysis of deaths under supervision since 2022 is detailed. The learning review completed for the first nine months of 2024/2025 includes analysis of cohorts such as gender, ethnicity and age. This includes findings in relation to engagement with mental health and substance misuse services. The team has also analysed specific cohorts of people on probation who have died, such as women and prisoners serving indeterminate sentences. This has informed some of the practice guidance and forums delivered by the drug and alcohol group. It is not clear, however, that findings from the death under supervision process are used consistently to review and improve delivery. In addition, the findings are nearly always relevant to other agencies, but there is no consistent guidance on how this information should be shared with them.

2.2 Conclusions and implications (Back to top)

Safeguarding responsibilities are shared across HMPPS. The PPG leads on adult safeguarding, while the Rehabilitation Directorate oversees health and substance misuse. The death under supervision team reports to the Security Directorate’s safety group, and suicide prevention is coordinated via a cross-directorate steering group, reflecting a complex strategic landscape.

These arrangements require a joined-up approach. Integrating safeguarding, health and wellbeing into strategic frameworks is a positive step, but implementation remains uneven. National leadership must continue to support regions in embedding policy into practice, ensuring safeguarding and wellbeing are treated as core elements of public protection and rehabilitation.

The updated Safeguarding Adults at Risk in the Community framework marks a significant step forward in clarifying responsibilities across probation regions. The appointment of regional safeguarding leads and clearer roles for PDU heads and senior probation officers (SPOs) are encouraging developments. However, inconsistent awareness of the framework and limited integration of safeguarding principles into everyday practice suggest that further work is needed to embed these expectations.

Strategic partnerships, particularly with the NHS, signal a welcome shift towards a more holistic approach to probation. Innovations such as regional health and justice coordinators and GP registration pilots are promising, and the Core20PLUS5 survey highlights probation’s role in improving access to health care. Yet, while health pathways are emerging, the operational focus on social care is underdeveloped. Probation practitioners’ lack of confidence in navigating adult social care and the absence of reliable referral data are barriers to effective support.

National strategies on drugs, alcohol, and suicide prevention provide clear direction and examples of good practice, such as co-located services and enhanced DRRs. However, risk management, particularly around drug-related deaths and suicide, is not consistently embedded in delivery. Training is often introductory, and safety planning is underused. The death under supervision policy offers a framework for learning, but its perceived focus on individual failings hinders engagement. A joined-up, trauma-informed approach is needed to ensure safeguarding, health, and wellbeing are fully integrated into probation practice, with national leadership supporting consistent implementation across regions.

3. Partnership working and local leadership (Back to top)

In this chapter we consider the impact of local leadership and multi-agency arrangements on managing the risks faced by people on probation.

3.1. Local leadership (Back to top)

Local authorities are responsible for establishing SABs, under section 43 of the Care Act 2014. Their purpose is to support and protect adults in their area who have care and support needs; are at risk of abuse or neglect; or are unable to protect themselves because of their needs. The Probation Service’s involvement with SABs is at PDU level. The probation policy statement on safeguarding adults at risk (2025) states that heads of PDUs should attend the board.

In the inspected PDUs, either the PDU head or (if they were unavailable) their deputy attended the board, in line with the policy statement. Some local arrangements varied. For example, where a SAB covered two PDUs, only the head of one would attend. The board chairs and adult social care (ASC) managers we met were positive about the Probation Service’s level of involvement with their SAB.

Attendance at SABs led to some positive outcomes for the Probation Service. In Suffolk, for example, a strengthened partnership with adult social care resulted in joint workshops for PDU staff, focusing on the risks to people on probation. The PDU safeguarding lead also attended the strategic Multi-Agency Safeguarding Hub board. Overall, however, we found little evidence that attendance at SABs was resulting in better services for people on probation, particularly in relation to ASC. The reasons for this lack of impact are not solely the responsibility of the Probation Service. One senior manager said:

“Probation influence on the SAB is minimal, as the primary driver for the board is social care for the elderly, people with physical and learning difficulties predominantly in care homes … it is often a question of resources and profile of people on probation are not really a priority.”

Another reason given for not prioritising the probation caseload at SABs was their focus on child safeguarding. In some PDUs the SAB had been integrated with the children’s board to form a safeguarding vulnerable people partnership. One senior manager said:

“We do focus more on child safeguarding rather than adult safeguarding … I attend the board and it is far more child focused than adult.”

Another factor limiting impact was that senior PDU managers attended multiple partnership meetings where safeguarding issues relevant to the probation caseload may be discussed. Drug-related deaths, for example, may be discussed at the combating drugs partnership meeting. Managers also attend community safety partnerships, domestic abuse partnership boards and violence reduction boards, where specific concerns may be addressed.

SABs are the principal board for adult safeguarding and delivering adult social care services. Given the heightened risk of suicide, drug-related deaths and physical ill-health among the probation caseload, this group should be a priority for the SAB. However, we saw little evidence that such risks, and the troubling data, were being shared with the SABs. In our view, information such as the analysis of deaths under supervision should be regularly reviewed, and findings that highlight gaps in multi-agency engagement should be clearly raised.

The other key probation issue that should be raised at board level is the referral pathway into adult social care. PPs had little confidence in the pathway and therefore made very few referrals. To support PPs making safeguarding referrals, the EQUIP framework sets out a three-stage test aligned with section 42 of the Care Act 2014.¹¹ Despite this guidance, PPs reported that probation referrals were rarely accepted because the threshold to access services was too high. SPOs did pursue some cases, usually without success, and there were no clear escalation processes in place for rejected referrals. There was also no awareness at PDU level of the possibility of escalating cases to the national social care team for appropriate action. Neither the Probation Service nor most SABs monitored ASC referrals, but the limited data provided for the inspection confirmed that the level of referrals nationally was low, and that there was inconsistency across the probation regions. In the good practice example below, a proactive approach has led to an increase in referrals, making it more likely that people on probation can access the services that they need.

Good practice example

The Liverpool SAB had identified that agencies, including probation, did not monitor their referrals to ASC. It introduced a dashboard to monitor referrals, which had been operating for five months at the time of the inspection. Probation referrals had been low, running at one or two per month. Probation managers, together with ASC staff, subsequently promoted the ASC pathway. This resulted in a significant increase in referrals, with nine recorded in the month of the inspection.

Some ASC managers and SAB chairs were clear that PPs’ lack of understanding of the Care Act 2014, and lack of training, contributes to the low rate of successful probation referrals. ASC referrals are covered in the mandatory online safeguarding training that PPs receive. It was, however, evident that not all PPs were clear about the criteria for referral. Completion rates for the online training averaged over 70 per cent across the PDUs, but far fewer PPs had completed the follow-up classroom-based safeguarding training. This is evidently an area for improvement.

In their analysis of the findings from SARs, Preston-Shoot and Braye (2024) examined 652 reviews between 2019 and 2023. Given the complexity and risks of the probation caseload, surprisingly few of the reviews involved people on probation, although this is further evidence of the limited involvement of ASC in probation cases. Their analysis of referral thresholds led to a finding that in some authorities a culture of ‘deserving and undeserving’ decision-making was in place. People on probation have often committed serious crimes, and it is likely that this has influenced some referral decisions.

People on probation identified access to mental health services as a problem. This was echoed by PPs and evident in the inspected cases. Missed appointments were cited as a common barrier. PPs complained that two failed appointments often resulted in a service being withdrawn, even in cases where there were serious concerns. While PDU managers recognised access to mental health services as a priority, the level of provision varied significantly.

In one PDU there was a long waiting list to begin Mental Health Treatment Requirements (MHTR). The local mental health service had been rated inadequate by the Care Quality Commission and had been in special measures. Senior managers had made efforts to improve access to the service for people on probation, but this remained inconsistent. In other PDUs, there was evidence of positive initiatives to improve access. In West Kent, a pathway was being developed to enable PPs to refer directly to the community mental health teams. In Hampshire North and East, health and justice coordinators had developed an escalation pathway with the local service provider that ensured rejected referrals could be reviewed by a senior nurse practitioner.

The difficulties that the Probation Service experiences in engaging services such as ASC and mental health lays bare the essential tension in relationships between the services. The Probation Service must maintain contact with people on probation, whereas other services only intervene if the stated threshold for need is met. This means that the Probation Service is frequently supervising people with complex needs who present a serious risk of harm, on its own. It has no direct leverage to engage services, and the effective management of the risks people on probation face often depends on decisions made by other organisations.

3.2. Operational delivery (Back to top)

nDelius registers

Effective partnership working to safeguard people on probation begins with accurately recording risk. The Probation Service uses over 70 nDelius registrations, including one for vulnerability, to log key risk factors. Some registrations are split between identifying the individual as either a victim or a perpetrator, and in some cases both. The use of these registrations was inconsistent and in some cases contradictory. For example, a person on probation might be registered as at risk of self-harm and suicide but not registered as vulnerable. This complexity highlights the need for consistent and informed use of registration categories to support safeguarding efforts.

There were positive examples of specific registers, such as ‘county lines victim’, that addressed risks to people on probation, but the absence of a register for sexual exploitation was a significant omission. Also, registrations were not always updated when the person on probation’s situation changed.

Overall, the nDelius registration process is over-complicated and the risks to an individual on probation are not immediately accessible. In our view, it should be reviewed and simplified.

Multi-agency risk management meetings

The governance of multi-agency risk management meetings (MARMM) is overseen by SABs. MARMMs can be convened for adults who may be at risk of harm to themselves, abuse or neglect but do not necessarily meet the statutory safeguarding criteria under section 42 of the Care Act 2014. Their aim is to facilitate a coordinated multi-agency response where traditional safeguarding procedures are insufficient. Services working with adults at risk are all entitled to institute a MARMM, which should be formally documented and notified to the SAB.

The awareness of and use of MARMMs varied across the PDUs, and we heard few examples of them being used for probation cases. In one PDU in the south west, a pilot had recently been set up to test the process for probation cases. The process was being actively promoted in PDUs, but leaders recognised that it was not yet achieving its potential impact for people on probation. For the process to become embedded in probation practice, it must demonstrate that it leads to the effective delivery of services. Achieving this will require proactive operational guidance and direction by the SABs.

The following case example from Wiltshire shows how a multi-agency approach supported a vulnerable individual in the justice system:

Good practice examples

Dan was chaotic and had been in the care system. In view of the risks he faced, he was moved to management by the integrated offender management team (IOM). The PP developed an excellent professional relationship with D, and service delivery was responsive to both his needs and the risk of serious harm. The MARMM process was used and all key agencies attended, including children’s social care and ASC. Although the risks to D remained, an agreed multi-agency approach helped to coordinate the delivery of services.

In some PDUs PPs were also able to refer to complex lives panels. These multi-agency panels are coordinated by the local authority and review complex cases with care and support needs. In many respects they mirror the role of MARMMs. We saw evidence in the inspected cases of these panels being used productively, and PPs were positive about the support they provided. However, as with MARMMs, their effectiveness relied on agencies agreeing to deliver services in a flexible and responsive way.

Multi-agency risk assessment conferences and MAPPA

Across the inspected PDUs, the Probation Service was an active participant in multi-agency risk assessment conferences (MARAC). This was also evident in the cases we inspected. There were also good examples of PPs exchanging information, making referrals and coordinating planning to keep victims of domestic abuse safe from harm.

We also saw MAPPA being used effectively during the inspection. In Suffolk, the MAPPA ASC representative arranged joint training days for ASC and probation staff. However, a persistent theme across the PDUs was the use of MAPPA Level 2 referrals to engage services, regardless of the imminence of risk of serious harm in the case. Ensuring multi-agency engagement is the key aim of MAPPA, but this should be for reasons of public protection rather than simply to ensure that agencies deliver services. As awareness of MARMM increases and the process becomes established, it should reduce the inappropriate use of MAPPA.

3.3. Engaging people on probation (Back to top)

To safeguard people on probation effectively, the Probation Service must listen to the individuals themselves and understand their experiences and perceptions of the risks they face. Engaging people on probation teams were established across the regions we visited, although some had vacancies. People with lived experience of the criminal justice system staffed the teams. We heard about some impressive initiatives to engage people on probation, including male peer support meetings and art groups. There were also examples of peer mentors working alongside health and justice coordinators to identify services for people who needed support for their health and social isolation.

The level of integration with the PDU teams varied, and this inevitably affected the degree to which EPOP teams supported PPs. In Liverpool North PDU, the teams worked collaboratively, with peer mentors actively involved in pre-release work, assessment and planning. In many respects the role of EPOP is still being established in the Probation Service. The peer support it provides to men and women can play a central role in addressing safeguarding risks.

3.4. Conclusions and implications (Back to top)

While Probation Service representation on SABs was broadly in line with policy expectations, its impact on service delivery for people on probation was limited. Attendance alone did not result in better access to ASC or more responsive safeguarding interventions. This may reflect the broader priorities of SABs, which remain focused on older adults and those in care settings, rather than the complex and often marginalised probation caseload.

Examples of promising local practice, such as joint training initiatives and dashboards to monitor referrals, were not widespread. The lack of consistent data on adult social care referrals, and the absence of escalation pathways for rejected referrals, indicate that the Probation Service is not yet fully embedded in safeguarding systems. This is compounded by limited awareness among PPs of referral thresholds and the criteria under the Care Act 2014, despite the availability of guidance and training.

The inspection also highlighted inconsistent engagement from mental health services. While some PDUs had developed escalation pathways or direct referral routes, others faced significant barriers, including long waiting lists and limited provision. This variation raises concerns about equitable access. It also highlights the limitations on the Probation Service’s ability to ensure appropriate support for people on probation.

MARMMs and complex lives panels offer potential ways of coordinating support for individuals who fall outside statutory safeguarding thresholds. However, their use remains patchy, and their effectiveness depends on the willingness of partner agencies to engage and deliver services. The inappropriate use of MAPPA to secure agency involvement is a concern and suggests a need to strengthen alternative multi-agency mechanisms.

Finally, EPOP teams are emerging as a valuable asset in safeguarding work. When these teams were integrated effectively, they contributed to pre-release planning and peer support. However, their impact was uneven and dependent on local structures and relationships.

4. Safeguarding people on probation (Back to top)

In this chapter, we review our case inspection findings and consider how effectively sentence delivery focuses on safeguarding adults on probation. We examine the reports submitted to court and consider the assessment and planning of cases, and sentence delivery. We also consider the impact of Probation Reset on safeguarding adults on probation.

4.1. Advice to the court (Back to top)

We inspected 99 cases across the six inspected PDUs, all of which began during a three-month period between May and August 2024. In each case, the individual had been identified as vulnerable by PPs on nDelius. The Probation Service provided court reports in 62 of these cases, which we reviewed to assess how the risks to the person on probation were identified and analysed. We also considered whether information was available from other agencies and whether the person on probation had been meaningfully involved in the preparation of the report.

In most of the court reports we inspected, the risks to the person on probation were identified and analysed. Effective practice included taking into consideration the person on probation’s view of any risks in relation to their safety and wellbeing, and consideration of their diversity and personal circumstances.

The following example from Hampshire North and East PDU illustrates good practice in working with an adult with learning difficulties:

Good practice example

Kevin was 21 years old when he was convicted of assaulting a family member. The court report used multiple sources of information, including input from a support worker and the individual’s education, health and care plan. This provided valuable insight into Kevin’s vulnerabilities and linked poor emotional regulation to his learning difficulties. The report also detailed the impact of unstable housing and financial pressure on Kevin’s autism and emotional self-control. The report explained how people with autism often struggle with change and can feel overwhelmed. This understanding of the pressures Kevin was facing was reflected in the sentencing proposal. This carefully considered the option of a community order with requirements, based on Kevin’s needs. He was subsequently sentenced to a 12-month community order with a 20-day rehabilitative activity requirement.

In nearly two-thirds of cases, the report included a sufficient analysis of the person on probation’s experience of trauma. The template for short format and standard delivery reports includes a specific section on trauma. However, in many of the reports we inspected, this section was only superficially completed, and trauma was addressed in other sections, such as those covering personal relationships. How trauma is addressed and integrated in the court template should be reviewed. The following example contains several significant omissions:

Poor practice example

Mark appeared before the court for multiple offences of theft, and he had a history of non-compliance with community orders. The report identifies concerns in relation to vulnerability but lacks sufficient analysis. Mark had been a long-term victim of cuckooing, yet the emotional and psychological impact of this was not explored. Substance misuse was considered in relation to further offending, but its personal impact and the risks posed by hard drugs were overlooked. Mark had experienced significant trauma, including childhood sexual abuse, physical assault, and homelessness, but these were not examined holistically. The recommendation for unpaid work failed to consider his physical condition or ability to comply.

Probation staff in courts carry out safeguarding checks to children’s social care, to protect victims and potential victims. Checks for the potential risks to the people on probation, however, are not always undertaken at the court stage. In the inspected reports, these checks had not been carried out in just over a quarter of the reports inspected. Without these checks, key information, both in terms of sentencing and the risk to the individual, is not included in the court report.

Twenty-one of the 62 reports were on women. Inspectors found little difference in the quality of the reports between men and women. This was also the case for reports on people from different minority ethnic backgrounds. There was, however, some difference in quality in relation to age. Almost all reports for people on probation aged over 56 were judged sufficient (six cases), while just over half of reports for those aged 18 to 25 were sufficient (16 cases).

In over two-thirds of cases, the proposal considered the person on probation’s ability to comply, and nearly three-quarters of case proposals were sensitive to the person’s individual circumstances and experiences of trauma.

4.2. Assessment and planning (Back to top)

The safeguarding guidance for PPs highlights the importance of the OASys assessment when assessing safeguarding risks. The seven top tips for adult safeguarding document, issued to guide PPs, focuses primarily on the risks to victims and potential victims, but also contains a section on the risks to the person on probation. In OASys itself there is a section to assess the person on probation’s vulnerability, risk of self-harm and risk of suicide. This is completed if these issues are identified in the screening section of the document.

The OASys assessment should identify whether the individual is vulnerable. In most cases, this had happened. However, in 13 out of the 99 cases the person on probation was flagged as vulnerable on nDelius but not assessed as vulnerable on OASys. On average, across the six PDUs, 20 per cent of women were assessed as vulnerable and five per cent of men. The OASys guidance on vulnerability lists factors such as bullying, assault, exploitation and involvement in organised crime. The assessment of men and women’s vulnerability may be accurate but, in our view, it is likely that stereotypical assumptions, particularly in relation to men, lie behind the disparity in the figures.

The term vulnerability was removed from the Care Act 2014 as there were concerns that it potentially stigmatised certain groups in the population. The usefulness of the term in probation assessments should also be reviewed.

The finding also raises questions about the Probation Service’s overall approach to and assessment of vulnerability in men. Hocken and Taylor (2022) and Mulcahy (2018) have highlighted the prevalence and impact of ACEs on individual wellbeing within the offending population. The number of men identified as vulnerable in the probation caseload appears low in the context of their findings. The Office for National Statistics Health Insight survey found that men are much less likely to approach their GP than women and less likely to seek help for mental health problems. In their work on men’s health, Galdas et.al (2023) stated that:

“Approaches that rely heavily on talking about problems in formal settings, eyeball to eyeball, can often feel uncomfortable, threatening, and unhelpful to a lot of men, and mismatched with how many experience and express distress, particularly those who have faced adversity, or hold rigid expectations around self-reliance.”

At national level, the assessing needs, strengths and risks project (ARNS) is reviewing OASys, with a view to replacing it. The project team has recognised the need for a bespoke approach to case management and for better integration of risk factors within assessments. Men make up 90 per cent of the probation caseload and it is therefore important that learning from across public services is considered in developing effective assessment and engagement strategies.

In the inspected cases, we identified the main risks to the individual as mental health (77 per cent); self-harm/suicide (64 per cent); alcohol abuse (37 per cent); drug abuse (35 per cent); domestic abuse (30 per cent); and intimidation, threat and harassment (18 per cent). Overall, we found the assessment of risks to people on probation to be sufficient in 58 per cent of the cases. Strong assessment practice included analysing how risks to the individual influenced their likelihood of reoffending and causing serious harm. In the best examples, practitioners had fully analysed risks such as exploitation and cuckooing and drawn clear links between these risks and the individual’s behaviour. Areas for improvement included engaging the person on probation and incorporating their views on the risks they faced. Inspectors found that just over half of the cases were sufficient in these areas.

The following example of good practice was noted in Suffolk:

Good practice example

The main safeguarding risks stemmed from Jake’s drug use, involvement in organised crime and his associates. These concerns were clearly identified, and the formal assessment contained a good level of analysis. It analysed the impact of drug use on Jake’s behaviour and his subsequent experience of violence, threats involving weapons and ruthless debt control. The risks of exploitation and cuckooing were also fully explored. The assessment provided a clear insight into the risks Jake faced and how these drove his continued involvement in serious crime.

Planning was sufficient in just under half of the cases (49 per cent). In many cases, this was because the plans focused on factors linked directly to offending, to the exclusion of the individual’s personal situation.

In 40 per cent of the cases (31) where inspectors identified that there was a risk of self-harm or suicide, there was no planning to address this concern. Similarly, in 83 per cent of cases (20) where criminal exploitation was identified as a risk, this was not identified and planned for.

Inspectors identified positive practice in cases where trauma support was included, and in one instance, an HMPPS safety plan was in place to manage suicide risk. Risks to the individual were generally recognised in risk management plans. However, most plans showed limited evidence of collaboration or direct involvement from the person on probation.

Poor practice example

Planning was almost solely focused on the risk of serious harm, with minimal consideration of Bill’s vulnerability and needs. It was evident that Bill was struggling with mental health issues and there are concerns about his personal wellbeing. The planning of this case focuses on risk management and does not include strategies or interventions to help Bill when he is distressed or experiencing suicidal ideation. The plan does not reference the recent loss of his mother or consider bereavement counselling. Both physical and emotional support are directly relevant to reducing his offending and improving his compliance.

4.3. Sentence delivery (Back to top)

Sentence delivery was the strongest area of practice, with nearly two-thirds of inspected cases (62 per cent) assessed as sufficient. Strengths included the approach taken by PPs in their meetings with people on probation. User Voice’s work highlighted the relationship people on probation felt they had with their PPs, with 75 per cent of those surveyed and 85 per cent of those interviewed viewing these positively. Two-thirds of survey respondents said that contact with their PP had helped them to access services.

The arrangements for and frequency of appointments took safeguarding needs into consideration in over three-quarters of cases (76 per cent), and in 14 out of the 19 licence cases, inspected risks to the person on probation were identified appropriately at the pre-release stage. Where the risk of suicide and mental health had been identified as concerns, sentence delivery was sufficient in most cases. However, performance was weaker in areas such as drug abuse, criminal exploitation and intimidation, threat and harassment.

The following good practice was noted in Liverpool North:

Good practice example

The PP built a strong relationship with Wendy, which helped support a consistent and joined-up approach. Her situation was chaotic, and she was often in crisis. Regular appointments helped provide stability and motivation, while referrals connected Wendy to key services that addressed personal safety, sexual exploitation, mental health, and drug use. A floating support service also helped with everyday tasks like shopping and cooking, making it possible for her to stay in accommodation. The coordinated support Wendy received was impressive and played a vital role in helping to keep her safe and stable.

Sentence delivery was much better for women on probation than for men. For women, inspectors assessed 74 per cent of cases as sufficient compared to only 56 per cent for men. To understand this discrepancy, many factors must be considered. Women on probation often present with caring responsibilities and at risk of domestic violence and sexual exploitation. In addition, men are more likely to commit a serious further offence (SFO), and in 2023/2024 they were responsible for 96 per cent of the offences submitted for a SFO review. This means the focus of PPs may inevitably be on the risks these men present rather than the risks to them. Many women on probation had bespoke services available to them in areas such as mental health and substance misuse and, in some PDUs, women-only reporting centres. PPs were clear about the need for trauma-informed approaches when working with women but were less able to articulate the need for such approaches when working with men. One SPO stated:

“there is very limited bespoke engagement for men and generally other services find their behaviour challenging … it seems like they find any excuse to avoid referrals … it is often all left to probation … we need to deliver a service which develops their trust and addresses issues such as shame, humiliation and fear.”

There were encouraging examples of bespoke approaches to probation practice. For example, in East Kent a male peer support group was established, and tailored approaches were developed for the under-25 cohort. This group is now managed by specialist teams and probation practitioners who understand the specific risks they face, including organised crime, cuckooing and exploitation. Again, in East Kent, to aid the transition from the youth justice service, young men were able to report to a dedicated hub away from the main probation office. The positive impact of these initiatives was seen in our inspection of cases. In total we looked at 23 cases in the 18 to 25 age range and found 65 per cent to be delivering services sufficiently to safeguard the person on probation.

The quality of the professional relationship developed by PPs with people on probation was central to the effective sentence delivery identified by inspectors. More than three-quarters of the people on probation contacted by User Voice felt they had a positive relationship with their PP. Comments made by people on probation included the following:

“Meetings are positive, my PP is working for me and is able to give me a positive outlook when I leave. Before I would have depressive thoughts but seeing her helps with these. She gives me confidence cos it’s not very good sometimes.”

“My time on probation has changed my life completely for the better I especially feel that my PP made an outstanding positive influence in my rehabilitation I will be eternally grateful for her support and the rest of the team at probation who have gone above and beyond to help me.”

“My PP is really helpful and listens and helps, she has given me numbers like citizens advice and MIND for mental health. We talk over and she gives good advice and keeps in contact with my social worker and with MIND.”

In many of the inspected cases PPs were faced with people on probation in crisis. The reasons varied but they included homelessness, mental health breakdown and violence in relationships. A multi-agency approach in such cases is often necessary, but PPs were frequently left managing cases on their own, despite having made referrals to other agencies.

The reasons for the lack of engagement from other services varied, including concerns about the individual’s motivation to engage and failure to meet service thresholds. However, PPs felt that this was often linked to how the probation role is perceived and concerns about the risks posed by the individuals. Comments included:

“When other agencies see probation involved, they are reluctant to get involved and there is a view that probation will do everything … there is a sense that probation have to go around begging favours off other services, have to persuade services to get involved even when there are obvious needs like physical health problems and mental health crises.”

“PPs are expected to do everything, social worker, therapist, teacher, the last thing we are is probation officer … when we are involved agencies leave it to us.”

“… our focus is meant to be on public protection, and we cannot deliver mental health and adult social care services.”

It is understandable that service providers have criteria for their involvement in cases and must target their resources effectively. However, some professionals still appear to view probation as primarily a welfare service. Inspectors were surprised, for example, to learn of an elderly man who had been convicted of serious sexual offences and was a double amputee but who supposedly did not meet the criteria for adult social care support in relation to his move to independent accommodation.

Safeguarding people on probation effectively requires a multi-agency approach. PPs play a pivotal role in this work, which to some extent is hidden in plain sight. Risks to and from the individual are closely linked and must be managed together. Issues such as accommodation, mental health and substance misuse are not only connected to the risk of serious harm, but also directly affect the risks faced by the individual themselves. Many of the people interviewed by User Voice were clear about this link. Their comments on why they offended included the following:

“I was a vulnerable person and in contact with dangerous people who took advantage, I tried to run away. I was also experiencing psychosis due to taking drugs and alcohol at the time nonstop.”

“I had some sort of psychotic episode where I took a knife to my husband and the police officer. Then they pepper sprayed me and arrested me which was very traumatic and put me in the cells for the whole weekend.”

“The last time I went in was for the assault on emergency workers. it was because I was having a complete mental breakdown, and I was also in pain and I felt that they weren’t helping me properly.”

4.4. Probation Reset (Back to top)

Probation Reset was implemented across the Probation Service in April 2024. It was designed to help target resources more effectively and manage high workloads. It introduced a new approach whereby, for most cases, proactive contact with the person on probation would cease after two-thirds of the supervision or licence period. There were some exceptions to this instruction and these included MAPPA, child protection and cases assessed as very high risk of harm. Risks to the person on probation were not explicitly included in these criteria.

We inspected 17 cases that had been subject to Probation Reset before 01 December 2024. This inspection took place relatively soon after the process had been introduced, which had an understandable impact on planning for the end of probation contact. Nonetheless, we identified concerns in the cases inspected, including instances where probation contact ended with some individuals being left without support from any agency. In some cases, safeguarding actions in relation to the individual had not been taken before probation contact stopped. Many PPs were still adjusting to the new process. In some cases, because of concerns about the person on probation’s welfare, the PP continued to maintain contact even though they had been directed not to.

4.5. Conclusions and implications (Back to top)

The current assessment frameworks, including OASys, do not fully capture the nuanced vulnerabilities of individuals on probation, particularly men. There was evident gender disparity in the assessment and identification of vulnerability. It is likely these reflect underlying stereotypical assumptions about presentation, particularly in relation to men. A review of assessment practices and terminology – especially the continued use of ‘vulnerability’ – is warranted.

The implementation of Probation Reset has implications for the safeguarding of people on probation. Proactively managing the workload is a positive step for the Probation Service but it is important that the ending of contact during the final third of supervision does not leave people on probation without adequate support. Safeguarding risks must be identified and planned for before contact is terminated.

Partnership working is a critical component of effective safeguarding. However, engagement from services to address safeguarding risks can be inconsistent and PPs are often left isolated in managing complex cases. The reluctance of some agencies to engage when probation is involved may reflect broader systemic issues or perceptions of probation’s role.

PPs play a central, yet often under-recognised, role in this work. The risks posed by and to the individual are frequently interrelated and must be addressed in a joined-up manner. Addressing factors such as accommodation, mental health, and substance misuse is essential to managing both the risk of serious harm and the risks faced by those on probation.

There are some impressive arrangements in place for delivering services to women. Bespoke approaches are also being developed for young men with the aim of improving engagement and delivering positive outcomes. The expansion and adaption of such strategies and approaches to other cohorts would further enable more effective safeguarding practices.

References (Back to top)

Bellis, M, Ashton, K, Ford, K, Bishop, J and Paranjothy, S (2015). Adverse Childhood Experiences and their impact on health-harming behaviour in the Welsh adult population. Public Health Wales NHS Trust.

Braye, S, Orr, D and Preston-Shoot, M (2014). Self-neglect policy and practice: Building an evidence base for adult social care. Social Care Institute for Excellence.

Carr, M J, Steeg, S, Webb, R T, Qin, P and Appleby, L (2020). Dual harm: self-harm and violent criminality in a Danish national cohort. The Lancet Psychiatry, 7(6), pp. 510–518.

Commission for Social Care Inspection (2008). Inspection of local safeguarding arrangements, care homes and home care agencies, as well as original fieldwork in five local authority areas.

Department of Health (2011). Safeguarding Adults: The Role of NHS Commissioners. London: HMSO.

Galdas, P, Siedler, Z and Oliffe, J (2023) Designing Men’s Health Programs: the 5 C framework. American Journal of Men’s Health.

HM Government NHS (2022-2025). The National Partnership Agreement for Health and Social Care for England: improving the quality of services for people in prison and those subject to statutory supervision by the probation service in the community. London: HM Government.

HM Inspectorate of Probation (2020). Exceptional Delivery Model Arrangements in Probation Services in response to the Covid-19 Pandemic. Manchester: HM Inspectorate of Probation.

HM Inspectorate of Probation (2023). A thematic inspection of work undertaken, and progress made by the Probation Service to reduce the incidence of domestic violence and protect victims. Manchester: HM Inspectorate of Probation.

HM Inspectorate of Probation (2024). The Quality of Services Delivered to Young Adults. Manchester: HM Inspectorate of Probation.

HM Inspectorate of Probation (2025). Annual Report 2024: Inspection of Probation Services. Manchester: HM Inspectorate of Probation.

HM Inspectorate of Probation and the Care Quality Commission (2021). A thematic inspection of community-based treatment and recovery work with people on probation. Manchester: HM Inspectorate of Probation.

HM Inspectorate of Probation (2021). A joint thematic inspection of the criminal justice journey for individuals with mental health needs and disorders. Manchester: HM Inspectorate of Probation.

HMI Probation and HMI Prisons (2008). A joint inspection of the treatment of offenders with learning disabilities within the criminal justice system – phase two in custody and the community. Manchester: HM Inspectorate of Probation.

HMPPS (2022). Building a recovery-oriented system of care. HMPPS Drug and Alcohol Operational framework. London: HMPPS.

HMPPS (2022). Reporting and Reviewing Deaths under supervision in the community.London: HMPPS.

HMPPS (2023). Probation Service National Partnership Framework Safeguarding Adults Boards. London: HMPPS.

HMPPS (2023). Probation Service Suicide Prevention Plan 2023-2026. London: HMPPS.

HMPPS (2023). The Seven top tips for Adult Safeguarding. London: HMPPS.

HMPPS (2024). Safety Plan A wellbeing and community support resource. London: HMPPS.

HMPPS (2024). Seven-minute briefing: Suicide Prevention. London: HMPPS.

HMPPS (2025). Safeguarding Adults at Risk in the Community, the probation service policy statement. London: HMPPS.

HMPPS (2025). Drug and Alcohol Operational Framework: Probation Strategic Delivery Guidance. London: HMPPS.

HMPPS (2025). Recalls-know the risk of self-harm and suicide (Probation) A safety learning bulletin. London: HMPPS.

Hocken, K and Taylor, J (2022). Trauma and the Experience of Imprisonment. Developing a trauma sensitive framework for prison rehabilitation. ResearchGate.

Independent Chief Inspector of Borders and Immigration (2018). An inspection of the Home Office’s approach to the identification and safeguarding of vulnerable adults. London: HM Government.

Mulcahy, J (2018). Daring to Ask “What happened to you?” Why correctional systems must be come trauma-responsive. ResearchGate (2018).

Office for National Statistics (2023). Drug-related deaths and suicide in offenders in the community, England and Wales. Office for National Statistics (ons.gov.uk).

Office for National Statistics (2023). Deaths related to drug poisoning in England and Wales 2022. Office for National Statistics (ons.gov.uk).

Office for National Statistics (2025). The ONS Health Insight survey. Office for National Statistics (ons.gov.uk).

Preston-Shoot, M and Braye, S (2024). The second national analysis of Safeguarding Adult Reviews, covering April 2019 to March 2023. Local Government Association.

Slade, K, Justice, L, Martijn, F, and Baguley, T (2024). Deaths among adults under supervision of the England and Wales’ probation services: variation in individual and criminal justice-related factors by cause of death. Health & Justice, 12, Article 10.

Stinson, P, Quinn, A, Condon, L and Morant, N (2021). Understanding self-harm in forensic mental health settings: findings from a qualitative study with service users and staff. Journal of Forensic Psychiatry & Psychology, 32(6), pp. 833–850.

UK Government (2025). Fit for the Future 10 Year Health Plan for England. London: NHS.

White, H R, Johnson, V, Buyske, S (2000). Parental modelling and parenting behaviour effects on offspring alcohol and cigarette use: A growth curve analysis. J. Subst. Abus. 12. pp. 287–310.

Annexe 1: Glossary (Back to top)

ACE		Adverse childhood experiences: experiences that occur during childhood and can include neglect, and physical and emotional abuse
ASC		Adult social care
ATR		Alcohol Treatment Requirement: a requirement that a court may attach to a community order or a suspended sentence order aimed at tackling alcohol abuse
CQC		Care Quality Commission
Child protection		Work to make sure that that all reasonable action has been taken to keep to a minimum the risk of a child coming to harm
CMHT		Community mental health team
DUS		Death under supervision: the process used by the Probation Service to review cases when someone dies while subject to probation supervision
DRR		Drug Rehabilitation Requirement: a requirement that a court may attach to a community order or a suspended sentence order aimed at tackling drugs misuse
EQUIP		EQUIP is the central online resource for information and guidance related to probation work in England and Wales
EPOP		Engaging people on probation
DHSC		Department of Health and Social Care
HMPPS		HM Prison and Probation Service (HMPPS): the single agency responsible for both prisons and probation services
IOM		Integrated Offender Management brings a cross-agency response to the crime and reoffending threats faced by local communities. The most persistent and problematic offenders are identified and managed jointly by partner agencies working together
ISG		Improvement Support Group: the national team responsible for highlighting and improving effective practice
MARAC		Multi-agency risk assessment conference: a meeting held by the representatives of various agencies to discuss and create a safety plan for victims of domestic violence or abuse
MAPPA		Multi-Agency Public Protection Arrangements: where probation, police, prison and other agencies work together locally to manage offenders who pose a higher risk of harm to others. Level 1 is ordinary agency management where the risks posed by the offender can be managed by the agency responsible for the supervision or case management of the offender. This compares with Levels 2 and 3, which require active multi-agency management
MARMM		Multi-agency risk management meeting held under the auspices of adult social care
MASH		Multi-Agency Safeguarding Hubs act as the first point of contact for new safeguarding concerns or enquiries. They usually include representatives from the local authority (children and adult social care services), the police, health bodies, probation and other agencies
MHTR		Mental health treatment requirement: a requirement that a court may attach to a community order, or a suspended sentence order aimed at delivering appropriate mental health intervention
MoJ		Ministry of Justice
nDelius		National Delius: the approved case management system used by the Probation Service in England and Wales
OASys		Offender assessment system currently used in England and Wales by the Probation Service to measure the risks and needs of offenders under supervision
PDU		Probation Delivery Unit
PP		Probation practitioner: the term used for both probation officers and probation service officers. Probation officers have completed a professional probation qualification, and they manage cases at all risk levels. PSOs do not have the probation qualification and do not manage high or very high risk of serious harm cases
PO		Probation officer: this is the term for a ‘qualified’ responsible officer who has undertaken a higher education-based course for two years. The name of the qualification and content of the training varies depending on when it was undertaken. They manage more complex cases
PSO		Probation services officer: this is the term for a responsible officer who was originally recruited with no qualification. They may access locally determined training to ‘qualify’ as a probation services officer or to build on this to qualify as a probation officer. They may manage all but the most complex cases depending on their level of training and experience. Some PSOs work within the court setting, where their duties include the writing of pre-sentence reports
SAB		Safeguarding Adults Board
SAR		Safeguarding adults review: a safeguarding adults review takes place when an adult with care and support needs dies or experiences serious harm due to abuse or neglect
SFO		Serious further offence: serious offences committed by people being managed by the Probation Service which are then subject to an internal review
SPO	Senior probation officer

Annexe 2: Methodology (Back to top)

The inspection sought to answer the following questions:

Does leadership support, promote and enable effective adult safeguarding practice for people supervised by the Probation Service?

Does strategic decision-making enhance and enable effective adult safeguarding practice?
Do structures and operating models support effective adult safeguarding practice?
Does the governance model clearly identify responsibility and accountability in relation to adult safeguarding policy and practice?
Are adult safeguarding polices communicated and understood within the organisation?
Is probation policy and practice informed by learning from the death on probation supervision reviews and other serious case reviews?
Are the views of people on probation sought, analysed and used to inform adult safeguarding practice?

How effective are the adult safeguarding arrangements at keeping people safe?

Are individuals at risk of harm in the probation caseload consistently identified?
Are practitioners aware of the adult social care threshold and referral process?
Are appropriate, high-quality referrals, made to the adult safeguarding teams?
Are appropriate actions and interventions undertaken when adult social care referrals are rejected?
Are the risks to people on probation given sufficient priority at a strategic and practice level?
Are the plans for monitoring, assurance, and evaluation of adult safeguarding sufficient?

How well do practitioners support adult safeguarding needs of people on probation?

Does the pre-sentence information provided to the court sufficiently address adult safeguarding concerns?
Do assessment, planning and reviewing practices effectively identify, analyse and address risks to the wellbeing of people on probation?
Do practitioners take sufficient account of the risks to the individual when delivering interventions and services?
Do practitioners sufficiently engage with other organisations in relation to the adult safeguarding concerns of individuals on their caseload?

Does the training and supervision of probation practitioners support the delivery of high-quality adult safeguarding practice?

Are practitioners provided with the right guidance, support, and oversight to make effective adult safeguarding decisions?
Do practitioners understand the key risk factors such as drug overdose and self-harm, in relation to adult safeguarding?
Have practitioners had sufficient training to make appropriate decisions and to undertake effective adult safeguarding practice?
Are practitioners confident in responding effectively to adult safeguarding concerns?
Are practitioners confident in balancing the demands of both public protection and adult safeguarding?
Do practitioners have sufficient capacity to effectively fulfil their safeguarding responsibilities in partnership with the relevant agencies?

Are arrangements with statutory partners and other agencies established, maintained and used effectively to respond to adult safeguarding concerns?

Is the probation service represented on the local Safeguarding Adults Board?
How well does the probation service participate in strategic partnership initiatives relating to adult safeguarding?
Does the probation service contribute effectively to multi-agency arrangements (e.g. MARAC/adult safeguarding serious case reviews)?
Is information about adult safeguarding gathered and shared with all relevant agencies, including police, adult social care, and substance misuse services in a timely way at the appropriate points of sentence delivery?

Case sample

A bespoke methodology was developed with HM Inspectorate of Probation’s research team. This covered court reports, assessment, planning, sentence delivery, and reviewing. It focused on the potential safeguarding concerns in each case and how these were incorporated into sentence management. This included both risks to the person on probation and the risk of suicide and self-harm. The inspection also considered whether any safeguarding issues identified were linked to the risk of reoffending and the risk of serious harm.

Cases were inspected remotely in the first two fieldwork weeks of the inspection. The six inspected regions provided caseload data using the following criteria on cases that began between 01 May 2024 and 31 August 2024:

caseload data on cases marked as vulnerable in nDelius
a sample of 100 cases for inspection will be selected from the case data provided: 99 cases in total were inspected.

Fieldwork

We undertook the fieldwork in the following PDUs:

Suffolk, East of England region
Liverpool North, North West region
Swindon and Wiltshire, South West region
West Kent, Kent, Surrey and Sussex region
Hampshire North and East, South Central region
Coventry, West Midlands region

Our inspection of the cases for each PDU took place remotely between 12 May and 23 May 2025. In all sampled cases, we considered how safeguarding issues were addressed in the pre-sentence report; the management of the sentence; the quality of assessment; the role of the PP in adult safeguarding; how well information was shared between agencies; and the impact of all activity on the person on probation.

On-site fieldwork in the PDUs was undertaken between 02 June and 18 July 2025.

In each PDU we held the following meetings with management and staff groups:

senior lead for adult safeguarding in the region/the head of operations
senior leaders with responsibility for adult safeguarding (at PDU and regional level)
MAPPA coordinator/MAPPA SMB chair
PDU MARAC/offender personality disorder leads
health and justice coordinators
engaging people on probation lead
probation practitioners working in sentence management teams
probation practitioners working in court teams
senior probation officers working in sentence management teams
senior probation officers working court teams
local adult social care and substance misuse service managers.

National fieldwork week

This took place during the week of 28 July 2025 when we undertook a series of meetings with national leaders in HMPPS to review adult safeguarding strategy and performance.

User Voice

User Voice undertook a survey of people on probation in each PDU. In addition, they conducted a series of in-depth interviews with people on probation. They received 242 responses to the survey and held 26 interviews. A separate report containing an analysis of this information will also be published.

Expert reference group

An expert reference group contributed to this report by advising on strategic and operational issues associated with safeguarding in the criminal justice system. The group membership was:

Professor Michelle McManus, Manchester Metropolitan University
Professor Kieran McCarten, University of the West of England
Marie Martin, Care Quality Commission

Press release (Back to top)

“Systemic barriers” to safeguarding adults at risk of harm supervised by the probation service

Effective Practice guide (Back to top)

Safeguarding adults on probation

User Voice report (Back to top)

User Voice Safeguarding Vulnerable Adults report

(PDF, 895 KB)

Acknowledgements and footnotes (Back to top)

This inspection was led by David Miners, supported by a team of inspectors and operations, research, communications and corporate staff. The manager responsible for this inspection programme is Helen Davies. We would like to thank all those who participated in any way in this inspection. Without their help and cooperation, the inspection would not have been possible. Please note that throughout the report the names in the practice examples have been changed to protect the individual’s identity.

Office for National Statistics (2023). Drug-related deaths and suicide in offenders in the community, England and Wales. ↩︎
HMPPS. Death under supervision data. ↩︎
Ibid. ↩︎
Ibid. ↩︎
Slade, K, Justice, L, Martijn, F, and Baguley, T (2024). Deaths among adults under supervision of the England and Wales’ probation services: variation in individual and criminal justice-related factors by cause of death. Health & Justice, 12, Article 10 ↩︎
Ibid. ↩︎
West Mercia Data Linkage project. West Midlands Probation Service, NHS Herefordshire and Worcestershire ICB, NHS Shropshire, Telford and Wrekin ICB, NHS Midlands and Lancashire (CSU) and Worcestershire Public Health participated in this project, which undertook an analysis of emergency department attendances and non-elective admissions by people on probation from Herefordshire and Worcester Probation Delivery Unit, between April 2022 and March 2025. ↩︎
EQUIP is a central online resource for information and guidance related to probation work in England and Wales. ↩︎
Office for National Statistics (2023). Drug-related deaths and suicide in offenders in the community, England and Wales ↩︎
A safeguarding adult review takes place when an adult with care and support needs dies or experiences serious harm due to abuse or neglect. ↩︎
This test is used by statutory and non-statutory SAB partners to determine the threshold for intervention. Section 42 requires safeguarding enquiries where an adult has care and support needs, is experiencing or is at risk of abuse or neglect and is unable to protect themselves due to those needs. ↩︎

Cookies on HM Inspectorate of Probation

Table of contents

Safeguarding adults at risk of harm supervised by the Probation Service in England: a thematic inspection

Foreword (Back to top)

Contextual facts (Back to top)

Executive summary (Back to top)

Recommendations (Back to top)

1. Introduction (Back to top)

1.1. Why this thematic? (Back to top)

1.2. Background (Back to top)

1.3. Aims and objectives (Back to top)

1.4. Report outline (Back to top)

2. Policy, strategy and national leadership (Back to top)

2.1. Policy and strategy (Back to top)

2.2 Conclusions and implications (Back to top)

3. Partnership working and local leadership (Back to top)

3.1. Local leadership (Back to top)

3.2. Operational delivery (Back to top)

3.3. Engaging people on probation (Back to top)

3.4. Conclusions and implications (Back to top)

4. Safeguarding people on probation (Back to top)

4.1. Advice to the court (Back to top)

4.2. Assessment and planning (Back to top)

4.3. Sentence delivery (Back to top)

4.4. Probation Reset (Back to top)

4.5. Conclusions and implications (Back to top)

References (Back to top)

Annexe 1: Glossary (Back to top)

Annexe 2: Methodology (Back to top)

Press release (Back to top)

Effective Practice guide (Back to top)

User Voice report (Back to top)

Acknowledgements and footnotes (Back to top)