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

Published:

A thematic inspection from HM Inspectorate of Probation has called for a renewed focus on embedding safeguarding at the core of probation practice. This thematic inspection explored the effectiveness of current policies, the quality of practice, and the outcomes for adults on probation identified as at risk, particularly in relation to suicide and self-harm.

While the primary focus of probation 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. Public protection is inevitably compromised when these people cannot access the services they need.

In a statement, Martin Jones, Chief Inspector of Probation said: “I am encouraged by many examples of innovation and dedication across probation regions, with emerging policy frameworks to address the complex vulnerabilities of the probation caseload. However, the key challenge remains: ensuring these ambitions are translated into effective frontline delivery.”

Inspectors found assessment frameworks were not fully capturing the nuanced vulnerabilities of people on probation, particularly men. Inspectors also called for a review of the term ‘vulnerability’ and how it is assessed by the Service, and highlighted the need for the risks faced by people on probation to be integrated into the new probation assessment framework currently under development.

The report highlights some positive developments with the introduction of health and justice coordinators in the regions. There have been constructive improvements to health and social care, including hepatitis C screening and the piloting of GP registration on probation premises.

The death under supervision review process which was introduced in 2022 has the potential to inform and improve service delivery. However, inspectors found practitioners apprehensive about the purpose of the process, perceiving it to focus on individual failings rather than systemic improvement.

Mr Jones continued, “These systemic barriers to safeguarding adults in the Probation Service must be addressed. National leadership need to support regions in fostering a culture where safeguarding is not viewed in isolation, but as integral to public protection.”

This thematic inspection makes eight recommendations to HM Prison and Probation Service, including to develop a strategy to ensure the death under supervision process focuses on systemic learning and development and to ensure that risks to people on probation are integrated into the assessment and planning framework for people on probation.

Key findings:

Policy, strategy, and national leadership

  • Findings reveal that the integration of safeguarding, health, and wellbeing into strategic frameworks has been implemented unevenly.
  • Some positive initiatives were found, such as hepatitis C testing on probation premises and there are plans to pilot more health-related activities across the Service, such as GP registration in probation offices.
  • Suicide prevention has emerged as a strategic priority, with regional discussions and training initiatives gaining traction. Probation practitioners require more robust support and training to manage the complex risks associated with suicide and self-harm.
  • The implementation of the national death under supervision policy has raised concerns. Practitioners expressed apprehension about the review process, perceiving it as focused on individual failings rather than systemic improvement.

Partnership working and local leadership

  • Referral pathways into adult social care were consistently understood and applied. The EQUIP framework offers some guidance, but referrals from the Probation Service are frequently rejected, and probation practitioners are unclear about how to escalate these cases.
  • The Probation Service relies on Multi-Agency Public Protection (MAPPA) arrangements to secure agency involvement, which is not always appropriate and underscores the need for alternative mechanisms.
  • Access to mental health services is variable. While some PDUs have developed innovative pathways, referral criteria and long waiting lists can still prevent access to services.

Safeguarding people on probation

  • Assessment and planning were inconsistent, and safeguarding risks were often overlooked or insufficiently addressed.
  • The assessment people on probation was inconsistent with significant variation in how key safeguarding registers were used and reviewed.     
  • Planning for safeguarding is an area for improvement. Inspectors found limited evidence of probation practitioners collaborating with people on probation, and safety plans were under used. Sentence delivery was significantly stronger, particularly for women and younger cohorts.
  • Probation Reset has significant safeguarding implications. The Probation Service must ensure safeguarding considerations are central when preparing to end contact.

ENDS

Notes to editor

  1. The report is available at justiceinspectorates.gov.uk/hmiprobation on 13 November 2025 at 00:01.
  2. HM Inspectorate of Probation is the independent inspector of youth justice and probation services across England and Wales.      
  3. HM Inspectorate of Probation inspected 99 cases across six regions within the Probation Service. On-site fieldwork was undertaken between 02 June and 18 July 2025.
  4. For media enquiries, please contact Louise Cordell, Head of Communications 07523 805224 / media@hmiprobation.gov.uk