Barrie Forster: Prevention of Future Deaths Report
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Date of report: 05/11/2024
Ref: 2024-0603
Deceased name: Barrie Forster
Coroners name: Andrew Cox
Coroners Area: Cornwall and the Isles of Scilly
Category: Other related deaths
This report is being sent to: Ministry of Housing, Communities, and Local Government | Ministry of Justice
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1. [REDACTED] Secretary of State for Housing, Communities, and Local Government 2. [REDACTED] Secretary of State for Justice | |
| 1 | CORONER I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall and the Isles of Scilly. |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 3 | INVESTIGATION and INQUEST On 5/11/24, I concluded the inquest into the death of Barrie Forster. I recorded the cause of death as: 1a) Multi-organ failure; 1b) Acute Upper Gastro-Intestinal Haemorrhage in a Man with Ischaemic Heart Disease and on Treatment with Apixaban; Craniofacial Trauma Necessitating Surgical Repair (Operation 21/11/2020). I recorded a conclusion that Barrie was unlawfully killed. In the event proper assessments had been made of the risk the perpetrator posed to Barrie and/or of the suitability of Barrie’s address as somewhere for the perpetrator to live, it is more likely than not that the perpetrator would not have been permitted to live at Barrie’s address upon release from custody and the assault would not have occurred when it did. |
| 4 | CIRCUMSTANCES OF THE DEATH Barrie was assaulted on 20/11/20. The perpetrator, [REDACTED], had been released from custody two days earlier. [REDACTED] had recently had three spells in custody the last two sentences having been imposed after offences committed against his sister who had the protection of a Restraining Order. The risk [REDACTED] posed to Barrie had not been assessed properly or at all by the Probation Service particularly in light of a complaint of sexual assault by Barrie Forster against another family member and in the context of recent assaults by [REDACTED] against other members of the family. Additionally, no, or no adequate, assessment had been made by the Probation Service of the suitability of Barrie’s address as a place at which [REDACTED] could reside after his release from custody. After an earlier release from custody [REDACTED] had been found a bed in approved premises where he had stayed for six months. Thereafter, he had stayed in two B&Bs in another county before returning to Cornwall where he was homeless for a period, living in a tent at different locations. After his most recent custodial sentence, a formal application for a bed at approved premises had not been made but, informally, members of the Probation Service had been told one was not available. Discussions were ongoing with the Council’s homelessness team, but accommodation had not been secured. [REDACTED] had earlier convictions for arson. The Probation Service had thought [REDACTED] would be found a room at a Travelodge or similar. In the event, on the day of his release from custody, it was brought to the attention of the Probation Service that [REDACTED] intended to sleep on a sofa at his father’s address. The suitability of this accommodation was not considered. The risk [REDACTED] presented to Barrie was not assessed. Had this been done, I found it was more likely that not [REDACTED] would not have been permitted to live with his father and the assault would not have occurred when it did. |
| 5 | CORONER’S CONCERNS During the course of these inquests, the evidence has revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. There is a lack of accommodation available to the Probation Service in which prisoners released from custody may properly be placed. This includes both Approved Premises (which I understand to be the responsibility of the MoJ) and more generally through the local authority to avoid homelessness. As a consequence, some prisoners are released and become effectively homeless (with increased difficulties in supervision) while others are accommodated at unsuitable premises, as happened in this instance. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 5 January 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED] – (sister) Probation Service I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. |
| 9 | [DATE] 5.11.24 [SIGNED BY CORONER] |