19 September 2019

Before HM Coroner Andrew Harris
Southwark Coroner’s Court
2- 19 September 2019

An inquest into the death of Alex Malcolm, who was 5 years old when he was killed by his mother’s ex-partner, has concluded finding his death was an ‘unlawful killing’. In a detailed narrative conclusion, the jury identified a series of failures by the National Probation Service (NPS), as well as system defects following major changes to probation services under ‘Transforming Rehabilitation’, contributed to Alex’s death.

Alex was brutally beaten in a park in Catford, South East London and died two days later on 22 November 2016. The then boyfriend of Alex’s mother, Marvyn Iheanacho, was later charged with his murder. Iheanacho had been under the supervision of the NPS after being released from prison on licence on 31 May 2016, where he had been serving a sentence for an assault on a former girlfriend. It was only after Alex was murdered that his mother Liliya Breha became aware of Iheanacho’s history of violence, licence conditions and high risk to partners and children.

After a twelve day hearing, the inquest jury gave a narrative conclusion which found that numerous system defects more than minimally contributed to Alex’s death. These included the major changes in probation services following Chris Grayling’s controversial ‘Transforming Rehabilitation’ policy in 2014. These changes led to higher workloads within the NPS which the jury said, “may have affected the effectiveness of the system to deal with high risk offenders”.

The jury further found the NPS at the time was understaffed; there was fragmented information held by different agencies which did not appear to enable effective information sharing; and significant shortages of places in Approved Premises. The jury also noted that the 2017 inspection report on the prison, HMP Wormwood Scrubs, found it was not managing high risk offenders adequately at the time, joint working with the NPS was poor, and there was a shortage of Offender Supervisors.

During the course of the inquest the NPS admitted that the perpetrator Iheanacho was wrongly classified under MAPPA (Multi Agency Public Protection Arrangements) before his release from prison. The jury found that this failure more than minimally contributed to Alex’s death. They noted that had the perpetrator been correctly categorised it was more likely that Liliya would have been informed of his history and risk, and that information would have been shared between other agencies, including the prison who had her details, and Children’s Services who would have been able to take steps to safeguard Alex.

The jury further found that the following key issues ‘more than minimally or trivially probably’ contributed to Alex’s death:

  • A serious of individual failures by NPS probation officers [detailed below], coupled with inadequate support and supervision;
  • The failure of relevant agencies to identify, request and share relevant information;
  • The NPS failure to adequately challenge or take action to recall the perpetrator at an appropriate stage in response to his failures to comply with licence conditions.

The inquest heard evidence that the probation officer supervising the perpetrator prior to Alex’s death had qualified that year but was immediately allocated Iheanacho’s and other high-risk cases with minimal supervision. This was despite her having limited experience of managing perpetrators of domestic violence. The jury found that the allocation of this case to this newly qualified officer without adequate supervision contributed to Alex’s death.

The probation officer was given sole responsibility over Iheanacho’s case 26 days prior to his release from prison, following a brief informal handover from her colleague. She was made aware of his licence conditions, which included standard conditions such as being of good behaviour and cooperating with his probation officer. He was also subject to various bespoke conditions including that he was not to have unsupervised contact with children under the age of 16 without the prior approval of his supervising officer and social services, and he was required to notify the NPS of developing relationships. The purpose of these conditions is to protect the public from harm, and also to manage and reduce risk.

On release from prison Iheanacho was subject to MAPPA, which is used to manage the risk posed by violent and/or sexual offenders. He was assessed as presenting a high risk of serious harm to partners (current and future) and a medium risk to members of the public, staff and children. Whilst the probation officer was aware of Iheanacho’s previous offences she did not look into or request further information on the details, due to the high workload. As such she was not fully aware of multiple previous incidents involving emotional and physical damage caused to children.

The officer told the inquest she found Iheanacho very challenging to manage, and said she was inexperienced and afraid of him and as such was more ready to accept what he said. The jury narrative found that the perpetrator was a manipulative and high risk offender who intimidated the officer, making it more difficult to manage the risk adequately.

On multiple occasions the probation officer was made aware that Liliya was Iheanacho’s girlfriend, but she did not investigate further or make a clear record of her contact details (although she did retain her mobile phone number). In June 2016, Iheanacho informed the officer that his partner had a 3 year old child called ‘Alex Breha’. The jury found the failure to identify this relationship and share information with relevant agencies contributed to his death. In June the probation officer also became aware that Iheanacho was no longer at his registered address, but he would not confirm where he was living. Failing to give information to probation officers can be grounds for recall to prison, but the officer did not pursue this.

The inquest heard that had relevant referrals been made, multi-agency meetings would likely have been initiated with police, children’s services and others engaging in processes to protect those at risk such as Liliya and Alex. A key consideration would have been disclosure of his offending history to his partner through ‘Clare’s Law’. This law allows people access to information about previous offences of their partners, either by requesting it or through proactive disclosure by agencies such as police or probation officers. However, Liliya was never contacted or given any information about Iheanacho’s past until after Alex’s death.

Liliya Breha, Alex’s mother, said: “I would really like to say that Alex didn’t have to die for system failures to be identified and for people to start to do their jobs properly. Alex was my heart beat and I miss him so much. He should be here right now going to school, playing with his friends. Someone took this away from him for no reason and the systems meant to protect us did not. I now hope changes will be made. I would also like to thank everyone who has been supporting and helping me during this horrible time.”

Sarah Kellas, Birnberg Peirce Ltd solicitors, who represented the family said: “This is a very very sad case; and another tragic and utterly preventable death which has followed Chris Grayling’s ‘Transforming Rehabilitation’ disaster and which has left Liliya shattered. The evidence from the inquest has highlighted the lack of understanding and training, and care taken by authorities responsible for the protection of the public to safeguard women and children against perpetrators of domestic violence.”

Selen Cavcav, Senior Caseworker at INQUEST, said: The critical conclusion of the jury once again exposes the consequences of the rushed and ill informed ‘transformation’ of probation services. Multiple opportunities to protect Liliya and Alex were missed, as their safety was put in the hands of inexperienced individuals working in overstretched services. This inquest has performed a vital function in publicly scrutinising these systemic failings, which must urgently be addressed at a national level.”

Harriet Wistrich, Director of Centre for Women’s Justice, said: “This case highlights just how important it is for all those working in the criminal justice system, from police through to probation, to have a proper understanding of the dynamics and risks of domestic violence and coercive and controlling behaviour.  With the necessary insight and proper resourcing this tragic death like many other domestic homicides could have been averted.”


For further information, interview requests and to note your interest, please contact INQUEST Communications Team: 020 7263 1111 or email Lucy.

The family is represented by INQUEST Lawyers Group members Sarah Kellas of Birnberg Peirce Ltd Solicitors and Rajeev Thacker of Garden Court Chambers.  

The other interested persons represented are the National Probation Service/Ministry of Justice, the Metropolitan Police, and two probation officers who are separately represented.

Other recent deaths involving under NPS supervision include:

  • Quyen Ngoc Nguyen, 28, died in August 2017 following sexual and physical violence by two men who had been released from prison on licence and were under the supervision of the National Probation Service. The inquest exposed a ‘dysfunctional’ system for public protection. Media release.
  • Lisa Skidmore, 37, was killed by a man under National Probation Service supervision on 24 November 2016. The inquest identified a failure of the probation services and police to respond to a clear escalation of risk, and highlighted failures in communication between agencies involved. Media release.
  • Connor Marshall, 18, died in March 2015, after being attacked by a man on probation who had breached the terms of his license and missed numerous meetings. See media coverage.
  • Lukasz Slaboszewski, 31, Kevin Lee, 48, and John Chapman, 56, were killed in March 2013 by a woman who was serving a community order and was under the supervision of probation services and known to have the “potential to cause serious harm”. See media coverage.

‘Transforming Rehabilitation’: was a programme of work intended to reform the supervision of offenders in England and Wales. It was launched by Chris Grayling, then justice minister, in a white paper in May 2013. A deeply critical review of progress of the programme, published by the National Audit Office in March 2019, highlighted the admission of the Ministry of Justice that the reforms had failed to meet targets.

The reforms split the delivery of probation services in two with the National Probation Service (NPS), managing high-risk offenders, and the predominantly private Community Rehabilitation Companies managing low or medium-risk offenders. The Ministry of Justice reported that “The NPS caseload increased by 10% between September 2014 and June 2017, creating considerable workforce challenges” (p.45, House of Commons Justice Committee, 22 June 2018, Transforming Rehabilitation: Ninth Report of Session 2017–19. Available here.)

Domestic Violence Homicides: data published on 13 September 2019 from police forces in England and Wales revealed that 173 people were killed in domestic violence-related homicides last year, a five year high. Also see Office for National Statistics 2018 data on domestic violence homicides.