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22-Year-Old Joe Pooley: Vulnerable, Failed By The Authorities And Murdered

Bereaved mother welcomes the publication of a review by Suffolk Safeguarding Partnership following the conclusion of the inquest into the death of 22-year-old

Suffolk Safeguarding Partnership has published a Safeguarding Adults Review (link below), and an addendum, which identifies failings on the part of the authorities involved with Joe.

The publication of the review follows the conclusion of the inquest into Joe’s death on 29 July 2022. Area Coroner Jacqueline Devonish, sitting at Suffolk Coroner’s Court, found that Joe was unlawfully killed and that one of those responsible for the killing – who had a history of violent offending – should have been recalled to prison before the killing, stating, “the failure to recall Luke Greenland [to prison] caused or contributed more than minimally, negligibly or trivially to Joe’s death”.

The coroner also highlighted a series of failings by various authorities involved with Joe, including Suffolk County Council and Suffolk Police.

Sam Nicholls, Joe’s mother, had warned since 2015 that Joe would be murdered, contacting Suffolk County Council, local councillors and MPs including David Ellesmere and Ben Gummer.

Joe Pooley was born on 20 June 1996. A loving son, brother and uncle, Joe was murdered, aged just 22, on 7 August 2018, by people he believed were his friends. Following the murder, Luke Greenland changed his name to Sebastian Smith and moved to Scotland to evade arrest and criminal liability. On 19 March 2021 Sebastian Smith, Sean Palmer and Rebecca West-Davidson were finally convicted of murdering Joe.

Suffolk County Council (SCC) was responsible for Joe’s care and welfare for almost the whole of his tragically short life. By 2003, Joe had been placed into foster care. From the age of nine to 16, Joe attended a special needs school. It was recognised that Joe was vulnerable to exploitation and abuse from his peers from an early age. SCC even maintained control of Joe’s finances through an appointeeship throughout his adulthood, such was his level of vulnerability. Although it was believed that Joe had autism and/or ADHD and/or a learning disability – and despite SCC’s obligations to Joe as a Looked After Child, then Care Leaver and then a Vulnerable Adult – Joe never received a formal diagnosis.

Although the need to safeguard Joe was obvious, he was nevertheless subjected to exploitation, abuse and intimidation throughout his life. Joe’s mother, Ms Nicholls, voiced her fears about Joe’s safety and welfare and in particular her fear that he would be killed. Joe also made repeated reports to SCC of his fears that he would be attacked or that he had been attacked, his possessions were regularly stolen or ‘lost’ and he made repeated requests for money and food, because he had none. SCC then allowed Joe’s Employment and Support Allowance to lapse, leaving him to live off his savings from his Personal Independence Payments, which soon ran out, leaving Joe with even less than he had before. By the time of the murder, Joe’s Employment and Support Allowance had not been reinstated.

Joe moved frequently between supposedly permanent and emergency accommodation and even had periods of street homelessness. Although Ipswich Borough Council recognised that Joe did not have capacity to manage a tenancy, SCC maintained for a number of years that he did, leaving him in limbo. By May 2018, in the weeks leading up to the murder, it had been finally recognised by Suffolk County Council that what Joe required was permanent supported accommodation, with staff on-site and CCTV, to assist him to avoid abusive and harmful peer associations. However, by the time of the murder, Joe had not yet moved into supported accommodation and was still living at the Kingsley Hotel, which was unsuited to his needs and enabled contact between Joe and those who killed him on the night of the murder.

In October 2017, Luke Greenland convicted of an offence in which he had assaulted a police officer who was trying to arrest him, by hitting him on the head repeatedly with a bottle and biting him. At the time of this conviction, Luke Greenland was already in custody serving a sentence for an offence of domestic abuse against a male partner.

Luke Greenland was released on 23 May 2018 on Home Detention Curfew (HDC), without any full pre-release risk assessment having been undertaken by Probation. Furthermore, no safeguarding checks were recorded for the HDC address to which Luke Greenland was due to move. He was permitted to move in with a woman, who it later transpired he was in a relationship with, despite his history of domestic abuse against male and female partners.

Luke Greenland was nevertheless known to pose a high risk of serious harm to the public, including male associates. It was confirmed in evidence that this meant the risk could happen at anytime and its impact was likely to be serious, meaning serious injury or death.

The post-release assessment by Probation includes reference to previous violent offences including a conviction for GBH in 2008 when Luke Greenland had stabbed someone in the chest with a 10 inch bread knife and then said, “If I have killed someone I need to take out the witnesses as well”. However, the assessment was insufficiently detailed in its analysis of the risk posed by Luke Greenland. Further, despite Luke Greenland’s licence including conditions for drug testing and engagement with substance misuse services, his probation officer enforced neither.

By 20 June 2018, the Electronic Monitoring Service (EMS) responsible for monitoring Luke Greenland had been informed that he had cut off his tag and left the address. A breach report was sent to the Public Protection Casework Section that same day, which should have been actioned within 24 hours, but it was not.

On 23 June 2018, Joe threw a stone at the window of a house. He was pursued by one of the occupants. The police attended. One of the occupants told the police that Joe had apologised and said that he had been paid to do it by Luke Greenland, a convicted criminal monitored by Electronic Monitoring Service (EMS), whom Joe had met while struggling in unsuited accommodation. Joe then told the police in an interview that he had been told to do it because it would “help Luke out” and that he did not want to do it but he was told that he would “feel the consequences” and he “needed the money”, so he did it. Despite the clear exploitation and coercion involved, the police failed to make a referral through the National Referral Mechanism, a framework for identifying and referring potential victims of modern slavery, and failed to carry out any checks on Luke Greenland. The police did, however, make a safeguarding referral to SCC, but failed to mention Luke Greenland’s name. The coroner found that Luke Greenland’s name ought to have been shared, which was accepted by the police in evidence. Had further investigations regarding Luke Greenland’s criminal history been undertaken, this would have disclosed his history of violent offending.

SCC also received a safeguarding referral from a Liaison & Diversion practitioner, who saw Joe while he was in custody. Despite having received two referrals about Joe being coerced into the commission of a criminal offence, and despite multiple safeguarding referrals in relation to Joe on other occasions being on record with SCC, no safeguarding enquiry under section 42 of the Care Act 2014 was commenced, as it ought to have been. Instead, Joe’s allocated social worker focused on his housing needs and finances, but still, those issues were not resolved by the time of the murder.

Luke Greenland came to the attention of the police again on 28 June 2018 when it was alleged that he had been in a café with knuckledusters, fired a taser and made a threat to kill a member of the public. No investigations were ever carried out with the café and no action was ever taken against Luke Greenland.

On 6 July 2018 the mother of the victim of the incident on 23 June 2018 called the police for an update on what was being done. She then called again on the 12 July saying she has received Facebook messages with an apology for Joe saying who did it. On the 13 July an officer visited her and put the intelligence on the system but the police failed to take further action against Luke Greenland.

On 20 June 2018, the Electronic Monitoring Service (EMS) sent a breach report to PPCS relating to Mr Greenland. He had removed his tag and left his residence the previous day. At this time PPCS was experiencing an increase in workload due to an increase in the use of the HDC scheme. There was a backlog of around 2 months for HDC recalls. Having been contacted on 26 and 27 July 2018 by probation, a caseworker identified Luke Greenland’s case as requiring immediate action. She prepared a draft Licence Revocation Order and emailed it to a manager, to approve. The manager approved, signed and returned the revocation but apparently, it was not seen by the caseworker. The caseworker later emailed saying that she was going to log off and would send the order out on Monday. However, she went on sick leave for three months and believed that someone had cleared her inbox. Approximately a week before Joe was killed, Luke Greenland took him to the woods and threatened him by telling him to dig his own grave.

On 7 August 2018, Luke Greenland and Sean Palmer walked with Joe along the towpath to the River Gipping and at a point near the bridge immersed him in the river by holding his head down and drowning him. Luke Greenland was sentenced to serve a minimum term of 21 years before he can be considered eligible for parole, Sean Palmer for 18 years and Becki West-Davidson for 17 years for murdering Joe.

A Safeguarding Adults Review considered the care provided to Joe throughout his life and made a number of findings and recommendations for improvements. SCC stated in evidence that they accepted the findings of the review in full.

The following are some of the findings the Area Coroner made as a result:

  • a. By the age of 15 Joe was clearly showing significant psychological and emotional distress which required therapeutic intervention. Had this been provided, it might have prevented Joe’s needs from escalating and helped to stabilise him.
  • b. Regarding the assessment of Joe’s suspected ADHD/Autism, the professional network failed to work together to proactively ensure that Joe’s needs were properly assessed. By the time of his death, he had been waiting 6 years for an assessment.
  • c. Cohesive multi-disciplinary planning should have taken place to ensure that a safeguarding plan was in place during Joe’s multiple exclusions from education as an escalation of risk was predictable as he approached adulthood. This should have translated into a post-18 safeguarding plan.
  • d. Joe was not allocated a social worker on a long-term basis until May 2017. This was not appropriate for someone with Joe’s complex needs and unstable situation and impeded preventative work to stop risks from escalating.
  • e. The concept of executive capacity was not well understood, leading to a lack of empathy for Joe’s situation.
  • f. A stalemate developed between IBC and SCC regarding his accommodation needs that was not resolved until a meeting in June 2018. This meeting should have been arranged much earlier given the long period of instability Joe had experienced.
  • h. Record keeping by statutory agencies was poor and serious safeguarding concerns were not identified or progressed as safeguarding enquiries.
  • k. No strategy meeting in respect of financial exploitation was convened.
  • l. A s42 enquiry should have been initiated as a result of what was known following the incident on 23 June 2018. The incident should also have triggered a referral through the National Referral Mechanism under the Modern Slavery Act 2015.

Sam Nicholls, Joe’s mother, said: “As someone who works within the care system I expected that the state authorities involved in this inquest would have welcomed the opportunity to learn from their mistakes and prevent more deaths occurring. Instead, I have been shocked to listen to the evidence when state witnesses have denied, obfuscated, and even stood by their totally inadequate actions and failures. Most disturbing of all, I had to listen to witnesses state, without any contrition or regret, that they would not do things differently in the future, even where their acts or omissions have already been deemed unacceptable or inadequate in other investigations and where they have simultaneously claimed that they accept those findings and recommendations.

“Joe ought to have been protected. That much is obvious to me and my family. My story is like so many others who battle week after week and year after year on behalf of vulnerable loved ones with special needs. I sent email upon email pleading to try to get Joe the most basic of protection he so badly needed, to which he was entitled and was actively seeking himself. I recognised the real and increasing risk to Joe’s life and warned the authorities. I did not know as much as the authorities and professionals involved in Joe’s life but I still foresaw that he would be killed: the police knew that my vulnerable son was being coerced and bullied by the man who would murder him weeks later, Joe told the police he needed help and needed to get away from the people who were exploiting and abusing him, the probation service knew Joe’s murderer was a high-risk violent offender recently released from prison on a curfew but when his murderer cut his tag off the PPCS failed to recall him and left him free to murder my son.”

Sarah Flanagan, Associate at Hodge Jones & Allen, stated: “This case highlights the consistent failures that the most vulnerable in our society are forced to endure. The case also highlights the fact that state organisations must fulfil their responsibilities towards all service users. Joe’s death could have been prevented by so many people in vital roles. The Area Coroner’s findings highlight the mistakes made across multiple institutions and we hope that it serves as a wake-up call for individuals involved in the care of vulnerable people in the hope that other needless, tragic deaths can be prevented.”

The full review by The Suffolk Safeguarding Partnership (Suffolk County Council, Suffolk Police, Suffolk Healthcare services) can be read here.