The Systems that failed Zara

Following Zara Aleena's murder, a number of independent investigations examined how a known offender came to be free despite repeated warning signs and opportunities for intervention.  These included an Independent Serious Further Offence Review by HM Inspectorate of Probation, internal investigations by the agencies involved, and a two-year inquest. Together, they identified failures across the prison, probation and policing systems. 

The offender who killed Zara had a long history of offending and violence. Yet important information about his behaviour, risk and offending history was not effectively shared between the agencies responsible for managing him.HM Inspectorate of Probation found that opportunities to reassess and escalate the level of risk he posed were missed. Information that should have informed decisions about his management was not brought together, and pre-release planning was inadequate. The Inspectorate also identified missed opportunities to recall him to prison following breaches of his license conditions. The inquest heard evidence of failures in risk assessment, information sharing, supervision, communication and decision-making. It also examined failures in attempts to locate and arrest the offender after recall procedures had begun. The jury concluded: “Zara’s death was contributed to by the failure of multiple state agencies to act in accordance to policies and procedures – to share intelligence, accurately assess risk of serious harm, act and plan in response to the risk in a sufficient, timely and coordinated way. "The jury also found there had been:

• Significant failures to appropriately assess risk.
• Failures to share intelligence and information.
• Inadequate decision-making, supervision and training.
• Failures to define, understand and execute responsibilities across multiple agencies.
• Failures to act in a sufficiently timely and coordinated way.

The Coroner subsequently issued Prevention of Future Deaths reports to multiple organisations, identifying concerns about risk assessment, information sharing, staffing pressures, professional curiosity and inter-agency communication. The independent findings were clear. The failures were not confined to a single decision, individual or organisation. They occurred at multiple points across the criminal justice system before Zara's murder. 

The next section explores why these failures matter, and what they tell us about the wider culture in which violence against women and girls continues to occur.