Prevention of Future Deaths Report: Terance Radford

Wednesday 20th March 2024 Westminster Hall

16:29

[Lee Anderson (Ashfield) (Reform UK)]

I beg to move,

That this House has considered lessons learned from the Terance Radford Prevention of Future Deaths Report.

It is a pleasure to serve under your chairmanship, Dame Maria. Today, I want to tell the story of two men. One of them, Terance Radford, was born on 11 August 1931 and died on 19 April 2019, aged 87. Terance was an upstanding citizen, a gentleman who made an outstanding contribution to his country, well-loved and well-respected throughout the community. The other man is a gentleman called Gavin Collins. He was a thief—that is the best way that I can explain it.

I will talk briefly about Terance—or Terry, as his family call him—and what kind of man he was. It is important to say that we are talking about not just a name, but a person, whose lovely family are in the Public Gallery on his behalf. Terry was an amazing dad and grandad, and all his family loved and respected him. They were, and still are, in awe of everything that he achieved in his life. He was born in Mansfield Woodhouse, which is the next constituency. The MP there, by the way, is Ben Bradley, who is very supportive of the case.

[Dame Maria Miller (in the Chair)]

Order. The hon. Gentleman means the hon. Member for Mansfield.

[Lee Anderson]

Sorry—the MP there is the hon. Member for Mansfield (Ben Bradley). I apologise, Dame Maria.

Terry was born in Mansfield Woodhouse and lived there all his life. He was proud of his village, and he cared deeply about his community. He went to the national school and had a traditional upbringing. His dad was a miner and his mum was a housewife who created a loving home for Terry and his three sisters. He excelled in his studies, and when he left school he went to work for the Metal Box Company in Mansfield, which was a major local employer and a place where my mother and many of my friends worked, actually. To further his education, Terry went to a local college to study engineering at night school, and he excelled. He went on to do his national service, in which he served in the Royal Navy as a petty officer working on minesweepers. He was an incredibly brave and dedicated man. When Terry had done his service, he went to work for Rolls-Royce in the aero-design team—he worked proudly on the RB211 fan blades. His job regularly took him to the United States for several weeks at a time to work for their sister company, and he always enjoyed coming back and sharing his knowledge with younger people.

When he was in his 50s, Terry decided to become a teacher; he worked at Valley Comprehensive School in Worksop, teaching woodwork and metalwork until he retired. Despite always having a demanding job, that was not enough for Terry. He always tried to serve his community in the best way that he could. He was a local councillor for many years and also took the post of head governor at several local schools in the Mansfield area. He was also a justice of the peace—a job that he enjoyed from 1971 to 1985.

Everyone in the community valued Terry for his honesty and integrity. He would always take time to help people. He was what we would probably call a salt-of-the-earth type of gentleman. He loved life. He was highly intelligent, a great conversationalist and great fun to be with. Everyone in his family loved to spend time with him. Terry was extremely fit for his age—he was 87 years old when he died. He used to go to the gym and use all the apparatus there, and he would go swimming three times a week, but his favourite time was time spent with family and friends, and especially with young people. He liked to spend time with his grandchildren and their friends. He was the family rock, the hub, the person his family would go to if they needed advice or comfort. That is a brief description of the type of chap that Terry was.

I will now talk about Gavin Collins. On 9 November 2017, Gavin was in court being sentenced to five months for an offence that he committed in May 2017. He had spent time on remand, which meant he was released the following day. He was re-arrested for offences including burglary and theft, all committed in December 2017. On 11 July 2018, Gavin Collins was sentenced to three years for burglary and theft from a dwelling. That is the sentence he was released early from.

On 4 April 2019, Collins’s paperwork was sent to Governor Archer at His Majesty’s Prison Ranby, who granted Collins early release for 18 April 2019; it was agreed that Gavin would go home on a tag. At that time, Collins was in segregation away from all the other prisoners because he had set fire to his cell twice and injured a prison staff member with a plastic knife. Collins had been placed on report. On 13 April 2019, the police informed the prison that they had decided not to pursue a criminal investigation as it was a matter that could be dealt with by the prison directly; that is a failure there. There are statements that Governors Archer, Cope and Fretwell had conversations on 15 April 2019 regarding Collins’s early release date. They were looking at a release date of 18 April due to the upcoming bank holiday—Friday 19 April was Good Friday. Collins was due to be released anyway on 29 April, but the investigation of him setting fire to the cell would have gone beyond that. The very earliest date for his release should have been 29 April, and that had always been scheduled.

On 16 April 2019, Collins woke up other prisoners in the night shouting that he was dying. He was medically checked over and found to be medically fit. Later that day, he was lying down on the ground in the exercise yard. He claimed to have been poisoned by methadone. The doctor was made aware of his behaviour. On 18 April, Collins was released in the early morning from HMP Ranby. A family friend collected him and said that he did not look right; he was talking funny and his behaviour was strange, as though he had been on drugs. The friend took him home and told family members how concerned he was for Collins. That was when the trail of havoc started.

On 19 April 2019, Collins forced his way into several people’s homes and stole three cars. He crashed the first two cars and then forced his way into a woman’s home by smashing the back door. Collins then used blood from his injuries to daub crucifixes on the heads of the women and her children, while talking about God and making threats to kill them. He then stole the woman’s car, which he used to drive into Mr Radford. Before he got out, he shouted, “I’ve killed him, I’ve killed the devil.”

Mr Radford had just gone out for his morning walk and was waiting near a bus stop, minding his own business. He died at the scene. Collins was later jailed for 21 years for manslaughter on the grounds of diminished responsibility, but Terry’s death need not have happened. Terry might still be here today had it not been for the failures of HMP Ranby and the three governors who made the wrong decision to release Collins, which ultimately led to the death of Terry Radford.

Terry’s family are sat in the Public Gallery today, and they think it is unacceptable. I think that is putting it mildly; it is actually criminal. They are unable to find out the outcome of the disciplinary proceedings of the prison governors concerned; had the proceedings taken place in a criminal court, they probably would have known by now. They attended the inquest every single day and found out the names of the people responsible for letting Collins out of prison. They saw the faces of the governors and watched them as they told untruths throughout the process, but the coroner knew the truth and got to the bottom of it. It is all now in the public domain and accessible to everyone, but the family are still not allowed to know what happened to the people who let Collins out of prison. That is wrong.

Terry’s family think that, as usual, the wrongdoers are protected and innocent people are left with no closure. They are doing their very best to move on, but they cannot move on because they want to know what has happened to the people who were ultimately responsible for the release of Gavin Collins, and then for their father’s—Terry’s—death. They think, and I agree with them, that the governors should have faced a criminal court for their actions, not just disciplinary proceedings. They do not understand why no one within the justice system wanted to take this further.

How could the governors get away with taking the law into their own hands by releasing the prisoner when they had no authority to do so? Why was it not investigated by Nottinghamshire police? The family know that the police went to HMP Ranby on the day of the incident to retrieve records. If the police had investigated thoroughly, they would have known what had happened. If the coroner could work out what had happened, then why could the police not do so? Should Nottinghamshire police have investigated this failing? I think they probably should have. In the prevention of future deaths report, the coroner’s answer to the question, “Was Mr Radford’s death avoidable?” was, “Yes.” Had Collins remained in prison, Mr Radford might have been here today.

There are many failings in the whole investigation, and many similarities, sadly, with the stabbings in Nottingham city last year. The family feel that no lessons have been learned. They want to know what actions have been taken against the individuals responsible, and whether any of them have been dismissed, downgraded or transferred from the Prison Service. The fact that they are not allowed to know makes them feel as if there has been a cover-up. Their wish is that none of these people are still working within the Prison Service, as that would be an absolute travesty.

I want to ask the Minister to look at the family here in the Public Gallery. This family, who lost Terry. We have two of his sons here; they have lost their dad—their loving father. They have come here today for justice. They want closure. I want him to look at them in the eyes when he rises to speak and to tell them what happened to those governors.

16:42

[Jim Shannon (Strangford) (DUP)]

I thank the hon. Member for Ashfield (Lee Anderson) for setting the scene so well, with the compassion and understanding that we expect of him and he has delivered on many occasions. Our sympathies are clearly with the family who are here seeking justice and understanding of what took place. The hon. Member has outlined the case very well, and I just want to make a few comments. It will not take very long, Dame Maria, but I think it is worth putting them on record because of the implications of the case.

I am pleased to see the Minister and the shadow Minister, the hon. Member for Brentford and Isleworth (Ruth Cadbury), here. We seek an understanding of what happened, how it happened and why it will not happen again. That is what I want to speak about.

When I read the details of the case, I was sickened and shocked. My thoughts immediately went to the family of, as the hon. Member described him, a spritely old gentleman, who had holidays planned and was enjoying a full life when it was taken from him by someone who had demonstrated that he had absolutely no regard for human life. To see this early release under curfew has undoubtedly shown, and sown concern about, a major flaw in the process.

The Minister is a compassionate man, who understands the issues. In his response, he will try to answer the questions we all have, and his response to the coroners’ report and recommendations is clear. The family of that gentleman and others in this place have asked how this was allowed to happen in the first place. How could a man who could not be kept under control in prison have been expected to abide by curfew obligations once released? The hon. Member for Ashfield clearly outlined the attitude of the man in prison, what he did, his threats to staff and his destruction of property. The ordinary person would say that he could not understand why this man was ever released, and yet because legislation or guidance did not directly say this, unfortunately, Terance Radford died.

To me, this is an indication of how decisions are made looking at the letter and not the spirit of the law. This was not about justice, compassion and understanding for family. No reasonable person could have determined that the spirit of this curfew option was for people such as this—I do not normally use this word—thug who had set fires and attacked prison guards in custody. Yet there is such a fear of impinging on the human rights of the prisoner that it must be black and white that this is only an option for those for whom it is safe. I firmly believe that we must come away from this fear and instil in our decision makers—in the courts of the land and in the authorities who make decisions—the confidence that judgment can and should be used, and that they will be supported in such decisions.

The lesson of Terance Radford is, I believe, a shame on society. It was a shame and disgrace that Gavin Collins could be released under the scheme. Here today we must ensure that this slavish adherence to the letter of a law, or omission of expressly stated reasoning, is never—and never can be—sound reason for releasing dangerous people on to our streets until we absolutely have no choice to do otherwise. We must have confidence in the law of the land and in the justice that we seek, support and wish for. This lesson is a hard one. It has been hard for the hon. Member for Ashfield to tell his personal story in this room today. It is harder still for Terance’s family, who grieve his loss and the grief of a society who understand how badly we have failed Terance, and them.

16:47

[Ruth Cadbury (Brentford and Isleworth) (Lab)]

It is a pleasure to serve under your chairmanship for what I believe is the first time, Dame Maria. I thank the hon. Member for Ashfield (Lee Anderson) for obtaining this important debate today, and for the humanity he brought to his speech. My thoughts are with Terance Radford’s family and friends for their bravery throughout this time, and for coming here today.

I have read the coroner’s report, the Ministry of Justice’s response and—perhaps most powerfully—what Terance’s family said in the aftermath of the killing. Terance, or Terry, was an 87-year-old grandfather who had served this country—a retired teacher and a former magistrate who was simply waiting for a bus before he was struck and killed by a car driven by a man released from prison the day before.

I will focus today on the specifics of the case, the wider issues within our prison, probation and justice system, and finally, the issues that remain within the home detention curfew system and other early release schemes. Three crucial issues in this case were ignored before the release of the driver whose actions killed Terance. First, he was being kept in a segregated wing after committing acts of violence, yet this was not considered to be a factor to prevent early release. Secondly, an ongoing investigation into his behaviour was still outstanding. Thirdly, the probation service had not done a proper risk assessment about his release. The report by the corner is damning—organisations not talking to each other, risk assessments not being carried out, and gaps in the early release scheme not being closed until it was too late.

Terance was failed by the justice system and by the Government. One key purpose of prison is to keep the public safe. We need to uphold confidence and support for our justice system, as other Members have said. I thank the hon. Member for Strangford (Jim Shannon) for his, as always, careful and considerate remarks.

Cases such as this have shaken our constituents’ faith in the justice system, and no more so than that of Terance Radford’s family and friends. According to reports, the driver had assaulted prison officers, threatened to kill an officer and set two fires to the prison. That is not an isolated case. Yes, the specific factors cited around home detention curfew may have been case-specific, but too often we have seen individuals released from prison without proper risk assessments and without different services talking to each other. We have seen three serious case reviews—Damien Bendall, Jordan McSweeney and Joshua Jacques—where individuals were released after incorrect or insufficient risk assessments, sometimes by staff with too little experience, and then the offender went on to commit a serious further offence.

We might ask why our justice system is in this state. For 14 years, we have seen a crisis in our criminal justice system—crises in our courts, our prisons and our probation sector. The loss of experienced staff and a high turnover in the staffing of prisons and the probation service means a crisis in which ever-bigger gaps are forming—gaps that create more victims.

The report from the former chief inspector of probation was damning. Too often, proper risk assessments are not happening. I am repeating myself, but that is no coincidence; time and again we see serious cases like this, where an individual has died, a report is released finding gaps, the Minister comes to this place and tells us that it is all broadly fine, and we are expected to wait until the next serious report to repeat the cycle.

It is on that subject that I want to probe the Minister on how we prevent that from happening, being quite aware that there is an outside chance that I might be in his position after the general election. The Government are currently looking to expand home detention curfew in the Sentencing Bill. Last Monday, in a statutory instrument debate, I asked the Minister when that Bill would be coming back. We have since read in The Sunday Times that the Justice Secretary has been having angry phone calls with No.10 about this, so I will give the Minister another chance: could he confirm when the Sentencing Bill will come back to this House? Do the Government still plan on expanding home detention curfew?

Likewise, if it is expanded, what specific safeguards will be in place to protect victims of crime, including victims of domestic violence? How will the Government ensure that there are adequate probation officers to carry out the required risk assessments if more people are released on home detention curfew? The Ministry of Justice impact assessment estimates that an additional 850 offenders will be managed by probation as a consequence of the changes. The probation service is already overstretched; how will it cope with an additional 850?

I also want to put on record my concern about the lack of transparency on the end of the end of custody supervised licence—ECSL—scheme. It is another scheme to release prisoners early, and it is now being expanded to release more prisoners, yet the Minister says that the Government will only publish numbers annually. Also on the ECSL scheme, I have seen an example where a victim of domestic violence saw their abuser released and housed near them. It was only after an intervention and escalation that alternative housing was found somewhere else. What is specifically being done to protect victims when prisoners are released early under the ECSL scheme?

We know that our criminal justice system is in crisis. It is heartbreaking and wrong that people such as Terance—a man in his 80s just waiting at a bus stop—end up featuring in reports and having their names echoing around this place, when those years of his life should have been spent with his family and loved ones. I look forward to the Minister’s response.

16:54

[The Minister of State, Ministry of Justice (Edward Argar)]

I am grateful to the hon. Member for Ashfield (Lee Anderson) for securing a debate on this important issue. It is, as we have all seen, inevitably a sad debate, given the nature of the tragic events we are discussing.

First, I express my deepest sympathy to the hon. Member’s constituents and to Mr Radford’s family and friends. I want to highlight, as the shadow Minister, the hon. Member for Brentford and Isleworth (Ruth Cadbury), did, the dignity that they have shown throughout what has been an horrific set of circumstances. The circumstances of Terance’s—Terry’s—death are truly terrible, and my thoughts are with them and the rest of his family. I also extend my sympathies to the other victims of Mr Collins’s crimes that day.

The hon. Member for Ashfield has rightly been tenacious in raising and pursuing this matter, and I am conscious that, prior to my appointment to my role in November 2023, he engaged with my predecessor. I have taken the time to read carefully his extensive correspondence with the previous Ministers.

The circumstances of this crime, and the other serious offences committed on 19 April 2019, are not just deeply troubling but deeply upsetting. I am grateful to the coroner for her work in highlighting areas in the home detention curfew policy, as it was at the time, that require action. That helps to ensure that we have updated, improved policies and practices in place to help prevent things like this from happening again.

I note the shadow Minister’s points, but I am going to focus on the specifics of the case, rather than ranging more widely into the broader political sphere. We took the findings and recommendations in the coroner’s report extremely seriously. I will explain the Government’s actions in response, although I fully appreciate that those will not lessen in any way the pain and the loss to Terry’s family and friends. I acknowledge that the internal investigation into the case identified errors and failures, which it is also important for me to speak about.

It may be helpful for me to say a little about the home detention curfew scheme, or HDC, under which Collins was released. It has been in place for over two decades, having been created and introduced in 1999 by the then Home Secretary, Jack Straw. It is a tool in successfully managing the transition of eligible offenders from custody back into the community. It does so by enabling certain prisoners to be released before their normal automatic release date while remaining subject to significant restrictions on their liberty, including a curfew, which is monitored by electronic tag. The scheme is limited to certain types of offenders: all sexual and serious violent offenders, for example, are excluded from it, as are those subject to Parole Board release. Offenders are required to undergo a robust risk assessment to ensure they are released only if there is a plan in place to manage them safely in the community.

I am sorry to say that, having looked into this case following the hon. Gentleman’s tabling of the debate, the process in Collins’s case was clearly found to have fallen short of what was expected and what people had a right to expect. Although the offences for which Collins was serving his sentence were correctly identified as eligible and suitable for HDC, the risk management planning was undertaken without all the relevant information being obtained, as the hon. Gentleman has highlighted. That included information about the mental health of Mr Collins at the time. I will say a little more about the investigation and its findings.

Protecting the public must be our overriding priority, and it is therefore right to keep HDC policy and practice under review, to ensure that it remains as robust and safe as possible. Of course, that must mean learning lessons and taking action when something goes tragically wrong, as it did on this occasion. Every failure or serious incident committed by someone who has been released on HDC is, rightly, taken incredibly seriously, and what happened in the case of Terry’s death was truly appalling.

I should have mentioned at the beginning that I am grateful to the hon. Gentleman for painting a very human picture and making this House, and those following our proceedings, very much aware that this is a real person. This was someone who served his community, served his country, and was much loved by his family and friends. He was only going about his normal daily life, which he should have been able to enjoy peacefully. I am grateful to the hon. Gentleman for making this a very human story and bringing that across in our debate.

We have taken actions to investigate what happened and address the concerns raised by the coroner. I would never wish in any way to detract—in what I say or in the lessons learned—from the huge impact that that has clearly had.

I will turn now to the lessons learned from the prevention of future deaths report. The report raised three central concerns about the HDC policy that was in place at the time of Collins’s release. First, the coroner —I pay tribute to His Majesty’s coroner, then Her Majesty’s coroner, for the work on this—highlighted that the prisoner in this case, at the time he was released on HDC, was being held in prison segregation due to his poor conduct in custody and concerns about the risks he might present to others in the prison, as highlighted by the hon. Member for Ashfield in his remarks. The coroner rightly raised concerns about release in that context and, as a result, we have since taken action to address that issue.

The policy framework has been amended to ensure that those in segregation are not released on HDC unless the most senior governor in the prison, the governing governor, has specifically considered those circumstances and determined that the offender can be safely managed in the community. It is now the policy that no one is released on HDC directly from segregation, unless the risks have been explicitly considered and a decision actively made at the time of release that HDC remains a safe and appropriate route.

Secondly, the report highlighted that the policy at the time required decision makers to consider the risks that the offender might present to those at the proposed curfew address, but not to the public more widely. Rightly, changes have been made to address that, too. The policy now in place requires that, when considering a prisoner for release on HDC, account must be taken of the risks presented overall to people in the community, not just those at the address the offender is going to. It has been made clear that those wider, more general risks must form part of the process of determining whether an offender is safe to be released on HDC.

Thirdly, concerns were raised that the HDC policy contained insufficient guidance on the need to share information properly between the various agencies and professionals involved in managing releases. I fully agree that such information sharing is vital to ensuring that any risks or concerns about a potential release are picked up and acted on. Therefore, again, the policy framework has strengthened the requirement to draw on information from all relevant departments of His Majesty’s Prison and Probation Service and from external agencies, including the police and social services, when making such HDC decisions. Again, it has been made clear that prisoners are not to be released on HDC if any important risk-management information is missing. The failings—let us call them what they are—and tragic circumstances of this case underline the importance of prisons, probation and the wider system working together to ensure the safe release of prisoners on HDC while maintaining public protection.

The hon. Member for Ashfield, entirely understandably, asks about the officers at HMP Ranby involved in this case, and the decision to release Collins on HDC. A thorough internal HMPPS investigation was conducted by senior managers into the release of Collins and the decisions leading up to his release on HDC, as the hon. Gentleman highlighted. That investigation concluded that Collins should not have been released from on HDC from HMP Ranby in April 2019, as the decision to release was not in line with HMPPS policy—I have already highlighted that not all relevant information about risk had been obtained to inform that decision.

The investigation also found that, as Collins had been subjected to adjudication proceedings, the HDC process should have been paused to allow those proceedings to take place. It also made a number of recommendations about policy and practice that have been taken forward, in addition to the changes I have described to the national policy framework to strengthen the approach to assessments, information sharing and decision making on HDC.

In the light of the investigation, HMPPS did decide that there were sufficient grounds to bring disciplinary proceedings against staff at the prison. As part of any internal disciplinary process, if the investigator finds any evidence that a criminal offence could have been committed, the matter is referred to the police to investigate. No evidence of criminal conduct by the three members of staff at HMP Ranby was found, so the matter was not handed to the police.

The hon. Gentleman mentions the police in that context. I am conscious that he will be aware that the police operate independently of the Government and indeed of the Home Office, their sponsoring Department, for want of a better way of putting it, and they make their own decisions. I am sure that his point will have been heard in that context, and I suspect that, knowing the hon. Gentleman as I do, he will have communicated those points directly to Nottinghamshire Police on behalf of his constituents. The hon. Gentleman is right to highlight that, absent criminal proceedings or public trial, there has been no public process around this.

Concluding that there was no evidence of criminal conduct, HMPPS then took action under its own disciplinary proceedings. I appreciate the points the hon. Member for Ashfield makes, and I understand why he makes them. Although it pains me, I am legally unable to disclose the details of those disciplinary proceedings, as I am advised that to do so would be acting in breach of the law. I totally appreciate and understand the point that the hon. Gentleman makes as, prior to taking this portfolio in November of last year, I served for a number of years as the Minister for Victims and Community Safety. I appreciate the importance of closure and of people being able to move on, even in a tiny way.

That said, I am sure that the process and decisions in this case have been looked to very carefully by senior officials in HMPPS. Following the hon. Gentleman’s securing of this debate, as well as the research I have done and the information I have asked to be provided with for it, it is an issue I intend to return to with my officials. I will continue to look into the points that the hon. Gentleman has raised. If it is helpful to the hon. Gentleman, I offer him a meeting with relevant senior HMPPS officials and me to discuss how that disciplinary process works and the legal implications of it. I suspect he would rightly put across his point there courteously but firmly. If he indicates that is helpful, I would be happy to have that conversation with him. I appreciate it will not go anywhere near as far as he may wish, but it may none the less be of some help. I leave that offer with him.

[Lee Anderson]

I completely understand that the Minister would be breaking the law to tell us what sort of disciplinary measures were taken on the three governors. However, can the Minister confirm whether the three governors are still working in the Prison Service?

[Edward Argar]

I am afraid, as I have said, I am unable to give any details on the nature of that disciplinary process in the Chamber. I hear everything the hon. Gentleman says, and I hope he will take up the offer of a conversation. That is his choice, and I will respect whatever decision he makes on that.

We take our responsibility to keep the public safe very seriously. Where there have been lessons to learn from horrific and tragic cases such as this, where the most horrendous outcome has occurred, we have taken decisive action to address and respond to the issues raised. I am incredibly grateful for the contributions to this debate, for its tone, and for the approach adopted by the hon. Member for Ashfield. I repeat my heartfelt condolences to Terry’s family and friends, who have suffered so terribly. I reiterate my gratitude to the hon. Gentleman for securing the debate and allowing us to cast a light on important issues that are of great concern both to those in the Chamber and more widely. I hope he will consider the offer of conversation.

17:09

[Lee Anderson]

Obviously, the family will be very disappointed with the outcome of the debate. I know that. Although I was encouraged by some of the things the Minister said about strengthening the framework—that is good news—we have governors who cannot carry out the most basic of tasks. Anybody in this room today would know that Mr Collins should not have been released on that day. Strengthening frameworks is all well and good, but when there is incompetence at the highest level—they are supposed to be carrying out the framework—it will not work.

Anybody who was part of that prison system at that time and who read Collins’s report would have said he was not fit for release. It appears to me that they just wanted to get rid of him and get him out of there, because he was a nuisance in the system. The consequence of that is the people sat in the Public Gallery, without their dad and without their family member. Strengthening frameworks is all well and good, but if we have incompetent people at the very top in the prison system, it is pointless.

[Dame Maria Miller (in the Chair)]

May I join others today in sending deepest sympathies to the family members of Terry who are with us today?

Question put and agreed to.

Resolved,

That this House has considered lessons learned from the Terance Radford Prevention of Future Deaths Report.

17:10

Sitting adjourned.