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Learning for the Police from Multi Agency Public Protection Arrangements (MAPPA) Serious Case Reviews - 2023

 Read the PDF version of the report

 Or see the digital version of the report below.

Following on from this publication we have also issued  three Spotlight Briefings which highlight and explore in more depth some specific issues we found in the research.  

The briefings will be of interest to police and multi-agency leaders and practitioners working with individuals under MAPPA. They provide insight from the study alongside links to helpful guidance and resources.

Spotlight Briefing - Mental Health and individuals managed under MAPPA

Spotlight Briefing - Vulnerability and individuals managed under MAPPA

Spotlight Briefing - Violence Against Women and Girls - MAPPA


Learning for the Police from Multi Agency Public Protection Arrangements (MAPPA) Serious Case Reviews 

April 2023

Darling, A.J, Fernandes Aguilera, M., Hawkins, K., Williams, H. and Cooper, E.


Partnership working and the whole system approach to offender management are long and well-established principles across criminal justice. The MAPP arrangements have been embedded over many years across agencies and have provided a framework for a consistent approach in seeking to protect the public from serious harm. This longevity has meant continued development of the arrangements in light of current thinking and operational practice, particularly the learning from serious case reviews, and this report needs to be considered in that context.

The report provides opportunities to reflect on previous success as well as for continued learning and development and I would like to thank the VKPP for the work undertaken to provide these insights and to help agencies continue to improve on our common goal of improving public protection.

CC Michelle Skeer, QPM, NPCC Lead for MOSOVO and MAPPA

1. Introduction

The National Policing Vulnerability Knowledge and Practice Programme (VKPP) was formed to improve policing’s collective response to the protection of vulnerable persons from abuse, neglect and exploitation. Working within the National Police Chiefs' Council (NPCC), to the Violence and Public Protection (VPP) lead and funded by the Home Office, the VKPP undertake a wide range of activities to help improve policing’s overall response to vulnerability, to reduce threat and harm, bring more offenders to justice and improve outcomes for victims.

This report presents key findings from national research carried out by the VKPP into the police role in cases involving serious further offending by individuals subject to multi-agency public protection arrangements (MAPPA). The study is the first national analysis of this kind, with key learning for the police and other stakeholders involved in MAPPA. The research aimed to:

  • understand the ways in which police, as one of the three MAPPA Responsible Authority agencies, feature in reviews of cases of serious further offending;
  • consolidate learning about practice that is identified as promising and missed opportunities, in both operational and strategic police responses to the management of individuals convicted of violent and sexual offences.

We also analysed and present key findings regarding the characteristics of perpetrators, victims and the MAPPA cases themselves.

This was an innovative study resulting from the proactive approach of policing and MAPPA Strategic Management Boards seeking to learn and develop practice in this complex area of public protection. The work builds on the VKPP’s previous analyses of other types of serious case reviews to identify police-specific learning, in line with the National Vulnerability Action Plan and the key themes in the College of Policing’s ‘perennial issues’ framework.

The research described in the report is based on the analysis of a large sample of MAPPA SCRs from across England and Wales which were completed between 2012 and 2021.  We present the findings arising from high-level quantitative analysis of all 81 of the provided reviews and from more in-depth qualitative analysis of the 57 reviews which were identified as containing specific police learning.

The VKPP, working with relevant NPCC leads and partners, are seeking to use the learning in this report to help improve and develop practice, both in relation to the management of MAPPA cases and in wider responses to vulnerability and public protection.

2. Background

2.1 The purpose of MAPPA

The purpose of MAPPA is to facilitate effective multi-agency working between agencies to prevent reoffending and protect the public, alongside known and potential victims, from the perpetrators of violent and sexual offences. MAPPA is a legislated set of arrangements which aim to provide structure through which agencies can best work together to manage individuals under this framework. Agencies working within MAPPA include the ‘Responsible Authority’ (police, the National Probation Service and the Prison Service) who manage[1] the perpetrators of violent and sexual offences to reduce the risk to the public alongside a number of other agencies who have a ‘duty to cooperate’[2]. Eligible perpetrators are placed into categories based on how they qualify for MAPPA management.

[1] Mental Health Services and Youth Offending Teams can also be in charge of managing some perpetrators

[2] Agencies with a ‘duty to cooperate’ under Section 325(3) of the Criminal Justice Act (2003) include Local Authority Social Services, Youth Offending Teams, Housing Authorities, Education Authorities, Mental Health Services, JobCentre Plus and Electronic Monitoring Providers.

The current national MAPPA guidance can be found here.

2.2 MAPPA Categories and Levels

Individuals supervised under MAPPA have a particular category and level. Until recently there were three formal categories within MAPPA to identify eligibility. A fourth category (Category 4) has now been added, for those classified as ‘terrorist or terrorist risk offenders’. We have not included this category in our analysis as there were no Category 4 offender SCRs in our data set. The Level of management refers to the degree of involvement required from agencies to manage the perpetrator.


  1. Individuals subject to Sexual Offender Notification requirements
  2. Violent offenders convicted of a specified violent offence and sentenced to at least 12 months custody or detained under a hospital order; or non-registered sexual offenders
  3. Other dangerous offenders who pose a high risk of serious harm but do not meet criteria for Category 1, 2 or 4, and who require management at Level 2 or 3


  1. Multi-agency support for lead agency risk management with information sharing
  2. Formal multi-agency meetings, including active involvement of more than one agency to manage the individual
  3. Formal multi-agency meetings and extra resources, the 'Critical Few' including Critical Public Protection Cases

2.3 MAPPA serious case reviews

MAPPA serious case reviews (SCR) are usually undertaken when an individual managed under MAPPA commits a serious further offence. The purpose of the SCR is to examine whether the multi-agency working arrangements already in place were effectively applied and whether the agencies worked together to do all they reasonably could to effectively manage the risk of further offending in the community. The aims of the SCR are to identify lessons learned and good practice, to determine actions to be taken and to inform the future development of MAPPA policies and procedures.

 SCRs can be mandatory or discretionary. The local Strategic Management Board (SMB) must commission a MAPPA SCR if:

  • the offender was being managed at Level 2 or 3 when the offence was committed or at any time in the 28 days before the offence was committed, and
  • the serious further offence was murder, attempted murder, manslaughter, rape, or attempted rape.

Discretionary SCRs can be commissioned by SMBs in other circumstances. The national MAPPA guidance explains it is difficult to prescribe discretionary criteria as much depends on the individual circumstances in particular cases. However, they suggest a discretionary SCR may be commissioned when a Level 1 offender is charged with murder, manslaughter, rape or an attempt to commit murder or rape; an offender being managed at any level is charged with another type of serious offence, or it would otherwise be in the public interest to undertake a review (National MAPPA Team, 2022).

Full details on conducting MAPPA SCRs are detailed in the national MAPPA guidance. The guidance chapter on SCRs has recently been updated and a new template for use in SCRs developed.

2.4 Review of literature

A review of annual MAPPA SMB board reports published over the last four years[1] identified several common issues faced in the management of MAPPA eligible offenders. These include securing suitable accommodation for perpetrators (especially upon release from prison), homelessness, mental health provision, increased demands on services due to escalated risk of domestic abuse during the pandemic, gang-related activity, serious group offending and County Lines offending. Within the MAPPA framework itself some SMBs noted an issue with the timeliness and quality of MAPPA referrals, a reduction in MAPPA resources which results in a higher workload for staff, too many cases being discussed within MAPPA meetings and variation in the quality of oral reports provided by case managers at meetings.

[1] Local Reports - Multi-Agency Public Protection Arrangements - MAPPA (

An examination of the wider literature demonstrated that to date, limited research has been conducted using MAPPA reviews as a source of data. This is likely in part due to their lack of public availability. Although there is a degree of consensus on the efficacy, need and importance of MAPPA, the findings from this previous literature emphasized some of the apparent shortcomings of the overall MAPPA framework in relation to public protection and signified that MAPPAs can be inconsistent at the national level (Hudson et al., 2015; Peck, 2011).

Overall, the assessment of the previous literature on MAPPA highlights that there are some significant gaps in knowledge relating to the current picture on the effectiveness of MAPPA. However, much of the previous research conducted is now relatively outdated, which does not necessarily capture the potentially dynamic vulnerabilities of victims and individuals being managed by MAPPA more recently or developments in policy and practice. Similarly, geographical analysis of MAPPA processes also remains limited; it is therefore important to assess MAPPA and MAPPA SCRs across a wide range of local authority areas and identify any relevant geographical or demographic nuances in the police learning. Specifically, SCRs require further scrutiny - particularly regarding the potential impacts of how the review process is conducted (such as who conducts it; the characteristics of the review) on the quality of police learning extracted. 

Colleagues at the Policing Institute for the Eastern Region (PIER), Anglia Ruskin University have recently conducted an extensive study on the process and outcome effectiveness of Multi-Agency Public Protection Arrangements, the most comprehensive investigation of MAPPA effectiveness to date. The findings from this research are expected to be published soon.

Part of the PIER study involved an analysis of a sub-sample of the serious case reviews we examined, with the focus of their analysis being multi-agency learning identified in SCRs. Once the study findings are published we will be able to identify any similarities and differences between police-specific learning and multi-agency learning more generally.

While the research we present here in our report identified key areas of specific learning for the police in relation to MAPPA, it is possible that some of the opportunities for learning and development might also be identified in the study conducted by PIER. If this were to be the case it would demonstrate the multi-agency nature of opportunities for practice development.

Additionally, it is important to note that the findings of our study also reflect those found in previous analyses of other types of statutory serious case review. This highlights the importance of considering the wider systemic issues which influence strategic and operational practice both within MAPPA and multi-agency working more broadly.

3. Methodology

MAPPA serious case reviews were obtained via information sharing agreements between the VKPP, the Ministry of Justice and Anglia Ruskin University. Each Strategic Management Board in England and Wales was asked to provide any relevant MAPPA SCRs completed between 2012-2021.

A total of 93 MAPPA serious case reviews were received, of which 81[1] were completed between 2012-2021 in England and Wales, and had police involvement prior to the serious further offence. These cases met the phase 1 initial criteria for inclusion[2] in the study.  Of the 81 reviews, 57 contained specific learning for the police and were included in the phase 2 analysis for this report.

[1] This represents approximately 75% of all SCRs (108) published during 2011 – 2021. Reviews were provided by 26 of the 42 Strategic Management Boards (SMBs) in England and Wales.

[2] SCRs completed between 2012-2021 in England and Wales and had police involvement prior to the serious further offence.  

During the phase 1 analysis stage, key characteristics and features of all 81 reviews were collected and recorded in an Excel database. In phase 2 of analysis, the 57 SCRs specifically identified as containing police learning were analysed in further depth using a qualitative analysis software programme (NVivo). The framework used for coding the reviews at this stage was based upon the College of Policing’s identified ‘perennial problems’ in policing framework. This qualitative analysis captured learning regarding police practice and a systems approach was used to explore not only ‘what’ happened, but also to try and identify ‘why’ missed opportunities occurred. However, not all reviews included description or analysis of systems explanations. Where it was possible to understand a broader systems explanation for the practice, we noted this.

3.1 Limitations of reviews and the analysis

While the reviews offer rich insight into policing practice in cases of serious further offending committed by MAPPA managed perpetrators, there were some limitations to the overall quality of learning contained within the review reports and of the analysis conducted, which must be acknowledged.

The SCRs analysed in this report only highlight the police practices involved in cases where a serious further offence (committed by an individual subject to MAPPA management, usually managed at Level 2 or 3) triggered a serious case review. They do not represent all serious offences committed by MAPPA perpetrators or the full picture of policing vulnerability.

Review reports in general vary in length, quality and methodology, with some better than others at describing practice clearly and accurately, exploring the reasons underpinning missed opportunities and identifying what good practice looks like. Recent guidance on SCRs from the National MAPPA Team standardises the terms of reference and methodology expected in SCRs. Recommendations at the end of reviews mostly highlight multi-agency messages meaning learning identified does not always translate into a direct recommendation for the police. More information on the quality of serious case reviews more generally can be found here

4. Key findings

4.1 Key findings regarding the characteristics of perpetrators, victims and MAPPA cases

 There were noticeable gaps in review reports regarding the personal characteristics and potentially protected characteristics of perpetrators. Even less was reported concerning the characteristics and protected characteristics of victims. This is a finding reflected across SCRs more broadly and indicates an important improvement that could be made in relation to data collection and reporting within MAPPA SCRs.

Perpetrator Characteristics

  • Predominantly male
  • Average age in both samples: 31 years old
  • The largest majority were in their mid-20’s and mid-30’s

Victim Characteristics

  • Predominantly female
  • Predominantly adults
  • Average age in full sample: 23 years old
  • Average age in SCRs with police learning: 26 years old
  • 1 in 5 were children and 1 in 10 were aged between 13 and 16

Case Features

  • Category 1 and Level 2 were most common
  • Most involved 1 serious further offence
  • Most involved serious injury and sexual harm
  • Common offences: rape, sexual offences and homicide

Perpetrator vunerabilities

Common vulnerabilities included:

  • Mental health needs; mood and personality disorders
  • Learning difficulties
  • Self-harm, alcohol and drug misuse

Victim vulnerabilities

Common vulnerabilities included:

  • Domestic abuse, stalking and harassment
  • Adverse childhood experiences
  • Drug misuse

4.2 Key findings regarding police practice

Identification & management of risk

The role of police in helping identify all relevant risks was an area of missed opportunity in many MAPPA SCR cases.

  • There were examples of not conducting suitable accommodation checks or background checks on supervised individuals, and not checking to verify self-reported information provided by supervised individuals.
  • Risk assessment delays and a lack of up-to-date information, including about perpetrators’ offending histories, meant police colleagues were not always obtaining or sharing necessary information with MAPPA partners.
  • Consideration of dynamic risk factors and responding appropriately to these was an issue in some cases. This included not taking sufficient account of changes in the individual's behaviour or circumstances as they changed over time and re-evaluating risk and needs accordingly.
  • Risks and vulnerabilities were sometimes missed when they related to children who were not the main identified victim or potential victim in police responses.  

Although relevant risk may have been appropriately identified in cases, there were some issues with the subsequent risk management.

  • Risk management plans were not always as robust, detailed or up to date as they should have been.
  • Changes in risk levels (or lack of change where required) were not always appropriately made or sufficiently justified.
  • Changes to risk management plans were sometimes made without consultation with other MAPPA partners or other key stakeholders.
  • ViSOR[1] records were not always up to date and there were missed opportunities to act quickly upon dynamic changes in risk.

[1] ViSOR- secure database that holds details of MAPPA offenders. More information about ViSOR can be found here: MAPPA Guidance ViSOR

Mental health needs featured regularly in MAPPA SCRs, sometimes associated with perpetrator learning difficulties or risk of self-harm. Around half of the individuals subject to MAPPA in our study were reported as experiencing mental health issues. Perpetrators not having appropriate or sufficient support could lead to a decline in their mental health and an increase in their risk of harm to themselves or others.

  • Police and MAPPA colleagues experienced real challenges when individuals were not considered to meet the necessary ‘thresholds’ for particular interventions or medical services.
  • The mental health needs of some supervised individuals were not always fully identified or responded to appropriately. Changes in these needs were not always reported or shared with other agencies as quickly as they should have been.
  • Not routinely inviting mental health representatives to MAPPA meetings resulted in missed opportunities to fully identify and manage risk and support needs.

Collaborative Working

While the reviews evidenced many examples of good cooperation and effective partnership working by police, they also showed that there were some issues with MAPPA meeting attendance and information sharing.

    • Police did not always attend necessary meetings, or those attending did not have the required level of seniority. Sometimes police colleagues with specialist knowledge of benefit to risk assessment and management were not included in MAPPA meetings.
    • Sometimes there was ineffective communication and information sharing between police colleagues as well as between police and other agencies. This was particularly so in the management of cross-boundary cases and where full police checks were not carried out and information shared with partners.
    • There was evidence that police did not always consult other agencies in decisions that required multi-agency input.
    • Opportunities were sometimes missed to use available preventative orders or changes to licence conditions to pursue or disrupt perpetrators and protect victims. Robust and timely action was not always taken in cases involving breaches of bail or licence conditions.

Several issues were identified regarding the effective management and administration of MAPP and associated meetings, including where police were the lead agency in the case or where a police representative was the MAPPA Chair.

    • The content of MAPPA meeting minutes was not always accurate, important content was missing or they were not shared in a timely way. Meeting governance could have been improved by ensuring specific ownership and accountability for actions with robust follow up, including appropriate professional challenge of other parties or agencies where necessary.
  • ViSOR records were sometimes out of date, with poor quality records or missing information. Information recorded on police systems did not always reflect the information held on ViSOR and vice versa, and with some police colleagues not having access to ViSOR when needed.

Victim care and engagement

The reviews evidenced some missed opportunities for victim engagement and safeguarding, particularly where children were involved.

  • While there was evidence of police engaging well with victims and potential victims, there were times when the support in place was not sustained over a period of time and communication with victims and potential victims not always being well managed.
  • In some instances, disclosures needed further exploration and should have triggered the initiation of child protection processes. Where this did not happen there was no additional support provided to children and their families.
  • There were also missed opportunities for police to refer victims to partner agencies and some evidence of a lack of appreciation of the experience of victimisation in some cases, particularly those involving domestic abuse and child sexual exploitation.

 Evidence and investigation

Police efforts to pursue and manage individuals subject to MAPPA were not always as effective as they might have been.

  • Linking to consideration of the ‘Voice of the Victim’, some reviews evidenced that no further police action was taken and investigations were filed prematurely, because victims did not want to engage with officers. However, there were still further opportunities available for information gathering to corroborate facts and potentially help protect victims from further harm as well as consider evidence-led prosecutions where appropriate.

Additional findings

 In addition to these findings regarding police practice, the research also identified some issues that forces and Strategic Management Boards might wish to consider with regard to recording and reporting in MAPPA cases and in commissioning SCRs. 

Additional findings for forces and Strategic Management Boards to consider

Equity, Diversity and Inclusion (EDI)

There was a lack of information concerning equity, diversity and inclusion contained within review reports, both in relation to individuals managed under MAPPA and victims. Better understanding of the characteristics and diversity issues of relevance would help build a better picture (locally and nationally) of any observable trends in the ways in which key characteristics of individuals managed by MAPPA and victims intersect with identified practice strength and practice gaps. The recent introduction of required EDI reporting for SMBs will help improve overall understanding of EDI in relation to MAPPA.

Voice of the victim

Similarly, review reports rarely contained representation of the victim’s voice (or that of their families) in the way that has become more common practice in other types of serious case review reports.

Recent updates to the national MAPPA guidance also highlight the need for MAPPA meeting attendees to discuss any diversity and equality considerations that impact on risk management. They also make clear the expectation for MAPPA meeting attendees to consider the voice of victims and individuals at risk as well as reminding them to consider personality disorder and experience of trauma. Additionally, recent revisions to the SCR template (MAPPA O) include specific sections on victim and family involvement.

Quality of reviews

While reviews were generally of good quality and helpful in identifying potential improvements to police and multi-agency practice, there were some limitations to the quality of learning contained within some of the reviews. Addressing these when commissioning or signing off review reports will help ensure reviews offer the best learning for practice improvement.


 The analysis of serious case reviews undertaken in this study revealed the extent of hard work and determined efforts made by police and other MAPPA agencies and stakeholders to supervise individuals subject to MAPPA and to protect the public from harm. The report has drawn attention to the areas featuring in serious case review reports where there is helpful learning for police to develop future responses in MAPPA cases, both with regard to single agency operational responses and police strategic management as part of the multi-agency responses as a Responsible Authority. The VKPP, working with relevant NPCC leads and partners, will use the learning in this report to help further improve and develop practice, both in relation to the management of MAPPA cases and in wider responses to vulnerability and public protection.

It is possible that there will be similarities in the findings from this research and the extensive study of the effectiveness of MAPPA recently completed by PIER. Any such similarities would demonstrate that those issues we identified as learning for the police were also evident among other agencies and in multi-agency arrangements more broadly. It is also notable that the findings our study also reflect those found in previous analyses of other types of statutory serious case review. This highlights the importance of considering the wider systemic issues which influence strategic and operational practice, by police and other agencies, both within MAPPA and wider multi-agency working.


Hudson, K., Taylor, C., & Henley, A. (2015). Trends in the management of registered sexual offenders across England and Wales: a geographical approach to the study of sexual offending. Journal of Sexual Aggression, 21(1), 56-70.

National MAPPA Team. (2022). MAPPA Guidance. Ministry of Justice, National Offender Management Service & HM Prison Service. MAPPA Guidance - Multi-Agency Public Protection Arrangements - MAPPA (

 Peck, M. (2011). Patterns of Reconviction Among Offenders Eligible for MAPPA. London: Ministry of Justice.