Home Secretary Yvette Cooper has described the failings by a college, the police and probation service which “probably contributed” to the death of a woman raped and strangled by a convicted sex offender as "shocking".
Killer Simon Goold met 26-year-old Elizabeth McCann at the Health and Wellbeing College in Ashton.
He plied her with drink before strangling her to death, and was sentenced to life in prison last year.
South Manchester Coroner Alison Mutch has issued a ‘prevention of future deaths report’ highlighting shortcomings which led to Elizabeth’s death.
When Elizabeth was raped and murdered at her home on Manchester Road, Ashton, Goold was on a life licence and on the Sex Offenders Register following convictions in 2009 for rape, sexual assault and assault.
He had been accepted at the college after it agreed to take on some probation clients.
Ms Mutch said in her report: “There was a failure by the college and probation to set up a clear documented system for how this would work and how risk would be managed.
“Within the college there was a failure to ensure that there was a system for how the information from probation would be received and scrutinised effectively.
“There was a failure by the college to set up a risk management system for attendees such as him
“As a consequence of these failures, her murderer joined the college without any risk assessment having been undertaken and without the college recognising the risk he posed.
“It is probable that had there been an effective system in operation that; either he would not have been accepted at the college at all or would have not have been accepted without a stringent plan to manage his risk, these failures by the college and probation probably contributed to Elizabeth’s death.”
Ms Mutch added that both probation and Greater Manchester Police were aware 53-year-old Goold posed a risk to women, especially around “alcohol use, lone females, intimacy and rejection”.
However, she said police and probation officers at the time were dealing with “caseloads far in excess of what were safely manageable”.
In a letter to the coroner this month, the Home Secretary said: "These failings are shocking and I am clear that the lessons must be learned across government and beyond.
"Your report is clear that more must be done to enhance the police's capability to sufficiently manage sex offenders in the community and I agree that is the case.
"We must deliver better protection for the public and outcomes for victims. The Government will be working closely with the College of Policing to improve training for officers."
Before Ms Mutch's report the executive team at the Pennine Care NHS Trust carried out a review of the college.
Now greater checks will be carried out into the backgrounds of prospective students. They will be asked if they are currently the subject of a police investigation or have been released from prison in the last 12 months. If the answer is yes, they must provide the name of the police or probation officer dealing with their case.
No one will be enrolled until these questions have been answered and police or probation have agreed they should be enrolled.
If there is a worry about an individual student, tutors are expected to raise this with senior college members and make notes on their concerns.
The report also reveals that Elizabeth’s murderer had told his police offender manager he had a “small relapse with alcohol” but the information was not shared with the probation service.
He also told his probation officer he had met a woman and believed it would develop into an intimate relationship.
Ms Mutch said: “There was a failure by GMP and probation to action that information.
“In addition, the police officer who was spoken to failed to appropriately record the information. This was probably due to the excessive workload in the unit against staff numbers. When it was indicated that the woman had decided not to pursue the relationship with him, police and probation failed to exhibit any professional curiosity and failed to speak to the woman.”
In July 2022, Goold approached a woman he met at college in an Ashton pub. He had been drinking and touched and tried to kiss her without consent.
She reported it to the college’s senior management team but they “failed to recognise it was a safeguarding issue” and only spoke to the convicted sex offender informally.
The following month, Elizabeth made it clear she didn’t want to have a relationship with Goold.
The report says if a referral system between the college and probation had existed it is probable the college would have known his status and escalated the event to probation.
Ms Mutch said: “It is probable that probation would have recognised this was a deteriorating situation, reassessed risk and taken steps to reduce the risk he posed to the public and in particular women.
“He continued at the college and probation were unaware of these events and no action was taken by them.
“It is probable that had there not been a failure to share the July 2022 incident which was caused by the previous failure Elizabeth McCann would not have died on the day she did.”
In court, it was revealed Goold was jailed in 2010, after he had raped a recently widowed neighbour at knife point, telling her “I want to kill you and bury you in my back yard”.
He was released on April 15, 2019, having been assessed and said to have developed good insight. Within months of release from prison, he enrolled as a student at The Health and Wellbeing College in Ashton – which is where he met Elizabeth.
Prosecutor Nick Johnson KC revealed that Goold already had 27 previous convictions, including offences of rape and sexual assault.
In a victim impact statement the court heard from Elizabeth’s mother.
She said: “Lizzie was the most amazing and beautiful daughter anyone could ask for and we will always miss her. Her personality touched anyone who met her.
“She was so trusting and despite being let down or used by people she called friends throughout her life, this never deterred her – she always wanted to make new friends.
“She was so excited when she found out she was pregnant with her daughter in July 2018.
“We have seriously struggled to accept that she is gone. I keep trying to ring her in an attempt to speak to her again, and I have dreams where I can’t quite reach her. We all just feel numb from her loss. As her mother, I felt her death was my responsibility as I failed to protect her. No parent should ever have to bury their child.”
Concerns highlighted by the coroner in her report included:
- The huge caseloads held by probation officers, many of whom are “young in service and experience”.
- The importance that newly qualified probation staff are closely supervised and supported by their managers.
- Information sharing between probation and groups such as drug and alcohol services was limited.
- Police are struggling to staff Sexual Offender Management Units.
- Communities are left at risk from sex offenders due to a lack of supervision.
- GMP chiefs have known about staffing levels for years and had decided to manage “far below the appropriate staffing numbers”.
- The police investigation into their role in relation to Elizabeth’s death was “poor in quality” and there was no evidence that any senior officer had considered the report.
Ms Mutch concluded: “The inquest was told that Health and Wellbeing Colleges would provide effective support for the communities they served. They were a national model.
“However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed.
“The college in Tameside served five boroughs of Greater Manchester and was run by the Mental Health Trust.
“It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed.”