A safeguarding review has identified six key recommendations following the murder of a vulnerable 22-year-old from Ipswich.

Joe Pooley was found dead in the River Gipping near London Road, Ipswich, on Monday, August 2018.

On March 19, 2021, Sebastian Smith, of Ramsay Road in Hawick, Roxburghshire, Sean Palmer, of South Market Road in Great Yarmouth, and Rebecca West-Davidson of Roper Court, Ipswich were found guilty of his murder.

The inquest into Mr Pooley's death recorded a verdict of unlawful killing. It added: "One of those responsible for his killing had a history of violent offending and had been released from prison on licence. He had breached the terms of that licence, and should have been recalled to prison before the killing."

Now, following an inquest into his death, Suffolk Safeguarding Partnership – which includes Suffolk County Council, Suffolk police and Suffolk healthcare services – has published six recommendations in the hope of preventing similar tragedies in the future.

A statement reads: "Joe’s tragic and untimely death has had a deep and lasting impact on all who knew and cared for him, and our thoughts remain with everyone affected and who are still grieving.

"The Suffolk Safeguarding Partnership conducted a review of Joe’s case in 2021, with learning identified across our partner agencies. Whilst the trial has been underway, we have been working closely with those agencies to ensure the learning is being embedded to make systems safer for people like Joe, and we will implement all the recommendations including those actions determined by coroner, however long it takes.

"The review highlighted where agencies have already changed practice following Joe’s tragic death, it is clear that much more still needs to be done. For example, the Partnership is ensuring member agencies are changing their practice in the following ways:

"Firstly, they need to assertively and intrusively engage with young people at risk and neither assume they’re OK or that they don’t want help.

"We often have to make a great effort to reach out to young people like Joe who have clear need of help whatever their attitude towards it is. It is not enough to say, we’ve asked and he doesn’t want any help.

"Second and as a community, we need to provide mental health support services to children and young people who do not have a formal diagnosis but who are clearly emotionally unwell. We will be holding a Suffolk-wide summit on the emotional well-being of our residents in October.

"Third, we must ensure that individuals without a formal diagnosis are not discharged simply because they are hard to engage. Partners need to work together to build rapport with customers, and where one service has an established relationship, these people should help broker introductions with the relevant service.

"Fourth we need to be aware of the impact on vulnerable people of being on a waiting list for an essential service. We had a pandemic and now we have an epidemic of waiting.

"We must intervene with early help, not wait ages for a specialist service. However fantastic a service is, it is not much use to anyone if it can’t be accessed when it’s needed.

"Next, safeguarding agencies need a greater understanding of mental capacity and to support people whose capacity is compromised to take safe decisions about themselves.

"The review highlighted that organisations have a good understanding of mental capacity and were applying it correctly for individual situations however, a holistic view that covered previous situations was not occurring meaning Executive Capacity was not considered.

"The local authority has invested heavily in training to provide practitioners with a better understanding of Executive Capacity, and we are encouraging partners to adopt this approach across the Suffolk care and protection system.

"Finally, we need to demonstrate greater management oversight of the risks to vulnerable young people placed in unsuitable temporary housing.

"Greater collaboration between social care and the district/borough housing departments has already begun. Work continues at a system level to identify those with upcoming housing needs with a view to developing joint commissioning strategies to ensure those transitioning from childrens into adult services have due consideration to their circumstances at a system level taking account of their housing, health, and social care needs.

"As you can see, there were opportunities for the system to help Joe more. We must learn from his story and ensure we continually work to improve services to keep young people safer in the future."