Serial rapist Joseph McCann carried out a series of sex attacks after being freed from prison following "major failings" by an "unstable" team of inexperienced probation staff, inspectors have found.
He was handed 33 life sentences with a minimum term of 30 years in December for the attacks on 11 women and children last year. But officials were warned years earlier that he had the hallmarks of a sex offender, with probation officers later missing eight chances to keep him behind bars.
Justice Secretary Robert Buckland asked Chief Inspector of Probation Justin Russell to carry out an independent review of the case , which highlighted a string of troubling findings.
- Details of graphic letters
Mr Russell's review found during his initial time in jail McCann was considered a "high risk of serious harm to family members" with concerns about domestic abuse and "graphic and detailed letters" written to relatives which had been intercepted by prison officers.
The inspector's report said: "Letters included threats of sexual violence and referred to wanting a 'clean young girl' on release."
McCann was "supported" by other family members who were also making "direct threats" at the time which saw police make efforts to protect the relatives affected.
Police had intelligence from 2003 which accused McCann and a family member of being involved in the abuse and sexual exploitation of young teenage girls.
The information was discussed at a meeting attended by authorities including his offender manager responsible for his case between May 2010 and 2013.
In April 2010 he sent a "threatening letter" which contained a "sexual reference" to his offender manager. His case was handed to another probation officer who, on advice of police, operated under a pseudonym for their own protection.
In 2013 intelligence received by prison service security identified once more that McCann, "with the collusion of his family, was attempting to find a 'young girl' for his release".
"This key intelligence was not shared with the NPS (probation service) and, therefore, did not inform subsequent risk assessments or release planning."
- Staff focused on burglary
Decisions not to recall McCann to prison were "too focused" on whether he would go on to carry out more burglaries and "were not based on an analysis of his patterns of behaviour, including his most recent behaviour on licence."
According to Mr Russell's findings, a detailed assessment of his behaviour "would have identified that his risk of serious harm had increased, and he should have been recalled.
"This was poor assessment practice and poor operational decision-making."
- McCann tried to escape from prison
The report said McCann's initial behaviour in prison was "poor", adding: "He was involved in violence and intimidation, and he failed mandatory drug tests.
"His behaviour resulted in adjudications and periods in the segregation unit."
He seemed "resistant" to rehabilitation programmes but did take part in one called Enhanced Thinking Skills in November 2009.
A report on his progress in the programme was "positive" but within days of taking part "he was transferred to a Category A prison following a planned escape attempt from HMP Wellingborough," Mr Russell's report said.
- Officials underestimated the risk he posed
McCann's ability to manipulate staff was "underestimated", Mr Russell found, adding: "His behaviour and mental health in prison was perceived to improve, based on his immediate presentation.
"This did not take sufficient account of his previous threatening and violent behaviour."
Staff failed to order any more mental health assessments after 2014.
After his release from prison in February 2019 McCann was the subject of Multi Agency Public Protection Arrangements (MAPPA) - in which police, probation and prison services work together to assess and monitor violent and sexual offenders to protect the public.
He was initially classed as requiring "level 2" attention, where his case is deemed to require the involvement of several bodies and regular meetings.
But he was downgraded to level one just 12 days after his release, classed as "ordinary management" just by his probation team.
The downgrading took place "too soon", Mr Russell said, saying that a higher level of monitoring was still needed due to his "high risk of serious harm".
- "Inadequate" plan for his release from prison
Another "key element" of planning for such a high risk offender to leave prison was making sure he had suitable accommodation.
He should have been given a bed in a bail hostel, known as approved premises, where he could be monitored by probation after being freed.
But after probation officers twice "tried, and failed" to get him a space he was instead allowed to live with family where he could not be monitored closely, Mr Russell said.
The Ministry of Justice is in the middle of expanding the number of approved premises on offer.
There are around 100 buildings and 2,200 beds currently available.