THE violent rape and murder of a pensioner by a registered sex offender "could not have been predicted or prevented" concludes an independent inquiry into the circumstances surrounding the death.

In May 2021, Esther Brown was killed by 30-year-old Jason Graham after he gained entry to her flat, in the Woodlands area of Glasgow, and carried out a brutal and sustained attack on her.

Graham, who had also been using the surname Evans at the time, is now serving life in the prison for the murder, which occurred while he was subject to monitoring as a registered sex offender. 

He had been released on a non-parole licence in June 2018 having been jailed for seven years for raping a 50-year-old woman in 2013.

READ MORE: Man admits raping and murdering Esther Brown 

A 60-page significant case review is to be published today and includes 11 recommendations and 14 suggested learning points for the multiple agencies involved, which include Police Scotland, the Criminal Justice Social Work and the Health and Social Care Partnership (HSCP).

Some seven areas of good practice were also highlighted. 

The report details how Graham was subject to curfew as part of his licence conditions but the report writer could find no details of the hours of the curfew.

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Specifics were said to have been unknown by both Police Scotland and Criminal Justice Social Work services and each agency believing the other to be responsible for monitoring the curfew.

The report stated that an electronic tag would have been “a better option and could have eliminated several issues highlighted”.

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However, it is noted that both agencies were performing unannounced visits on Graham in the community to an enhanced level.

Questions had been raised by community members about the fact Graham was using an assumed name following his release but Detective Superintendent Nicola Kilbane said he had registered the name Evans with police.

Graham had been arrested for a multiple alleged attacks on women, including an assault on a 17-year-old girl he was in a relationship with in 2010 in which he pinned her to a bed and "strangled" her.

READ MORE: Police hunt for perpetrator following murder of Esther Brown

Two years later he was detained for having carried out a similar assault on an 18-year-old girlfriend.

The significant case review details how Graham witnessed the death of his mother when he was five in what was a suspected suicide. 

He had no contact with his father and was taken in by his grandparents but began using alcohol and cannabis at the age 10 before his substance use and offending behaviour accelerated from the age of 14. 

Graham was said to have engaged well with services and no issues had been raised regarding his behaviour. 

His GP, the report said, had given the wrong information to community mental health services and so Graham was seen alone by a female consultant psychiatrist.

However, the psychiatrist reported good engagement from Graham over nine meetings, describing him as "mentally well" and "never under the influence".

The Scottish Prison Service is criticised for a lack of engagement and effective information sharing with other agencies, including failing to inform the parole board that in HMP Glenochil Graham had been dealing cannabis, selling his prescription medication and was in a sexual relationship with another prisoner.

One of the key recommendations is that the Scottish Government should consider alcohol and substance testing for all appropriate licence conditions.

MAPPA (Multi Agency Public Protection Arrangements) is the process in Glasgow for managing the risk that registered sexual offenders and restricted patients present to communities, and was praised in the report for its effectiveness. 

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There are currently 839 registered sex offenders being monitored by MAPPA in the Greater Glasgow area. 

The report details how Graham had been drinking and smoking cannabis in a local pub with family members on the day of the murder. 

When his behaviour became aggressive towards other patrons, the 30-year-old was ordered to leave the bar around 6pm and was heard to say "I know when I'm not wanted" as he was leaving.

Graham was then seen on CCTV in a back lane behind Ms Brown's tenement flat shortly before he gained entry to the building.

The two were unknown to one another. 

The High Court in Glasgow heard horrendous details of Ms Brown's final hours and Graham was later sentenced to life with a minimum term of 19 years for the murder and 80 months for rape.

Ms Brown was an active, loved and valued member of her local community, involved in a number of charities, local groups and her church, and it had been her friends who reported her missing when she did not show up for several social activities. 

Susanne Miller, chief officer of Glasgow HSCP, said officials had, unusually, been keeping in close contact with community members and Ms Brown's friends and were meeting with them before the publication of the report to discuss its findings.

Ms Miller said: "We express our condolences to Esther's friends and family in the summary to the report itself because that is something we want absolutely to acknowledge.

"We have stayed in touch in particular with the local community throughout this significant case review and have a meeting with a small number of representatives of the local community to offer them the opportunity [to view the report]. 

"We very much acknowledge the importance of the local community to Esther and of Esther to the local community.

"We took a decision among the chief officers to consider the local community as Esther's family.  

"It is unusual but we took that decision with all the chief officers and we had stayed in correspondence with the local community throughout the significant case review process."

Ms Brown was a founding member of the Woodlands Community Garden, sat on the board of trustees of the Woodlands Community Trust and also helped run the community cafe.

Last year a carved memorial stone in the form of a birdbath was unveiled in her memory in Woodlands Community Garden as the centerpiece of a rockery and wildlife area to mark Ms Brown's love of nature. 

Ms Kilbane said: "Unfortunately nothing will bring back Esther and our thoughts remain very much with her family, friends and the community who loved and respected her.

"Jason Graham is currently serving life imprisonment as a consequence of his actions, and his actions alone."

The recommendations in the report have been accepted by the agencies involved and work is now underway to determine how to implement any necessary changes to working practice. 

A Scottish Government spokesperson said: “Our thoughts and sympathies continue to be with Esther Brown’s family and friends.

"We take the responsibility of protecting the public very seriously and whilst these kinds of incidences are extremely rare, we will carefully consider the recommendations in the Significant Case Review with a range of partners to determine how best to take forward the improvements highlighted.”