Domestic Homicide Review 20 overview

Overview Report regarding Jane who died in January 2020 – Final v5.

Written by: Steve Appleton, Managing Director, Contact Consulting (Oxford) Ltd

Independent Chair and author

August 2021 / Updated May 2022

A message of condolence

The Domestic Homicide Review Panel wishes to express its condolences to the family and friends of those affected by the events described in this report. The panel hopes that the process will provide some answers to their questions. 

1. Purpose of the Review

  1. Domestic Homicide Reviews came into force on 13th April 2011. They were established on a statutory basis under Section 9 of the Domestic Violence, Crime and Adults Act (2004). The act states that a Domestic Homicide Review should be a review ‘of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by:
    • a person to whom he was related or with whom he was or had been in an intimate personal relationship, or
    • a member of the same household as himself, held with a view to identifying the lessons to be learnt from the death’
  1. The purpose of a Domestic Homicide Review is to:
    • Establish what lessons are to be learned from the domestic homicide regarding the way in which local professionals and organisations work individually and together to safeguard victims;
    • Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result;
    • Apply these lessons to service responses including changes to policies and procedures as appropriate;
    • Prevent domestic violence and homicide and improve service responses for all domestic violence and abuse victims and their children by developing a co-ordinated multi-agency approach to ensure that domestic abuse is identified and responded to effectively at the earliest opportunity;
    • Contribute to a better understanding of the nature of domestic violence and abuse; and highlight good practice.
    • Identify what needs to change in order to reduce the risk of such tragedies happening in the future to prevent domestic violence homicide and improve service responses for all domestic violence victims and their children through improved intra and inter-agency working.
  1. In addition to agency involvement the review also examined the past to identify any relevant background or trail of abuse before the homicide, whether support was accessed within the community and whether there were any barriers to accessing support. The review seeks to identify the lessons that may be learned from this case and through its recommendations, assist in making victims and those affected by domestic abuse safer in the future.

2. Subjects of the review

White British female
Date of birth: February 1980
Date of death: January 2020

White British male
Date of Birth: November 1982

  1. The panel is aware that the preference of the Home Office Quality Assurance panel is for these reports to use pseudonyms. The overview report and the executive summary use the pseudonym Jane to represent the victim in this case. Jane’s mother suggested this pseudonym. The pseudonym Craig has been used to represent Jane’s former partner. Jane’s eldest son is represented by the pseudonym Colin. Her younger son is represented by the pseudonym Roger. Both are aged over 18.
  2. In Devon an Executive Group accountable to Safer Devon Partnership oversees the response to deaths potentially requiring a domestic homicide review. Through a locally agreed protocol the Community Safety Partnerships in Devon meet the statutory requirements for such reviews through Safer Devon Partnership. Membership of the Executive Group is listed in Appendix A.
    This report was approved by the review panel following a panel discussion of the draft, and a meeting to agree the recommendations and action plan. The aforementioned DHR Executive Group and the CSP Chair subsequently approved its submission to the Home Office.
    No parallel reviews were undertaken or were in train during the period that the DHR took place.

3. Process of the review

  1. Jane’s death was referred to the Safer Devon Partnership by Devon and Cornwall Police in March 2020 for consideration against the criteria for a Domestic Homicide Review. At that point toxicological and post mortem results were outstanding. Further information was gathered from agencies and post mortem results were shared by the Coroner. The decision to hold the Domestic Homicide Review was taken in July 2020 having decided that the criteria set out within The Act was met. The independent chair and author was appointed through an open tendering process in October 2020.
  2. The Domestic Homicide Review has been conducted in line with the expectations of the Multi-Agency Statutory Guidance for the Conduct of Domestic Homicide Reviews 2013. This guidance is issued as statutory guidance under section 9(3) of the Domestic Violence, Crime and Adults Act 2004. It has since been updated and was republished in December 2016. This review has used this revised guidance in the development of this Overview Report.
  3. The review has considered agencies contact/involvement with Jane in the two years prior to her death in January 2020. This timeframe was decided by the panel who agreed that having reviewed the chronologies and scoping information, this timeframe was proportionate to learn lessons for improving the response to domestic abuse today. 
  4. The timescale for completion of the review was affected by the outbreak of COVID-19. As a result of the social distancing policy put in place in March 2020, it was not possible for the panel to meet in person. Despite this, the panel meetings were effective and conducted in accordance with the national guidance.
  5. The key purpose for undertaking these reviews is to enable lessons to be learned from homicides where a person is killed or dies by suicide as a result of domestic violence and abuse. In order for these lessons to be learned as widely and thoroughly as possible, professionals need to be able to understand fully what happened in each homicide, and most importantly, what needs to change in order to reduce the risk of such tragedies happening in the future.


  1. All documents and information used to inform the review are confidential. The findings of the review will remain confidential until the Overview Report, Executive Summary and Action Plan have been reviewed and approved by the Home Office.
  2. The over-arching aim of this Domestic Homicide Review was to increase safety for those who may experience potential and actual incidents of domestic abuse by learning lessons from the death in order to change future practice. It was conducted in an open and consultative fashion bearing in mind the need to retain confidentiality and not apportion blame. Agencies sought to discover what they could do differently in the future and how they could work more effectively with other partners and take action to make necessary changes.
  3. The Panel requested and reviewed Individual Management Reviews from each of the relevant agencies defined in Section 9 of the Domestic Violence, Crime and Victims Act (2004), and invited responses from any other relevant agencies or individuals identified through the process of the review
  4. The Panel sought the involvement of family members to ensure that a robust analysis took place of the full circumstances surrounding the incident under review.
  5. The Domestic Homicide Review considered the intervention and contacts between agencies and the individuals who are the subjects of the review in the two-year period prior to and including the date of Jane’s death in January 2020. Any matters believed to be of relevance identified in the course of the Domestic Homicide Review inquiries that occurred outside that two-year period have also been included.

Principles of the Review

  1. The Domestic Homicide Review was undertaken in accordance with the current national Domestic Homicide Review Guidance, most recently updated in December 2016. It was guided by seven principles:
    • The Domestic Homicide Review will be objective, independent & evidence-based.
    • The Domestic Homicide Review will be guided by humanity, compassion and empathy, with the subjects of the review at the heart of the process.
    • The Domestic Homicide Review will ask questions, identify issues and make recommendations that seek to reduce or prevent future harm, learn lessons
    • The Domestic Homicide Review will not blame individuals or organisations, but if the evidence supports it, will seek to ensure that organisations are held to account for actions or the lack of.
    • The Domestic Homicide Review will respect equality and diversity, giving due accord to the nine protected characteristics.
    • The Domestic Homicide Review will be conducted in an open and transparent way whilst safeguarding confidential information where possible.
    • The Domestic Homicide Review will culminate in an Overview Report and Action Plan to effect change and disseminate lessons learned.

4. Terms of Reference

  • Examine the events leading up to the incident, including a chronology of the events in question.
  • Review the interventions, care and treatment and or support provided. Consider whether the work undertaken by services in this case was consistent with each organisation’s professional standards and domestic abuse policy, procedures and protocols including Safeguarding Adults.
  • Review the communication between agencies, services, friends and family including the transfer of relevant information to inform risk assessment and management and the care and service delivery of all the agencies involved.
  • Identify any care or service delivery issues, alongside factors that might have contributed to the incident.
  • Examine how organisations adhered to their own local policies and procedures and ensure adherence to national good practice.
  • Review documentation and recording of key information, including assessments, risk assessments, care plans and management plans.
  • Review the impact (or otherwise) of the victim’s planned appearance as a witness in a trial relating to domestic abuse previously perpetrated towards her by the perpetrator in this case and the way in which agencies responded to their needs.
  • Examine whether services and agencies ensured the welfare of any adults at risk, whether services took account of the wishes and views of members of the family in decision making and how this was done and if thresholds for intervention were appropriately set and correctly applied in this case.
  • Whether practices by all agencies were sensitive to the gender, age, disability, ethnic, cultural, linguistic and religious identity of both the individuals who are subjects of the review and whether any additional needs on the part of either were explored, shared appropriately and recorded.
  • Whether organisations were subject to organisational change and if so, did it have any impact over the period covered by the DHR. Had it been communicated well enough between partners and whether that impacted in any way on partnership agencies’ ability to respond effectively.
  • Identifying and highlighting any examples of good practice so that these may be used to inform service improvement and development.

5. Methodology

  1. An initial scoping process was undertaken to establish the agencies and organisations that had had contact with Jane and Craig. As part of this process a list of agencies and relevant contacts was developed, and a timeline was created. This process enabled the gathering of information about types and level of contact and informed the decisions about which agencies and organisations to approach to request Individual Management Reviews.
  2. Individual Management Reviews were requested from four agencies to establish if there had been contact with Jane and if so the nature of that contact and any services or interventions provided.
  3. The objective of the Individual Management Reviews which form the basis for the review report was to provide as accurate as possible an account of what originally transpired in respect of the incident itself and the details of any contact and/or service provision by agencies to Jane.
  4. The Individual Management Reviews were to review and evaluate this thoroughly, and if necessary, to identify any improvements for future practice. The Individual Management Reviews were also to assess the changes that have taken place in service provision during the timescale of the review and considered if changes are required to better meet the needs of individuals at risk of or experiencing domestic abuse.
  5. Individual Management Reviews were reviewed by the panel members and were presented and discussed at a panel meeting. Questions were asked and clarifications sought by the panel regarding specific elements of each of the Individual Management Reviews. Some Individual Management Reviews were amended and resubmitted as a result of those discussions.
  6. The Individual Management Reviews have been signed off by a responsible officer in each organisation and have been quality assured and approved by the review panel.
  7. This Overview Report is based on Individual Management Reviews commissioned from local agencies as well as summary reports and scoping information.
  8. The report’s conclusions represent the collective view of the review panel, which has the responsibility, through its representatives and their agencies, for fully implementing the recommendations that arise from the review.

6. Involvement with the family

  1. The panel has sought throughout the review to ensure that the wishes of the family members have informed the Terms of Reference and are reflected in the report.
  2. The Chair of the Panel spoke with Jane’s mother as part of the review. This conversation took place virtually as a consequence of COVID-19 restrictions. The interview was held in April 2021.
  3. Jane’s mother has been provided with information about support and advocacy.
  4. Jane’s mother was provided with a copy of the draft of this overview report and had the opportunity to comment on and her reflections have been incorporated prior to its finalisation.

7. Contributors to the review

  1. Four agencies contributed to the review through the submission of Individual Management Reviews and the provision of initial scoping information. Those agencies were:
    • Devon and Cornwall Police
    • GP surgery – primary care
    • Splitz Support Service
    • Royal Devon & Exeter NHS Foundation Trust

The agencies identified above each provided IMRs that were reviewed by the panel and used by the panel in reaching their conclusions.

8. Panel membership

Steve AppletonManaging Director Contact Consulting – Independent Chair
Chrissy StowerHead of Service, Splitz Devon Domestic Abuse Services
Rachel Wetton
(replacing Chrissy Stower)
Head of Service, Splitz Devon Domestic Abuse Services
Hannah GethinClinical Safeguarding Specialist
Clinical Commissioning Group
Helena RiggsPractice Lead – Adult Safeguarding
Devon Adult Social Care
DS Phil LeonardDetective Sergeant, Devon and Cornwall Police
DCI Nicola SeagerDetective Chief Inspector Devon and Cornwall Police
Dave WhelanCommunity Safety Coordinator, Community Safety Partnership
Annette EmanuelSenior Safeguarding Nurse Specialist, Royal Devon & Exeter NHS Foundation Trust

The members of the panel were independent and had no prior contact with the subjects of the Domestic Homicide Review or knowledge of the case.

9. The Overview Report author

  1. The independent Chair of the anel and author of the DHR Overview Report is Steve Appleton. Steve trained as a social worker and specialised in mental health, working as an Approved Social Worker. During that time, he worked with victims of domestic abuse as part of his social work practice. He has held operational and strategic development posts in local authorities and the NHS. Before working independently, he was a senior manager for an English Strategic Health Authority covering Thames Valley and central southern England. He had particular responsibility for mental health, learning disability, substance misuse and offender health.
  2. He has considerable experience in health and social care and has worked with a wide range of NHS organisations, local authorities and third sector agencies. At the time of writing he was managing director of his own limited company, a specialist health and social care consultancy.
  3. Steve has led reviews into a number of high profile serious untoward incidents particularly in relation to mental health homicide, safeguarding of vulnerable adults, and investigations into professional misconduct by staff and has chaired a Serious Case Review into an infant homicide. He has chaired and written a number of DHRs for local authority community safety partnerships across the country. He has completed the DHR Chair training modules and retains an up to date knowledge of current legislation
  4. Steve as independent chair and author has never been employed by any of the agencies concerned with this review and has no personal connection to any of the people involved in the case. He has undertaken one previous DHR for Safer Devon.

10. Equality and Diversity

  1. The panel has been mindful of the need to consider and reflect upon the impact, or not, of the cultural background of Jane and if this played any part in how services responded to their needs.
  2. “The Equality Act 2010 brings together the nine protected characteristics of age, disability, gender reassignment (with a wider definition) marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation.” There are further considerations relating to income and pay gaps, the gender power gap in public sector leadership positions and politics, and the causes and consequences of violence against women and girls, under the Gender Equality Duty.
  3. The nine protected characteristics in the Equality Act were considered by the panel and none were found to have direct relevance to the review. However, the protected characteristics were considered in the Terms of Reference of the review. The panel ensured that the review always gave detailed consideration to issues of equality and diversity in their thinking about the engagement and involvement of organisations and professionals and where identified, the impact of them on decision making.

11. Dissemination

  1. The Overview Report will be sent to all the organisations that contributed to the Domestic Homicide Review. A decision about publication of the Overview Report will be made by Safer Devon following approval by the Home Office Quality Assurance Panel.
  2. Members of the family who contributed to the review were given an opportunity to review and comment on the draft Overview Report and Executive Summary. The Independent Chair then made a small number of changes and additions to the draft report to take account of their feedback.

12. Introduction and summary background

  1. Jane had been in a relationship with Craig for approximately seven or eight months prior to her death. This timing was arrived at based on records relating to a report received by the police in November 2018, when Jane is reported to have ended the relationship and disclosed the length of time she and Craig had been together.
  2. Jane’s mother told the DHR that Jane met Craig through a mutual friend at a BBQ and they started dating after this. She had known Craig for a while as a friend and he seemed to her like a nice man but things changed very soon after they got into a relationship.
  3. Within a couple of weeks Craig had given her the ultimatum of he either moved in or they ended the relationship and kept telling her she didn’t love him if he wasn’t allowed to move in. Jane felt it was too soon and fought to keep him out of the house, but he eventually started to stay over more and more and moved himself in.
  4. Craig was controlling of Jane and he wanted her to change how she did everything. He would become violent with her if he didn’t get his own way and would often say to Jane ‘It’s my way or no way’. He didn’t want her to have a relationship with her family and friends and she started to withdraw from them.
  5. At the time of her death, Jane had been preparing to give evidence in a Crown Court trial relating to offences of sexual assault committed by Craig against her. Craig was also facing other charges relating to similar offences committed against other women. The offences against Jane for which Craig was on trial were committed in July 2019.
  6. About a week prior to the incident in July 2019 Jane had ended her relationship with Craig. He had sought emergency accommodation but still had belongings at Jane’s home. On the date of the offence Craig had attended Jane’s home, and while heavily intoxicated, he repeatedly banged on the window of the property. Jane refused to let Craig into her property, but he climbed through an open window and gained entry.
  7. Jane had called the police, as had a neighbour who had heard the couple arguing. Police arrived and detained Craig. Enquiries revealed that he had pinned her on the sofa, had inappropriately touched her and had made attempts to remove items of her clothing.
  8. Craig was later released on bail, which he breached a number of times. He was arrested for bail breaches and the Crown Prosecution Service authorised a number of charges against him including sexual assault, assault by beating and violence to secure entry. He was remanded in custody to stand trial at Exeter Crown Court in January 2020. He was subsequently found guilty and sentenced to two years and 11 months imprisonment
  9. On the day of her death, Jane was found by attending police officers. She was clearly deceased. There were a number of empty blister packets of prescription medication near her body, and further empty packs were found in the kitchen waste bin.
  10. No obvious suicide note was located. There was a notepad that contained a list of issues that indicated concerns Jane had in relation to her stepfather. None of these issues indicated any form of abusive relationship, nor did it contain any indication of intent by Jane to take her own life.
  11. Jane’s death clearly coincided with the day she was due to give evidence in Crown Court as a victim of domestic abuse related sexual offences.
  12. The police concluded that Jane’s death met the criteria for a Domestic Homicide Review as it appeared to be either a suicide or unexplained death following domestic abuse.

13. Overview of organisations’ involvement

The involvement of the GP practice – Primary Care

  1. The GP practice IMR notes that Jane had a longstanding depressive illness, her first episode of depression occurred in 2007. She experienced periods of low mood, which the GP believes to have been “reactive to her life circumstances”. It is also recorded that she experienced post-natal depression in 2014/15 and in 2015 was referred to a Community Mental Health Team following concerns that she was experiencing suicidal thoughts.
  2. The IMR notes that Jane had previously been offered a range of treatments including anti-depressant medication, counselling via a local Depression and Anxiety service, referral to a Community Mental Health Team (CMHT) and psychological therapy. Jane was discharged from the CMHT service following non-attendance at appointments.
  3. Jane’s first recorded contact with her GP practice within the timeframe of the DHR was in March 2017. She had contacted the practice by phone and following a triage call was seen for an appointment. The issue related to the presence of blood in her urine. It is important to note that Jane had experienced a trapped nerve in her back, which caused a lot of pain, and had also necessitated her being catheterised. Advice and medication was prescribed and she was advised that at her next visit a District Nurse would review the catheter.
  4. The next recorded contact was in May 2017. This was a triage call with the Out of Hours GP service. The records note that Jane had a history of back pain and was being treated with painkillers. The IMR notes that the GP record shows Jane stating that this latest contact and back pain episode resulted from an ‘altercation with her ex-partner’. The notes do not state the details of the ex-partner. Jane received advice about ongoing use of pain alleviating medication and was advised to see her own GP. There is no record that she did this. There is no recorded contact with medical staff in the practice.  
  5. In February 2018 Jane had three contacts with the GP practice, two of which took place by telephone. The first concerned a muscle spasm in her back, for which she was prescribed diazepam. The second related to sciatica and she was advised to take paracetamol. The third appointment was a GP home visit related to back pain and depression. The GP notes do not record what exploration took place in relation to the type, cause or interventions offered in relation to the reported depression. At the end of March 2018 Jane had a GP appointment, which it is understood took place in person. The only detail recorded is that Jane was ‘feeling more positive’ but there is no further information about why or what had changed, either in her physical and mental health or in respect of her relationship.
  6. The next contact with the GP practice was a phone appointment in late August 2018. Again, this related to a muscle spasm in Jane’s back. She was again prescribed diazepam.
  7. In mid-September 2018 Jane consulted her GP with abdominal and pelvic pain and she again consulted the GP at the start of October 2018. She was referred to hospital for a scan following this appointment.
  8. About four weeks later at the start of November Jane again saw her GP reporting abdominal pain. This was due to a ruptured ovarian cyst. She was referred for emergency surgery at the Royal Devon & Exeter hospital.
  9. At the end of December 2018 Jane met with her GP and reported continuing back pain and depression. The detail of the depression and any intervention is not recorded in the notes provided to the DHR.
  10. In January and February 2019 Jane had two appointments with her GP, the first was related to back pain and depression, the second related to contraception.
  11. In late April Jane had an appointment with the practice nurse. She again reported ongoing back pain but also had a chest infection, for which antibiotics were prescribed.
  12. The next contact was in late June when Jane called the practice by phone while she was away from her local area. She was experiencing a further back muscle spasm and was requesting medication that was subsequently prescribed.
  13. In July 2019 Jane had an in-person GP appointment. She reported ongoing back pain and was experiencing anxiety. She reported to the GP that her ex-partner had recently breached bail and had assaulted her. She said she had an appointment with Splitz, the local domestic abuse service. The GP record shared within the IMR does not set out what further exploration of this took place during the consultation.
  14. At the end of August 2019, following a phone appointment, Jane was referred by her GP for physiotherapy for her back problem.
  15. In early September 2019 Jane contacted the GP via the reception at the practice to request a referral for use of a gym. This was followed by a message to the GP practice at the end of September 2019. The physiotherapy service reported that Jane was experiencing suicidal thoughts. The GP attempted phone contact with Jane but got no response. A message was left for her, which advised her to contact the NHS 111 service for crisis team support. Four days later at the start of October 2019 the GP again attempted phone contact with Jane but got no response. A message was left asking Jane to contact the practice.
  16. At the end of November 2019, the GP practice had phone contact with Jane. She was reporting further back pain and a possible urinary tract infection. She was prescribed antibiotics.
  17. In mid-December 2019 Jane contacted the GP practice and left a message with reception. She was requesting Morphine tablets, as she was concerned she would run out over Christmas. These were not prescribed for her. This was her last contact with the practice before her death in January 2020.

The involvement of the Royal Devon and Exeter NHS Foundation Trust

  1. The Royal Devon and Exeter NHS Foundation Trust (RD&E) had a number of contacts with Jane between 2017 and the end of 2019. These were almost all exclusively related to her chronic spinal condition.
  2. The first recorded contact was in mid-February 2017 when Jane presented at the Emergency Department of the RD&E and was seen by the medical team there. She presented with back pain and urinary retention. She was referred to the Spinal Clinic. A week later she was seen in the Spinal Clinic and her condition was suspected to be an S1 nerve root problem. The L5-S1 spinal motion segment, also called the lumbosacral joint, is the transition region between the lumbar spine and sacral spine in the lower back. Jane was referred for a Magnetic Resonance Imaging (MRI) scan.
  3. About a month later, at the end of March 2017, Jane was contacted by the Consultant to give her the MRI scan results by phone and she was referred for a procedure known as a nerve root block. A nerve root block is an injection of local anaesthetic and steroid injected under X-ray guidance into the area where the nerve exits the spinal column.
  4. In mid-May 2017 the procedure took place, the intention was to provide Jane with pain relief and relief of her symptoms and improve her quality of life. Two weeks later Jane presented to the Emergency Department with back pain and was again referred to the Spinal Clinic team. She was discharged from the Emergency Department with pain relief medication.
  5. Three weeks later in June 2017 Jane again presented to the Emergency Department with ongoing back pain. She was again referred to the Spinal Clinic team.
  6. A month later in late July 2017 Jane presented to the Emergency Department. She was experiencing swelling in her legs. The notes indicate she was discharged with advice, but the nature of that advice is not recorded.
  7. In mid-August 2017 the Spinal Clinic team saw Jane. This was for investigation. The records do not describe the nature of the investigation or the advice provided to Jane.
  8. In mid-September 2017 Jane was seen in the Spinal Clinic. She complained of ongoing thigh pain and of incontinence. The notes indicate she was then seen by the Emergency Department but do not describe the nature of that contact.
  9. In mid-October 2017 had a further appointment with the Spinal Clinic. She was referred to the community service, this was with the intention of making service more accessible to her as the service would visit her, removing the need for her to travel to appointments. She was discharged from the Spinal Clinic team following this appointment.
  10. In January 2018 there is a record of a missed appointment with the Spinal Clinic, but there is no record of her having been re-referred in the information reviewed by the DHR panel.
  11. In May 2018 Jane received a spinal epidural steroid injection at hospital and received follow up from the Pain Clinic.
  12. The next recorded contact was mid-September 2018. By this time the Spinal Clinic team was again seeing Jane. On this occasion she was seen by an Occupational Therapist and as a result of this appointment, she was referred for Occupational Therapy and physiotherapy.
  13. At the start of October 2018 Jane had an appointment with her Consultant, a medication adjustment was made but the information provided to the DHR panel does not record the nature of that adjustment.
  14. Jane did not attend an appointment with the Pain Management Rehabilitation team in late October 2018.
  15. Jane underwent a surgical procedure in mid-November. This was related to the ruptured cyst. Once the procedure was completed Jane was discharged having been given advice about pain management.
  16. In mid- December 2018 Jane did not attend an appointment that had been arranged with a Clinical Psychologist at the RD&E.
  17. The next recorded contact was in March 2019 when Jane underwent a further nerve root block procedure.
  18. In May 2019 a Clinical Psychologist saw Jane. The information provided to the DHR panel does not describe the detail of the appointment and it was not possible to locate any further information relating to this.
  19. In September 2019 Jane did not attend a planned physiotherapy appointment. Her GP was notified of her non-attendance.
  20. In late October 2019 Jane met her Consultant for a pain management review. She was referred for a further MRI scan. This was her last contact with the RD&E.

The involvement of Splitz

  1. Splitz is an independent charity and provider of domestic abuse support services in southwest England.
  2. Jane’s first contact with Splitz was in early July 2019. Splitz received a referral from the Multi-Agency Risk Assessment Conference (MARAC) via the police. This followed a sexual assault against Jane by her then ex-partner, Craig. Following receipt of the referral, an Independent Domestic Violence Advocate (IDVA) was allocated Jane’s case. The IDVA attempted contact with Jane by phone, there was no answer so the IDVA left a message.
  3. The following day the IDVA called Jane again and spoke with her. The IDVA explained her role to Jane and also talked about issues of confidentiality. Jane stated that her relationship with Craig was over and she had no intention of restarting it. She was clear that she wanted his belongings out of her home and wanted to “move on” with her life. The IDVA advised that she would contact the council to see if they could help with removal of belongings. Jane said she had to call the police because Craig had breached his bail conditions by contacting her, but that she felt safe at home, but was still anxious when the doorbell or the phone rang as she expected it to be Craig. Jane stated she did want to pursue a restraining order, but also wanted to think about a non-molestation order. The police were due to visit that day to fit an alarm at her home. She also said that her sister had invited her to stay with her over the weekend. The IDVA advised Jane about emergency housing options as well as local refuge provision. Jane stated she would like to meet the IDVA in person and an appointment was made with her to take place a few days later. The IDVA also provided safety advice and explained the MARAC process to Jane. The IDVA said she would seek some legal advice about the non-molestation order.
  4. Four days later, in mid-July 2019 the IDVA went to the agreed location to meet with Jane, but she did not attend. Jane sent a text message saying she could not meet as planned and would need to rearrange.
  5. On the same day Splitz received an email from the police Domestic Abuse Unit stating that they had spoken with Jane and they were arranging the alarm. The following day the IDVA attempted to contact Jane by phone but got no reply, so left a message.
  6. The next day Jane and the IDVA had a conversation by text message. She told Jane that the police had contacted her to say that Craig was still harassing her, and offered words of concern for Jane. The IDVA stated she was arranging an appointment with a solicitor for advice about a non-molestation order. The same day the IDVA emailed a local solicitor seeking an appointment.
  7. Later that day the IDVA was advised by the police of a call made to them by Jane when she reported that Craig had been trying to unload her shopping trolley at a supermarket the previous day. Jane said she was scared. Craig, who was in breach of bail conditions, had been arrested by the police. He had been charged with two offences: sexual assault and assault by beating (at the start of July 2019). He was also charged with using violence to secure entry and had been remanded in custody to appear before magistrates. The police had advised Jane of these developments.
  8. At the end of July 2019 the IDVA met with Jane in person. Jane was very talkative during the meeting. She told the IDVA that she did not talk to anyone else about the domestic abuse she has suffered. Jane stated that she was willing to support Craig’s prosecution but was very anxious about attending court. The provision of a Court IDVA was to be discussed at their next meeting. Jane stated that she had no intentions of resuming the relationship and was pleased she is out of it now and hoped Craig would leave her alone after his release from prison.
  9. Jane stated she was confused about what was going on with the police so the IDVA called the DAU. They restated the charges Craig faced and stated he had pleaded not guilty to all offences and there would be trial. The DAU stated that Craig had not made any bail pleas and was remanded until later in August unless he made an application and was released on bail.
  10. The IDVA explained all this to Jane who stated she was willing to attend court but wanted to think about whether she would prefer a screen or a video link.
  11. Jane and the IDVA discussed Jane’s past abusive relationships, which she struggled to see as abusive because those men didn’t hit her often. It was agreed that the IDVA and Jane would complete a couple of sessions of domestic abuse awareness work together to increase Jane’s knowledge of domestic abuse. The IDVA discussed the MARAC in full. Jane stated she wanted nothing mentioning in particular except for the alarm the police installed.
  12. She reportedly became very emotional and stated she was scared the alarm might be removed after 30 days and that Craig might then be released. The IDVA stated she would discuss this with the Domestic Abuse Officer (DAO). Jane stated she was happy living where she was and would consider a restraining order to keep Craig out of the local area completely. If she could not get a restraining order, she was willing to look at getting a non-molestation order, reconfirming her earlier statements. Jane stated that she struggled to get around because she had a disability, which affects her spine. Requested home visits in future.
  13. At the end of July 2019 a pre-MARAC meeting was held. The DAO’s were considering removing the alarm in Jane’s home while Craig was on remand, but reinstalling it should he be released, thus enabling her to have the alarm for longer overall. The IDVA also made a home visit request for Jane through her manager.
  14. At the start of August 2019 the IDVA attended Jane’s address to meet in person. Jane stated she had been feeling lonely as her family had gone to visit other family members in another part of the country some distance away. Jane couldn’t go because at the start of the week her back problem deteriorated and she ended up in hospital as she couldn’t move.
  15. Jane stated she had received the court letter asking her to attend Craig’s trial at the start of January 2020. Jane stated she believed the date was so far away because Craig had another trial coming up with his ex-partner.
  16. Jane confirmed she would be attending court and wanted to give evidence as close to home as possible. Jane and the IDVA drafted a final restraining order and the IDVA stated she would send this off to the witness care officer the next day. The IDVA and Jane completed the domestic abuse awareness work.
  17. Jane requested that the IDVA attend court with her in January but the IDVA advised she had made a referral to the court IDVA for this as it is unlikely she would be able to remain involved for this long. Jane stated she would have preferred the IDVA to attend. The IDVA said that she would explore this at her next supervision with her manager.
  18. Jane and the IDVA had an hour of conversation around the domestic abuse awareness work and Jane became upset stating that the abuse was all so clear to see when what had happened to her was written down.
  19. The IDVA and Jane focussed on self-esteem and self-confidence gaining and Jane stated she was using YouTube and other online self-help resources to build her confidence.
  20. The IDVA advised Jane that because Jane’s risk was low at this time and because Craig was remanded in custody until trial in January that her case would likely be closed. Jane was upset but stated she understood. She was advised that she could call the IDVA for one off advice should she need to in the future but if she wished to access full support again she could go through the Splitz helpdesk.
  21. Jane thanked the IDVA for all the support she had given her over the past months and stated she would like to work with Splitz again once Craig was released to make sure she felt safe at home. The IDVA stated she would contact the court IDVA once she was back from annual leave and would try to arrange one joint visit so Jane would not feel as nervous about a new worker. Jane agreed to this. A further appointment was made for the middle of August 2019.
  22. The day after the appointment the IDVA contacted the officer in the case (OIC) to enquire if they would like Jane to complete a Victim Personal Statement (VPS). Jane had also asked the IDVA if she could drop her phone into the police station so it could be analysed for further evidence. The IDVA stated she could not do that so would seek advice about whether a police officer could collect the phone from Jane. Jane again stated her wish to obtain a restraining order that covered the local area as this would make her feel safer.
  23. A week later, the IDVA phoned Jane to let her know that she had not heard back from the OIC so she would assist Jane with the VPS and then email it to the police.
  24. In mid-August Jane and the IDVA met in person. Jane said she felt ok to complete the VPS herself, the IDVA said she would type it up for her and send it to Jane for approval. Jane was observed to be upset during the meeting and the IDVA offered emotional support. They made plans to meet again the following week, but Jane cancelled that meeting. In between the IDVA completed the VPS and shared it with Jane for her approval.
  25. At the end of August 2019, the IDVA received a text from Jane apologising for cancelling their recently planned meeting and asking if they could rearrange. A couple of days later, at the start of September 2019, the IDVA tried to call Jane but got no response. The IDVA completed the referral to the Court IDVA.
  26. At the start of September, the IDVA was contacted by the Witness Care Officer (WCO) at the Courts. This confirmed the requirement for Jane to give evidence at the trial, which was listed for early January 2020. The IDVA advised that she had talked to Jane about this and that she was panicking a little that her family would be called to give evidence, but the IDVA had assured her that she was the only witness that had been called to give evidence. The IDVA planned to send a court letter out to her with all the details of the trial.
  27. The WCO enquired whether Jane would like to give evidence via video link from her nearest court or would she like to use the video link from a private room within the Crown Court building. The WCO also asked if the IDVA could provide a note detailing Jane’s current feelings towards giving evidence and being in the court room with the defendant and how a video link would improve the quality of her evidence. This would enable the WCO to complete an application for Jane to give evidence via video link so that it was on the court records.
  28. The terms of restraining order were passed to the OIC. The IDVA maintained contact with the WCO by email in relation to the court appearance, in particular in relation to travel to and from court given Jane’s back and mobility issues. A further email exchange took place at this time that concerned the contents of the restraining order:
    • Not to contact Jane directly or indirectly by any means
    • Not to mention Jane directly or indirectly on any form of social media
    • Not to enter Devon, England
    • (It is worth trying for initially as Craig has no local connection in Devon except for having two children in the area, which he isn’t allowed to see as the children’s mother has a restraining order against him. Plus Jane has appointments for her health all over Devon which he is aware of)
    • If we cannot have ‘Not to enter Devon’ can we request:
    • Not to enter (a specific part or parts of) Devon, England including those where Jane has lots of family that Craig knew the addresses of)
  1. In late October 2019 the IDVA spoke with Jane by phone to enquire how she had been feeling. Jane stated she was much brighter and was trying to go out more often. They agreed to make an appointment to meet with a police constable (Constable A). This meeting took place by phone rather than in person. Constable A notified Jane and the IDVA that Craig had only entered a guilty plea to the charge of common assault. Jane was upset and angry about this. Constable A confirmed the case was still going to trial at the start of 2020 and confirmed the intention to visit Jane to take a further statement from her. The IDVA was able to support Jane and provide reassurance. Jane said she felt strong and wanted to give evidence so no other woman had to go through what she had been through.
  2. In late November 2019 the IDVA made enquiries about housing and possible move for Jane. The advice was that Jane would need to register with the housing authority. The IDVA and Jane exchanged text messages about this, and Jane responded saying she was doing OK and continued to pursue the housing move options.
  3. There was a Splitz case review in mid-December 2019. It was noted that Jane had not responded to the IDVA’s most recent messages. The IDVA had got agreement that she would support Jane into the New Year and close her case following the trial. At this time it was also confirmed that the Court Service would provide taxi transportation for Jane for the trial so she could attend the court. There continued to be a number of email and phone contacts between the IDVA and housing authorities. The IDVA shared the information she had received at regular intervals, providing practical advice about next steps for registering for a house move.
  4. A few days before Christmas 2019 Jane contacted the IDVA to thank her for her efforts and asking for further support with the housing process. Jane stated in a text that she was unsure how a move would happen, that she had experienced more back pain, had had an MRI and was awaiting another spinal block injection, that her step-father was not well and that she and her mother were in contact again and that Jane felt overwhelmed by all that was going on.
  5. Jane followed this with a further text message outlining some issues relating to welfare benefits, problems with collecting medication and that she was experiencing a lot of pain.
  6. At the start of January 2020, the IDVA attended court and met the WCO. The IDVA had discussed the details of the trial with Jane. At 9.31 that morning the IDVA had texted Jane to say she was at the court and was waiting for her. After 20 minutes the IDVA tried to call Jane but got no response. The OIC and the Crown Prosecution Service officer met the IDVA who relayed concern for Jane as she was now late in attending the court. The IDVA called the WCO and asked her to check whether Jane had checked into a local hotel that been arranged for her. It was established that she had not checked into the hotel and this further heightened concern about her.
  7. The IDVA found the OIC and CPS representative and advised them she felt that officers needed to go out to check on Jane. The OIC called for a unit to attend Jane’s address.
  8. Prosecution attended and spoke with the IDVA, OIC and CPS and stated that if Jane was located and brought to court it was unlikely that the trial would go ahead due to the time slot running out. The IDVA advised that Jane wanted a restraining order and if nothing else this this was her main goal for the court case. The OIC confirmed he had the restraining order terms wanted by Jane in his bundle of court papers.
  9. Around 30 minutes later the OIC received a call back stating that a police unit had attended and they had found Jane deceased at her home address.
  10. The following day the IDVA emailed the WCO to enquire what had taken place at court after she had left. She was advised that a hearsay trial was planned. This took place and Craig was sentenced to two years and 11 months imprisonment.

The involvement of Devon and Cornwall Police

  1. The first contact between Jane and Devon and Cornwall Police (DCP) was in the middle of November 2018. Jane contacted DCP and advised them that her relationship with Craig had ended and that he had not responded well to this. He had refused to leave Jane’s address and wanted to work things out with her. Once Craig was told that the police were going to attend, he left the address and was not present when DCP officers arrived. Jane described no offences to them. A non-crime domestic abuse enquiry was created and a Standard Domestic Abuse Stalking and Harassment (DASH) assessment was completed. A Green (low risk) Vulnerability Screening Tool (ViST) was also completed. The police removed Craig’s belongings and took them to his home address.
  2. The next contact was two weeks later at the start of December 2018. Jane contacted DCP and reported that Craig was present at her address and was intoxicated, he was asking to stay with her. His flat had been damaged in a fire. Jane had asked Craig to leave her home and when he refused to do so he became aggressive. DCP attended and again no offences were disclosed. Craig left in a taxi when officers arrived. The IMR states that safeguarding advice was provided to Jane. A non-crime domestic abuse enquiry was created and a Standard DASH was completed.
  3. The next contact took place seven months later in early July 2019. DCP received a 999 call from Jane. She reported that Craig had broken into her home and sexually assaulted her. She later provided a statement to officers detailing the allegations. This resulted in the recording of three crimes Sexual Assault, Harassment Without Violence and Burglary. Craig was detained by officers at the scene, arrested and taken into police custody where he was interviewed.
  4. Following this interview, a decision was taken not to pursue the burglary allegation. There was insufficient evidence to seek a charging decision for harassment and sexual assault and Craig was released on conditional police bail to enable DCP officers to gather further evidence. One of the conditions of his bail was that he was not to contact Jane, directly or indirectly through any means. An Amber (medium) ViST was created for Jane’s son, who was not present during the incident.
  5. This incident generated a high-risk DASH and as a result safeguarding measures were put in place. This included the provision of an alarm at Jane’s home and a referral was made to MARAC and to Splitz. A police Domestic Abuse Officer (DAO) was allocated. A note was also created in relation to Jane’s address. This was placed on the DCP computer system.
  6. Two days after the incident, Craig breached his bail conditions. He contacted Jane indirectly via her uncle, stating that he loved her and that he was very upset. Jane did not want to be seen by officers when the matter was reported and indicated she wanted to arrange an appointment to see an officer at a time convenient to her. Five days after this contact, Jane provided a statement to officers and this was passed to the OIC. The OIC made the decision to deal with this incident as a separate allegation of harassment rather than a breach of bail.
  7. A further nine days later in mid-July 2019 the police received a 999 call from Jane stating that Craig had been attempting to contact her and that he had approached her at the supermarket. This was a breach of his bail conditions. He was located by DCP officers and arrested. Whilst in Police custody a decision was sought from Crown Prosecution Service (CPS) to charge Craig with offences relating to the incident at Jane’s home address in early July 2019. The CPS authorised charges of Sexual Assault, Harassment and Violence to Secure Entry. Following being charged Craig was refused bail and kept in custody for an appearance before Magistrates Court. The Court refused to grant Craig bail and instead sent him to prison, where he would be held pending his next Court appearance.
  8. The Harassment investigation was to continue at the request of CPS. A further statement from Jane was required. Over the following weeks the OIC made numerous appointments with Jane, but she either cancelled or the OIC was committed with other matters and therefore no further statement was ever taken.
  9. At the start of August 2019 DCP made a MARAC referral. This was discussed at a pre-MARAC meeting and as Craig had been charged and remanded it was decided only to mention at the MARAC, this was standard practice. IDVA support was in place by this time and was continued, along with DAO input.
  10. In mid-October 2019, the Splitz IDVA contacted DCP. Jane, who was in a distressed state, had contacted her. She had received a letter from Craig, who was in prison on remand. The exact contact of the letter was not disclosed. The IDVA arranged to meet Jane the following day and make a further appointment to meet her with the OIC to gather an outstanding statement regarding the harassment and to be sighted on the contents of the letter Craig had sent. The DAO emailed a safeguarding form to the prison advising them that Craig had been charged with offences relating to domestic abuse and as such he should be prevented from making contact with Jane.
  11. The letter from Craig to Jane was not seized and a further statement was not obtained from Jane as she did not attend the appointments with the OIC and IDVA.
  12. A file was submitted to the CPS for consideration for a further charge of harassment against Craig.
  13. The letter from Craig to Jane was later found at the time of her death.
  14. The final involvement of DCP was when Jane was found deceased by officers in early January 2020. Concern had been raised in relation to her by the IDVA as she had not attended court to give evidence against Craig. When officers attended her address, they found Jane deceased. There was no suicide note, but there was a list of grievances she had with her stepfather. Jane’s death was investigated by officers and a file submitted to the Coroner. The cause of death was believed to be an overdose using prescribed medication.

14. The views of Jane’s mother

  1. The Chair was able to conduct an interview with Jane’s mother in April 2021. This interview took place virtually as a result of the COVID19 restrictions. Prior to the meeting Jane’s mother had contact with Safer Devon officers, who provided her with information about the DHR process and ensured she was fully informed about the progress with the review to that point.
  2. The purpose of the interview was to provide Jane’s mother with an opportunity to give her insights and views about Jane and her circumstances. It also aimed to ensure that a clearer picture of Jane as a person could be established.
  3. Jane’s mother started by talking about her own background. She was born in London and moved to Devon 30 years ago. She works for the NHS and has also run a small local café. She has worked for the NHS for 12 years. Sadly, her partner died last year. Jane’s mother also stated that she had a heart operation in 2018 and the stress of Jane’s death has not helped her recovery.
  4. Jane was born in London and was 11 when the family moved to Devon. Jane has a sister, and two stepbrothers. The children went to a former grammar school in London and when they moved to Devon with their older stepbrother, they were nicknamed the ‘posh kids’. Jane didn’t excel in school and had her son Colin at the age of 18. Six years later she had her daughter Janet, and she went back to college and trained as a beauty therapist. Jane worked hard in the café where her mother worked, but really wanted to set up her own business.
  5. Jane broke up with Colin’s dad when Colin was a year old. Jane’s mother said that Colin’s Dad was allegedly aggressive, and on one occasion grabbed Colin and tried to push Jane’s mother’s head through a door when she intervened.
  6. Jane met Janet’s dad and they were together for nine years, but he had a drink problem stemming from childhood issues. They broke up due to constant arguments.
  7. Jane went on to have her youngest son Roger. Jane left Roger’s dad due to his drug misuse. Jane gave birth to Roger at her mother’s house, and it was a traumatic birth for mother and baby. At the time Roger’s dad denied he was his son.
  8. When Roger was 18 months old Jane collapsed. She was told it was ‘all in her head’ but was later found to have a prolapsed disc and trapped nerve. This led to her experiencing depression.
  9. Jane saw someone at the Depression and Anxiety team in the local hospital, but that person then went off on long term sick.
  10. Roger’s Dad started seeing him and asked for full custody saying Jane was using illicit drugs and he and his partner took Roger one night leaving Jane devastated. Roger was then diagnosed with a serious health condition. Jane was not allowed to see Roger when he was in hospital.
  11. Jane was suffering from low self-esteem and had gone from a size 10 to a size 18. Her mother believes this was due to the medication Jane was taking.
  12. Jane’s mother said that Jane met Craig, who was known to the family (and lived in the same block of flats as Colin) and although they talked to her about his aggression, Jane said she thought he had changed.
  13. Jane’s mother said that once Jane was in the relationship with Craig, she stopped communicating and visiting family as much as she had prior to meeting him. Jane’s mother said that Craig displayed coercive behaviour. Jane’s mother described how one evening Jane went to her mother’s road and called her from outside where she stood in her pyjamas. Craig turned up and the police were called. After this she told her mother less and less about her relationship with Craig.
  14. Jane’s mother described how one evening, Craig went through Jane’s window and it was the neighbours who called the police. She knew that Jane gave a statement to the police.
  15. Jane’s mother knew that Jane was due in court to give evidence against Craig. On the Thursday before the court hearing Jane’s mother was with Jane’s sister when Jane called and asked them both to go over that evening as she had something to tell them. Jane’s mother described how she went to the house, knocked on her door but Jane did not answer. She said she called Jane a few times but there was no reply. She said that Jane was due to meet a professional from the hospital and he went around on the Friday but left when there was no response.
  16. Jane’s sister lives relatively close to her mother and they have provided support to each other.
  17. Jane’s mother talked about her partner, who she met when Jane was four years old. They were married for 19 years but their relationship ended. They divorced but later he regretted leaving and they recommenced a relationship but did not re-marry.
  18. Jane’s mother described how the relationship between her partner and Jane was ‘rocky’ post their divorce and once they got back together. She felt Jane’s personality changed as a result of the medication she was taking.
  19. Jane’s mother described how her relationship with Jane changed and that the communication between them became more sporadic and that Jane was distant, when in the past they had been very close.
  20. Jane’s mother said that she felt that the hospital team who were dealing with Jane’s back pain did not respond to her properly and did not take her problem seriously. She also felt that Jane’s mental health was not good but that she may have needed more specialist input.
  21. The interview concluded by the Chair thanking Jane’s mother for her time, offering condolences and provided information about the next steps in the DHR process.

15. Analysis of the Individual Management Reviews

Primary Care – the GP practice

  1. The GP practice had numerous contacts with Jane in the period covered by the DHR, and prior to that timeframe. The IMR demonstrates that the professionals at the GP practice had a good knowledge of Jane and her background. This included her history of depression and her physical health difficulties.
  2. There is evidence that the practice were aware of Jane’s depression dating back to 2007 when she first exhibited symptoms. The professionals at the practice were also aware of other events in Jane’s life that affected her mental health and wellbeing, including her chronic back problem.
  3. The GP practice had also detailed the incidence of post-natal depression and appropriately referred Jane to community mental health services as she was experiencing suicidal ideas.
  4. There is evidence that the GP practice offered a range of treatment and support to Jane. This included anti-depressant medication as well as pain relief medication to alleviate her back pain.
  5. Jane was also appropriately directed to other services including further referrals to the Community Mental Health Team (CMHT) and for psychological therapy to assist her in coping with her physical symptoms.
  6. Jane’s contact with the GP practice was often by phone and it is clear that those calls to the practice were responded to swiftly. Jane was able to contact the practice easily and the IMR demonstrates that although she sometimes failed to attend in person appointments, the practice was flexible in enabling her to have phone consultations on numerous occasions.
  7. Although the GP practice did provide some support to Jane in relation to her depression, the main feature of their interactions with her was her back pain and the chronic condition that caused that pain.
  8. Although Jane was referred for psychological therapy she did not attend those appointments. The IMR demonstrates that the reason for this revolved around her ability to travel to those appointments.
  9. The GP practice took account of National Institute for Care Excellence (NICE) guidance for the treatment of depression. The GP prescribed a Selective Serotonin Reuptake Inhibitor (SSRI) in line with NICE guidance. The GP had not considered a different type of anti-depressant as this would have been outside the scope of practice in primary care. The usual response in response to non- improvement would be for a specialist psychiatric opinion. Jane did not attend such appointments to allow for a further assessment and treatment review.
  10. The IMR states that due to Jane’s inconsistent attendance at appointments it had not been possible to obtain a specialist opinion in relation to her treatment for persistent low mood.
  11. Within primary care a review for a patient presenting with chronic depression includes a review of current mood, suicide risk, review of current treatment including compliance and effectiveness as well as side effects. These reviews did take place. The reviews considered wider social circumstances including any safeguarding concerns. None were identified.
  12. Where clinically indicated liaison would take place with other agencies. There is limited evidence of such liaison taking place, but it did happen. There are no identified gaps of care within the reviews provided by the GP practice for Jane.
  13. Jane was referred for psychological therapy but not by the GP practice, rather this was done by the Occupational Therapist (OT) at the RD&E hospital. The OT did not notify the GP practice and as such they were unaware of the referral. If that information had been shared, it would have assisted the GP practice in their understanding of what was happening for Jane, and they may have been able to provide support and encouragement to her in attending those sessions. They would also have been able to provide advice and information to the psychological therapy service about Jane’s difficulties in attending appointments.
  14. Jane’s mental health was clearly of concern to the GP practice and they were well aware of the background to this. The internal peer review of her case identified that she had a significant risk profile for suicide, not least this was associated with long term depressive symptoms, chronic pain, high dose medication, some of which were highly controlled drugs and challenges related to possible social isolation. It was not until July 2019 that the GP practice became aware of issues relating to domestic abuse.
  15. The GP practice has clearly demonstrated that it has considered the opportunities to mitigate the risks that Jane experienced and presented. There is evidence that the referrals to CMHT and the prescribing practice were appropriate.
  16. In late September 2019 the OT did contact the GP practice to advise them that Jane was experiencing suicidal thoughts. The practice responded to this by phoning Jane on the same day, and again the following week, leaving messages on both occasions. Jane did not respond to those messages and no additional follow up was undertaken by the GP practice. If this had happened it is likely that Jane would have been referred to the local crisis team, but this did not happen. The IMR states that even if that had happened it may not have mitigated the risks that were heightened as Craig’s trial approached.
  17. Domestic abuse was not a major feature of the interactions between Jane and the GP practice. The practice became aware of the domestic abuse in July 2019. This was when she presented at the practice following the assault on her. She did tell the practice that the domestic abuse had been perpetrated by Craig and that she was getting support from Splitz.
  18. There is evidence that the GP practice had been one of several in Devon that had received funding to pilot the Identification and Referral to Improve Safety (IRIS) project, from April 2019. Practice staff were able to confirm that the use of the programme had improved their ability and confidence in recognising and responding to domestic abuse. However, there were no examples that any specific action was taken in this case as a result.
  19. At the end of December 2019 Jane did make a request for additional pain relief medication, specifically Morphine. This was less than three weeks before she died. Jane was concerned she might run out of medication over Christmas. The request for medication was made to reception staff and was passed to the doctor for review. It was noted that a prescription had been issued the day before for the usual monthly amount. Therefore, a further prescription was not issued. This was in accordance with prescribing policy and practice and shows that the practice were being careful to ensure that Jane did not have excess supplies of medication. This has led the DHR panel to make recommendation two later in this report.
  20. Although it is clear that the GP practice made appropriate referrals to other services, the IMR provides clear evidence that Jane found it difficult to attend those services.
  21. The GP practice IMR makes two recommendations and these are set out later in this report.

The Royal Devon and Exeter NHS Foundation Trust (RD&E)

  1. The majority of contact between Jane and RD&E professionals related to her chronic back condition and the associated significant pain that she experienced as a result.
  2. The treatment that Jane received was clearly focused on the alleviation of that pain. It involved at least two procedures that attempted to nullify the pain by using nerve blocking interventions. It also included the use of pain relief medication, some of that using highly controlled drugs including Morphine.
  3. The IMR demonstrates that the professionals treating Jane were aware of her previous history of mental health difficulties, notably depression. They were aware of three previous overdoses, all of which took place in Jane’s teenage years and a further overdose that took place in early 2015.
  4. Jane’s back pain was treated effectively and in accordance with expected practice. Although her condition showed some change in the time she was being seen by RD&E, those changes were not considered to ones that provided an explanation for the high levels of ongoing pain she experienced.
  5. It is clear that professionals felt that the nature of the physical pain Jane experienced had a detrimental effect on Jane’s mental health and emotional wellbeing. They expressed the view that some of this emotional distress was in excess of the presenting clinical symptoms and this may point to other potential causes.
  6. Despite this view, there is clear evidence that the effect of her back condition was particularly debilitating for Jane and at times this made her life very challenging and that it imposed limitation on her. These limitations extended to her ability to attend appointments that required any lengthy travel. There is evidence that demonstrates that professionals at the RD&E made efforts to ensure that rehabilitation services could be offered to Jane as close to home as possible.
  7. Despite what were demonstrably positive relationships with her key care providers at RD&E, Jane often missed appointments and did not respond to letters or phone calls to rearrange those appointments.
  8. The IMR states that Jane did disclose to professionals that she experienced a lot of stress in her life. In particular she talked of the challenges and difficulties of parenting while in constant pain. It was in this context that she was referred for assessment by a Clinical Psychologist. This assessment, which took place in May 2019, resulted in a lengthy letter to Jane’s Consultant. This set out a diagnosis of anxiety but also noted that Jane was not experiencing any suicidal thoughts or ideation. Jane did consent to being referred to the local Improving Access to Psychological Therapies (IAPT) service.
  9. The Pain Clinic that treated Jane did ask questions about her home life but there is no evidence that she was asked specifically about domestic abuse.
  10. The care and treatment offered to Jane by the RD&E was of the standard that would be expected.


  1. Splitz had perhaps the most in depth professional relationship with Jane of those organisations that had contact with her. The input of the IDVA was clearly of great help to Jane and the IDVA herself worked effectively to build a relationship of trust with Jane. As a result, the IDVA was able to garner further information that enhanced the understanding of the challenges she faced in her daily life and the impact of the domestic abuse perpetrated against her.
  2. The catalyst for the involvement of Splitz was the incident in July 2019 when Jane asked Craig to leave her home and ended their relationship. It is known that he did leave but then returned, forcibly entering her home through a window, and then sexually assaulting her. In the course of this, he threw her to the ground and hurt her back. It is also believed that he attempted to smother her.
  3. There is clear evidence of effective liaison and communication between the IDVA and other professionals and agencies. Most notably this took place with court officers, the police including the DAO and housing agency officials.
  4. The IDVA kept detailed and extensive notes and records of her interventions with Jane. This is well evidenced in the detail contained in the chronology provided. It shows that the IDVA conducted a range of work and was careful to ensure this was properly documented.
  5. The IDVA was able to secure an alarm for Jane’s home and was clearly particularly concerned to do what she could to ensure Jane’s safety. She was also especially concerned to ensure Jane felt supported in preparing to give evidence in court at Craig’s trial. This extended to prolonging her involvement even once Craig was remanded in custody.
  6. The IDVA effectively supported Jane in preparing a Victim Personal Statement and the application for a restraining order against Craig. She also worked to support and advise Jane on her search for alternative housing in another area.
  7. The support to be provided was always carefully explained, and great care was taken to ensure confidentiality. A safety plan was developed with Jane and she was regularly provided with a written record of the advice and guidance she had received. The IDVA also completed a risk assessment that was regularly updated.
  8. The IDVA made sure that Jane was kept updated with all developments in the court process, as well as any discussions at MARAC and communications with the Officer in the Case from the police
  9. It is evident that Jane was in control of the support she received and the IDVA acted in a person-centred way throughout her interactions. The IDVA also sought regular supervision and guidance from her line manager and the wider team where appropriate.
  10. All this demonstrates good and effective practice on the part of the IDVA and Splitz.

Devon and Cornwall Police

  1. Devon and Cornwall Police (DCP) had several contacts with Jane, the majority of these occurred within the timeframe covered by the DHR process.
  2. There is clear evidence that DCP responded swiftly to contact from Jane and attended promptly. The information provided for review indicates that DCP officers were focused on Jane and her safety in their contact with her.
  3. In response to her call in early July 2019, in which Jane reported the incident of sexual assault against her after Craig had entered her home, DCP officers were able to attend quickly and were able to locate and detain Craig.
  4. DCP officers interviewed Craig under caution. Following that interview a decision was taken not to seek authority to make a charge against Craig as there was insufficient evidence to do so. It is clear that DCP officers considered this carefully and sought the necessary advice and authority from a specific officer, known as a Gatekeeper. Such officers usually hold the rank of Sergeant and have received specialist training for the role and responsibility for taking such decisions.
  5. The decision of the Gatekeeper was that there was insufficient evidence to seek authority to charge from the Crown Prosecution Service while Craig remained in police custody. The decision was clearly taken with diligence and in the knowledge that there were still witness statements to obtain and Craig’s mobile phone was still to be downloaded and analysed. These were likely to be time consuming but valid lines of enquiry for the police.
  6. DCP took the decision to release Craig on bail but with conditions. This was an appropriate action and in accordance with accepted practice and within legal frameworks. The conditions put in place included restrictions on where he could go and that he could not contact Jane directly or indirectly. There is evidence that demonstrates that an Inspector, who reviewed the circumstances of Craig’s arrest, made the decisions in relation to bail by taking into account the nature of the offence(s) and whether releasing him on bail with restrictions was appropriate and proportionate. The fact that Craig was released on bail with the specific conditions outlined demonstrates that DCP considered the risks to Jane and carefully considered the options available before proceeding.
  7. It was appropriate for DCP officers to complete a DASH in response to the incident. There is evidence of clear guidance being available to officers about when to complete a DASH and this guidance was followed. Officers considered the range of information they received from Jane when completing the DASH. The information contained in the IMR demonstrates that the grading on the DASH as high risk was appropriate.
  8. DCP officers allocated a Domestic Abuse Officer (DAO) to the case, this was part of the safeguarding approach they undertook and enabled the provision of a Home Office alarm and also a warning flag being placed on file in relation to Jane’s address. This meant that any officer called to the address would be aware of the intelligence related to her case.
  9. Because of the high risk grading on the DASH, Jane was referred to the MARAC. Her case was discussed at a MARAC in late July 2019 and as a result the Splitz referral was made and an IDVA was allocated. Given Craig’s previous history of domestic abuse, the MARAC considered the use of the Domestic Abuse Disclosure Scheme (DVDS). The MARAC was of the opinion that Jane should be aware of Craig’s previous history in order to assist her in making informed choices and decisions about her own safety. This demonstrated that they were focused on her needs and her safety. The disclosure was made in mid-October 2019 by the IDVA.
  10. While on bail Craig made two attempts to contact Jane and this was a breach of his bail conditions. The first occasion was when Jane was approached by one of Craig’s family members, who passed a message to her from Craig, saying that he still loved her. This happened three days after the offence in July 2019. Jane did provide a statement to DCP two days after the approach from the family member. The police considered it appropriate for this statement to be taken in a fixed appointment rather than the deployment of officers at the time. The statement was forwarded to the Officer in the Case (OIC). It is the judgment of the IMR author that it would have been best practice to have taken the statement from Jane on the day of the breach of bail conditions, but there is no evidence that the delay had any negative or adverse impact or that it increased the risk to Jane.
  11. The second breach of bail conditions was in mid-July 2019. Jane had dropped items belonging to Craig at his new address. There is no information to indicate if she knew whether he would be present or not. Craig was present and approached Jane and attempted to embrace her. Jane informed the OIC of the breach. The OIC decided that rather than respond to the two separate incidents of bail breach, Craig should be located and arrested for harassment. The IMR states that the rationale for this decision was that although breaching Police Bail carries a power of arrest, it only does so if the offences for which the person is bailed are at a stage where they can be formally charged.
  12. The OIC recorded on the log that at the time charges were not ready and therefore arresting Craig for breaching his bail would be ineffective and would not carry any sanctions. However, if he was arrested for the substantive offence of harassment, he could be kept in custody for up to 24 hours and be formally interviewed for the matter.
  13. Craig was located and subsequently arrested. It is the opinion of the IMR author that this was an effective use of legislation and an example of the understanding of the OIC to act proactively and effectively towards someone who clearly had disregard for his bail conditions.
  14. Craig appeared at Magistrates Court and was refused bail. The fact that he had breached his Police Bail conditions added further weight to what was already a serious matter coupled with the fact that this was a High-Risk Domestic Abuse case. Refusing his bail and keeping him in prison was appropriate and had the added outcome of safeguarding Jane.
  15. Craig entered a not guilty plea to all the charges against him and a case was then prepared for Crown Court. DCP referred Jane to the Police Witness Care Unit (WCU). This unit is staffed by Police Staff and their duties include liaising with witnesses, offering support and preparing them for attending court and giving evidence.
  16. This referral and subsequent engagement demonstrated an understanding by DCP of the need to support Jane in preparing to give evidence against Craig. There is clear demonstration in the IMR of effective interactions between Jane and the WCU. This included enabling Jane to give evidence via a video link from another room in the court building, consideration of her physical health issues and the impact they would have on her travelling to court. The WCU explored ways to assist with this and arranged taxi transport and booked a hotel room for Jane.
  17. The last contact between the WCU and Jane was to confirm her taxi and hotel bookings.
  18. In October 2019 the IDVA from Splitz contacted DCP and spoke to the DAO. She advised that Jane had received a letter from Craig, who was in prison on remand at the time. The OIC was alerted to this and a discussion took place between the IDVA, DAO and OIC about how to respond to this. They agreed that the IDVA would arrange to meet with Jane and then arrange a date for the OIC to attend and retrieve the letter and take a further statement. The DAO also wrote to the prison to alert them that Craig had been able to send the letter, including a safeguarding form and that the prison should monitor his mail and prevent him making contact with Jane.
  19. The Safeguarding Form used by DCP has been designed so that the Police can inform prison staff when a Domestic Abuse perpetrator comes into the prison. The purpose being that the form will inform the prison of any safeguarding issues, particularly around preventing communication between the perpetrator and the victim. Once highlighted to the risks via the Safeguarding Form, the prison staff can put measures in place to prevent any communication. The form should be completed and submitted at the point when a perpetrator is charged and put before the Court. On this occasion the form was not completed at the point when Craig was charged and remanded and subsequently the prison was not aware of any ongoing safeguarding issues. This has led the panel to make recommendation four later in this report.
  20. The result was that Craig was able to compose and post a letter from the prison to Jane without being challenged or prevented. Whilst this form is readily available to officers, the IMR process has revealed that there is no formal policy or guidance on the use of the form and as such it is left to the individual to use or not. The IMR process has also highlighted that some DAO’s across DCP use it routinely and others do not or only use it sporadically. This is not good practice and is an issue for DCP to address.
  21. The letter from Craig to Jane was never retrieved prior to her death. The OIC recorded accurately his attempts to meet with Jane over the following weeks and why they did not meet up. This was primarily because Jane cancelled their meetings.
  22. The letter was later discovered after Jane’s death by a relative and passed to the OIC. The IMR author has seen a copy of the letter. Their judgement is that the contents of the letter are by no means threatening. However, its receipt would have had a direct impact on Jane. The letter is written, rather than typed and is two pages long. Craig attempts to explain his guilt and regret at his treatment of Jane and tells her how he is attempting to change his life with regular exercise, counselling and medication. The letter is signed off by Craig asking Jane to forgive him and keep in touch should she want to.
  23. The DCP IMR makes one recommendation, which is set out later in this report.

16. Conclusions

  1. This section sets out the conclusions of the Domestic Homicide Review panel.
  2. Having reviewed and analysed the information contained within the Individual Management Reviews and having considered the chronology of events and the information provided the panel has drawn the following conclusions relating to organisational involvement and come to more general conclusions about this case.
  3. Jane had a short relationship with Craig, but it was one that was characterised by his controlling and coercive behaviour. Jane’s decision to end the relationship was not one that Craig reacted to positively and ultimately this led to his assault upon her in July 2019.
  4. Craig sought to move in with Jane very soon after their relationship started. While such a swift desire to co-habit is not necessarily unusual, research does point to this being a marker for the potential of domestic abuse. Dr Jane Monkton Smith’s research on the eight stages homicide timeline indicates that where a ‘romance develops quickly into a serious relationship’ this should be considered a factor on the timeline to domestic abuse and homicide.
  5. Evidence from research and surveys of victims indicates that the risk of further violence and harm actually increases at the point at which a victim leaves a perpetrator. A study of 200 women’s experiences of domestic abuse commissioned by Women’s Aid (Humphreys & Thiara, 2002) found that 76% of separated women had experienced post-separation verbal and emotional abuse and violence, including: 41% subjected to serious threats towards themselves or their children; 23% subjected to physical violence; 6% subjected to sexual violence; and 36% stated that this violence was ongoing. There is evidence that the risk of domestic homicide is increased post-separation.
  6. Canadian research has indicated that 40% of women and 32% of men who were in a former violent marriage or common-law relationship experienced violence post-separation. Research demonstrates that the risk of lethal violence is particularly high following parental separation, especially within the first few months .
  7. More recent research in 2017 published in the Journal of Interpersonal Violence found that separated women were more likely than non-separated women to be victims of interpersonal violence in most years from 1995 to 2010.
  8. Taking the evidence into account indicates that Jane was at higher risk of domestic abuse and violence due to the fact that she had recently ended her relationship with Craig.
  9. Jane was coping with a long-term back condition. This had a direct impact on her life, both in terms of her ability to travel to appointments, but most significantly it meant constant and debilitating pain. She underwent treatments that were intended to alleviate that pain. It is however clear from the information reviewed, that the level of pain remained high and it was constant. There is little doubt that experiencing this level of pain and the other impacts it brought had a direct and adverse impact on Jane’s mental health and wellbeing.
  10. Jane had a recorded history of depression, suicidal ideation and of overdose. It is striking that this history and those incidents of self-harm are recorded, but there is very little further exploration of the antecedents and responses to them. This represents a significant gap in the knowledge about Jane that was available to professionals. Had that information been given greater focus, it is likely that it would have informed a clearer view of her risk of future overdose and suicidal intent.
  11. There are examples of professionals not communicating as effectively as they could have done. In particular, when the RD&E Occupational Therapist referred Jane to the IAPT service, this information was not shared with colleagues in primary care at the GP practice. It is accepted good practice that where the person remains the responsibility of primary care, as Jane was, that they would review and establish if access to the service had been successful and where necessary offer support to overcome any barriers to access. Because the GP practice was not aware of the referral to IAPT, professionals at the practice could not do this. While it is the view of the DHR panel that this did not directly influence the outcome, it is an area of practice that requires further improvement.
  12. The GP practice was aware of Jane’s mental health history and the incidence of depression. However, there is little evidence that this was discussed or explored with her in any detail. It is understandable that the focus of the consultations was on her physical issues, notably her back condition and the resulting pain management. It would have been helpful for Jane’s mental health, including the impact of her physical condition on her mental health to have been considered more fully.
  13. The information reviewed suggests that in the period covered by the DHR, Jane’s mental health did not deteriorate to a point where specialist mental health services would have been appropriate or necessary. In the past this was not the case, but her engagement with those services was sporadic and she was ambivalent about accessing the support the CMHT could provide. Having said this it may have been helpful for the GP practice to have sought advice and guidance about Jane and her management in the context of the impact of her physical condition on her mental health and levels of anxiety.
  14. Two-thirds of people with a common mental health problem also have a long-term physical health problem. One of the most common types of long-term pain is back pain. Many people with back pain find it difficult to engage in normal activities and can experience symptoms of depression and anxiety. Research has shown that clinicians should be aware of potentially high rates of emotional distress syndromes in chronic low-back pain and enlist mental health professionals to help maximize treatment outcomes.
  15. Jane’s mental health does appear to have deteriorated in September 2019. Although the GP practice was aware that Jane was experiencing suicidal thoughts, their attempts to contact her and follow up were not responded to. That follow up was restricted to phone calls. Other options, including writing to her or placing a reminder on her notes to ensure that any clinician in contact with her could raise the issue were not undertaken. The DHR panel is aware that the GP practice has understood that this is an area for improvement and one they are addressing. This led to the panel making recommendation three later in this report.
  16. The GP Practice was one a several practices within the Devon Clinical Commissioning Group footprint to receive additional funding to pilot the Identification and Referral to Improve Safety (IRIS) project for two years from April 2019. This is a general practice based Domestic Violence and Abuse training, support and referral program for primary care staff. The practice did not utilise the IRIS model in their contact with Jane. The rationale for this has not been able to be established but it had only been in place for three months and as a potential result staff were unsure or unsighted at that early stage of implementation.
  17. The practice has since confirmed that following introduction of IRIS, now over three years ago, practice staff have increased in confidence recognising domestic abuse and appropriate questions to ask a patient who they suspect may be experiencing this. The practice has regular contact with an IRIS counsellor which has continued during Covid 19 remotely.
  18. The WCU worked effectively to support Jane and demonstrated practice that was of a high standard. They took clear steps to support her in preparing to give evidence in the trial and made specific arrangements to make this easier, including hotel booking and transportation as well as the plans for a video link.
  19. Although the WCU worked effectively, it is less evident that they, or other agencies, sufficiently considered the emotional and mental stress that was placed on Jane in respect of preparing to give evidence against Craig. It would have been helpful for other agencies to have been alerted to the fact that Jane had potential vulnerabilities so that a more holistic and multi-agency plan of support could have been put in place for her. They did demonstrate some good practice and this led the panel to make recommendation one.
  20. The contact from RD&E was of a good standard and there is evidence throughout the IMR that the professionals involved in Jane’s care and treatment were compassionate and were person centred in their approach.
  21. It was through the Pain Clinic that Jane was referred for IAPT services. This referral was not notified to the GP Practice. It is clear that there was recognition of Jane’s mental health issues and her previous suicidal intent. There is evidence that this was recognised and discussed but it is not evident that this was given any significant focus or consideration.
  22. For the majority of the period covered by the DHR, agencies were unaware of any issues of domestic abuse in relation to Jane. Her relationship with Craig was relatively short in duration and the only incidence known to all was the one in July 2019. Other incidents from 2018 were not widely known about, other than by DCP.
  23. Currently RD&E staff do not have access to a patient’s mental health notes. In situations like this staff are reliant on the patient to inform them of any mental health services that they are involved with. RD&E staff could have contacted Devon Partnership Trust Psychiatric Liaison Team or the GP to find out contact details of any mental health professionals involved. They may have been able to work together to encourage Jane to attend appointments. If RD&E staff were able to access relevant mental health notes in future it would help them identify risk factors related to an individual’s mental health.
  24. Splitz had the most contact with Jane. In particular the IDVA involved had numerous contacts and provided a high level of support and advice. It is the conclusion of the DHR panel that the IDVA displayed a high level of professionalism and commitment, and that she exhibited excellent practice throughout her work with Jane.
  25. The IDVA displayed good communication with other agencies, most notably with DCP but also with housing agencies while exploring options for Jane to move to another area.
  26. The IDVA provided emotional support and took care to follow up messages and phone calls. She undertook additional work to assist with the preparation of the VPS and to attend court to support Jane.
  27. The IDVA sought supervision and advice from her manager appropriately.
  28. The work of the IDVA and Splitz demonstrated a high degree of focus on Jane as a victim of domestic abuse and sexual violence. There was a clear person centred approach, which was clearly and accurately recorded. They also kept Jane’s case open when it would usually have been closed in order to ensure support was available and was consistent.
  29. Overall the conclusion of the DHR panel is that the intervention of Splitz was of a high standard.
  30. DCP did respond to Jane in an appropriate and swift way. In doing so they took care to ensure assessment of her risk using the DASH process. Recording of these assessments was accurate and timely and led to a referral to MARAC. This was good practice.
  31. The decisions taken in relation to Craig and the granting of bail with conditions were, in the judgment of the DHR panel, appropriate and proportionate. It demonstrated a thorough understanding of the legislative frameworks and how they could best be used to respond.
  32. The use of the DVDS was another example of good practice. It is the conclusion of the DHR panel that it was appropriate to make the disclosure of Craig’s history to Jane. This was done after careful consideration and demonstrated a wish to ensure she could take informed decisions.
  33. DCP did experience some challenges in engaging Jane, and she sometimes failed to respond to calls or appointments. There is evidence that they sought to follow up with her and on most occasions were successful in doing so.
  34. The one deficit highlighted from the DHR process is that failure to complete the Safeguarding form when Craig was remanded to prison. This meant that the prison was unaware that he was prohibited from contacting Jane, and as a result he was able to write to her. There was a lack of understanding and an inconsistent approach to the use of the Safeguarding form. This is now being addressed by DCP. This led to the panel making recommendation four.
  35. The co-ordination between the OIC, DAO and the IDVA was effective and demonstrated good information sharing and a joined up approach.
  36. The use of routine enquiry about domestic abuse is largely absent, although there is evidence that training and awareness through IRIS had been undertaken in primary care. NHS Devon CCG is in the process of commissioning an Interpersonal Trauma Response Service for all GP practices in Devon, to start in April 2023. We believe that this service will significantly improve the willingness and ability of primary care practitioners to identify and support patients with current or historic experience of domestic abuse and/or sexual violence. A strong element of the business case for this service was learning from previous DHRs in Devon.
  37. There is little consideration of the impact of the use of prescription medication in the contacts between Jane and health professionals. The only issue of significance was when she requested additional medication in the run up to Christmas 2019. The request was denied because she only recently had a prescription approved. Given her mental health issues and history of overdose it is a cause of concern that greater prominence was not given to the use of highly controlled prescription medication and the risks associated when used by someone with a history of overdose.
  38. There has been a dramatic increase in fatal poisonings involving opioid analgesics globally. Research has shown that comorbid conditions that pose risks for suicide, especially depression, are prevalent in people living with chronic pain. The true numbers of failed attempts and successful suicides are unknown and may never be determined. Yet risk factors for suicidal ideation are so high in this population that it must be assumed that some proportion of those who die of drug overdoses might have intended to end their lives, not just temporarily relieve their pain. This led the panel to make recommendation two.
  39. The degree to which Jane’s mental health was considered as a potential risk in relation to her overall wellbeing did not feature strongly in the information provided to the DHR panel. It is our conclusion that Jane did experience anxiety and low mood, and that much of this was related to her back pain. The extent to which her anxiety was heightened by the prospect of giving evidence cannot be determined.
  40. There is no clear evidence that demonstrates that Jane received any support related to the sexual assault committed against her.
  41. It is by no means certain that the circumstances of Jane’s death were linked to her chronic pain, but it clearly had a direct impact on her mental health.
  42. It is clear that Jane’s experience in July 2019 was traumatic. She coped with a range of challenges in her life, but the evidence indicates that she was at times ambivalent about accepting or engaging with support services, although the IDVA was successful in building a good working relationship with her.
  43. Her case highlights issues relating to support to victims of domestic abuse, both in terms of the impact of the abuse itself but also giving evidence, and the need to identify and respond to mental and physical health concerns in a co-ordinated and holistic way.

17. Lessons to be learnt

  1. The majority of the lessons learnt from this review are contained within the conclusions. However there are some specific learning points that the DHR panel have identified. These are as follows:
  2. There is a need to give additional focus to the knowledge, understanding and approach of DCP to adult safeguarding when individuals are detained in Her Majesty’s Prisons and the use of the local frameworks, processes and forms for communicating safeguarding issues to the prison.
  3. The lack of a national approach to the use of Safeguarding forms within constabularies means that practice will vary depending on geography. There is a potential for confusion and inconsistency to develop without clear advice and guidance within constabularies themselves about the use of such forms and processes.
  4. Access to records and notes between different agencies and between departments within agencies themselves was problematic. Without access to notes and records it is hard for professionals to build a clear picture of a person’s circumstances and the other supports they are receiving.
  5. There is a need for more proactive communication between professional across agencies. There are examples in this case that demonstrate that professionals in health organisations did not communicate the outcomes of their interventions or actions, including not advising that a referral had been made. The effect of this did not have direct influence on the outcome, but highlights the need for improved inter-agency and inter-professional dialogue and partnership working.
  6. A further learning point from this DHR is the need to engage primary care colleagues in MARAC discussions and decisions. The GP practice was not in receipt of information from the MARAC and this is something that should be addressed.
  7. Given that Jane did not recognise herself as a victim of domestic abuse, this case further highlights the need to focus not only on the raising of awareness, but of how that work is targeted and its outcomes reviewed. By doing this, it will enable such awareness raising to ensure it is effective and encourage more people to recognise the signs that they are being domestically abused.

18. Recommendations

  1. This section of the Overview Report sets out the recommendations of the Domestic Homicide Review panel.

Domestic Homicide Review Recommendations

  1. The Court Service locally should undertake a process to review the support that is available to victims of domestic abuse who give evidence in trials against their perpetrators. This process should include those working with the police Witness Care Unit within DCP. It should seek assurance that good practice is consistently applied.
  2. The Clinical Commissioning Group should share the example of good process and practice in the management of patients who are prescribed highly controlled analgesic medication where there are mental health issues with all GP practices in Devon. Sharing this positive example will ensure that learning is disseminated widely.
  3. The Clinical Commissioning Group to remind all GP practices and NHS secondary care services the importance of the process for follow-up of patients who do not attend appointments and that they are used consistently.
  4. Devon and Cornwall Police should continue to progress their work to ensure improved understanding of the use of the Safeguarding process and forms in relation to raising or advising of safeguarding concerns relating to individuals detained within Her Majesty’s Prison Service. DCP may also consider how to ensure greater consistency in the use and completion of the form locally, but also whether there is merit in taking this issue to national police forums for further discussion and development.
  5. The Safer Devon Partnership should co-ordinate its members to consider how the good practice identified in this DHR can be disseminated locally to improve local practice. It should also undertake a focused piece of work to raise awareness of the risks posed in relation to domestic abuse and recent separation of partners.  

IMR recommendations

Devon and Cornwall Police

Devon and Cornwall Police to produce policy and guidance on the use of the Safeguarding Form and ensure this is readily available to all officers and Police Staff.

Royal Devon & Exeter NHS Foundation Trust

Pain clinic staff to ask patients routinely about domestic abuse so that they have an opportunity for disclosure.

Pain clinic staff to be able to access information from DPT about pain clinic patients who are also under the care of mental health services. This would ensure that every opportunity was taken to ask the patient relevant questions about their mental health at pain clinic appointments and minimise risk that the patient may self-harm.

Domestic Abuse training for all pain clinic staff. This will ensure that staff always have professional curiosity and are confident to ask the right questions to encourage disclosure of domestic abuse. Then appropriate support can be offered.

GP practice

Review of partnership working between primary care and secondary mental health services (CMHT and IAPT) where the patient does not attend appointments and there remains a level of risk although thresholds are not met for a referral for a Mental Health Act Assessment. In order to achieve this recommendation this would need to be a joint action with Devon Partnership NHS Trust.

The GP Practice will consider developing a protocol to follow in the event on failed contact with a patient who is potentially high risk. This may include follow up in writing, alerts on the record and liaison with other agencies.

Appendix A: Safer Devon Partnership oversight of Domestic Homicide Reviews

The Safer Devon Partnership provides the strategic leadership for addressing community safety matters across Devon, aiming to work together to enable the people of Devon to feel and be safe in their homes and communities. Partners include the four Community Safety Partnerships in the county, the Police, the Fire and Rescue service, the Clinical Commissioning Groups, Public Health Devon, the Office of the Police and Crime Commissioner, the National Probation Service, the Community Rehabilitation Company and the County Council.

One of Safer Devon Partnership’s responsibilities is to provide (on behalf of the Community Safety Partnerships) the governance for domestic homicide reviews as they are required in the county. Under the protocol agreed, this is delegated to an Executive Group. At the time of this review the Executive included representatives of:

  • Devon County Council
    • Elected Member with responsibility for Community Safety
    • Principal Communities and Commissioning Manager (with responsibility for Domestic and Sexual Violence and Abuse)
    • Safer Devon Partnership Manager
    • Principal Social Worker, Adult Services
  • Devon & Cornwall Police
    • Detective Chief Inspector for Local Investigations (Devon) and SODAIT
    • Detective Sergeant from Serious Case Review Team
  • Devon Clinical Commissioning Group
    • Lead Nurse, Safeguarding Adults
  • Devon Partnership Trust
    • Managing Partner, Safeguarding
  • Chair of the East and Mid Devon Community Safety Partnership

The final version of this Overview report will initially be distributed to:

  • Members of East and Mid Devon Community Safety Partnership via its Chair
  • Chief Executive and officer with responsibility for domestic homicide in East Devon District Council
  • Safer Devon Partnership Executive Group
  • Safer Devon Partnership’s domestic homicide review Executive Group
  • Members of the Devon Domestic Abuse Local Partnership Board
  • Chair of the Torbay and Devon Safeguarding Adults Partnership
  • Chair of the Devon Safeguarding Adults Review Group
  • Chair of the Devon Children and Families Partnership (Devon’s Local Safeguarding Children’s Board) and the Chair of its Serious Case Review Subgroup
  • Police and Crime Commissioner for Devon, Cornwall and the Isles of Scilly
  • All organisations named in Table 2

Appendix Two

Glossary of Terms

CPS – Crown Prosecution Service – government organisation responsible for prosecuting criminal cases at court.

DASH – Domestic Abuse, Stalking and Harassment – assessment tool used by Police and other agencies to assess associated risk to victims of domestic abuse by perpetrators.

DAO – Domestic Abuse Officer – specially trained Police officer or support staff in matters of domestic abuse.

DVDS – Domestic Abuse Disclosure Scheme – also referred to as Clare’s Law. A process whereby a member of the public can apply for information pertaining to a named individual who has a history of domestic abuse.

IDVA – Independent Domestic Violence Advisor – suitably trained individual who is assigned to a victim of domestic abuse to offer advice and support.

MARAC – Multi Agency Risk Assessment Conference – meeting of professionals from safeguarding agencies to discuss high risk domestic abuse cases with a view to formulating appropriate plans to safeguard victims and offer

OIC – Officer in the Case – nominated Police officer who is responsible for an investigation.

ViST – Vulnerability Screening Tool – process of identifying vulnerabilities, grading of the risk and signposting to relevant agencies. A ViST form is submitted whenever a police officer identifies a person (adult or child) with care or support needs and / or is at risk of abuse or exploitation. This ViST is then graded green, amber or red. Red, amber and 3 green ViSTs in 3 months (escalating concern) are reviewed by the CST (Central Safeguarding Team) which receives and processes the ViST to identify cases requiring further multi-agency assessment and intervention.
WCU – Witness Care Unit – team of Police staff who manage witnesses through the Court process.