Domestic Homicide Review Case 10 – Executive Summary

Arising from the death of “Ms A” – August 2016. Safer Devon Partnership on behalf of Exeter Community Safety Partnership.


How the Review worked

  1. This is a summary of Safer Devon Partnership domestic homicide review into the death of Ms A, aged 36, in Exeter in August 2016. She was killed by Mr V, then aged 42. (Their names have been changed in this report.) She recently ended their long term relationship. Both were Bulgarian nationals, who had lived in Britain just a few months, working in Exeter. She was a hotel housekeeper he was a contract cleaner. Mr V was convicted of murder in May 2017 and sentenced to life imprisonment with a minimum term of 19 years. 
  2. As required by law, Safer Devon Partnership set up a Domestic Homicide Review and asked local agencies to check whether either Ms A or Mr V had contacted them. The only contact was two attendances by Ms A at the hospital run by Royal Devon and Exeter NHS Foundation Trust (the hospital). 
  3. The Review Panel asked the hospital to provide information through an Internal Management Report (whose author was not involved in the events). They also asked other local agencies, including domestic abuse services, about how they help people like Ms A who are new to the area and have limited use of English. 
  4. In investigating the crime, Devon and Cornwall Police worked with police in Bulgaria to ask people who knew the couple there about their past relationship. They also interviewed people who had known them in Exeter. Professional interpretation was used where needed. The Panel was briefed by police on what they had learned. 
  5. The Panel invited Ms A’s family to take part in the Review through her half-sister Ms K, who lives in Bulgaria. A translated draft of this report was sent to Ms K after an introductory interpreted telephone call. After studying it she had no queries or points to add.  The Review Panel offer their condolences to all Ms A’s family and friends.
  6. The Panel invited several of the people who had known Ms A or Mr V in Exeter to share their views, offering interpreting or translation where required. Three people shared written statements with the Panel. The Panel member for Devon County Council also consulted some Bulgarians involved in community networks in Exeter. They pointed out that Bulgarians in Devon are not a single “community” but tend to turn to a small circle of fellow nationals for help and advice. They may see domestic abuse as a problem to handle within the family rather than report to authorities. The Panel thanks all who contributed information. Where this report refers to the views of family, friends and community it draws on these sources, but does not claim this view is shared by all. 

Review Panel

  1. The Domestic Homicide Review Panel met four times and also shared information by email. Panel members were from Devon & Cornwall Police (Serious Case Review Team), Devon County Council (Communities Team), Exeter City Council (Policy Officer, Communications & Community Engagement), Royal Devon and Exeter NHS Hospitals Trust (Senior Safeguarding Nurse), Splitz Support Service – provider of domestic abuse services – (Devon manager). The Panel was supported by the Safer Devon Partnership Co-ordinator for Domestic Homicide Reviews, who is contactable at Devon County Council. 
  2. The Panel’s Independent Chair and report author has knowledge of community safety, partnerships and domestic abuse and experience of previous domestic homicide reviews. She has a past career in public sector regulation and has never been employed by any of the agencies concerned with this Review. None of the panel had any direct connection with the people, events or decisions covered by the review.
  3. The Review Panel operated collaboratively to reach agreed conclusions. The final report has been agreed by the Chairs of Safer Devon Partnership and Exeter Community Safety Partnership and quality assured by the Home Office. 

Terms of reference

  1. The review considers agencies’ involvement with Ms A and Mr V from December 2015, when she arrived in Britain, until her death in August 2016. It does not cover previous events in Bulgaria. 
  2. The terms of reference reflect Home Office guidance on domestic homicide reviews and the context for this homicide. In summary they were to invite family and friends to be involved, review agency contacts with the victim and perpetrator for opportunities to identify or prevent domestic abuse, and report on lessons for improving services. Taking account of what was known in this case, they look at barriers to Ms A knowing of and accessing services, and wider lessons for raising awareness among migrant workers of domestic abuse and help available.
  3. The Panel took account of the Equality Act 2010. The ethnicity of both the victim and the perpetrator was “White Other”, and their position as newly arrived, legally resident, migrant workers with limited fluency in English is relevant. The Review does not cover immigration policy.


What happened

  1. The murder took place at Flat P, a studio flat in central Exeter. which Ms A sublet, informally, from a Bulgarian contact who was not living in it at the time.
  2. Ms A had been a victim of domestic abuse by Mr V throughout their 16-year relationship in Bulgaria. This involved emotional, financial and physical abuse. He did not have a criminal record for this, as when she had tried to escape or seek help, he persuaded her to stop. Her move to Britain seems to have been agreed with him, to increase their income, but was also, for her, to gain more freedom. 
  3. Ms A flourished in her few months in Exeter without Mr V, getting promotion at work and making friends. She started a new relationship with Mr T, a Bulgarian living near Flat P.  However, Mr V still had a controlling influence, with access to her Facebook account and to their children, who remained with relatives in Bulgaria. When he decided to come to Exeter too, in April 2016, she allowed him to share her cramped flat and bank account but did not agree to end the relationship with Mr T and return to him. 
  4. Mr V initially tolerated this situation and socialised with her Exeter friends. However, in May 2016, after a party, he damaged her possessions and injured her finger. After this she spent most nights with Mr T, but as there was no room for her to join his shared house, she had to return to Flat P each day to get her possessions, wash and cook, despite fear of Mr V.
  5. In June 2016 Ms A had her only contact with public services in Devon: two related visits to the Royal Devon and Exeter Hospital in Exeter. She visited the Emergency Department on feeling dizzy at work, and they arranged an outpatient appointment at a stroke clinic. On both occasions Mr T, understood by hospital staff to be her partner, accompanied her and interpreted. Doctors at the hospital encouraged Ms A to register with a General Practitioner (GP), to get treatment to prevent future illness, but she had not done so by the time she died in early August.
  6. Mr V denies the killing, so has offered no reason for it. At the time Ms A was preparing a special meal for Mr T. It is unlikely that he planned the murder, as disposing of her body from the top floor of a shared house then took him much effort. Mr V had no contact with police, council or health services before this.

Key issues arising

Was help available?

  1. Agencies in Exeter did not know that Ms A was at risk or have any opportunity to intervene. The Review therefore looked at:
    • what services were available which could have helped if they had known of her fear of Mr V, his past abuse, or his assault on her in May 2016;
    • how these services help victims who speak little English; and
    • what may have prevented Ms A, or others aware of the abuse, from contacting services. 
  2. Neither Ms A nor Mr V had registered with a GP. She could have done this at a health centre very close to Flat P, which has welcome notices in several languages, and some Bulgarian patients. GPs can help patients who disclose fear of a partner to get in touch with domestic abuse services.
  3. Ms A received appropriate and timely health care on her two visits to the hospital in June. Staff in these departments are trained to look for signs of domestic abuse and to ask the patient, on their own, if concerned. At the time Ms A had no injuries, and a good relationship with Mr T who was with her, so there were no such signs. However, if she had sought healthcare after an assault by Mr V, hospital staff would have done a formal risk assessment. If she had told them the full story, they would probably have judged her to be at high risk and arranged help through a referral to the MARAC (multi-agency risk assessment conference). 
  4. If Ms A had reported the assault in May to Devon and Cornwall Police, this would have been recorded as a reported crime of assault and criminal damage. Following the policy on responding to domestic abuse, Mr V would have been arrested and interviewed; and a risk assessment form completed with Ms A. If she had told police about the past abuse this, again, would have led to a MARAC referral. Police could have ordered Mr V to stay away from Flat P for a period, through bail conditions or a Domestic Violence Protection Order. 
  5. Even if no assault had taken place in May, Devon Domestic Abuse Service (provided in 2016 by Splitz) would have advised Ms A if she had contacted them after Mr V’s arrival. The history of abuse, living arrangements and having started a new relationship would have justified a high risk assessment, again leading to referral to MARAC. 
  6. Given the history, Ms A was at risk of domestic abuse as soon as Mr V arrived in Britain and moved in with her, so could have asked Exeter City Council to treat her as homeless through fleeing domestic violence. The Council would then have offered her temporary accommodation in or out of the area depending on the risk assessment, and ensured she was in touch with Splitz. 
  7. Ms A’s situation at the MARAC agencies could have arranged help including alarms, advice from police domestic abuse specialists on keeping herself safe and help in finding somewhere else to live. Further support (even without the MARAC referral) would have been given by Splitz, through an Independent Domestic Violence Advisor helping Ms A with safety planning, housing, health, developing her confidence and increasing her knowledge of her rights.

Was language a barrier?

  1. All the agencies discussed above have well established arrangements for helping people who do not speak English. Depending on the circumstances and individual needs, this would be through interpretation by a trusted friend or relative, or by professional interpretation through a telephone service or in person, aiming to give the victim confidence of privacy. However, Ms A might not have known this and have assumed that she would need a friend from her limited local circle to translate for her. 
  2. Bulgarian was the 20th most common nationality of UK residents in 2016, so is not a language featured when Devon services do use multi-lingual publicity. In her 7 months in Britain Ms A had gained some knowledge of English through day to day activities and classes. She probably used translation software on her phone. However, she may not have known the English terms “domestic abuse” or “domestic violence” had she wanted to search for and then auto-translate information on sources of help. 

What other barriers were there?

  1. Information and access to public services. Ms A found accommodation and a job through friends and contacts of the same nationality. While she used a smart phone for internet searches and Facebook, and information about local agencies is available online, she may just have asked friends or colleagues as she recognised the need, as she did with emergency hospital treatment. The main hospital, police station, council offices and health centre were within walking distance of her home in central Exeter, and well signed. While physical access to services is barrier to domestic abuse victims, including migrant workers, in rural areas, it was not for her. 
  2. Insecurity. As European Union citizens exercising treaty rights to work in Britain, with the correct documents, Ms A and Mr V had no reason to fear contact with officials.  However, Ms A may have been concerned about revealing her address, as they lived in Flat P under an informal arrangement with the official tenant. This would not have prevented her getting most services. Ms A may have realised that her options for staying safe in Exeter, without leaving her job and new partner, were limited, as Mr V’s offences in Britain would not have led to imprisonment. She may also have realised that British authorities could not ensure the safety or welfare of their children, who remained under his influence in Bulgaria.  

How can migrant workers be encouraged to report domestic abuse?

  1. The strategy for responding to domestic abuse in Devon is set out in “Ending Domestic and Sexual Violence and Abuse: Devon’s Vision 2016-2021”, produced by the Devon Domestic and Sexual Violence and Abuse Alliance which includes public, voluntary and private sector agencies. The mission is to empower individuals, families, communities and organisations across Devon to challenge and end domestic and sexual violence and abuse. Development drew on analysis of victims’ stories, though the sample did not include victims whose first language is not English, or recent migrants. The strategy does recognise that victims from minorities “are likely to face additional barriers to receiving the help that they need due to a variety of reasons, such as English not being their first language and fear that services will not understand their cultural traditions and norms”.
  2. It is difficult to find up to date resources to encourage the reporting of domestic abuse in minority languages, e.g. downloadable leaflets explaining what it is and how to get help. The use of popular translation software to convert materials developed in English is problematic, as the term “domestic abuse” may not translate accurately. It would be very helpful to have a nationally curated source of these, along with a list of domestic abuse agencies which specialise in reaching particular cultural groups.
  3. Useful work was done across Devon between 2008 and 2011 to engage black and minority ethnic groups with domestic abuse services. This included research, a conference, production of guidelines and training, and distribution of materials in minority languages.  However, amid reduced budgets and re-organisation of local services, much of this work was not passed on. 
  4. There has been renewed attention to this issue within Exeter since the homicide. Exeter Domestic and Sexual Violence and Abuse Forum, which is linked to Exeter Community Safety Partnership, held an event with representatives of black and minority ethnic groups in September 2016.  This identified issues which may be relevant across the county for the Devon Domestic and Sexual Violence and Abuse Alliance to consider. Splitz, with funding from Exeter City Council and Devon County Council ran a project in Exeter in 2018 to work with volunteers in minority communities to identify culturally specific issues relating to domestic abuse, and tailor resources, training and information for those communities. 
  5. Exeter City Council is reviewing its wider arrangements for consulting with black and minority ethnic residents, recognising that flexibility is needed in engaging grass roots social networks with diverse interests. New approaches are emerging including a cross-cultural and cross-faith group working with council officers to strengthen networking between smaller support groups. 
  6. In the past five years there has been limited attention in Devon to helping migrant workers understand or access public services. This contrasts with effective inter-agency work which was done a decade ago to respond to the expansion of EU migration to the south west. That included welcome packs, outreach initiatives, and links to the new cultural and social support groups which emerged. However, it pre-dated the arrival of most Bulgarian migrants which occurred from 2014 on. 
  7. There are some structures for regional or sub-regional discussion by agencies of issues affecting migrant workers, including the South West Forum for Migrant Workers and the Devon Migrant Worker Action Group (which includes Plymouth and Torbay Councils). Domestic abuse has not been a focus of recent action. Devon County Council and Exeter City Council have routine contacts with businesses through regulatory roles and in their leadership role on economic and community development. These channels are currently being used to raise awareness of modern slavery. Without distracting from that vital issue, there is scope to also use council connections with business to help employers signpost services to migrant workers who are legally present, and to promote guidance such as the Public Health England employers’ toolkit on domestic abuse.


  1. The murder of Ms A by Mr V was the final act of violence in a long history of his abuse of her, unknown to public agencies until her death. Most had occurred in Bulgaria. She recognised and partially resisted his control but did not report her concerns to public agencies in Britain. This may have been because, until the murder, the degree of physical abuse she experienced here was much less than in the past, or because she lacked information about the help available.  It is unfortunate that she did not take the hospital’s advice to register with a GP, as the new patient check would have given her a good opportunity to disclose her history and concerns. 
  2. Although public agencies in Devon did not know that Ms A was at risk, so had no opportunity to intervene, they can learn from this tragedy about how well prepared they are to help other victims of domestic violence who are new to the country.

Lessons to be learned

  1. Public services in Exeter would have been able to help Ms A and offer protection from Mr V if she had told any of them about his treatment of her.  All recognise that victims of domestic abuse may not have English as their first language, have arrangements in place to offer interpreters, and had access points within easy reach of her home and workplace. 
  2. There is a cultural dimension to the understanding of what domestic abuse is, and to expectations of the role of public services in tackling it. It is important that Devon agencies build on past research and continue learning how to ensure minority ethnic communities know about and are comfortable using domestic abuse services, and that this includes newly arrived European migrant workers such as Ms A.  
  3. More generally, public agencies in Devon lack a clear approach to understanding the experience of international migrants coming to work in the county or taking this into account where relevant to service design. This contrasts with their proactive approach in the previous decade. There are regional or sub-regional forums which consider some issues affecting migrant workers, but it is not clear how they hear the views of migrant workers, ensure that women’s experience is considered, or share learning about effective ways of communicating. 

Recommendations from the Review

  1. These recommendations are developed in more detail in a separate action plan overseen by Safer Devon Partnership. 

R1 Identify key communication messages and channels to encourage recognition and reporting of domestic abuse experienced by migrant workers in Devon.  

R2 Conduct a desktop exercise to revisit studies and guidance used in Devon in the past decade to promote safety and wellbeing among newly arrived migrant workers. Identify key points which still appear relevant and practical in preventing domestic abuse and share these within the Devon Domestic and Sexual Violence and Abuse Alliance. 

R3 (National, Home Office) Ensure there is an up to date list at national level of resources on which local areas can draw to respond to domestic abuse victims who are not fluent in English. 

A PDF of this page is available here – Domestic Homicide Review Case 10 – Executive Summary