Domestic Homicide Review Case 15 – Executive Summary

Arising from the death of “Tigre” – January 2018 

Safer Devon Partnership on behalf of Exeter Community Safety Partnership. Author (on behalf of review panel) Christine Harbottle – January 2021

Introduction

Review process

1. This is a summary of the Safer Devon Partnership domestic homicide review into the death of Tigre, undertaken on behalf of Exeter Community Safety Partnership in whose area she lived. Pseudonyms, chosen by their families, are used for the victim and perpetrator.  
2. Tigre, aged 32, was killed in January 2018 by Canada, then aged 36, who regarded her as his girlfriend. He was convicted of murder in July 2018 and sentenced to life imprisonment with a minimum term of 15 years. The Review Panel recognises the grief and loss experienced by the families of both Tigre and Canada and offers its condolences.
3. Tigre and Canada were each receiving community mental health treatment from Devon Partnership Trust. They lived at separate addresses in supported accommodation in central Exeter commissioned by the Trust. Both had a long history of contact with public agencies, were of White British ethnicity and had lived in Exeter for many years.  Both had long term mental ill health, entitling them to disability benefits. The Review considered how this protected characteristic under the Equality Act 2010 may have affected their access to or experience of services. 
4. As required by law, Safer Devon Partnership set up a domestic homicide review and asked local agencies to check their records of contact with Tigre or Canada. Neither had any contact with domestic abuse services. Table 1 shows the agencies which they had significant contact. These provided information to the Review as shown^[1] in Table 1. 

Table 1: Agencies contributing evidence

1. The insights of Tigre’s and Canada’s families were invited, but not all those contacted took up the offer. The Panel appreciates the contribution of Tigre’s father and his partner, Canada’s parents and sister, and a friend of Tigre who met the Independent Chair. Where references are made to the views of family and friends in this report they draw from these sources and from family contact with agencies, but do not claim to be the views of all members of the family or friends.

Review Panel

1. The DHR Panel met eight times and also conferred by electronic means. No members of the Panel had any prior direct involvement with the events or decisions covered by the review, or management responsibility for any staff whose actions are described. The Panel’s Independent Chair and report author has knowledge of community safety, partnerships, domestic abuse and experience of previous domestic homicide reviews. She has a past career in public sector regulation and has been a trustee of a national charity providing care and housing support. She has never been employed by any of the agencies concerned with this Review. 
2. In addition to the Independent Chair, Panel members were as follows. 
   From public agencies: 

• Devon & Cornwall Police (Detective Sergeant, Serious Case Review Team); 
• Devon County Council (Principal Social Worker – Commissioning; Public Health – Substance Misuse); 
• Devon Partnership NHS Trust (Managing Partner – Safeguarding and Public Protection); 
• Exeter City Council (Policy Officer – Environmental Health and Licensing); 
• National Probation Service (Senior Probation Officer);
• NEW Devon Clinical Commissioning Group^[4] (Commissioning manager, mental health)

From the voluntary sector:

• Hollywell Housing Trust (a Trustee new in 2018 who had other relevant experience of the voluntary sector in Exeter);  
• Splitz Support Services – domestic abuse service in Devon (Training and Development Team Manager)

The Panel was supported by the Safer Devon Partnership Co-ordinator for Domestic Homicide Reviews, who is contactable at Devon County Council. 

1. During the Review a multi-agency learning event was held, facilitated by the Independent Chair and two Panel members. This brought together some of the Devon Partnership Trust staff who had worked with Tigre or Canada and staff from the housing and care services involved, including Rethink, Home Group and Caraston Hall, to identify lessons learned. 
2. The Review Panel operated collaboratively to reach agreed conclusions. These have been discussed with the families, whose views have been taken into account, [are to be] agreed by the Chairs of Safer Devon Partnership and Exeter Community Safety Partnership and are subject to quality assurance by the Home Office. 

Terms of reference

1. The Review’s main focus was on the six months (July 2017 to January 2018) in which Tigre and Canada were in a relationship. To understand their situation when they met it considered agency contacts with Tigre since her move into Address C in 2015, and with Canada from his discharge from Langdon Hospital (forensic mental health service run by Devon Partnership Trust) to Address A in 2016. It also looked at previous responses to violence by Canada. Earlier life events and interactions with agencies in Devon were considered only where relevant to understanding the later events or the nature of domestic abuse. 
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 the involvement of family and friends, review agency contacts with the victim and perpetrator for opportunities to identify or prevent domestic abuse, and report on lessons for improving services. The Panel agreed, in the light of initial information available, that key areas of focus should be: 
   • how Tigre’s and Canada’s histories and situation at the time of meeting influenced the risk of domestic abuse in their relationship;
   • the development of the relationship including any domestic abuse prior to the homicide; and
   • how agencies worked with each other and with relatives and took account of the relationship and its risks in interactions with each of the couple.

Findings

Summary chronology

1. Tigre and Canada met in late July 2017, when they were living in separate supported housing projects, commissioned by Devon Partnership Trust and funded as aftercare under Section 117 of the Mental Health Act (a statutory right following certain types of detention under the Act).  Both had long term mental health problems for which they were receiving community treatment from the Trust, having had several periods of inpatient treatment in the past. Each had some supportive contact with family members living in the area. 
2.  Tigre’s history of relationships with men included one recorded incident of domestic abuse and a pattern of transitory relationships often associated with drug use. Her two children had been adopted at birth, which continued to distress her. Since 2015 she had lived at Address C, run by Caraston Hall, where staff support focussed on getting her to take her medication, look after her physical health, and avoid misuse of drugs. 
3. Tigre was intelligent, energetic and loved music. She could be outgoing and friendly but had variable moods and motivation to engage. Caraston Hall raised two safeguarding alerts with Devon County Council in 2016, concerned about vulnerability and risk in her relationships with men and the effect of drug misuse on her mood. These were dismissed at the triage stage. Caraston Hall then referred Tigre to RISE for help in ending drug misuse. Her needs were assessed as low and after one support phone call in January 2017 she declined further contact. At the time she met Canada, plans were being made for her to move to Torbay for a fresh start away from drug using contacts.
4. Canada had a history of aggression towards women, including his mother, past partners, and health staff. This often involved attacks to the neck or head and included a strangulation assault reported by a girlfriend (who was unwilling to support prosecution) during a previous stay at Address B in 2011. His most recent inpatient stay (2012-2016) was under a hospital order following such assaults. His discharge to community treatment was under Multi Agency Public Protection Arrangements (MAPPA), Level 1, and a Community Treatment Order, both overseen by Devon Partnership Trust. 
5. In July 2017 Canada lived at Address A, a house run by Hollywell Housing Trust, who provided housing support. He and the other tenant received additional support from live in Home Group staff. One reason he needed this was that he was functionally illiterate through missed schooling and mild learning difficulty. The transition from hospital to this placement in October 2016 went well, but in 2017 his behaviour became increasingly challenging, affected by drug use. Just before Canada met Tigre, Home Group had told Devon Partnership Trust that they had serious concerns about risk to their own staff, and Hollywell was considering giving Canada notice.  Due to staff turnover at Devon Partnership Trust, his community consultant psychiatrist was then a locum and his care co-ordinator had changed in May.
6. Over the last weekend in July 2017 Tigre went missing from Address C, staying at Address A. Agencies quickly identified that she and Canada were in a relationship and that this put her at increased risk, but a police visit to Address A found her safe. Home Group decided they could not leave their staff at Address A but continued to offer telephone support to Canada through August and September. Devon Partnership Trust and Caraston Hall warned Tigre, in general terms, that Canada posed a risk of violence. Caraston Hall contacted Devon County Council’s safeguarding team who decided not to raise a Safeguarding Concern, which would have been the first step for further investigation. Hollywell started eviction procedures, concerned about the risk to their staff and neighbours without the Home Group presence. Devon Partnership Trust arranged several multi-agency meetings during August in an effort to safely manage presenting risks, although none which brought all relevant agencies together. 
7. Tigre spent most of her time at Address A from August to November, returning to Address C a few times a week. Caraston Hall staff attempted to engage with her when they could, particularly to get her to take medication. Both Tigre and Canada often took drugs (cannabis and amphetamines) during this period.  Devon Partnership Trust, backed by Home Group until October, ensured Canada got to clinics for his fortnightly depot injections, apart from one in early October. Tigre had broken off contact with her father, but Canada’s family remained in contact and expressed increasing concerns about the situation, including a written complaint in November. A review by a Consultant Psychiatrist on 11^th October renewed Canada’s Community Treatment Order. Due to staffing changes, this was the fourth psychiatrist responsible for Canada in a year. 
8. In September, while the legal process for eviction was still in progress, student neighbours of Address A complained about noise levels. Exeter City Council took enforcement action, and the neighbourhood police team, aware of Canada’s record, provided safety advice to them and the neighbours. The Council’s Housing Options Team also became involved in seeking alternative accommodation for Canada.
9. In October Devon Partnership Trust transferred Tigre from their Active Review Team to the Community Mental Health Team to allow for more frequent contact. However, she did not attend any appointments offered by her new care co-ordinator. Her last meeting with Trust staff responsible for her was on 11th September with her consultant psychiatrist and previous care co-ordinator.  She was noted to have accompanied Canada to some of his appointments after that. 
10. Neither friends nor those staff who saw them together witnessed arguments or violence between Canada and Tigre before the homicide. Canada appears to have seen the relationship as long term, hoping to set up home with Tigre and describing himself as in love with her. Tigre’s views and hopes cannot be easily ascertained, but she gave no indication of sharing this plan. It seems likely that she initially chose to spend time with Canada, seeing it as freedom from constraints, while returning to Caraston Hall when she wanted space apart from him. Canada threatened staff at Address C on occasions when she returned there. Her independence from his influence was weakened by absence from support, treatment and family. A friend observed him as being “her shadow”. 
11. In November Devon Partnership Trust and Caraston Hall held a risk strategy meeting to discuss concerns about the relationship. Points raised included Canada’s controlling influence on Tigre, although with no indication of physical violence; problems finding alternative accommodation for Canada; and the risk of Tigre losing entitlement to housing benefit for Address C through absences. 
12. On completion of the eviction process by Hollywell, Exeter City Council made an emergency placement of Canada in a city centre guest house in early December. He lost this due to drug use and Tigre staying, then was homeless for a few days before Devon Partnership Trust commissioned a further supported housing placement at Address B, run by Rethink. Meanwhile Caraston Hall had given notice to Tigre who was increasingly disengaged. Though she still spent most of her time with Canada, there are indications that by then Tigre was contemplating ending the relationship. 
13. On 19^th December Canada moved into Address B, and Devon Partnership Trust held a further risk strategy meeting about the relationship and where both Canada and Tigre might live in future. (Rethink were not included in this.) This led to the clinical team leader having a short meeting with both Tigre and Canada when they came for his depot injection the following day. They agreed that a meeting could be set up in January for both of them and their care co-ordinators. A scheduled Mental Health Act Review Panel on 27^thDecember renewed Canada’s Community Treatment Order, which he had wanted revoked. However, the Trust’s social circumstances report to the panel included only a passing reference to Tigre and none to any risk he posed to her. 
14. Canada’s challenging behaviour continued at Address B, including noise, drug use and allowing Tigre in without permission. His care coordinator and the Rethink service manager met him, after his first depot injection of 2018, to agree a behaviour contract.  Meanwhile Tigre’s care co-ordinator, increasingly concerned about risk, unsuccessfully sought help from other Trust services to engage her. 
15. The day before the homicide, Tigre went from Address C to Address B and spent most of the day and evening with Canada there or nearby. Both had rejected scheduled contact with their key workers earlier in the day. Shortly after midnight they went together to Address C, which, against the rules and with the sleep-in staff member unaware, he entered with her. Five hours later, in the course an argument heard by residents of neighbouring rooms, he strangled her. 

Table 2: Key events before Tigre and Canada met

Table 3: Selected events during the relationship

Key issues arising

Setting the context for the relationship

1. Before the relationship started there had been some effective single and inter-agency actions which improved Tigre’s safety or reduced the risk of Canada harming others, but also some missed opportunities. 
2. Canada’s past assaults had resulted in short prison sentences and a hospital order under the Mental Health Act. Correct processes were followed for interventions under Act. The reported 2011 assault was investigated, and support offered to the victim although the evidence was insufficient for prosecution. Through the MAPPA process and Devon Partnership Trust records, information on Canada’s history of violence was available to some decision makers. Canada had a planned and managed transition from Langdon Hospital to Address A in 2016. This included consideration at MAPPA meetings, communication with his mother and discussion of risks with support providers. 
3. During the first part of 2017 Devon Partnership Trust provided appropriate care and support to Tigre, responding to changes in her mental state. Caraston Hall staff co-operated effectively with Trust clinicians and her family to help her sustain her tenancy and treatment and look forward, although the company’s internal review found failings in how they recorded their work. The limited response given by RISE to Tigre at the start of 2017 was a missed opportunity for her mental health and support teams to draw on substance misuse expertise in planning how to make the most of the times when she was open to change.  
4. Arrangements for deterring drug misuse by Canada were ineffective. Home Group, who were expected to manage and monitor substance misuse, had no sanctions available to them and their observations were not seen as evidence of breach of his Community Treatment Order. Testing for drug misuse at scheduled Devon Partnership Trust clinics did not detect the extent of his use. There was no contact with drug treatment services until September 2017, and then only a self-referral which understated the problem. 
5. Devon Partnership Trust’s focus for Canada was his mental disorder.  They sustained community treatment for this, but, with limited expertise in forensic provision in the community team, found ensuring compliance the conditions of his Community Treatment Order problematic. He would engage just enough to persuade clinicians not to return him to hospital. However, Hollywell and Home Group thought they had been assured he could be recalled to hospital if the community placement was not working. They struggled to manage behaviours that were increasingly outside their expertise and risk frameworks.
6. The Trust’s response to concerns raised by Home Group and Hollywell about Canada’s deteriorating behaviour was inadequate to address the escalating risks. An extra outpatient consultant appointment arranged in July 2017 was with a locum new to the case. His decision not to recall Canada to hospital was found by the Trust’s Serious Incident Review to be “fine line – within the boundaries of an acceptable clinical decision”. However, it is not clear that information from Home Group staff was fully taken into account.  By the time a multi-agency meeting was held, Tigre had joined the scene. With hindsight, there were grounds for recalling Canada to hospital just before they met, which would, unwittingly, have protected her.

Risk to Tigre from Canada

1. Tigre was at risk of domestic abuse by Canada from the start of their relationship due to his history of violence and her vulnerability. Although no violence had been reported since he started medication via depot injections in 2014, he had used it in the past when frustrated at his situation. Victims included women who were close to him. Some staff found him intimidating. Tigre had a history of transitory relationships and what others saw as unwise choices with men, sometimes associated with cannabis supply. She was inattentive to aspects of personal safety, for example fire risk. 
2. There were some protective factors in place when they met. Both had some recent positive response to mental health treatment and support. They were each in supported housing, with staff presence, some distance from each other, and relatives who took an active interest in their welfare. The risk of harm to Tigre grew as these factors were eroded.  She and Canada spent most of their days and nights out of touch with services, with no staff presence at Address A or constraints on drug use. He discouraged her from attending appointments without him. Tigre took her medication intermittently and from October 2017 had virtually no contact with Devon Partnership Trust. While Canada continued his mental health treatment his anti-social behaviour increased and his family observed him becoming increasingly unkempt. 
3. The homicide occurred when the risk had been further raised by instability in the relationship and uncertainty about where each would live in future. The protective factor of living separately in staffed accommodation had been restored but did not prevent the murder occurring in her room.  

Recognition of the risk

1. Agencies recognised that there was a risk to Tigre (and others) from Canada but recording and communication of this was patchy. 
   • Home Group and Caraston Hall recognised the risk from the start of the relationship. Both contacted Devon County Council’s Safeguarding Team saying Tigre was at risk from Canada, while also managing risk to their own staff.
   • The Council did not record a Safeguarding Concern following these contacts, on the basis that the agencies had not obtained Tigre’s consent before contacting them and that she had capacity to make unwise choices. They therefore did not investigate further whether the situation met the criteria for a Safeguarding Enquiry. The perceived dismissal of concerns affected other agencies’ recognition of the risk.
   • Clinical staff at Devon Partnership Trust recognised that the risk of violence from Canada might escalate after Home Group withdrew support but regarded this as due to his behaviour not due to any deterioration in his mental state. Canada remained compliant with treatment for his mental disorder. Trust staff working with Tigre recognised her to be at high risk due to self-neglect and vulnerability. In co-operation with Caraston Hall, they warned Tigre that Canada posed a risk of violence or harm, judging her to have capacity to choose to see him despite this.
   • The first full consideration of the risks arising from the relationship was over two weeks after it started, at a Risk Strategy Meeting involving Devon Partnership Trust, Caraston Hall and Home Group. The relevance of Tigre’s history of choices and of Canada’s violence to women were recognised, but not framed as potential domestic abuse. 
   • Systems for oversight of risk were not used properly. Trust staff did not record the risk in their Risk Management System. There was no agreed record of the way forward other than in Tigre’s clinical notes. Consequently, as the Trust Safeguarding Team were not informed of the situation, they could not offer advice. Caraston Hall’s internal documentation focused on risks of self neglect with no specific reference her relationship with Canada.
   • Canada’s care co-ordinator encouraged him to self-refer to RISE in September 2017 but did not brief them on the extent of his drug misuse or its impact on risks to Tigre. This influenced RISE’s assessment of his case as low priority, closed after two unanswered phone calls. 
2. The complaint about noise at Address A was handled well by police and Exeter City Council in mitigating risk to the staff and neighbours, and communication with Home Group and Hollywell. However, under a more holistic multi-agency approach, their visit could have been an opportunity to check more fully on Tigre’s welfare. 
3. In the last two months of the relationship agencies were more focused on preventing Canada becoming homeless than on the increasing risk to Tigre.
   1. In the urgent task of finding Canada alternative accommodation on eviction from Address A, the impact on Tigre (and on Canada’s mother) got little attention. This was a missed opportunity to reach out to Tigre, as she lost her unofficial base, and to plan better control of Canada’s access to her at Address C and her own future. 
   2. When Canada was placed with Rethink, the key risk identified from Devon Partnership Trust’s referral was relapse if he became homeless. The desired outcomes did not mention relationships.  Concerns about Canada’s challenging behaviour and risk to women were understated. Rethink’s internal assessments rightly identified further risks, but these were not recorded correctly in their internal systems nor did they seek information about the problems Home Group had with him. 
   3. There was no direct contact between Rethink and Caraston Hall due to data protection concerns. Rethink therefore knew little of the nature of the relationship and Tigre’s vulnerability. The overall effect was that Rethink had taken on a client who, with hindsight, they judged to be on the borderline of acceptable risk for the service, without full information and were not alert to the particular risks to Tigre. 
   4. Devon Partnership Trust convened two further Risk Strategy Meetings to discuss Canada and Tigre in November and December 2017, but the only external agency invited was Caraston Hall. Despite increasing concerns about the risk, no advice from the Trust safeguarding team, police or domestic abuse agencies was sought, nor were the risks Canada posed to Tigre raised through MAPPA or MARAC. These were missed opportunities to have the benefits of a multi-agency agreement of the level of risk and how this should be shared and mitigated.  
   5. Neither the concerns about Tigre nor the problems Rethink were experiencing with Canada’s behaviour were reported to the Mental Health Act Panel which reviewed his Community Treatment Order in late December. Thus, it did not have the full picture to establish whether his behaviour met the threshold where he could be recalled to hospital under the Mental Health Act. 
   6. Canada’s recorded criminal history did not highlight his past use of partial strangulation. Strangulation is a common method used by men on women in domestic violence and may cause internal damage without visible injury. It is recognised in the DASH^[5] form but is often recorded by police as a common assault. That does not reflect the potential for serious or fatal injury, or domestic abuse as an aggravating factor. The Crown Prosecution Service Charging Standards allow the more serious charge of Actual Bodily Harm where the level of injury is simply a part of the overall harm. 

Response to the risk

1. At no point was there a multi-agency approach involving all the relevant agencies to mitigate the recognised risk of domestic abuse. Inter-agency meetings did not include some relevant partners and did not result in written plans available to all who did attend. Multi agency solutions providing comprehensive support to both Tigre and Canada were not sought.  Individual agencies responded following their own priorities, sometimes consulting a partner agency. Although most of the staff involved acted with concern, compassion and commitment, lack of co-ordination hindered the effectiveness of these efforts.  
   • After the relationship had continued for a few weeks with no incidents of violence, inter-agency discussion mainly concerned the impact of Tigre’s overnight stays with Canada on both maintaining access to supported housing.  At no point was the agreed inter-agency tool for domestic abuse risk assessment, the DASH form, used.
   • The general warning given to Tigre that she was at risk did not draw on available powers which might have had more impact on her. Under the Domestic Violence Disclosure Scheme police could have briefed Tigre more fully on Canada’s past offending. Had the risk to Tigre been logged on the Trust’s Risk Management System, internal systems could have prompted consideration of this.
   • Individual agency plans tended to focus on other significant risks, for example aggression towards staff, or Tigre’s neglect of her physical health. Devon Partnership Trust concentrated on the impact of the relationship on mental health treatment, not the couple’s mutual reinforcement of harmful habits or the increasing squalor in which they lived.  
2. At the time of the homicide Devon Partnership Trust staff were considering identifying shared accommodation. This was not an appropriate solution given the level of concern and risk presented by Canada and the fact the clinical record reflects that Tigre appeared less committed to her relationship with Canada. This option was prompted by the reality that both ignored rules about overnight visitors in separate accommodation. However, it bypassed the task of supporting Tigre to make an informed decision about her future which would have allowed her to safely end the relationship. Moreover, neither had been offered any targeted help in understanding healthy relationships. 
3. The response to Tigre focused on trying to re-engage her with services both at Caraston Hall and Devon Partnership Trust, but with limited success. 
   • Caraston Hall staff took appropriate actions when they did establish contact, for example offering pregnancy tests, helping hygiene, offering assurance and sometimes turning Canada away. However, their documented plans for Tigre did not name Canada or include proposals for reducing the risk of domestic abuse, which could have hindered support staff working consistently to agreed goals.
   • Devon Partnership Trust’s transfer of Tigre from the Active Review to the Community Mental Health Team in October was well intended but counterproductive. While it increased the staff time allocated, Tigre’s new care co-ordinator never met her, despite repeated attempts. Working part time, and for her own safety unable to visit Address A alone, she had limited scope to engage a client as unpredictable as Tigre. The net effect was to lose the connection the previous care co-ordinator had made with Tigre and other agencies. The Trust has since adjusted policy and practice to reduce the risk of such discontinuity.
   • There was no contingency planning as to how to help Tigre should she want to end the relationship, although separation is known to raise the risk of domestic abuse. The only planning for her future, had Caraston Hall proceeded with the eviction, was for her to live with Canada, thus making it harder for either to end the relationship. 
   • Agencies rightly took into account the Mental Capacity Act and the right of adult service users to make choices but did not consider fluctuating capacity. After September 2017, although Caraston Hall was the only agency with direct contact with Tigre, there was no formal reconsideration of her capacity to make decisions concerning Canada, despite observations that she was neglecting her health and under the influence of drugs and alcohol and the concerns about Canada’s controlling effect on her.
4. The response to Canada from Devon Partnership Trust focused on getting him to clinics to take medication and did not address the gap in the support they commissioned for him. 
   • Clinicians judged that as Canada was mentally well efforts should continue to support him in the community despite clear breaches of the terms of his Community Treatment Order. They challenged him but accepted his pattern of claiming he was now compliant. Lack of continuity in medical staff may have contributed to tolerance of his behaviour. A recall to inpatient care could have benefitted him, by interrupting access to drugs, and have disrupted the relationship to protect Tigre. Instead, the October 2017 renewal of the Community Treatment Order weakened the conditions, and the December Mental Health Act Panel, while continuing it, did not strengthen them. 
   • The Trust did not address the impact on Canada or others of the withdrawal of the Home Group service. There was no evidence that he no longer needed daily on-site support to live in the community, but no alternative provision was made. There were only limited attempts to address the behaviour which had caused Home Group’s withdrawal, and no success in tackling his substance misuse. For nearly five months Canada received a far lower level of contact than agreed. His family repeatedly expressed their concern about this, the effect on his health, and the impact on them. 
5. The time taken to find alternative supported accommodation for Canada, shows a misalignment to need of either the process for assessment, or the local provider market, or both. Despite more than four months warning, Canada’s eviction from Address A left Tigre, the public and his family at risk.
   • While it was appropriate for agencies to help Canada understand his legal right to challenge the eviction, his hope to be able to stay in Address A and move Tigre in was never realistic. Devon Partnership Trust did not succeed in getting him to see this, or in finding suitable alternatives to recommend. There was insufficient consideration of how options for him affected risk to Tigre.
   • When Canada moved to emergency accommodation arranged by the City Council there was still no support arrangement in place, and he soon lost the room through breaking rules, then broke in to Address A to find bedding.  
   • There was no full multi-agency assessment of the type of support package Canada needed. His family were encouraged to seek privately rented accommodation for him without an assessment of the risk of aggression, e.g. in a further dispute over noise. When he did start his placement at Address B, Rethink did not put in place a safety management plan or set goals other than contact with staff.
   • The understandable focus on finding a placement close to his mother limited the options for finding a provider able to cope with his drug use and may have influenced Devon Partnership Trust’s underestimate, in briefing Rethink, of the risk he continued to pose. 
6. The families of both Tigre and Canada were concerned about their welfare and the effect of their relationship, but Devon Partnership Trust did not engage them appropriately in finding the way forward.
   • Tigre withdrew consent, in mid-2017, for either Caraston Hall or Devon Partnership Trust to give her father information about her, as was her right. However, under the principles of the Trust’s 2018 Carers Strategy which allow “general” information still to be shared, staff could have maintained more contact with him than they did (but not have given information on Canada or the relationship). Given Tigre’s tendency to withdraw then renew consent, inviting her to make an Advance Statement, enabling relatives to be contacted in particular circumstances, might have helped. Late in December 2017 Tigre agreed orally that information could be shared, but, as unwritten, this was not acted on. 
   • Consent from Canada was in place, but the Trust’s communication with his family during his relationship with Tigre was below standard. His mother, who under current Trust policy would be recognised as a carer, his sister and his father had valid concerns which were not addressed in a timely way.  Several administrative failures in communication added to their perception that no-one was listening. 

Community Treatment Orders

1. Devon Partnership Trust could have recalled Canada to hospital in July 2017, and possibly later on, for not complying with the terms of his Community Treatment Order. This was what Home Group and (later) his family wanted and thought justified, based on their observations – reported to the Trust – of his condition and the risk to others. However, Consultant Psychiatrists judged that Canada did not need to be recalled to hospital for treatment of his mental disorder – a necessary condition. These were clinically marginal decisions, by staff who had not been around during handover of Canada by the forensic team, and fuller attention should have been paid to the views of those in frequent contact with him. Canada was sufficiently skilled in his presentation to make clinical staff doubt they could argue successfully for recall, particularly in a system with considerable pressure on beds. Langdon Hospital occupancy in 2017 was 100%, as has been the case for several years. 
2. While such a recall would, with hindsight, have protected Tigre from Canada for a while, it would only have postponed the question of how to enable him to live safely in the community. Community Treatment Orders are not intended to return patients to hospital whenever their behaviour is problematic, and further detention might have successfully been challenged at a Mental Health Act tribunal. Home Group and Hollywell understood the Community Treatment Order to be an assurance that mental health services would keep Canada compliant with its conditions including those on substance misuse. This was to overestimate its powers. The recent Independent Review of the Mental Health Act^[6] is in general terms critical of Community Treatment Orders and calls for numbers to be halved. It agrees there is a role for them, with people who have been on a hospital order as an example but prefers better support in the community. The real issue for public services is how that can be provided safely. 

Alternative responses

1. All agencies, with hindsight, recognised that an agreed inter-agency approach to the whole situation was needed. Frameworks were available for this, which could have drawn in expertise which was not used, particularly on domestic abuse. However, the Review recognises that these might not have prevented this homicide or another adverse outcome, given Canada’s lack of insight into his condition, Tigre’s acceptance of risks in relationships, and the legal limitations on restricting choices or ensuring compliance with agreements.
2. Drug misuse was a key factor in this tragedy, disrupting engagement of both Tigre and Canada. It was probably mutually reinforced and affected their capacity to choose well. Yet only token efforts were made to address it. Canada was offered no specialist help on substance misuse until nearly a year after starting his Community Treatment Order, when RISE did not learn enough about him to prioritise structured treatment. Had there been communication between Devon Partnership Trust and RISE prior to his discharge from Langdon, as is offered for offenders leaving Devon’s prisons, Canada and Home Group could have received help from the treatment service from the start of his community placement. 
3. Professional advice on domestic abuse should have been sought, both when the risk that Canada would harm Tigre was first recognised and at key decision points thereafter. This was available within Devon Partnership Trust through its Safeguarding Team and to staff of any agency through Splitz, which offers a direct line for professionals through its helpdesk. This could have challenged the proposal from the December risk strategy meeting that the couple might share accommodation and should be asked about this when together. 
4. Several multi-agency frameworks could have been used, each with established working procedures. While differing in remit, they basically bring the same agencies to the table, and none gives additional resources or powers. However, use of any of the frameworks would have shown that the risks required multi-agency collaboration; clarified the position on sharing information; added expertise to risk assessment and produced a shared record of what had been agreed. This main reason this did not happen was lack of awareness of the frameworks and referral channels. 
   • Referral to Safeguarding through Devon County Council was attempted by two support agencies but not accepted as a valid concern. This influenced the work of other agencies involved who accepted the local authority’s position without escalation or challenge. A Safeguarding Enquiry would have provided the multi-agency forum for a potential solution and shared assessment of risk. 
   • This response was not unusual for the Council at the time. In 2017/18 Devon recorded a low level of “safeguarding concerns” compared to other authorities, taking account of population size, and converted fewer of these to Safeguarding Enquiries.  For both measures Devon moved significantly closer to the national average in the year following the homicide, as the Council analysed and changed its practice.
   • Multi Agency Public Protection Arrangements (MAPPA) had been used effectively in managing Canada until his discharge from Langdon Hospital in 2016 but had no later effect on recognition and management of risk, although any agency could have asked for his MAPPA level to be reviewed. 
   • The most relevant framework was the Multi Agency Risk Assessment Conference (MARAC) which looks at high risk domestic abuse cases. The non-statutory agencies were not clear that they could refer direct to this on their own professional judgement and expected Devon Partnership Trust to do so if required. (Home Group was also limited by the referral process requiring details of a potential victim, not perpetrator.) However, Trust staff did not use their internal risk system to alert their Safeguarding Team, and most of those involved had not yet completed the training which covers MARAC. 
   • A new approach to Safeguarding training introduced by Devon Partnership Trust in 2017 raised compliance with mandatory Level 3 training for clinical staff to 48% by January 2018, from 10% in June 2016. (In May 2019 it was 90%). Those who had not yet taken it included several key staff involved with Canada or Tigre. Completion of the training would have provided a better understanding of domestic abuse, and of systems to identify and address the risks. The Trust also offers optional stand-alone training on domestic abuse. 
5. Beyond formal frameworks, a key factor in supporting people with complex needs is collaboration at the front line. To engage individuals effectively, including their relationships, staff need to understand how their own contribution to progress and safety fits in with that of others, and be aware of triggers that escalate dangerous behaviour.  Despite examples of staff reaching out across agencies to protect Tigre, the default was focus on agency priorities, without a shared picture or goals. There was limited progress in engaging either Tigre or Canada in positive activities before they met, and none after it, with the focus mainly on the basics of daily living and avoiding harm. A culture encouraging front line staff to recognise and solve problems through collaboration, seeking permissions as needed, might have found better ways to help both of them. 

Pressures on community services

1. The challenge of finding new accommodation and support for Canada was in the context of increasing need and stretched services. His situation was not exceptional, locally or nationally, with the voluntary sector reporting rising numbers and complexity of need among service users^[7]. These pressures damage trust between agencies, which can lead to defensive rather than co-operative action. In a system under pressure, effective working with other agencies is key to making the best use of available resources to support vulnerable people. Skills in this are important at all levels.
2. The Care Quality Commission’s inspection of Devon Partnership Trust in November 2017 found that overall the Trust provided a Good service. The rating for Forensic Inpatient / Secure Services (covering Langdon Hospital) improved to Excellent. However, the rating for Community-based Mental Health Services for Adults of Working Age dropped to Requires Improvement.  A significant factor in this was staffing capacity. Long term sickness and vacancies within teams had impacted staff caseloads. Staff felt that they were not always provided with the resources to deliver the services effectively. In July 2017 the Community Mental Health Team had a vacancy rate of 11% overall, 17% for qualified nurses. Changes in both medical and non-medical staff supporting Canada had an impact on relationships and partnership working.
3. Given this context, clear agreement between commissioners and providers on the scope and standards of services is vital. Arrangements for national oversight of this provision, beyond general provisions of law, are patchy, but Devon Partnership Trust does monitor the accommodation and related support it commissions^[8].  Contracts with providers specify the support required for each client, but not the level of staff training, nor the support to the client the provider can expect from Trust staff.  This causes tensions, also noted in recent Safeguarding Adults Reviews, between housing providers and the Trust about what should be expected from their services. 

Conclusions

1. This tragedy illustrates a system failure to prevent the killing of a woman, vulnerable through mental health and drug misuse, by a man who shared these vulnerabilities and had a history of aggression to women. This occurred despite both having support allocated from publicly funded services, though that support was hampered by their lack of engagement. The risk was recognised, but the attempts to mitigate it were ineffective and did not draw on available frameworks for addressing domestic abuse. 
2. This section outlines the lessons learned from this Review along with progress already made on some of the issues. The Recommendations which follow set out how the lessons will be applied. 

Lessons to be learned

Inter-agency response to people with complex needs

1. Agencies need work together to help clients with significant and complex needs. A focus solely on their own core responsibilities is insufficient to mitigate risk and promote wellbeing. “Complex” should not just mean individuals recognised by several agencies to have high needs. It should include people who are difficult to support due to multiple factors which may not meet individual service thresholds and take account of their relationships with others who are vulnerable, being sensitive to the potential effects of past trauma.  Agency culture and expectations, and staff skills in working in a multi-agency context, are as important to this as formal process. Factors which enable a co-ordinated response include shared:
   • understanding of roles, responsibilities and plans;
   • information on the risk of harm, including known triggers;
   • commitment to joint action when problems arise, and means to escalate concerns; and to
   • good communication including, where appropriate, with relatives.
2. Substance misuse can be a significant barrier to the effectiveness of support plans, so other agencies should refer proactively into drug and alcohol treatment provision and seek early involvement of specialist services in multi-agency planning. 
3. Multi-agency working needs clarity for clients and their families on how queries, comments and complaints about their overall support may be made. Devon Partnership Trust’s strategy for carers would form a useful basis for a protocol which other agencies working with them on complex cases could share. 
4. There has been some progress in this direction. Devon is developing a multi-agency complex cases forum, learning from a similar scheme in Plymouth. Devon Partnership Trust now has an internal forum for discussion of complex cases.  The Trust has improved its approach to contracting with housing providers, aiming to ensure robust arrangements for safeguarding, information sharing, management of risk and monitoring.

Supported accommodation

1. Accommodation has long been recognised as a key component of health and wellbeing and in the rehabilitation of offenders. Enabling support from staff with the time to treat clients as individuals is often a key factor in recovery. Such accommodation and support come from a mixed market of non-statutory agencies, including housing associations, charities and the private sector. As recently highlighted by the Charity Commission, there is no national system of oversight^[9]. There are no overall arrangements for predicting demand in Devon, planning the level of resources, or identifying gaps either by geography or type of support. With increases in both the volume and complexity of need, this should be addressed at a strategic level in the county, aiming for capacity to find suitable placements quickly. 

Training and skills

1. The histories of Tigre and Canada illustrate the wide range of agencies and staff roles in contact with them, all with a need to collaborate with each other and with the potential to identify domestic abuse. This underlines the importance of training on domestic abuse and, more broadly, developing skills in collaboration across agencies. When staff face a difficult situation in a multi-agency context they need to know about existing frameworks which may be relevant. Where domestic abuse is a risk, these include MARAC, the Domestic Violence Disclosure Scheme and MAPPA. Agencies of all sizes need to ensure staff know who to turn to for advice on these. 
2. Training coverage and content has improved since the homicide: 
   • In April 2019 92% of all registered clinical staff at Devon Partnership Trust were compliant with Level 3 Safeguarding training.
   • The non-statutory bodies involved in this case have confirmed that they have appropriate arrangements in place for staff training. 
   • Splitz has obtained funding for 2019/20 to provide training and support to Housing Associations, specialist housing providers and housing support agencies across Devon which will raise awareness of domestic abuse.

Agency internal arrangements

1. Devon County Council has made progress improving its response to safeguarding referrals, working with other south west authorities on a regional review of practice, and its internal process and website. Relationships with care providers and partner agencies have developed, resulting in advice being sought prior to a concern being raised. Further improvement work is under way, with a Peer Review of adult safeguarding due within the next 12 months.
2. Frequent changes in clinical staff at Devon Partnership Trust have impeded the development of positive therapeutic relationships and understanding of the clients. A factor in this is the national shortage leading to difficulties in recruiting experienced and senior staff. This makes arrangements which facilitate continuity of care all the more important.  These include careful handover including briefing incoming staff on the role of other agencies involved with their clients, and any urgent issues raised by partner agencies. 
3. In a positive step for clients such as Canada, the Trust was chosen by NHS England in May 2018 as a pilot site for new community forensic teams. The main aim of the two-year pilot is to reduce length of stay for patients in secure care through the provision of specialist community forensic teams who will facilitate transition to the community. As well as providing more specialist and robust direct patient care in the community, the team plans to work very closely with supportive accommodation providers to give them extra training, consultation and supervision to support patients in the community and help them engage in more meaningful activity. 
4. Correct use of internal systems was an issue at some level for most of the agencies involved, and improvements have been made based on learning from this tragedy.  Hollywell and Rethink concluded they needed to be more thorough at the referral stage. Caraston Hall identified inconsistencies within its recording systems which it has addressed through standard operating procedures. Exeter City Council has updated its process for registering clients who may pose risks to employees. 

Recommendations from the Review

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

R1 Improve arrangements for the co-ordination across agencies of services for clients with complex needs, including those who, overall, have a high level of need or risk but may not meet individual service thresholds. 

R2 Improve communication and joint working arrangements between Devon Partnership Trust and local drug and alcohol treatment providers for mental health patients with substance misuse problems.  

R3 Review the nature and level of public agency commissioning of accommodation and associated support services for vulnerable adults in Devon to ensure appropriate facilities are available to meet needs safely at a choice of locations. 

R4 Improve the handling of adult safeguarding referrals where there are difficulties obtaining consent to refer or where the referrer has serious concerns about the response.

R5 Ensure that staff working directly with clients in all agencies providing or commissioning care or support for vulnerable people receive training, appropriate to their role and in line with the 2018 Inter Collegiate Guidance, on adult safeguarding including domestic and sexual violence and abuse. 

R6 In managing structural and personnel changes, seek minimal effect on continuity of care for mental health clients, including liaison with other agencies involved with them. 

R7 Review the way in which Devon and Cornwall Police record, investigate and present evidence to the Crown Prosecution Service (CPS) regarding assaults involving strangulation. 

R8 In evaluating the Devon Partnership Trust pilot of a community forensic team, take account of the views of partner agencies on how the team collaborates with their services.  

R9 Ensure there are arrangements by which staff at any level in agencies working with individuals who pose risks are alert to the potential use of multi-agency frameworks for managing them and can access information and advice on their use.

^[1] In Table 1“I” is an Internal Management Review specifically to inform the Domestic Homicide Review, “E” an external review, required by another statutory process, made available to the Review, and “O” an internal review of learning from the homicide for the Board of a non-statutory organisation.  

^[2] The statutory process required by the NHS following patient deaths in such circumstances. This was carried out by independent external reviewers from Enable East. 

^[3] This followed the pattern of an Internal Management Review but was undertaken by Devon County Council as commissioner due to the change in service provider.

^[4] From April 2019, Devon Clinical Commissioning Group

^[5] Domestic Abuse, Stalking and Harassment – an agreed interagency form used with suspected victims. 

^[6] Modernising the Mental Health Act Increasing Choice, Reducing Compulsion Dec 2018

^[7] For example- Clinks: The state of the sector 2018 / Key trends for voluntary sector organisations working in the criminal justice system.

^[8] The Trust manages the provision of identified accommodation needs for individual clients of mental health services under a contract with Devon County Council

^[9] Speech by Chair, Charity Commission Annual Public Meeting, 3rd Oct 2019.

A PDF of this page is available here – Domestic Homicide Review Case 15 – Executive Summary