Domestic Homicide Review Case 15 – Overview

Arising from the death of “Tigre” – January 2018

Safer Devon Partnership on behalf of Exeter Community Safety Partnership January 2021



  1. This report of a domestic homicide review examines agency responses prior to the murder of Tigre, a resident of Exeter, by Canada, who regarded her as his girlfriend, in January 2018. (These are pseudonyms which were chosen by their families.) As they were in an intimate relationship, this was a domestic homicide under the terms of the Domestic Violence, Crime and Victims Act (2004). By taking a holistic approach the review seeks to identify appropriate solutions to make the future safer. 
  2. At the time her death Tigre was aged 32 and Canada was 36. Both were of White British ethnicity, living separately in supported accommodation, and receiving community mental health treatment. Both had a long history of contact with public agencies. The Review gave attention to various time periods between 2001 and the homicide, proportionate to the scope to learn lessons for improving the response to domestic abuse today. This is explained in #10 below. The Review Panel recognises the grief and loss experienced by the families of both Tigre and Canada and offers its condolences.
  3. The key purpose for undertaking domestic homicide reviews is to enable lessons to be learned from homicides where a person is killed 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. 
  4. This Overview Report aims to draw out key themes and lessons from a complex story. Thirteen agencies involved in supporting Tigre and / or Canada have contributed to this review. The report is structured as follows:
    1. Introduction – to the Review and its terms of reference; 
    2. Approach – how the Review worked;
    3. What happened – an account of key events;
    4. Analysis – of how agencies acted;
    5. Conclusions – key learning points and recommendations.


  1. The findings of each review are confidential. Information identifying individuals is available only to participating officers/professionals and their line managers. Pseudonyms are used in this report to protect the identity of the people involved.


  • This review began in July 2018, following the criminal trial, and was concluded in October 2019. National guidance says that the overview report should be completed, where possible, within six months of the commencement of the review. This was not possible as Devon Partnership Trust did not release to the Panel its own external reports on the death until November 2018.


  1. This version of the Overview Report is for publication on the website of the Safer Devon Partnership along with the Executive Summary. Paragraphs 35 to 206 of the full report have been redacted from this version as they contain detail on the backgrounds and lives of Tigre and Canada that in the opinion of the Review Panel and Author do not need to be in the public domain in order for the analysis of events and findings of the Review to be understood.. The full unredacted version will be disseminated to multi-agency partnerships responsible for reducing domestic abuse, individual agencies and family as described in Appendix A. 

Terms of Reference

  1. The agreed terms of reference reflect Home Office guidance on domestic homicide reviews and set the purposes of the review as to:
    • establish what lessons are to be learned from the death regarding the way in which professionals and organisations in Devon work individually and together to safeguard victims;
    • apply these lessons to service responses including changes to inform national and local policies and procedures as appropriate; 
    • identify clearly how and within what timescales any recommendations will be acted on, and what is expected to change as a result;
    • 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.
  2. The Panel agreed, in the light of the initial information available, that the Review should focus on the following questions:
    • What elements of Tigre’s and Canada’s situation when they met, and of their past histories, influenced the risk of domestic abuse in their relationship?
    • What is now known about the nature and development of the relationship and any domestic abuse prior to the homicide?
    • Did agencies, singly and together, take sufficient account of the relationship and associated risks in their care planning and other interactions with each of the couple?
    • How well did agencies work with each other and with relatives, particularly over the two years before the homicide? What helped or hindered this?
  3. The Panel identified relevant time periods to focus on as follows:
    • The period between the couple meeting in July 2017 and the homicide, covering what is known about the course of their relationship and how agencies interacted with each of them, including recognition of and response to the relationship.
    • For each of them, what is known about their life and their interaction with agencies over the period between the previous change of accommodation and the start of the relationship. For Tigre this was March 2015 when she started living at Address C, managed by Caraston Hall[1]. For Canada this was August 2016 when he left Langdon Hospital (Devon Partnership Trust’s forensic inpatient unit) to live in a Hollywell Housing Trust property, Address A, with care provided by Home Group. 
    • For Canada, all earlier interactions with the criminal justice system, including reported assaults where no further action was taken, the MAPPA (Multi Agency Public Protection Arrangements) process and any detentions under the Mental Health Act. 

[1] Caraston Hall is a private provider of supported living services to people with mental health problems or learning disabilities. 


Decision to undertake a review

  1. 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.  
  2. Devon & Cornwall Police referred the death of Tigre to Safer Devon Partnership as a potential domestic homicide in January 2018.  In line with the protocol, the Domestic Homicide Review Co-ordinator for Safer Devon Partnership then asked agencies to check records of their contacts with Tigre and Canada.  In the light of the initial information available, the Executive Group agreed at their meeting on 5thFebruary to initiate a Domestic Homicide Review, and appointed an Independent Chair. 

Evidence considered

  1. The following agencies provided detailed information for the Review, such as a chronology. Eight of these agencies were also asked to prepare either an Internal Management Review, which is an internal report whose author was not involved in the events, or an equivalent by an external reviewer. Two others provided copies of internal investigations undertaken for their own Boards. Further information about these sources is given in Table 1 and Appendix B. Domestic abuse agencies in Devon confirmed that they had received no contact from or about Tigre.

Table 1: Agencies contributing evidence

Key to Info column: C – chronology or records only; E – external review; I – Internal Management Review; O – other form of internal investigation report.

AgencyServices providedInfo
Caraston HallSupported accommodation for TigreO
Devon & Cornwall Police (D&C Police)Response to calls relating to Tigre being in vulnerable situation and to noise complaint. I[2] 
Devon County Council Children’s Services arranged safeguarding and adoption of Tigre’s children.Adult Social Care received and triaged safeguarding concerns about Tigre.
Devon DoctorsOut of hours primary care to Tigre. (No incidents relevant to this Review.)C
Devon Partnership Trust (DPT)Mental health care for both, in both community settings and inpatient units.  E
Exeter City CouncilHousing advice for both. Action on behalf of neighbours complaining about noise. I
Hollywell Housing TrustCharity providing a housing and tenancy management service for people with learning disabilities, including Canada at Address AI
Home GroupHousing Association providing care and support to Canada at Address AI
Rethink Mental IllnessCharity providing supported accommodation to Canada at Address BO
Royal Devon & Exeter NHS Foundation TrustPregnancy care for Tigre; paediatric treatment for Canada; Emergency Department responses to bothI
South Western Ambulance Services NHS TrustParamedic treatment of Tigre at Caraston HallC
Together Devon Drug & Alcohol Services(Previous service provider RISE) had referrals for drug treatment for both.E
  1. Additional sources of evidence were as follows.
    • The insights of people who had known Tigre and Canada were sought as discussed below.
    • The Independent Chair interviewed a senior staff member from each of Hollywell, Home Group and Caraston Hall. 
    • A half day shared learning meeting was held in January 2019 bringing together staff from Devon Partnership Trust, Hollywell, Home Group and Rethink. The Panel members from Splitz and the Trust helped facilitate this event.
    • The National Probation Service panel member provided a summary of relevant policy on Multi Agency Public Protection Arrangements.
    • Splitz Support Service briefed the Panel on how domestic abuse agencies can advise other agencies on managing vulnerable adult clients seen as at risk of domestic abuse. 
    • Regulatory reports on key agencies were reviewed. 

Involvement of family, friends and wider support networks

  1. Safer Devon Partnership recognises that the quality and accuracy of domestic homicide reviews can be significantly enhanced by family, friends and wider community involvement, and that victims’ families should be given the opportunity to be integral to reviews. Such participation is voluntary for those involved, and Safer Devon Partnership seeks to provide appropriate support and a choice of means of contact. 
  2. Tigre and Canada had both left their family homes in early adulthood, and neither had subsequently married or formed a stable long-term relationship.  Both remained in contact to varying degrees with their parents (divorced in each case) and siblings (see Table 2), sometimes living with them for short periods. Some of these relationships were, at times, troubled.

Table 2: Family context during the relationship

Father (living in Exeter)Father (living in south east)
Mother (living in Somerset)Mother (living in Exeter)
Full, half & step siblings (various locations)Older sister (living in midlands)
Father’s partner (living with him from 2015 on).Paternal grandmother (living in Exeter)
2 children (adopted, no contact)1 child (adopted, no contact)
  1.  The Panel made initial contact with Tigre’s family through the police Family Liaison Officer during the trial to explain that the Review would follow, provide contact details and signpost an advocacy service. Initial contact with Canada’s family, to let them know of the Review was made via the Devon Partnership Trust Serious Incident Review. During the Review the Independent Chair held meetings with Tigre’s father, accompanied by his partner, and with Canada’s mother and sister, to ask about their observations and concerns. Canada’s father took up the option to contribute at the draft report stage. 
  2.  Comments on the draft report from Tigre’s father and his partner, and from Canada’s sister, mother and father have been taken into account.  Further details of these contacts are given in Appendix C. Information from the families, both from their contributions to this review and from their earlier contacts with agencies, is included in this report. The Panel appreciates their help. 
  3. Neither Tigre nor Canada was engaged in employment, education or volunteering in the three years prior to the homicide. They each had a range of friends and contacts who shared their supported accommodation or socialised in central Exeter. The Panel, taking account of the vulnerability[3] of these friends, sought direct contact with only one, a woman friend of Tigre. Information from another friend of Tigre who had given evidence during the criminal investigation was summarised in the Police Internal Management Review, as was information from two men who had shared accommodation with Canada and one with Tigre.   
  4. The Panel values the contribution of relatives and friends to the Review.  Where references are made to the views of family and friends in this report they draw from these sources, but do not claim to be the views of all friends or family members. 

Review Panel

  1. The Domestic Homicide Review Panel members were as shown in Table 2. The Panel held eight face to face meetings between 23rd July 2018 and 4th April 2019 and conferred by electronic means and sub-group meetings to clarify evidence, share family comments on the draft, and finalise details of the report. 

Table 3: membership of the Review Panel

AgencyJob title
Devon & Cornwall PoliceDetective Sergeant, Serious Case Review Team
Devon County CouncilPrincipal Social Worker – CommissioningPublic health (substance misuse)
Devon Partnership NHS TrustManaging Partner – Safeguarding & Public Protection
Exeter City CouncilPolicy Officer – Environmental Health and Licensing
Hollywell Housing TrustTrustee[4]
National Probation ServiceSenior Probation Officer
NEW Devon Clinical Commissioning Group[5]Commissioning manager (mental health)
Splitz Support ServicesTraining and Development Team Manager
  1. 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 Review Panel operates collaboratively to reach agreed conclusions. This report and recommendations were agreed by the whole Panel and signed off by the Chairs of Safer Devon Partnership and Exeter Community Safety Partnership. A draft report was sent to the Home Office for Quality Assurance in February 2020 and the response received in June 2020.
  2. The Independent Chair, who was also the author of the report, 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. Further details of her relevant experience are given in Appendix D. The Panel had administrative support from the Safer Devon Partnership Co-ordinator for Domestic Homicide Reviews, based at Devon County Council.

Parallel Reviews

  1.  The Panel has drawn on internal reviews carried out by agencies under their own processes, either directly or through their Internal Management Reviews (Appendix B). These included two complementary Serious Incident Reviews commissioned by Devon Partnership Trust from a specialist external consultancy, Enable East, which ran in parallel with the initial stages of this Review[6]. The scope of these was to review the services offered by the Trust:
    • to Tigre from January 2017 to  January 2018
    • to Canada from his first contact with community services in October 2016 to the date of the homicide[7]
  2. The Trust asked the independent investigators to consider whether there were any gaps or deficiencies in the care and treatment offered to Canada and if any failings had contributed to the death of Tigre. It also asked for identification of areas of best practice, opportunities for learning and areas where improvements to services might be required which could help prevent similar incidents from occurring. 

Equality and diversity

  1. The Panel has considered the relevance of the nine protected characteristics under the Equality Act 2010 in setting the terms of reference and conducting the Review. The sex of the victim was relevant given the prevalence of violence against women and girls. The only other characteristic specifically relevant to their situation was disability. Both had long term mental ill health, entitling them to disability benefits. Canada had a mild learning difficulty. The report comments on how these factors may have affected their access to or experience of services. 
  2. Tigre had a diagnosis of hebephrenia (disorganised schizophrenia). She was intelligent, and bilingual, but found it hard to concentrate for long. Canada had a primary diagnosis of paranoid schizophrenia and also “mild mental retardation” and dissocial personality disorder. He had difficulty reading and writing, and in listening to complex information. He was provided with a court intermediary during his trial, due to limitations in his communication skills.  A Home Group support worker, writing in September 2017, commented “Most of Canada’s support needs centre around his comprehension. Unfortunately, he has learnt to cover his lack of understanding well and often appears to understand but does not.”

What happened

  1. This section starts by summarising the facts of the homicide and outcome of the trial. It then traces key elements of the history of both Tigre and Canada, covering the following periods:
    • •Background context for each
  2. Agency contacts with Tigre while at Address C before meeting Canada
    • Response to violence by Canada prior to his move to Address A
    • Agency contacts with Canada while at Address A before meeting Tigre
    • Agency contacts with both, in the following time blocks:
      • Mid July 2017 (the start of the relationship) to September 2017 – includes Home Group’s withdrawal of care from Address A
      • October – November 2017- includes Canada’s eviction from Address A
      • December 2017 until the homicide – includes Canada’s admission to Address B.
    • The perspectives of the families, as expressed to agencies during contact from 2016 on, and in their contributions to the Review, are then summarised.
  3. These accounts combine evidence from the contributing agencies and draw on a detailed chronology held in spreadsheet form as a working document for the Panel. People and places are introduced with code names: a reference list of these is at the end of the report (before the appendices). An overview at the end of the section sums up this descriptive account and provides a timeline of key events, leading into the Analysis section which follows.

The homicide

  1. The homicide took place in Tigre’s room at Address C, a multi-occupancy home run by Caraston Hall in Exeter, at around 5.30am[8] on Day H[9] in January 2018. The couple had spent most of the previous afternoon and night together. This was initially in Canada’s room at Address B, another multi-occupancy home in Exeter, run by Rethink Mental Illness, where both smoked cannabis, and around the city centre. Just after midnight they made the short journey to Address C on Canada’s motorcycle, via a cashpoint and shop. The shop assistant recalled them arguing about what food to buy.
  2. The resident at Address C in the room adjacent to Tigre’s reported, after the death was discovered, that he had heard them arguing at around 5.30am. He described Tigre as really screaming “Get out of my house”. She sounded angry. He then heard Canada saying “No but I love you” and heard thumps. He said Tigre sounded angry and upset and Canada sounded panicky.
  3. Canada admitted killing Tigre, by holding her neck, then leaving without calling an ambulance or alerting staff. A post mortem later confirmed death by strangulation. Canada had minor injuries, consistent with Tigre attempting to fend him off. 
  4. Canada was charged with murder and pleaded self-defence. Some weeks after his arrest, when his mental state was assessed, it was determined that he was mentally well and should be subject to criminal proceedings.  The trial at the Crown Court focused on whether he intended to kill Tigre. He was found guilty of murder and sentenced in July 2018 to life imprisonment with a minimum term of 15 years.  

REDACTION: for the purposes of publication only, detailed narrative on the backgrounds of Tigre and Canada, and their engagement with different agencies, has been redacted from this version of the Overview Report. This detail is included in the full version of the report distributed to agencies and is summarised in the following overview.

Overview of what happened

  • This section summarises the events described above [in redacted section]. Selected dates are shown for reference in Tables 3 and 4. 

Table 4: Key events before Tigre and Canada met

1994  Referred to Child Guidance Service
2001  First assault on his mother reported to police
2004  Assaults on mother leading to court action. 
2005First of many mental health inpatient admissions First discussed at MAPPA. 2 spells in prison. 
2006  Detained under hospital order.
2007Police identify as victim of domestic abuse   
2011Child born and adopted Left hospital for supported living at Address B. Assaulted girlfriend also living there.
2012  Assaulted male fellow resident, recalled to hospital for breach of Community Treatment Order. 
2013Child born and adopted Convicted of assaults on hospital staff.
2014Last episode of inpatient mental health treatment  
2015Placed in supported accommodation at Caraston Hall  
2016Caraston Hall raised safeguarding alerts and referred her to RISE Moved from Langdon Hospital to Address A, under CTO. MAPPA level reduced to 1. 
Jan 2017RISE closed case.  
Early Jul 2017Offered placement in Torbay Risk Meeting (DPT & Home Group). Staff at Address A increased. Review with psychiatrist.
  1. Tigre and Canada met in late July 2017, when they were living in separate supported housing projects with housing benefit paid through Exeter City Council. Both had long term mental health problems for which they were receiving community treatment from Devon Partnership Trust, having had several periods of inpatient treatment in the past. Both were receiving additional support at their accommodation commissioned by the Trust and 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. 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.
  3. 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. 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 (Level 1) and a Community Treatment Order, both overseen by Devon Partnership Trust. 
  4. In July 2017 Canada lived at Address A, a house run by Hollywell Housing Trust, who provided housing support, which he had moved to in 2016 on leaving Langdon Hospital. He and the other tenant received additional support from live in Home Group staff.   While this initially went well, in the first half of 2017 his behaviour became increasingly challenging, affected by drug use. Due to staffing changes at Devon Partnership Trust, his care co-ordinator changed in May 2017. At the point where 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.  
  5. 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 an initial 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 warned Tigre that Canada had a history of violence. Caraston Hall contacted Devon County Council’s safeguarding team who decided there was no basis for intervention. Hollywell started eviction procedures, concerned about the risk to their staff and neighbours without the Home Group presence. Devon Partnership Trust arranged various meetings to review the situation during August, although none which brought all these agencies together. 
  6. 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, in particular to provide her 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. A review by a Consultant Psychiatrist on 11th October renewed Canada’s Community Treatment Order. Due to staffing changes, she was the fourth consultant community psychiatrist responsible for Canada in the previous year. 
  7. The legal process for eviction took some time, and in September 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.
  8. 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.  However, she was observed accompanying Canada to some of his appointments after that.
  9. 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 frequent absence. 
  10. Shortly after this Canada’s sister, reflecting the family’s concerns that he was “going downhill” and could become homeless, made a formal complaint to Devon Partnership Trust about lack of support and of alternative accommodation. The official response to this, dated just before the homicide, reached her after it.
  11. On completion of the eviction process by Hollywell in early December, Exeter City Council made an emergency placement of Canada in a city centre guest house. He lost this due to drug use and Tigre staying, then was homeless or with relatives 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.
  12. On 19th 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 a proposal made to both, when Canada attended for his depot injection the following day, of a meeting in January for both of them and their care co-ordinators.
  13. 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 on Day H-6, after his depot injection, 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. 

Family perspectives

  1. Information about contact from family members, and their recollection of particular events, has been included within the timeline above. This section covers broader points made in contact with the families during the Review. It also summarises complaints made by Canada’s sister to various agencies in November 2017 and their response.  
  2. A point made strongly by both families was that drug misuse had not been taken seriously or related to mental wellbeing. They understood that cannabis use in adolescence, probably involving more potent varieties and sometimes other illicit drugs, was thought to have contributed to the development of mental illness for both Tigre and Canada. They argued that using cannabis and amphetamines while in supported housing receiving mental health treatment must undermine its effectiveness. Yet they felt services treated it as a minor problem, with Devon Partnership Trust saying it was a choice adults could make, and Caraston Hall being ineffective in preventing residents from inviting in drug pushers. Neither family thought their relative had been offered any real help to reduce their drug misuse. 

Tigre’s family

  1. Tigre’s father felt that services had been reactive rather than proactive in working with her, and active intervention not offered until she was in crisis. Mental health services had failed her in that her first child was conceived during a spell in an inpatient unit. He said social workers had not communicated effectively with Tigre and her family about the reasons for her children being adopted, and this had affected her confidence in services in general. He understood that cognitive behavioural therapy had been suggested (around 2015) after her last period of inpatient treatment but that it had not been delivered. 
  2. Tigre’s father expressed concern about the apparent ease of access non-residents had to Caraston Hall while Tigre was there. His perception was that local drug dealers were able to get residents to let them in, with sleep-in staff unaware and CCTV ineffective as a deterrent. He had hoped that a move on placement from Caraston Hall would have been found, preferably somewhere rural to disrupt contact with city drug users and engage her in constructive activities. 
  3. Tigre’s father had not been aware of her disengagement from services in the second half of 2017, nor of the risks posed by her relationship with Canada. This is a matter of deep regret to him, as he had successfully maintained contact with his daughter over many years, even when she was most unwell. He recognised Tigre’s right to withdraw consent for information to be shared with him. This had happened from time to time in the past, but she would normally soon change her mind. He thought she used the threat of withdrawing consent if she did not get what she wanted (eg money), as the only form of control available to her. 
  4. Tigre’s father did regularly phone Caraston Hall to ask about Tigre’s welfare and was confident that he could have positively influenced her to maintain contact with the service and protect her from Canada. He thought there should be a way in which services could give him a headline view of her welfare or risks she faced, even when permission to disclose clinical information had been withheld. He was also concerned that Tigre orally renewing permission to a Caraston Hall worker was not sufficient for them to update him on the situation she then faced, and that her capacity to make decisions was often referred to but never formally explored. 
  5. Tigre’s father stressed the importance of making her fully aware of Canada’s recorded history of assaults early in the relationship, rather than a general warning that he could be violent. He thought this might have persuaded her, particularly if he himself had also been informed and able to influence her. While he had not had the opportunity to observe the relationship at the time, information gained through the trial about Canada’s attitude and past behaviour made him aware of the risk to Tigre of pulling apart from him. 

Canada’s family

  1. In mid-November 2017 Canada’s sister, who had been in telephone contact with him and their parents, cited Hollywell and Devon Partnership Trust in social media posts saying he was being made homeless. There was subsequent email contact with her by both organisations as described below. Tigre is not mentioned in any of the correspondence.
  2. The Chief Executive of Hollywell emailed on 23rd November to explain the issues and the charity’s actions to Canada’s sister. This included the following points:
    •  “This is definitely not a case of Hollywell evicting Canada simply because we want the house back. I completely understand why you feel Canada has been let down by mental health and his support team.”
    •  “Canada moved into [Address A] on the understanding that he would have 24-hour care from Home Group, which was the case until July … We wrote to Canada and his housemate a number of times between January and July as well as attending house meetings to explain that their behaviour on terms of smoking inside the house, allegedly taking drugs and finding an imitation firearm … was putting their tenancy at risk. Unfortunately, these breaches continued…”
    • “We have tried very hard to work with Devon Partnership Trust to find a solution and get Canada housed in more suitable supported accommodation as we are simply not able to provide housing to someone with his needs without external support from a care provider. … I cannot see that they have made any progress …. We have tried very hard to allow adequate time for alternative accommodation to be found … I don’t understand why we are now 13 days from eviction and nothing has been done. We can’t delay it any longer as the owner[1] will not allow us to.”
    • “This has put us in an incredibly difficult position as it’s clear … that Canada needs support from mental health to continue to be able to live independently. … We are getting daily complaints about the noise coming from the property… Making the decision to evict someone is not something we take lightly and is an extremely rare occurrence …. We have reached a point where we can do no more, hence instructing the bailiffs which is the standard process for a court eviction where a tenant has not left the property when they have been asked to. I have tried numerous times to get a clear answer from mental health over the last 5 months.” 
    • “I can … understand why … you are so angry with the situation and those who are meant to be supporting Canada …. I’m afraid that we cannot change the fact that Canada will be evicted on 5th December – the focus now needs to be on ensuring that Devon Partnership Trust and the local authority housing team ensure that Canada is found alternative accommodation before this date.”
  3. In acknowledging this the same day, Canada’s sister expressed concern that she had received no response from Devon Partnership Trust beyond a tweet from their Chief Executive on 20th November, and that PCC2 was not responding to her messages. She thought that her brother should not have been taken to court for breach of tenancy as his agreed support had been withdrawn. She commented “If the Home Group staff wouldn’t support Canada due to fear for their own safety why is he allowed to live in the general population? The whole situation with court proceedings along with the possibility of become homeless is additional stress that is really affecting Canada’s well-being and state of mind making him very vulnerable at the moment.”
  4. Canada’s sister had emailed Devon Partnership Trust on 19th November 2017 via its Patient Advice and Liaison Service. The message started “… whomever receives this … I trust that you will forward to the people named … and anyone you think will address this promptly. After speaking to my very distressed brother and parents over the weekend. … I am appalled that your service is letting my brother down once again.” She expressed serious concerns that PCC2 was not supporting Canada to find new accommodation or communicating with the family. “My parents have told me he isn’t doing anything.” She was aware that a visit to a potential placement in North Devon was planned but argued that this would be unsuitable as “he will be a long way from his friends and family and he needs them for support”. She warned that “Canada is very stressed and depressed at the moment and rapidly going down hill in his mental health.”
  5. The Patient Advice and Liaison Service responded on 21st November saying that they had contacted PCC2 about concerns and that he had assured them he had been in touch and had given her his email address for direct contact. “We felt … you would be able to discuss these issues directly with PCC2”. 
  6. On 26th November Canada’s sister emailed the Trust again, this time including Home Group’s Complaints Panel, with a formal complaint against both the Trust and Home Group, copying in external parties including the Care Quality Commission. She included the correspondence with the Patient Advice and Liaison Service and parts of her correspondence with Hollywell. Points she made included: 
    • “My concern is that since Home Group withdrew the 24hr care for Canada in July and he has received no support and DPT have failed to find alternative care or accommodation giving Hollywell House no choice but to evict Canada.” 
    • She had spoken to PCC2 on 24th November but thought what had been done was “very little” and “way too late”. She asked why support from voluntary sector befriending and advice services had not been arranged for Canada. 
    • “Since the summer I have seen Canada rapidly go down hill and I fear it will not be long before he goes back to his old ways or does something silly. … Canada is very low and vulnerable at the moment and he is only days away from being homeless and hearing how depressed he is very distressing”. 
  7. On 27th November 2017 a Complaints Investigation Officer from the Trust’s Patient Advice and Liaison Service responded, sending a Complaints Resolution Plan which restated the complaint for her to check, and explaining that consent from Canada would be needed to share any clinical information. It recorded the desired outcomes as “You would like to know why replacement accommodation was not provided before an eviction notice was served. You would like accommodation to be found close to your brother’s friends and family.” It did not pick up the point about the gap in support at the accommodation. A response signed by the Trust Chief Executive was promised by 27th January 2018. On 28th NovemberHGCL spoke to Canada’s sister to clarify her concerns. As a result of this no complaint was logged on Home Group’s system but HGCL offered to liaise with the Trust’s Complaints Investigation Officer. 
  8. The complaint made by Canada’s sister was investigated by the Trust through a review of records and interview with PCC2. The investigator obtained Canada’s permission to share clinical information. On Day H-2 the Trust Chief Executive signed the letter setting out the results. This gave assurance that the investigator had found evidence that PCC2 had tried to prevent the eviction, despite Canada’s “traits of aggression”.  “Your brother was deemed to have capacity to understand the actions and decisions he was taking at the time.”  The investigator had seen documentation showing PCC2 “had maintained frequent communication” with Canada and his family offering advice and support and that PCC2 and other Trust staff had contacted other accommodation providers for Canada. “Many providers refused to accept your brother due to him having a history of not respecting house rules, continuing his illicit drug use and potential risk to other tenants.” “Unfortunately, the ideal accommodation could not be found and is still being sought.”
  9. The letter concluded by noting that Canada was now in mental health supported accommodation with Rethink, and that there was a plan to move him to a bedsit at the end of the month. It was postmarked on Day H+2 and reached Canada’s sister on Day H+3 – the day he was charged with murder. Understandably, this only added to his family’s distress. 
  10. In their contributions to this Review, Canada’s family expressed deep frustration that services had not listened to them. “It will keep happening until people closest to them are listened to.” Both his mother, seeing him frequently, and his father on more occasional visits, said that they had seen his mental and physical condition deteriorate during his relationship with Tigre, but staff did not accept this as a symptom of mental illness. 
  11. Canada’s family think he should have been recalled under the Community Treatment Order as he was using drugs and had admitted this to Trust staff, and it was clearly harming him. They said that, while he did not like being told what to do, he should have been given clear rules and made to stick to them. They felt that both Home Group and Devon Partnership Trust tolerated his substance misuse. They were also disappointed that he had not been given more support to engage in positive activities in the community, for example to improve his reading. 
  12. Canada’s family recognised his relationship with Tigre as bad for both of them but described him as genuinely loving her and wanting to get married, live together and have a family. He had sometimes believed her to be pregnant and welcomed this. They were distressed by Tigre’s lack of care for herself and the example this set him. His mother, who saw the couple together more often than most other observers, regarded Tigre has the one who was more controlling. She said Canada had once asked her “What do you do when someone keeps hitting you and poking you?” but could not accept her answer of “walk away”

[1] Of Address A – a privately owned house which Hollywell rented.

Table 5: Selected dates of events during the relationship

20/7/17(Probable) first meeting
27/7/17Tigre stayed at Address A with Canada
29/7/17 Home Group withdrew staff from Address A due to risk to them.
31/7/17 First eviction notice served
7/8/17Caraston Hall safeguarding referral to Devon County Council  
10/8/17 Professionals meeting held.
17/8/17Risk Strategy meeting for both
6/9/17 Referred to RISE
11/9/17Saw consultant psychiatrist and care-coordinator at outpatient appointment 
19/9/17 First noise complaint to Exeter City Council re Address A.
4/10/17 Missed depot injection.
5/10/17Did not attend first appointment with new care co-ordinator. 
6/10/17 RISE closed case due to lack of contact.
11/10/17 Depot injection (1 week late), CTO reviewed and renewed.
17/10/17 Meeting with Housing Options
16/11/17Risk Strategy Meeting for both
26/11/17 Complaint from sister re lack of planning & support and impact on mental health.  
4/12/17 Left Address A for emergency accommodation at Address D. Assault on mother. 
14/12/17Given 28 days notice to leave Caraston Hall for non-complianceLost Address D for drugs & Tigre staying. Burgled Address A for bedding.
18/12/17Aggression from Canada to Caraston Hall staff stopping him entering with Tigre
19/12/17 Moved into Address B (Rethink)
19/12/17Risk Strategy Meeting
20/12/17Spoken to together when Canada attended for depot injection
27/12/17 CTO renewed at MHA Panel
 January 2018 dates (part-redacted) 
Day H-6 Depot injection & meetings
Day H-2 Written warning from Rethink 
Day H-1Each refused contact from key worker. Most of day together at Address B.
Day HWent together to Address C about 1am. He killed her there 5.30am.


  • This section analyses the events described above, considering why they occurred and whether different decisions or actions may have altered the course of events. It reviews in turn:
    • agency involvement prior to the start of the relationship as relevant to the nature of the risk to Tigre from Canada or agency preparedness to address it;
    • the risk to Tigre from Canada over the course of the relationship;
    • how and when agencies recognised and recorded that risk;
    • how agencies, individually and together, responded to the risk;
    • what alternative responses might have been considered; and
    • system issues affecting the ability to respond well.

Setting the context for the relationship

  1. Prior to the start of the relationship 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 a short prison sentence and a hospital order. There had been insufficient evidence to prosecute him for the 2011 assault reported by his former girlfriend Resident 1. Through the MAPPA process and police and Devon Partnership Trust records, information on his history of violence was available to some decision makers. However, his record on the Devon County Council Care First system did not mention violence towards women. 
  3. The Devon Partnership Trust Serious Incident Review found correct application and recording of Mental Health Act interventions.  It judged that the Trust had a comprehensive care plan in place for Tigre with evidence of regular and appropriate care and support from health teams. The specified contact interval at this point was monthly but she was seen more regularly than this when her needs increased, for example in February 2017 when action by the clinical staff resulted in an identified improvement.
  4. Tigre and Canada both benefited from supported accommodation funded as aftercare under Section 117 of the Mental Health Act. Such aftercare, for as long as needed, is a statutory right following certain types of detention under the Act. Tigre was placed at Caraston Hall, where staff co-operated effectively with Trust clinicians and her family to help her sustain her tenancy and treatment and look forward. While Caraston Hall staff were aware of Tigre’s needs and working to engage her, the company’s internal review found gaps in how they recorded their work with her. This included absence of key information, little evidence of clinical reasoning behind decisions and a general lack of coherence in the overall record system for Tigre. 
  5. Two referrals from Caraston Hall to Devon County Council’s Safeguarding Team about Tigre in 2016 were dismissed at the triage stage. This helped set an expectation that this service would be unlikely to help in the event of future concerns about relationships which Caraston Hall staff regarded as unwise. 
  6. Caraston Hall referred Tigre to RISE for help with substance misuse in December 2016, but RISE did not get full information about her situation, saw it as a low priority and closed the case when Tigre declined help after one phone conversation, in which she said she was happy with her progress. Her use of cannabis and alcohol did not in fact reduce and her motivation to change fluctuated. This 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.  
  7. Canada had a planned and managed transition from Langdon Hospital to Address A in 2016. This included consideration at MAPPA meetings and communication with his mother. Risks were discussed both with Hollywell, which provided accommodation with tenancy support, and Home Group offering more intensive enabling support. The arrangement was under the Devon Enhanced Community Recovery Service which commissions support for people with severe and enduring mental health issues in their own homes.
  8. While some consideration had been given to deterring drug misuse, of which Canada had a long history prior to his hospital admission, the arrangements were ineffective. His Community Treatment Order included a condition on testing for drug misuse, and that he must only consume alcohol in (unspecified) agreed quantities. Home Group were expected to manage and monitor substance misuse, but this relied on staff influence, as there were no sanctions available to them. They did not manage to establish the clear rules and routine which his family felt he needed.
  9. Neither at the start of the community placement, nor when it became clear that substance misuse was a partial cause of difficulties managing Canada in the first half of 2017, was there any referral to RISE. This could have been made by any of the agencies with his consent, which could have been sought at the start of the Order. While Canada did not meet the threshold on substance misuse for “dual diagnosis”, a request for consultancy support on managing him could have been made to RISE at this stage. Success in helping him avoid substance misuse on his return to the community would have supported efforts by Home Group to engage him in constructive activities. 
  10. Ensuring that Canada complied with the conditions of his Community Treatment Order was problematic, despite tenacious efforts of staff from both Devon Partnership Trust and Home Group to get him to appointments. The Trust’s Serious Incident Review commented that “Although he did break the terms of his CTO he would re-engage as required and stayed very close to what was required. The culture and bias for community clinical staff is to maintain clients in successful community placements. This may have influenced the decisions [not to] revoke his CTO, supporting his often expressed wish that he did not want to return to hospital.” 
  11.  There is limited expertise in forensic provision amongst Trust community teams and the forensic service (which includes Langdon) was not expected to provide support to clients after their discharge from this specialist service. In Canada’s case it would have been helpful if staff from the forensic service had been able to provide community support following discharge or at least participate in reviews of his Community Treatment Order.
  12. Devon Partnership Trust’s response to the concerns raised by Home Group and Hollywell about Canada’s deteriorating behaviour in the first half of 2017 was inadequate to address risks which had escalated since the initial placement. Home Group had expected a three monthly review, including a medication review from clinical staff at the Trust, but this did not always happen. Hollywell reported that some messages expressing concerns were unanswered or received a dismissive response. 
  13. Some positive steps were taken in June and early July, including agreement of funding for Home Group to have waking night staff at Address A, and arrangement of an extra outpatient consultant appointment. However, this was with a locum new to the case. The Care Co-ordinator, himself fairly new to the case and about to go on holiday, urged colleagues to set up a multi-agency meeting during his absence, but this did not happen for three weeks, by which time Tigre had joined the scene. The relevance of Canada’s status as MAPPA Level 1 with the Trust as lead agency was not discussed. The Trust focus was his mental disorder, and they were successful in sustaining community treatment for this. However, his landlord, carers and family thought they had been assured he could be recalled to hospital if the community placement was not working. When this did not happen, the other agencies felt risk had been transferred to them which they could only handle by withdrawing services. When seeking guidance and support, it would have been helpful had mental health professionals recognised that housing workers were struggling to manage behaviours that were increasingly outside of their expertise and risk frameworks. 
  14. Home Group informed the Individual Patient Placement Directorate of Devon Partnership Trust, their commissioners, of concerns via phone calls and emails. This is their normal practice. However, Home Group pointed out that it would be useful to have a protocol on ways to escalate concerns with more senior managers. 
  15. Those involved with Canada at this point (mid July) could not have known that he was about to meet Tigre. With hindsight, action could have been taken then which would, unwittingly, have protected her. At this point the case for recalling Canada to hospital under the Community Treatment Order was judged by the Devon Partnership Trust Serious Incident Review to be “a considered but ‘fine line’ decision… within the boundaries of a reasonable clinical decision”. However, it is not clear that information from Home Group staff and his family about signs of mental ill health as well as anti-social behaviour was fully taken into account

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, hers of risk taking, and both being vulnerable due to their mental health problems. Canada had used violence, on a number of past occasions when frustrated at his situation. This was usually against women who were close to him, including his mother and former partners, and often directed at the neck or head of his victims. Some staff and other clients in previous placements, including men, found him intimidating. Home Group were concerned about the safety of staff caring for him at Address A. Tigre had a history of transitory relationships with men, sometimes associated with cannabis supply.  Those responsible for her care thought her choices unwise.  She was also inattentive to aspects of personal safety, for example dental health and fire risk. Both showed volatile behaviour and reluctance to comply with rules. 
  2. When the two met in July 2017 there were some protective factors in place. Both had a recent history of some positive responses to mental health treatment and support. They were each in supported housing, with staff presence, some distance from each other. Canada had not been seen to use violence since starting medication via depot injections in 2014. Tigre had recovered from a period of instability earlier in the year, after adjustment of her medication, and was hopeful about a proposed move to Torbay. Both were in touch with relatives who took an active interest in their welfare.
  3. As the relationship progressed, the risk of harm to Tigre grew. Her drug use increased, adding amphetamines to cannabis. (Living with Canada, and availability of his money, enabled this, but it is not possible to know how they influenced each other in drug purchase and use.) She spent much of her time away from Caraston Hall, so had less contact with staff who could support her and ensure she took medication, including contraceptives. Missed doses and illegal drugs reduced the effectiveness of her treatment, affecting her mental health. Following the withdrawal of Home Group staff from Address A, Tigre and Canada spent most of their days and nights out of touch with services. Tigre ceased contact with her father and did not renew her consent for services to keep him informed. From October 2017 she kept no appointments with Devon Partnership Trust. Canada’s mother found him less easy to contact and was concerned about Tigre’s influence on his lifestyle. Canada continued his mental health treatment but used illegal drugs alongside it. The level of anti-social behaviour, for example excessive noise at Address A, increased. 
  4. Canada appears to have seen the relationship as long term, talking of his hopes to set up home with Tigre, get married and have children, and describing himself as in love with her. Tigre’s views and hopes for herself cannot be easily ascertained.  While she missed her children and had hopes of a future in which she could get them back or establish a new family, she gave no indication that she saw Canada as the route to this. 
  5. It seems likely, from the evidence available, that the course of the relationship from Tigre’s perspective was as follows.
    • She was initially attracted to Canada and freely chose to spend time with him, both at Address A, where they had the freedom of a house with no staff reminding her to stay clean and tidy, and going out together to socialise in the city centre. 
    • From the start Canada was present with her most of the time except when she returned to her room at Caraston Hall. A friend observed him as being “her shadow”. He discouraged her from attending appointments unless he could accompany her. An early outcome of this was her turning down the offer to view the proposed placement in Torbay. Another was that he lost interest in his pigeons.
    • As the relationship continued her independence from Canada was weakened by increased substance misuse, which he possibly funded, and increasing absence from support and treatment. He followed her into Address C when he could, but staff there recognised that she valued it as a space where she could be apart from him. 
    • Tigre accepted the situation and neither friends nor those staff who saw them together witnessed arguments or violence between them before the homicide. However, she appeared less lively than before, and both of them became increasingly unkempt. 
    • Towards the end of 2017 Tigre was contemplating ending the relationship, though she still spent most of her time with Canada even after his eviction from Address A. She talked about resuming contact with her father. Canada threatened staff to try to get into Caraston Hall on occasions when she returned there. She may have broken with him for a few days in November and had a brief relationship with another Caraston Hall resident in December. 
    • Tigre was under notice to leave Caraston Hall and knew that Canada wanted agencies to place them together but had not engaged sufficiently to ask about her options or make a choice.  
  6. The homicide occurred when the risk had been further raised by this instability in the relationship. The protective factor of the couple living separately in staffed accommodation had been restored. However, this did not prevent them being together at night in Tigre’s third floor room, with staff unaware of a quarrel loud enough to wake residents of neighbouring rooms.  

Recognition of the risk

  1. Multi Agency Public Protection Arrangements (MAPPA) had been used effectively in managing Canada prior to his discharge from Langdon Hospital in 2016. After that his MAPPA status was ambiguous. The September 2016 MAPPA Panel put him at Level 1, so having single agency management in the community. However, his convictions were not for the violent offences which qualify for Category 2, so he was Category 3 , which is either managed on a multi-agency basis at Level 2 or 3 or removed from the arrangements. This position was an unintended outcome of the way mental health and criminal justice processes had interacted over the period 2004 to 2012. Although several assaults by Canada against women were recorded, his prison sentence was for related crimes (harassment and burglary) which were easier to prove without victim co-operation. Assaults against staff while he was in hospital had not led to a further sentence as he was already detained under a hospital order.
  2. Canada’s MAPPA status had little practical effect on the recognition and management of risk after October 2016. The ambiguity had the benefit that MAPPA was mentioned on some of the referrals to support agencies, and was in police records, signalling that there was a risk of violence. A September 2016 police intelligence entry describes the behaviours indicating Canada is in need of mental health support. “When unwell he will show aggression, shout, be over active, display paranoia ..”. However, Devon Partnership Trust did not set out what the MAPPA status meant for their management of Canada, nor consider referring him back to MAPPA as a potential Level 2 when concerns increased.
  3. The start of the relationship raised concerns at both supported housing placements, and they appropriately alerted other agencies. Caraston Hall’s concern arose not only from Tigre’s absence overnight but because the Chief Executive, in a previous job, had contact with Canada including knowledge of the 2011 incident with Resident 1. Home Group, already having difficulties at Address A, were concerned at Tigre’s overnight presence and drug use there. Home Group staff rightly contacted Caraston Hall on learning (from Resident 3, who already knew her) that she lived there.
  4. Police made welfare checks on request from other agencies, which included checking for signs of domestic abuse. They were first involved on 28th July when Tigre was reported vulnerable and missing and visited her at Address A to check she was safe. They visited again on 16th September following a second report from Caraston Hall that she was missing. Officers were content there was no indication of domestic abuse on those occasions, and that Tigre demonstrated awareness of her situation and had a plan for her immediate future actions. As concerns had been raised that she may be at risk of domestic abuse from Canada it would have been good practice to create a link between the two names on the police UNIFI system. This was not done but is unlikely to have affected subsequent events.
  5. Although the start of the relationship coincided with, and may have contributed to, Home Group’s withdrawal of staff from Address A, other risks obscured focus on Tigre in that decision and the reaction to it. While Home Group had given repeated warning to Devon Partnership Trust that they might have to remove staff, the risk of a hostile reaction from Canada to the 28th July police visit was a factor the timing. The intensive contact over the following week between Home Group, Hollywell and Devon Partnership Trust largely concerned the overall increased risk at Address A with Home Group staff off site, and Hollywell consequently starting eviction proceedings. Hollywell identified a risk to staff and neighbours due to Canada’s violent and unpredictable history but did not learn of Tigre’s presence at Address A until later.
  6. Home Group did recognise the risk to Tigre and shared their concerns with Caraston Hall. Both support agencies, appropriately, contacted Devon County Council’s Safeguarding Team to report potential risk to Tigre due to Canada’s history of violence. In neither case was this recorded as a safeguarding concern. The Home Group caller, a frontline worker, was, incorrectly, given the impression nothing could be done until an incident occurred, and the Council did not make any record of the call. Caraston Hall, where the call was from a senior member of staff, were able to have a fuller discussion, but were informed at the end that it would not be recorded as a Safeguarding Concern. There was therefore no formal triage as to whether to open a Safeguarding Enquiry (see Appendix E). In making this decision the Council did not use all the information available or ask relevant questions. Tigre’s personal circumstances, support need, care plan and risk assessment were not fully explored in the context of the concerns raised.
  7. In deciding not to record a Safeguarding Concern on 7th August the Council’s Safeguarding Team did not take account of information easily available to them. Their Care First system recorded alerts for Tigre in 2013 and 2016, (not taken beyond triage), indicating a risk profile of non-prescribed drug use, noncompliance of prescribed medication, risk arising from relationships with men, alleged domestic abuse, coercion and unstable mental health. As in 2016, a key factor in the Council’s response was the judgement that Tigre had mental capacity and was therefore free to make unwise choices. (See Appendix E for an outline of the law on mental capacity.) This is an important tension which a Safeguarding Enquiry would have had to consider, but the criterion for opening an Enquiry (see Appendix E) is not mental capacity as such, but ability to protect oneself. Given Canada’s volatility and record of assaults, the withdrawal of his support staff and Tigre’s absence from her support and history of self-neglect, that could not be assumed.
  8. The Safeguarding Team also had access to the Care First records on Canada, which included a warning that staff should not see him alone. They had recently (May 2017) been granted access to Devon Partnership Trust’s records, which outlined his history of violence to women and action already taken by Trust staff to warn Tigre about him. There is no indication that these were used, nor that any consultation beyond the caller was done. The Care First record uses only the ambiguous phrase “his history of abuse”, which does not show whether he was the perpetrator or victim. The Safeguarding Team need a valid reason to look at records of an individual other than the subject of the concern. There is no written record of the information provided by or to Caraston Hall other than the Care First note. However, it is very likely that the caller did say that Canada was thought to have a history of violence against women and certain that she would have explained this if asked.
  9. A further factor in the decision not to record a Safeguarding Concern, and central to the feedback given to Caraston Hall, was that Tigre had not been informed of or consented to the referral. While keeping the subject informed rightly forms part of safeguarding guidance, there is no requirement for the person reporting a concern to obtain consent in advance. This response ignored the point Caraston Hall staff had made, that they had tried to speak to Tigre without Canada present but had been unable to do so.
  10. Whether or not accepting a Safeguarding Concern and potentially opening an Enquiry would have changed the immediate course of events, acknowledging the situation as an adult safeguarding risk would have provided a framework for a more effective multi-agency response. The perceived dismissal of concerns affected other agencies’ recognition of the risk. Staff interviewed for the Devon Partnership Trust Serious Incident Review said learning that both support providers had contacted the County Council Safeguarding Team without result had discouraged them from looking to internal safeguarding arrangements for help.
  11. Devon Partnership Trust recognised that the risk of violence from Canada might escalate without support but did not use their own risk management system to record it. They did advise that due to his volatility their (female) accommodation officer should not meet him in person. They did not regard this as a mental health problem since he remained compliant with treatment. Although clinical notes acknowledged the risk should be recorded in the Trust’s Risk Management System, this was never done. The Trust’s Safeguarding Team (whose role is outlined in Appendix E) were therefore unaware of the situation. This failure to follow procedure undermined the Trust’s process for oversight of risks including domestic abuse, and meant clinical staff were not offered the in-house advice available.
  12. The Trust ensured that Tigre acknowledged the risk from the relationship and was seen to have capacity to make choices. She was encouraged to contact staff if she had any concerns. She was not given information about domestic abuse agencies, but it is unlikely that she would have made use of leaflets or self-referral. Staff are often faced with the dilemma of wanting to protect mental health clients from making what are perceived to be poor choices but recognizing that they must work within the law. Tigre’s clinical notes contain structured risk assessments which were regularly reviewed. Her risk rating was judged to be high due to self-neglect and vulnerability. It is not clear that the risk to her was prominent in Canada’s clinical records, so it may not have been considered in all the decisions made about his care.
  13. Multi-agency meetings to discuss the risk from the relationship were held in August 2017 but were not based on an understanding of domestic abuse. The professionals’ meeting on 10th August, mainly concerned with Canada’s future, noted that he now had a girlfriend who was also vulnerable and was at risk of violence due to his history. The first full consideration of the risks arising from the relationship came in the Risk Strategy Meeting on 17th August, which explored the issue in depth. This involved Devon Partnership Trust staff familiar with each of the couple, and staff from Caraston Hall and Home Group. The relevance of Tigre’s history of choices which put her at risk, and of Canada’s violence to women were recognised. However, this was not put into context as a relationship with potential domestic abuse, and the focus was on possible future violence rather than coercion or control. Few of those present had received training in recognising and responding to domestic abuse. The meeting discussed confidentiality and agreed Tigre should know of concerns about Canada’s violent history, but there was no consideration of involving police through the Domestic Violence Disclosure Scheme (outlined in Appendix E). Tigre’s clinical records include detailed notes of the Risk Strategy Meeting, but no minutes were produced for the other agencies involved, so there was no agreed record of the way forward.
  14. Caraston Hall’s internal review identified shortcomings in their records of risk and mitigating action. Their latest Risk Plan and needs assessment (dated October 2017) focused on self-neglect. Her financial and sexual vulnerability were cited, and a history of allowing male visitors to stay at Caraston overnight without permission, but there was no reference to specific risks from her relationship with Canada, such his past violence and her frequent absences. The review found that staff were concerned about Tigre and aware of the risks. However up to date records are important to ensure that all staff understand current risks and plans to mitigate them.
  15. Subsequent Risk Strategy Meetings convened by Devon Partnership Trust to discuss the relationship had even less multi-agency involvement, so limiting the knowledge available. The only external agency invited was Caraston Hall, although Hollywell were still involved in November and Rethink had just taken on Canada in December. Exeter City Council had asked, the day before the November meeting, for a multi-agency meeting about Canada’s accommodation, and had been dealing, separately, with the noise complaint. Despite increasing concerns about the risk, and urgent messages from Canada’s family about their worries for him, no advice from the Trust safeguarding team, police or domestic abuse agencies was sought. Completion of a DASH form was noted as an action at the December meeting, but this had not been done by the time of the homicide 3 weeks later. 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.
  16. Devon Partnership Trust missed opportunities to engage with Tigre. When she accompanied Canada to his fortnightly clinics, Trust staff recorded her presence, but with no reference to the behaviours displayed or their interaction with each other. Given concerns about the risks to her both from Canada and her failure to respond to contact from her own clinical team, these were chances to monitor and engage her.
  17. The risks arising from Canada’s substance misuse were not shared with RISE. Canada’s care co-ordinator encouraged him to self-refer in September 2017, and later chased RISE to contact him, but did not brief them about any aspect of the relationship with Tigre or how his drug misuse increased risk to her. Indeed, as Canada gave only partial disclosure of the range and level of his drug use to RISE, they saw him as only low priority, so closed the case after two unanswered phone calls.
  18. The neighbourhood police team covering Address A recognised the risk of violence from Canada when Exeter City Council sensibly checked before visiting to deal with the noise complaint. PCSO1 learned from police systems that Canada was on a level 1 MAPPA, and, appropriately, contacted Home Group and added to the police intelligence system their view that Canada posed a risk to women “trying to be authoritative”. He warned the Environmental Health technician not to visit alone and advised the female students who had made the noise complaint not to call at Address A . This approach was effective in mitigating the risk to public safety.
  19. Exeter City Council Environmental Health staff took account of risks from Canada in their contacts. However, the technicians did not carry out a formal risk assessment or share the information about risk with anyone outside their team. While Environmental Health work is inherently based on risk assessment, the Council did not at the time have a set procedure for assessing risk in these circumstances but did hold an Employee Protection Register which could have logged a warning. Although the early information about the noise complaint said that Canada blamed his “girlfriend”, neither the police nor Environmental Health identified a risk involving Tigre. She was present with Canada on the joint visit on 13th November. Nothing to cause concern about her was seen and following standard procedure the Council informed Hollywell as landlord that she appeared to be living there. However, under a more holistic multi-agency approach, this visit could have been an opportunity to check on her welfare.
  20. Little attention was given to the risks to Tigre when Canada moved from Address A. An attempt was made to place him in North Devon, which could have ended the relationship, but this was unsuccessful, and there appears to have been no discussion of how to help Tigre adjust had it succeeded. When the eviction process finally concluded Canada left Address A on 4th December for a temporary bed and breakfast placement at Address D. While Devon Partnership Trust and Exeter City Council rightly focused on preventing him becoming street homeless, there was no recognition of the increased risk to either Tigre or his mother (who was in fact the target of his frustration that day). This was a missed opportunity to reach out to Tigre, who had lost her unofficial base, and to plan better control of Canada’s access to her at Address C and to help her consider her own future. Predictably, the temporary placement quickly failed as Canada used drugs and allowed Tigre to stay at Address D. In the increasingly urgent task of finding him alternative accommodation, the risk to Tigre got little attention. There is only a passing reference to her in the social circumstances report written for the December Mental Health Act Panel, and no indication that she was vulnerable or at risk from him.
  21. In commissioning support from Rethink at Address B, Devon Partnership Trust made no mention of risk to Tigre. The key risk identified in the referral was relapse if he became homeless. Current risk of harm to others was rated as low, with the history of harm to others being described as prior to hospital admission in 2011 and problems with authority in hospital. The application for funding to the Individual Patient Placement team referred to the breakdown of Canada’s placement with Home Group as being triggered by recreational drug use which their staff were unable to manage due to his challenging behaviour. The desired outcomes of Rethink work specified in the funding application made no mention of Tigre or of any other relationship. This understated the level of concern about Canada’s challenging behaviour and risk to women.Despite the history of the couple staying with each other in breach of their tenancies, no arrangements were made for Rethink and Caraston Hall to share information on risk. An email about Canada’s attempt to enter Address C the night before he moved to Rethink, was sent to Rethink by Devon Partnership Trust two days after the event (21st December). The next day Canada completed standard Rethink documentation including a data consent form and authority to process and disclose information. However, there was no direct contact between Rethink and Caraston Hall, nor, due to data protection concerns, was Caraston Hall officially told where Canada was living. Rethink therefore had limited awareness of the nature of the relationship and of Tigre’s vulnerability.
  22. Rethink recognised that Canada posed more serious risks than they had expected but did not explore them fully. Rethink’s internal Safety Assessment was completed on 28th December 2017 so took account of their initial experience of Canada. It rated 4 of 5 risk areas as ‘high’, including risk of harm to others and mood swings. However, the risks were not recorded on Rethink’s client information system nor Safety Management Plans. Rethink did not contact either Home Group or Devon Partnership Trust to seek fuller information about the difficulties Home Group had in managing Canada. The Safety Assessment noted “Canada states he is not using [drugs] anymore”, but there was no evidence confirming this (unlikely) change of behaviour.
  23. Rethink’s internal review identified gaps in their recording of information, including the decisions on Canada’s verbal and written warnings for anti-social behaviour in January 2018. The link to Canada’s 2011 stay at Address B when he attacked Resident 1 was not made at the time. The overall effect of the gaps in information provided, sought and recorded 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. While they rightly recognised that Canada posed high risks, they were not alert to the particular risks to Tigre.

Response to the risk

Overall approach

  1. The concern and compassion of most staff, their commitment to seeking an appropriate response and tenacious efforts to engage Tigre and / or Canada were noted in individual agency reviews, particularly from Devon Partnership Trust, Caraston Hall, Home Group and Hollywell. The multi-agency focus group confirmed this picture, and the Review Panel commends it. The analysis that follows looks at what helped or hindered the effectiveness of those individual efforts do deal with a situation which, was, as a family member put it, “a recipe for disaster”. 

Within the relationship

  1. The agencies involved with both Tigre and Canada made some response to the recognised risk of domestic abuse, sometimes based on consultation with another agency. However, at no point was there a multi-agency approach to mitigating that risk involving all the relevant agencies. 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 of them maintaining access to supported housing.  At no point was the agreed inter-agency tool for domestic abuse risk assessment, the DASH form, used. 
  2. There was a proactive approach to warning Tigre that she was at risk, but it did not draw on available powers for fuller disclosure which might have had more impact on her. VCC1, on being made aware of the relationship, discussed the risk with Caraston Hall and took action with them to warn Tigre. They let her know that Canada posed a risk of violence or harm and reminded her of the risk of self-neglect. This would have been an appropriate point to invoke the Domestic Violence Disclosure Scheme thus involving the police in briefing Tigre on Canada’s past offending. The scheme allows for a complete and thoughtful disclosure appropriate to the circumstances while ensuring all data protection requirements are met. While prompt action to contact Tigre was appropriate, guidance from the Trust’s Safeguarding Team was not accessed, nor was the risk to Tigre ever logged on the Trust’s Risk Management System. These internal systems could have prompted consideration of use of the scheme.
  3. Individual agency plans tended to focus on other significant risks, for example of aggression from Canada towards staff, or of Tigre’s self-neglect harming her physical health. Devon Partnership Trust concentrated on the impact on the mental health of each of them – for example Tigre missing her medication. They did not consider the wider implications of Canada’s level of risk, Tigre’s vulnerability, their mutual reinforcement of harmful habits or the increasing squalor in which they lived.  Multi agency solutions providing comprehensive support to both were not sought. 
  4. In the three risk strategy meetings held by the Trust the focus was directed at mental health interventions only and not the wider implications of risk management and Tigre’s vulnerability, including potential domestic abuse. While meeting notes were recorded in Trust clinical records, no minutes or action plans were sent to other agencies. Thus the meetings did not result in any form of plan being agreed by and available to all the agencies involved. Although the social circumstances report prepared for the December Mental Health Act Panel had standard questions about risk to others, the answers given made no mention of domestic abuse or of risks arising to either from the relationship, so the Panel did not address this when renewing the Community Treatment Order conditions. 
  5. In considering responses, agencies rightly took into account the Mental Capacity Act and the right of adult service users to make potentially unwise choices. Tigre’s capacity was explicitly considered in contacts with her between July and September, but a formal assessment was not undertaken. However, after that, although Caraston Hall was the only agency with direct contact with her, there was no formal reconsideration of whether she retained capacity to make decisions concerning Canada. There was reason to think her capacity to consent might fluctuate, as she was observed to be neglecting her health, to be with him under the influence of drugs and alcohol; and concerns had been raised about Canada having a controlling effect on her.
  6. 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 in making an informed decision about her future which would have allowed her to safely end the relationship. Moreover, neither had been offered any help targeted at helping them understand what healthy relationships involve

In care for Tigre

  1. The response to Tigre focused on trying to re-engage her with services both at Caraston Hall and Devon Partnership Trust. VCC1 was tenacious in her attempts to engage with and support Tigre even though the size of the caseload for staff within the Active Review Team was significant. Caraston Hall staff took appropriate actions when she turned up, for example offering pregnancy tests, helping her with hygiene, offering assurance and sometimes turning Canada away. They also made efforts to reach her at Address A when she disappeared for longer periods. However, their documented plans for her did not name Canada or include proposals for reducing the risk of domestic abuse. 
  2. Indeed, the Caraston Hall internal review found a number of failings in internal record keeping and led to a further review of paperwork and new operating practices and procedures. Key meetings with Devon Partnership Trust staff were generally only indicated in the Caraston Hall clinical record by the date of occurrence, it not being usual practice to record the content or outcomes. There was no evidence that these meetings led to amended or re-prioritised planning. The support plan and risk management plan for Tigre were incomplete and inadequate. This could have prevented support staff delivering the agreed interventions consistently in line with agreed support goals.
  3. Devon Partnership Trust’s transfer of Tigre from the Active Review Team to the Community Mental Health Team in October was well intended but counterproductive. While it increased the staff time available to engage her Tigre’s new Care Co-ordinator never met her, despite making repeated attempts using different methods of contact and seeking advice from colleagues for more intensive support as her needs increased. These attempts were hampered by two factors. For her own safety VCC2 rightly avoided visiting Address A alone to find Tigre, but was thus limited to inviting her to Caraston Hall or clinics, or accompanying PCC2 when he went to Address A. As she worked part time, she had limited scope to seize opportunities to engage a client as unpredictable as Tigre. The net effect was that the connection VCC1 had made with Tigre and with other agencies was lost, and VCC2 had no personal knowledge of Tigre to draw on in discussing the way forward. The Trust’s Serious Incident Review noted a wider issue of fragmentation within its community services, pointing out that the transfer of clients between teams presents problems with continuity of care and the development of positive and therapeutic relationships with clients. As a result of this the Trust made policy and practice adjustments which aim to ensure patient need is at the forefront of decision making.
  4. During 2017 clinical staff considered detaining Tigre under the Mental Health Act for Tigre and judged that it was not appropriate. The Devon Partnership Trust Serious Incident Review judged that these were clinical decisions made by senior and experienced clinicians and appropriately recorded. The Mental Health Act requires the ‘least restrictive option’ and the associated code of practice is clear that if a patient can be safely and lawfully treated without detention they should not be detained. 
  5. 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. (It is identified as a risk factor in the DASH form, but that was never completed for her, and as discussed below some staff had not been trained in its use).  The recommendation that an alternative placement for Tigre be sought remained in the Caraston Hall support plan, but no action on this was taken during the relationship. In a rare phone contact with her Care Co-ordinator in November she said the relationship was over. This was an indicator of increased risk, which was not recognised, and also a brief opportunity to engage her and explore her wishes which could have been seized had agencies been alert to its importance. While the separation lasted only a few days, information gained from fellow residents after the homicide indicates Tigre was getting tired of Canada. Moreover, within 3 weeks he was due to leave Address A, disrupting their pattern of life. The only planning for her future, had Caraston Hall proceeded with the eviction, was for her to live with Canada. Had the homicide not happened, this would have made it harder for either of them to end the relationship. 
  6. From mid 2017 on Tigre had withdrawn consent for both Caraston Hall and Devon Partnership Trust to give her father information about her. As she was an adult, staff were obliged, under most circumstances, to respect her confidentiality and her instructions on sharing personal information. However, they could have maintained more contact with him than they did under the principles set out in the Trust’s 2018 Carers Strategy (written after this tragedy) which allow “general” information still to be shared. General information would not, however, include informing Tigre’s father than she was in a relationship with Canada, nor that he had a history of posing a risk to women.
  7. Given Tigre’s long history with mental health services and tendency to withdraw and renew consent for contact, it would have been helpful if the Trust had invited her, in a more stable phase, to make an Advance Statement to enable relatives to be contacted in particular circumstances, although this would have been over-ridden by her subsequent insistence that no information was shared with her father. Late in December 2017 Tigre agreed orally that information could, once again, be shared, but as this was unwritten it was not acted on. It is unlikely that someone whose lifestyle is chaotic would take time to write their instruction

In care for Canada

  1. Devon Partnership Trust focused on managing Canada’s mental health through ensuring he took his medication and was seen at clinics. Although they understood the level of risk they judged that Canada was mentally well and that efforts should continue to support him in the community despite lapses in compliance with the terms of his Community Treatment Order. Clinicians challenged him regarding his behaviour, but his recorded responses followed a pattern of claiming he was now compliant. The lack of continuity in medical staff overseeing the Order may have contributed to tolerance of Canada’s behaviour. Senior experienced clinical staff made judgements not to revoke the Order even when there had been clear breaches of conditions and he could have been recalled to hospital. These clinical decisions are well documented, recording that there was no evidence of a deterioration in his mental health.
  2. In Trust contacts with Canada, consideration was given to his mental state and to the level of risk, but not to addressing his criminal behaviour. Trust staff suspected that Canada continued to take illicit drugs during the course of his care and had been told this by Home Group and his family, but there are no entries in his clinical records made about any actions taken to address this, other than random urine testing. The Devon Partnership Trust Serious Incident Review is clear that this use of illicit drugs was in breach of Community Treatment Order requirements and could have resulted in his recall to inpatient care. This could have benefitted him, by interrupting access to drugs, and have disrupted the relationship to protect Tigre.
  3. In focusing on whether Canada’s mental health had deteriorated, Devon Partnership Trust did not address the impact on him or others of the withdrawal of the Home Group service they had commissioned. His mental health was no better, and his behaviour worse, than in October 2016 when he was assessed as needing daily on-site support to live in the community. His ability to understand forms and systems remained limited. Although it was clear that finding new accommodation would take months, there was no referral for alternative floating support. The Trust’s Serious Incident Review found no suggestion that financial constraints directly affected the level of care offered.
  4. For nearly five months Canada received a far lower level of contact than agreed and funded. His family repeatedly expressed their concern about this, the effect on his health, and the impact on them. His Care Co-ordinator undertook some tasks support staff would have done, eg accompanying him to court and reminding him about clinics. Exeter City Council liaised with the Care Co-ordinator to provide the housing advice due to a vulnerable adult, also providing advice for Canada’s mother, who was helping him buy food and worried that she might be expected to take him in. However, these inputs could not replace the support package commissioned to accompany the Community Treatment Order.
  5. There were only limited attempts to address the behaviour which had caused Home Group’s withdrawal. Devon Partnership Trust recognised that Canada’s known drug misuse would make him unacceptable to many local providers and got him to self-refer to RISE. The referral was seen by RISE as low priority, based on the limited information Canada had disclosed, despite chasing by the Care Co-ordinator. They closed the case after two unanswered phone calls, without reporting back to the Trust. There was no impact on the substance misuse.
  6. The October 2017 renewal of the Community Treatment Order weakened the position further by removing the conditions relating to substance misuse and residence. This endorsed what had become the position in practice: that Canada could be confident of avoiding a recall to hospital provided he attended for his depot injections and presented well at appointments with Trust staff. This reflected the Trust’s focus on his mental health, and the position that only the conditions directly relating to mental health treatment could be enforced.
  7. No progress had been made by October in finding alternative supported accommodation for Canada, who was reluctant to engage with the process. Caraston Hall were even asked to consider taking him, but rightly refused given the risk to Tigre (and other female residents). The Trust’s Accommodation Officer pointed out that Canada would need to consider placements out of area, but only one (in North Devon) was visited. The focus on finding an Exeter placement was understandable given the wishes of Canada and his family, and the risk of further discontinuity in his clinical care. However, this delayed finding a provider able to cope with him. Given the difficulty in finding a local solution, a wider search for providers able to take on his risks should have been considered.
  8. Exeter City Council’s Housing Options and Environmental Health teams did not contact each other about Canada although they were working with him at the same time. Housing Options were aware that anti-social behaviour was the reason behind Canada’s eviction and Environmental Health knew that Housing Options potentially had a role to play in terms of finding Canada further accommodation. Both teams recognise that it would have been useful to have a fuller picture of Canada’s circumstances to enable them to respond. Their contacts were not a missed opportunity to identify domestic abuse, as the officers concerned knew other agencies including police were already involved and did not themselves witness situations of concern.
  9. Despite more than four months warning, Canada’s eviction from Address A left Tigre, the public and his family at risk. When he moved to emergency accommodation arranged by the City Council at a guest house (Address D) there was still no support arrangement in place, and he soon lost the room through breaking rules. Before a placement was agreed with Rethink, Canada broke into Address A to find bedding.
  10. The failure to find an alternative before the eviction shows a misalignment to need of either the process for assessment, or the local provider market, or both. While it was appropriate for Devon Partnership Trust and the City Council to help Canada understand his legal right to challenge the eviction, his hope to be able to stay in Address A and invite Tigre to move in was never realistic. Home Group offered insights into Canada’s support needs from their experience. However, there was no full multi-agency assessment of the type of support package Canada needed, or explicit consideration of how options for him would affect risk to Tigre. Communication with his family did not adequately address their anxiety about him. This may have influenced the Trust’s underestimate, in information given to providers, of the risk he continued to pose. Their view, eg in the December 2017 social circumstances report, that he could live in privately rented accommodation provided he took his medication and had some tenancy support ignored the history of nuisance to neighbours and threats to women in authority.
  11. Rethink’s internal review recognised that their record keeping and planning for Canada did not meet the standards detailed within their Integrated Support and Safety Planning Policy. While Rethink undertook their own risk assessment and identified risks they had not been briefed on, the only goal recorded in their client information system for Canada was to have day to day contact with staff. No Safety Management Plans were included, despite preventative action having been identified in their Safety Assessment. This meant their staff response to Tigre’s visits to Address B was not well informed.
  12. The 27th December formal review of the Community Treatment Order by a mental health panel did not take full account of Canada’s situation. They heard assurances from Canada about his substance misuse, but these were not tested for credibility against other evidence. The Trust’s investigation of the complaint by Canada’s sister, written within a few working days of this, blamed his “continuing illicit drug use” for the delay in finding accommodation. The panel did not hear about problems Canada was causing at Rethink, or about the continuing risks to Tigre. The panel did, however, continue the Order, against Canada’s expressed wish to end it.
  13. Devon Partnership Trust’s communication with Canada’s family over the period of his relationship with Tigre was below the expected standard, although consent from Canada was in place. In the light of his mother’s frequent contact with him, including assisting him with shopping and housing applications, she was acting as a carer in the terms recognised by the strategy adopted by the Trust in 2018. She and other family members felt their concerns and questions were not addressed and calls not returned. Through an administrative error the Trust had addressed correspondence to Canada’s father, who was the Nearest Relative recognised by the Mental Health Act, to his mother’s address. His father was therefore unaware for several months that Canada had left Langdon Hospital.
  14. The Trust’s PALS service did not recognise that Canada’s sister’s mid-November email expressed a frustration which required more than a reminder that she could contact the care co-ordinator. Her more formal complaint the following week was recognised as such and an investigation started, but the urgency of the concerns the family were raising about Canada’s condition was not recognised. Rather, they received an explanation of the Trust’s actions to house him (but not of the gap in support staff) in a letter approved by the Chief Executive before the homicide but posted after. The administrative failure to recognise the name and recall the letter reinforced the family’s perception that no-one was listening. A separate error by Enable East in giving their phone number for contact during the Serious Incident Review compounded this.

Alternative responses

  1. All agencies, with hindsight, recognised that an agreed inter-agency approach to the whole situation was essential. While the analysis above has identified points at which communication, consultation and record keeping could have been better, it is unlikely that these alone would have affected the outcome. This section considers some of the frameworks that might have been used to design, plan and deliver a more holistic approach, drawing in expertise which was not used, particularly on domestic abuse. 
  2. Maintaining Canada and Tigre safely in community placements was challenging given his lack of insight into his condition, her tendency to accept risks in relationships and the legal limitations on restricting their choices or ensuring compliance with agreements on behaviour. In analysing alternative courses of action agencies could have taken, the Review recognises that there is no assurance that these would have prevented this homicide or another adverse outcome. 

Involving substance misuse specialists

  1. Drug misuse was a key factor in this tragedy, but only token efforts were made to address it. For both Tigre and Canada it disrupted their engagement with health and housing services, and it seems likely that once together they mutually reinforced their substance misuse. It may have led to fluctuating capacity to recognise risks and exercise choice. There was no indication that either was dealing in significant quantities or was being exploited by a criminal network.  
  2. Although the initial form of the Community Treatment Order had conditions that Canada should not use drugs or excess alcohol, he was given no specialist help to address these habits in the community. Home Group and Devon Partnership Trust staff encouraged him to desist, but it was not until nearly a year after leaving Langdon that he was put in touch with the treatment service, RISE. Had a proactive referral been made, or information about the positive drug tests been shared, the treatment service would have reprioritised him into structured treatment, rather than having to accept his assertion that cannabis was the main drug of choice and not at a problematic level. 
  3. An even more effective approach would have been communication between Devon Partnership Trust and RISE prior to discharge from hospital.  This might have resulted in Canada and his support workers having a trusted contact in the treatment service from the start of his placement at Address A. It might have helped him accept that drug screening tests conducted under the Community Treatment Order were for his benefit. There are arrangements for such pre-release contact for offenders leaving Devon’s three prisons.
  4. There was little opportunity for police to use their powers to tackle Canada’s use of illicit drugs, although their intelligence records did note suspected drug use at Address A. The only drug offences on his criminal record were for possession of cannabis in 2005 and earlier. Magistrates do not grant a warrant for police to enter properties unless offences are substantial and have wider public interest. Police could have seized drugs and charged Canada with possession if they had seen them when visiting for other purposes, or if shown drugs found by Home Group or Hollywell staff.  Without good reason to think Canada was carrying a substantial amount of drugs a stop and search under the Misuse of Drugs Act would not have been justified. Testing for riding his motorbike under the influence of drugs would have been justified had that information been passed to police. Without specific information such a vehicle stop would have been a general policing response if the motorbike was seen mobile. Neither this nor possession would have been likely to bring a custodial sentence. 

Involving domestic abuse specialists

  1. Professional advice on domestic abuse should have been sought. The risk that Canada would harm Tigre was identified almost as soon as the relationship started. However, while the term “domestic abuse” was used in some discussions within agencies and in inter-agency meetings, the problem was not framed as this. As discussed below, many of the staff involved had not had an appropriate level of training in safeguarding at the time. Advice was available, both within Devon Partnership Trust through its Safeguarding Team, and to staff of any agency through the commissioned provider of domestic abuse services in Devon, Splitz. This could have been given despite Tigre herself being unlikely to seek or accept direct help from Splitz. Devon County Council Safeguarding Team should also have been able to signpost advice on domestic abuse to any agency, regardless of whether they recorded a safeguarding concern. 
  2.  Advice to the professionals involved from a domestic abuse specialist would have been of value both when the risk was first recognised and at key decision points thereafter. In particular, this would have challenged the proposal from the December risk strategy meeting that the couple might share accommodation, and that a meeting with both present was the right way to ascertain their wishes.  However, any approach to help Tigre choose a safer way forward would have been reliant on her engagement. 
  3.   Splitz operates a single point of access helpdesk. This function takes referrals and assesses the risk and needs of victims of domestic abuse, but also provides advice and information to professionals, members of the community and family members.  Due to the number of calls into the helpdesk, early in 2017 a specific professionals’ line was set up to fast track their enquiries. Splitz also offers training and workforce development, and staff frequently attend team meetings and forums to brief other professionals on identifying domestic abuse and making referrals.

Using formal multi-agency frameworks

  1. The Devon Partnership Trust Serious Incident Review concluded that a fundamental reason for the tragic death was the absence of a robust multi-agency approach to the complex needs of both parties, and staff having too narrow a focus on their mental health status.  Canada presented a challenge to many agencies but did not easily match the requirements of their systems and processes to allow a positive response. The Risk Strategy Meetings convened by the Trust invited one or two external agencies, but, in effect, took their views into the Trust’s own planning, rather than producing agreed multi-agency plans.
  2. Several multi-agency frameworks could have been used, each with established working procedures: a Safeguarding Enquiry, re-referral to MAPPA or referral to the Multi Agency Risk Assessment Conference (MARAC) which looks at high risk domestic abuse cases. While these differ in their remit, and to some extent in membership (see Appendix E), they would basically have brought the same agencies to the table. None of the frameworks gives any additional resources or powers to act. However, any of them would have brought recognition that management of the risks required multi-agency collaboration; clarity on seeking consent to share information, or to justify sharing it without consent; assessment of the level of risk based on more informed input on domestic abuse, substance misuse and offending; and a shared record of what had been agreed. Of the three, MARAC was probably the most relevant to preventing the homicide. Any of the agencies could have made a referral to MARAC based on professional judgement. 
  3. Several factors contributed to the frameworks not being used. The only one attempted – referral to Safeguarding through Devon County Council – had not been accepted, influencing expectations all round. The non-statutory agencies were not clear that they could refer direct to MARAC or MAPPA and expected Devon Partnership Trust to be the agency that would do this if required. This was reasonable, as, unlike them, the Trust had access to information about both parties. However most of the Trust staff involved had not, at the time, completed the safeguarding training that covered domestic abuse risks assessment and referral to MARAC, and did not alert their own Safeguarding Team via the internal risk management system. While Home Group had significant concerns about the potential risk from Canada, they knew very little about Tigre, could not have used the DASH form, which is victim focused, as a way in to MARAC. 
  4. As discussed earlier, Canada’s MAPPA status was ambiguous and forgotten. Whilst the police receiving the information about Canada’s anti-social behaviour in 2017 did not identify a particular risk at the time, the officer was aware of the MAPPA unit where advice could have been sought. Other agencies should also have a point of contact with knowledge of MAPPA who can advise those with concerns about the process and whether a referral is appropriate. This would assist them to flag up concerns based on the actions of a potential perpetrator rather than knowledge of the victim

Empowering problem solving at the front line

  1. While formal frameworks are useful, a key factor in working with people with complex needs whom services find difficult to support is collaboration at the front line, both for individuals and, where appropriate, couples. A culture that supports this is important. There were examples of staff reaching out across agencies to protect Tigre, for example when Caraston Hall and Home Group responded to the start of the relationship, in the two Devon Partnership Trust clinical teams discussing the risks and police supporting environmental health. However, the default position was that each agency focused on its own remit and priorities, so staff did not benefit from a shared picture or goals. There was limited progress in engaging either Tigre or Canada in positive activities prior to their meeting, and none after it, with the focus mainly on the basics of daily living and avoiding harm. Incomplete records also left some support staff reliant on oral briefings on risks and plans.  
  2. To ensure they engage effectively with the unique circumstances of each individual, including their relationships, staff need to understand how their own contribution to progress and safety fits in with that of others. All also need to be aware of triggers that could escalate dangerous behaviour, and how to respond.  A culture which encouraged front line staff to recognise and solve problems through collaboration, seeking permissions as needed, might have found better ways to monitor both Tigre and Canada during the second half of 2017. For example, the environmental health officers could have been encouraged prior to their visit to look out for Tigre, seeing her as a potential victim as well as an accomplice to anti-social behaviour. Devon Partnership Trust could have offered contact to Tigre at Canada’s scheduled clinics (where he had to stay for 2 hours monitoring after each injection). Caraston Hall and Rethink could have prepared a joint plan for responding to attempted overnight stays, either seeking their clients’ consent to share relevant information, or justifying it on the basis of the risk to Tigre (and to others at Address B given her history of accidentally starting fires). 
  3. Devon Partnership Trust does have experience of enabling such frontline collaboration. The Care Quality Commission report (discussed below) “found good examples of staff working closely with local teams such as the police and the local housing services. Staff had worked with them and attended meetings in order to share risks and to build relationships for the benefit of services users.”

Revoking the Community Treatment Order

  1. Home Group and (later) his family wanted and thought justified, based on their observations – reported to the Trust – of his behaviour and health and the risk to others. However, the threshold for recall under a Community Devon Partnership Trust could have recalled Canada to their secure 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 behaviour and health and the risk to others. However, the threshold for recall under a Community Treatment Order is relatively high. The criteria are that recall to hospital is needed for treatment of the mental disorder and that there would be a risk of harm to the patient’s health or safety or to others if not recalled.
  2. As discussed earlier, these were clinically marginal decisions, and fuller attention should have been paid to the views of those in frequent contact with Canada. The Community Treatment Order had been made on handover from the forensic hospital, but the community mental health clinicians reviewing it had not (through staff turnover) been involved then. Canada was sufficiently skilled in his presentation to mental health professionals to make them doubt they could argue successfully for recall, particularly in a system where there is considerable pressure on resources, especially beds. Availability of forensic hospital beds was a background pressure: Langdon Hospital occupancy in 2017 was 100%, as has been the case for several years.
  3. While such a recall would, with hindsight, have protected Tigre, at least from Canada, it would only have postponed the question of how to enable him to live safely in the community. One purpose of Community Treatment Orders is public safety, but they are not intended to result in someone being returned to hospital whenever their behaviour is problematic. Canada might have successfully challenged further detention through a Mental Health Act tribunal. However, in the time that took Tigre might have re-engaged with her own support.
  4. The recent Independent Review of the Mental Health Act is in general terms critical of Community Treatment Orders and calls for numbers to be halved. It agrees there is a role for them, giving people who have been on a hospital order as an example, but sees better support in the community as preferable. The real issue for public services is how that can be provided safely. 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.

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

System issues


  1. Devon County Council’s Safeguarding Team decided the situation did not meet the criteria for their involvement despite two housing providers attempting to raise a concern. This response was not unusual for the Council at the time. National data first published in 2018 demonstrates that in 2017/18 Devon recorded a low level of “safeguarding concerns” compared to other authorities, taking account of population size. As illustrated in Figure 1, the rate increased in the year following the homicide, as the Council changed its practice, so the gap probably reflected the Council’s response more than how many people were at risk or how many people contacted the Council with a possible concern.

Figure 1: Safeguarding concerns per 100,000 population[14]

  1. In 2017/18 of the concerns recorded within DCC only 25% were converted to an enquiry. The rate for England was 38%, but this is an experimental statistic[15], so differences in terminology and recording practice may contribute.  Again, the gap reduced during 2018, following a “deep dive” analysis of local practice prompted by the national figures (Figure 2). 

Figure 2: Safeguarding enquiries per 100,000 population

Accommodation and support

  1. The challenge of finding new accommodation and support for Canada was in the context of increasing need and stretched services. Both at Panel meetings and at the Learning Event there was a clear view that his situation was not exceptional. This is a local reflection of a national situation. For example, Clinks, the umbrella organisation for voluntary agencies working with people in the criminal justice system, reported[1] that “The number of service users continues to rise with 55% of organisations telling us the number of people they are working with increased…. This year, again, the overwhelming majority of organisations report that the needs of their service users have become more complex (80%) and urgent (73%). .. This ongoing trend will be having a cumulative impact on voluntary sector services, their staff and volunteers. It is likely to be putting them under increasing pressure as they work to address and meet the needs of their clients. Further, this finding also indicates that service users are likely to be experiencing sustained levels of complex and urgent needs.”
  2. These pressures damage trust between agencies, which can lead to defensive rather than co-operative action. Exeter City Council Housing Options staff recognised that if Canada were discharged from mental health support due to non-engagement, which PCC2 raised during the 15th August 2017 meeting with them, a risk arose as they still had a duty to house him.  The City Council has found that this is a regular occurrence but that there is no mechanism for responding to such concerns. Hollywell concluded in their contribution to this Review that they needed to “to review our … risk appetite ..and .. better interrogate partners’ commitments to support and supervision …Without greater assurances and support from statutory partners Hollywell is less likely to take on tenants with greater levels of complexity.”
  3. Arrangements for national oversight of this provision, beyond general provisions of company law, health and safety etc, are patchy. Charities and housing associations are accountable to national regulators whose main remit is finance and governance rather than quality. The Care Quality Commission only has a role where clinical services or personal care are provided.[2] There is no generally applicable user feedback or peer review system. Services may have multiple commissioners. The Chair of the Charity Commission recently drew attention to the “problem in the supported housing sector … that there is no shared understanding – between providers and beneficiaries – of what ‘supported’ accommodation means and how much individual support people residing in such settings can expect, and there is no framework of oversight, ensuring that support provided to individuals is sufficient.”[3]
  4. Given this context, clear agreement between commissioners and providers on the scope and standards of services is vital. Devon County Council contracts Devon Partnership Trust to manage the provision of identified accommodation needs for individual clients of mental health services. Funding for each placement is approved through application by the client’s care co-ordinator to a Trust panel which includes clinicians and managers. There is a contract, for each client, between the Trust and housing provider, which specifies the level of support required from the provider and the value of the contract. However, it does not detail the level of clinical support to the client that the housing provider can expect from Trust staff or from other agencies. This causes tensions between housing providers and the Trust about what should be expected from their services. Concerns were raised by Home Group, to this Review and in the Trust’s Serious Incident Review, that clinical staff did not understand what their staff could, and could not, offer. Concerns about commissioners’ matching of clients and services have also been raised in recent Safeguarding Adults Reviews in Devon. 
  5. Although not a requirement of their agreement with Devon County Council, Devon Partnership Trust does monitor the accommodation and related support commissioned. There is no national system for inspection of the quality of such services unless they carry out one of the activities regulated by the Care Quality Commission. However, the Trust has a system to ensure contractual requirements are met by accommodation providers, with a checklist of points to review on regular visits, including looking at the property and reviewing a sample of care plans. Under this scheme Caraston Hall had bi-monthly visits from the Trust’s social care contract and review manager.  Home Group reported a good working relationship with the Devon Partnership Trust Individual Patient Placements team and believe they are well supported by this team.
  6. It is the responsibility of the Board of a private or voluntary sector agency providing housing or support to ensure policies and procedures are set in line with any relevant legislation or national standards and that there are arrangements to ensure compliance. Home Group and Rethink, providers with national scope, use internal quality assurance systems. However, Rethink found risks from Canada identified by their staff had not been recorded properly on their main internal systems. Caraston Hall’s internal review found that there appeared, at the time of the homicide, to be no standard operating procedures in relation to support planning, review and recording with which to cross reference support plans.

[1] Clinks: The state of the sector 2018 / Key trends for voluntary sector organisations working in the criminal justice system.

[2] This did not apply to Caraston Hall, Hollywell, or the services provided by Home Group at Address A or Rethink at Address B .

[3] Speech by Baroness Stowell, Charity Commission Annual Public Meeting, 3rd Oct 2019.

Skills and training

  1. In a system under pressure, effective working with other agencies is key to making the best use of available resources to support vulnerable people. This case has illustrated how skills in this are important at all levels. Devon Partnership Trust’s Serious Incident Review said that staff would benefit from regular clinical supervision and / or action learning to develop skills and explore thinking around the management of complex cases, and to share learning and good practice. Development of such skills is likely to be of increasing value to all agencies.
  2. Many of the Devon Partnership Trust staff involved in the provision of care, and in risk management meetings convened to consider the risks posed by Canada to Tigre were not up to date with mandatory training requirements. Policy in 2017 required the clinical staff concerned to be trained to Level 3 safeguarding which is designed to improve awareness and knowledge relating to safeguarding of vulnerable adults at risk. A new approach to Safeguarding Training introduced by the Trust that year increased compliance with this level from 10% in June 2016 to 48% (600 staff) in January 2018. However, several key staff involved with Canada or Tigre, including PCC2 and VCC2, had not undertaken the training by the time of the homicide. In the Community Mental Health Team as a whole, while 98% had undertaken basic Safeguarding Training by July 2017, only 17% of those required to had undertaken the Level 3 training.
  3. Completion of the training would have provided a better understanding of domestic abuse, and of the systems in place within the Trust, which could have supported the efforts of Trust staff to identify and address the risks. The mandatory training includes comprehensive information on domestic abuse, use of DASH risk assessment, the Domestic Violence Disclosure Scheme and Multi Agency Risk Assessment Conferences (MARAC). It reminds clinicians of the mandatory questions on domestic abuse which should be included in all assessments and routinely reviewed. In addition, it includes information on how to refer and on escalation processes, where clinicians have concerns that a referral has not been triaged as meeting the criteria for a safeguarding enquiry. The Trust also offers optional stand-alone training on domestic abuse through e-learning and face to face. Training is supported by use of workbooks, leaflets and self-help guides and web-based information available to both staff and patients.Devon Partnership Trust’s contracts with accommodation and support providers do not specify the level of training required for staff. Caraston Hall’s Safeguarding Adults from Abuse Policy for 2017-18 covered domestic abuse and included provision for all staff to undertake the Devon County Council Safeguarding Adults Alerter’s course, and Service Managers to complete Level 3 Practitioner training. All staff have to complete mandatory safeguarding training every 2 years and safeguarding is part of staff supervision sessions, provided every 6 weeks. Rethink expected all staff to complete a mandatory safeguarding adults e-learning package, which includes domestic abuse, as part of their 12 week induction. Managers are responsible for ensuring that training undertaken by staff is discussed in supervision so understanding of safeguarding is clearly established and further support identified if required. This can be delivered by individual safeguarding briefing sessions developed by the charity and available to all managers. At the end of 2017 74% of staff at Rethink’s Devon Supported Housing Service had completed safeguarding training. currently 100% of staff have completed safeguarding training.
  4. Exeter City Council identified through its Internal Management Review that their housing and environmental health staff who were in contact with Canada would have benefited from training on domestic abuse, to enable them to recognise situations of concern, know how to refer to the appropriate agency, and challenge other agencies if they do not feel risk is being appropriately addressed.

Recognising the risk of violence

  1. Strangulation is known to be a common method used by male perpetrators of domestic homicides on female victims. The DASH form takes account of this risk in the question: “Has [name] ever attempted to strangle/choke/suffocate/drown you?”, and practice notes to the form say that any attempt at closing down the victim’s airway should be considered high risk.   Strangulation may often not produce visible injuries but may cause injuries internally. It is recognised in guidance to police and paramedics on “red flag criteria” requiring hospital assessment.  
  2. Canada’s recorded criminal history did not highlight his past use of partial strangulation. (His father noted that this was a technique he had adopted for self-defence when younger.) Due to the lack of visible injuries strangulation is often recorded by police as a common assault, which does not reflect the potential for serious or fatal injury. Domestic violence is itself considered an aggravating factor, so a strangulation in a domestic abuse context should be recorded as a more serious offence. The Crown Prosecution Service Charging Standards allow for a wider view. “The degree of harm caused will in many cases be more than just the level of injuries sustained. There will be cases where, although the level of injury may be quite minor, the circumstances in which the assault took place e.g. repeated threats or assaults on the same complainant or significant violence (e.g. by strangulation), make a charge of Actual Bodily Harm appropriate rather than one of Common Assault. There should be an assessment of the overall harm caused when deciding on charge and awareness that the level of injury is simply a part of the overall harm.”

Pressures on community mental health services.

  1. The Care Quality Commission’s unannounced inspection of Devon Partnership Trust in November 2017 found that overall the Trust provides a Good service, as had the previous inspection (December 2016). The rating for Forensic Inpatient / Secure Services (covering Langdon Hospital) improved to Excellent, and the Trust’s regional leadership on forensic care was commended. However, the rating for Community-based Mental Health Services for Adults of Working Age (previously inspected in 2015) went down from Good to Requires Improvement.
  2. A significant factor in this was staffing capacity. Long term sickness and vacancies within teams had impacted assessment times and the size of staff caseloads. Staff shortages also impacted on the ability to safely deliver the duty phone services where patients could phone in to access support. Staff felt that they were not always provided with the resources to deliver the services effectively: for, example, cover for sickness and vacancies. In July 2017 the Community Mental Health Team had a vacancy rate of 11% overall, 17% for qualified nurses.
  3. The Trust’s Serious Incident Review reported that:
    • There are a number of community based clinical teams within Devon Partnership Trust, with differing responsibilities resulting in unclear pathways. In addition to unclear pathways, levels of vacancies and changes in personnel inhibit the development of therapeutic long term relationships with clients. Changes in both medical and non-medical staff supporting Canada had an impact on relationships and partnership working.
    • “In interviews with many Trust staff and staff working in partner agencies there was a level of concern expressed about the deterioration of partnership working due to increasing pressures faced by community services, and increasing fragmentation of this service.”
    • “Home Group expressed concern that the care coordination service is severely stretched. They reported the crisis service to be unresponsive and unhelpful, reluctant to see people in their own home and overly restrictive in terms of accepting referrals.”


  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 sets out the lessons learned from this Review along with progress already made on some of the issues. The Recommendations which follow show 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, such as making decisions based only on mental health, is insufficient to mitigate risk and promote wellbeing. To quote recent national research, to which Devon agencies contributed: “People are complex: everyone’s life is different, everyone’s strengths and needs are different. The issues we care about are complex: issues – like homelessness – are tangled and interdependent. The systems that respond to these issues are complex: the range of people and organisations involved in creating ‘outcomes’ in the world are beyond the management control of any person or organisation…. [so agencies should work together in] a way that is human, prioritises learning and takes a systems approach.”
  2. Devon Partnership Trust’s Serious Incident Review rightly concluded that the Trust needs to develop more robust arrangements for the management of complex cases. “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. It should take account of their relationships with others who are vulnerable and be sensitive to the potential effects of past trauma. Where two clients are in a relationship where domestic abuse is considered a risk, services working with them should look at their situation as a whole. While mental health services may often be involved, the principle applies more widely.
  3. Agency culture and expectations, and staff skills in working in a multi-agency context, are as important to this as formal process. A participant in the Review commented “Had we all been able to work together without the constraints around risk of blame, then both information sharing and joint working could have significantly reduced the risk of this incident occurring. There needs to be more of an understanding that these stakeholder/multi agency meetings and conversations should be a ‘safe space’ to enable organisations to share honestly and ask for help from one another.”
  4. This tragedy has illustrated some factors which could enable a co-ordinated response:
    • shared understanding of roles, responsibilities and risks;
    • information on the risk of harm, including MAPPA status and known triggers for escalation, available to all services;
    • shared plans, with client consent, as the norm;
    • commitment to joint action in the event of escalating risk or deteriorating mental health or behaviour;
    • the expectation of effective and timely communication between agencies and, where appropriate, with relatives;
    • arrangements by which any agency can escalate through senior management if seriously concerned that the response by another agency is inadequate.
  5. 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. Home Group, prompted by this tragedy, now request earlier meetings with Devon Partnership Trust’s Individual Patient Placement Directorate regarding risk concerns with other clients. The Trust has tightened the Enhanced Community Recovery Service Contract guidance, to promote NHS support for contract providers when dealing with risk.
  6. Substance misuse can be a significant barrier to the effectiveness of support plans. This should lead to early involvement of specialist substance services in multi-agency planning to ensure appropriate risk assessment and treatment where necessary. It is important that partner agencies understand how to refer proactively into drug and alcohol treatment provision, as self referrals may not work in the same way: individuals are not always honest about the level, impact and type of drug use until trust is developed with the service. Police powers, while understandably targeted at more serious drug related crime, could occasionally be used to disrupt illicit drug use within an overall multi-agency plan for a vulnerable person.
  7. The involvement of relatives adds further complexity, but it is important that they, too, understand the multi-agency approach. Devon Partnership Trust’s staff guidelines on working with carers (2018) summarise “Some would argue that serious mental health problems present the greatest challenge in trying to maintain positive understanding and communication between those who care as partners, friends or relatives, the staff from all services, statutory, voluntary and independent, and the service users themselves.” Multi-agency working needs clarity for clients and their families on how queries, comments and complaints about their overall support may be made. The Trust’s strategy for carers would form a useful basis for a protocol which other agencies working with them on complex cases could share.


  1. The overarching arrangements for responding to the risk of serious harm to vulnerable adults are through the inter-agency Devon Safeguarding Adults Board. Devon County Council holds the statutory duty for triaging concerns and carrying out Safeguarding Enquiries and so influences what staff of all agencies see as a “safeguarding” risk which might justify intervention. Over the period relevant to this case, Devon was less likely than comparable authorities to record issues reported to them as safeguarding concerns. Those it did record were less likely than in comparable authorities to lead to a full enquiry after the initial triage. Such variation risks confusion as many services likely to raise concerns work across local authority boundaries, and all have staff or clients with experience of other parts of the country.
  2. The Council has made progress in closing this gap since the homicide, working with other south west authorities on a regional review of practice, reminding its own staff of correct process and improving information on its website. Improvements to the organisation of some internal NHS safeguarding teams, including Devon Partnership Trust, have helped in gaining appropriate referrals. Relationships with care providers and partner agencies have developed, resulting in advice being sought prior to a concern being raised. A referral form for health and social care professionals who work directly with adults has been updated to prompt provision of a full picture about the person’s situation and evidence of high risks. Outcome letters have been developed to help the safeguarding team consistently provide written feedback on the outcome of a safeguarding referral with a clear rationale as to why the decision has been reached. Further improvement work is under way, including further visits to community teams from the Safeguarding Practice Lead, and a Peer Review of adult safeguarding due within the next 12 months.

Supported accommodation

  1. Accommodation has long been recognised as a key component of health and wellbeing and in the rehabilitation of offenders. Section 117 of the Mental Health Act mandates the offer of supported accommodation after detention under the Act. Enabling support from staff with the time to treat clients as individuals is often a key factor in recovery. Such accommodation and support comes from a mixed market of non-statutory agencies, including housing associations, charities and the private sector, some with a specialist focus and some offering a range of provision. The Devon mental health accommodation providers’ network includes twelve organisations, of which six qualify for Enhanced Community Recovery Service placements. There are no overall arrangements for predicting demand, planning the level of resources, or identifying gaps either by geography or type of support. The Individual Patient Placement Directorate pays for out of area placements as required, but has not drawn from this work to identify whether increased local provision of the right sort could reduce that spending. 
  2. Wider social trends and pressures on public finances are likely to mean the demand for suitable supported accommodation increases both overall and in the level of individual client need. This needs to be addressed at a strategic level in the county, with the aim of having capacity in the system to find a more suitable placement quickly if one breaks down or a client agrees to move away from unhelpful influences. 
  3. Devon Partnership Trust, acting on a recommendation from the Serious Incident Review, has improved its approach to contracting with housing providers, aiming to ensure robust arrangements are in place for safeguarding, information sharing and management of risk. This includes new standards and monitoring arrangements for both regulated and non-regulated providers

Training and skills development

  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. Direct contact with professionals from other agencies, for example through joint training events, shadowing or joint projects, aids mutual understanding. While the Trust has improved its own compliance with safeguarding training, some of the smaller partners it relies on have less expertise in this. Rethink, one of the larger providers, identified learning from this tragedy about increasing awareness of awareness of domestic abuse within their training, whether supporting the victim or the alleged perpetrator.  As identified by Exeter City Council, staff in a range of public facing roles may encounter examples of domestic abuse and would benefit from training on how to respond. 
  2. When staff face a difficult situation in a multi-agency context they need to know about the existing frameworks which may be relevant. Where domestic abuse is a risk, these include MARAC, the Domestic Violence Disclosure Scheme and MAPPA. In addition to coverage in mandatory safeguarding training, staff also need to be able to access advice on whether these are relevant to a particular case. Agencies of all sizes need to ensure staff know who to turn to. 
  3. Training coverage and content has improved since the homicide: 
    • The external reviewers undertaking Devon Partnership Trust’s Serious Incident Review, from July 2018, found “notable improvements to safeguarding systems” within the Trust, with new and improved safeguarding training and an improvement to levels of staff compliance with safeguarding training. In May 2019 90% of all registered clinical staff were compliant with Level 3 training.
    • The staff team of Rethink’s Devon Supported Housing Service undertook an externally accredited course on risk management in June 2018. All staff at the had completed safeguarding training had completed safeguarding training as at April 2019. Within the charity as a whole, all lessons learnt from safeguarding issues are discussed within teams and changes in practice are embedded, where appropriate. Key organisation learning from safeguarding events is provided to operational services in the form of scenario based briefings. All staff receive briefings on local authority and Rethink Mental Illness Safeguarding Adults Policies in line with any updates and changes.
    • Splitz has obtained government funding for 2019/20 to provide training and support to Housing Associations, specialist housing providers, and housing support agencies across Devon to assist people with complex need to protect their tenancies and ensure these providers have good awareness of domestic abuse.
    • Caraston Hall has implemented a more systematic approach to staff training, particularly on support planning, record keeping and working with dual diagnosis clients. It has also run bespoke sessions for management development and on managing challenging clients

Agency internal arrangements

  1. Frequent changes in clinical staff at Devon Partnership Trust have impeded the development of positive therapeutic relationships and interfered with the ability of clinical staff to develop an understanding of the clients. A factor in this is the national shortage of many clinical grades in mental health services, 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.
  2. In a positive step for clients such as Canada, Devon Partnership Trust was one of three sites awarded contracts by NHS England in May 2018 to become pilot sites for new community forensic teams. The main aim of the two-year pilot, which will be closely monitored and evaluated by NHS England, is to reduce length of stay for patients in secure care through the provision of specialist community forensic teams who will work alongside inpatient teams to help facilitate transition to the community and provide more robust community treatment and support. The multi-disciplinary team will be relying upon a relational model to help understand and support the patients they are working with, following on from the relational discovery approach of inpatient services at Langdon Hospital.
  3. 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 help ensure that the placements themselves are better equipped to support the patients in the community and help them engage in more meaningful activity. A fuller description of the service is given in Appendix E.
  4. Correct use of internal systems was an issue at some level for most of the agencies involved. Devon Partnership Trust staff failed to use their risk management system and made mistakes in communication with relatives. 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 implementing standard operating procedures for client assessment, support planning, incident reporting and risk management processes. In addition, the company has introduced a new system for recording communication with external agencies and a regular audit of client support files.
  5. The need for an updated process for employee protection has already been recognised within Exeter City Council. The Principal Health and Safety Officer is now leading a Safety of Employees Review Group which now meets monthly to review assault incidents that have been added to AssessNet (the health and safety case management system). The group decides whether to add the perpetrator to the Employee Protection Register and whether sanctions are needed beyond any emergency measures already in place. The group also looks at individuals on the Register whose cases are up for review to check whether they still need to be included or can be removed because they no longer pose a risk. An email then goes out to all staff to alert them that new entries have been included on the Register and advising them to check it.


  1. These recommendations are developed in more detail in the separate action plan and are cross-referenced here to the supporting paragraph in this report. 

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. (#355-#359, #361)

R2 Improve communication and joint working arrangements between Devon Partnership NHS Trust and local drug and alcohol treatment providers for mental health patients with substance misuse problems.  (#360)

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. (#364-#365)

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. (#362-#363)

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. (#367-#369)

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. (#370)

R7 Review the way in which Devon and Cornwall Police record, investigate and present evidence to the Crown Prosecution Service regarding assaults involving strangulation. (#348-#349)

R8 In evaluating the Devon Partnership NHS Trust pilot of a community forensic team, take account of the views of partner agencies on how the team collaborates with their services.  (#371-#372)

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. (#368)

Key to name codes

Note that staff roles were those held at the time relevant to the action described. 

Address AWhere Canada lived until early Dec 2017Hollywell Housing Trust
Address BWhere Canada lived at time of homicideRethink Mental Illness
Address CWhere Tigre lived at time of homicideCaraston Hall
AMHP1Approved Mental Health PractitionerDevon Partnership Trust
CP1Consultant Psychiatrist for TigreDevon Partnership Trust
CP2Consultant Psychiatrist for Canada (summer 2017)Devon Partnership Trust
CP3Consultant Psychiatrist for Canada(autumn 2017)Devon Partnership Trust
CT1Clinical Team LeaderDevon Partnership Trust
FSW1Forensic Social WorkerDevon Partnership Trust
HGCLClinical LeadHome Group
MHRW1Mental Health Recovery WorkerRethink
MHRW2Mental Health Recovery WorkerRethink
PCC1Care Co-ordinator for Canada to May 2017Devon Partnership Trust
PCC2Care Co-ordinator for Canada from May 2017Devon Partnership Trust
PCSO1Police Community Support Officer from neighbourhood team covering Address ADevon & Cornwall Police
Resident 1Girlfriend of Canada in 2011 when both lived at Address B. 
Resident 2Male resident of Address B in 2012 
Resident 3Co-tenant of Address A with Canada  
RM1Service Manager for Address B Rethink Mental Illness
RR1Recovery Worker (substance misuse)RISE
SM1Service ManagerCaraston Hall
SMHP1Senior Mental Health PractitionerDevon Partnership Trust
Tech 1Environmental Health TechnicianExeter City Council
Tech 2Environmental Health TechnicianExeter City Council
VCC1Community psychiatric nurse (Active Review Team) for Tigre to Oct 2017. Devon Partnership Trust
VCC2Care Coordinator for Tigre from October 2017Devon Partnership Trust

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 Group was led by the Chair of the Safer Devon Partnership Board, and included representatives of:

  • Devon County Council 
    • Chief Officer for Communities, Public Health, Environment and Prosperity 
    • 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 

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

  • Tigre’s father (and other family members on request).
  • Canada’s mother, father and sister.   
  • Members of Exeter Community Safety Partnership via its Chair.
  • Chief Executive and officer with responsibility for domestic homicide reviews (in this case the Director – Communities, Health, Wellbeing, Sport and Leisure) of Exeter City Council 
  • Members of the Safer Devon Partnership Board
  • Safer Devon Partnership’s domestic homicide review Executive Group 
  • Chair of the Devon Safeguarding Adults Board
  • 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 Child Safeguarding Practice Review Group.
  • Police and Crime Commissioner for Devon, Cornwall and the Isles of Scilly
  • All organisations named in Table 1.

Appendix B: Agency reviews

The Panel drew on the reviews by individual agencies shown in the table below. Most were Internal Management Reviews prepared for the Domestic Homicide Review following Home Office Guidance. The Panel agreed to accept the independent external reviews commissioned by Devon Partnership Trust from Enable East as part of the NHS Serious Incident Review process following the homicide as fulfilling the role of an Internal Management Review. Two of the not for profit agencies providing services had undertaken internal reviews through their own governance processes before the Domestic Homicide Review started, and the Panel agreed to use these.

An Internal Management Review (reported to the agency concerned and the Domestic Homicide Review Panel only) is carried out by an agency officer not involved in the case, typically one with a quality assurance role. They review the agency’s records and policies, interview staff involved (where appropriate and still contactable) and report on:

•           the chronology of relevant interaction with the victim and / or perpetrator;

•           what was done or agreed;

•           whether internal procedures were followed; and

•           conclusions and recommendations from the agency’s point of view.

Agency & report writerIndependence statementSources
Caraston HallNon-executive Board MemberThe author of report has no personal connection or direct line management responsibilities for this caseInternal documents including notes, referrals, meeting minutes, assessments, support plans, correspondence, email, policies.
Devon & Cornwall PoliceDetective Sergeant Serious Case Review TeamThe author of the report confirms that they have no personal connection or line management responsibility for this case.Force information systems including UNIFI, Storm, Compact and Sharepoint. Police National Computer. Selected evidence used by the criminal investigation. Interview with PCSO1.
Devon County CouncilTeam ManagerSpecialist Placement TeamThe author of this report has no personal connection or line management responsibility for this case.Care First 
Devon Partnership TrustIndependent Review (in two separate reports) of services offered by the Trust to Canada and to Tigre. Undertaken by Linda Glasby & Tracey Greatrex, Enable East, who reported they were given full access to clinical notes and Trust documents, and were confident that staff interviewed were open in their discussions.Trust clinical records and other documents. Interviews with Trust staff involved in the care and treatment of both Canada and Tigre. Interviews with managers of Home Group and Caraston Hall. Interviews offered to families (see Appendix C).  
Exeter City CouncilPolicy Officer and Corporate Safeguarding Lead, Environmental Health & Licensing.The author of the report confirms that they have no personal connection or line management responsibility for this caseEnvironmental Health, Housing Options and Benefits case management systems.Clarifications from staff involved in the case and discussion with their managers.
Hollywell Housing TrustTrusteeThe author of this report confirms that he has no personal connection or line management responsibility for this case.Information from all the Hollywell staff involved who had contact with Canada. Discussion with the Chief Executive Electronic records and logs of incidents, development and subsequent actionsRecords of tenancy review meetings.
Home GroupRegistered Manager covering area (appointed in 2018)The author of the report confirms that they have no personal connection or line management responsibility for this case.Review of records.
Rethink Mental Illness Head of Community Services (South) and Head of Quality Assurance.Terms of reference set by, and reported to, the charity’s Integrated Governance Overview GroupService user database and incident and accident management database. The Human Resources system to re the experience and shift patterns of staff.Interviews with Service Manager, RM1 
Royal Devon and Exeter NHS Hospitals TrustSenior Safeguarding NurseThe authors of the report confirm that they have no personal connection or line management responsibility for this case.Electronic records of Emergency Department and other hospital systems.Hospital notesIt was not possible to speak to staff involved as they have left the Trust or retired.
Together Drug & Alcohol ServicesPanel member from Public Health substance misuse commissioningAuthor is commissioner not provider.Archived records from RISE (previous service provider). Discussion with current service provider. 

Appendix C: Involvement of family, friends and support networks

Initial contact with Tigre’s family (father, mother and brothers) was through the Police Family Liaison Officer, who explained that a Domestic Homicide Review would follow after the trial. In co-operation with the Safer Devon Partnership Domestic Homicide Review Co-ordinator, the officer arranged for the family to receive the explanatory leaflet from the Home Office, details of an advocacy organisation, and the Co-ordinator’s contact details. On the day the Independent Chair observed part of the trial the officer introduced her to Tigre’s parents, and this provided the opportunity for discussion of what the Review aimed to achieve.

Following the trial, the Co-ordinator sent further messages for Tigre’s father, mother and elder brother which included an offer to facilitate contact with an advocacy organisation and to discuss the draft terms of reference of the Review. The family preferred not to contribute at this point. However, Tigre’s father and his partner did meet the Enable East Reviewer, who reflected their views in the Devon Partnership Trust Serious Incident Report. 

The Co-ordinator let the family know that the invitation for them to offer views remained open, and in March 2019 Tigre’s father and partner met the Independent Chair and the Public Health member of the Panel and provided helpful insights into Tigre’s situation and family concerns and discussed potential recommendations. The meeting was recorded by consent. Her mother did not accept the offer of contact.

For reasons explained in the report, the Panel sought contact with only one of Tigre’s friends. She is a survivor of domestic abuse whose comments to the media had been reported after the trial and was known to one of the Panel members. She met the Independent Chair and the Co-ordinator at an early stage of the Review and shared her memories of Tigre and insights into her situation. 

The initial stages of this Review ran in parallel with the Enable East reviews commissioned by Devon Partnership Trust, and it was agreed that the Trust’s representative on the Panel would facilitate co-ordination of contact with relatives, and that the Domestic Homicide Review would not directly contact Canada’s family until the Serious Incident Review relating to him was complete. 

The Enable East review invited contributions from Canada’s father and mother. However, the invitation gave an incorrect telephone number, so his mother, who does not use email, did not make contact at that point. Ill health and distance prevented his father’s participation. When the Serious Incident Review was complete the reviewer met Canada’s mother and sister to explain the findings and passed on an invitation to contact the Domestic Homicide Review Co-ordinator. It was at this point that Canada’s sister made the reviewer aware of her November 2016 complaint to Devon Partnership Trust. 

Canada’s mother and sister both took up the offer of contact with the Domestic Homicide Review. In March 2019 his sister emailed copies of the complaint and related correspondence and social media activity, and then had a telephone conference with the Independent Chair which covered these and broader background. Canada’s mother met the Independent Chair and the Exeter City Council panel member to talk about Canada, the services he received and his relationship with Tigre. She was accompanied by a woman friend to support her. The friend had known Canada so also contributed to the discussion. Understandably, Canada’s mother expressed frustration at not being listened to in the past.  In this and related telephone contact with the Co-ordinator assurance was given that her contribution was valued. Regrettably, due to technical problems, neither of these meetings was recorded, but participants were given the written notes to check afterwards. 

Tigre’s father received a copy of a draft report in August 2019, and, after an agreed period to study it, he and his partner met the Independent Chair and Splitz panel member to discuss it. The draft report was amended to take account of their comments, which were recorded by consent.

The Independent Chair, with the police panel member, then met Canada’s mother and her friend to discuss the draft report (in September 2019). Canada’s sister did not take up the offer of further contact at that point. Attempts to contact Canada’s father had initially been unsuccessful, but he was able to meet with the Independent Chair and Safer Devon Partnership panel member in October 2019 to discuss the draft report and contributed information by email in advance of this. These meetings were recorded by consent.  The report was further amended to take account of comments made at these meetings, 

The Panel appreciates the contributions and insights of both families, and their desire to see the lessons from this review applied. 

Appendix D Independent Chair / Report Author

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. 

Appendix E: Explanatory notes

Community Forensic Team – pilot

In a pilot scheme started in May 2018 Devon Partnership Trust has a Community Forensic Team (CFT), a small multidisciplinary team working (Monday to Friday) as part of the wider community forensic services (CFS) that also includes Pathfinder, FIND and Offender Personality Disorder Services. The team will work from Easby House as a base and form their own Community Forensic Services Local Delivery Unit, under a Service Manager.

The CFT have a whole-time Consultant Psychiatrist, an 8c Psychologist, three Occupational Therapists and three Community Psychiatric Nurses, a Social Worker and a Peer Support Worker. The team will offer full care coordination for the patients that they have assessed and who meet the team’s eligibility criteria. The main criteria for referrals to the team are:

  • The patient is currently in a secure setting
  • The patient is from, or will be willing to be discharged to the Devon area
  • There are significant risks of harm to others
  • The CFT could shorten or improve the patient’s transition to the community.

Community Treatment Orders

A Community Treatment Order, under Section 17A of the Mental Health Act, provides a framework for the management of patient care in the community and gives the Responsible Clinician the power to recall the patient to hospital for treatment if necessary. The framework includes regular review and means of appeal.

A Community Treatment Order may be made if the certain criteria are met, including

  • The patient is suffering from a mental disorder of a nature or degree which makes it appropriate for them to receive medical treatment;
  • It is necessary for the patient’s health or safety, or for the protection of other persons, that they should receive such treatment; 
  • Subject to the patient being liable to be recalled, such treatment can be provided without their continuing to be detained in hospital; 

Conditions set depend upon the patient’s individual situation. The purpose of these is to: 

  •  Ensure the patient receives treatment for their mental disorder; and
  • Prevent risk of harm to the patient’s health or safety or to protect others.

This might cover for example:

  • Stipulating where and when the patient is to receive treatment;
  • Stipulating where the patient is to live; or
  • Requiring avoidance of known risk factors or situations relevant to the patient’s mental disorder.

Domestic Violence Disclosure Scheme

The Domestic Violence Disclosure Scheme, commonly known as Clare’s Law, allows people to request information from the police about their partner’s previous offending history in relation to domestic violence, the “right to know”. Further the police have a “right to tell” those identified as being at risk from domestic abuse by a partner. It is not in fact a law but a process that suggests a multiagency agreement is normally required to confirm the risk and the need to share the information. Information sharing is still governed the Data Protection Act. The process allows for third party concerns whereby a friend, relative or agency may raise the concern to the police and trigger consideration of a disclosure to the potential victim. 

Any agency can trigger this process by contacting police and asking for the process be considered for a particular couple. Information will normally only be shared with the individual at risk unless for some reason they cannot protect themselves effectively when a carer may also receive a disclosure.

In Exeter considerations for disclosure under the scheme are discussed at the fortnightly MARAC meeting to provide the multiagency consideration the process requires to authorise the action. Police may assess applications at an early stage and decide that there is nothing to disclose and provide a letter outlining that fact but being mindful that the police record does not hold all information about people. The scheme provides certainty for professionals from all agencies and allows for considered discussion of what and how disclosures should be made. It may be decided that someone other than the police deliver the information. 

Individual Patient Placement (IPP)

IPP is a Devon Partnership Trust service with responsibility for specialist individual patient placements which are commissioned to meet an individual’s complex needs which cannot be met in Devon. These placements are usually out of area.

The IPP Directorate is a commissioning and contracting function which makes it different to other Directorates within the Trust.  It commissions and approves funding and placements in a range of contexts which include:

  • High Dependency Inpatient Rehabilitation (HDIR) (Open) – Out of Area and Langdon Hospital
  • Enhanced Community Recovery Service (ECRS)
  • Psychiatric Intensive Care Unit (PICU).

Tasks undertaken by the IPP team include:

  • Facilitate a safe repatriation back to Devon to the least restrictive environment
  • Reviewing out of area placements and treatment (attending CPA’s, Mental Health Act Tribunals, Multi-Agency Public Protection Arrangement, strategy meetings, safeguarding ,etc.)
  • Provide advice using their expert knowledge to recommend appropriate placements, treatments and care pathways
  • Advise on appropriate funding streams
  • Well established links to Secure Services – attending Langdon referral and discharge meeting
  • Advise and recommendation for appropriate step down placements
  • Key stakeholders on IPP funding and review panels
  • Authorise and validate invoices
  • Key member and link to Social Care panels

MAPPA: Multi-Agency Public Protection Arrangements

Multi-Agency Public Protection Arrangements (MAPPA) are multi-disciplinary meetings held on those individuals most at risk of causing harm and are designed to protect the public from serious harm.  They require the local criminal justice agencies and other bodies dealing with offenders to work together in partnership in dealing with these offenders.  Typically a MAPPA panel might consist of the Police, Probation Service, Prison Service, accommodation providers, drug and alcohol service providers and Social Services. Local arrangements for MAPPA meetings vary. Those for Exeter (and Torbay) they are held weekly, hosted by Probation and are represented by regular attendees, and chaired by either a probation manager or senior police officer. Each agency considers what they can provide to enhance the risk management plan within their own sphere of professional responsibility. Individuals are referred mainly, but not only, by police and probation. Referrals are considered by a screening panel who decide whether a case meets the criteria for a panel meeting to be convened.

Individuals subject to MAPPA arrangements are placed at one of three levels and in one of three categories.  The Levels are from 1 to 3 where Level 1 is a single agency managing the individual and Level 3 applies to a small number of offenders requiring  exceptional resources eg for cross-border working.  At an initial MAPPA meeting the Level and Category of the person is determined.  The Level can be escalated at subsequent meetings if the situation warrants it.  The Categories are 1 (sexual), 2 (violent) and 3 (other dangerous offender).  There is a specific list of offences and sentences associated with Category 2. To qualify for Category 3 there must be a conviction or caution for an offence which indicates that the offender is capable of causing serious harm and the requirement for and possibility of active multiagency management. Category 3 cases are therefore only managed at Levels 2 or 3

Within MAPPA meetings all agencies scrutinise the risk management plan, compiled by the responsible Probation Officer, and make suggestions as to the management and monitoring of the individual or for any further specific actions to be taken (like referrals to other agencies/services, drug screening, home visits etc).  MAPPA meetings are only held on people as long as their risk is assessed as requiring it.  When the assessed level of risk falls and the risk is thought to be manageable, the individual is moved down a level, held at MAPPA Level 1 by a single agency (usually Police or Probation), without panel meetings, or discharged from MAPPA altogether.  MAPPA does not give supervising agencies any additional powers: it is a system for assessing and managing risk.

Agencies make their own arrangements for recording the MAPPA status of their clients. The Devon and Cornwall Police UNIFI system person record displays a warning showing the MAPPA level. When individuals are actively managed by the MAPPA panel (ie at Level 2 or 3) the system links the person record linked to an interested parties marker which notifies a specific officer or team when a crime or piece of intelligence is linked to that person. Interested person markers allow those with specific responsibility to assess and react to any such updates. Once a MAPPA subject is no longer managed under the process the UNIFI marker is removed, though any intelligence submitted during that period remains on the record to be seen by officers dealing with them in the future. 

MAPPA status can be disclosed to a third party. Disclosure must comply with the law, be necessary for public protection, and be proportionate. Police can disclose where others may be at risk e.g. in supported accommodation. 

MARAC: Multi Agency Risk Assessment Conference

This is a regular meeting where information is shared on the highest risk domestic abuse cases between representatives of local police, probation, health, child protection, housing practitioners, Independent Domestic Violence Advisors and other specialists from the statutory and voluntary sectors. After sharing all relevant information about a victim, representatives discuss options for increasing safety for the victim and turn these options into a co-ordinated action plan. At the heart of a MARAC is the working assumption that no single agency or individual can see the complete picture of the life of a victim, but all may have insights that are crucial to their safety

Mental Capacity

Adults have a legal right to make their own decisions, even when they are unwise, as long as they have the capacity to make that decision and are free from coercion or undue influence. In addition, the decision needs to be informed by the possession of all relevant information.

The Mental Capacity Act recognises the following principles: 

  • A person must be assumed to have capacity unless it is established that he lacks capacity
  • A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success.
  • A person is not to be treated as unable to make a decision merely because he makes an unwise decision.
  • An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests.
  • Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action.

Devon Safeguarding Adults Board Guidance states: “People generally have the right to take risks and to live their life as they choose. These rights, including the right to privacy will be respected and weighed up when considering safeguarding duties and responsibilities. They will not normally be overridden other than where there they would be likely to suffer serious harm, or where they lack the capacity to make relevant decisions in an informed way or where there may be risks to other adults with care or support needs. Information may need to be shared and gathered in order to assess the level of risk that someone faces.” 

Risk management policy (Devon Partnership Trust)[21]

Risk management is a core component of mental health care. Practitioners make decisions every day about how to help clients manage their potential self-harm or neglect. Good risk assessment should be structured, evidence-based and as consistent as possible across different settings or different service providers.

Devon Partnership Trust’s Risk Management Strategy recognises risk management should aim to improve a person’s quality of life and their plans for recovery, whilst being mindful of the safety needs of the person, those in their immediate social network and the wider population. The Trust endorses positive risk management and will support any risk-related decision if it is:

  • Considered – carefully, collaboratively, based upon the best information available and conforming with relevant guidelines/best evidence.
  • Recorded – in accordance with the tool/structured prompt and record system in place and that identified risks are reflected in overall treatment/care/risk management plans.
  • Communicated – the relevant people are involved/informed in a timely way. 

The Trust has in place a risk management strategy and a set of policies and procedures relating to the management of risk. The assessment and management of risk is the responsibility of all staff key actions include:

  • It is essential to raise any queries or concerns in relation to risk through your managerial and/or professional line manager.
  • Ensure your decisions and responses to risk assessment and management are considered carefully, collaboratively and based on best information available conforming with guidelines and best evidence.
  • Record your risk assessment on a person’s notes in accordance with standing operating procedures for the system used and complete incident form if required.
  • Ensure you communicate information to the relevant people in a timely way
  • Ensure Recovery principles are at the heart of risk management care planning. 

Safeguarding at Devon Partnership Trust

Devon Partnership Trust has a central safeguarding team which operates a duty system to allow clinicians to contact them, during working hours, for urgent advice. In addition, safeguarding supervision clinics are held across the Trust every week where any staff may consult with a member of the team. Safeguarding referrals can be made via the Trust’s Risk Management System, introduced in May 2017, which allows a single front door for all incident reporting and safeguarding referrals. All safeguarding adults concerns are triaged by the safeguarding team within 24 hours, Advice is provided to clinicians reporting concerns and where appropriate the referral is forwarded to the relevant local authority. The system enables corporate oversight of safeguarding concerns.

Safeguarding Adult Enquiries

[Extract from Devon Safeguarding Adults Self-Neglect Directory, 2018]

A Safeguarding Adult Enquiry can be used to enable multi agency information sharing, risk assessment and protection planning, or contingency planning in the following situations.

  • An adult at risk has been identified as having a pattern of behaviour of serious self-neglect resulting in, or likely to result in, serious harm.
  • They have capacity to make relevant decisions but have refused essential services, without which their health and safety needs cannot be met.


  • the health and social care process that the person is eligible for, such as adult social care, mental health or substance misuse service, have been provided but have not been able to mitigate the risk of serious self-neglect that could result in significant harm.

In these cases, Safeguarding Adults processes can be used to enable multi-agency risk assessment and protection planning to take place. While it may not always be possible to safeguard someone from self-neglect if they fail to engage with services or a protection plan, the Safeguarding Adults process can help ensure that all those involved are aware of the following;

  • All information available on level of risk
  • Who to share any further risk information with
  • What support can be offered, and by whom
  • What protection or contingency planning can be made

[Extracts from Devon Safeguarding Adults guidance: “Deciding when and how to carry out a Safeguarding Adults Enquiry”.]

When a concern that an adult is at risk of abuse has been reported to Devon County Council it is recorded as a Safeguarding Adults Concern. Information is gathered and recorded to help decide whether a Safeguarding Adults Enquiry is needed or whether other actions should be taken.

The criteria for the Local Authority to make (or cause to be made) whatever enquiries it thinks necessary to enable it to decide whether any action should be taken, is that an adult:

(a) has needs for care and support (whether or not the authority is meeting any of those needs),

(b) is experiencing, or is at risk of, abuse or neglect, and

(c) as a result of those needs is unable to protect him/herself against the abuse or neglect, or the risk of it.

Objectives of a Safeguarding Adults Enquiry: 

  • Establish facts
  • Ascertain the adult’s views and wishes
  • Assess the need for protection, support and redress
  • Protection from abuse, in accordance with the adults wishes
  • Make decisions on follow up action needed and who will take it
  • Enable the adult to achieve resolution and recovery.

[1] Caraston Hall is a private provider of supported living services to people with mental health problems or learning disabilities. 

[2] The Police included within their chronology and Internal Management Review records from Multi Agency Public Protection Arrangements (MAPPA) meetings concerning Canada.

[3] As reported by agencies already in contact with them

[4] Voluntary role May 2017 to April 2019. 

[5] From April 2019, following reorganisation, Devon Clinical Commissioning Group.

[6] These reviews were not started until after the trial, at the request of police.

[7] The start point for the Serious Incident Review of Canada is his first appointment with a community mental health team psychiatrist. He started as a tenant at Address A in August, while still at Langdon Hospital, spending increasing time there during the transition period, with contact continuing with the inpatient forensic team.  He first met the care coordinator from the community mental health team in September 2016. 

[8] This time, admitted by Canada, was consistent with evidence of their movements from CCTV and the testimony of the occupant of the neighbouring room, 

[9] To assist anonymisation of this report, the date of the homicide is referred to as Day H, and other dates in January 2018 in terms of the number of days before or after this. 

[10] Of Address A – a privately owned house which Hollywell rented.

[11] Some of the previous MAPPA minutes list Canada as a category 2 offender and others as a category 3. See Appendix E for an outline of the framework..

[12] The warnings also took into account information about Resident 3.

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

[14] Comparator group refers to a group of councils with a similar context. 

[15] Experimental Statistics are official statistics published to involve users and stakeholders in their development and to build in quality at an early stage. Limitations may apply to the interpretation of these data.

[16] Clinks: The state of the sector 2018 / Key trends for voluntary sector organisations working in the criminal justice system.

[17] This did not apply to Caraston Hall, Hollywell, or the services provided by Home Group at Address A or Rethink at Address B .

[18] Speech by Baroness Stowell, Charity Commission Annual Public Meeting, 3rd Oct 2019.

[19] Visit 27th – 29th November, report published May 2018.

[20] “Exploring the new world: Practical insights for funding, commissioning 

 and managing in complexity” Collaborate for Social Change 2019

[21] These paragraphs taken from the Devon Partnership Trust Serious Incident Reviews

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