Domestic Homicide Review Case 17 – Executive Summary

Under section 9 of the Domestic Violence, Crime and Victims Act 2004 

Review into the death of Louise in April 2019 

Report Author: Christine Graham 

February 2023


Safer Devon Community Safety Partnership wishes at the outset to express their deepest sympathy to the family and friends of Louise.  This review has been undertaken in order that lessons can be learnt from what happened to Louise in order to better protect others in the future. 

The review has been carried out in an open and constructive manner with all the agencies, both voluntary and statutory, engaging positively.  This has ensured that we have been able to consider the circumstances that ultimately culminated in this homicide in a meaningful way and address, with candour, the issues that it has raised.  We are particularly grateful to the family of Louise and her friends who helped us better understand her in an attempt to recognise what life was like for her. 

The review was commissioned by Safer Devon Community Safety Partnership on receiving notification of the death of Louise in circumstances which appeared to meet the criteria of Section 9 (3)(a) of the Domestic Violence, Crime and Victims Act 2004.

The Review Process 

This summary outlines the process undertaken by the Safer Devon Community Safety Partnership Domestic Homicide Review Panel in reviewing the murder of Louise who was a resident in their area. 

The pseudonym Louise has been used for the victim in this case.  Louise was 35 years old when she was murdered at her home by the perpetrator in April 2019.  The perpetrator was a lodger with whom she had been involved in an intimate relationship. 

The perpetrator will be known only as the ‘perpetrator’.  This has been done to protect the identity of those involved and their families.

Following Louise’s death, the perpetrator was charged with her murder.  He subsequently pleaded guilty and was sentenced in September 2019.  He was sentenced to life imprisonment, to serve a minimum of 14 years before he can consider application for release. 

The process for this review began when the Community Safety Partnership were notified of the death, by the police, on 7th May 2019.  There followed a meeting of the Executive Group that is accountable to the Safer Devon Partnership on 14th May where the decision to hold a DHR was taken.  All agencies that had potential contact with the victim/perpetrator were asked to check and secure any records in relation to them.  

The Home Office were notified on 6th June 2019 and an Independent Chair was appointed.

Due to unexpected circumstances the Chair withdrew from the role in October 2019 and thus a new Chair and Author were identified and appointed in January 2020.

Contributors to the Review

The following agencies contributed to this review by way of Individual Management Report (IMR):

  • Devon and Cornwall Police 
  • Devon County Council – Children’s Social Care 
  • Devon Partnership Trust 
  • Public Health Nursing 
  • Royal Devon and Exeter Hospital 

Home Start contributed to the review by way of a summary report.

The DHR Panel assured themselves that all reports were written independently by staff not directly involved in this case. 

Louise’s sister engaged with the review by way of personal interview and acted as the point of contact for her family.  A number of friends of Louise and people who knew the perpetrator engaged with the review by way of virtual meetings and correspondence. 

The perpetrator declined to engage with the review process. 

The Review Panel Members

The members of the Review Panel were:

Gary Goose MBEIndependent Chair  
Christine Graham Overview Report Author  
Lara Stead Education Safeguarding OfficerBabcock LDP
Nicky SeagerDetective Chief Inspector Devon and Cornwall Police
Rob Gordon Detective Sergeant – Criminal and Serious Case Review TeamDevon and Cornwall Police
Kate Nightingale Replaced by Michelle Kirkham Serious Case Review & Domestic Homicide Review CoordinatorDevon County Council 
Sam Peterson[1]Service Development Manager – (Domestic Abuse and Homicide)Devon County Council 
Val Watkins Named Nurse Safeguarding Children Devon County Council – Children and Family Health 
Emmy TomsettSenior Manager –Quality Assurance, Reviewing and Safeguarding Service Devon County Council – Children’s Social Care 
Penny Rogers Deputy Director –Safeguarding & Public ProtectionDevon Partnership Trust
Melinda Pogue-JacksonPolicy Officer – Community Safety, Safeguarding and Equality & DiversityExeter City Council 
Laura RobertsDesignated Nurse for Safeguarding Adults NHS Devon Clinical Commissioning Group 
Alison Roberts Senior Safeguarding Nurse SpecialistRoyal Devon and Exeter NHS Foundation Trust 
Chrissy Stower replaced by Julie Reeves  Team Manager Splitz Domestic Abuse Support Services 
Jo DarkeFunding and Development ManagerHome-Start Exeter, East and Mid Devon 

All members of the panel were independent of the case. 

The panel met five times, each virtually due to the Covid-19 restrictions in place for the majority of this review.  The review panel meetings concluded in November 2021.

The Independent Chair and Report Author

The Report Author for this review is Christine Graham who worked for the Safer Peterborough Partnership for 13 years managing all aspects of community safety, including domestic abuse services.  During this time, Christine’s specific area of expertise was partnership working – facilitating the partnership work within Peterborough.  Since setting up her own company, Christine has worked with a number of organisations and partnerships to review their practices and policies in relation to community safety and anti-social behaviour. As well as delivering training in relation to tackling anti-social behaviour, Christine has worked with a number of organisations to review their approach to community safety.  Christine served for seven years as a Lay Advisor to Cambridgeshire and Peterborough MAPPA, which involves her in observing and auditing Level 2 and 3 meetings as well as engagement in Serious Case Reviews.  Christine chairs her local Safer off the Streets Partnership.  

The Independent Chair for this review is Gary Goose who served with Cambridgeshire Constabulary attaining the rank of Detective Chief Inspector: his policing career concluded in 2011.  During this time, as well as leading high- profile investigations, Gary served on the national Family Liaison Executive and led the police response to the families of the Soham murder victims.  From 2011, Gary was employed by Peterborough City Council as Head of Community Safety and latterly as Assistant Director for Community Services.  The city’s domestic abuse support services were amongst the area of Gary’s responsibility.  Gary concluded his employment with the local authority in October 2016.  He was also employed for six months by Cambridgeshire’s Police and Crime Commissioner developing a performance framework.  

Gary and Christine have completed, or are currently engaged upon, a number of Domestic Homicide Reviews across the county in the capacity of Chair and Overview Author.  Previous domestic homicide reviews have included a variety of different scenarios: male victims; suicide; murder/suicide; familial domestic homicide; a number which involve mental ill health on the part of the offender and/or victim; and, reviews involving foreign nationals.  In several reviews, they have developed good working relationships with parallel investigations/inquiries such as those undertaken by the Independent Office for Police Conduct (IOPC), NHS England and Adult Care Reviews.

Neither Gary Goose nor Christine Graham are associated with any of the agencies involved in the review nor have, at any point in the past, been associated with any of the agencies.[2]

Both Christine and Gary have completed the Home Office online training on Domestic Homicide Reviews, including the additional modules on chairing reviews and producing overview reports, as well as the DHR Chair Training (Two days) provided by AAFDA (Advocacy After Fatal Domestic Abuse).  Details of ongoing professional development are available in Appendix Three of the Overview Report. 

The Terms of Reference for this Review

Terms of Reference for the Domestic Homicide Review into the death of 


1          Introduction

1.1       This Domestic Homicide Review (DHR) is commissioned by the Safer Devon Community Safety Partnership in response to the death of Louise, which occurred in April 2019. 

1.2       The review is commissioned in accordance with Section 9, The Domestic Violence, Crime and Victims Act 2004. 

1.3       The Chair of the partnership has appointed Gary Goose MBE and Christine Graham to undertake the role of Independent Chair and Overview Author for the purposes of this review.  Neither Christine Graham nor Gary Goose is employed by, nor otherwise directly associated with, any of the statutory or voluntary agencies involved in the review.

2          Purpose of the Review 

The purpose of the review is to: 

2.1       Establish the facts that led to the homicide on 17th April 2019, and whether there are any lessons to be learned from the case about the way in which local professionals and agencies worked together to safeguard Louise. 

2.2       Identify what those lessons are, how they will be acted upon, and what is expected to change as a result. 

2.3       Apply these lessons to service responses including changes to inform national and local policies and procedures as appropriate. 

2.4       Additionally, establish whether agencies have appropriate policies and procedures to respond to domestic abuse, and to recommend any changes as a result of the review process. 

2.5       Contribute to a better understanding of the nature of domestic violence and abuse.

3          The Review Process 

3.1       The review will follow the Statutory Guidance for Domestic Homicide Reviews under the Domestic Violence, Crime and Victims Act 2004 (revised 2016). 

3.2       This review will be cognisant of, and consult with, the criminal investigation and subsequent criminal justice processes.  It will be similarly cognisant of, and consult with, the process of inquest held by HM Coroner.

3.3       The review will liaise with other parallel processes that are ongoing, or imminent, in relation to this incident in order that there is appropriate sharing of learning.  

3.4       Domestic Homicide Reviews are not inquiries into how the victim died or who is culpable: that is a matter for coroners and criminal courts. 

4          Scope of the Review 

This review will: 

4.1       Draw up a chronology of the involvement of all agencies involved in the life of Louise and the perpetrator to determine where further information is necessary.  Where this is the case, Individual Management Reviews will be required by relevant agencies defined in Section 9 of The Act.  

4.2       Produce IMRs for a time period 1st August 2016 – date of Louise’s murder in April 2019.

4.3       Invite responses from any other relevant agencies, groups or individuals identified through the process of the review. 

4.4       Seek the involvement of family, employers, neighbours and friends to provide a robust analysis of the events. 

4.5       This review will consider the times that Louise was known to have been in abusive relationships previously, and the factors that might have prevented her from seeking help.  

4.6       This review will consider whether there is evidence to show a trail of abuse and, if so, what could be done differently to better protect others in the future. 

4.7       Produce a report which summarises the chronology of the events, including the actions of involved agencies, analyses and comments on the actions taken, and makes any required recommendations regarding safeguarding of families and children where domestic abuse is a feature. 

4.8       Aim to produce the report within the timescales suggested by the Statutory Guidance subject to:

  • guidance from the police as to any sub-judice issues,
  • sensitivity in relation to the concerns of the family, particularly in relation to parallel enquiries, the inquest process, and any other emerging issues. 

5          Family Involvement 

5.1       The review will seek to involve the family in the review process, taking account of who the family may wish to have involved as lead members and to identify other people they think relevant to the review process. 

5.2       We will seek to agree a communication strategy that keeps the families informed, if they so wish, throughout the process.  We will be sensitive to their wishes, their need for support, and any existing arrangements that are in place to do this. 

5.3       We will work with the police and coroner to ensure that the family are able to respond effectively to the various parallel enquiries and reviews, thereby avoiding duplication of effort and minimising their levels of anxiety and stress. 

6          Legal Advice and Costs 

6.1       Each statutory agency will be expected and reminded to inform their legal departments that the review is taking place. The costs of their legal advice and involvement of their legal teams is at their discretion.

6.2       Should the Independent Chair, Chair of the CSP or the Review Panel require legal advice then Safer Devon Community Safety Partnership will be the first point of contact. 

7          Media and Communication 

7.1       The management of all media and communication matters will be through the Review Panel. 

Summary Chronology   

Louise and this perpetrator had been in a relationship for only a few months.  They had met after she had separated from her husband, and he moved in with her as a lodger: around six-months before her death.  It is from that initial financial arrangement that their relationship developed.  On an evening in April 2019, Louise and the perpetrator had dinner and drinks with friends.  They returned home by taxi just before 1 am.  

The perpetrator was then seen cycling along a nearby road at around 2.20 am.  At 4.25 am that morning, Louise’s mobile phone was used to call 999.  This was the perpetrator calling the police from outside the local shop.  

He spoke to the police and told them that he had killed his girlfriend and was waiting outside the shop for the police to pick him up.  He told the operator that ‘basically tonight, we’ve been arguing for months and months and months and tonight I strangled her’.  He said that this had happened an hour or two earlier.  He was asked how he knew that she was dead, and he said that he had tried to resuscitate her for about 20 minutes but there was nothing.

Officers attended Louise’s home and found her lying on her bed under a duvet.  She had been strangled.  

Prior to meeting this perpetrator, in 2015, Louise purchased the house in which she was murdered.  She married in 2017 and had two children.  Her husband was the father of the youngest child.  Her children both had ongoing health issues that necessitated numerous admissions to hospital.  Louise and her husband separated in June 2018. 

Over a period of time, Louise had foreign students lodging with her.  In October 2018, she was struggling financially so advertised for a lodger.  This was when she met the perpetrator; they began a relationship during the subsequent months.  

The perpetrator was a man who had a significant criminal history of violence and alcohol- related offending.  However, his recorded convictions appear confined to a period in his younger life, and save for an issue of drunkenness in 2012, his previous convictions had ended in 2003 – some 16 years before this homicide.  What has become clear, however, is that his recorded convictions do not represent the level of risk that this perpetrator posed – much of which was ‘hidden’ within single agency files or known to previous partners. 

Whilst his convictions may have ended in 2003, his violent and abusive behaviour continued with at least three previous partners. His behaviour included allegations of extreme violence, including strangulation and threats to kill, of those previous partners.  Some of this behaviour was reported either to the police or other agencies.  None of it resulted in a criminal prosecution, although for one reported attack he spent time on remand before the case did not continue to trial.  His victims were mentioned at MARAC meetings.  The reasons for there being no prosecutions are discussed within the overview report.

He last came to notice for these reported attacks in 2016.

After the perpetrator began lodging with Louise it appears that an intimate relationship began with weeks.  In December 2018 she miscarried a pregnancy, citing this perpetrator as the father to friends, although she continued to introduce him as a lodger to others she came into contact with. 

At the end of December Louise overdosed and was hospitalised under the Mental Capacity Act.  At the time of the incident, she was at home with her young son.  She cited a number of issues all coming to a head at once as being the cause.  Louise left the hospital before she was seen by the psychiatric services (at around 4am in the morning) and as a result her sister raised calls for concern about her safety with the police. 

When the police attended Louise’s home, she would only talk to them through the door and reassured them that she was safe although they waited until her sister arrived to care for her.  Louise followed this incident up with a GP appointment where she spoke about difficulties with her ex-husband and several other life stressors.  It appears that this perpetrator accompanied her to the GP, who recorded his presence as ‘supportive’.

Due to the nature of the overdose incident Children’s Social Care became involved to ensure the continued safety of Louise’s children.  During the engagement that followed, with a number of agencies supporting Louise with her struggles, it appears that none recorded the details of this perpetrator.

In mid-February the perpetrator called the police asking for help as he had separated from his partner, Louise, and he needed to get some of his property from her address, but that Louise said that he owed her £700 and she was retaining his property until this was paid, or she would sell his property.  Louise then called the police to request attendance.  Police attended and facilitated the retrieval of some of his belongings and updated that Louise’s locks had been changed.  While the police were present, it became clear that there had been an argument the previous evening.  During this argument, the perpetrator had smashed a glass over his own head and pushed it into his neck.  The enquiry was then updated to a domestic incident, and it was noted that the relationship was over.

Louise then called the police again, a couple of hours later, to say that whilst they had been in attendance, she had blocked the garage with her car so that the perpetrator could not retrieve his belongings from there.  He had waited nearby for her to move the car and then he had entered the garage and taken his property.  She did not want the police to attend as she was going out.  They did attend but did not get an answer at the address.  

Towards the end of March, Louise contacted her neighbour in the early hours of the morning and asked him to clear up some glass.  She said that she and the perpetrator had had an argument and he had smashed a drinking glass on his head.  She had taken his key and kicked him out.  A short while later, Louise told him that the perpetrator would be moving back in 3 days a week, as she loved him, and he deserved a second chance.  

In Mid-April Louise told her sister that the perpetrator was staying over most nights, did not pay rent, and had another address.  Louise and the perpetrator took her children to stay with her sister and family over the weekend.  Her sister’s partner commented that Louise and the perpetrator were arguing whilst there, and her son said that they were having an ‘in the face’ argument.  The children then went to stay with relatives whilst Louise and the perpetrator returned home.  

Later in April, the perpetrator murdered Louise.

Key issues arising from this review

Louise knew little about this perpetrator when he came into her life only 6 months before eventually murdering her.

At the time they first met, she was struggling financially following separation from her husband.  She was struggling with some health issues of her children and some legacy issues between her and her ex-husband.  There seems little doubt that this perpetrator recognised those vulnerabilities and exploited them to his own ends.

After initially appearing supportive, they embarked upon an intimate relationship resulting in Louise becoming pregnant; a pregnancy that she miscarried.  It seems clear that before long the perpetrator resorted to his normal controlling behaviour.  This is likely to have contributed to Louise self-harming and ending up in hospital.  Despite this, and out of feelings of fear, despair, dependence, love, or indeed a combination of some or all of these, Louise’s caring nature gave him a second chance.  That second chance proved fatal.

There were opportunities to identify the danger that existed within this relationship.  Some of Louise’s friends and family raised concerns with her about him and an ex-partner of his contacted her to tell of the danger she faced from him.  For all of the complicated feelings outlined above, Louise stayed with him, even after she knew he was becoming controlling, and they had initially separated.  

We do not know if Louise knew about the Right to Ask under ‘Clare’s Law’.  We know that she did not make an application for such a disclosure and even if she had, it is not clear that the Police would have disclosed what they historically knew about him.  This issue is discussed in depth within the full report. 

When Children’s Social Care became involved following Louise’s overdose, they did not feel that the issue amounted to one where they could ask for checks on who was living in the house.  Even if they had, it remains unclear whether the revelation of his past convictions or intelligence about the previous allegations made against him would have been fully revealed.

Similarly, the police had only one interaction between the couple a few weeks before Louise’s murder. Due to the nature of that incident, and, frankly, resourcing levels, no checks as to the perpetrator’s background were carried out.  Even if they had been the police are clear that it would not be an easy decision to determine whether a pro-active Clare’s Law disclosure would have been made. 

All of this led to a very dangerous man being left to carry on in a relationship with a woman who was vulnerable and thus exploited physically, emotionally, and financially by him.  

Each of these issues is discussed in detail within the full report in relation to this case.  Scrutiny of this case has led to the identification of several areas for learning and five recommendations which this review feels will make the future safer for others. 


There is only one person responsible for Louise’s murder: that is the perpetrator in this case.  He alone savagely killed her in her own home – a home that she had provided for him as a lodger and out of which a relationship grew between them.

It is clear that the risk he posed to her was not recognised by those who came into contact with them both.  He strangled Louise to death – information was ‘held’ within files that he had attempted to strangle two previous partners, both of whom had been high-risk MARAC victims.  However, as he was not convicted of an assault relating to those attacks, his true risk was not identified.  

Attempted strangulation is a significant level of inter-personal violence and subject to much current debate about becoming a specific criminal offence.  None of this will help in cases where there is no conviction, as information about the reported incident could remain ‘hidden’ and not visible.  It is the view of this review that reports of attempted strangulation should always be recorded; they should be visible to those charged with safeguarding and with appropriate caveats about the safety of using such information. 

A simple, but hugely significant, learning point from this review, however, is the positive impact of a simple telephone number of a support service being on the back of a toilet door.  In this case, seeing that number prompted a previous partner of this offender to call it and make arrangements for safe exit from the relationship.  It, and the subsequent actions of that specialist service, undoubtedly saved that woman’s life.  Examples such as this should be reinforced to ensure the practice is maintained, and to demonstrate its real value.

Lessons Identified

  1. The review noted that the value of posters with domestic abuse information on the toilet doors in public building, such as hospitals, should not be underestimated. 
  2. It was noted that Hampshire Constabulary passed the information to Devon and Cornwall Police in a timely and proactive manner. 
  3. That every opportunity to make a routine enquiry about domestic abuse is not taken within the hospital. 
  4. There is no formal policy that sets out joint-working between CSC and Home-Start.  This has resulted in Home-Start no longer taking cases that are open to CSC. 
  5. That Home-Start volunteers would benefit from specialist domestic abuse training, particularly regarding coercive and controlling behaviour.  



  1. It is recommended that the Gynaecology Department works with the Health IDVA to ensure that all staff are confident in asking a direct question about domestic abuse.  
  2. It is recommended that the current paperwork is updated to include a routine enquiry about domestic abuse on all proformas in the clinics.  


  1. It is recommended that the Case Resolution Policy is followed in cases of failed engagement with other agencies.  It is recommended that bite-sized learning and a ‘one minute guide’ will give practitioners a greater understanding of the Case Resolution Process and their roles and responsibilities within it. 


  1. It is recommended that discussions take place between CSC and Home-Start to, firstly, establish if CSC see the benefit of the support that Home-Start can bring to families on CPP or CIN.  Secondly, if this value is acknowledged, a Standard Operating Procedure should be drawn up to set out how communication between the two parties will work going forward.  


  1. It is recommended that Home-Start provides additional training, provided by a local organisation who can explain the services available locally, that particularly focuses upon coercive control and the new legislation.  

[1] Joined the panel in 2021

[2] Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews (para 36), Home Office, Dec 2016