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.
This Overview Report has been compiled as follows:
- Section 1 will begin with an introduction to the circumstances that led to the commission of this review, and the process and timescales of the review.
- Section 2 will set out the facts in this case including a chronology to assist the reader in understanding how events unfolded that led to Louise’s death.
- Section 3 will provide detailed analysis of the information of agency involvement.
- Section 4 will set out the information provided by family and friends.
- Section 5 deals with the evidence of domestic abuse in this and previous relationships.
- Section 6 analyses the key issues considered by this review.
- Section 7 summarises the lessons identified during the review.
- Section 8 will bring together the recommendations that arise.
- Section 9 draws together the conclusions of the Review Panel.
- Appendix One explains the Safer Devon Partnership oversight of DHRs.
- Appendix Two provides the terms of reference against which the panel operated.
- Appendix Three details the ongoing professional development of the Independent Chair and Report Author.
Where the review has identified a potential opportunity to intervene, this has been noted in a text box. Examples of good practice are highlighted in italics.
Section One – Introduction
Summary of circumstances leading to the Review
- 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.
- It is believed that 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 markings around her neck that were purple in colour, like bruising. She was only wearing a pair of briefs and a necklace. The police made efforts to perform CPR. When the ambulance service arrived, they took over. They began to make attempts to resuscitate her, but she was pronounced dead at the scene.
- When the police arrested the perpetrator, he was asked about blood that was on his hand, he said it was from his neck where he had tried to kill himself. Upon checking, he was found to have superficial scratches on the right side of his neck which he said he had done to himself.
- The post-mortem found that Louise had died from strangulation.
- The perpetrator was charged with her murder and was subsequently found guilty. He was given a life sentence, with 14 years 2 months before he can begin to apply for release.
1.2 Reasons for conducting the Review
1.2.1 This Domestic Homicide Review is carried out in accordance with the statutory requirement set out in Section 9 of the Domestic Violence, Crime and Victims Act 2004.
1.2.2 The review must, according to the Act, be a review ‘of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by:
- A person to whom he was related or with whom he was or had been in an intimate personal relationship, or
- A member of the same household as himself, held with a view to identifying the lessons to be learnt from the death’.
1.2.3 In this case, the perpetrator had been in a relationship with Louise. Therefore, the criteria have been met.
1.2.4 The purpose of the Domestic Homicide Review (DHR) is to:
- Establish what lessons are to be learned from the domestic homicide regarding the way in which local professionals and organisations work individually and together to safeguard victims
- Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result
- Apply these lessons to service responses including changes to policies and procedures as appropriate
- Prevent domestic violence and homicide and improve service responses to 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 possible opportunity
- Contribute to a better understanding of the nature of domestic violence and abuse
- Highlight good practice.
1.3 Methodology and Timescales for the Review
- The Safer Devon Partnership was advised of the death by Devon and Cornwall Police on 7th May 2019. This was a timely notification and demonstrated a good understanding by the police of the need for a referral at the earliest opportunity.
- 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. A meeting of this group was held on 14th May 2019 and the decision was made to undertake a Domestic Homicide Review. This decision demonstrates a good understanding by the Chair of the Partnership of the issues surrounding domestic abuse and a willingness to welcome external scrutiny of the case in order that lessons can be learnt.
- The Home Office was advised of this decision on 6th June 2019 and an Independent Chair and Report Author were appointed.
- Agencies were asked to secure and preserve any written records that they had pertaining to the case. Agencies were reminded that information from records used in this review were examined in the public interest and under Section 115 of the Crime and Disorder Act 1998, which allows relevant authorities to share information where necessary and relevant for the purposes of the Act, namely the prevention of crime. In addition, Section 29 of the Data Protection Act 2018 enables information to be shared if it is necessary for the prevention and detection of crime, or the apprehension and prosecution of offenders. The purpose of the Domestic Homicide Review is to prevent a similar crime.
- A chronology was compiled bringing together the information that was known by each agency.
- The criminal trial was held in September 2019.
- The family were notified by the Safer Devon Partnership that the review was to take place on 17th October 2019. This took longer than would ordinarily be expected and has led to clarity within the local process around the prompt notification of families in future cases.
- Due to unexpected circumstances, not related to the case, the appointed Chair withdrew from the role and Gary Goose and Christine Graham were appointed in January 2020 to undertake the review. At this point, the Review Panel had not met.
- The first Review Panel meeting was held on 20th March 2020. The following agencies were represented at this meeting:
- Babcock International
- Devon and Cornwall Police
- Devon County Council – Serious Case Review & Domestic Homicide Review Coordinator
- Devon County Council – Children and Family Health
- Devon County Council – Children’s Social Care
- Devon Partnership Trust
- NHS Devon Clinical Commissioning Group
- Splitz Domestic Abuse Support Services
- Apologies were received from Exeter City Council.
- At this meeting, the process of the Domestic Homicide Review was explained to the panel, with the Chair stressing that the purpose of the review is not to blame agencies or individuals but to look at what lessons could be learned for the future.
- The Review Panel considered its composition and agreed that it brought together the relevant expertise in relation to the circumstances of this case. The Terms of Reference were agreed subject to the family being consulted.
- Individual Management Reports were requested from:
- Devon and Cornwall Police
- Devon County Council – Children’s Social Care
- Devon Partnership Trust
- Public Health Nursing
- Royal Devon and Exeter Hospital
- Following investigation by the Chair and Report Author, Home-Start was asked to submit a Summary Report.
- At this point, the coronavirus lockdown began and delayed the time in which these reports could be completed.
- The Review Panel met five times and the review concluded in November 2021.
- Once the Review Panel was happy with the report, the DHR Executive Group and CSP Chair approved the report prior to it being submitted to the Home Office.
1.4.1 The content and findings of this Domestic Homicide Review are held to be confidential, with information available only to those participating officers and professionals and, where necessary, their appropriate organisational management. It will remain confidential until such time as the DHR has been approved for publication by the Home Office Quality Assurance Panel.
1.4.2 To protect the identity of the deceased, their family and friends, Louise will be used as a pseudonym to identify the deceased hereafter and throughout this report. This pseudonym was chosen, at the request of the family, by the Report Author. The person responsible for her death will be referred to as the perpetrator, as requested by the family.
1.4.3 Louise’s child’s father refers to the father of her eldest child – this is not her ex-husband.
1.4.4 Louise’s ex-husband is the father of her second child.
1.5.1 The final version of this Overview Report will initially be distributed to:
- Louise’s family
- Louise’s child’s father
- Members of Exeter Community Safety Partnership via its Chair
- Chief Executive and officer with responsibility for Domestic Homicide Reviews of Exeter City Council
- Safer Devon Partnership’s Domestic Homicide Review Executive Group
- Members of Devon Domestic Abuse Local Partnership Board
- Chairs of the Devon Locality Sexual Violence and Domestic Violence and Abuse Forums
- Chair and Manager of the Torbay and Devon Safeguarding Adults Board
- Chair and Manager of the Devon Children and Families Partnership (Devon’s Local Safeguarding Children’s Board)
- Police and Crime Commissioner for Devon, Cornwall, and the Isles of Scilly
- All organisations involved in the Review Panel
- Domestic Abuse Commissioner for England and Wales
1.6 Contributors to the Review
- Those contributing to the DHR do so under Section 2(4) of the statutory guidance for the conduct of DHRs and it is the duty of any person or body participating in the review to have regard for the guidance.
- All Review Panel meetings included specific reference to the statutory guidance as the overriding source of reference for the review. Any individual interviewed by the Chair or Report Author, or other body with whom they sought to consult, were made aware of the aims of the Domestic Homicide Review and referenced the statutory guidance.
- However, it should be noted that whilst a person or body can be directed to participate, the Chair and the Review Panel do not have the power or legal sanction to compel their co-operation, either by attendance at the panel or meeting for an interview.
- The following agencies contributed to the review:
- Babcock International
- Devon and Cornwall Police
- Devon County Council – Children’s Social Care
- Public Health Nursing
- Royal Devon and Exeter Hospital
- The following individuals contributed to the review:
- Family and friends of Louise
- Former partners of the perpetrator
- The perpetrator was contacted and invited to contribute to the review. He responded by saying that he was willing to be involved with the review but that he did not feel that the time was right. It was agreed that he would be contacted again at the conclusion of the review. To date, due to the Covid-19 restrictions placed within the prison that he is serving his sentence, no personal or virtual meeting has been possible.
1.7 Engagement of Family and Friends
- Family and friends are integral to any Domestic Homicide Review and the Independent Chair and Report Author wishes to record thanks to the officers of Devon and Cornwall Police who have greatly assisted the review in engaging those who have contributed to the review.
- Louise’s sister was written to by the Chair and Report Author in March 2020. In June 2020, she met with the Chair and Report Author. The terms of reference and the objectives of the review were discussed with her. We spoke about the review, and it was agreed that review contact would be via the Chair and Author. Louise’s sister has been supported throughout the review by the Victim Support Homicide Service.
- The father of Louise’s youngest child was written to by both the Community Safety Partnership and the Chair and Report Author. He did not make contact and the review respects his position.
- Between June and August 2020, a number of online meetings and phone calls were held with friends of Louise, and ex-partners of the perpetrator.
- Louise’s sister was provided with a copy of the draft report to consider at her own pace with her support worker. Her comments have been incorporated into the report.
- Once the report was published, copies were provided to the mothers of the perpetrator’s children, Louise’s child’s father, and those friends who had contributed and specifically asked for a copy of the report.
1.8 Review Panel
1.8.1 The members of the Review Panel were:
|Gary Goose MBE||Independent Chair|
|Christine Graham||Overview Report Author|
|Lara Stead||Education Safeguarding Officer||Babcock LDP|
|Nicky Seager||Detective Chief Inspector||Devon and Cornwall Police|
|Rob Gordon||Detective Sergeant – Criminal and Serious Case Review Team||Devon and Cornwall Police|
|Kate Nightingale Replaced by Michelle Kirkham||Serious Case Review & Domestic Homicide Review Coordinator||Devon County Council|
|Sam Peterson||Service Development Manager – (Domestic Abuse and Homicide)||Devon County Council|
|Val Watkins||Named Nurse Safeguarding Children||Devon County Council – Children and Family Health|
|Emmy Tomsett||Senior Manager –Quality Assurance, Reviewing and Safeguarding Service||Devon County Council – Children’s Social Care|
|Penny Rogers||Deputy Director –Safeguarding & Public Protection||Devon Partnership Trust|
|Melinda Pogue-Jackson||Policy Officer – Community Safety, Safeguarding and Equality & Diversity||Exeter City Council|
|Laura Roberts||Designated Nurse for Safeguarding Adults||NHS Devon Clinical Commissioning Group|
|Alison Roberts||Senior Safeguarding Nurse Specialist||Royal Devon and Exeter NHS Foundation Trust|
|Chrissy Stower replaced by Julie Reeves||Team Manager||Splitz Domestic Abuse Support Services|
|Jo Darke||Funding and Development Manager||Home-Start Exeter, East and Mid Devon|
1.8.2 All members of the panel were independent of the case.
1.9 Domestic Homicide Review Chair and Overview Report Author
1.9.1 Christine Graham 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.
1.9.2 Gary Goose served with Cambridgeshire Constabulary rising to 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.
1.9.3 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.
1.9.4 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.
1.9.5 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.
1.10 Parallel Reviews
1.10.1. There were no parallel reviews.
1.11 Equality and Diversity
1.11.1 Throughout this review process, the Review Panel has considered the issues of equality. In particular, the nine protected characteristics under the Equality Act 2010. These are:
- Gender reassignment
- Marriage or civil partnership (in employment only)
- Pregnancy and maternity
- Religion or belief
- Sexual orientation
1.11.2 Women’s Aid states: ‘domestic abuse perpetrated by men against women is a distinct phenomenon rooted in women’s unequal status in society and oppressive social constructions of gender and family’. According to a statement by Refuge, women are more likely than men to be killed by partners/ex-partners, with women making up 73% of all domestic homicides, with four in five of these being killed by a current or former partner. In 2013/14, this was 46% of female homicide victims killed by a partner or ex-partner, compared with 7% of male victims.
1.11.3 The majority of perpetrators of domestic homicides are men – in 2017/18, 87.5% of domestic homicide victims were killed by men. Furthermore, in 2017/18, 93% of defendants in domestic abuse cases were men, and in 2017, 468 defendants were prosecuted for coercive and controlling behaviour, of which 454 were men and only nine were women.
1.11.4 The Femicide Census 10-year report found that the largest number of femicides (888, 62%) were carried out by men who were currently or had been previously been in an intimate relationship with the victim.
Section Two – The Facts
2.1.1 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 and is referred to throughout the report as her ex-husband. Her children both had ongoing health issues that necessitated numerous admissions to hospital. Louise and her husband separated in June 2018.
2.1.2 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.
2.1.3 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.
2.1.4 For the purposes of this review, the perpetrator’s domestically abusive behaviour began in 2007. Although the records are slightly confusing, it appears that the police were called initially to two reports (June and September) of verbal arguments between the perpetrator and the person we will call ‘Partner 1’. No violence was disclosed during the DASH process, but it is noted on the police record that additional anonymous information was received in relation to the second call that said he had slammed his partners head against the floor, causing injury – Partner 1 did not disclose this although she did feel concerned enough to leave the property with her child to get away from him. She also said that his behaviour was getting worse, he was causing self-harm by banging his head and causing it to bleed, talking about suicide, and that he was a jealous partner and feared that violence could be directed towards her.
2.1.5 The perpetrator’s behaviour continued to deteriorate. On a further separate occasion, he called the police saying he had attempted to drown himself but when police and medical staff arrived, he was uncooperative and aggressive. As a result, he was detained under S136 MHA and taken to a local hospital for treatment.
2.1.6 The situation worsened significantly in December of 2007 when police were called by Partner 1. She disclosed that violence had gone on from April and the final act that caused her to call police was when she was thrown to the floor by him and he pinned her head to the floor, causing injuries. He denied this had happened and initially no action was taken by the police; however, it was recognised as a very high-risk case that should go to MARAC.
2.1.7 Partner 1 then contacted the police again. He was subsequently arrested for the reported assaults, but the CPS determined insufficient evidence to mount a prosecution. It does appear that this ended his relationship with Partner 1.
2.1.8 In November 2008, police were called by the landlord of a private rented property as a result of violence and damage involving the perpetrator, a new partner (Partner 2), and another female. The incident involved a bed being thrown out of the property and verbal arguments. No charges followed but a DASH was completed with Partner 2, who described the perpetrator as controlling and violent; however, she did not disclose any personal violence. Police information then indicates that she moved away because of a ‘bust up’ with him shortly afterwards. However, in 2011, the police were called again as he had thrown all her clothing out a property. A DASH was recorded as STANDARD risk for this incident.
2.1.9 In February 2012, the perpetrator was involved in an incident relating to an ex-partner (Partner 3) where it is alleged, he punched her in the face and stole a phone. Witnesses present, seem to back-up his account of things and although he was arrested, no further action was taken against him.
2.1.10 By late 2013, he was with a new partner (Partner 4). Police were called to a report of violence, and it was alleged that he strangled her. She had visible marks upon her neck and disclosed further previous unreported violence. He was arrested, charged, and remanded in prison. She had a police alarm fitted to her property and a high-risk DASH was completed in which the victim disclosed her fear that he would kill her.
2.1.11 The following day, Partner 4 contacted police and said that she wanted to withdraw her statement. A week later, a withdrawal statement was taken with the victim saying she ‘just wanted to get on with her life’. Although the withdrawal statement was noted at a court hearing in early November, he was remanded in prison for a further week before making a bail application; following which, he was released with conditions not to contact the victim.
2.1.12 In late November, the victim made a further statement which it appears led to the case being withdrawn in January when no evidence was offered by the CPS.
2.1.13 The case continued to be active at MARAC and by April 2014, he had markers for violence, risk to child, and MARAC on his police record.
2.1.14 In September 2016, a specialist domestic abuse service raised the case again at MARAC. The victim (Partner 4) had told them that since the original charges were dropped, the violence had continued and in August, he had strangled her in front of her child. He was constantly violent and threatened to kill her and her partner if she left. She was being assisted in obtaining a non-molestation order and was helped to leave by the service. She did not feel able to engage with police, but a weapons marker was added to his record as information had been received about a machete being with him. The case was placed as a high-risk MARAC. No crime reports were recorded, and no arrests were made in relation to this information.
2.2 Detailed Chronology from 1st August 2016 to 16th April 2019
|1st August||Louise attended Royal Devon and Exeter Hospital where it was confirmed that she was pregnant.|
|September||The perpetrator presented at Exeter City Council seeking social housing. It was explained that he was adequately housed with his mother, so he was not a priority. He was advised to look at shared accommodation which he would be eligible for. He seemed happy with the advice given.|
|21st September||The perpetrator’s police record was updated to record that there was a non-molestation order in place in connection with Partner 4, and a weapons marker was added.|
|November||Louise began to act as a host for a local language school.|
|24th March||The perpetrator visited his GP as he had an outburst of frustration at work and had been dismissed. He felt frustrated at this repetitive cycle of behaviour. Having had a supportive chat with his GP, it was agreed he would make a further appointment to discuss a referral for a mental health assessment.|
|27th March||Following the birth of her child, Louise and her family were visited for a new birth assessment by the health visitor. Both parents and children were present. The Devon assessment framework was completed giving a health profile for the whole family. No further needs were identified, and the family were assessed as needing universal services. Louise and her husband reported that they had a very positive relationship having recently married and reported they both had supportive extended family. Domestic abuse was not discussed or recorded, and no reason given.|
|1st April||The Health Visiting Hub received a referral from the GP as the youngest child had recently been admitted to hospital. The GP described anxiety in the family due to the ill health of their 2 children and a still born baby prior to the birth of their child. There was no domestic abuse identified.|
|4th April||The perpetrator had an appointment with his GP. This was his first appointment after moving from Exeter where he said there had been lots of negatives. He was suffering with anxiety and depression and was not at work. He reported that his previous GP had been able to make a mental health diagnosis as he had a special interest, but his review was due. He said he had social anxieties, anger issues, pressured speech and was described by the GP as ‘being a bit all over the place’. He said he was currently renting a room from his friend’s mother. The GP was to obtain his records and assessments from the previous GP. From this point, the perpetrator was not fit for work on recurring certificates that were issued.|
|11th April||The perpetrator saw his GP again the following week with anxiety and depression. He said he was feeling very low and had experienced a panic attack a few days earlier. He stressed his concerns about his life and that his ex-partner was not replying to his messages about his son. He had last been binge drinking six months earlier and was now only drinking beer occasionally when out with friends, and was not drinking alone. He had not taken any drugs for a few years. He said he did not want counselling at present. The GP was to undertake a mental health referral review in two weeks’ time.|
|13th April||Health visitor home visit. The baby was seen to be growing well. The focus of this visit was on the health of the children and there was no clear view of what life was like in the home, for either the children or adults.|
|18th April||The perpetrator’s GP referred him to Devon Partnership Trust (mental health services). He explained that the perpetrator had done some at home/online questionnaires which he felt pointed to a personality disorder. He was concerned that he may have bipolar disorder. The GP reported that the perpetrator’s main problems were that he could not keep a job, and he could not maintain relationships or partnerships. He said that he reported extensive social anxieties, anger issues and was a bit all over the place. The GP observed that he was quite chaotic, had flight of ideas, pressured speech. He asked them to consider assessing the perpetrator for a mood disorder or diagnosis of mania/bipolar, and consider if he would benefit from a mood stabiliser. He had also told his GP that he used to take drugs but had not done for many years. He also used to binge drink but that he had not had much alcohol, at least for six months.|
|24th April||The perpetrator received a letter from the Mental Health Assessment Team (MHAT) at Devon Partnership Trust inviting him for an assessment on 25th May.|
|27th April||Louise was seen by the health visitor for a Maternal Mental Health review in her home. She agreed that she wanted some help as she described life as difficult, leading to her feeling anxious. No referral for additional support was made and the health visitor did not explore with Louise what family life was like.|
|4th May||Louise and baby seen at home by the health visitor following another incident of ill health for the baby. Louise reported that she felt less anxious as she was focussing on fund raising for the hospice.|
|25th May||The perpetrator attended Devon Partnership Trust for his assessment. He was diagnosed with Emotional Unstable Personality Disorder and was given a detailed plan of engagement including CMHT, and therapy offered including the CHANGE Programme, and self-referral to Devon Recovery Learning College. At the time of his assessment, it was noted that he had £19,000 of debt.|
|5th June||A detailed summary of the outcome assessment was sent to the perpetrator by Devon Partnership Trust.|
|12nd June||The perpetrator saw his GP as he was still suffering with depression and anxiety.|
|20th June||The perpetrator was advised by Devon Partnership Trust that he was on the waiting list for the CHANGE programme. He was then notified, on 26th June, that he was on the waiting list for an appointment with the Community Mental Health Team (CMHT). He was advised how he could access support in the interim.|
|4th July||The CMHT rang the perpetrator as he had failed to attend his appointment, but no contact was made. He failed to attend further appointments on 17th, 24th and 27th July. He was then discharged from the CHMT after he did not attend a further appointment on 10th August. On 31st August, he saw his GP and explained that he had forgotten about the appointment as he could not think straight, and his head was all over the place. He said that his mother had taken over organising so hopefully it would not happen again. The GP made a further referral to the psychiatrist. This referral was made on 11th September.|
|19th||Follow-up appointment with Louise. Louise was invited to contact the health visitor as and when she felt the need, but it was not reported that she was given any strategies to manage the baby’s screaming, or any exploration of the effect it may be having on the family.|
|24th August||Royal Devon and Exeter Hospital wrote to Louise’s GP as she had not attended two previous clinics (these were for medical, and unrelated issues).|
|12th September||Devon Partnership Trust offered the perpetrator a further assessment appointment by letter and text. The appointment was for 10th October and he was texted and telephoned to remind him of the appointment. He was then offered a further appointment on 9th November.|
|September||Louise’s GP wrote to the Royal Devon and Exeter Hospital to request a further appointment. The GP explained that she had not attended previous appointments as she was having some issues with her health.|
|October||Louise and her husband prepared to move to Spain.|
|20th October||Louise was referred to Devon County Council by her eldest child’s school due to poor attendance. She was issued with a School Absence Penalty Notice sometime between January 2018 and July 2018.|
|6th November||Louise received a letter from Royal Devon and Exeter Hospital on 6th November to advise that the results from the unrelated medical investigations were normal.|
|7th November||The perpetrator saw his GP on 7th November and expressed concern about his housing situation. He said that couples in the accommodation were fighting which made his anxiety worse. He said that he wanted to move to Exeter to be near his son: the GP agreed to provide him with a letter of support as he was at the bottom of the housing allocation list.|
|3rd December||The police were called after a domestic argument between Louise and her husband. A DASH risk assessment was completed with Louise and was graded as STANDARD, as she answered ‘no’ to almost all the questions. The questions that she answered ‘yes’ to, indicated that arguments were occurring more frequently, partly due to their child who was unwell, and that they were becoming increasingly unhappy with each other. Louise did not consent to her details being shared with other agencies and therefore no further action was taken, and the incident was closed.|
|15th January||Louise’s GP called the Health Visiting Hub to ask for an experienced health visitor to make contact with Louise to help her with weaning, as she was experiencing considerable anxiety about the poor health of her two children.|
|2nd February||An experienced health visitor visited Louise to undertake a 12-month developmental review. Louise reported ongoing difficulties with his sleep and eating.|
|22nd February||Louise reported to her health visitor that she was experiencing ongoing sleep problems with her youngest child, which was putting a strain on her marriage. A referral to the sleep clinic was made. This lack of professional curiosity may have missed an opportunity to greater understand the parents’ relationship.|
|8th May||Louise, with her youngest child, attended the sleep clinic where routine advice was given to help to settle the child and encourage them to remain asleep. Louise did not return for the follow-up appointments.|
|13th June||Louise’s GP contacted the health visitor and requested support for Louise as she was experiencing considerable anxiety. There is no evidence from the records that a visit or further contact was made.|
|30th July||Louise saw her GP and reported that she had split up from her husband on 25th. He had been sending her messages that he was going to kill himself. He was staying with his parents and Louise needed to take time off work, so a certificate was issued to say that she was not fit for work and the diagnosis was given as family stress.|
|31st July||Louise’s husband was admitted to hospital having made a serious attempt on his life. He was advised to stay away from the family home. ED advised the MASH in Exeter. The notification from the hospital in Hampshire advised that Louise’s husband had made a serious attempt on his life, having left the family home, and returning to his family in another county. The children were not known to Childrens Social Care (CSC), so the information was filed as ‘for information only’.|
|3rd August||The health visitor received a letter from Frimley Health NHS Trust following the suicide attempt of Louise’s husband. This said that he had cited arguing with his wife and their child’s constant hospital admissions as the reason. The health visitor offered a support home visit, but the family were not at home when the health visitor attended at the pre-arranged time. She was asked to make contact to make another appointment. The health visitor ensured that the social worker had been informed of the incident.|
|6th August||The health visitor contacted the MASH for additional information but was advised that further action was to be taken by Children’s Social Care. The health visitor sent Louise an appointment letter to reassess support for the family. There is no evidence of a multi-agency view of the family. There is no record of Adult Mental Health Services, GP, or social work assessments and support. There is evidence of liaison and appropriate information sharing.|
|7th August||Louise was absent from work from 7thAugust to 22nd August, due to anxiety, stress, and other psychological illness.|
|14th August||Louise contacted the police as her husband had sent a text indicating that he was considering suicide. The call was transferred to Hampshire Police, they were given his location and he was visited at his father’s home: he was safe and well. Although the incident was primarily a concern for welfare, Hampshire Police identified that there may be an element of coercive control in this incident and notified Devon and Cornwall Police about their concerns. Devon and Cornwall Police contacted Louise, but she declined to engage through fear that circumstances would worsen and said that this was the first time. No DASH was completed and therefore there was no risk assessment.|
|4th September||Louise was absent from work between 4th and 14th September, due to anxiety, stress, depression, or other psychological illness.|
|5th September||Louise spoke to her GP. She said that it was six weeks since her marriage had ended. Her job was due to end as they were meant to be moving to Spain. She said that she was crying all the time and struggling to cope. Her GP discussed her going to stay with her family for support. She said that she had interviews on Thursday and would consider this after that. She was given another sick note for 3rd – 14th September. Louise also agreed that she would ring her health visitor to discuss help with her youngest child. She contacted the GP on 12th September to request a letter for her travel insurance, as she was not fit to fly. The GP asked her to provide the forms and advised that it would not say that she was unfit to fly but would state ‘marital breakdown’.|
|18th September||Louise spoke to the health visitor and said that she and her husband had separated. She said that she had left her job as they were planning to move to Spain. She reported that she had financial difficulties and the health visitor agreed to refer her to Home-Start, and liaise with the Nursery for support.|
|18th September||Home-Start received the referral from the health visitor.|
|26th September||Louise saw her GP. She spoke about her husband. She said he was living near London and she was taking the children at the weekend, as they had not seen him since he left. She reported that she had a new job as head receptionist at a dental practice.|
|Towards the end of October, the perpetrator moved into Louise’s home having answered an advert for a room. Although he moved in as a lodger, they very soon became a couple and lived together at this address.|
|29th October||The health visitor telephoned Louise. She left a message asking her to make contact the following day.|
|November||Two further calls were made by the health visitor in November and a message was again left, but Louise did not reply.|
|8th November||Louise saw her GP. She reported that she was drinking 3.5 litres of Malibu and coke each week, but she did have dry days. Louise agreed to try and reduce her alcohol intake and would come back if she felt no better in four weeks.|
|22nd November||Louise saw the GP about an unrelated physical issue. During the consultation, she disclosed that her husband was now ringing her all of the time saying he was cutting himself and was going to kill himself. She was given a certificate to say that she was not fit for work – from 22nd to 25th November.|
|26th November||Louise was visited by the Home-Start co-ordinator to assess her needs and establish if she was willing to work with Home-Start.|
|29th November||Louise spoke to her GP on the telephone on 29th November when she said that her ‘life continues to be a massive drama’ and she had now found out that she was pregnant. She said it was not planned, it was not her husband’s baby, and she wanted a termination. This was booked. Louise told friends that the perpetrator was the father of the baby. Louise had told another friend that neither she nor the perpetrator wanted the baby.|
|5th December||Louise was seen at Royal Devon and Exeter Hospital when a miscarriage was confirmed by scan. She had been pregnant for approximately six weeks.|
|12th December||Louise was introduced to her Home-Start volunteer and the first visit was arranged for 22nd January 2019.|
|End of December||Just before Christmas, Louise introduced the perpetrator to her neighbour as her new lodger.|
|29th December||The police were called by the ambulance service to Louise’s address by her ex-husband. Louise, who was at home alone with her son, had taken an unknown substance (white powder that was possibly cocaine) along with 55 assorted painkillers and a litre of Malibu. She disclosed that she had wanted to commit suicide, the following day, by driving into the central reservation on the motorway.When the ambulance arrived, Louise was acting erratically and did not want to go to hospital: she was deemed to not have capacity and therefore was taken to hospital under the Mental Capacity Act. Louise disclosed that a number of traumatic life experiences had come at once – the breakdown of her marriage, a miscarriage, her father being ill, and her child being so poorly. Louise’s child was taken home by her friend to care for overnight.|
|30th December||Louise arrived at Royal Devon and Exeter Hospital at 12.39 am on 30th December. A MASH form was completed but Louise left the hospital at 3.48 am, before she was seen by the psychiatric liaison team. It was noted that she would be followed up the next day by the single point of access.|
|Later that morning, Louise’s sister was driving down to collect her child. She was concerned as Louise had discharged herself from hospital at 4 am – she asked the police to check her address to be sure she was OK. Louise had left before a psychiatric assessment could be undertaken and the hospital were keen to speak to her. When the police attended Louise’s address and made enquiries, they were told that her ex-husband had been at the address the previous morning and that there had been lots of shouting. Louise would only speak to the officers through the door, and said that she was alright but did not wish to speak to them and would not let them in. It was agreed that they would wait until her sister arrived to support her.|
|31st December||When Louise saw her GP, accompanied by her boyfriend (who the GP noted as having a different name to that of the perpetrator), on 31st December, she disclosed that the overdose had been impulsive after she had drunk a lot of alcohol after finding out that her ex-husband had allegedly stolen the children’s Christmas money. She told the GP that she did not wait to be seen as her ex-husband was threatening to come and take her child away. She said that her children were with her sister and social services were involved. She was concerned that she had been told that her ex-husband was being very helpful as she felt that he was manipulating everyone. Her boyfriend, the perpetrator, was described by the GP as very supportive, and they both agreed that they would not drink any alcohol. She was given a certificate to say she was not fit for work – from 31st December to 14th January.|
|2nd January||Children’s Social Care received a referral regarding Louise’s overdose whilst responsible for her child’s care. They were advised that her presentation appeared erratic and that she had discharged herself from hospital before a psychiatric assessment could be undertaken. It was agreed that an urgent assessment was needed under Section 17.|
|10th January||Louise’s GP sent a copy of her consultation notes to the social worker as requested.|
|21st January||Louise spoke to the health visitor on the phone. She said that, since her marriage breakdown, she was experiencing financial difficulties. She requested Healthy Start vouchers to help with the children and was signposted to Devon County Council for 2gether funding for childcare. It was also suggested that she contact the Citizen’s Advice Bureau for debt advice. Louise reported to the health visitor that her child was under a Child in Need plan, which was not previously known to the health visitor.|
|Louise was phoned by the Home-Start co-ordinator to check she was still expecting the volunteer to attend the next day. Louise asked the co-ordinator to make a referral to Turntable, as she was short of money and needed a mattress and new stair carpet – which she did.|
|22nd January||Louise phoned the Home-Start co-ordinator and said that she wanted to be honest with them and she disclosed that she had taken an overdose over Christmas. She said that CSC had been involved but that the children were not on the Child Protection Register.|
|23rd January||The Home-Start volunteer telephoned the co-ordinator as she was concerned, after the first visit, about the youngest child’s development.|
|24th January||The health visitor called the Social Worker (SW). There was no response from the SW, and the health visitor did not escalate this.|
|25th January||Louise’s children stayed over with a friend. Louise told her friend that she wanted to get the perpetrator out of the house. She wanted him to leave as his moods were up and down, she thought he was bipolar, and couldn’t deal with his moods. She described him as high maintenance. She told her friend that she thought that the police might have to be called to get him to leave.|
|28th January||The Home-Start co-ordinator phoned the Health Visiting Hub and spoke to a health visitor about the level of social care involvement. The health visitor said that she did not know and logged a call with the SW.|
|4th February||The Home-Start volunteer emailed the co-ordinator and advised that there was now a male lodger in the house. The co-ordinator phoned Louise and asked about the level of debt that she was in. She said that this had been rising since her husband had left in July. She asked Louise if the SW had been in touch and Louise said she had not spoken to her for about a month. The co-ordinator asked for the name of the lodger, which Louise gave. However, although the first name was correct, she gave a different surname.|
|6th February||The Home-Start co-ordinator phoned the SW and left a message asking for an update on their involvement. She also discussed the case with the Trustee with responsibility for safeguarding. It was agreed that they would continue to support Louise but monitor closely.|
|19th February||The perpetrator called the police at 1.08 pm saying that he was at the property with his friend and wanted to collect his property, 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 at 1.21 pm. Police attended at 1.34 pm 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. The police left at 2.47 pm. Louise then phoned the police, 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.|
|Louise cancelled the visit of the Home-Start volunteer on 26th February.|
|27th February||Louise’s child had been admitted to hospital and she left the child on the ward to go home and look after the other child. CSC was advised. No concerns were recorded by CSC.|
|As she had not heard back from the SW, the Home-Start co-ordinator called again. She spoke to the SW and she said that the file was still open and that she had carried out an assessment, as well as consulting with the GP, paediatrician and school. She said that she did not think that the family met the threshold for Child Protection or Child in Need. She was planning to discuss with her manager whether they should be stepped down to early help, or closed altogether. She agreed to send the co-ordinator a summary report, but this was never received.|
|End of February||Louise left her job.|
|2nd March||A former partner of the perpetrator made contact with Louise, as she was worried for her.|
|5th March||The Home-Start co-ordinator phoned Louise to see if the volunteer’s visit was going ahead. Louise said that her child was in hospital, having been diagnosed with Kawasaki’s disease. She also said that she had lost her job because of the time off that she needed to take, and asked the co-ordinator about any support that might be available to her. The co-ordinator emailed Louise with details of the benefits she was entitled to, and advised her to contact Citizens Advice.|
|12th March||The Home-Start volunteer was unable to contact Louise, so did not visit. The next day, 13th, Louise contacted the co-ordinator and said she sometimes had problems with her phone signal and provided her landline number.|
|22nd March||The health visitor phoned CSC for an update on the family. The call was not returned, and this was not followed up by the health visitor.|
|27th March||Louise told a friend that it was going really well with the perpetrator and that she was super happy.|
|Last week in 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.|
|1st April||After her visit to Louise, the Home-Start volunteer phoned her co-ordinator as she felt that she kept ‘getting thrown by things’, meaning things that she was not aware of. For example, Louise was sending her child to a childminder, three days a week, and was starting to take in foreign students. She also said that Louise had told her that the child had unexplained bruising and asked the volunteer to accompany her to an appointment with the paediatrician, which she did. She said that Louise had pointed out the bruising to the paediatrician who had taken this concern seriously and made notes. She had told Louise that it could be due to the child being on a high dose of aspirin. During this visit, Louise told the volunteer that the perpetrator was still living at the property and she suspected that they may now be in a relationship.|
|7th April||Four students from the language school came to stay. They stayed until 13th April.|
|11th April||Louise told her sister that the perpetrator was staying over most nights, did not pay rent, and had another address.|
|13th – 14th April||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.|
|15th April||The Home-Start co-ordinator visited Louise to carry out a review, having arranged this over text. It was 1.30 pm when she arrived, and it took a while for Louise to answer the door. She was dressed in her dressing gown and said that she had sent a text to rearrange for the next day, but the co-ordinator had not received this. Louise asked her to go in and wait whilst she got dressed. She said that she had been in bed because she was exhausted after a 600-mile round trip dropping her children off with family (it was the Easter holidays), and that she was on her own. They discussed her finances and Louise said that she was getting on top of things. She asked about the students and Louise said she had recently had six to stay. She said that they were usually over 16, but sometimes were as young as 14, and she was not expecting any more until the summer. The co-ordinator asked if she was now in a relationship with the perpetrator. She said that she was and it was going well, and the children really liked him. Louise’s main concern was about her elder child, as she had recently said that she hated her, which had upset Louise. The co-ordinator asked if the SW had been in touch recently and Louise said she had visited the previous week, but was not sure why she had visited. She said that the SW had talked a lot and Louise did not know what she was going to do. The co-ordinator promised to call the SW and ask about her visit and clarify the purpose for Louise. It was agreed that support would continue for another three months and then the co-ordinator would visit to review again.|
|16th April||Louise spoke to her sister by Facebook Messenger for the last time. They discussed nursery fees, and Louise said that the perpetrator was out at work doing a labouring job.|
|At about 6.30 pm, Louise’s neighbour arrived home and was told by his partner that there was loud music coming from the direction of Louise’s house and this continued on and off until they went out. Louise and the perpetrator then attended the home of a couple they had known for a few weeks – having met when they were each in the park with their children. They arrived at 7.30 pm. During the evening, the couple had quite a lot to drink and were described as ‘bickering’, particularly about the use of their mobile phones. Louise was upset that the perpetrator was recording her on his phone. The friend asked Louise if she was OK and she said: ‘it’s OK I deal with it all the time… He’s very controlling’. The atmosphere between Louise and the perpetrator made the other couple feel very uncomfortable. Louise then called for a taxi at 12.38 am. When the taxi arrived, Louise went to sit in the front and the perpetrator said: ‘no, back seat’.She got in the back and the friend got the impression that the perpetrator was controlling towards Louise.|
|April||Louise was murdered by the perpetrator|
Section Three – Detailed analysis of Agency Involvement
The chronology set out in Section 2 details about the information known to agencies involved. This section summarises the totality of the information known to agencies and analyses their involvement.
3.1 DEVON AND CORNWALL POLICE
3.1.1. This review is concerned with what can be learned from the awful death of Louise. The police only had the one interaction with the couple where they became aware of their relationship. However, in assessing what can be learned from this case, to better protect others, it is right that we look at whether the information known to police resulted in an effective risk assessment and identification of the danger he presented to any woman who he became involved with.
3.1.2 It is for that reason that we have looked at the police interaction with partners of the perpetrator prior to Louise.
3.1.3 The police became aware that the couple were potentially in a relationship in one interaction with them, which occurred in February 2019. They became aware as a result of a telephone call from the perpetrator to them, indicating that the relationship was over but that he needed police assistance to get belongings back from Louise’s address. It is now clear, with the benefit of this retrospective view, that at the time, Devon and Cornwall Police had significant information within the totality of their force information systems to say the following:
3.1.4 Two of the perpetrator’s ex-partners had reported him strangling them. They had been called to domestic abuse related incidents in relation to four previous partners, including the two who had reported strangulation and both of whom feared he would kill them. They also said he was controlling and jealous. He had spent time on remand in prison for one of the strangulation attacks. He was violent towards his partners and at times used violence upon himself. He had been the perpetrator on two high-risk MARAC cases in the five years preceding this case, and police had fitted alarms to two of his previous partner’s homes. His police record had markers on it for violence, weapons, MARAC, and that he posed a risk to children.
3.1.5 Put together in this way, the potential risk he posed to any woman with whom he entered a relationship seems clear. However, the circumstances surrounding the incident, how it was reported, and risk assessed as an isolated instant, all contribute to the wider risk not being recognised. These are central issues to reviews such as this and therefore it is important that we unpick how and why this happened, and crucially, if we can learn from it to better protect others in the future.
3.1.6 This perpetrator had not been convicted of any offences in relation to any of the reports made by his ex-partners. His previous conviction for violence was not for domestic abuse.
3.1.7 The previous reports made to the police are laid out in Section 2 of this report. Police investigated the reported assaults by Partner 1. The Crown Prosecution Service felt unable to prosecute the case on the evidence available at the time. However, separately from the potential for prosecution, efforts were made to safeguard this partner and the relationship ended after the reports were made to the police.
3.1.8 In relation to the strangulation and violence towards Partner 4 (2013), the police arrested the perpetrator. He was charged and remanded in prison. The victim in this case made a statement withdrawing the allegation shortly after he was first remanded; however, he was further remanded which is an indication of an intention to prosecute the case without the cooperation of the victim. It was only when a further statement was made by the victim that the case was discontinued. The case remained as a high-risk MARAC for several months and various safeguarding measures were put in place to safeguard her. The perpetrator managed to remain in contact with Partner 4, thereafter, because of their child.
3.1.9 Two years after that previous report (by now 2016), having endured further violence, she was strangled again, and she went to a specialist domestic abuse service who worked with her to help her safely escape him. They rightly referred the case back to MARAC where it was again considered as a high-risk case. However, no crime reports were raised by the police to investigate what this victim had told the service.
3.1.10 The Force itself rightly say that crime reports should have been raised. However, given all of the information that has become available to this review, it seems unlikely that the victim would have felt able to engage with the police, and thus a prosecution would almost certainly have failed. Nevertheless, it would have meant that a positive decision would have had to have been made about what level of investigation, if any, could be undertaken. Devon and Cornwall Police now have a clear policy in place to record crimes reported from third party professionals, in accordance with Home Office Counting Rules.
3.1.11 All this information, as said, was held within police systems at the time they became aware that Louise had been involved in a relationship with this perpetrator (February 2019). None of this information, nor any of the allegations, were proved and thus none of it sat on his conviction record.
3.1.12 What this review is concerned with, is whether the systems in place in Devon and Cornwall Police allow this cumulative information to assist them in their safeguarding work with potential victims such as Louise. In other words, do their systems allow them to ‘join the dots’ quickly enough for them to realise that the person they encountered on that relatively innocuous incident in February 2019 was a person who presented a real risk to any woman with whom he became involved? In this case, that primary safeguarding work could be assisted by the Domestic Violence Disclosure Scheme (DVDS). That will be discussed later within this report.
3.1.13 Before moving to discuss those issues, it is important that we look in detail at the interactions Louise had with police in the months leading up to her death.
3.1.14 3rd December 2017
3.1.15 The police were called after a domestic argument between Louise and her husband. It was noted that they had been on a night out and they had fallen out because Louise’s husband became jealous of her behaviour with another male, and he had stormed off in the car. A DASH risk assessment was completed with Louise and was graded as STANDARD, as she answered ‘no’ to almost all the questions. The questions that she answered ‘yes’ to indicated that arguments were occurring more frequently, partly due their child who was unwell, and that they were becoming increasingly unhappy with each other. She also said that her husband had previously threatened to commit suicide by jumping from a bridge. Louise did not consent to her details being shared with other agencies and therefore no further action was taken: the incident was closed.
3.1.16 The review notes that, as this incident was originally called in by Louise as a concern for the welfare of her husband, the focus was on him as a missing person. This led to a number of policies not being followed in relation to the completion of ViST. For example, it is clear that for the latter part of the argument which took place at home, a child was present. Therefore, a ViST should have been completed in line with policy, which states that this is the case whenever a child is present. This would have allowed the information to have been shared with other agencies around the ongoing welfare of the child, if it was deemed appropriate.
The review notes that this was correctly identified as a domestic incident and a DASH risk assessment was requested when the Crime Standards Unit (who check all crimes and enquiries) noted that this had been incorrectly recorded: the corrections were then made. The review notes that this checking process identified the oversight at an early stage. This is an example of good practice.
The review notes that there was an opportunity for the officers attending to think about the bigger picture when they are dealing with families, and have a broader consideration for the type of incident they are presented with, rather than focusing only on the incident that was called in to the police. The review accepts that this was an individual learning opportunity rather than an organisational wide issue; however, forces should encourage professional curiosity and critical thinking whilst dealing with such incidents.
3.1.17 14th August 2018
3.1.18 Louise contacted the police as her husband had sent a text indicating that he was considering suicide. The call was transferred to Hampshire Police, they were given his location and he was visited at his father’s home: he was safe and well. Although the incident was primarily a concern for welfare, having spoken to Louise directly, Hampshire Police identified that there may be an element of coercive control in this incident and notified Devon and Cornwall Police about their concerns.
This is an example of good practice by Hampshire Police
3.1.19 Devon and Cornwall Police contacted Louise. She was not sure if she wished to make a complaint, so the log was kept open until 18th August, when she was spoken to again.
3.1.20 When Louise was spoken to, she said that this was the first occurrence of this type and that she did not perceive this to be a crime. Therefore, no crime or enquiry was recorded by Devon and Cornwall Police.
3.1.21 The IMR author noted that it was acceptable to consider this as not being a domestic incident; therefore, a DASH risk assessment was not required, and no further recording was needed.
3.1.22 The IMR author also noted that Louise had said that she did not want to engage for fear that the circumstances might worsen. This, and the indication from Hampshire Police who had also spoken to Louise, were sufficient for further exploration. Louise was spoken to by officers of Devon and Cornwall Police and the information that she gave them did not give reason for a crime report to be recorded.
3.1.23 29th December 2018
3.1.24 On 29th December, the police were called by the ambulance service to Louise’s address by a friend of Louise’s. Louise, who was at home alone with her son, had taken an unknown substance (white powder that was possibly cocaine) along with 55 assorted painkillers and a litre of Malibu. She disclosed that she had wanted to commit suicide, the following day, by driving into the central reservation on the motorway.
3.1.25 When the ambulance arrived, Louise was acting erratically and did not want to go to hospital: she was deemed to not have capacity and therefore was taken to hospital under the Mental Capacity Act. Louise disclosed that several traumatic life experiences had come at once – the breakdown of her marriage, a miscarriage, her father being ill, and her son being so poorly. The officers described, ‘big concerns for her mental state of mind’. Louise’s child was taken home by her friend to care for overnight, after the police had carried out checks on police systems.
3.1.26 A red ViST was submitted, and a police enquiry was created on UNIFI. By this time, arrangements had been made for Louise’s sister to drive down and collect her son. This ViST stated: ‘Louise believes that she is fine and is coping however appears to be in a desperate position’.
3.1.27 The next morning, Louise’s sister was driving down to collect her son. She was concerned as Louise had discharged herself from hospital at 4 am, before her psychiatric assessment, and asked the police to check her address to make sure she was OK. This request was declined by the police as there was no-one available to attend and they would not have power to force entry: at that point, they would only have been able to knock on the door. There was no indication that there was an obvious and immediate threat to Louise’s life, which would have allowed a power of entry. The incident log was updated saying, ‘presumably as the hospital allowed the female to discharge herself from hospital, they deemed her to have capacity to make the decision for herself’. Louise’s sister was called back to say that they would not be attending and that she should update the police when she arrived at the property.
The review notes that, at this point, there may have been an issue in the different interpretation of the terms ‘discharged herself’. What was not clear was whether she had formally discharged herself or had just walked out of the department.
3.1.28 Approximately 15 minutes later, after the message had been left with Louise’s sister, the psychiatry department of the hospital rang to report Louise as a missing person: having self-discharged prior to being seen by them. The hospital explained that although she did not need any medical attention or assistance, it was necessary for her to be evaluated.
3.1.29 As a result of this call, and a further call from Louise’s sister, the control room sergeant reassessed the case and deployed officers to Louise’s address.
3.1.30 Enquiries made with neighbours indicated that Louise had an argument with her husband at the address the previous day and there had been lots of shouting. The review is not able to be certain if this argument was with her husband or the perpetrator.
|At this point, the enquiry should have been transferred to a domestic abuse enquiry. This would have then prompted a DASH risk assessment and there was, therefore, no DASH risk assessment completed. The review accepts that it is likely that Louise would not have co-operated with this, but it was, nonetheless, an opportunity for dialogue with her.|
3.1.31 Louise was eventually roused and was spoken to through the door. She refused to allow officers in, or speak to them further. The officers remained at the address until Louise’s sister arrived, and arrangements were made for her to support Louise and her children. This is an example of good practice.
The review notes that Louise’s daughter was not present when the ambulance and police arrived and therefore was not included on the ViST submission: this was an omission. These details were obtained at a later date and added to the ViST.
3.1.32 19th February 2019
3.1.33 The perpetrator called the police saying that he was at the property with his friend and wanted to collect his property, 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. 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.
3.1.34 A couple of hours later, Louise called the police 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.
3.1.35 The officer attending the original incident asked Louise to complete a DASH risk assessment, but she declined. However, the officer completed a ‘refused DASH’ report. When retrieved, this DASH record stated that there were no children present; however, it is clear from the ViST completed, that Louise’s son was there. The IMR author is confident, having spoken to the attending officer, that a refused DASH was completed but, for technical reasons, this was not appended to the enquiry at the time of creation. After a number of emails, the DASH was uploaded, stating that there were no children present. This was incorrect and does not reflect the form completed by the attending officer.
The review is advised that, at the time of this incident, there was a technical problem with attaching DASH forms to any crimes or enquiries, but that this problem has now been resolved.
3.1.36 The ViST risk assessment was completed in full for the children and included details relating to education, GP, and an acknowledgement that the case fitted the criteria for Operation Encompass. However, as it was half-term holiday, the information was not shared in the usual way.
3.1.37 A follow-up enquiry by the Report Author confirms that, in Devon and Cornwall Police, notification of incidents that occur in the holidays sit outside the remit of Operation Encompass. During school holidays, incidents that occur where children are present are shared with Children’s Social Care (CSC) in the normal way, and it is anticipated that CSC will notify schools in accordance with their assessment. Within Devon and Cornwall Police, information, following a DA incident, is shared directly with schools, via telephone update, so appropriate support and due consideration can be met the next morning. Therefore, this is not achievable during school holidays due to the time delay.
3.1.38 The Report Author has been advised by the Operation Encompass charity that the scheme has evolved over the years and some police forces are now sending ‘notifications’, as opposed to telephone calls. They also note that schools appreciate the information about incidents in the holidays as it assists their understanding of the lived experience of the child in the holiday, and so that support can be put in place.
3.1.39 The review has asked Devon and Cornwall Police to look specifically at whether changes could be made to their Operation Encompass scheme that would enhance its effectiveness. They have addressed this issue fully and responded as follows:
126.96.36.199 At the present time, there is no capability in Devon and Cornwall Police to provide Operation Encompass updates to schools during the school holidays.
188.8.131.52 Operation Encompass has not operated in the school holidays as it is intended that the notification results in the school being aware as soon as possible (ideally the next day) so they can provide additional support to the child in school that day. It is not a replacement for normal statutory safeguarding processes but does provide school with early knowledge about an incident at home, which may result in them completing their own safeguarding referral if there are additional concerns about the child. In school holidays, they will not be seeing the children, so the primary function of Op Encompass providing support immediately in school cannot be fulfilled.
184.108.40.206 However, Devon and Cornwall police do automatically share all red and amber VISTs, and three green VISTs within a three-month period, 365 days of the year. This is on a CARA (Child At Risk Alert) download and is emailed every morning to each Local Authority Children’s Services and Education and Health SPOCs (Single point of contacts). The Education SPOC will then forward the individual VISTs on the CARA to the relevant Designated Safeguarding Lead at each school so when the term starts, the school will be aware of any domestic related incidents.
220.127.116.11 During term time, all ViSTs with school age children are downloaded and form part of the Encompass process. In recognition of some officers still not grading domestic related VISTs as at least amber, as per guidance, any green ViSTs are upgraded by CST (Central Safeguarding Team) staff to amber ViSTs to ensure they appear on the CARA (the CARA is only populated with amber and red ViSTs, and three green VISTs within a three-month period).
18.104.22.168 The CARA is the first step in instigating the multi-agency safeguarding process and is shared with key partners, including education SPOCs for onwards dissemination to schools. Therefore, during term-time, the school should receive the notification twice, once through encompass, and once through the CARA via the education SPOC. CST also manually reviews all red and amber child VISTs (and three green in three months) 365 days of the year, and will add value through research and send through to Children’s Services.
22.214.171.124 However, it is recognised that during school holidays and for children not of school age (i.e. under 5s), if there is officer error and the VIST is graded green from a domestic abuse incident, then these will not reach the school through the CARA process. CST are in the process of developing the Operation Encompass download so that green VISTs are highlighted. This is due to be completed in the next few weeks and, from that point, any green VISTs seen on the Operation Encompass download, 365 days of the year, will be upgraded to amber by CST staff. This has not been done previously as CST have not had the resource capacity to go through all the VISTs individually on the Operation Encompass download to find the greens when not delivering Op Encompass (i.e. during holidays). Therefore, the education SPOCs will receive these notifications throughout the year to ensure schools are informed of domestic incidents involving their children.
126.96.36.199 The review is grateful for their considered response and notes that, whilst the report has been going through the Home Office Quality Assurance process, further changes have been made and reports now go to schools regardless of the school holidays.
The review is satisfied that as the ViST was green, it was not assessed by the Central Safeguarding Team and not shared with other agencies on a child at risk alert (CARA). The subsequent DASH, once recorded, was graded as STANDARD risk, with no consent from Louise to share the information and, therefore, there was no subsequent involvement of Splitz or the Domestic Abuse Officer.
3.1.40 Use of DASH risk assessments
3.1.41 The policy of Devon and Cornwall Police is that every domestic abuse crime or incident should have a DASH risk assessment completed. If one is not present, then a supervisor must provide a rationale as to why this is the case. Only at this point, can a crime or enquiry be filed without a DASH attached.
3.1.42 The review accepts that there will be occasions when an individual declines to complete a DASH risk assessment. In these circumstances, a DASH refused is submitted with as much detail as possible from the officer’s knowledge and interaction with the individuals. This was the case in the relevant incident in February 2019.
3.1.43 Compliance with DASH risk assessments is overseen via Force Performance and the Vulnerability Business Board.
3.1.44 The above, details the totality of the police involvement with Louise in the months leading up to her death, and in particular their knowledge of any relationship that existed between her and this perpetrator.
3.1.45 This review acknowledges that the officers who attended the February incident acted entirely appropriately. They recognised the incident potentially as one of domestic abuse and completed a DASH and ViST.
3.1.46 We return then to the issue as to what more can be done to better protect others in the future from perpetrators whose history exists within a variety of different policing recording systems, and thus whose risk is not immediately apparent.
3.1.47 In this case, the incident that police attended did not suggest any immediate threat or indeed ongoing risk to Louise. Looking at the incident itself, that ongoing risk is mitigated by the fact that both individuals indicated that the relationship was at an end. Of course, information that the relationship was at an end should not be taken as a definitive ‘end’, as human nature is such that some couples regularly separate and reconcile for a variety of reasons. The risk in this case was entirely around the individuals’ concerns and not the circumstances of the specific incident.
3.1.48 The circumstances of this incident meant that little or no further background checks on either party were undertaken. This is the first point of ‘break-down’ in this case. Effectively, the police knew their names but did not undertake any level of further research which may have revealed his past, and her recent vulnerabilities, and thus may have led to further considerations about safeguarding. Due to the volume of reports received, the police prioritise cases that are identified as immediate and serious risk, and there are significant resource implications for detailed research on all reports. It is not proportionate to manually consider a detailed historic intelligence check in every case, and significant resourcing or enhancements in IT would be required to achieve this.
3.1.49 It is appropriate for the review to consider whether a disclosure under the ‘Right to Know’ element of the Domestic Violence Disclosure Scheme should have been considered in this case.
3.1.50 Domestic Violence Disclosure Scheme (DVDS), also known as Clare’s Law
188.8.131.52 Louise’s family feel that, if Louise had known the extent of his abusive history, she would have made different choices and she would have left the relationship sooner. The review has considered if the police missed opportunities to make such a disclosure to Louise.
184.108.40.206 In the time that Louise was in a relationship with the perpetrator, the police had two contacts with her. The first was in December 2018 when Louise took the overdose. There was nothing in the information that the police had that indicated that Louise was, or had been, in a relationship with the perpetrator. In fact, enquiries with neighbours revealed that the previous day she had been arguing with her ex-husband. Therefore, this was not an opportunity missed to undertake a disclosure to Louise.
220.127.116.11 The second incident was in February 2019 – that incident is set out in previous paragraphs.
18.104.22.168 There is no evidence that a DVDS disclosure was considered by officers. The preceding paragraphs explain why his true risk was not identified and thus why it was not considered. The review has sought to understand that had it been considered, would Louise have been warned about his past?
22.214.171.124 The review notes the significant difference that exists between this perpetrator’s conviction history and the behaviours that had brought about a number of police calls, his arrests (and one occasion, remand in prison) for domestic abuse, and three reports of strangulation. He was involved in high-risk MARAC cases in relation to two of his previous partners, and those two partners had both said that they feared he would kill them. His partner prior to Louise was so scared of him that she worked with a specialist service to safely exit from him.
126.96.36.199 DVDS scheme is a safeguarding process, not a process that relies solely upon conviction records. The fact that the one incident to which the police were called, between this perpetrator and the victim, was not considered a high-risk incident, meant that checks upon him and his true background were not triggered and thus the real risk he posed was not identified. This meant that they did not consider a pro-active disclosure under the DVDS scheme. This review has asked Devon and Cornwall Police specifically, in light of all of the information that is now known and was available in the various records held by the police, whether a proactive disclosure would have been granted had officers triggered the process? It remains the view of the force that such a disclosure would have been unlikely, even if the reported strangulation of 2016 had been recorded as a crime.
188.8.131.52 Reflecting upon the guidance that was available from the Government to police forces at the time of the incident, this review concluded that a case in favour of a proactive disclosure could have been made, however, equally a case for not disclosing could also have been made.
184.108.40.206 In all cases, police must consider the first principle – that of the three-stage test. The Government guidance says:
Principle 1: Three stage disclosure test
The police have the common law power to disclose information about an individual where it is necessary to do so to protect another individual from harm. The following three stage test should be satisfied before a decision to disclose is made:
- It is reasonable to conclude that such disclosure is necessary to protect A from being the victim of a crime;
- There is a pressing need for such disclosure; and
- Interfering with the rights of B, including B’s rights under Article 8 of the European Convention of Human Rights, to have information about his/her previous convictions kept confidential is necessary and proportionate for the prevention of crime. This involves balancing the consequences for B if his/her details are disclosed against the nature and extent of the risks that B poses to A.
This stage of the test involves considering:
i Whether B should be asked if he or she wishes to make representations, so as to ensure that the police have all the necessary information at their disposal to conduct the balancing exercise, and
ii The extent of the information which needs to be disclosed – e.g. it may not be necessary to tell the applicant the precise details of the offence for the applicant to take steps to protect A.
Some of the considerations in favour of disclosure include:
- The significant level of intelligence (held within police crime recording and command and control systems) that existed relating to his domestic abuse towards previous partners
- That allegations of strangulation had been made on more than one occasion
- Previous cases that had gone to MARAC that involved him and were considered high risk.
Some of the considerations in favour of non-disclosure include:
- No previous convictions for domestic abuse
- The timeliness of his previous convictions and domestic abuse incidents
- That the relationship was at an end
- Whether the victim was already aware by another means such as being told by someone else.
220.127.116.11 It is noted that Louise could have made an application under the DVDS scheme but never did. Her family feel that this is because she did not know about it. A search of the Devon and Cornwall Police website found that the information is accessible. When ‘can I find out if my partner is violent’ was searched, the following pages were displayed:
- I think a friend/relative is with a partner who may be abusive/violent/. Can I find out more information under Clare’s Law?
- My partner is violent, I am frightened, what can I do?
- Can I find out if my partner has a history of abuse or violence (Clare’s Law)?
18.104.22.168 The website provides a link to a very comprehensive and straightforward booklet explaining what the DVDS scheme is and how it will work. This is an example of good practice.
22.214.171.124 The fact that the Domestic Abuse Bill will enshrine the DVDS in law, and that so much debate has been held nationally about strangulation, in particular, will help police forces in future rebalance their thinking in a much clearer way about disclosures and the potential for disclosures such as this.
3.1.51 This review has asked Devon and Cornwall Police to comment specifically upon the issues raised by this case. Their response appropriately identifies the real-world difficulty in resourcing to the level that would be required to fully research each and every report made to them, irrespective of the level of apparent seriousness of the incident. They comment as follows:
126.96.36.199 There is currently no capacity in Devon and Cornwall Police for frontline practitioners (response officers for example) to carry out any sort of cumulative risk assessment, or specialist, in depth risk assessment, in respect of every domestic abuse incident. This will be undertaken by specialist staff when the risk is assessed as High.
188.8.131.52 There is an expectation, set out in policy, that a DASH risk assessment tool will be used and submitted, even if there is no engagement from the victim.
184.108.40.206 It is not anticipated that research including historic crimes, intelligence, enquiries, and previous convictions would be possible in all cases – especially those that present as a standard risk. It is possible that response officers may be passed warning markers on an individual whilst they are at the scene of an incident, and it is possible they may pick up on these markers when they are finding the person’s record to append to the crime or enquiry. This would not, however, trigger an automatic need to further research every single person with a warning marker.
220.127.116.11 To expect them to dig deeper than this is unrealistic given the volume of domestic incidents in force on a daily basis. The number of resources available versus the number of incidents do not allow for in depth research on each one by frontline practitioners. Instead, they are expected to be professionally curious, ask questions, explore the incident they are at, and assess accordingly as standard, medium, or high risk. This allows the force the opportunity to best target the finite resources available to achieve the maximum amount of safeguarding work to be undertaken, against the cases that present the highest immediate risk. In Devon and Cornwall Police, this is typically undertaken by a specialist Domestic Abuse Officer (DAO).
18.104.22.168 In the case of this DHR, the incident in February 2019 prompted officers to correctly record an enquiry, a DASH risk assessment graded standard, and a ViST. No further research was instigated because of the standard-risk grading. No specialist research was later undertaken by a DAO as their attention would have been taken up with high-risk cases. Had the incident that trigged the MARAC marker being within the last 12 months, this may have instigated further research.
22.214.171.124 There is no capacity at this time to change this practice and, as such, the force must continue to address those cases where there is known, immediate risk.
126.96.36.199 Had the risk that the perpetrator presented been identified in this case, there may have been no disclosure made because of its historic nature. The report authors have rightly identified the fine balance of proportionality in making the disclosure of his right to a private life, and Louise’s right to life. It is considered unlikely that had all the potential research been done, a disclosure would have been authorised – although it should be noted that our Detective Inspectors are cognisant of previous strangulation as a high-risk indicator.
188.8.131.52 Our force utilises officers of the rank of Detective Inspector to make DVDS decisions. This is not common practice across the UK. A recent benchmarking exercise performed by the force was answered by seven other forces and identified varying practices across the UK with many exercising that decision-making at Detective Sergeant rank sometimes through centralised specialist units rather than locally via BCU officers/DAOS.
184.108.40.206 The force is satisfied that Devon and Cornwall’s response to DVDS at this time is as efficient and streamlined as possible, given availability of resources and how these are managed. We acknowledge that should resources not be an issue, DVDS consideration for all DA cases, regardless of risk, would be best practice.
220.127.116.11 Devon and Cornwall Police will be introducing a new computer system in the early summer of 2022. It is expected that this will change the way information is held and presented to officers when they are searching an individual. How this will impact on DA and DVDS in particular, is not fully understood, but it is likely to improve safeguarding practices and access to information. However, the force Lead for domestic abuse has already indicated that the new system will not alter the force approach to domestic abuse in the short to medium term.
18.104.22.168 Family feedback
22.214.171.124 Having shared the report with Louise’s sister, she asked the review to quantify the number of cases that may arise in the force area: Devon and Cornwall Police have provided the following information.
126.96.36.199 For the period 1st September 2020 to 31st August 2021 there were:
188.8.131.52 Over 32,000 separate incidents of domestic abuse recorded by Devon and Cornwall Police. These were made up of more than 21,000 crimes and over 11,000 enquiries. DASH risk assessments were undertaken in more than 65% of these. DASH was refused in 16% of crimes, and 29% of enquiries. In these cases, the officers submitted a DASH with the information that they could find.
There were 18% of crimes with no DASH at all. The reasons for this varied including, on occasions, multiple crimes stemming from one incident. There were 3% of enquiries with no DASH
The police advised that it is difficult to say how many resulted in further research without looking at each individual crime or enquiry. However, there is an expectation that high-risk cases (more than 1350) would have in-depth research completed and, if capacity allowed, some of the 11500 medium cases.
184.108.40.206 Louise’s sister has provided the following statement:
220.127.116.11 Having read through the Report it is clear to me that had certain circumstances been handled differently Louise could be alive today. Louise was an individual who clearly demonstrated a vulnerability and, as a family, our expectation is on the police, social services, and other authorities to have protected her and her children. Louise reached out for help on several occasions but wasn’t strong enough to have read the eight signs that proceed a domestic homicide. The expertise of the officers attending, supported by running the name through the database, would have instantly alerted them to the fact that they were dealing with not only a dangerous individual but an individual with previous history and an individual that was a risk to the children. The outcome had this one check being made on the initial visit could very much mean that Louise‘s life could’ve been saved, and her children would still have their mother. I appreciate that it takes time to run a name through the database however if it is done for all domestic incidences, I think not only it protects future victims it will also protect children and the officers attending the incident.
3.2 ROYAL DEVON AND EXETER HOSPITAL
3.2.1 Louise had three main contacts with the hospital during the scope of the review.
3.2.2 December 2018
3.2.3 Louise attended the hospital following a miscarriage. This was an unplanned pregnancy and the email from her GP surgery noted that she was due to have a termination the following week.
|The paperwork used for such an appointment has a prompt question: ‘DA question asked’. However, this was not completed. Although it said she was living with her partner but not married, there is no rationale for why the domestic abuse question was not asked and this may have afforded an opportunity to have provided support to Louise.|
3.2.4 The IMR author identified that in the Gynaecology Department, domestic abuse is not something that is routinely asked of patients, but the department acknowledged that this needs to happen.
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.
It is recommended that the current paperwork is updated to include a routine enquiry about domestic abuse on all proformas in the clinics.
3.2.5 December 2018
3.2.6 Louise attended the Emergency Department after taking an overdose mixed with alcohol. During her time in the hospital, there were opportunities for staff to ask Louise about domestic abuse. Firstly, when she was admitted to the ED and, secondly, when she was assessed by the team in the ED.
3.2.7 Whilst in the ED, Louise was intoxicated, and staff found it difficult to engage with her. She was described as spending most of the time on her phone and therefore staff were not able to find the appropriate time to ask the question. The opportunity to ask the ‘routine question’ may have presented itself during her time in ED when she was assessed after the initial triage: there is no evidence that this was undertaken. A further opportunity would have occurred when it was planned that the psychiatric liaison team would speak with her, but unfortunately, Louise left the department before this could occur.
The review does not believe that this reflects negatively on the hospital.
3.2.8 As an employee of the Trust for six years
3.2.9 Louise worked for the Royal Devon and Exeter Hospital for 6 years. She was described by her line manager at the time of leaving, as hard-working and always happy to pick up extra work. She had a good relationship with her line manager and openly discussed her personal life, as well as work. When she left her job, she was believed to be still living with her husband and that she left work as the family were moving to Spain.
3.2.10 Whilst working for the Trust, she had an average sickness record.
When staff return to work, they are asked if the reason for their sickness was due to domestic abuse, so that support can be offered. The review accepts that this was not the case when Louise was employed by the Trust: this policy has since been changed.
The review notes that as part of this review, Louise’s employment has been discussed by the Domestic Abuse Operational Group to identify any lessons that could be learned. As a direct result of Louise’s death, a routine enquiry is made as part of the exit interview.
Whilst the review notes that these changes would not have impacted directly on Louise, as she was not in a relationship with the perpetrator at the time, they are examples of good practice.
3.2.11 The perpetrator had no contact with Royal Devon and Exeter Hospital within the scope of the review. He did, however, have four contacts outside the scope, which are included as background.
3.2.12 On 16th September 2007, the perpetrator was taken into ED after a near drowning following an overdose of cocaine. He had self-harmed five times in the previous month and was sectioned under Section 136 of the Mental Health Act.
3.2.13 The perpetrator attended ED on 7th September 2009 with an injury to his right hand, having punched a wall.
3.2.14 On 3rd April 2011, the perpetrator attended ED having fallen from a roof window whilst taking recreational drugs.
3.2.15 The perpetrator was taken to ED by police on 16th August 2012 with a head injury sustained in a fall. He was reported, by the ambulance staff, to be aggressive and agitated. He was uncooperative and difficult to assess as he was combative with staff. He continued to be abusive and aggressive to staff, and his partner, whilst in the department, so the police were called to re-attend, and he was re-arrested.
The review acknowledges that this was an appropriate way to deal with him on this occasion.
There are no recommendations for this organisation.
3.3 CHILDREN’S SOCIAL CARE, DEVON COUNTY COUNCIL (CSC)
3.3.1 At the time of Louise’s death, CSC was in the process of completing an assessment following her overdose in December 2018.
3.3.2 It has to be said from the outset that the information from Louise’s sister varies widely from the records held by the CSC, in particular, in relation to the number of telephone calls she says she made, and the information she was given. This review cannot reconcile that difference.
3.3.3 Prior to December 31st 2018, there was little contact with the family. There was one issue of direct child protection concern relating to one of the children in September 2014, which involved that summer’s craze of “Ice Bucket Challenges”. The child was three at that time and this was judged to be a ‘lapse of judgement’ on Louise’s part. A report of domestic dispute was received in December 2017 where an argument occurred between Louise and her then partner. This took place in a public place and there were no indications of violence, and he had left the scene. A further report in connection with her ex-husband was received in July 2018, when she made a serious suicide attempt. However, this was following the couple’s separation and he was elsewhere when this occurred. It is against this context that the CSC were involved during the time of Louise’s relationship with this perpetrator.
3.3.4 The first referral recorded is the report on 30th December 2018 in relation to Louise’s overdose. This is later described in the GP report received on 9th April 2019, as part of information gathering for the Children & Family Assessment, as a ‘spontaneous’ response to circumstances rather than a well-thought-out attempt to end her life. This triggered an assessment under Section 17 (Child in Need) referenced.
3.3.5 This assessment was allocated to the social worker on 4th January 2019, but there was no progression within the recommended timeframes of 45 days to completion – this would have seen a conclusion by 8th April 2019, unless other factors identified from the assessment required further work. The social worker acknowledged this delay in her communication with Louise on 9th April 2019, where she apologised for the ‘drift & delay’.
3.3.6 The assessment was ongoing at the time of Louise’s death, but the likely recommendation mentioned in the supervision entry of 16th April 2019 was that the family should be supported under a Child in Need Plan, and allocated for ongoing work.
3.3.7 Children’s Social Care formed the view that the family had created their own safety plans within the maternal family network to support Louise, and her sister and parents had the care of her child at different times in the January-April period.
3.3.8 From January 2019 to April 2019, there are no records that indicate that this perpetrator’s presence in the family’s life was known to Children’s Social Care.
3.3.9 Had the assessment proceeded within the timeframes set down, all the available information would have been better understood within the work to address the family’s problems, and additional sources of support identified, where necessary, at an earlier stage.
3.3.10 Although this perpetrator was not known as a factor in Louise’s life, had the assessment been undertaken within the expected timeframe, his presence may have become known as part of the process. However, even if his presence had become known then, as this was a Child in Need case, there would have been no trigger outside of a Section 47 investigation to undertake a DBS check on him without his consent. The case did not have direct child protection issues as a core area of concern, and Louise was not seen as a risk to her children.
3.3.11 The fact that the law would preclude any lawful checks being carried out to establish the nature of who was living in the house, had his identity become known during any assessment, is of great concern to this review. However, the legislators, in passing the regulations that protect individuals’ rights to privacy balanced against the state’s role for safeguarding, must take the view that some level of risk is acceptable. Sadly, in this case, that risk has been fatal.
There are no recommendations for this organisation.
3.4 CHILDREN AND FAMILY HEALTH DEVON on behalf of PUBLIC HEALTH NURSING
3.4.1 Public Health Nursing service offered a comprehensive package of health care to Louise commencing in April 2012, following the birth of her first child. During early childhood, the child had multiple attendances at hospital with breathing difficulties and had a diagnosis of brittle asthma. Louise received medical support from the paediatric team in the Royal Devon and Exeter Hospital and accessed the Public Health team for routine health and developmental reviews. Following the child’s second birthday, Louise sought support for behaviour and sleep management which she followed, and a positive outcome was reported.
3.4.2 Following the birth of her second child, the Health Visiting team completed a family health needs assessment which identified their parents had recently married, with supportive extended family to both parents. No factors of concern were identified at this assessment, but Universal Plus service was offered due to the health needs of the children. Louise and the children engaged regularly with the Health Visitor services until December 2018, following Louise’s hospital admission due to an alcohol and drug overdose. Health Visiting services offered the family additional support, but Louise did not engage. The Public Health Nursing Team were unaware of Louise’s relationship with the perpetrator.
3.4.3 Lack of professional curiosity and critical thinking
3.4.4 The review notes that the Health Visiting service had a number of interactions with Louise. The review accepts that at the first meeting on 27th March 2017, her husband was present, which would have precluded enquiry about domestic abuse.
|However, at the following visits, Louise was never asked about how things were at home. This was despite Louise disclosing issues that should have triggered concern such as anxiety, bereavement, sleep problems putting a strain on the marriage, attempted suicide by husband, and separation. These were opportunities to open dialogue and gain a greater understanding of the real issues that were affecting her.|
3.4.5 There was no knowledge of potential risks to the adults in the household. The family health needs assessment of 27th April 2017 was not revisited or updated in subsequent contacts. The practitioners involved with Louise were assured by her ability to cope with two children, both having chronic illness, reinforced by the positive presentation of her children.
The review notes that, in light of Louise’s death, the Family Health Needs Assessment is now completed with all families receiving the Universal Plus or Universal Partnership Plus level of service.
|Clinical supervision was not recorded during the review period, thereby, missing an opportunity for critical thinking and reflection.|
The Review Panel considered if a recommendation should be made about training about health visitors but, as the Devon Children and Families Partnership are in the process of rolling out newly created and updated training that will be mandatory for all health visitors, this would be out of date.
3.4.6 Referrals for further support
3.4.7 The review notes that Louise was referred to other agencies who could support the family, particularly Home-Start. This is an example of good practice.
3.4.8 Engagement with other agencies
3.4.9 Louise engaged with her health visitor on 21st January 2019, and she referred in the conversation to a social worker. The health visitor was not, until that time, aware of any involvement by Children’s Social Care.
3.4.10 Between 24th January and 22nd March, the health visitor tried to make contact with the social worker without success. There is no evidence that the health visitor escalated this within her organisation.
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.
3.5 HOME-START EXETER
3.5.1 Home-Start is a national charity supporting families with children under the age of 5 who are struggling to deal with a range of challenges. Home-Start Exeter, East and Mid Devon is managed independently by a Board of Trustees and receives a Quality Assurance assessment from Home-Start UK. The group trains volunteers to give support, friendship, and practical help to local families, often in times of crisis. The volunteers are themselves parents and support families to make changes that will have a life-long effect for the family, in particular the children. Volunteers are ‘matched’ with a family and visit them once a week on a regular basis for, on average, 6-9 months.
3.5.2 The organisation follows safer recruitment policies when recruiting volunteers. The volunteers complete a 40-hour Volunteer Preparation Course, written by Home-Start UK. Once matched with a family, the volunteer receives regular formal supervision from their Volunteer Co-ordinator at least every month, but contact may be more frequent.
3.5.3 Families being supported, receive a review visit from the Volunteer Co-ordinator every three months.
3.5.4 Louise and her family were referred to Home-Start by Louise’s health visitor on 18th September 2018. Following an assessment on 26th November, Louise was matched with a volunteer and introduced to her on 11th December. She then worked with Home-Start until her death – being seen by them for the last time on 15th April.
3.5.6 The Home-Start co-ordinator undertook an assessment with Louise on 26th November – this is standard practice and allows the family the opportunity to express their needs and identify how they think the volunteer can help.
3.5.7 Louise said that she had little support in a number of areas – managing the children’s behaviour, coping with the children’s mental health, and managing the household budget. She described the medical conditions that her youngest child had. She said there was no social care involvement but, if her ex-husband was involved in another incident, they would become involved. She said that the only statutory services involved were the Royal Devon and Exeter Hospital and a dietician. She signed the ‘Privacy Notice and Consent Statement’ which confirmed that she understood the safeguarding responsibilities of Home-Start.
3.5.8 A risk assessment was conducted as part of this initial visit. Louise said that there would only be herself and the children present during visits. The co-ordinator explained that the sessions were more beneficial if visitors could be kept to a minimum when the volunteer visited. When asked about problematic drug and alcohol abuse in the family, Louise said that there was none, but then during the conversation revealed that she sometimes drank too much when things got on top of her. Louise was asked if she had ever been subject to domestic abuse. She said no but questioned whether there had been coercive control in a previous relationship.
3.5.9 Social Care involvement
3.5.10 Home-Start is a preventative service, and the local scheme does not accept referrals from families who have a Child Protection Plan or are at Child in Need level. This is due, in part, to a reduction in staffing levels as a result of funding cuts in 2016, and to protect volunteers from situations where there are highly complex needs.
3.5.11 Home-Start had been informed that CSC was de-escalating their support with a view to closing the case.
The review notes that, since Louise’s death, the local scheme has taken the decision not to accept referrals until there is clearly no longer a formal connection with CSC. This decision not to support families with CPP or CIN is because the organisation does not feel that the information flow from CSC to Home-Start is reliable enough, and they sometimes felt that they were ‘working in the dark’.
|The review finds this very disappointing. Given the times of austerity that we work in, the voluntary sector is invaluable to supporting the delivery of statutory services, and feels that Home-Start was not treated as an equal partner in this case. A number of families would be much more receptive to the support of someone from a voluntary agency rather than a statutory service such as CSC.|
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.
3.5.13 Home-Start fully complied with their safeguarding responsibilities. When the volunteer was concerned about the unexplained bruising on the child, they were reassured by the paediatrician.
3.5.14 Domestic abuse training
3.5.15 As part of the review, the Report Author has met with the co-ordinator with a view to understanding the training that volunteers are given around domestic abuse. As part of the initial training (40 hours), a half day is allocated to domestic abuse. This training covers the following key messages:
- Domestic abuse is far more than physical abuse
- Domestic abuse is about power and control
- That undoubtedly men are victims of domestic abuse, but the overwhelming majority of victims are women
- The reasons why some people do not report domestic abuse
- Domestic Abuse Helpline numbers
- How to offer support someone who is a victim of domestic abuse
- Some case studies that explore how the volunteer would support in different situations.
3.5.16 Home-Start offer ongoing training for volunteers that will look at topics in more detail
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.
3.5.17 The review is aware, having spoken to both the co-ordinator and the volunteer, that they were both very affected by Louise’s death.
The review is aware that Home-Start facilitated counselling for both. As a small charitable organisation, with limited resources, this is commendable and an example of good practice.
3.6 DEVON PARTNERSHIP TRUST
3.6.1 Devon Partnership Trust provides mental health services.
3.6.2 The perpetrator was seen on a single occasion, 25th May 2017, following referral by his GP. The referral letter was detailed. He was given a diagnosis of Emotionally Unstable Personality Disorder and offered the CHANGE programme. He did not respond to invitations to appointments, despite letters and text reminders, nor any of the subsequent efforts by Devon Partnership Trust to engage him in therapeutic work –he was eventually discharged from the service after failing to attend three appointments in July 2017.
13.6.3 His GP re-referred him in September 2017, and he was offered a further assessment appointment – he failed to attend and was discharged in November 2017.
The review concludes that there was a timely and robust assessment of the perpetrator’s needs, and an offer of therapeutic work to address the problems that he had identified. There is evidence of attempts being made to engage with him.
There are no recommendations for this organisation.
Section Four – Information provided by Family and Friends
4.1 Louise was described as being kind and generous and would do anything for anyone. Everyone spoken to by the review could give an example of this. One friend described her being there for her when she had a bereavement. Another person described an incident when her child was in hospital and Louise came with spare underwear and toiletries for her. Yet another described a time when she was admiring an ‘elf on the shelf’ that Louise had and commented that her child would appreciate that. Louise immediately gave it to her, saying they could get another one.
4.2 She was described as a very feisty girl who did not mince her words. She had a ‘heart of gold’ and was always keen to socialise. Louise was described as very trusting and always looking for the good in people. She was said to be very friendly in a motherly sort of way.
4.3 Louise’s sister described her as an introvert who lacked in confidence and self-esteem. She did not like people looking at her and hated to be the centre of attention. That said, she was very loyal. There were areas of life with which Louise struggled. She found coping with money hard. It has been said that ‘she did not enjoy being an adult and did not cope with it’. In some ways, she was quite childlike – at Christmas she was like a ten-year-old.
4.4 All Louise cared about was her family. Her children were her life. She was happy on her own and did not always have to be in a relationship. She was described as a fantastic, protective mother. Her children came first in every way. She was not a pushover and would fight for her children.
4.5 Although Louise found relationships at work hard, she was described by her line manager at the time of leaving, as hard-working and always happy to pick up extra work. Her friends also talked of how hard-working she was, sometimes having three jobs.
4.6 The tributes that the review has heard are best summed up by one person who said: ‘I could not have wished for a better friend’.
Section Five – Domestic Abuse
5.1 In this section of the report, the review will explore the evidence that we have that there was a trail of domestic abuse in the relationship between Louise and the perpetrator. This section will consider the misogynistic and controlling behaviour displayed by the perpetrator.
5.2 The review is particularly grateful to previous partners of the perpetrator. Louise had been in a relationship with him for a relatively short period of time, so their insight into his controlling and coercive behaviour is invaluable.
5.3 HIS RELATIONSHIP WITH LOUISE
5.3.1 We know that Louise was somewhat secretive about the relationship with the perpetrator. There is a suggestion that he asked her to lie to agencies about his name. It is believed that he told her that this was because he owed money on a flat that he had once rented. Louise’s sister said that she was so ‘by the book’ and that for her to lie to an authority was a sign that she was being manipulated and controlled.
5.3.2 Louise told friends that the perpetrator had trouble handling his drink and had a bad temper. She said that he was moody and volatile.
5.3.3 Louise’s sister talked about the perpetrator having accompanied Louise and the children to visit her just before she died. She described how he was ‘putting on a performance’. He was effusive about her curtains, which she felt was odd. When she said to Louise that he needed to relax, Louise said that he wanted to get her onside.
5.3.4 Coercion and control
5.3.5 On one occasion, Louise had a friend round to the house with her children. The perpetrator was there with his child but because he and Louise had had a row, he stayed upstairs with his child and would not come down. She went up and told him that there was food, but he refused to come down and join in. He came down and made food for himself and his child. This made an atmosphere in the house.
5.3.6 On the evening of her death, Louise and the perpetrator spent time with friends. During the evening, the perpetrator was recording Louise, who had been drinking, on his phone. She asked him to delete it which he agreed to do, but she was not sure if he did or not. When the friend asked Louise if she was OK, Louise said: ‘it’s OK, I deal with it all the time… He’s very controlling’.
5.3.7 When they were leaving to go home in the taxi, Louise made to sit in the front and the perpetrator said: ‘no, back seat’. She got in the back seat and her friend told police that she had the impression that the perpetrator was controlling towards Louise.
5.3.9 A number of people said that they did not see Louise as often when she was in a relationship with the perpetrator.
5.3.10 One friend talked about regularly spending an evening with Louise when they would have something to eat and watch TV. The perpetrator would sit in the room with them all evening. Louise said that he did not do this with other people and the friend felt that he was keeping guard over what she might say about him.
5.3.12 The perpetrator had intimidated Louise by telling her that ‘social services would take her children away’.
5.3.13 He would boast that he was a boxer.
5.3.14 Everyone that we spoke to referred to the perpetrator having told Louise that he was on licence for attempted murder. The review has researched this claim and can find nothing to substantiate this. The only explanation is that he used this as a means of warning Louise about what he was capable of.
5.3.15 Economic abuse
5.3.16 The perpetrator did not always pay rent when he was living with Louise. There is a suggestion that she allowed this so that things would appear that all was well.
5.3.17 Psychological abuse
5.3.18 In March 2019, he smashed a glass over his head during an argument.
5.4 HIS RELATIONSHIP WITH PREVIOUS PARTNERS
5.4.1 In order to protect the previous victims who have spoken openly to the review, the following is a combination of the information gathered from more than one person, and it has been presented in such a way as not to identify who said what.
5.4.2 When women first met the perpetrator, he was charming. He was nice to them. At the beginning of the relationship, he was effusive in the loving things that he said to women.
5.4.3 He was described as violent, volatile and unpredictable. It was said that ‘in a nutshell, he is a psychopath, controlling, manipulative’. He was described as ‘Jekyll and Hyde’ and he could go from 0-10 in seconds over something so simple as his dinner not being hot enough. He would jump around punching his fists, and his eyes would go black.
5.4.4 He was described as ‘Mr Nice Guy’ outside, but that this ‘Mr Charmer’ was only a camouflage for what he was really like. He was described as a complete narcissist.
5.4.5 It was said that she thought he must be very popular as people did what he said. However, she later realised it was because they were afraid of him.
5.4.6 He was described as becoming very controlling very early in their relationship.
5.4.7 It was said that ‘every day with him was a living hell’.
5.4.8 Coercion and control
5.4.9 He was described as having Obsessive Compulsive Disorder (OCD), although he was never diagnosed with this condition. He had to have everything clean and tidy. He would scream at her if she did not do the washing up in a certain way. The women would try to do things his way to keep the peace, but he would constantly change the rules.
5.4.10 He would control when they went out and what they wore.
5.4.11 The perpetrator had a way of making women feel sorry for him. He would talk about his terrible childhood experiences as a way of making them feel sorry for him, and he claimed to have a number of personality disorders. He would always blame someone or something else.
5.4.12 He would use child contact as a means of controlling the women he had been in relationships with. He would not return the children on time but would bring them home when he ran out of money. He told women that if they prevented him having access to the children, he would kill them.
5.4.13 Psychological abuse
5.4.14 He was psychologically abusive to women, and they lived in fear of his violent outbursts.
5.4.15 Following a verbal argument, he hit himself repeatedly causing himself to bleed. On more than one occasion, he threatened to take his life by suicide. He would use the threat of suicide to control his partners –they would, therefore, be concerned about him and want to molly coddle him.
5.4.16 He was described as jealous.
5.4.17 He would belittle his partners in public and make fun of them. Friends would laugh but for them it was not funny because they knew what was behind his words, and what he was threatening.
5.4.18 On one occasion, he slammed the door shut to prevent his partner leaving the room and she felt trapped. He then said: ‘I would love to kill you’. She believed he would and was trapped for hours.
5.4.19 He had repeatedly threatened to kill women, often if they left him.
5.4.20 Physical abuse
5.4.21 When describing the physical abuse, women described how in the early months of the relationship there was a subtle build-up to the violence.
5.4.22 He had, on occasion, repeatedly banged a partner’s head on the floor. He had thrown them to the floor and pinned their face down, causing them injury. He had thrown drinks over them. He had dragged them down the stairs.
5.4.23 There were numerous times when he had tried to strangle women. He had held a woman by the throat with both hands so that she was not able to breathe and left visible injuries (red marks, bruising and scratching). On another occasion, they had a row, which was not unusual, and he put his hands around the woman’s throat and squeezed until she passed out. She does not know how long she was unconscious but when she came around, he was screaming at her to get out.
5.4.24 Non-fatal strangulation has been shown in some studies to increase the risk of homicide by sevenfold.
5.4.25 He would clench his fist and punch it into the palm of the other hand, constantly shouting at them. He had grabbed them by the jaw/chin and started shaking them.
5.4.26 He had jumped on top of them, pinning their arms to the wall behind them. He had then begun squeezing their arms really hard whilst shouting at them. They have had bruises to their upper arms. He would then make them buy long sleeved tops to cover it. He would then go for their arms causing a lot of bruising.
5.4.27 One time, he and a partner were watching TV and had an argument – he grabbed her by the head and threw her to the floor, where she hit her head on the side of the washing machine. He continued to scream and shout at her as he put his full weight on her and ripped her earring out. He then got up and started punching himself in the head causing his eyebrow to split.
5.4.28 On another occasion, he grabbed her by the throat, and it all went white, and she started to pass out, she managed to say I have had enough and he said you have had enough and started to squeeze her throat again – this time she did pass out.
5.4.29 Economic abuse
5.4.30 There were times when he did not work and he would demand money from his partners, including benefits that were for the children. He would control what was bought, for example, when they went shopping. One gave an example of him refusing to allow her to buy a melon, as he did not want this.
5.4.32 It was said that he could manipulate a situation and their way of thinking to the point that they did not know if their own thoughts were true.
5.4.33 The perpetrator is best described by Sandra Horley in the first line of her book, ‘Power and Control – Why charming men make dangerous lovers’, when she says: ‘The Charm Syndrome is a distinct pattern of behaviour. It is a man’s use of charm to gain control over a woman. Once he has achieved that control, Charm Syndrome Man may or may not continue to charm his partner. But what he will always do is assert and reinforce his control by emotional and sometimes physical abuse’.
5.4.34. As part of their input to the review, one of the perpetrator’s previous partners told the Report Author that she had left him after receiving support from the local domestic abuse service. She had seen their number on a poster on the back of a toilet door in the local hospital.
The review notes that initiatives such as this go on all around the country with little means of measuring their effectiveness. This personal testimony demonstrates that this act alone may have saved a woman’s life.
5.5 HOMICIDE TIMELINE
5.5.1 The review has already set out that Louise’s relationship with the perpetrator was relatively short. The time between them meeting and her being murdered was approximately 6 months. The review has therefore considered the speed with which the relationship escalated into homicide.
5.5.2 The analysis here draws on the research of Professor Jane Monckton-Smith of University of Gloucestershire into Intimate Partner Femicide Timeline. This research has identified eight stages through which a relationship that ends in homicide is likely to go. By considering this timeline, we can see that the relationship follows this timeline, and the different stages can be seen.
5.5.3 As we consider the different stages of this timeline, we are very aware that, given the planning that took place, the perpetrator could have, at any point, changed his mind and not proceeded with the killing of Louise.
5.5.4 Stage One – Pre-relationship history
5.5.5 Previous history of abuse is acknowledged in research to predict future abuse (Websdale, 1999), and we know that the perpetrator had a long history of abuse going back over many years and numerous partners. The behaviours that he displayed were very similar from one relationship to another. The perpetrator displayed the warning signs identified by Monckton-Smith – a history of controlling patterns, previous arrests for domestic abuse, being jealous and possessive, a criminal history, an inability to accept being challenged and being thin-skinned and confrontational.
5.5.6 Stage Two – Early relationship behaviours
5.5.7 Monckton-Smith describes the relationship speeding up with early declarations of love, possessiveness, and jealousy. We know that this relationship began very quickly. The perpetrator moved into Louise’s home at the end of October as a lodger, however, they began a relationship almost immediately. This is one of the warning signs highlighted for this stage, along with early pregnancy.
5.5.8 Monckton-Smith notes that when stages 1-2 are positively identified, there is a much higher likelihood that attempts at separation later in the relationship will be met with resistance.
5.5.9 Stage Three – Relationship warning signs
5.5.10 Even from the limited information that we have about the relationship, we have seen that he was abusive and controlling towards Louise. We know that Louise reduced the contact that she had with her friends, which is one of the warning signs – she prioritised him over her friends, thereby establishing the control that he had. When we look at the warning signs identified by Monckton-Smith, we see violence and strangulation which was, very much, part of the perpetrator’s history of abuse.
5.5.11 The research by Monckton-Smith highlights that this stage is found to have the most diversity in length of time. For some it could be 3-6 weeks and in others it could be up to 50 years. We know that in this case, the time was, at the most, six months.
5.5.12 Stage Four – Trigger warning signs
5.5.13 The research shows that the biggest trigger for domestic homicide is separation or the threat of separation. We know that Louise and the perpetrator had separated and although at the time of her death they were back in a relationship, they had been living separately.
5.5.14 Stage Five – Escalation warning signs
5.5.15 At this point, the research says there will be evidence of an escalation in the warning signs, such as the concerning behaviours becoming more frequent or more serious. This escalation appeared, in the research, to be an attempt to re-establish control or status. It is hard for us to pinpoint an escalation as Louise did not report the abuse that she was experiencing. However, given his history, it is not unreasonable to assume that this occurred.
5.5.16 Stage Six – Change of thinking/decision
5.5.17 This stage appears to occur in or at the end of a period of escalation and may be a response to perceived irretrievable loss of control and/or status. Monckton-Smith notes that one of the warning signs is that things may become calmer. We know that Louise met with Home-Start on 15th April and, as part of this meeting, she said that they were getting on well and that she felt chilled and happy. It might be that the change of thinking occurred when they split up for two weeks. One person expressed the view that he planned to kill her as she had tried to separate from him.
5.5.18 Stage Seven – Planning warning signs
5.5.19 It is interesting that, with knowledge of the Homicide Timeline theory, more than one person who spoke to the review, said that they believed that the perpetrator had planned to kill her – that it was not spontaneous.
5.5.20 At the time that Louise was killed, she had arranged for her children to stay with family, so that they ‘could spend time together, getting to know each other’. A number of people have said that this type of arrangement was always made in advance and was not a spontaneous event, as it was on this occasion. There is a view that the perpetrator had planned to kill her whilst the children were away. This is an example set out in the research – seeking an opportunity to get the victim alone.
5.5.20 Stage Eight – Homicide characteristics
5.5.21 The homicide timeline identifies the most common characteristics of the intimate partner femicide timeline as a clear homicide with confession, which features in this case. Research identifies that the homicide more usually occurs in the home of the victim (Brennan 2016).
5.5.22 Monckton-Smith notes that, whilst the details will vary from case to case, in those studied, the perpetrator had, in all cases, travelled along through these stages. Highly violent perpetrators may travel through stages 4-8 much more quickly.
5.5.23 Importantly, Monckton-Smith notes that progression through each of the stages is not inevitable, and interventions can prevent the cycle from progressing. The perpetrator could have changed his mind at any point.
Section Six – Analysis
6.1 The perpetrator
6.1.1 His background
6.1.2 The perpetrator has disclosed a troubled upbringing with mention of sexual abuse in his teenage years by a family member, although this has not been confirmed. His mother threw him out of the family home when he was 14 years old and then he lived with his older sister. This only lasted for a few months as he did not attend school and did not abide by her rules.
6.1.3 He has used drugs and alcohol over the years, and this will be discussed in due course.
6.1.4 His previous conviction history
- July 1999 – Drink driving, driving without licence and insurance – Disqualified from driving
- September 1999 – Actual Bodily Harm Section 47 and Grievous Bodily Harm Section 20 – 4-month detention for each offence, to run concurrently
- October 1999 – Actual Bodily Harm Section 47 – 4 months detention to run concurrently with the above (sentenced all at the same time)
- August 2002 – Criminal damage – Originally sentenced to 12 months conditional discharge, later changed to 3 months detention at young offenders’ institution for breach of conditional discharge (see entry 20/04/2003 below)
- November 2002 – Common Assault – Fine
- April 2003 – Grievous Bodily Harm Wounding Section 18 and breach of conditional discharge from 2ndAugust 2002 – 5 years detention in young offenders’ institution
- 17th August 2012 – Being drunk on a highway in a public place – Penalty Notice for Disorder.
6.1.5 His mental health
6.1.6 The perpetrator has sought help for his mental health issues over the years. In September 2015, he spoke to his GP about low mood and anxiety; he described that his mood was up and down, day by day. He said that he did not have any suicidal thoughts. In April 2016, the perpetrator spoke to his GP about his low mood. He said that he was anxious at times and was concerned about the possibility of an underlying mental health condition. He said that this impacted upon life as repeated cycles of destructive behaviour in relationships/jobs, etc. He said that he had done online questionnaire about personality disorders and had scored highly.
6.1.7 In September 2016, a marker was placed on the Police National Computer to note the perpetrator’s propensity to use weapons.
6.1.8 He then saw his GP in April 2017. His GP noted that his main issues were, at that time, that he could not keep a job, and could not maintain friendships or partnerships. He noted that he had extensive social anxieties and anger issues. The GP noted that when he spoke to him, he was quite chaotic, had flight of ideas, and pressured speech.
6.1.9 The GP, in his referral, noted that the perpetrator was concerned that he may have a personality disorder, having done some online questionnaires. He told the GP that there was a family history of bipolar disorder and wondered if he may have this.
6.1.10 Following a mental health assessment in May 2017, the perpetrator was diagnosed with Emotionally Unstable Personality Disorder. A letter was sent to him, after the diagnosis which advised him that: ‘You are presenting with very clear symptoms of emotionally unstable personality disorder. These symptoms include a history of unstable relationships, rapid changing moods, intense reactive emotions, chronic feelings of emptiness, history of self-harm and impulsive behaviours (binge drinking, binge eating, spending large amounts of money, self-harm and unprotected sex)’.
6.1.11 He was offered a range of treatment options, but he did not attend any of the appointments sent to him. He was re-referred by his GP in September 2017, and again did not engage with the appointments sent to him.
6.1.12 In sentencing, the Judge noted that whilst a medical report had been provided, the defence had not used this as mitigation.
6.1.13 Whilst the review cannot be certain, there is a sense, from his interaction with mental health services and what his previous partners have told us, of the perpetrator seeking a ‘label’ on which he could blame his abusive behaviour, without any motivation to accept any help or intervention to mitigate its impact.
6.1.14 The part that alcohol played in his abuse
6.1.15 Research finds that between 25% and 50% of those who perpetrate domestic abuse have been drinking at the time of the assault, and cases involving severe violence are twice as likely to include alcohol. It has also been found that in an intimate relationship where one partner has a problem with alcohol or other drugs, domestic abuse is more likely to occur. However, the impact of alcohol on domestic abuse is complicated.
6.1.16 Previous partners have spoken of his controlling and abusive behaviour being at its worst when he had been drinking alcohol, albeit he had not always been drinking alcohol when he was abusive. Research has shown that having an expectation that drinking alcohol will lead to aggressive behaviour increases the risk of committing violence towards a partner.
6.1.17 It is important that we remember that domestic abuse is about power and control by one partner over the other. Not all alcoholics are abusive and not everyone who abuses their partner is an alcoholic. Whilst we can say that alcohol is a compounding factor in a person being abusive towards their partner, we must avoid suggesting that it causes it. Alcohol is not the cause of the abuse nor the violence: the desire for power and control is. Alcohol may be offered as a reason, or an excuse, for the abuse but this should not be accepted. Also, the responsibility for his actions should not be removed from the perpetrator on account that he was drunk.
6.1.18 In this particular case, we can see that the perpetrator was violent towards women when he was under the influence of alcohol, but the power that he exerted over his partners was not limited to times when he had taken drugs and alcohol.
6.2 Louise’s vulnerability
6.2.1 Louise had experienced some very stressful experiences in her life. Her second child died, prior to birth, as a result of medical complications. She had a further pregnancy where one of a set of twins died prior to birth.
6.2.2 Both of Louise’s children suffered with medical conditions that required extensive monitoring and frequent admissions to hospital. This caused Louise stress and anxiety.
6.2.3 At the time that Louise met the perpetrator, she had been through a stressful period in her life. She had given up her job and sold her furniture – she had arranged to rent out her house as she and her husband were to make a new family start in Spain. Shortly before they were due to leave, the marriage ended, and Louise stayed in the house with the children.
6.2.4 After her marriage ended, Louise became fairly isolated. She did not have any adult company in the evenings after she had settled the children for the night, and she was lonely.
6.2.5 As she was struggling financially, she advertised for a lodger to assist her finances. As has already been discussed, Louise and the perpetrator very soon began a relationship.
6.2.6 In November 2018, Louise found out that she was pregnant with the perpetrator’s baby. She then experienced a miscarriage at the beginning of December. At the end of December, an ambulance was called as Louise had taken a mixture of a white powder (which was possibly cocaine), 55 painkillers, and a litre of Malibu.
6.3 What barriers prevented Louise from leaving the relationship? What might have helped her to leave?
6.3.1 The review is aware that Louise had been in touch with a former partner of the perpetrator. She had told her that he was violent and had tried to strangle her. Louise said that he had not been violent towards her but that they had arguments and he had been trying to control her. She told her family and friends that she had been told that he ‘was not a nice man’. She said that as he still had access to his children, he must be OK.
6.3.2 As far as the review is aware, Louise and the perpetrator had separated in February 2019, and then they resumed their relationship. Research tells us that, on average, a woman will attempt to leave seven times before finally leaving for good, so we should not be surprised that Louise was not able to extricate herself from this relationship at the first attempt. We must also remember that the perpetrator was a serial perpetrator of domestic abuse and therefore adept at rekindling relationships.
6.3.3 Louise had not been in a relationship with the perpetrator for very long, and the relationship was relatively hidden from those professionals with whom Louise had contact. When Louise did speak to her friends about what was happening, they told her categorically that she should leave him. She was warned that they would break up many times and that he would ‘worm his way back in’. It is possible that Louise then became more secretive about what was happening in the relationship. The review is clear that none of Louise’s family or friends should reproach themselves for what happened – there is only one person responsible for Louise’s death.
6.3.4 There are many reasons why a woman is unable to leave an abusive relationship. It is possible, as discussed earlier, that having tried to separate from the perpetrator, he planned to punish her for this.
Section Seven – Lessons Identified
7.1 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.
7.2 It was noted that Hampshire Constabulary passed the information to Devon and Cornwall Police in a timely and proactive manner.
7.3 That every opportunity to make a routine enquiry about domestic abuse is not taken within the hospital.
7.4 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.
7.5 That Home-Start volunteers would benefit from specialist domestic abuse training, particularly regarding coercive and controlling behaviour.
Section Eight – Recommendations
8.1 ROYAL DEVON AND EXETER HOSPITAL
8.1.1 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.
8.1.2 It is recommended that the current paperwork is updated to include a routine enquiry about domestic abuse on all proformas in the clinics.
8.2 CHILDREN AND FAMILY HEALTH DEVON on behalf of PUBLIC HEALTH NURSING
8.2.1 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.
8.3 CHILDREN’S SOCIAL CARE AND HOME-START
8.3.1 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.
8.4.1 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.
Section Nine – Conclusions
9.1 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.
9.2 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.
9.3 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.
9.4 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.
Appendix One –
Safer Devon Partnership’s 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, HM Prison and Probation Service, 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 included representatives of:
- Devon County Council
- Cabinet Member for Public Health, Communities and Equality
- Programme and Commissioning Manager, Communities (Interim Chair)
- Public Health Programme Manager, Domestic and Sexual Violence and Abuse
- Safer Devon Partnership Manager
- Principal Child and Family Social Worker, Children’s Social Care
- Principal Social Worker (Commissioning), Adult Care and Health
- Devon & Cornwall Police
- Detective Chief Inspector for N.E.W. Devon
- Detective Sergeant from Serious Case Review Team
- Devon Clinical Commissioning Group
- Head of Safeguarding
- HM Prison and Probation Service
- Head of Devon and Torbay
- Exeter Community Safety Partnership
Appendix Two – Terms of Reference
Terms of Reference for the Domestic Homicide Review into the death of Louise
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 in 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.
Gary Goose and Christine Graham
Independent Chair and Overview Author
Appendix Three –
Ongoing Professional Development of Independent Chair and Report Author
3.1 Christine has attended:
- AAFDA Information and Networking Event (November 2019)
- Webinar by Dr Jane Monckton-Smith on the Homicide Timeline (June 2020)
- Ensuring the Family Remains Integral to Your Reviews – Review Consulting (June 2020)
- Domestic Abuse: Mental health, Trauma and Selfcare, Standing Together (July 2020)
- Hidden Homicides, Dr Jane Monckton-Smith, AAFDA (November 2020)
- Suicide and domestic abuse, Buckinghamshire DHR Learning Event (December 2020)
- Attended Hearing Hidden Voices: Older victims of domestic abuse, University of Edinburgh (February 2021)
- Domestic Abuse Related Suicide and Best Practice in Suicide DHRs, AAFDA (April 2021)
- Post-separation Abuse, Lundy Bancroft, SUTDA (April 2021)
- Ensuring family and friends are integral to DHRs, AAFDA (May 2021)
- Learning the Lessons: Non-Homicide Domestic Abuse Related Deaths, Standing Together (June 2021)
- Suspicious Deaths and Stalking, Professor Jane Monckton-Smith, Alice Ruggles Trust Lecture (April 2021)
- Reviewing domestic abuse related suicides and unexplained deaths, AAFDA (May 2021)
- Young people and stalking: Reflections and Focus, Dr Rachel Wheatley, Alice Ruggles Trust Lecture (May 2021)
- AAFDA DHR Chair Refresher Training (August 2021)
3.2 Christine has completed the Homicide Timeline Online Training (Five Modules) led by Professor Jane Monckton-Smith of University of Gloucester.
3.3 Gary and Christine have:
- Attended training on the statutory guidance update (May 2016)
- Undertaken Home Office approved training (April/May 2017)
- Attended Conference on Coercion and Control (Bristol, June 2018)
- Attended AAFDA Learning Event (Bradford, September 2018)
- Attended AAFDA Annual Conference (March 2017, 2018 and 2019)
- Attended Mental Health and Domestic Homicides: A Qualitative Analysis, Standing Together (May 2021)
- Attended AAFDA DHR Chair Refresher Training (August 2021)
 Joined the panel in 2021
 Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews (para 36), Home Office, Dec 2016
 (Women’s Aid Domestic abuse is a gendered crime, n.d.)
 ONS (2018), ‘Domestic abuse: findings from the Crime Survey for England and Wales: year ending March 2018’. https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/domesticabusefindingsfromthecrimesurveyforenglandandwales/yearendingmarch2018#the-long-term-trends-in-domestic-abuse November 2018.
 (Office for National Statistics, Crime Statistics, Focus on Violent Crime and Sexual Offences, 2013/14 Chapter 2: Violent Crime and Sexual Offences – Homicide, n.d.)
 CPS (2018), ‘Violence against women and girls report, 2017-18). September 2018 https://www.cps.gov.uk/sites/default/files/documents/publications/cps-vawg-report-2018.pdf
 Ministry of Justice (2018), ‘Statistics on women and the criminal justice system 2017’. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/759770/women-criminal-justice-system-2017..pdf November 2018.
 UK Femicides 2009-2018, Femicide Census,
 A therapeutic programme which aims to support those (often with complex histories of abuse) who have been diagnosed with Emotionally Unstable Personality Disorder.
 Devon and Cornwall’s Vulnerability Screening Tool
 This is the process by which schools will be informed where children were present at a domestic incident in their homes the day before.
 Green ViSTs will only be reviewed by the Central Safeguarding Team if there are three or more within a three-month period. Otherwise they are appended to the police record of the individual as intelligence so that they can be referred to if necessary.
 A therapeutic programme which aims to support those (often with complex histories of abuse) who have been diagnosed with Emotionally Unstable Personality Disorder.
 Campbell et al., 2007, cited in Domestic Abuse, Homicide and Gender, Monckton-Smith, J., et al., 2014, Palgrave
 Power and Control – Why charming men make dangerous lovers, Sandra Horley CBE, Vermilion, London, 2007
 MoncktonSmith, Jane (2019) Intimate Partner Femicide: using Foucauldian analysis to track an eight stage relationship progression to homicide. Violence Against Women, University of Gloucestershire
 Websdale, N. (1999) Understanding Domestic Homicide. Boston: Northeastern University Press cited in ibid.
 Brennan, D. (2016) Femicide Census. Retrieved March 30, 2018, from http://www.northwalespcc.
gov.uk/Document-Library/Advice/Femicide-Census-Report-2016.pdf cited in https://www.womensaid.ie/download/pdf/jane_monckton_smith_powerpoint_2018_compatibility_mode.pdf
 Bennett L. and Bland P. Substance Abuse and Intimate Partner Violence, National online recourse centre on violence against women, cited in Alcohol, Domestic Abuse and Sexual Assault, 2014, Institute of Alcohol Studies
 McKinney C., et al. (2008) Alcohol Availability and Intimate Partner Violence Among US Couples, cited in Alcohol, Domestic Abuse and Sexual Assault, 2014, Institute of Alcohol Studies
 Galvani S. (May 2010) Supporting families affected by substance misuse and domestic violence, The Tilda Goldberg Centre for Social Work and Social Care, University of Bedfordshire, ADFAM, p5 cited in Alcohol, Domestic Abuse and Sexual Assault, 2014, Institute of Alcohol Studies
 Intimate partner violence and alcohol, World Health Organisation, 2006