Overview Report Executive Summary regarding Jane who died in January 2020
Steve Appleton, Managing Director, Contact Consulting (Oxford) Ltd
Independent Chair and Author
August 2021 / Updated May 2022
A message of condolence
The Domestic Homicide Review Panel wishes to express its condolences to the family and friends of those affected by the events described in this report. The panel hopes that the process will provide some answers to their questions.
- Jane had been in a relationship with Craig for approximately seven or eight months prior to her death. This timing was arrived at based on records relating to a report received by the police in November 2018, when Jane is reported to have ended the relationship and disclosed the length of time she and Craig had been together.
- Jane met Craig through a mutual friend at a BBQ and they started dating after this, She had known Craig for a while as a friend and he seemed to her like nice man but things changed very soon after they got into a relationship.
- Within a couple of weeks Craig had given her the ultimatum of he either moved in or they ended the relationship and kept telling her she didn’t love him he if wasn’t allowed to move in. Jane felt it was too soon and fought to keep him out of the house but he eventually started to stay over more and more and moved himself in
- Craig was controlling of Jane and he wanted her to change how she did everything. He would become violent with her if he didn’t get his own way and would often say to Jane ‘It’s my way or no way’. He didn’t want her to have a relationship with her family and friends and she started to withdraw from them.
- At the time of her death, Jane had been preparing to give evidence in a Crown Court trial relating to offences of sexual assault committed by Craig against her. It is understood that Craig was also facing other charges relating to similar offences committed against other women. The offences against Jane for which Craig was on trial were committed in July 2019.
- About a week prior the incident in July 2019 Jane had ended her relationship with Craig. He had sought emergency accommodation but still had belongings at Jane’s home. On the date of the offence Craig had attended Jane’s home, and while heavily intoxicated, he repeatedly banged on the window of the property. Jane refused to let Craig into her property, but he climbed through an open window and gained entry.
- Jane had called the police, as had a neighbour who had heard the couple arguing. Police arrived and detained Craig. Enquiries revealed that he had pinned her on the sofa, had inappropriately touched her and had made attempts to remove items of her clothing.
- Craig was later released on bail, which he breached a number of times. He was arrested for bail breaches and the Crown Prosecution Service (CPS) authorised a number of charges against him including sexual assault, assault by beating and violence to secure entry. He was remanded in custody to stand trial at in January 2020.
- On the day of her death, Jane was found by attending police officers. She was clearly deceased. There were a number of empty blister packets of prescription medication near her body, and further empty packs were found in the kitchen waste bin.
- No obvious suicide note was located. There was a notepad that contained a list of issues that indicated concerns Jane had in relation to her step-father. None of these issues indicated any form of abusive relationship, nor did it contain any indication of intent by Jane to take her own life.
- Jane’s death clearly coincided with the day she was due to give evidence in Crown Court as a victim of domestic abuse related sexual offences.
- The police concluded that Jane’s death met the criteria for a Domestic Homicide Review as appeared to be either a suicide or unexplained death following domestic abuse.
The DHR process
- 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 (CSP) in Devon meet the statutory requirements for such reviews through Safer Devon Partnership.
- This report was approved by the review panel following a panel discussion of the draft, and a meeting to agree the recommendations and action plan. The aforementioned Domestic Homicide Review (DHR) Executive Group and the CSP Chair prior to its submission to the Home Office subsequently approved it.
- No parallel reviews were undertaken or were in train during the period that the DHR took place.
- The decision to hold the Domestic Homicide Review was taken in September 2020 having decided that the criteria set out within The Act was met. The independent chair and author was appointed through an open tendering process in October 2020.
- The Domestic Homicide Review has been conducted in line with the expectations of the Multi-Agency Statutory Guidance for the Conduct of Domestic Homicide Reviews 2013. This guidance is issued as statutory guidance under section 9(3) of the Domestic Violence, Crime and Adults Act 2004. It has since been updated and was republished in December 2016.
Contributors to the Domestic Homicide Review
- Individual Management Reports (IMRs) were requested from the agencies that had been in contact with or providing services to Jane and Craig. The objective of the IMRs which form the basis for the DHR was to provide as accurate as possible an account of what originally transpired in respect of the incident itself and the details of contact and service provision by agencies with both the subjects of the DHR.
- The IMRs were to review and evaluate this thoroughly, and if necessary, to identify any improvements for future practice. The IMRs have also assessed the changes that have taken place in service provision during the timescale of the review and considered if changes are required to better meet the needs of individuals at risk of or experiencing domestic abuse.
- Four agencies contributed to the review through the submission of Individual Management Reviews and the provision of initial scoping information. Those agencies were:
- Devon and Cornwall Police
- GP surgery – primary care
- Splitz Support Service
- Royal Devon & Exeter NHS Foundation Trust
The agencies identified above each provided IMRs that were reviewed by the panel and used by the panel in reaching their conclusions
Other contributors to the DHR
- The Chair of the Panel spoke with Jane’s mother as part of the review. This conversation took place virtually as a consequence of COVID-19 restrictions. The interview was held in April 2021.
- Jane’s mother has been provided with information about support and advocacy.
- Jane’s mother was provided with a copy of the draft of this overview report, and had the opportunity to comment on and her reflections have been incorporated prior to its finalisation.
The Domestic Homicide Review Panel Members
|Steve Appleton||Managing Director Contact Consulting – Independent Chair|
|Chrissy Stower||Head of Service, Splitz Devon Domestic Abuse Services|
(replacing Chrissy Stower)
|Head of Service, Splitz Devon Domestic Abuse Services|
|Hannah Gethin||Clinical Safeguarding Specialist|
Clinical Commissioning Group
|Helena Riggs||Practice Lead – Adult Safeguarding|
Devon Adult Social Care
|DS Phil Leonard||Detective Sergeant, Devon and Cornwall Police|
|DCI Nicola Seager||Detective Chief Inspector Devon and Cornwall Police|
|Dave Whelan||Community Safety Coordinator, Community Safety Partnership|
|Annette Emanuel||Senior Safeguarding Nurse Specialist, Royal Devon & Exeter NHS Foundation Trust|
The members of the panel were independent and had no prior contact with the subjects of the Domestic Homicide Review or knowledge of the case.
The Overview Report author
- The independent Chair of the panel and author of the DHR Overview Report is Steve Appleton. Steve trained as a social worker and specialised in mental health, working as an Approved Social Worker. During that time, he worked with victims of domestic abuse as part of his social work practice. He has held operational and strategic development posts in local authorities and the NHS. Before working independently, he was a senior manager for an English Strategic Health Authority covering Thames Valley and central southern England. He has a particular responsibility for mental health, learning disability, substance misuse and offender health.
- Steve is entirely independent and has had no previous involvement with the subjects of the DHR. He has considerable experience in health and social care and has worked with a wide range of NHS organisations, local authorities and third sector agencies. At the time of writing he was managing director of his own limited company, a specialist health and social care consultancy.
- Steve has led reviews into a number of high profile serious untoward incidents particularly in relation to mental health homicide, safeguarding of vulnerable adults, investigations into professional misconduct by staff and has chaired a Serious Case Review into an infant homicide. He has chaired and written a number of DHRs for local authority community safety partnerships across the country. He has completed the DHR Chair training modules and retains an up to date knowledge of current legislation
- Steve as independent chair and author has never been employed by any of the agencies concerned with this review and has no personal connection to any of the people involved in the case. He has undertaken one previous DHR for Safer Devon.
Terms of Reference
- Examine the events leading up to the incident, including a chronology of the events in question.
- Review the interventions, care and treatment and or support provided. Consider whether the work undertaken by services in this case was consistent with each organisation’s professional standards and domestic abuse policy, procedures and protocols including Safeguarding Adults.
- Review the communication between agencies, services, friends and family including the transfer of relevant information to inform risk assessment and management and the care and service delivery of all the agencies involved.
- Identify any care or service delivery issues, alongside factors that might have contributed to the incident.
- Examine how organisations adhered to their own local policies and procedures and ensure adherence to national good practice.
- Review documentation and recording of key information, including assessments, risk assessments, care plans and management plans.
- Review the impact (or otherwise) of the victims planned appearance as a witness in a trial relating to domestic abuse previously perpetrated towards her by the alleged perpetrator in this case and the way in which agencies responded to their needs.
- Examine whether services and agencies ensured the welfare of any adults at risk, whether services took account of the wishes and views of members of the family in decision making and how this was done and if thresholds for intervention were appropriately set and correctly applied in this case.
- Whether practices by all agencies were sensitive to the gender, age, disability, ethnic, cultural, linguistic and religious identity of both the individuals who are subjects of the review and whether any additional needs on the part of either were explored, shared appropriately and recorded.
- Whether organisations were subject to organisational change and if so, did it have any impact over the period covered by the DHR. Had it been communicated well enough between partners and whether that impacted in any way on partnership agencies’ ability to respond effectively.
- Identifying and highlighting any examples of good practice so that these may be used to inform service improvement and development.
Key findings and conclusions
Having reviewed and analysed the information contained within the IMRs and having considered the chronology of events and the information provided, the panel has drawn the following conclusions:
- Jane had a short relationship with Craig, but it was one that was characterised by his controlling and coercive behaviour. Jane’s decision to end the relationship was not one that Craig reacted to positively and ultimately this led to his assault upon her in July 2019.
- Craig sought to move in with Jane very soon after their relationship started. While such a swift desire to co-habit is not necessarily unusual, research does point to this being a marker for the potential of domestic abuse. Dr Jane Monkton Smith’s research on the eight stages homicide timeline indicates that where a ‘romance develops quickly into a serious relationship’ this should be considered a factor on the timeline to domestic abuse and homicide.
- Evidence from research and surveys of victims indicates that the risk of further violence and harm actually increases at the point at which a victim leaves a perpetrator. A study of 200 women’s experiences of domestic abuse commissioned by Women’s Aid (Humphreys & Thiara, 2002) found that 76% of separated women had experienced post-separation verbal and emotional abuse and violence, including: 41% subjected to serious threats towards themselves or their children; 23% subjected to physical violence; 6% subjected to sexual violence; and 36% stated that this violence was ongoing. There is evidence that the risk of domestic homicide is increased post-separation.
- Canadian research has indicated that 40% of women and 32% of men who were in a former violent marriage or common-law relationship experienced violence post-separation. Research demonstrates that the risk of lethal violence is particularly high following parental separation, especially within the first few months .
- More recent research in 2017 published in the Journal of Interpersonal Violence found that separated women were more likely than non-separated women to be victims of interpersonal violence in most years from 1995 to 2010.
- Taking the evidence into account indicates that Jane was at higher risk of domestic abuse and violence due to the fact that she had recently ended her relationship with Craig.
- Jane was coping with a long-term back condition. This had a direct impact on her life, both in terms of her ability to travel to appointments, but most significantly it meant constant and debilitating pain. She underwent treatments that were intended to alleviate that pain. It is however clear from the information reviewed, that the level of pain remained high and it was constant. There is little doubt that experiencing this level of pain and the other impacts it brought had a direct and adverse impact on Jane’s mental health and wellbeing.
- Jane had a recorded history of depression, suicidal ideation and of overdose. It is striking that this history and those incidents of self-harm are recorded, but there is very little further exploration of the antecedents and responses to them. This represents a significant gap in the knowledge about Jane that was available to professionals. Had that information been given greater focus, it is likely that it would have informed a clearer view of her risk of future overdose and suicidal intent.
- There are examples of professionals not communicating as effectively as they could have done. In particular, when the Royal Devon & Exeter Hospital (RD&E) Occupational Therapist referred Jane to the Improving Access to Psychological Therapies (IAPT) service, this information was not shared with colleagues in primary care at the GP practice. It is accepted good practice that where the person remains the responsibility of primary care, as Jane was, that they would review and establish if access to the service had been successful and where necessary offer support to overcome any barriers to access. Because the GP practice was not aware of the referral to IAPT, professionals at the practice could not do this. While it is the view of the DHR panel that this did not directly influence the outcome, it is an area of practice that requires further improvement.
- The GP practice was aware of Jane’s mental health history and the incidence of depression. However, there is little evidence that this was discussed or explored with her in any detail. It is understandable that the focus of the consultations was on her physical issues, notably her back condition and the resulting pain management. It would have been helpful for Jane’s mental health, including the impact of her physical condition on her mental health to have been considered more fully.
- The information reviewed suggests that in the period covered by the DHR, Jane’s mental health did not deteriorate to a point where specialist mental health services would have been appropriate or necessary. In the past this was not the case, but her engagement with those services was sporadic and she was ambivalent about accessing the support the Community Mental health Team (CMHT) could provide. Having said this it may have been helpful for the GP practice to have sought advice and guidance about Jane and her management in the context of the impact of her physical condition on her mental health and levels of anxiety.
- Two-thirds of people with a common mental health problem also have a long-term physical health problem. One of the most common types of long-term pain is back pain. Many people with back pain find it difficult to engage in normal activities and can experience symptoms of depression and anxiety. Research has shown that clinicians should be aware of potentially high rates of emotional distress syndromes in chronic low-back pain and enlist mental health professionals to help maximize treatment outcomes.
- Jane’s mental health does appear to have deteriorated in September 2019. Although the GP practice was aware that Jane was experiencing suicidal thoughts, their attempts to contact her and follow up were not responded to. That follow up was restricted to phone calls. Other options, including writing to her or placing a reminder on her notes to ensure that any clinician in contact with her could raise the issue were not undertaken. The DHR panel is aware that the GP practice has understood that this is an area for improvement and one they are addressing.
- The Witness Care Unit (WCU) worked effectively to support Jane and demonstrated practice that was of a high standard. They took clear steps to support her in preparing to give evidence in the trial and made specific arrangements to make this easier, including hotel booking and transportation as well as the plans for a video link.
- Although the WCU worked effectively, it is less evident that they, or other agencies, sufficiently considered the emotional and mental stress that was placed on Jane in respect of preparing to give evidence against Craig. It would have been helpful for other agencies to have been alerted to the fact that Jane had potential vulnerabilities so that a more holistic and multi-agency plan of support could have been put in place for her.
- The contact from RD&E was of a good standard and there is evidence throughout the IMR that the professionals involved in Jane’s care and treatment were compassionate and were person centred in their approach.
- It was though the Pain Clinic that Jane was referred for IAPT services. This referral was not notified to the GP Practice. It is clear that there was recognition of Jane’s mental health issues and her previous suicidal intent. There is evidence that this was recognised and discussed but it is not evident that this was given any significant focus or consideration.
- For the majority of the period covered by the DHR, agencies were unaware of any issues of domestic abuse in relation to Jane. Her relationship with Craig was relatively short in duration and the only incidence known to all was the one in July 2019. Other incidents from 2018 were not widely known about, other than by Devon & Cornwall Police (DCP).
- Currently RD&E staff do not have access to a patient’s mental health notes. In situations like this staff are reliant on the patient to inform them of any mental health services that they are involved with. RD&E staff could have contacted Devon Partnership Trust Psychiatric Liaison Team or the GP to find out contact details of any mental health professionals involved. They may have been able to work together to encourage Jane to attend appointments. If RD&E staff were able to access relevant mental health notes in future it would help them identify risk factors related to an individual’s mental health.
- Splitz had the most contact with Jane. In particular the Independent Domestic Abuse Advisor (IDVA) involved had numerous contacts and provided a high level of support and advice. It is the conclusion of the DHR panel that the IDVA displayed a high level of professionalism and commitment, and that she exhibited excellent practice throughout her work with Jane.
- The IDVA displayed good communication with other agencies, most notably with DCP but also with housing agencies while exploring options for Jane to move to another area.
- The IDVA provided emotional support and took care to follow up messages and phone calls. She undertook additional work to assist with the preparation of the VPS and to attend court to support Jane.
- The IDVA sought supervision and advice from her manager appropriately.
- The work of the IDVA and Splitz demonstrated a high degree of focus on Jane as a victim of domestic abuse and sexual violence. There was a clear person centred approach, which was clearly and accurately recorded. They also kept Jane’s case open when it would usually have been closed in order to ensure support was available and was consistent.
- Overall the conclusion of the DHR panel is that the intervention of Splitz was of a high standard.
- DCP did respond to Jane in an appropriate and swift way. In doing so they took care to ensure assessment of her risk using the DASH process. Recording of these assessments was accurate and timely and led to a referral to MARAC. This was good practice.
- The decisions taken in relation to Craig and the granting of bail with conditions were, in the judgment of the DHR panel, appropriate and proportionate. It demonstrated a thorough understanding of the legislative frameworks and how they could best be used to respond.
- The use of the DVDS was another example of good practice. It is the conclusion of the DHR panel that it was appropriate to make the disclosure of Craig’s history to Jane. This was done after careful consideration and demonstrated a wish to ensure she could take informed decisions.
- DCP did experience some challenges in engaging Jane, and she sometimes failed to respond to calls or appointments. There is evidence that they sought to follow up with her and on most occasions were successful in doing so.
- The one deficit highlighted from the DHR process is that failure to complete the Safeguarding form when Craig was remanded to prison. This meant that the prison was unaware that he was prohibited from contacting Jane, and as a result he was able to write to her. There was a lack of understanding and an inconsistent approach to the use of the Safeguarding form. This is now being addressed by DCP.
- The co-ordination between the Officer in Charge (OIC), Domestic Abuse Officer (DAO) and the IDVA was effective and demonstrated good information sharing and a joined up approach.
- The use of routine enquiry about domestic abuse is largely absent, although there is evidence that training and awareness through IRIS had been undertaken in primary care. The information reviewed indicates that there were no specific examples where Jane’s presentation might have promoted routine enquiry.
- There is little consideration of the impact of the use of prescription medication in the contacts between Jane and health professionals. The only issue of significance was when she requested additional medication in the run up to Christmas 2019. The request was denied because she only recently had a prescription approved. Given her mental health issues and history of overdose it is a cause of concern that greater prominence was not given to the use of highly controlled prescription medication and the risks associated when used by someone with a history of overdose.
- There has been a dramatic increase in fatal poisonings involving opioid analgesics globally. Research has shown that comorbid conditions that pose risks for suicide, especially depression, are prevalent in people living with chronic pain. The true numbers of failed attempts and successful suicides are unknown and may never be determined. Yet risk factors for suicidal ideation are so high in this population that it must be assumed that some proportion of those who die of drug overdoses might have intended to end their lives, not just temporarily relieve their pain.
- The degree to which Jane’s mental health was considered as a potential risk in relation to her overall wellbeing did not feature strongly in the information provided to the DHR panel. It is our conclusion that Jane did experience anxiety and low mood, and that much of this was related to her back pain. The extent to which her anxiety was heightened by the prospect of giving evidence cannot be determined.
- There is no clear evidence that demonstrates that Jane received any support related to the sexual assault committed against her.
- It is by no means certain that the circumstances of Jane’s death were linked to her chronic pain, but it clearly had a direct impact on her mental health.
- It is clear that Jane’s experience in July 2019 was traumatic. She coped with a range of challenges in her life, but the evidence indicates that was at times ambivalent about accepting or engaging with support services, although the IDVA was successful in building a good working relationship with her.
- Her case highlights issues relating to support to victims of domestic abuse, both in terms of the impact of the abuse itself but also giving evidence, and the need to identify and respond to mental and physical health concerns in a co-ordinated and holistic way.
The Domestic Homicide Review Panel made the following recommendations arising from the review. They were developed in direct response to the key findings and conclusions. The full Overview Report describes the linkages between the findings and recommendations in more detail.
- The Court Service locally should undertake a process to review the support that is available to victims of domestic abuse who give evidence in trials against their perpetrators. This process should include those working with the police Witness Care Unit within DCP. It should seek assurance that good practice is consistently applied.
- The Clinical Commissioning Group should share the example of good process and practice in the management of patients who are prescribed highly controlled analgesic medication where there are mental health issues with all GP practices in Devon. Sharing this positive example will ensure that learning is disseminated widely.
- The Clinical Commissioning Group to remind all GP practices and NHS secondary care services the importance of the process for follow-up of patients who do not attend appointments and that they are used consistently.
- Devon and Cornwall Police should continue to progress their work to ensure improved understanding of the use of the Safeguarding process and forms in relation to raising or advising of safeguarding concerns relating to individuals detained within Her Majesty’s Prison Service. DCP may also consider how to ensure greater consistency in the use and completion of the form locally, but also whether there is merit in taking this issue to national police forums for further discussion and development.
- The Safer Devon Partnership should co-ordinate its members to consider how the good practice identified in this DHR can be disseminated locally to improve local practice. It should also undertake a focused piece of work to raise awareness of the risks posed in relation to domestic abuse and recent separation of partners.