Domestic Homicide Review Case 23 – Executive Summary

Arising from the death of “Neil” – December 2020 

Safer Devon Partnership on behalf of East and Mid Devon Community Safety Partnership November 2023

Introduction

  • This is a summary of the Safer Devon Partnership domestic homicide review (DHR) into the death of Neil, undertaken on behalf of East and Mid Devon Community Safety Partnership, where he lived in Town H. Pseudonyms are used for the victim, perpetrator and their families in accordance with Home Office guidance. The Review Panel offer condolences to all those affected by this tragedy. 
  • Neil, aged 54, was killed in December 2020, at his home, by Tracy, then aged 51. Both were of White British ethnicity. She was his ex-wife and at the time of the homicide both live-in partner and paid carer. In February 2022 Tracy was convicted of manslaughter and sentenced to eight years in prison.  Her subsequent appeal on the length of the sentence was rejected. 
  • As required by law, Safer Devon Partnership set up a DHR and asked local agencies to check whether either Neil or Tracy had contacted them. Nine agencies confirmed contact with the victim and/or perpetrator and provided information for the Review. These were Devon and Cornwall Police; Devon County Council; Devon Doctors (out of hours service); Devon Partnership NHS Trust; the GP Practice[1] at which both Neil and Tracy were registered in 2020; Rethink Mental Illness; Royal Devon University Healthcare NHS Foundation Trust; Sanctuary Housing; South West Ambulance Services NHS Trust. Those in bold had significant involvement and were asked to prepare an Individual Management Review (IMR): an internal report whose author was not involved in the events.
  • The insights of people who had known Neil and Tracy were invited. The Panel appreciates the contribution of their daughter and of Neil’s mother and stepdaughter who met the Independent Chair of the DHR, facilitated by Victim Support. Other relatives and friends were contacted but chose not to take part. An anonymised summary of relevant evidence they had given in the criminal investigation was shared with the Panel by the police. 
  • The Panel drew on information from Together Devon (Drug and Alcohol Service), FearLess Domestic Abuse Service (known as Splitz at the time of the homicide) and East Devon District Council about services available locally.  It also had access to the judge’s remarks on sentencing.
  • The DHR Panel met five times and also conferred by electronic means. Membership was as shown in Table 1. The Panel was supported by the Safer Devon Partnership Co-ordinator for Domestic Homicide Reviews, who is contactable at Devon County Council. 

Table 1: Membership of the Review Panel

Agency Representatives  
n/a Independent Chair REDACTED
Devon and Cornwall Police Detective Chief Inspector and Detective Sergeant, Criminal Case Review Unit Lee Nattrass
Phil Leonard
NHS Devon2Interpersonal Violence and Trauma Lead Collette Eaton-Harris
Devon County Council Service Development Manager (Domestic Abuse and Homicide) Care Direct Plus Centre Manager (North Devon) Simon Milner
Wayne Mizen
Devon Partnership Trust Deputy Director, Safeguarding & Public Protection Senior Safeguarding Manager Anthony Vaughan
East Devon District Council Community Safety Manager Dave Whelan
Royal Devon University Hospitals Trust Senior Safeguarding Nurse Specialist Alison Roberts
FearLess (formerly Splitz) Deputy Team Manager Julie Reeves
Together Devon Head of Service and Development Joni Nash
  • The Panel’s Independent Chair has relevant experience including as Chair of previous domestic homicide reviews. She has a past career in public sector regulation and has been a trustee of a national charity providing care and housing support. She has no other connection with Safer Devon Partnership, has not been employed by any of the agencies concerned with this review, and has no personal connection to people involved in the case. 
  • No members of the Panel had direct involvement with the events or decisions covered by the review, or management responsibility for staff whose actions are described. The Review Panel operated collaboratively to reach agreed conclusions. These have been discussed with the family, whose views have been taken into account, agreed by the Chairs of the DHR Executive Group of the Safer Devon Partnership and East and Mid Devon Community Safety Partnership and are subject to quality assurance by the Home Office. 
  • The review considers agencies’ involvement with Neil and Tracy from late 2014 to 2020. This covers the period when they resumed a relationship, having had little contact since their divorce in 1993. The Panel took account of protected characteristics under the Equality Act 2010, recognising disability as a relevant factor in both parties’ access to and experience of services, and sex as a factor which may have affected perception of Neil, a man, as a potential victim of abuse.
  • The terms of reference reflect Home Office guidance on DHRs and the particular context for this homicide. In summary they were to invite the involvement of family and friends, review agencies’ contact with the victim and perpetrator for opportunities to identify or prevent domestic abuse, and report on lessons for improving services. 
  • The Panel agreed, in the light of initial information available, that the Review should cover how Tracy being Neil’s Personal Assistant may have affected the risk of domestic abuse and agencies’ opportunities to recognise and address it. As Neil was a disabled person with capacity to make decisions, he was Tracy’s employer, with Devon County Council responsible for assessing his level of need and authorising funding available for him to pay for assistance under the national Direct Payments scheme. 

Findings

  1. Neil, a qualified welder, had lived in Town H since his teens. Ill health, including chronic pain, had prevented him from working since around 2002. His marriage to Tracy was brief (1990 to 1992) and there is no evidence indicating domestic abuse during this or his second marriage which ended in 2012. Neil and Tracy’s two children, brought up by his parents, who lived nearby, had close contact with him and his stepdaughter (of similar age), but none with Tracy.   
  2. Tracy had a troubled background prior to meeting Neil and after their divorce. Although no offences were successfully prosecuted, it is likely that she had experienced sexual violence and domestic abuse from other men. Her health records show a history of post-traumatic stress disorder, anxiety and depression. She had also used illicit drugs and had taken overdoses of prescribed and illicit drugs. In November 2014 she was referred to the MARAC[2] by the hospital Emergency Department after presenting in a disturbed state and naming a former partner as the perpetrator of unspecified domestic abuse. She declined support on domestic abuse subsequently offered by agencies.   
  3. Tracy and Neil reconnected in late 2014 – a step probably initiated by her but welcomed by him. Over the six years until she killed him, their relationship moved from two decades apart to his depending on her for assistance with daily living, and accepting her living in his home, managing his finances and representing his views to agencies. At some point (probably by early 2015) she left her previous address and lived with Neil, in separate bedrooms, in the terraced house he rented from social landlord Sanctuary Housing. For at least the final three years he paid her as a Personal Assistant using his Direct Payment disability benefit. 
  4. Payment of household members is not normally allowed under this scheme. Care Direct Plus (a section of Devon County Council’s Adult Social Care) who authorised this arrangement were given Tracy’s previous address and told that the relationship was only professional. Other agencies understood them to share an address, and generally saw them as a couple in a personal relationship, sometimes with Tracy viewed as an informal carer, and sometimes with Neil seen as a supportive partner to her. 
  5. Between 2015 and 2020 the couple had a series of contacts with the health service, police and Sanctuary Housing. These arose from their physical and mental health conditions, occasional episodes of alcohol-related anti-social behaviour and missed rent payments. While these agencies generally responded in line with policy and exchanged information appropriately, the Review identified some gaps in communication and recording and missed opportunities for referral for help with substance misuse. 
  6. Two incidents in which the couple were arguing noisily while both were under the influence of alcohol led to police completing a DASH[3] risk assessment for Tracy. In 2015, graded Low risk, she cut herself while breaking into Neil’s home after they had locked themselves out. In 2018, graded Medium risk, Tracy gave an inconsistent account indicating Neil might have put his hands on her throat. She accepted the police offer to take her to her sister’s home for the night but declined further contact and support.  Neil did not disclose any abuse by Tracy or her role in his care, so no risk assessment was undertaken for him.  
  7. When interviewed by police during the 2015 incident, Tracy disclosed a historic sexual assault from before she met Neil. This led to a police investigation and, in 2017, a trial in which the accused was acquitted. During this process Tracy had regular contact with a Police Sexual Offences Officer. She was offered support from an ISVA[4] and made limited use of this, just to deal with anxiety about giving evidence.  
  8. Of all the problems seen by other agencies, the only aspect that Care Direct Plus was aware of was Neil’s physical disability, which had led to their involvement with him since 2008. Despite a policy of annual reviews of people on the Direct Payments scheme, they had personal contact with Neil only at two periods after Tracy returned to his life: in 2017 when the increased package of care through which he paid her was agreed, and in late 2020 when trying to carry out an overdue review of that care, which was interrupted by the homicide. While Care Direct Plus staff saw no indication of domestic abuse or difficulties in the relationship in 2017, there were several factors that should have prompted earlier follow up, including indications that Tracy was helping Neil manage finance, enquiry about the implications if she lived with him and, in 2020, lack of response to attempted contact. 
  9. The homicide occurred shortly after Christmas 2020, when Covid restrictions applied.  Care Direct Plus had, in mid-December, succeeded in conducting a telephone assessment. This followed a pattern also seen in health service contacts, of Tracy speaking and Neil confirming his presence and consent. It resulted in referral to another team to look at the need for handrails. The homicide – a single fatal blow with a kitchen knife – occurred before that home visit was due, on an evening when both Tracy and Neil had been drinking heavily. Tracy had recorded a conversation with Neil about their relationship, which includes aggression towards him. After this she phoned her sister, again recording the conversation, leaving the phone connection live while the stabbing occurred. Evidence from this and the scene established that the blow was not struck in self-defence.
  10. According to friends and family, Neil was not aggressive or violent and towards Tracy. They described her as often being under the influence of alcohol and verbally aggressive and abusive towards Neil, belittling him and on occasion physically abusive. Neil continued to tell relatives that he was happy with Tracy up to the end of his life. Family and friends describe him as kind and trusting, and also a man with pride who would not want to admit to being a victim of any form of abuse.

Conclusions

  1. Neil was the victim of domestic abuse from Tracy, not only in the killing, but previous verbal, physical, and probably financial abuse. She had a significant degree of control over his life: living in his home; understood by friends and health services to be his partner; being the primary carer employed through his disability benefits; speaking on his behalf on health, social care and housing; trusted by him to manage money and appointments. Despite this, there is no indication that he wanted to separate from her. The barriers to seeking help which apply to any victim of control were strengthened by his disabilities, gender and the impact of the Covid pandemic on social contact and agency capacity. 
  2. With hindsight, Tracy’s relationship to Neil could be interpreted as ‘an intentional pattern of behaviour which takes place over time, in order for one individual to exert power, control or coercion over another’. (Controlling or Coercive Behaviour: Statutory Guidance Framework, 2023). Her actions included repeated verbal abuse and physical intimidation, and she had significant control over his finances and means of communication. It is not possible to be sure whether Tracy ever experienced physical assault by Neil, as she alleged in her trial defence. She had sufficient knowledge of support services and freedom in communication and movement to report this. Several aspects of Tracy’s relationship with Neil in the period covered by this review fit patterns of control that have been seen in other domestic homicides. These include the rapid (re)start, her management of what agencies knew, increasing control of communications and finance, escalation in verbal abuse as circumstances changed, and (cited by the judge in sentencing) misrepresentation of the victim after death. 
  3. Action by agencies in 2020 could not have prevented the homicide unless Neil had sought help to change his situation. In earlier years, particularly between 2017 and early 2020, agencies, collectively, had information that could have prompted more attention to the nature of the relationship and its risks and shown the importance of encouraging Neil to speak for himself. Unconscious bias may have inhibited recognition of a male as a potential victim of abuse by a female ‘carer’. Services were available that would have offered help in respect of both domestic abuse and substance misuse. However, as by choice he did not own a mobile phone and had restricted mobility, Neil had little opportunity to see publicity for them. His family, although increasingly concerned at Tracy’s control over him, did not know that help on domestic abuse was available for men. 
  4.  Lack of professional curiosity, incomplete records, and Tracy’s deceit meant that no agency saw harm sufficiently serious to trigger a safeguarding review and so get the full picture. Her ambiguous role as partner-carer / paid personal assistant / ex-wife was accepted with little question by agencies in the form presented to each. While all have policies that recognise domestic abuse by women on male victims, it seems more likely someone would have recognised the pattern of control had the genders been reversed. 
  5. The Review’s analysis of agencies’ interactions with Neil and Tracy, drew overall lessons spanning specific points detailed in the fuller Overview Report. 
    • Professional curiosity is important in all roles to enable professionals to question and challenge the information they receive, identify concerns, and make connections to enable a greater understanding of a person’s situation.  
    • The Direct Payments system for personal care, in rightly giving choice and responsibility to the person needing assistance, inevitably leaves risk of abuse by a personal assistant. The rules which prevent a partner or household member being employed as an assistant without special agreement are easily avoided, as in this case, since address checking is the responsibility of the person receiving care. Care Direct staff did not have sufficient understanding of the nature of coercive control to identify signs of such abuse. 
    • While control within domestic abuse is increasingly recognised, research into signs that men are victims of it, and into culturally acceptable ways to help them recognise and disclose it, is not yet well developed. Moreover, while female paid or unpaid care of men with disabilities is a common pattern, the potential for the woman to have abusive levels of control does not fit the standard picture of either domestic abuse or carer abuse. With 1 in 30 men experiencing domestic abuse each year, it is important to find ways to raise awareness of the risk and of the availability of help.

Lessons learned and recommendations.

  1. Lessons from this tragedy have already been partially addressed through action within agencies. Others are covered in the recommendations that follow. Action already taken includes:
    • Tighter processes within Care Direct Plus for verifying the identity of a personal assistant and authorising cases where an assistant lives with the disabled person. 
    • Staff within Care Direct Plus and the GP Practice reflecting with colleagues on personal learning from this case in relation to professional curiosity and record keeping. 
    • Staff at Royal Devon University Hospitals Trust making use of an on-site Independent Domestic Violence Advisor to give them advice and support patients. 
    • Sanctuary Housing adoption of a new domestic abuse policy and extended staff training on domestic abuse and anti-social behaviour.
  2. Lessons are also being addressed through current developments:
    • Devon County Council is introducing more thorough training on domestic abuse which will be mandatory for staff in Adult Social Care including Care Direct Plus. This includes emotional and financial abuse, indicators of coercive control, and a case study of potential abuse of a vulnerable male by a carer. 
    • NHS Devon is rolling out a programme of training and support for GP practices on responding to interpersonal trauma, and the GP Practice attended by Neil is proactive in booking this. 
    • Domestic abuse service FearLess designed their new website to emphasise the all-inclusive nature of the service, recognising that domestic abuse can affect anyone. Their plan for 2023 communications includes specific periods of heightened awareness for certain groups including men. FearLess will ensure their planned myth busting on social media includes specific awareness raising that domestic abuse impacts both men and women.
    • Royal Devon University Hospitals Trust plans, as part of an upgrade of its patient record system, to send automatic reminders to staff who miss domestic abuse screening questions without noting the reason. 

The Review recommends the following further actions, which are developed in more detail in a separate Action Plan. 

R1 When capacity in Devon CC prevents undertaking annual review of Direct Payments clients in accordance with the Care Act 2014, follow a clear process for prioritizing reviews and monitor the impact.

R2 Review Together Devon’s information about the referral process for drug and alcohol services, and the accessibility of that information, and redistribute this to partner agencies.  

R3 Ensure that Devon Partnership Trust initial assessments clearly record how abuse was explored. 

R4 Strengthen messaging to GP Practice staff about safeguarding and risk. 

R5 Extend domestic abuse training within Sanctuary Housing to more staff groups. 

R6 Increase confidence of staff at pre-operative clinics, including those for men’s health specialties, in asking questions related to domestic abuse. 


[1] Not named to anonymise location of homicide. While Neil was a long term patient at this practice, Tracy transferred to it from a nearby practice in 2018. 

[2] Multi Agency Risk Assessment Conference

[3] Domestic Abuse Stalking and Harassment

[4] ISVA: Independent Sexual Violence Advisor