Domestic Homicide Review Case 23 – Overview

Arising from the death of “Neil” – December 2020

Safer Devon Partnership on behalf of East and Mid Devon community safety partnership November 2023


  1. The Domestic Homicide Review Panel offers condolences to the family and friends of Neil and others affected by the events described in this report. (As expected under Home Office guidance, all personal names in this report are pseudonyms.)


  1. This report of a domestic homicide review examines agency responses and support given to Neil, a resident of East Devon, prior to his death in December 2020. The review takes a holistic approach to identify ways to make the future safer.
  2. Neil, aged 54, was fatally stabbed by Tracy, then aged 51, who lived with him at Address A. She was convicted of his manslaughter in February 2022. As she was his ex-wife and current partner this was a domestic homicide under the terms of the Domestic Violence, Crime and Victims Act (2004). Both were of White British ethnicity. Neil’s physical disabilities, which limited his mobility, entitled him to funding for personal assistance under the Direct Payments scheme. Tracy had been paid as his personal assistant since 2017. 
  3. The review considers agencies’ involvement with Neil and Tracy from 2015 to 2020. This covers the period when they resumed some form of relationship, having had little contact since their divorce in 1993. Relevant information available about their earlier history and other relationships has also been taken into account.
  4. The key purpose of domestic homicide reviews is to enable lessons to be learned from homicides where a person is killed as a result of domestic violence and abuse. For these lessons to be learned as widely and thoroughly as possible, professionals need to be able to understand fully what happened in each homicide, and most importantly, what needs to change in order to reduce the risk of such tragedies happening in the future.

Confidentiality and timescale

  1. This Overview Report and the accompanying Executive Summary have been approved for publication following quality assurance by the Home Office. Documents used in evidence remain confidential. 
  2. This review began in April 2021. A draft report was submitted to the Home Office for quality assurance in March 2023.  Feedback was received in October 2023 and has been taken into account in this final version. National guidance says that the overview report should be completed, where possible, within six months of the commencement of the review. This was not possible in this case, as the trial did not take place until February 2022, and police requested aspects of the Review be postponed until after that. 
  3. The report is being disseminated to multi-agency partnerships responsible for reducing domestic abuse, individual agencies and Neil’s family as described in Appendix C. 

Terms of Reference

  1. The agreed terms of reference reflect Home Office guidance on domestic homicide reviews and set the purposes of the review as below.
    • Examine the events leading up to the death.
    • Review the interventions, care and treatment 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.
    • Examine whether and how services and agencies ensured the welfare of any adults at risk, and any care or service delivery issues that might have contributed to the death.
    • Review documentation and recording of key information, including assessments, risk assessments, care plans and management plans.
    • Consider whether organisations were subject to organisational change and if so, whether communication of changes affected on partners agencies’ ability to respond effectively.
    • Identify examples of good practice to inform service improvement and development.
  2. The Panel agreed, in the light of the initial information available, that the Review should cover how Tracy being Neil’s personal assistant paid under the Direct Payments scheme may have affected the risk of domestic abuse and agencies’ opportunities to recognise and address it.


Decision to undertake a review

  1. In Devon an Executive Group accountable to Safer Devon Partnership oversees the response to deaths potentially requiring a domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act (2004). Through a locally agreed protocol the Community Safety Partnerships in Devon meet the requirements of the Act through Safer Devon Partnership. Membership of the Executive Group is listed in Appendix A.  
  2. Devon & Cornwall Police referred the death of Neil to Safer Devon Partnership as a potential domestic homicide on 29th December 2020. In line with the protocol, the Domestic Homicide Review Co-ordinator for Safer Devon Partnership then asked agencies to check records of their contacts with Neil and Tracy. In the light of a summary of information compiled, the Executive Group agreed to initiate a Domestic Homicide Review and appointed the Independent Chair. 

Evidence considered

  1. The following agencies provided detailed information for the Review, such as a chronology or case notes. Those shown in bold were also asked to prepare an Individual Management Review (IMR), which is an internal report whose author was not involved in the events. Further information on the Individual Management Reviews received is given in Appendix B. 
    • Devon and Cornwall Police
    • Devon County Council
    • Devon Doctors (out of hours service)
    • Devon Partnership NHS TrustPractice P1 (GP practice for both Neil and Tracy in 2020)
    • Rethink Mental Illness
    • Royal Devon University Healthcare NHS Foundation Trust
    • Sanctuary Housing
    • South West Ambulance Services NHS Trust.
  2. The following agencies reported that they had no relevant contact with either Neil or Tracy: CAFCASS, Devon Rape Crisis & Sexual Assault Service, East Devon District Council, National Probation Service, South Devon & Torbay Hospital, Splitz Domestic Abuse Support Service, Together Drug & Alcohol Services.
  3. Additional sources of evidence were as follows.
    • The insights of people who had known Neil and Tracy were sought as discussed below.
    • Splitz provided a briefing on services for male victims of domestic abuse, East Devon DC on activity to raise awareness of domestic abuse within the district, and Together Drug & Alcohol Services on the substance misuse services available locally during the relevant period. 
    • The Panel had access to the transcript of the judge’s remarks on sentencing and to information about Neil’s disability benefits held by the Department for Work and Pensions. 

Involvement of family and friends

  1. Safer Devon Partnership recognises that the quality and accuracy of domestic homicide reviews can be significantly enhanced by family, friends and wider community involvement, and that families should be given the opportunity to be integral to reviews. Such participation is voluntary for those involved, and Safer Devon Partnership seeks to provide appropriate support and a choice of means of contact. 
  2. Neil and Tracy married, and their daughter Alice was born, in 1990. Their son was born in 1992. Within a year the couple had split up, with Neil and the children moving in with his parents, who were also in Town H.  In 2004 he married Susan, who already had a daughter, Jemma, close in age to Alice. While Neil’s children remained with their grandparents, the two households were close as they grew up. The second marriage ended in 2014, by which time Susan had already moved out. Tracy resumed contact with Neil and by 2015 was living with him. Neil’s children and stepdaughter remained in regular contact with him until his death, as did his mother.  She, Alice and Jemma lived in Town H and Neil’s son elsewhere in Devon. 
  3. Tracy was not involved with the upbringing of Alice or Neil’s son, or in contact with them as adults until 2014. She had another daughter, Molly, born in 1996, who lives in Town H, and other partners including, to around 2013, Gary.  She kept in touch with her sister in Exeter. 
  4. The Panel appreciates the contribution of Alice, Jemma and Neil’s mother who offered their insights to assist the Review, assisted by Victim Support. This was helpful in identifying lessons from the tragedy. Other relatives and friends were invited to share their views but declined. The police representative on the panel provided an anonymised summary of perceptions of the relationship between Neil and Tracy presented in evidence from relatives or friends. Where references are made to the views of family or friends in this report they draw from these sources, but do not claim to be the views of all members of the family or friends. Further details of how people who knew Neil or Tracy were involved are given in Appendix C. 

Review Panel

  • The Domestic Homicide Review Panel members were as shown in Table 1. The Panel met five times by video-conference between 21st August 2021 and 21st September 2022, and conferred by electronic means to clarify evidence and finalise details of the report.  

Table 1: Membership of the Review Panel

Agency Representatives     Name
n/a Independent Chair     REDACTED
Devon and Cornwall Police Detective Chief Inspector and Detective Sergeant, Criminal Case Review Unit     Lee Nattrass    Phil Leonard
NHS Devon2 Interpersonal 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
  • No members of the Panel had any prior direct involvement with the events or decisions covered by the review, or management responsibility for any staff whose actions are described. The Review Panel operated collaboratively to reach agreed conclusions. The NHS Devon Panel member liaised with Practice P on sections of the report relating to their role. The Area Operations Manager for Sanctuary Housing attended the fifth meeting of the Panel to discuss the draft report and action plan. The report and recommendations are agreed by the whole Panel and are signed off by the Chairs of Safer Devon Partnership and East and Mid Devon CSP.
  • The Independent Chair, who was also the author of the report, has never been employed by any of the agencies concerned with this review, and has no personal connection to any of the people involved in the case. Further details of her relevant experience are given in Appendix A. The Panel had administrative support from the Safer Devon Partnership Co-ordinator for Domestic Homicide Reviews.

Equality and diversity

  1. The Panel considered the relevance of the nine protected characteristics under the Equality Act 2010 in setting the terms of reference and conducting the Review. These are age, disability, gender reassignment, marriage or civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation. 
  2. Neil and Tracy were middle aged, White British, heterosexual and not known to practice a religion. Neither had gender reassigned, and Tracy’s pregnancies were long before the period covered by this Review. They had been married to, and divorced from, each other long before the homicide, but were living together again when it occurred. The Review considered how agencies recorded their relationship status. 
  3. The Panel recognised disability as a relevant factor in both parties’ access to and experience of services. Neil had long term physical disability which meant he needed assistance from a carer. He suffered from chronic pain, which may have limited his choices. Both Neil and Tracy had mental health problems of a level requiring recognition and response by agencies. The Panel identified sex as relevant, as it may have affected perception of Neil, a male, as a potential victim of abuse.

Background Information

  1. The homicide took place at Address A, a two storey, two-bedroom general needs terraced house held on an assured tenancy from Sanctuary, a Housing Association, which provided housing management. This had originally been in Susan’s name, with Neil added as a joint tenant in December 2012 – perhaps preparatory to their separation, as the couple had lived there for some years. Susan had left by July 2014, but the change back to a single tenancy was not completed. From agency contacts and family recollections it is clear that Tracy had moved in before May 2015, although her name was never added to Sanctuary’s list of household members. 
  2. Just after 9pm on an evening in late December 2020 Tracy called emergency services saying that she had stabbed Neil. The ambulance crew was unable to save his life. Police attending arrested Tracy. Evidence from the scene showed that both she and Neil had been drinking heavily. Tracy had recorded a conversation with Neil at 8.30pm 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. 
  3. The post-mortem found a single stab wound over 20cm deep made with a thin sharp kitchen knife, passing in front of the ribs into the liver and kidney, severing the portal vein, with the inevitable result that Neil bled to death.  
  4. Tracy was charged with murder, then found guilty of manslaughter at the Crown Court in February 2022, and also guilty of four counts of assaulting emergency workers at the scene of the homicide. She was sentenced to eight years imprisonment. 


  1. This section summarises information available to the Review about what happened. Later sections of the report analyse and draw lessons from this. The first sub-section reports how family and friends described Neil’s relationships prior to 2014, then chronicles relevant agency contacts with Neil and Tracy in this period. Subsequent sub-sections describe agency contacts each year from 2015 to 2019, omitting some primary care contacts on physical health issues. This is followed by a sub-section on family observations of the relationship over that period. A final sub-section covers both family and agency information relating to 2020. 

History to 2013

  1. The key family events over this period are outlined in #17-18 above, with the further description below based on what family told the Review, agency records and evidence obtained by police during the criminal investigation.  
  2. Neil came from a military family which travelled, finally settling in Town H in his teens. His interests included football, rugby and music, including playing guitar and drums. He qualified as a welder and had a variety of local jobs until his health prevented him from working. 
  3. Tracy was pregnant (with Alice) when she married Neil in 1990. After their son was born in June 1992 there was a short period when Neil moved out of the home, leaving the children with Tracy, but maintaining contact. Neil’s mother visited the children each day. Family memories of this time include Tracy having “numerous boyfriends”, different people looking after the children, and an occasion when Tracy came back drunk after a night out and put her fist through a window. “She wasn’t motherly.” There is, however, no evidence indicating domestic abuse by either Tracy or Neil during their short marriage or the divorce proceedings.
  4. By the end of the year the relationship had ended, and both children and Neil were living with his parents, with a residency order later made to require this and restrictions on Tracy’s contact with the children under custody arrangements in the divorce. “All the schools and clubs that we went to had to know that she wasn’t allowed any contact with us”. The children recall being told not to mention her name in front of Neil as it upset him. On accidental encounters in the town “She would make a big scene that was frightening to us”. 
  5. Tracy’s health records show a history of post-traumatic stress disorder, post-natal depression and anxiety and depression. She had also used illicit drugs and had taken overdoses of prescribed and illicit drugs.
  6. Around 1995, Neil met and later married Susan, moving out of his parents’ home to live with her nearby. Susan’s daughter Jemma, a year younger than Alice, did not have contact with her own father as a child, and had a close relationship with Neil as stepfather. By mutual agreement Alice and her brother remained with their grandparents. The two households were close, with examples cited including celebrating birthdays and Christmas together, activities at weekends, attending each other’s school performances. “We had a very stable upbringing….., It would sound strange because we were separated. But that’s kind of how it began and stayed. But we were quite content with that.” This closeness continued when Neil and Susan moved to Address A around 1999. 
  7. Tracy moved away from Town H for a while, then returned. The children did not visit her home and indeed were “vigilant” to avoid her spotting them when they visited Susan’s mother who lived on the same street. They were aware of rumours that she was involved in drug use and dog fighting. 
  8. Around the turn of the century, Neil had to give up work when he became ill. Between 2002 and 2011 he had multiple contacts with the Royal Devon and Exeter Hospital (RD&E)[2] Pain Clinic, relating to chronic pain in his back and groin. Despite this, according to family, the household did not have financial problems. Susan was the one who organised “paperwork” but Neil had his own bank account and arranged his own medical appointments. He “was an avid Mod in his day” and continued to ride a scooter, including to hospital appointments, until breaking his leg in a fall from it in 2013. According to family Neil, until the end of his life, did not have a mobile phone, preferring to use a landline. 
  9.  Susan, a local authority employee, eventually became unsatisfied with the marriage due to the impact of his illness on their life together. They divorced in 2014. Susan had moved out in 2012, leaving Neil in Address A. It was a stressful time for Neil as his father had recently died, and his alcohol use increased. All the children were adults, living independently, by this time. Neil’s son moved into Address A for a while to support his father. Susan settled in another county. 
  10.  In November 2008, following the first assessment of his needs by Devon County Council adult social care, Neil started to receive 9 hours a week self-directed support payment. This continued, with the level periodically reviewed, until his death, increasing to 13 hours per week in April 2009 and 16 hours plus 2 for essential shopping from May 2013. Devon’s social care records (a case management system known as Care First) show that Neil opted for the direct payment arrangement as his care needs fluctuated. 
  11. Neil was not known to Devon and Cornwall Police prior to 2015 and has no historic links to any crimes or incidents of domestic abuse. Tracy had convictions for several crimes in this period, but none relating to violence or domestic abuse. 
  12. In May 2015, during a police interview about an incident covered later in this report, Tracy made a historic allegation of rape by a customer of her parents’ hospitality business, while she was aged 12-14. Relevant aspects of agency contact with her during the investigation and subsequent trial, which did not lead to a conviction, are covered later in this report. In a mental health assessment in 2016, Tracy said she had engaged in deliberate self-harm between ages 15 and 17, and had taken numerous overdoses over the years, up to 2015. 
  13. Devon and Cornwall Police recorded domestic incidents in 2006 and 2008 involving Tracy where the perpetrator was her male partner at the time, Gary. These were verbal arguments, with both parties observed to be under the influence of alcohol.  In May 2010 Tracy attended the emergency department at the RD&E with lacerations which she ascribed to “messing around” and being pushed into a metal pole. She had been drinking alcohol and was reluctant to stay after receiving treatment. In April 20I2 Tracy phoned Devon Doctors saying she was depressed, and that she had recently tried to take her own life. She reported that her GP had recently prescribed anti-depressants. When a Devon Doctors clinician called her back the telephone was answered by a man who denied any knowledge of her. In 2013 Tracy and Gary were subject to a Police Problem Solving Plan due to incidents of anti-social behaviour between them and their neighbours. Her address then was Address B, also in Town H. 

Developments in 2014

  1. At some point in late 2014 Tracy and Neil resumed contact. Family recollections differ on the sequence of events which led to this. Neil told family he was lonely, needed someone and wanted to hear Tracy’s side. They had a meal out together, and a few weeks later Alice was surprised to find her living at Address A, but recalls Neil saying “Oh well, she’s got nowhere to live.” Neil’s mother, though angry and worried at Tracy’s return, recognised that her son was “thrilled Tracy was back”, and “claimed she had changed and that she was not what she used to be”. 
  2. On 9th November 2014 Tracy called the Direct Payments team in Care Direct Plus, the part of Devon County Council overseeing his social care. (See Appendix D.) The note recorded on the Care First system is ““T/C from Tracy stating that she is Neil’s first ex-wife (Neil was in attendance). She stated that his second ex-wife Susan is attempting to claim fraudulent benefits using her previous relationship with Neil as a basis for such claims. They were ringing to ensure that DCC records show that Susan should not be considered as a family member. Advised that the Direct Payments agreement is in the sole name of Neil so we would not give any information to a third party without his consent. They were happy with that”. 
  3. The staff member taking the call alerted the Care Direct Plus Assessment and Review Team (see Appendix D). On 20th November a social care assessor noted on Care First “Discussed with [duty team leader]. Agreed that the message is clear in that Neil is requesting that Susan is removed from his records as she is not considered to be a family member. Therefore [Care First] updated.  It is open to Neil to report his concerns to the police/DWP.”
  4. There is no reason to think there was any foundation to this allegation against Susan, and no report of fraud was made. Care Direct Plus made no further contact with Neil until April 2017. 
  5. On 11th November 2014 Tracy flagged down a passer-by in Taunton by who took her to the RD&E Emergency Department.  The passer-by was concerned as Tracy had disclosed that she had been a victim of domestic violence. Hospital staff noted her as behaving strangely, telling different stories, and saying that she was a victim of domestic abuse and had lost babies. She said she had a long history of depression and had been drinking alcohol for the past few days. Tracy was assessed by a doctor from the Psychiatric Liaison team at the hospital later that night, who referred her to the Devon Partnership Trust Crisis Response and Home Treatment Team (Crisis Team). She was also given contact details for the Samaritans and for domestic abuse service SAFE. The Crisis Team advised passing on their contact details but assessed that a review was not clinically indicated at that point. Records show that the Psychiatric Liaison team then made several unsuccessful attempts to contact Tracy to pass on this information. 
  6. At the hospital Tracy named her ex-partner Gary as a perpetrator of domestic abuse. She described Neil, who joined her at the hospital, as supportive and not the perpetrator.  She did not report any specific matters of domestic abuse or wish to speak to either the police or be referred to an IDVA (independent domestic violence advisor). Hospital staff made a referral to the Exeter, East and Mid-Devon MARAC (Multi Agency Risk Assessment Conference)[3]. Through this information was shared with partner agencies and domestic abuse support services. The information provided by Tracy included that she was now in a relationship with Neil but still in regular contact with Gary, sometimes going out drinking with him. She did not cite having experienced strangulation or choking. 
  7. A Police Domestic Abuse Officer (DAO) made the relevant Neighbourhood Police Officer aware of Tracy and placed a warning marker on Address B, so that in the event of any calls to it, attending officers would be informed that there were concerns for domestic abuse. Devon & Cornwall Police also recorded the referral on their Unifi system as a domestic violence management enquiry. The MARAC recommended that the IDVA continue to try and engage with Tracy, but records show that she chose not to engage.  A letter was sent to her GP informing them of the incident and a further referral made to Devon Partnership Trust. Tracy was at this point registered with Practice Q. The MARAC referral was then closed. 
  8. Devon Doctors took a call from Tracy on the evening of 13th November 2014 concerned that the Crisis Team had not yet called.  She was advised to contact them again.  An hour later Neil left a voicemail message with the Crisis Team, who called him back the following morning. The note of the call reads “Neil reports that Tracy is currently staying with him in the short term, and that last night she was threatening to kill herself and he is finding it extremely difficult trying to help her. He is unclear as to how much she is drinking currently, reported that she recently took off, was found in Taunton, had been drinking and taking boxes of pills. He feels that she desperately needs support, he is very afraid that she will end her life, reports that that they were given the Crisis Team number and he is requesting support from the team at this time. Tracy is currently asleep and Neil will be going out shortly, due to return by 11am. I have agreed to ask the team to call back later to triage appropriateness of input by Crisis Team or for signposting to appropriate services.” Primary care records note that Tracy took a drug overdose on 17th November but there is no further detail.
  9. In December 2014 Tracy did have a triage review from Devon Partnership Trust. The outcome was referral to Practice Q’s Counselling Service. According to a later referral letter from the GP to Devon Partnership Trust “unfortunately this referral seemed to get lost in the system and due to the long waiting list for practice counselling this was not noticed until Tracy came to see me again [in May 2016]”. 
  10. It is relevant to later analysis that police records relating to Address B link Tracy to it in 2014 but not in any subsequent years. East Devon DC records show Tracy as responsible for Council Tax at Address B in 2014, but not at any East Devon address after that. Benefit claims made by Tracy to East Devon DC in later years indicate, on a balance of probabilities, residence at Address A. 

Agency contact in 2015

  1. Devon Partnership Trust’s Crisis Team had no contact from Tracy during 2015 but did receive a call from Neil on 4th February enquiring about waiting times for the (GP) Practice Counsellor. Primary care consultations by Neil during 2015 suggest he became sexually active again then. 
  2. On 25th May 2015 police were called to Address A by neighbours reporting arguing and smashing of items inside and outside the house. Police found Tracy and Neil were together, with Tracy injured by broken glass. Sanctuary maintenance staff also attended. The couple both said this was not a domestic incident and that they had returned home drunk and found they had locked themselves out of the property as Neil had lost his keys. They then broke a window and door to gain entry. Tracy declined to answer questions for the DASH (Domestic Abuse, Stalking and Harassment) risk assessment, but did during this interview report being raped in the early 1980s. Police created a crime report for the historic allegation, graded the current risk as Low in their DASH assessment, and recorded the incident as Non-Crime Domestic, with no further police action. 
  3. Tracy was taken to the RD&E Emergency Department, accompanied by Neil, where she said her injuries were due to the smashed window. Hospital staff noted her as accompanied by “husband (divorced)”. They asked Neil to leave, but Tracy refused to have him out of the room. Medical notes describe her as “Very angry and refusing to engage. Intoxicated, able to hold conversation and manipulate it to her advantage.  Possible danger to herself, others and husband.” Neil is recorded as keen for her to be sedated so she could get help, saying “Why can’t you stab her with something to keep her here? I’ll sign something, I’m her husband.” There is no record of any discussion with him about potential risk he might face from Tracy. 
  4. Tracy refused to wait for the mental health team. Hospital staff called the police, as she was outside the hospital with Neil and being violent and aggressive towards staff and other patients. Both Neil and Tracy were under the influence of alcohol. Police attended and spoke to Tracy. No criminal offences were disclosed and Tracy and Neil left the hospital in a taxi.  Following a further call from staff at RD&E requesting that Tracy return to the hospital for a Mental Health Act Assessment, police located the couple in the taxi on their way back to Town H. Tracy stated that she was going back to her place and just wanted to get her head down. She would go to the doctor’s tomorrow. Assessment by officers at the scene considered Tracy not to be at any immediate risk and this was agreed by hospital staff. Arrangements were made by Tracy to see the Mental Health Team the following day. 
  5. Sanctuary’s customer contact system recorded the reasons for the damage to the house, that police attended, and that Neil’s “partner” was taken to hospital, but their note did not include her name or whether police considered this to be a domestic incident. In follow up contact, the Sanctuary housing officer noted that neighbour was concerned about drunk and anti-social behaviour, including shouting and bad language, and had seen a woman (who the neighbour referred as “the tenant”), climbing through the broken window. 
  6. On 28th May 2015 the housing officer made an unannounced visit to Address A and spoke to Neil, who apologized for the behaviour which he said was a one-off with lost keys and alcohol fuelling the situation and argument. He referred to “his friend” living with him at Address A in separate bedrooms for the past six months. The housing officer gave advice on installing a key safe but did not note Tracy’s name, which appears nowhere on Sanctuary records prior to the homicide.
  7. On 30th May 2015 a Police Sexual Offences Liaison Officer (SOLO)[4] interviewed Tracy using the Achieving Best Evidence process, about her recent disclosure of historic child sex offences. Tracy was offered referral to an ISVA (Independent Sexual Violence Advisor) but declined initially and did not respond to later offers of contact by an ISVA by mobile phone and letter. No current safeguarding issues were identified. The SOLO agreed with Tracy on contact every few weeks unless there were any relevant updates, and subsequently heard that she was being referred for counselling by her GP. 
  8. In November 2015 Tracy received a Penalty Notice for Disorder following arrest for being drunk and disorderly, after an argument with a taxi driver and being abusive towards police officers who intervened. 

Agency contact in 2016

  1. On 16th June 2016 police and ambulance were called by a member of the public contacted by Tracy in a distressed state, partially dressed and talking about taking her own life.  Neil, described as her partner, arrived at the scene a little later. The ambulance crew assessed Tracy as drunk. She refused medical assistance and was taken home to Address A. Police closed the incident log, as no offences committed but noted her connection to the Problem Solving Plan from 2013. This may be the same incident recorded in the Sanctuary anti-social behaviour system when on 23rd June a neighbour reported “drunk behaviour by a female living at” Address A and seeing the partially clothed woman on the doorstep unable to get into the house, shouting “Neil let me in”. The Sanctuary note refers to police resolving the situation, but the police have no record from that date. Sanctuary wrote to Neil to remind him of tenancy conditions. 
  2. The police investigation of historic sex offences against Tracy continued during 2016, with contact from the SOLO every 4-6 weeks. Tracy did not raise any concerns about domestic abuse in her current situation. Neil told the investigating officer that he was aware of the sexual abuse because Tracy had told him when they married in 1990. 
  3. In a call to Devon Doctors on 7th May 2016 (about a physical health issue) Tracy said she was taking anti-depressants but “felt fine in herself”. In a follow up call with a GP on 10th May she was “well in self but not so good psychologically”, having “longstanding issues from childhood, partner supporting her”. She saw Dr WW, a female GP at Practice Q, on 13th May with Neil (noted as ex-husband) and reported low mood, being tired and socially isolating herself. Neither had drunk alcohol for 3 months and both admit this had been getting out of control.  She spoke about historic sexual abuse which was going to court, though no date had then been set. 
  4. In response Dr WW chased the counselling referral (from 2014), and on 26th June Tracy was assessed by a counsellor, based at Practice Q and commissioned by Devon Partnership Trust. Neil attended with her, and told the counsellor that Tracy appeared to have two distinct personalities and was “a risk to herself”. The counsellor recommended some coping strategies and wrote to Dr WW saying she felt Tracy was suffering from Dissociative Identity Disorder as a result of post-traumatic stress, so should be referred to mental health services.  The counsellor judged that she could not provide the appropriate support herself.
  5. On 6th July police referred Tracy to the Exeter Sexual Abuse Referral Centre (SARC) for support from an ISVA in relation to historic sexual abuse. The allocated ISVA left voicemails for Tracy on 7th, 19th and 21st July without getting a response. 
  6. On 20th July 2016 Dr WW contacted the SARC to ask who could offer Tracy counselling. The SARC responded on 21st July that they had so far been unable to make contact with her. On 4th August Tracy contacted the ISVA and made and appointment for 23rd August. When Tracy saw Dr WW on 8th August she agreed to be referred to the Community Mental Health Team and said she had an appointment arranged with the SARC. However, the SARC records do not show the August meeting as having taken place. 
  7. On 15th August  Dr WW referred Tracy to Devon Partnership Trust. The referral letter cited the court proceedings, also said that she had “a long history of mental health problems with low mood, anhedonia and is increasingly socially isolating herself”, and admitted that the 2014 referral by the Mental Health Assessment Team to the practice counselling service had got lost. 
  8. The Mental Health Assessment Team saw Tracy on 31st August 2016. The family form she completed as part of this described Neil as her husband. She said she had moved out of a private let property on being made redundant was at that point staying three nights a week with “her ex-husband Neil” and sofa surfing on the other days. The assessment noted that Tracy described her partner, children and grandchildren as robust positive factors. 
  9. This assessment included a mandatory question about current abuse, and Tracy did not report any.  The clinician’s feedback to her records that she described times of becoming “increasingly agitated, emotionally detached and unpleasant towards your partner; none of which you can remember”. The clinical notes refer to her as having stopped smoking cannabis at the start of the year and also having stopped binge drinking. They include a detailed risk assessment focussed around risks relating to suicidal and violent behaviour, noting that she had taken overdoses over the years, most recently in 2015. There is no information about the impact of substance misuse or contact with other services. The clinician concluded Tracy was experiencing depression and symptoms of post-traumatic stress disorder. The outcome was referral on to ReThink Mental Illness and an increase to her medication (Setraline), to be subsequently managed by her GP. 
  10. The referral form to Rethink’s Community Opportunities programme in Town H, received on 7thSeptember 2016, said that “Tracy is experiencing a depression and requires support to leave her home and socialise. Additionally she would like to better structure her day with meaningful activities. She may require support with securing herself permanent accommodation also”. It is not clear from the records what aspirations about future accommodation Tracy had expressed during the consultation. On 12th September a Rethink Mental Health Recovery Worker wrote to Tracy asking her to contact the service to within 2 weeks to arrange an appointment to discuss her current needs and how the service can support her. The letter said the service aims to meet people within 8 weeks. Tracy did not respond, so Rethink closed the case in December 2016. 
  11. On 1st August 2016 Sanctuary called Neil regarding arrears in his payment of rent. Neil passed the phone to Tracy to discuss this, and she told them she had accidentally ended the direct debit. Sanctuary sent a new direct debit form and a form by which Neil could authorise her to discuss the tenancy with them. This was returned on 9th August and listed her address as c/o Address A. Arrears continued to build and in November 2016 a Sanctuary Income Officer visited Neil, who said that as far as he was aware payments had left the bank. 
  12.  On11th October 2016, with the trial due to start soon, Tracy did meet the ISVA, for the first time. She said that Neil (described as her partner) could not attend to support her as he “too poorly”. She was highly anxious about the trial. Special measures were discussed. Tracy described having a dissociative personality disorder, triggered when distressed. She said she became aggressive and swore when experiencing an episode and there were no warning signs prior to an attack. The ISVA advised her to make the police aware so that the court could be informed prior to trial.
  13. At the next session with the ISVA, on 1st November 2016, Tracy was less anxious. Arrangements were made for attending court with the ISVA. Tracy reiterated that her main concern was her dissociative personality disorder being triggered when she gave evidence. Asked how this is likely to present, Tracy said she becomes very rude, swearing and might walk out of the court room. The ISVA offered to notify the court and ensure that regular breaks are provided and emailed the Witness Care Unit about this on 2nd November. On 23rd November 2016 the trial was postponed, so the ISVA and Tracy agreed to make contact again in the new year.

Agency contact in 2017

  1. Issues with payment of rent arose again early in the year. On 3rd February 2017 Tracy called Sanctuary to make a rent payment using Neil’s bank card. They correctly refused to take this as he was not present. On 3rd April, Sanctuary’s income team phoned Neil. He gave them permission to speak to Tracy. At that point arrears were over £1900. With Neil agreement, a payment of £800 was taken from his card, and a direct debit set up to cover the rent plus a contribution to paying off arrears. 
  2. On 3rd February 2017 the ISVA texted Tracy asking how she was. On 13th April the ISVA called and an appointment was made for 25th April to prepare for court and make travel arrangements. The ISVA emailed the barrister and Witness Care Unit again regarding special measures, updating on Tracy’s condition and the need for regular breaks.
  3. Care Direct Plus (Eastern) was the section of Devon County Council’s adult social care department responsible Neil’s social care support including annual review of his Direct Payment allowance for self-directed support, a provision under the Care Act 2014. (See Appendix D for the policy context.)  Until April 2017 Neil’s Direct Payment had been paid into his bank account, for him to pay for sessional support as he chose. Care Direct Plus had not reviewed this situation since 2013, although their policy was annual review. 
  4. Between 11th and 26th April 2017 CDP1, an Independent Living Advisor within Care Direct Plus direct payments team made several attempts to speak to Neil but noted difficulties reaching him or him not being able to speak to her as feeling unwell. The aim of her contact was to talk to Neil about moving his budget to a Devon Card, meaning that while he still had choice of about how to spend it on activities meeting his assessed needs, payments would be made through the Devon Card, not via his bank account. (See Appendix D.) She did this because Neil had not been submitting any records to show how he was spending the Direct Payment but was paying friends in cash. 
  5. Neil’s family were aware that he paid some male friends for sessional assistance. The lack of records means it is not known what payments he had made to Tracy by this stage. When contact was made on 26th April, Neil told CDP1 that he was paying “his current personal assistant’s tax” from his own money. CDP1 explained why this did not meet employment regulations. Neil consented to a reassessment as his needs had changed. This led to a referral to the Care Direct Plus Community Health and Social Care Team (see Appendix D) for a face to face assessment “to gain a true picture of his current needs and structure around his care needs”.
  6. On 3rd May Tracy gave evidence against the man accused of sexual assault on her when she was a child, with ISVA support. Neil gave evidence of her earlier disclosure to him. On 6th May the trial reached a Not Guilty verdict. The ISVA tried to contact Tracy to ask how she was. On 30th May 2017, as there had been no contact from Tracy, the SARC wrote to her advising her of criminal injuries compensation and how to claim. Her file was then closed to the ISVA service. She had not accessed counselling through the SARC. 
  7. On 17th May 2017 CDP1 visited Neil to discuss his Direct Payments, and they agreed it would be best for him to have a managed account through the Devon Card. The Care First note said that “Neil said he had found a personal assistant who CDP1 met on the visit. Neil said he was pleased to have something now official who could work with him flexibly to support his personal care needs.” CDP1 recalled that on this visit Tracy was not present in the home when she arrived but entered shortly after. She said both were pleasant, the house clean and tidy, and Neil relaxed on the sofa. Nothing would have alerted her to suggest anything was wrong. CDP1 was not aware that Tracy was Neil’s ex-wife. 
  8. On 17th June 2017 Neil taken to hospital after tripping over, with a bottle of brandy in his hand. The broken glass caused deep wounds to his arm. Tracy called an ambulance. The SWAST incident record said that he had been drinking all day in the pub that the fall had been witnessed (but did not state the source of this information). It includes “On crew arrival Neil and his wife stumbled to the ambulance. Neil clearly intoxicated. … Wounds were cleaned and dressed, all very deep. No observations were taken as Neil was volatile, one minute talking, calm and polite, the next aggressive and swearing.” The RD&E Emergency Department notes also ascribe the injury to falling after a day’s drinking, while carrying a brandy bottle, but differ on which arm was involved, and say that the fall was while walking home. He was treated but did not need admission to hospital.  A standard letter recording treatment with sutures was sent to his GP, but this did not mention that it arose from an alcohol related injury. 
  9. On 31st July 2017 CDP1 phoned Neil to review the new payment arrangements, then noted “The 8 week Devon card managed account review showed that the managed account was going well.  Payments are being made to Tracy. Call made to Neil who said he was pleased the Direct Payments and he now has regular care with Tracy. Neil to call if further guidance and support is required.” The arrangement in place was through Disability Focus, a charity which provides a payroll service and handles tax returns and offers information on employers’ responsibilities. Neil remained the employer, responsible for telling Disability Focus what hours to pay and to whom. 
  10. On 6th September 2017 Sanctuary raised a Notice of Seeking Possession due to arrears, as two direct debits had failed. On 8th September the income officer saw Neil, who claimed to be unaware of these failures or of the level of arrears. On 11th September Tracy phoned the income team to say she would pay on 26th September, and that Neil was in hospital. (There is no record of such a hospital stay.) She then made a payment of £600 on 19th, phoning on 21st to check that it had been received. The Sanctuary note refers to her as “tenant’s carer”. 
  11. On 14th September 2017 a Social Care Assessor (CDP2) from the community health and social care team made a pre-arranged visit to Address 1 to assess Neil’s needs. Tracy was also present. They discussed “the changes to Neil’s care and support and that Tracy was carrying out longer working hours due to the increased support needs.” Neil gave consent for CDP2 to speak with his GP, Dr ZZ, at Practice P. On 21st September CDP2 recorded on Care First that “Dr ZZ advised that he was living with widespread arthritis in the spine and neck causing him pain and impacting on this mobility, also with cysts on his kidneys requiring periodic treatment; the GP further advised that the medication he was on could reduce his presentation in terms of communication, however that in his (the GP’s) opinion Neil retained capacity to make informed decisions.” On 22nd September CDP2 referred Neil for an occupational therapy assessment. 
  12. On 27th September 2017 CDP2 contacted the Direct Payments team for clarification around how things would change if Tracy were to move into Neil’s spare room. They advised that this would need to come under “exceptional circumstances”, which would have to be agreed by her manager. CDP2 was informed she would need to make a case as to why Tracy needed to or should move into the property, and that would need to update the Direct Payments team if it was agreed. There is no record of what prompted this enquiry or whether CDP2 did raise the issue with a manager. No such “exceptional circumstances” provision was agreed, and Care Direct Plus continued, up to the point of Neil’s death, to think that Tracy was not resident at Address A. On 6th October the Care First records were updated to show Tracy as “other professional relationship” with Neil, giving her address as Address B.  
  13. On 29th September 2017 CDP2 made a home visit to Neil with Tracy present. Neil was independently able to mobilise down the stairs and into the living room. “He explained that it was a good day.” CDP2 informed Neil he was on the occupational therapy waiting list and would be contacted soon. She had a conversation with both Neil and Tracy “around the issue of Tracy providing support over the 16 hours she is currently contracted to give. A contingency was agreed where Neil could have funding to pay Tracy during the times he is more unwell. Neil commented that he was happy as long as Tracy was being paid for all the hard work she does to help him.” Neil also expressed appreciation of CDP2’s involvement.
  14. On 3rd October 2017 Sanctuary received and checked the third party form signed by Neil giving Tracy, c/o Address A, authority to discuss tenancy details. Tracy again tried to make a rent payment using Neil’s bank card, without him present. The Sanctuary income team declined this and gave information on how to make a standing order. On 8th December, an income officer called Tracy who said she was trying to assist Neil with his finances and was in the process of obtaining Power of Attorney. She said she would ensure his monthly Direct Debit was met and would set up an additional Standing Order sufficient to clear the arrears by March 2018. 
  15. On 26th October 2017 an Occupational Therapist from Care Direct Plus community health and social care team completed an assessment of Neil. This led to equipment provision including a bath lift and special bed. The assessment notes that Tracy was in the process of applying for Lasting Power of Attorney for both health and finances. “Neil says that Tracy manages all his finances, paperwork, appointments and bills.” Neil described his support needs as including help with feeding and washing, paperwork and finances. He said he was at risk of falls, did not feel safe alone, could walk with crutches when well, and found it difficult to get out of the home. He said he relied on Tracy to make difficult decisions including organising appointments. He said he felt socially isolated. The referral section of the assessment states that Neil “would like to have a live in carer and has someone in mind for it.” There is no further mention of this in the assessment. It also notes that Neil said he is always given choices regarding the care being provided by Tracy. In evidence to the IMR, the Occupational Therapist recalled Neil as lucid and rational. 
  16. Following this assessment and authorisation of the support plan by a team manager, the Direct Payment was increased, from 6th November 2017, to 21 hours per week to fund self-directed support in relation to domestic routines, safety and mobility, personal hygiene and nutritional needs plus 2 hours to assist with essential shopping. Care First records from 2017 show that Neil consistently refers to Tracy as someone he wishes to speak on his behalf and is presented on visits to be someone he relies on and is comfortable in the company of.
  17. Neil had pointed out ways in which Address A was difficult for him to live in as there were stairs to the bathroom and expressed a preference for living in a bungalow. The Occupational Therapist provided a statement of evidence to support this. There is no record that any application to find alternative housing through Sanctuary or East Devon DC was made. However his family say he managed the stairs, which had bannisters, reasonably well.  
  18. On 23rd November 2017 Neil had a consultation at the RD&E Pain Clinic, where both a social and clinical history were taken. He said he was in pain 90% of the time and spends much of the day in bed. There is no mention in the notes of discussion of domestic abuse. Up to this point RD&E records show Susan and Neil’s mother as his next of kin. 
  19. On 28th November 2017 Tracy saw a GP at Practice Q and explained a facial cut as due to falling over after drinking pink gin. 

Agency contacts in 2018

  1. On 19th January 2018 Neil saw his GP about his mood (noted as “irritable”) and was advised to self-refer to Devon Partnership Trust’s Depression and Anxiety Service. He did not do this. On 16thMarch Neil saw a consultant urologist at RD&E with chronic pelvic pain. 
  2. On 19th March 2018 Tracy made a 999 call, not giving any details but leaving the line open. The call taker heard a verbal argument between a male and female, with the male heard to say “I don’t want to hurt you”. Officers went to Address A and found Tracy and Neil both heavily under the influence of alcohol.  Officers spoke to them individually, out of the other’s hearing. Initial accounts given by each stated nothing had happened and both were happy. Both denied calling the police, saying they had been drinking and just wanted to go to bed. After a while Tracy told the officers that Neil had put his hands around her throat. With her agreement, police took her from Address A to her sister’s home in Exeter for immediate safeguarding. Tracy told police she did not want the relationship to end, but she “needed some space” from Neil. A DASH risk assessment for her was graded as Medium. This included “No” answers to the questions on whether Neil had ever tried to strangle or choke her, and to consent for her details being shared with supportive agencies.  
  3. Tracy refused to provide a statement and said she would not support police action. Neil was not arrested. Officers recorded a crime of common assault, filed as Not Proceeded With. The rationale given was that there were no visible injuries, no independent witnesses, and no account from Tracy. Shortly after her removal Neil called police with aggressive language about his dogs. Police planned to attend the following morning, but by then Neil had called again, apologizing, and saying that he had been drunk, “was OK” and that his dogs had not attacked anyone. 
  4. On 20th March 2018 Neil, who had been receiving Employment and Support Allowance since 2012, made a claim for Personal Independence Payment (PIP) as required under the change to the benefits system. The medical questionnaire returned to Department of Work and Pensions on 13thApril records that Neil had a PA coming in three times a day for an hour to help with food and drinks and that it was filled in by Tracy for Neil.
  5. On 10th May 2018 Tracy called the Sanctuary income team in response to a letter sent to Neil about £450 rent due. She told them he had got confused, and that she was on holiday and had “only left £420 in the account for him while she was away”. She made a partial payment from her own account and said she would sort things out on her return the following week. 
  6. On 13th May DWP recorded Neil as failing to attend an assessment appointment. On 17th May Tracy, noted as “unofficial representative” phoned DWP, explaining his failure to attend as that she was away on holiday and he could not leave his home alone. Following this up with another call on 18th May, on which Neil is noted as also present, Tracy, described as his carer living at the same address as Neil, said that he had periods when he was not capable of handling his own affairs. This led to DWP acceptance, at the end of July, that there was good cause for the missed appointment. 
  7. On 23rd May Tracy had an outpatient appointment at RD&E for review of a painful bunion. On 27th May 2018 she registered as a new patient at Practice P, a move from Practice Q, only a few doors away, which she had previously attended.[5] In the subsequent few days before her new patient assessment on 1st June she made a number of prescription requests and changed the pharmacy at which to collect them. On 1st June 2018 Neil’s GP noted that his “ex wife gave him amphetamines – vastly improved pain” and, concerned about this use of amphetamines, subsequently adjusted Neil’s medication. 
  8. The new patient registration process for Tracy logged her as a “carer for Neil at Address A”, with the same landline number for both “home” and “work”. Identification including a utility bill and bank statement was checked. Her full medical records were transferred by 1st August. 
  9. On 19th June 2018 an Income Officer visited Address A but was unable to speak to Neil as “a lady” (presumably Tracy, but no name or role recorded) answered the door and said that Neil was in bed seriously ill. She also said that his Personal Independence Payment / Disability Living Allowance had been stopped as he failed to attend an assessment, and that she was trying to get it reset. 
  10. On 4th September 2018 Neil had an outpatient consultation at RD&E about pain management. Tracy attended the minor injury unit in Town H on 24th September 2018 with abdominal pain, ascribed to muscle strain after lifting young grandchildren, and again on 3rd December with a facial injury noted as “tripped at work”, with detail as “at work tripped on carpet fell forward hitting face on door frame”. The record of this does not show any enquiry about which workplace was involved, or about domestic abuse. She was advised to go to the RD&E for an X-ray, but there is no record that she did. 
  11. On 29th September 2018 DWP awarded Neil the standard rate of care and mobility PIP.  Tracy had called twice since July to chase progress. On 7th November DWP received notice of intention to appeal this decision.

Agency contacts during 2019

  1. On 28th January 2019 Tracy visited Practice P about breathing difficulties. She was advised to go to hospital and “offered help with partner as feels carer and cannot leave him. Offered different options for care but declined.” Further appointments in February and March followed to manage asthma and COPD (chronic obstructive pulmonary disease).  Over the rest of the year she had approximately monthly visits for a range of physical conditions, none indicative of domestic abuse. 
  2. On 25th February 2019 Neil visited his GP who noted that his pain was well controlled with patches, but he was “very irritable and not sleeping, thoughts of self-harm”. He made a referral to the community mental health team. Both family and Dr ZZ recall this as being suggested by Tracy. The referral letter says Neil has frequent suicidal thoughts, is very irritable and verbally aggressive to his partner (ex-wife). “Until now she has been positive and very supportive of him, she now feels she will harm him if this continues.” Dr ZZ, contributing to the IMR, said he did not believe this was to be taken literally. 
  3. On 27th February, following receipt of this referral, DPT’s Mental Health Assessment Team, as part of their standard triage process, telephoned Address A and spoke to Tracy. (It is not clear from the record whether the nurse also spoke separately to Neil.) The DPT summary of the primary reason for referral is that “Neil was experiencing suicidal thoughts and that his partner was angry with him.” The record made of the call notes that “She does not feel he is a risk to himself and she does not feel that she would ever harm him despite feeling like she wants to kill him at times.” There is also a note that “He is verbally aggressive to her”. Following this conversation the urgency of the referral was downgraded. DPT then wrote to Neil offering an assessment on 20th March. He was advised that he could bring a partner or carer to the assessment if he wished. 
  4. At a tribunal on 8th March 2019 the appeal on the rate of Neil’s PIP payment was successful, and it was raised to Enhanced for both daily living and mobility, backdated to 27th June 2018. This was confirmed in a letter to him, copied to Tracy as his representative, dated 2nd April.
  5. Tracy accompanied Neil at his DPT appointment on 20th March. The clinician conducting the assessment was no longer working for DPT at the time of this Review and could not be interviewed to inform the IMR. The family form completed at the assessment described Neil as being single and living with his ex-wife who was described as being his carer and noted that he had adult children. The Mental Health Assessment noted that “Neil explained that he didn’t want to discuss his family. He doesn’t get on with his parents or siblings. He had major conflict with them following the break-up of his first marriage several years ago. His 2 children stayed with his parents and Neil sought custody of them. He says his parents tried to stand in his way to prevent them from living with him and so he ‘washed his hands of them’. His children are now grownup and live away. He maintains contact with them. He re-married …. They have now separated however Neil is still sharing the tenancy until he can find somewhere else to live.”
  6.   The assessment included exploration of the interface between Neil’s physical poor health (fibromyalgia) and psychological wellbeing. The assessment has two references to past substance misuse by Neil.  (The first contains a factual error, and the second has no indication of date or corroboration from other sources. They are included here as a record of what the clinician noted Neil as saying at that point.) “He says he has got through a bottle of vodka since his wife left 2-3 weeks ago however it made his fibromyalgia condition worse and so he has stopped drinking. No history of problematic alcohol use.” “He says he had an 8 year opiate addiction and after 3 attempts he went through a rapid withdrawal without help.”
  7. The assessment explored the impact on Neil of residing in the same property as his ex-partner and he described how she supported him to access and complete daily tasks. Asked about his financial situation, Neil “felt that winning an appeal into his benefit cut and having his benefits reinstated along with a backdated award was a huge stress relief for him.” No current or historical domestic abuse in their relationship was reported, nor is the payment of Tracy as his Personal Assistant mentioned. The record of the assessment does not make any specific comment on the points raised in the referral about Tracy being angry with or feeling that she might harm Neil. 
  8. The DPT risk assessment which formed part of this Mental Health Assessment was rated as low risk. A detailed letter with the outcome of the assessment and recommendations for his future care was sent to Neil on 4th April 2019 and copied to his GP. The recommendations concerned possible access, via GP referral, to Health Psychology, Neil to discuss his pain with the GP and potential access to a Fibromyalgia group.  DPT records the letter as having been sent to Practice P, and the family recall Neil showing them his copy. Practice P has no record of this letter from the Community Mental Health Team.  Dr ZZ had, however, recently changed Neil’s anti-depressant, and increased the dosage of that following a review in July 2019. 
  9. On 17th April 2019, at 2.30am, Neil was triaged in the RD&E Emergency Department, saying he was “stuck in Exeter tonight and had nowhere else to go”. He said he had multiple medical issues but felt no worse than he normally does. He was discharged, with a referral for a chronic pain consultation, but stayed in the waiting room until morning when he could get a lift home. 
  10. On 21st July 2019 at 5:24am Tracy was seen at the RD&E Emergency Department after being attended found intoxicated and partially clothed in a hedge. Asked whether she had been sexually assaulted she thought not but was not sure. She did not want police involvement. 
  11. On 5th November 2019 police attended a domestic abuse incident in which Tracy’s daughter Molly was the victim. Tracy was a witness to what had occurred but refused to give a statement. Molly told the police her injury was accidental. The outcome was a MARAC referral for Molly. 
  12. On 28th November an Income Officer from Sanctuary visited Address A. The note says that Neil was ill in bed but agreed for his partner (name not noted) to discuss the rent account, which at this stage was slightly in credit despite some missed payments. 
  13. On 27th December 2019 Neil attended a pre-operative clinic prior in preparation for a day case operation (removal of a testicle). At this appointment he named Tracy as his next of kin. The pre-operative assessment includes a routine question on domestic abuse. While the rest of the form was fully completed, this was not asked and no rationale given as to why not. The question should only be asked if patient is alone, but the form provides a “not asked” box to tick if not asked and this was not completed.  It is not clear from the notes whether Neil was accompanied at this appointment. 

Family observations 2015 to 2019

  1. The family found Tracy’s return puzzling and disturbing, although recognising that Neil welcomed it.  Neil’s mother avoided interaction with Tracy throughout this period, while continuing to speak to Neil frequently. Alice initially tried to avoid all contact with Tracy. At first Tracy acknowledged this by staying upstairs when Alice visited the house. When Alice’s daughter (her first child) was born, she wanted her to know Neil as a grandfather but to have no contact with Tracy. There was a difficult situation at Alice’s wedding, which Neil did not attend as Tracy was not invited. A pragmatic acceptance that Tracy would see the children was reached, but Alice remained uncomfortable in the relationship. 
  2. Family knew that Tracy was being paid by Neil as a carer from the start of their resumed relationship. They think the relationship was initially a friendship, perhaps with some sexual intimacy later, but that due to health conditions of both parties that was not a primary focus. Tracy used the second bedroom, and Neil had a hospital style bed in his. Tracy was seen to be looking after him well at the start, providing meals and keeping the house clean, and with no signs of drug or alcohol misuse.
  3. With hindsight, family see Tracy’s relationship with the grandchildren (including Jemma’s children) as helpful in some ways but manipulative. Neil “adored” the children and Tracy did assist him to spend time with them. She gave lavish gifts which they did not see how she could afford. They were aware of bills not being paid on time – something they say had not happened to Neil before this period. Tracy appears to have seen Jemma as the most likely to sympathise with her and spoke to her about Neil using disparaging terms. 
  4. Tracy, who did not drive, used taxis or lifts from friends and family, or sent messages to family members asking them to do shopping. She got Neil a mobility scooter, which he saw as a humiliating alternative to the motor scooter he had previously had, so refused to use. He “struggled with buses” so was effectively dependent on family or friends for lifts, and rarely left the house otherwise.  Family recall several occasions when Tracy had left him locked in the house, and he could not open it to a visitor as he had no key. Alice and Jemma had originally had keys but did not after the lock was changed.[6]
  5. Tracy appeared to be taking more control of Neil’s contacts with health services and medication. Other family members had been accustomed to taking him to appointments and on occasion accompanying him at them. “But then all of a sudden that wasn’t allowed. It had to be her that went in with him”. 
  6. Family members were worried to see Tracy giving Neil a cupful of pills at a time, and think he had lost track of what he was taking and why, whereas he used to sort out his own medication. They saw little benefit from his 2019 mental health assessment, which Tracy had prompted. They query whether she had undue influence on Neil’s medication as she sometimes saw the doctor about him without him present. They say she made a “song and dance” in pharmacies asking for extra medication (which was not given) and see this as a danger sign that could have been spotted. 

Events in 2020

  1. On 3rd January 2020 Neil had the planned surgery under local anaesthetic at the RD&E. On the Elective Surgery Assessment Form relating to admission the two sections regarding domestic abuse were left blank. No concerns or discussions about domestic abuse are noted.  This surgery was successful in significantly reducing his pain. As noted by the judge in sentencing: ““Approximately a year before his death, Neil had had an operation which meant that his health improved significantly. He had good days and bad days but his overall pain levels reduced. He reduced his medication, he got his appetite back and his outlook on life became a lot brighter.”
  2. On 10th February 2020 Sanctuary noted a request to replace a bedroom light fitting at Address A, after “carer pulling light from ceiling replacing a bulb”. The call taker confirmed contact details for Neil as tenant and Tracy as Personal Assistant. 
  3. Between January and March 2020 Tracy visited Practice P twice and had a phone conversation about her own physical health. At the start of the Covid-19 pandemic she was classified as high risk due to her underlying health conditions. 
  4. From 7th May 2020 on, Practice P made several attempts to contact Neil, by text, landline and letter, in connection with a review of his medication, but did not get through until 22nd June. In a subsequent call to a GP on 29th June Neil reported some improvement in pain relief but “not self – wife thinks gone looney”. A further medication change was made. Neil was due to have an in-person appointment with a GP on 9th July but cancelled it as he had an emergency tooth extraction (which family recall).
  5. Between June and August 2020 Tracy had four consultations with staff at Practice P: three concerned with her chronic obstructive pulmonary disease, and one in which she cited worsening anxiety about going out as she was at high risk of Covid, which resulted in a restart of antidepressant medication.  
  6. According to family, when Covid restrictions came into force, Neil wanted to stay at home, but Tracy did not like the Covid rules and blamed him for having to stay in the house. She wanted to visit her sister and daughter, but Neil was worried about her going and asked her not to. Towards the end family felt “blocked out” with Neil locked into the house, and Covid restrictions meaning that they were not allowed into it. 
  7. On 25th August Neil was prescribed antibiotics, following a telephone consultation about a dental abscess. At a planned review by telephone on 3rd September his regular GP assessed him as “In good spirits. Seems better and doing more at home now.” A further review was scheduled for 2ndOctober but Neil did not take the call, nor attend an appointment at the surgery on 8th October. He did have a consultation on 19th November which involved a medication review and discussion about his previous hospital treatment. His mood appeared to his GP to be stable in the months prior to his death. 
  8. Between March and September 2020 Sanctuary made several unsuccessful attempts by letter and telephone to contact Neil to discuss arrears due to failed direct debits. They received responses from email accounts in Tracy’s name. The arrears were low as payments just had to cover the shortfall in housing benefit. 
  9. On 22nd October 2020 Care Direct Plus assigned the “overdue review” of Neil’s support to Social Care Assessor CDP3, who, by 2nd November had made 11 attempts to contact him to arrange a Care Act review. These were through telephone calls, text messages and by letter. None received a response. Over the subsequent month CDP3 made further attempts at contact, including to Tracy.  A call was also made to Neil’s mother, who was recorded as next of kin on the Care First system, but as this went to voicemail with no personalised message, no message was left. 
  10. On 4th December Tracy had a consultation with her GP about exhaustion, night sweats and loss of appetite. She said that low mood / depression was not at that time an issue for her. 
  11. Also on 4th December Tracy telephoned CDP3 and a telephone assessment of Neil was agreed for 9th December. During this call CDP3 spoke directly to Neil about the need for a review. He reported that “things were fine and he may need a few more hours support”. “Neil said Tracy can discuss this on his behalf as she knows his needs very well”. On 9th and 10th December CDP3 phoned several times, getting no response, despite leaving a text message for Tracy asking her to call. 
  12. On 12th December Neil attended a clinic appointment at the RD&E to discuss his request for removal of his remaining testicle. Again, the medical notes contain no evidence that he was asked about domestic abuse. On 15th December he reported neck pain to his GP, who made a referral for physiotherapy. On 15th December CDP3 sent further telephone and text messages requesting an urgent call back to complete the review. 
  13. On 16th December CDP3, following further unsuccessful attempts to telephone Neil and Tracy, sent a text to Tracy advising that either Neil or she, as his representative, was required to make contact as a matter of urgency to arrange another date to complete the telephone review. The text warned that if there was no response the current Direct Payment was at risk and a letter would be sent advising that it could be withdrawn. This produced a callback from Tracy, who provided a new landline number and said that her own mobile had a poor signal so she could only access messages every few days from another part of the town. (This claim is contradicted by her use of the phone on the night of the homicide later that month.)
  14. CDP3 started the review, obtaining consent from Neil, who was present, for Tracy to speak on his behalf. She noted “Neil has difficulty hearing on the telephone due to hearing impairment, requested PA to support”. Interviewed for the IMR, CDP3 could not recall the exact words but clarified that he said this directly to her.  She said on the occasions (in trying to set up the review) that Neil answered the phone he spoke briefly to her and then shouted for Tracy who would come to the phone. CDP3 said when she spoke with Tracy on this occasion it was clear she was sitting next to Neil and would check things with him, and he would respond and CDP3 could hear him. Through all the contact she had with them they both presented as agreeing about his care needs. CDP3 perceived Tracy as advocating well for Neil and seeming to know him very well.
  15. Tracy said she worked 7 days a week, visiting 4 times a day and covering more hours than the Direct Payment provided for. She said her daughter supported Neil if she was unwell. CDP3 obtained consent from Neil for a face to face assessment to be completed, as it was not possible over the phone to fully assess needs or establish how the hours funded by Direct Payment were being used. This was due to the mismatch between the care reported as being given and the care agreed on the care plan, rather than other concerns. 
  16. On 23rd December CDP3 discussed Neil’s needs with the Duty Manager, and they agreed to make a referral to the Community Rehabilitation Team for an occupational therapist to make a stairs assessment, and to the Community Health and Social Care Team for a face to face review. CDP3 informed Tracy of this – she again said she had consent from Neil to speak on his behalf. Tracy said that Neil had now agreed to have a pendant alarm and confirmed that she had the contact details (provided earlier) through which this could be arranged. (There is no indication that action was taken on this before the homicide.) CDP3 called the Community Rehabilitation Team to make the referral. On getting an answerphone message warning of Covid-related delays, CDP3 called the RD&E Urgent Community Response service (UCR) for advice, as she was concerned about risks to Neil of using stairs. 
  17. The UCR, which is a community service which works with patients in their homes, triaged this on the same day as a request for an occupational therapist to assess Neil’s falls risk and his home to determine if it could be made safer. They also linked it to the referral from the GP for physiotherapy. CDP3’s referral summarised Neil’s physical health problems and also said he had significant hearing impairment making telephone communication difficult. The referral stated that Neil received Direct Payments for a personal assistant, Tracy (phone number included) who “visits frequently”. The referral was triaged and passed to RD&E’s Community Rehabilitation Team (CRT). Assessing the risk of fall within the home environment is an “amber” priority for the CRT, with a target of a visit within 1-2 weeks. 
  18. On 24th December, Care Direct Plus noted a message from UCR saying that they had, by telephone, made an arrangement to visit on Neil on 30th December. The occupational therapist who had telephoned Neil had spoken to Tracy, who advised that the assessment, to look at handrails for stairs, was not urgent and could wait until a few days after Christmas. 
  19. On Boxing Day (26th December 2020) Jemma visited Address A, insisting on going into the home.  Neil told her it was one of the best Christmases he had had. He said that Tracy had been drinking, but he had not. On 27th December Neil’s mother visited Address A, again hearing from Neil that it had been the best Christmas in years, which she interpreted as being because it was quiet and at home. 
  20. The URC team discussed this referral on 28th December and on 30th December initiated attempts to contact Neil on his home number and Tracy on her mobile. As they were unable to get through in the morning two staff visited Address A at 1pm, to learn of the homicide from a neighbour. The system by which Neil’s death should have been flagged on his RD&E record had not been used. 
  21. The following description of the homicide uses extracts from the judge’s remarks on sentencing, addressed to Tracy.  
    • “You and he decided to have a night watching films and it is clear that your intention was to drink heavily. You brought a mattress down to the living room so that you would not have to negotiate the stairs up to bed. You bought a medium sized bottle of pink gin at around 6pm and, between you, consumed virtually the whole of it in the space of less than 3 hours. As a result of a combination of the drinking and his medication, Neil was intoxicated to the point of being barely able to speak. … I am sure that you were also drunk, albeit less so than he was.”
    • “At c8.15pm .. you wrote in a What’s App message to your sister “Neil is getting on my last nerve. He can’t stop freaking out. Seriously needs to stop. My brain is hurting”. Between 8.30 and 8.46pm your smartphone recorded a drunken and rambling conversation which was taking place between you and Neil.”
    • “At the beginning of the recording there are bizarre exchanges in which you quiz Neil about using a sleeper hold on you, or strangling you, in the past. He accepts that he did so often when you put this to him, albeit he was clearly very drunk and what you said to each other in the course of the conversation was less than coherent.” 
    • “You accepted in evidence that you were driving the conversation. You were being very forceful with Neil. You can be heard abusing him ….. and threatening to punch him. You can also be heard slapping him repeatedly. He can be heard threatening to retaliate if you hit him again, but you do not stop and there is no real evidence that he did take action.  You also accepted in evidence that what you said in that conversation indicated that you wanted the relationship to end, …., wanted change and wanted to bring things to a head.” 
    • “Remarkably, you phoned your sister at 8:56pm, approximately 10 minutes before the stabbing occurred, and the phone was still connected when you stabbed Neil. You were in the kitchen. You complained to your sister that Neil was trying to bite you. She treated this as a bit of drunken mucking about …. You began demanding to speak to her son. In her evidence she described you as drunk, ranting down the phone to her …..” “You had no marks on your body to suggest that he had bitten you on the night in question, or harmed you in any way.”
    • “It appears from the evidence that when your nephew refused to take your call you put the phone down and picked up a large knife. There was then a pause during which your sister heard you tapping the knife on a surface in the kitchen and Neil was heard to tell you to behave. You then stabbed him. Your sister told the court that she heard nothing to indicate that you were having a row with each other and nor did she hear Neil being verbally or physically aggressive to you.” 
    • “I am sure that the reason why Neil did not sustain any defensive wounds was that your attack on him was sudden and unexpected…..Neil had no opportunity at all to defend himself, or was incapable of doing so because he was so intoxicated. Your sister gave evidence that he sounded astonished at what you had done.”
    • “I cannot be sure that Neil did not make any sort of movement towards you either before or after you picked up the knife. But it is clear to me that… Neil did not do anything which came close to justifying your stabbing him. … Your ability to repel him is amply demonstrated by your aggressive behaviour towards him in the past.”
    • “I accept that there was no planning or premeditation. You picked up a knife which was on a surface in the kitchen and acted after a short pause, and in the moment. ….You called 999 immediately, and you were then anxious to do what you could to save his life, although there was in fact nothing that you could do. I accept that you were and are remorseful although the degree of your remorse was not such as to prevent you from seeking to blame Neil for what happened in a way which exaggerated his behaviour towards you.” 


  1. This section summarises the events described above. Following sections analyse what can be learned, leading to conclusions and recommendations. 
  2. Over the six years before she killed him, Neil’s relationship with his ex-wife Tracy moved from no contact over two decades since their divorce to dependence on her for assistance with daily living, accepting her living in his home, managing his finances and representing his views to agencies. For at least the final three years he paid her as a Personal Assistant using his Direct Payment disability benefit. However, Care Direct Plus (run by Devon CC) who authorised this arrangement thought Tracy lived elsewhere and 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. 
  3. Over this period the couple had a series of contacts with the health service, police and Sanctuary Housing. These arose from physical and mental health conditions, occasional episodes of alcohol-related anti-social behaviour and missed rent payments. There was generally appropriate exchange of information among these agencies. However, the only aspect that Care Direct Plus was aware of was Neil’s physical disability, which had led to their involvement with him. They had personal contact only at two periods since Tracy returned to his life: in 2017 when the increased package of care through which Neil 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.
  4. The analysis which follows considers what can be inferred about the nature of the relationship, then examines the role each agency played, identifying both good practice and opportunities missed. Overall conclusions and lessons are drawn in the final part of the report. 


The nature of the relationship

  1. Neil had continued to tell relatives that he was happy with Tracy up to the end of his life. Some of the friends and relatives who considered her to be a negative influence acknowledge that this caused friction as he was “besotted” by her.
  2. 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. Although active as a young man, his health condition, which included chronic pain, later prevented this. During Covid friends say he became something of a recluse, although still having some face-to-face contact with family and phone contact via the landline. The judge said: ““From the evidence which I heard during the trial, it is clear that he was very much loved by his family including his children Alice, [her brother] and Jemma and his mother …. He was a committed family man. The loyalty of his friends … during his life was also clear for all to see.” 
  3. 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. As observed by friends and family, Neil was never aggressive or violent towards Tracy. They described her as often being under the influence of alcohol and often verbally aggressive and abusive towards Neil, belittling him and on occasion physically abusive. 
  4. The judge, in sentencing Tracy, said to her:
    • “Neighbours reported frequently hearing you shouting aggressively at Neil, swearing at him and abusing him, particularly in the 2 years or so leading up to his death. A common theme in what you were shouting was that he was lazy and useless because he slept a lot and did not help with the household chores. They did not hear Neil shouting back. Indeed they barely heard him at all.“
    • “Neil … was described by family, friends and neighbours as laid back and placid, although his sense of humour could be poorly judged. He could also say or do things which were irritating, particularly when he had been drinking.”
    • “You grew increasingly resentful of the fact that, although his health was better, he continued to rely on you to do all of the work connected with your home. You felt that he was now able to do a lot more, and it was only laziness which prevented him from doing so.” “It is clear that as the Covid 19 pandemic progressed, tensions between the two of you grew.” “The rows between you grew more frequent. [A friend], who was in a bubble with you, told the court that Neil couldn’t do anything right as far as you were concerned, that you would pick on every little thing, that your language towards Neil was harsh, and that occasionally he would see you shove or slap Neil. He said that, although you were both friends of his, he found it uncomfortable to be with you and he therefore visited less frequently than he used to.”
  5. In reference to elements of the trial defence case, the judge in sentencing said to Tracy: 
    • “On the basis of the evidence about strangulation, there had also been abusive behaviour towards you by Neil in the past, albeit you had behaved aggressively and abusively towards him on numerous occasions.” “But this is not a case in which you were driven to the edge by abusive behaviour by Neil, or you were responding to such behaviour at the time. You were frustrated with him, and with your circumstances more generally.
    • “The jury received evidence of a diagnosis of complex PTSD and Emotionally Unstable Personality Disorder in your case, although there was also evidence that a number of your problems arose from many years of abusing alcohol and drugs. I accept that these conditions may make a person hypervigilant and liable to overreact to a perceived threat. But I do not accept that these symptoms were a significant factor in your commission of the offence. This is not a case in which you overreacted to a significant threat which Neil posed. It is a case in which you were drunk, and your anger and frustration with Neil, which had built up over many months, led you to stab him when you could easily have walked away.”
    • “It was highly regrettable that you were prepared to suggest to the jury that, as part of a pattern of alleged controlling behaviour, Neil would have sex with you against your will. This was totally inconsistent with what you said to the police in interview when they pressed you on this topic. You told them, in terms, that “We haven’t had sex for about 2.5 years now”.
  6.  Tracy had persuaded Neil to give her access to his bank account. Neil told his mother that Tracy had use of his debit card on about one day a week. His family doubt he was aware of what she bought with it. Following his death, family reviewed his bank statements and other records and say they found patterns of spending that they think he would not have knowingly agreed, including significant payments to individuals connected to Tracy, and links to Amazon and PayPal accounts using her email. They also say that many childhood mementoes, which had been in the attic at Address A, had been disposed of without any consultation with them. The criminal investigation into the homicide did not include scrutiny of the couple’s financial records, so did not establish the extent of any financial abuse.
  7. 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. In an evidence statement in September 2021 Neil’s mother said. “I recently heard someone on the news talking about coercion and I think if I had heard this a year ago, I would have said this was happening to my son. Up until he died, I didn’t know it was a thing that existed. She controlled everything about him. I wish I had stopped it.” Most of the other witness statements reviewed by police described Tracy as being a controlling influence over Neil. 
  8. Reviewed as a whole, many aspects of this relationship fit patterns of control that have been seen in other domestic homicides[7], with the perpetrator: 
    • Encouraging a rapid escalation of the relationship after its (re)start.
    • Seeking to impress some family members favourably while detaching the victim from others. 
    • Avoiding some contacts with official bodies, but when unavoidable, presenting as themselves well and showing the victim as accepting or welcoming the situation. 
    • Benefiting from a gradual shift of control of communication and finance.
    • Presenting their own irritation as the victim’s mental health problem. 
    • Escalating verbal abuse when the context changed, as it did through Covid, the victim’s improved health, and an imminent Care Act review.
    • Behaving unusually just before the homicide, for example the phone recording and call.
    • Misrepresenting the victim after death.

How agencies responded to Neil and Tracy


  1. Neil had been receiving Direct Payments for assistance with daily living under the oversight of Care Direct Plus for several years before he renewed his relationship with Tracy in late 2014. With hindsight, her action, within weeks, in getting his second ex-wife Susan struck from their list of his family members appears significant. As Neil participated in that call, there was no reason to refuse the request, and the decision was checked with the duty team leader. The call, where Tracy said she too is his ex-wife, remained on file, but no Care Direct staff involved in later contact realised that Tracy had any past or current intimate relationship with Neil. 
  2. The contact indicated to Care Direct Plus a change in Neil’s domestic circumstances, so could have prompted the annual review of Direct Payments which was already overdue. Within that, he could have been invited to name other family contacts. Although he regularly saw his adult children and stepdaughter, Care Direct Plus only had contact details for his mother. The lack of alternatives may have delayed the 2020 review. 
  3. It was not until 2017 that Care Direct Plus contacted Neil to arrange a review. The Independent Living Advisor then followed correct practice in recognising that he was not recording payments he made appropriately, but would struggle to use online services, and so should transfer to a managed account. She arranged this on a visit, meeting Tracy but with there being no sign that she was not, as presented, a suitable Personal Assistant living at another address. A telephone check was made on the new arrangement after 8 weeks, in line with policy. 
  4. The Independent Living Advisor explained to Neil his responsibilities as an employer of a Personal Assistant, but the level of detail is not clear from the records. In 2017 Independent Living Advisors did not have standard written materials to pass to recipients of Direct Payments about their responsibilities as employers. This is now provided as standard, and publicly accessible online. It was Neil’s responsibility, not that of the Council or Disability Focus, to check Tracy’s suitability and confirm her address, as he had mental capacity to make decisions about who to employ. While Devon CC’s Direct Payments policy is unchanged since 2017, practitioner guidance and information available and shared with service users has been thoroughly reviewed and improved since then.
  5. The review of Direct Payments rightly prompted a social care assessment later in 2017, which in turn led to an occupational therapy assessment of equipment needed in the home. Permission to contact Practice P about his health was given by Neil. This would have remained valid in 2020, but was not used then, despite Care Direct Plus being concerned about inability to contact Neil. 
  6. Over the series of contacts in 2017, there were no indications of domestic abuse or difficulties in the relationship apparent to Care Direct Plus staff. The arrangement at this point may have been working well for both of them. The couple’s presentation of Neil’s care needs and the support provided by Tracy fitted the assumption that she lived elsewhere. However, there were several elements that should have prompted further exploration or future follow up.
    • The social care assessment records that Neil wanted a live in carer, and he had asked about the implications if Tracy moved in to the second bedroom. He was given the correct advice that this would need an “exceptional circumstances” approval. It would have been good practice to explore the reasons for this request more fully, and to note the question of who was living in the home as something to follow up in future. With hindsight, it seems likely that Neil and Tracy did not pursue the idea of getting approval for the “move” as this might have revealed that past claims were based on inaccurate information. 
    • Tracy described providing more hours of care for Neil than his Direct Payments budget covered. While the budget was increased, Care Direct Plus recognise that they should have clarified what she was doing as informal support in addition to the paid hours, and asked whether she wished to recognise herself as a carer and consider her own needs through a Carer’s Assessment.  She might not, however, have taken this up, to avoid revealing that her relationship with Neil was not as it had been presented to the Council. But based on what they did know, Care Direct Plus could have noted to follow up in future reviews. 
    • Neil told staff that Tracy helped him manage money and paperwork and mentioned the potential for her to get Lasting Power of Attorney. While there is no indication that this was set up, there is clearly a potential conflict of interest in a Personal Assistant paid through public funds, known to be assisting with financial management, holding such a role. This should have prompted further follow up from the Care Direct Plus Arranging Support Team. 
  7. Instead, Care Direct Plus attempted no further contact with Neil until late 2020. By this time the review was flagged as “overdue” on their system. The policy is annual reviews. In practice, records show that in Devon overall 51% of cases were reviewed in 2018-19 and 47% in 2019-20, the years in which Neil had no review. The service was thus failing significantly to meet its declared standard well before Covid had an effect.  Care Direct Plus does not monitor the proportion of clients going two successive years without review.  We estimate it to be between 2% and 26%[8], putting Neil in the minority repeatedly overlooked. The only prioritisation factor the Council has cited in explanation is change in activity. Thus, while Tracy continued to claim the same weekly hours from Neil as personal assistant, checking that the arrangement between them remained appropriate was deemed low priority. Such a basis of judgement seems inadequate in the light of what other agencies saw in those years. 
  8. In attempting the Care Act Review in 2020, CDP3 held on to the case without getting a meaningful response from Neil or Tracy, or seeking management support, for longer than expected practice. Family expressed concern that only one attempt was made to contact Neil’s mother and say that a request for call back could have been left on her answerphone without including confidential details. Eight weeks elapsed between allocation of the review, already flagged as overdue, and it taking place by telephone. This occurred straight after a text warning to Tracy that the Direct Payments could be affected, yet her excuses for previous delays in contact were accepted without being noted as a cause for concern. 
  9. CDP3 followed correct practice during the phone contact in confirming directly with Neil that he wished Tracy to speak on his behalf and that he was present during the call. On the basis of information gained through telephone conversations, she made appropriate referrals for visits by other teams. However, despite the clues in the 2017 records, and the initial resistance to contact in 2020, she did not enquire about where Tracy was now living or what degree of control she had of Neil’s finances. Nor were these flagged in the referral as matters to be checked on a home visit where it would have been easier to see Neil on his own. However, in the context of Covid restrictions, it is likely that had Tracy revealed in late 2020 that she was living at Address A, this would have been accepted as a suitable arrangement. 
  10. The Council is entitled to add conditions to a Direct Payment. One of these may be a requirement that the Direct Payment is not used to pay a person identified by the Council as “unsuitable to provide care and support to the person with eligible needs”. It is not, however, the Council’s role to proactively check suitability. This means that it is important that, in the contacts they do have, staff are alert to indications of abuse. In the period 2017-2020, training on the recognition of and response to domestic abuse formed part of wider mandatory safeguarding training for Devon County Council adult social care staff, including those in Care Direct Plus, but specific e-learning on domestic abuse was only mandatory for the Safeguarding team. 
  11. A collaboration between multi-agency partnerships in Devon and Torbay is developing a new domestic abuse training package. From 2023 this will be mandatory for operations staff in Devon County Council Adult Social Care. Care Direct Plus staff will be expected to complete levels 1 and 2. These aim to develop ability to recognise domestic abuse; understand responsibilities in safeguarding people; give confidence to provide a proactive and safe response to families seen as experiencing domestic violence and abuse. The content covers coercion, physical, sexual, economic, psychological and emotional abuse, indicators of coercive control and the role of DASH risk assessments. 
  12. A valuable aspect of the new training is that it includes a case study of a carer relationship (daughter caring for father) which explores abuse in the context of disability. Neil’s family emphasised the importance of tackling unconscious bias which may make front line staff less likely to recognise male than female domestic abuse victims.  The training reinforces the importance of professional curiosity. Qualified staff (including occupational therapists) will also take Level 3, which uses a workshop approach. The Council plans to ensure that relevant learning from Safeguarding Adults and Domestic Homicide Reviews can be fed into the training. 
  13. Care Direct Plus has introduced some relevant process changes. Additional Know Your Customer checks are now undertaken to ensure compliance with banking regulations. These essentials confirm a Personal Assistant’s identity but are not a credit check or DBS equivalent that indicates the person is of good character. Their intention is to prevent money laundering. There is an increased emphasis on seeking authorisation for exceptional circumstances where the person providing support is a family member living in the same household. (These were, however, relaxed during the COVID-19 pandemic with the initial review period extended from 12 to 26 weeks in most cases.) The responsibility for obtaining authorisation is with the care managers. Arranging Support Teams do not routinely check a Personal Assistant’s status.


  1. Neil received support from GPs and nurses at Practice P for many years, including for low mood. He, and Tracy when she transferred there in 2018, consulted on numerous occasions about various health issues. They had the same registered GP, Dr ZZ, who saw them on the majority of visits.
  2. Domestic abuse and sexual violence (DASV) are associated with higher prevalence of a number of health conditions[9] including fibromyalgia[10].  However, NHS Devon notes that the evidence base for comorbidity of abuse and health conditions is derived from research into female patients[11], with little on male, non-binary and trans patients.  Whilst research in this area continues[12] NHS Devon is advising Primary Care clinicians in respect of male patients, to use their knowledge of indicators for female patients in combination with their professional/clinical judgement and with an awareness that male victims of abuse are less likely to talk about threat and fear despite the risk they are under. 
  3.  Both Tracy and Neil presented with clinical indicators that should prompt a trained clinician to consider enquiry as to whether they have current or past experience of abuse and whether they would benefit from support to address these traumas.  A key aspect of NHS current DASV strategy is to make training available to all 121 surgeries across Devon, on recognising clinical indicators of DASV. Unfortunately, neither Practice P nor Practice Q were pilot sites for training. Tracy’s primary care record was flagged to show past notification from police of her as a victim of domestic abuse.  The flag remained on her file when she transferred to Practice P.  However, with no specific medical reason for staff to speak to Tracy about the flag, or clear practice recommendations, this was not something that was considered in consultations with her.  The Practice has, following participation in this Review, proactively sought training on domestic abuse from Devon’s domestic abuse team.
  4. In June 2018, a few days after Tracy transferred to Practice P, there was a missed opportunity to discuss the inappropriate drug use risk to Neil when he disclosed that his ex-wife gave him amphetamines. (This may have been from her own medication, but family think it may have been illicit drugs). Her own medical records had not been transferred at that point, nor her new patient check completed, so this may not have been apparent as an action by a carer. It could also have prompted further discussion and consideration of him as an adult in need of safeguarding. However, it is likely that Neil, who reported positive effect of the drugs, would not have given consent for a safeguarding referral at this point. 
  5. Dr ZZ knew Neil well and was confident that he had capacity to make decisions for himself regarding his health. However, one of the means of contact used by Practice P for contact with Neil was text, which would have been seen first by Tracy as Neil did not use a mobile phone. While Tracy often attended Neil’s consultations, Dr ZZ saw this as supporting but not taking over his medical care, with no indication that she had undue influence on his medication. Neil discussed medication directly with Dr ZZ in 2020 and felt he was on the appropriate dose. He believes Neil would have been able to tell him in confidence if he had concerns or felt coerced by anyone. However, family question this view, and think Neil would have found such disclosure difficult. 
  6. Positive family or partner support in contact with health services is important to a lot of patients.  In the absence of other factors, Tracy’s involvement was not considered to be an indicator of coercion or control. On reflection, the Practice recognises a lack of professional curiosity in respect of the tensions between Neil and Tracy indicated in his 2019 referral to mental health services. At this point Tracy had been known to them as a patient for only 8 months. It is also regrettable that whatever communication error led to the report from Devon Partnership Trust back to the GP not being noted by the Practice was not spotted and followed up. Practice P is looking at their process for checking the outcome when patients are referred to specialist services due to concerns about their mental health. 
  7. Practice P was aware, when she transferred to them in 2018, that Tracy was a carer for Neil, but there is no evidence that consultations with him included enquiries about how the care arrangements were going – even when tension between them was cited in his 2019 referral to mental health services. Neil’s family highlighted the six-week period in May/June 2020 when Practice P tried to contact him to arrange a medication review, using means of communication which family suspect were, by then, in effect controlled by Tracy. On reflection, Practice P recognise the need to consider that what may present as support can instead be coercion and that GPs need to consider the opportunity the patient has to speak to a GP alone. They have also reflected that as part of holistic care GPs could ask patients about care arrangements. 
  8. Tracy had access to a DPT-commissioned counsellor through Practice Q. The counsellor was aware of Crown Prosecution Service guidance on therapeutic support for victims of sexual violence involved in a criminal prosecution but felt unable to offer this due to the nature of Tracy’s mental health presentation. Referral by her then GP to the SARC was good practice, as they would have been able to offer or refer to specialised support if she had engaged more fully with them. The support in attending court which she did accept from the SARC was relevant to her situation. 
  9. Practice P is looking at how they offer to talk to and support patients who have been victims of abuse. They hope to benefit from a training and support service which NHS Devon is commissioning for GP practices, to start from April 2023. This will increase understanding of the impact of interpersonal trauma such as sexual abuse and ability to talk to patients in a trauma informed way. It is notable that previous domestic homicide reviews in Devon identified learning on the potential role of primary care practitioners in identifying domestic abuse and that this learning formed part of the case for commissioning the new service. The new service will combine training for GP teams with an offer of support for those referred, including adults who are seeking support for their own behaviour in relationships. A learning point from this Review is that the new service should monitor uptake by male patients. 


  1. All clinical staff at RD&E are trained in recognising domestic abuse, with additional training and support for those in areas such as the Emergency Department. The Trust took appropriate steps when Tracy came to the Emergency Department in a distressed state in November 2014 and alleged domestic abuse by Gary. This led to a referral to MARAC and for mental health follow up. 
  2. During the 2015 incident RD&E collaborated with police to try to engage with Tracy when she attended the Emergency Department with a glass injury after she and Neil had locked themselves out of Address A. The main concern noted was that she might self-harm. Neil is recorded as asking “What do I do?”. More could have been done at that point to ask him about his own situation and offer support. The role of alcohol in the incident, and possible referral to specialist help, could also have been flagged to Tracy’s GP. 
  3. Neil was known to RD&E over a long period, mainly through his contacts with the Urology and Pain teams. While there was nothing in his presentation to signal a domestic abuse risk, there were several missed opportunities to enquire about his situation or offer support during the last three years of his life. 
  4.  He visited the Emergency Department in June 2017 with glass injuries ascribed to heavy drinking, and in April 2019 in a confused state. Emergency Department staff are trained to ask questions about domestic abuse, using a targeted approach to decide whether to make further enquiries. While neither incident fitted the criteria for this, the first indicated alcohol misuse which could have led to an offer of support, either through referral at the time or through alerting the GP practice when reporting his emergency treatment to them. 
  5. Neil had planned surgery at the start of 2020 and an outpatient appointment to discuss further surgery two weeks before his death. Since 2016 the RD&E has had a standard question in pre-operative paperwork asking whether the patient feels frightened by their partner or someone at home, and from 2018 this has been mandatory for day case surgery too, regardless of gender. However, it was not completed for either visit, nor was any reason for not asking recorded. This failure to follow policy meant missed opportunities to invite Neil to disclose any concerns, at a time when his wider contacts were limited by Covid restrictions. His family have pointed out the importance of specialities concerned mainly with men’s health giving as much attention to domestic abuse as those for women. 
  6. The Trust now employs a Health IDVA providing support to patients and staff at risk of domestic abuse. She has provided bespoke training across a diverse number of areas in the trust to ensure that staff are confident in asking and acting upon the domestic abuse questions. This has raised awareness and staff frequently contact the IDVA or Safeguarding team for support for patients. Domestic abuse questions are easily accessible within patients’ electronic hospital records. In a planned future system update staff will have reminder best practice advisory alerts until the questions have been completed or a rationale given for why they cannot be. 
  7. RD&E staff in the UCR and CRT teams responded well to the referrals for Neil which reached them just days before his death. From the information passed by Care Direct Plus this met the criteria for a visit within two weeks, ie 6th January 2021, but a visit was arranged for 30th December, which was within 3 working days. Staff, unfortunately unaware of the homicide, were diligent in attempting contact by phone and through a site visit on that date. 


  1. The Trust’s Mental Health Assessment Team saw Tracy promptly when her GP referred her in 2016. This included a detailed risk assessment and enquiry about family circumstances and abuse and noted that she said she had stopped binge drinking and using illegal drugs. At this stage Tracy said she found Neil supportive but spoke of her “unpleasantness” towards him. While this language would not trigger safeguarding concerns at that stage, it is relevant to later interpretation of risks in the relationship. She was not, at this stage, being officially paid as his Personal Assistant, so this was not an opportunity to identify that as problematic. The decision to refer Tracy to support from Rethink Mental Illness was appropriate to the assessed risk but had no benefit in practice as she did not respond to their standard, one off, invitation to make contact. 
  2. The Mental Health Assessment Team assessment of Neil in 2019 appears to have been conducted with Tracy present, despite her anger with him being cited in the GP’s referral, and her words about “feeling like she wants to kill him at times” being noted in an initial call about the appointment. Nothing was noted about the tone of voice Tracy used – whether it could have been heard as joking or as carer fatigue. Had these words been used by a man about his female partner, it is possible that the clinician would have recognised the risk of domestic abuse. 
  3.  No link to Tracy’s previous record of mental health problems appears to have been made. While the assessment did explore Neil’s feelings about having his ex-wife as a live in carer, there is no clear record that he was asked about potential abuse. Nor does the record show that her role as a paid assistant with access to his bank account was identified. The recommendations to his GP did not include any specific response to the anger cited in the referral. Nor, if it was assumed she was a voluntary carer, was signposting to carer support offered. 
  4. Clinicians in Devon Partnership Trust have access to safeguarding training which includes detailed information on domestic abuse. The Trust now has access to Mental Health IDVAs. Their roles are becoming established in the Trust. They are able to support patients and staff members who have concerns around Domestic Abuse and Violence. 


  1. Police action was appropriate and proportionate in their contacts with Tracy and Neil over the period covered by this Review. 
  2. In the November 2014 incident involving her former partner, Tracy was offered but declined support both at the time and following referral to the MARAC. Her address at the time, Address B, was flagged with a warning marker on police systems. 
  3. In responding to the events arising from the couple breaking into Address A after losing the keys in May 2015, police acted in line with Force policy and guidance, completing a DASH risk assessment despite Tracy’s refusal to engage, recording the incident as Non-Crime Domestic, and enabling her to report historic sexual assaults. A further action of completing a Vulnerability Screening Tool[13] for Tracy following her disruptive behaviour at the hospital could have been taken, but the details were already known to health services so this would not have made a difference in practice. 
  4. Police contact with Tracy during the trial arising from the historic allegations was in line with good practice, with appropriate contact with both the investigating officer and the SOLO, and the offer of further support from an ISVA. 
  5. Police attending Address A in March 2018 met a chaotic situation with both Neil and Tracy heavily intoxicated and neither ready to engage. In driving Tracy to stay with her sister after she mentioned Neil holding her throat they responded to her as a potential victim, provided protection from any further assault, and completed the DASH assessment in line with policy. 
  6. The police decision not to arrest Neil on suspicion of assault was reasonable. It was unlikely that it would have reached the threshold for him to be charged without a statement from Tracy, given the lack of visible injuries or independent witnesses. However, Force policy and guidance on domestic abuse at the time was not followed in that the decision about arrest was not explicit on the incident log or crime report, so not reviewed by a more senior officer. Tracy’s role in assisting Neil with daily living was not apparent to the officers attending, so no assessment of his vulnerability was made. He had not disclosed any abuse by her, and there were no witnesses present, so no DASH was completed for him. This was in line with policy and guidance on the DASH process, which applies regardless of gender. 


  1. Sanctuary did not keep records of who was living at Address A up to date, so had limited information about Neil’s situation and potential vulnerability. He was not the original applicant for the tenancy but had been added as a joint tenant to Susan, and his 2015 request to change this to a sole tenancy was not followed through. His son, who had lived there for a short time around 2012, remained listed as a household member, but despite several contacts which indicated that a woman was living with Neil at Address A, no enquiries were made of her name or status.
  2. Sanctuary took appropriate action in May 2015 to repair the house, liaise with police, listen to neighbours’ concerns and remind Neil of his tenancy obligations. However, the disturbance was treated as noise nuisance, with the potential for domestic abuse not recognised. Sanctuary recognise that they should have established who the woman involved in the incident was, and whether she was the “friend” Neil told the housing officer was now living at Address A. They should also, in line with their procedures at the time, have assessed the vulnerabilities of those involved. 
  3. Sanctuary’s response to a neighbour’s concerns in June and July 2016 was not in line with their procedures at the time.  The initial call was treated as a report of noise nuisance. More questions should have been asked about the pattern of such incidents, and whether the caller knew the name of the woman concerned. Follow up with the complainant was outside the guidance of 5 working days. While the housing officer respected the wishes of the complainant to remain anonymous, this should have been discussed further, including assessing their vulnerability and providing reassurance. As consent was not given by the complainant to contact Neil, his version of events was not obtained, or his vulnerability, or Tracy’s considered. The letter reminding him of his tenancy terms was not saved on the correct internal system. 
  4. Sanctuary’s Income team followed process in their actions during 2017, including refusing to take a payment from Neil’s card without him present. However, Sanctuary recognise that more professional curiosity should have been shown as to his apparent lack of awareness of the state of his finances, his state of health, and why Tracy was seeking a Power of Attorney. The single visits to Address A in 2018 and 2019 did not note Tracy’s name or role or include any questions about Neil’s health. During 2020 the Income team accepted being unable to reach Neil directly and did not consider possible implications of Tracy changing to email as her contact method. Good practice would have been to make the Housing team aware of a possible safeguarding concern at some point in this sequence. The Income team has amended their guidance on taking card payments in the light of learning from this Review. 
  5. At the time of the homicide all Sanctuary staff had to undertake basic safeguarding training, but domestic abuse training was not mandatory for housing or frontline staff. Domestic abuse was discussed as an addition to case management of anti-social behaviour (ASB). The ASB policy and procedure included the definition and outline expectations relating to domestic abuse, but this did not form part of a separate standard training package or induction process for Housing Officers.  
  6. Since the homicide Sanctuary has strengthened its response to potential incidents of domestic abuse.  It now has a standalone domestic abuse policy and procedure, which sets out expectations of housing staff with key targets and timescales.  Specific guidance regarding indicators of abuse is available for all staff. During 2022 Sanctuary is rolling out DASH risk assessment training to all Housing Officers and Area Managers, with the aim that all will have attended by the end of the year. 
  7. In 2021 Sanctuary set up an Antisocial Behaviour working group which has representatives from front line housing staff and senior managers, including the call centre.  This group is tasked with actioning quick wins through revisions to practice but also instigating larger national changes. These include a review of the training of Housing Officers.  ASB champions have been identified to support Housing Officers. 

Other support available


  1. The judge, on sentencing Tracy, said that “It was .. clear from the evidence that alcohol and drugs had played an important role in your life for a number of years and that they contributed significantly to your volatile personality and behaviour.” “Your sister told the court that you and Neil were in the habit of binge drinking on a regular basis.” Despite this there is no record of either Tracy or Neil ever being referred to substance misuse services in Devon. 
  2. Until 2018 the provider in Devon for adults with substance misuse issues was RISE, which accepted referrals by telephone or in person at three hubs across Devon, including one in Exeter. The RISE team provided services including an open access mutual aid group at a base in Town H. These services are now delivered through Together, whose referral routes and services are summarised in Appendix E. 
  3. Had either Tracy or Neil been referred to RISE by any service concerned about harm occurring to them while intoxicated, they would have had an assessment and been passed to a Recovery Worker. (Couples who are referred are allocated different workers.) The Recovery Worker would have completed a Risk Assessment and Management Plan and a care plan that looks at individual holistic goals and includes goals related to substances, health, relationships and pro social activities. They would have been seen regularly by the Recovery Worker and supported in managing their alcohol use. Relevant support and signposting would have also been available around domestic abuse and safeguarding.  


  1. The annual crime survey for England and Wales found a quarter of all domestic abuse crimes in 2018/19 were committed against a male victim. In the same year 16 men died at the hands of their partner or ex-partner compared with 80 women, according to the Office of National Statistics (ONS) data. The crime survey found that that 3.8% of men (equal to 786,000) and 7.5% of women (1.6m) were victims of domestic abuse. Mankind ( and the Mens Advice Helpline are national services dedicated to offering support to male victims. 
  2. Splitz have offered support to male victims of domestic abuse, and victims with disabilities, since taking on the contract for delivering domestic abuse services in Devon in 2014. 
  3. Since 2014 a domestic and sexual violence and abuse forum has existed under the East & Mid Devon Community Safety Partnership. The partnership has been actively engaged with local and national partners including SAFE (Stop Abuse for Everyone) in Devon and Splitz. An example of the work they conduct is a 2016 press releases placed into the local “Herald” Newspaper outlining what Domestic Abuse is from both a male and female perspective, as well as signposting organisations who can provide support for both victims and perpetrators. 
  4. Between October 2017 and January 2018 Splitz, in conjunction with East and Mid Devon district councils and Devon Rape Crisis, ran a campaign to highlight services by advertising on the back of Argos till receipts in stores in the area. Local radio and social media have also been used to promote awareness of domestic abuse and relevant services. While Neil did not use social media or do the shopping himself, such wider publicity might have reached his male friends, who were aware of Tracy’s behaviour to him. However, his female relatives, while commending the idea of publicity through shops, said it was important that women know that services for men are available, so they can find out what help is available for male relatives or friends they are concerned about. “Men won’t be as quick to pick up the phone as a woman would be.”
  5. Had either Neil or Tracy asked for rehousing due to domestic abuse East Devon District Council housing department would have secured emergency accommodation for them whilst enquiries were undertaken, probably away from Town H. Although the longer term outcome would have depended on the facts provided the threshold for accommodating in the first instance would be low, based on the Housing Options team having a ‘reason to believe’ that there would be a homeless/domestic violence situation.


  1. The judge, in sentencing Tracy, said “The jury has found you guilty of manslaughter. They rejected your argument that the stabbing was an accident and/or that you acted in lawful self-defence. But they were not sure that you intended to cause him really serious harm.” It is not the role of this Review to question that verdict or reach a conclusion on Tracy’s intentions. 
  2. 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. It is not possible to be sure whether she also experienced physical violence from him. She had sufficient knowledge of support services and freedom in communication and movement to report this if she chose but did not. 
  3. While tensions in the relationship were known to some extent by family, friends, and some agencies, the homicide came as a surprise to all, and could not have been predicted. Nor could action by agencies in 2020 have prevented it unless Neil had sought help to change his situation. It seems unlikely that he wanted to separate from Tracy: he told family that his Christmas with her, shortly before the homicide, was a happy one. 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. 
  4. 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, Neil had little opportunity to see publicity for them, and his family, although concerned at Tracy’s control over him, and aware of domestic abuse publicity aimed at women, did not know that help was also available for men. 
  5.  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. 

    The Covid pandemic played an indirect role in the tragedy. Neil’s access to public services was not significantly affected by Covid.  Both he and Tracy had a series of health service contacts over the year. Care Direct had, at the time of the homicide, arranged an in person visit to look at adaptations to the home. However, concern about risk of Covid infection, plus rules limiting external contacts, set the context for Tracy’s growing frustration with Neil, and gave her an excuse for keeping his family at a distance.

Lessons to be Learned

  1. From the specific points identified in the analysis above, some themes emerge: 
    • 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, as 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. While policies recognise that this occurs, unconscious bias can be a barrier to spotting it. With 1 in 30 men experiencing domestic abuse each year[14], it is important to find ways to raise awareness of the risk and of the availability of help.
  2. As shown in the analysis above, 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 Practice P 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.
    • Sanctuary Housing has amended their process for taking card payments to include consideration of whether the card holder is vulnerable and at risk from potential financial abuse.
  3. Lessons are also being addressed through developments currently in progress:
    • 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 Practice P is proactive in booking this.
    • Domestic abuse service FearLess (formerly Splitz) is clear that they are an all-inclusive organisation, recognising that Domestic Abuse can affect anyone. They have deliberately designed their new website to emphasise the all-inclusive nature of the service. They have a detailed plan for 2023 communications and marketing, which includes specific periods of heightened awareness for certain groups, including men. One of their significant aims is to deliver myth busting sessions for the sector during the next year, running this across their social media. FearLess undertakes to ensure this includes a specific awareness raising around the fact 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.


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

R1 When capacity in Devon CC prevents adherence to the policy of annual reviews of Direct Payments clients, 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 staff within [Practice P] about safeguarding and risk.

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

R7 Increase confidence of staff at pre-operative clinics, including those for men’s health specialties, in asking questions related to domestic abuse.


Alphabetical list of the abbreviations and anonymised staff names used in this report. 

Address A      Neil’s home during period covered by Review

Address B     Tracy’s home in 2014

ASB                anti-social behaviour 

CDP1             Independent Living Advisor, Care Direct Plus

CDP2, CDP3 Social Care Assessors, Care Direct Plus 

COPD            chronic obstructive pulmonary disease

CRT                Community Rehabilitation Team 

DAO               (Police) Domestic Abuse Officer 

DASH             Domestic Abuse, Stalking and Harassment (risk assessment tool)

DASV             Domestic abuse and sexual violence 

Dr WW           GP in Practice Q

Dr ZZ              GP in Practice P

IDVA               independent domestic violence advisor

ISVA               Independent Sexual Violence Advisor

MARAC          Multi Agency Risk Assessment Conference

PIP                  Personal Independence Payment 

Practice P     GP practice in Town H, attended by both Neil and Tracy in 2020

Practice Q     GP practice in Town H, attended by Tracy until 2018

RD&E             Royal Devon and Exeter Hospital 

SAFE             Stop Abuse for Everyone

SARC             Sexual Abuse Referral Centre 

SOLO             (Police) Sexual Offences Liaison Officer 

Town H         Town in which homicide took place

UCR               Urgent Community Response service

Appendix A: Safer Devon Partnership oversight of Domestic Homicide Reviews

The Safer Devon Partnership provides the strategic leadership for addressing community safety matters across Devon, aiming to work together to enable the people of Devon to feel and be safe in their homes and communities. Partners include the four Community Safety Partnerships in the county, the Police, the Fire and Rescue service, NHS Devon, the Office of the Police and Crime Commissioner, Probation 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 a Core Group. At the time of this review the Core Group included representatives of: 

  • Devon County Council 
  • Lead Officer for DHRs, Devon and Cornwall Police
  • HM Prison and Probation Service: Head of Devon and Torbay
  • Principal Social Worker, Commissioning, Adult Commissioning and Health, representing Torbay and Devon Safeguarding Adults Partnership
  • Head of Practice, Social Work Academy, Quality Assurance, Reviewing & Safeguarding Service, Children’s Social Care, representing the Devon Children and Families Partnership
  • Head of Safeguarding, NHS Devon Integrated Care Board
  • Managing Partner, Safeguarding, Devon Partnership NHS Trust
  • Chair of the relevant Community Safety Partnership (CSP) when decisions are taken on any DHR falling within the CSP area.
  • Representatives of other agencies may be invited to join the Core Group for a specific purpose, at the discretion of the Chair.  

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

  • Members of East and Mid Devon Community Safety Partnership via its Chair
  • Chief Executive and Community Safety Manager in East Devon District Council
  • Safer Devon Partnership Executive Group
  • Members of the Devon Domestic Abuse Local Partnership Board
  • Chair of the Torbay and Devon Safeguarding Adults Partnership
  • Chair of the Devon Safeguarding Adults Review Group
  • Chair of the Devon Children and Families Partnership (Devon’s Local Safeguarding Children’s Board) and the Chair of its Serious Case Review Subgroup
  • Police and Crime Commissioner for Devon and Cornwall
  • Domestic Abuse Commissioner for England and Wales
  • All organisations contributing evidence (#13).

Independent Chair / Report Author

The Panel’s Independent Chair and report author has knowledge of community safety, partnerships, domestic abuse and experience 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 never been employed by any of the agencies concerned with this Review.

Appendix B: Individual Management Reviews

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

  • the chronology of relevant interaction with the victim and / or perpetrator;
  • what was done or agreed;
  • whether internal procedures were followed; and
  • conclusions and recommendations from the agency’s point of view.
AgencyIMR writerNotes
Devon and Cornwall PoliceDetective Sergeant, Criminal Case Review UnitSources: UNIFI and STORM police systems, Police National Computer, records of MARAC meetings
Devon County CouncilCare Direct Plus Manager (Northern Devon) Sources: Care First (social care records). Interviews with staff directly involved and Adult Social Care managers. 
Devon Partnership Trust Deputy Director:  Safeguarding & Public ProtectionElectronic patient records reviewed and relevant policies considered to ensure practice aligned with policy.
Practice PGP Safeguarding Lead for the practice, in consultation with Practice Manager, NHS Devon DASV Lead and Safeguarding Primary Care team.Sources: medical records from 2015-2020Discussion with registered GP for both Neil & Tracy.
Royal Devon University Hospitals NHS TrustSafeguarding Nurse SpecialistSources: hospital electronic records, Urgent Care Response community team notes. 
Sanctuary HousingOperations Manager plus Area Housing ManagerSources: customer contact systems, anti-social behaviour records, other documents. 

Appendix C: Involvement of family, friends and support networks

Contact between the Review and Neil’s relatives was facilitated by an experienced member of Victim Support Service Homicide Team (VSS), who was consulted by the Chair as to the family’s preferences.  VSS explained to them before the trial that a DHR would take place and that they could choose how to be involved. Information provided to the family by VSS included the Home Office leaflet for families. The outcome was that in conducting the Review and sharing its conclusions the Panel engaged with the family through Alice, the daughter of Neil and Tracy, Jemma, his step-daughter and Neil’s mother. 

At the request of the police, the Chair had no direct contact with the family until after the trial, but information on the Review process and timing was passed to them via VSS. Neil’s son, via VSS, declined contact initially and when the draft report was discussed. Alice agreed to provide her brother with information about the Review should he wish it. 

In May 2022 the Chair held a video meeting with Alice and Jemma, who chose to be together at Jemma’s home for the call, with the VSS worker present on the call and speaking to them privately after it. The DHR Co-ordinator was present to take notes. By mutual agreement, an audio recording was made and transcribed. Prior to this meeting the draft terms of reference for the Review had been shared and explained by VSS, and no changes were requested. Neil’s mother chose not to be involved with the Review at this stage but later gave consent for police to share her statement.

Following this meeting, the DHR Co-ordinator, in consultation with the police, sought contact with Tracy’s sister and two male friends of Neil. One of the friends chose not to contribute, and the others did not respond. Police had also checked at the start of the Review whether Tracy’s former partner Gary wanted to contribute information. He chose not to. 

During the period of focus, Neil was dependent on disability benefits as his health condition meant he had been unable, for many years, to continue to work. Tracy was paid as his part time personal assistant, and sometimes undertook casual work at care homes. No insights from colleagues or employers were therefore available to the Review.  

Through VSS the Chair kept the family informed of the timetable of the Review. In December 2022 the Chair and DHR Co-ordinator met Alice and Neil’s mother and stepfather in a council office in Town H to discuss the draft report, which they had received in advance. Jemma, also invited, was unable to attend on the day. The Panel member for East Devon District Council joined part of the meeting discuss family observations on availability of local publicity for services available to male victims of domestic abuse. The VSS worker was present and spent time with the family afterwards, passing on their comment that it had been a very productive meeting. 

Following the meeting, the draft report was amended to reflect family comments or clarify explanations in response to points they raised. Recommendations were adjusted. 

Appendix D: Direct Payments Policies

This explanation is drawn from Devon County Council (DCC)’s Individual Management Review. It is based on the council’s ASC (Adult Social Care) Policy 06/07/2020. The main difference between this and the previous policy (dated 06/05/2016) is that 2020 one includes much more detail, process, and practice guidance. Previously, more guidance could be found in The Care Act 2014; the Care and Support Statutory guidance and DCC’s ASC practice guidance. ASC practice guidance is now incorporated into the current policy. There are not any changes in principle.  

Self-Directed Support

The Care Act states that we need to consider promoting independence and reducing the needs that a person has at every opportunity. Self-Directed Support promotes people’s independence by increasing the level of choice and control they have over support services they receive, improves their experience of these services and improves the benefits and outcomes for their health and wellbeing. The Council will encourage the person’s choice and control over their support arrangements wherever possible so funding can be used flexibly to create innovative, personalised packages of care that meet their identified outcomes.

A Direct Payment and responsibilities

A Direct Payment will usually be accessible on a Devon Card. The person, or an appropriate person acting on their behalf will take full responsibility for arranging the support they need. The Personal Budget can only be spent on activities that meet the person’s assessed needs. 

Having more choice and control means having more responsibilities. The person managing the direct payment must be able to understand the contractual arrangements with providers and ensure support needs are always covered. The responsibilities increase if the person is directly employing a Personal Assistant because they take on all the responsibilities of an employer and need to be able to understand and manage them efficiently and legally. The care manager will ensure that Self-Directed Support is an appropriate way of meeting the person’s needs; there is an appropriate person to manage the Direct Payment; and the money is used in ways that are appropriate and not prohibited by the Care Act Regulations (see exceptional circumstances).

The Council is entitled to add conditions to a Direct Payment. One of these may be a requirement that the Direct Payment is not used to pay a person identified by the Council as unsuitable to provide care and support to the person with eligible needs.

Exceptional circumstances

The use of a Direct Payment to pay a family member living in the same household as the person with care and support needs will not be permitted except in exceptional circumstances. The Covid-19 pandemic may be the cause of such exceptional circumstances. Where the care manager believes these exceptional circumstances exist, they can submit a request to their line manager. The request must evidence clear reasons for the request. Any agreement for exceptional circumstances must be approved in writing by the Council. All exceptional circumstances agreed will be as a short-term solution for up to three months after which the arrangements will be reviewed. 

Personal Assistants (PAs)

A PA is an individual support worker who is either ‘employed’ or ‘self-employed’. The Council requires Direct Payment recipients to purchase and maintain appropriate Employer’s Liability Insurance for all PAs and the cost will be included in their Personal Budget. 

All PAs engaged must be suitably qualified. PAs are not subject to the same regulatory requirements as other care providers. The cared for person or the Nominated/Authorised person must be prepared to have oversight and monitoring of the quality of care provided by a PA. If any concerns arise, these should be dealt with by the person responsible for managing the Direct Payment in the first instance. If there is evidence of abuse or neglect of someone who is unable to protect themselves because of their care and support needs this must be reported to Devon County Council Care Direct. 


The Council’s Arranging Support Team will provide initial support to new Direct Payment recipients. If after three months the person managing the Direct Payment is unable to manage independently, the person will be recommended for commissioned services. The Council will review the management of the Direct Payment at 8 weeks and annually. A review of the person’s support needs may be triggered if the monitoring of the Direct Payment raises concerns about the person’s support needs.


CDPE – Care Direct Plus Eastern. Hub covering eastern area in Devon made up of the following teams:

  • ART- assessment and review team, part of CDPE made up of social care assessors completing telephone-based assessments and team managers.
  • CHSCT- community health and social care team made up of team managers, social care assessors, social workers and occupational therapists. This team completes face to face assessments for more complex assessments; assessments that require longer term care management; or when telephone assessment is not considered safe.
  • AST- arranging support team, part of CDPE, with three parts- direct payments, commissioned services and placements. Made up of arranging support advisors, arranging support coordinators and team managers.

Appendix E: Drug and Alcohol Referral

Referral routes (2022) for drug and alcohol services in Devon.

[1] Pseudonyms are used for the two GP practices involved to support anonymization of this homicide.  

[2] The Royal Devon and Exeter NHS Hospitals Trust became part of a larger Trust (Royal Devon University Healthcare NHS Foundation Trust) in April 2022. This report uses the abbreviation RD&E to refer, according to context, to the Trust as it was at the time or the hospital site in Exeter.

[3] The MARAC is a meeting of professionals from safeguarding agencies to discuss high risk domestic abuse cases with a view to formulating appropriate plans to safeguard victims and offer support.

[4] A specially trained Police Officer whose role is specifically to provide support to a victim of serious sexual offences.

[5] The reason for a patient changing to another GP practice is not normally recorded. 

[6] The front door lock was changed by Sanctuary following the 2015 incident when the door was damaged.

[7] See, for example “In Control” by Jane Monkton Smith, Bloomsbury 2021

[8] If the 49% missed in 2017-8 were prioritised in 2018-9, 2% (49-47) were missed again. Alternatively, if the chance of being missed in 2018-9 was independent of whether reviewed in 2017-8, the chance of being missed in both was 0.49*0.53 (=0.26). 





[13] A process of identifying vulnerabilities, grading risk and signposting to relevant agencies

[14] National crime survey for England and Wales, year to March 2020, age 16-74.