Executive Summary June 2018 – Ms X, died November 2014
- This report of a Domestic Homicide Review undertaken by the Safer Devon Partnership on behalf of Northern Devon Community Safety Partnership is to review the death of Ms X, who was killed by her son Mr X in Devon in November 2014. Mr X was convicted of murder in October 2015 and is serving a prison sentence.
- The key purpose for undertaking Domestic Homicide Reviews is to enable lessons to be learned from homicides where a person is killed as a result of domestic violence. In order 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.
- The report examines engagement between agencies and both Ms X and Mr X over the period 2009 to2014. Ms X had lived abroad for the six years before that, with minimal contact with her son. While her early adult life and his childhood were troubled, the Panel judged that investigation of the distant past would not further the purpose of the review, which is to improve current services.
- The review was conducted by a panel with an Independent Chair and representatives withrelevant professional roles from:
- Devon County Council
- North Devon District Council
- Devon & Cornwall Police
- Northern Devon Healthcare NHS Trust
- Devon Partnership NHS Trust
- NEW Devon Clinical Commissioning Group
- The Independent Chair has knowledge of Community Safety Partnerships and domestic abuse, experience of previous Domestic Homicide Reviews and has never been employed by any of the agencies concerned with this review. None of the panel had any direct connection with the people,events or decisions covered by the review.
- The review report draws on information and analyses from the agencies which were involved witheither the victim or her son. (A check of other agencies, including Devon County Council and local domestic abuse services, found no contact.) The public bodies involved were:
- Devon and Cornwall Police
- Devon Doctors (out of hours general practitioner (GP) service)
- Devon Partnership NHS Trust
- National Probation Service (Devon & Torbay Local Delivery Unit)
- NEW Devon Clinical Commissioning Group (in relation to primary care)
- North Devon District Council
- Northern Devon Healthcare NHS Trust
- Royal Devon and Exeter NHS Foundation Trust
- South West Ambulance Trust
- In addition, the review drew on extensive information provided by:
- RISE Recovery – a voluntary sector substance misuse service;
- The local charity then known as Barnstaple Poverty Action Group which provided advice and support to Ms X during 2009 and 2010; and
- ZZZCO1 a family run company which provides accommodation and housing support to vulnerable people, which was Ms X’s landlord and provided housing support from late 2009 until her death.
- After being notified of this domestic homicide, Safer Devon Partnership took the initial steps required for a review, establishing joint chronology of agency contact with the victim and perpetrator. The confirmation of terms of reference and preparation of individual management reviews by agencies was deferred until after the trial. Individual management reviews (detailed reports to the panel required from public bodies with significant contact) were prepared by Devon and Cornwall Police, Devon Partnership NHS Trust, North Devon District Council and RISE Recovery.
- The panel drew up an overview report based on these reports, other information about local services and conversations with family and friends of the victim. In its analysis, the panel addressed equality and diversity factors by recognising the impact of disability resulting from physical and mental health problems.
- A draft report was discussed with the victim’s family and their comments taken into account. This version takes account of feedback from the Home Office Quality Assurance Panel. The overview report is available to the agencies responsible for responding to domestic abuse, but, at the family’s request, is not in the public domain to protect their privacy.
1 This is a pseudonym used to give anonymity to staff of a small business.
CIRCUMSTANCES OF THE HOMICIDE
- Ms X had married and been widowed twice. Her first husband was the father of Mr X, her only child, and took his own life when the boy was about 7 years old. Her second marriage, a few years later, was said by family to be turbulent. After the death of her second husband (in an accident) while they were living abroad, Ms X returned to North Devon, effectively destitute, early in 2009.
- Mr X had a troubled childhood, including a short period in care, and was unemployed for most of his adult life, with periods of rough sleeping and begging. He served prison sentences for crimes including burglary and assault. His health records prior to 2009 include treatment for drug misuse and mental health crises.
- By mid-2013 Ms X had, in some ways, improved her situation, with support from agencies as outlinedin Table 1. She had re-established contact with her only son and had local friends who were mutually supportive. She had been living in the same flat for three years, with regular visits from a skilled housing support worker. For at least part of that time she had avoided drug and alcohol misuse. Surgery had addressed a spinal problem, although it still caused her pain and she was unable to work. She had received an inheritance which gave her some choices about her future.
- Ms X’s home was a one bedroom flat Home B, on the first floor of a mid- terraced urban property in North Devon rented from ZZZCO, who provided housing support through weekly visits. With hindsight, it is clear that Mr X had unofficially made his home with his mother for at least a year before her death, although he had (supported by housing benefit) a rented room in another town until March 2014, seven months before the homicide.
- By the autumn of 2014, Ms X’s situation had deteriorated. Her physical weakness had increased tothe point where she was unable to get out of the house without assistance. She appearedincreasingly neglectful of herself and the home, although reluctant to seek medical or social carehelp.
- As established at his trial, Mr X murdered his mother at the flat on 3rd November 2014. He hit her about her face with his fist and fractured six of her ribs, and then used a kitchen knife to stab her inthe neck. He claimed they were using heroin together, and he lost his temper when he found that shehad used it all. Her body was not discovered for some days, by which time Mr X had been detained under the Mental Health Act for subsequent actions elsewhere.
Both Ms X and Mr X had a number of contacts with support agencies over the period 2009 to 2014.Table 1 summarises these to show, with hindsight, the links between their stories.
Table 1: Summary Chronology
|YEAR||CONTACT WITH MS X||CONTACT INVOLVING BOTH||CONTACT WITH MR X|
|2009||Returns destitute to Devon Referred by GP to support from Barnstaple Poverty Action Group which continues through year. Assistedwith housing by North Devon District Council, and starts drug treatment At end of year moves to ZZZCO’s staffed hostel and receivesmedical treatment for spinal condition from GP, Northern Devon Healthcare NHS Trust & Royal Devon and Exeter NHS Trust||Ms X describes troubled family relationship to drug service psychiatrist.|
For much of the year Ms X and Mr X rent separate bedsits at the same address, and sometimes share meals.
|Completes drug treatment early in the year.|
With help from NorthDevon District Council,moves from roughsleeping to tenancy, andreceives floating supportat end of year when given notice to quit.
Is on a 12 month community order withprobation.
|2010||Continues drug treatment to successful end in June Supported by ZZZCO at ZZZHome then in move on flat. Changes GP due tomove. Attends some but not all outpatient appointments (surgery follow up) at Royal Devon and Exeter NHS Trust.|
Claiming disability benefits.
|Ms X tells ZZZCO that her son, along with her friends near her new flat, is a good support.||Successfully completes probation order.|
Moves to new tenancy with advice from North Devon District Council.
|2011||Has contact with GP about pain control for spinal condition, and at least one fall.|
Attends some outpatient appointments at Royal Devon and Exeter NHS Trust. Receives housing support through weekly visits fromZZZCO. Claiming disability benefits.
|Accesses drug treatment (methadone, key worker sessions & workshops) from February with DDS2.|
Level of engagement variable.
|2012||Starts the year drinking to cover difficult memories but seen by ZZZCO to improve and take more care of herself during spring.|
ZZZCO encourages her to see GP, but she is not keen to.
In September is treated by Northern Devon Healthcare NHS Trust A&E as in pain following an earlier fall.
Her mother dies.
|In March ZZZCO note Mr X is visiting mother, helping her with meals and having positive effect on her mood.|
August – Mr X, back in Devon, threatens self- harm in Ms X’s flat. She calls police, and he is detained and admitted to Devon Partnership NHS Trust. Ms X completes DASH3 assessment with police – standard risk.
Symptoms recorded by DPT for Mr X include fantasies of harming Ms X, which he later says were invented. After 2 nights in hospital he discharges himself and is taken back to her flat, with her consent. Both are present at a follow up visit by Devon Partnership NHSTrust 2 days later.
Later in month police find him wandering in confused state and return him to the flat.
In December, ZZZCO and North Devon District Council query whether Mr X is living with Ms X but they both deny.
|By Feb nearly clean from drugs for a year. Opts to reduce methadone with support from DDS. Selling Big Issue.|
In June moves to another south coast area (camping) and arranges for his drug treatment to continue there. In July arrested after violence and theft in shop there.
In August he is back in North Devon, and not maintaining contact with either of the treatment services.
In October he is sentenced to 21 days in prison for the July offences, and serves this in November.
In late December, starts claiming housing benefit again, in a different North Devon town.
|2013||January: Tells GP she is due to get a legacy and planning holiday abroad.|
July: Receives the legacy (but does not report it to any agency at that point)
|Jan: Mr X tells DDS worker that he is caring daily for Ms X.|
October – ZZZCO note evidence that Mr X using bed in Ms X’s flat.
|Refers himself back to DDS in February and continues treatment, with some missed sessions, throughout year. Admits regular heroin use.|
September – is arrested for assault in pub in Cornwall
|2014||February – sees GP for additional prescriptions due to holiday.|
March onwards – increasing evidence of poor condition noted in ZZZCO visits.
May – ZZZCO discussing alternative housing for Ms X now she has legacy
Sept – closes housing benefit claim due to legacy.
October – frequently cancels scheduled ZZZCO visits. Last seen 27th Oct. Final text saying she will be out sent on 3rd Nov.
|Go together on holiday to Eastern Europe, informing prescribers and ZZZCO. Return early: ZZZCO gather that Mr X wanted to movethere but Ms X refused.|
In Sept Mr X tells RISE he is living with mother and giving informal care at her flat.
Increasing concern from ZZZCO at negative impact of his presence.
End Aug – Ms X phones GP about concern for Mr X but fails to make offered appointment.
Late Sept – Ms X seems to want to talk to housing support worker about Mr X but not in his presence.
Late Oct – in RISE assessment Mr X talks about relationship with Ms X.
3rd Nov – homicide.
|March: Sentenced for the Cornwall assault – 2 months imprisonment, suspended. Ends tenancy of room.|
Continues RISE treatment until June, but with diminishing contact. Admits heroin use and sometimes not collecting methadone.
Re-refers end Sept, with last appointment attended 21st Oct, and following one (27th Oct) missed
Was there a record of domestic abuse?
- The roots of this tragic killing of a gentle, twice widowed woman by the son she loved lie deep in his childhood, her turbulent marriages, and debilitating substance misuse by both of them over many years. This review looks only at the final six years of their relationship, re-established when she returned to Devon. By then both were in different ways damaged, fragile and holding together chaotic lives. In identifying lessons for public services, we recognise the pain of friends, family and workers who gave long term support, and inevitably wonder what else they could have done.
- It seems likely that at the start of 2014 the relationship between Ms and Mr X was fairly positive, withthe pair taking a holiday and making plans together. Although her mobility was limited, she had a degree of independence from her son, with her own phone, and a circle of friends who assisted her.She had opportunities to speak to ZZZCO staff, and with their help to others such as her GP, without Mr X being present. There is no evidence that he was violent to her before the homicide.
- There was increasing danger in her situation, which she had perhaps started to recognise by the timeof the murder. Her independence of mind and suspicion of official intervention made her reluctant to contact statutory agencies about her concerns or for advice. However, in the 6 weeks before her death she made two tentative attempts to do this but did not take up the offer of fuller conversation.
- Ms X cared about her son and was concerned for his welfare. She seems to have wanted his company, at least until the last few months, but confided to friends an increasing concern about his presence in the flat and his mental state. Mr X regarded himself as providing care for his mother, and did do this to some extent. However, he also exploited her through occupying her bedroom for most of that year, and almost certainly spent most of her legacy within a year on drugs or in other ways of no benefit to her. These are forms of domestic abuse.
- There is no simple explanation as to why this crime occurred. Mr X’s own accounts after arrest and during trial changed, and this was the first known occurrence of him harming Ms X. Several causal factors came together in this lethal violence, and with hindsight can be seen to create a dangerous situation: her frailty, his instability and his easy access to her home.
What did agencies know?
- No single agency held sufficient information to predict this homicide. While the information held by October 2014 should, if pooled, have caused concern and more active investigation, it did not indicate that violence this severe was likely. However, the Review Panel understands the family’s concern that there was not a stronger response to signs of Ms X’s increased vulnerability.
- With many agencies involved with Ms X and/or her son, but no one responsible for assessing them together, there were missed opportunities despite staff doing their best to help them individually. In October 2014 four agencies held information about both parties and their relationship.
- ZZZCO knew that Ms X had become more frail and was short of money, that Mr X was frequently in the flat; that she had concerns that she was unwilling to speak about in his presence, and was increasingly putting off support visits.
- RISE knew that Mr X had a troubled childhood and ambiguous current relationship with his mother, with whom he lived and to whom he provided some form of care. They knew that he was using heroin daily and had convictions for violence.
- Ms X’s GP knew that Ms X had, unusually for her, called the practice to seek advice about Mr X but then failed to make an appointment as invited. They also knew her to be physically frail and a regular user of painkillers with a past history of substance misuse.
- While Devon & Cornwall Police had no immediate involvement, their records showed that Mr X was under a suspended sentence for assault, had previous convictions and that two years earlier he had apparently been living with Ms X and had been sectioned after an incident recorded as domestic abuse of the lowest risk category.
- Had any agency, between June and October 2014, triggered an adult safeguarding intervention, this picture could have been assembled. A health and social care team could have offered an assessment and possibly a package for personal care. However, the indications from previous contacts are that Ms X would have been reluctant to accept intervention. Her family accept this, offering the explanation that she would not have wanted anyone to know she was using heroin. She would have been judged to havecapacity to make decisions about her own health and welfare.
- ZZZCO could have been more proactive in getting evidence that Mr X was living in the flat, and seeking to prevent this. The Review Panel understands the family concern on this point. However, it is unlikely that Ms X would have co-operated with any enforcement measure to keep him away, and if evicted for breach of tenancy could have ended up in worse accommodation. Perhaps the safest option would have been for her to move to sheltered accommodation in an access controlled setting, with daily rather than weekly support, and encouragement to resume drug treatment.
- There was circumstantial evidence that Mr X was misappropriating his mother’s money and illegally supplying drugs to her. The family think this was happening, and expressed surprise that drug paraphernalia was not found in ZZZCO’s housing support visits. The panel were surprised that thepattern of cash withdrawals from her account appears not to have resulted in questions being raised by her bank. Here again it is very unlikely that Ms X would have co-operated with any investigation by the landlord or police.
What can be learned to improve future practice?
- The review identified a number of changes, listed below, that had been made in Devon during 2015 and2016 and addresses concerns raised by this homicide. Further progress during 2017 is shown in the accompanying action plan.
- A Single Safeguarding Process has been introduced across Devon and Cornwall Police. This includes the ViST (Vulnerability Indicator Screening Tool). This assists officers in the identification of vulnerability at an early stage and helps to provide the required level of support or intervention based on the individual’s needs. The ViST is completed when any child, or an adult identified as vulnerable, comes to notice, and all operational officers are trained in its use. While this could have helped Ms X in 2012, it would not have helped her in 2014, as police had no contact with her.
- Devon County Council now provides more advice for services, family and friends on how to refer someone into adult services. This is relevant as ZZZCO felt unsure who to talk to about their concerns.
- Much progress has been made in joining up drug and alcohol treatment systems in Devon particularly around safeguarding. There is much more emphasis on an individual’s circumstances, including housing and family members, which now form part of a “routine enquiry” and “Think Family” approach.Changes introduced by RISE aim to allow staff to identify potential areas of risk including safeguarding, domestic violence, financial difficulties and social needs, and make appropriate referrals to other agencies to address these areas. RISE is also ensuring closer adherence to policy by staff, with particular focus on the “Did Not Attend” policy to ensure a more pro-active approach to maintain service user engagement.
- Devon Partnership NHS Trust’s Devon Liaison & Diversion Service / Street Triage will soon be able to access RISE records when treating patients referred by the police. This will enable them to advise and inform the police in relation to relevant information such as risk, engagement and medications.
- The Royal College of Anaesthetists has published new guidance to support prescribing of opioid medicines for pain, which includes a section on prescribing for patients with a history of substance misuse. Locally, the Medical Director of Addaction (a partner in RISE) is available to advise GPs oncomplex cases of pain management interacting with substance misuse.
- Prompted by an earlier Domestic Homicide Review, Safer Devon Partnership commissioned publicity materials to raise awareness that parents can also be victims of domestic abuse and that help is available. A campaign using these materials ran across the county linked to Mothers’ Day in 2015.
- The overall lesson from this case is of the importance of the “Think Family” approach even when there are no children in the family. Agencies must raise any potential safeguarding concerns about adults at risk of abuse and neglect in a timely manner to ensure relevant information is shared in order toidentify patterns or wider concerns.
- As above, public services have, since the time of the murder, introduced a number of changes to encourage this. Our recommendations below deal with some further points of learning from thereview, and are developed in more detail in the separate action plan. While not making a further recommendation here, the review panel also noted that this case underlines the importance of a recommendation made by a previous Domestic Homicide Review (Case 4), on the importance of availability of help for adult victims of childhood abuse.
- R1 Ensure police undertake DASH (Domestic Abuse, Stalking and Harassment) risk assessment to a consistently high standard.
- R2 Improve police implementation of the multi-agency protocol on detention under the Mental Health Act 1983.
- R3 Ensure that the “Think Family” approach remains embedded within operational practice in RISE, is included in the specification in any recommissioning of the service, and isunderstood by all front line staff.
- R4 Signpost providers of specialist housing for vulnerable adults, including those in the private sector, to sources of advice on domestic abuse and related risks.
- R5 (National) In national analysis of DHR findings, identify other cases where banks might have seen indications of financial exploitation. If justifiable by the evidence, recommend the production of guidance by an appropriate financial oversight body.
A PDF of this page is available here – Domestic Homicide Review Case 5 – Executive Summary