Executive Summary March 2016
- This is the report of a Domestic Homicide Review (DHR) undertaken by the Safer Devon Partnership (SDP) on behalf of South Devon and Dartmoor Community Safety Partnership (CSP). The review examines the death ofSubject A, who was killed by her estranged husband, Subject B in January 2015. Subject B was convicted of murder on 3rd November 2015; he had initially denied murder but changed his plea to guilty during the trial. He was sentenced to life imprisonment with a minimum custodial term of seventeen and a half years.
- The key purpose for undertaking DHRs 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 explores any engagement between agencies and the Subjects of this review prior to Subject A’s death.
- The review was conducted by a panel with an independent chair and representatives of:
- Safer Devon Partnership
- South Devon and Dartmoor CSP
- Teignbridge District Council
- New Devon Clinical Commissioning Group
- Devon and Cornwall Police
- Commissioning Manager for Substance Misuse
- Public Health Programme Manager
- No members of the panel had any prior direct involvement with the events or decisions covered by the review. An Independent Chair with knowledge of community safety, partnerships and domestic abuse, and experience of previous DHRs, was appointed to steer the work of the panel and draft the report. The independent Chair had no personal connection with any of the people involved in the case, but did serve in Devon and Cornwall Police from 2003 to 2010.
- The review sought information from a wide range of voluntary and statutory agencies in Devon. There was no trace of any relevant contact between either Subject and these agencies. Friends and family who were spoken to reported that there had been no such contact nor a wish to make any. Neither subject had any history of involvement with the police.
- The review was initiated in January 2015, following the death of Subject A. The confirmation of terms of reference and the establishment of the review panel was deferred until criminal proceedings were completed in November 2015.Given that there had been no agency contact with the subjects of the review, no Individual Management Reports (IMR’s) were required.
- The panel drew up an overview report based on police reports, discussions with friends and consideration of the circumstances within the panel. The overview report is available to the agencies responsible for responding to domestic abuse, but it is not in the public domain to protect the privacy of those (other than the victim and perpetrator) whose stories are included in this report. Specifically this includes the children of the family.
CIRCUMSTANCES OF THE HOMICIDE
- Subject A was murdered during the late afternoon of Wednesday the 28th of January 2015. The exact time of death has not been determined but her telephone communications and the identified movements of Subject B identify the time of death as between 1500 and 1640. Subject A’s body was discovered in the premises at about 0310 in the early hours of Thursday 29th January 2015.
- Subjects A and B were still going through divorce proceedings. Subject A told Subject B that she had been to see her solicitor about the divorce the day before and following this wanted to go to the flat to take photographs as part of the valuation process. Subject A had previously asked Subject B for keys to the premises, but had not been given any. The visit to the flat was pre-arranged via text messages between subjects A and B. Subject A had a nine minute phone call with Subject B before they met.
- Before she went to see Subject B she spoke to her Mother and said that she was feeling quite wobbly. Her mother states that this was the first time that she thought that there might be a problem.
- Subject B arrived at the flat at around 2.50pm on 28th January 2015. He sent a text to Subject A to say that he was there and that the door was open. Subject A arrived soon after. It is not known exactly what happened in the premises. Subject B claims that Subject A began to take photographs within the premises, using her smartphone.
- The account of what took place within the premises comes predominantly from the police interviews with Subject B. He chose not to answer questions but through his solicitor provided prepared statements.
- Subject B told the police that Subject A opened the loft hatch and found a number of cultivated cannabis plants. He said that having seen them, she told him that she would not let him see their children again and that she would bankrupt him, unless he quickly agreed to her settlement terms.
- Subject B reported a heated argument including shouting and swearing. He reported that she poked him with her fingers in his chest. She made to leave the flat and he pushed her against the wall. He said that her head hit the wall and she immediately dropped down to the ground and that he lay on her side without moving. In his second interview Subject B reported stamping on her head. He said he moved her body to the lounge, a distance of about 1 metre. He picked up the flex from the nearby tumble dryer and pulled it around her neck. He believed that the entire incident took no more than 10/15 minutes.
- Soon after the murder Subject B received a call from the children’s school, asking him to collect the boys. He left immediately and collected the children. Subject B then went through a complex set of actions apparently designed to hide Subject A’s body and to prepare a false trail for the police. He concealed her car, removed the SIM card from her phone and sent text messages implying he was looking for her. He also wrapped her body in layers of plastic and hid it in a shared cupboard on a landing in the house that the flat was part of.
- Subject B’s actions managed to conceal Subject A’s body and the murder over the evening of the 28th January. The police found Subject A’s body as part of their investigation in the early hours of the following morning, 29thJanuary. Once the body was found Subject B began to admit his involvement in the murder and during interview gave the police his two prepared statements.
- In this tragic case a separation and divorce turned into the murder of a young mother by her estranged husband. There were no apparent precursor incidents, none that could have reasonably predicted the terrible outcome; there was no prior warning of this crime. There had only been minimal reports of earlier domestic incidents and these had been made to friends rather than agencies. The incidents reported were not sufficiently serious to cause the friends concern and would have been below the threshold that would trigger action by any agency. If Subject A had been concerned about the incidents she could have reported them to the police who would, at least, have recorded them.
- There is no evidence to suggest that Subject A had been a victim of domestic abuse in prior relationships nor that Subject B had exhibited violence in previous relationships.
- Neither Subjects A or B sought, or had any reason to be offered, support in respect of domestic abuse. Subject A was participating in local mutual support groups addressing her past misuse of alcohol and drugs.
- This homicide could not have been predicted by any agency, nor is there any realistic action that an agency could have taken that would have prevented it. There is no intervention that any agency could have reasonably offered to either party which could have changed the outcomes of this case.
- While the homicide could not have been predicted and therefore not prevented, it is possible that if Subject A had been accompanied by a friend during her meetings with Subject B he might have been deterred from his murderous course of action.
- If the new law dealing with coercion and control had been in place prior to this murder it is unlikely to have applied in this case. The coercion and control exercised by Subject B on Subject A is unlikely to have been considered, by Subject A, nor by the police or CPS as being at the level that would attract a criminal investigation or prosecution. The benefit of that law however, is not simply that it can lead to a prosecution, rather that it allows for conversations about coercion and control and may lead both victim and perpetrator to consider what is happening in their relationship. No agency had any relevant contact with Subject A prior to the homicide, nor any reason to assess whether she was at risk from Subject B. No agency had any relevant contact with Subject B prior to the homicide, nor any reason to assess whether he was a risk to Subject A or to any other person.
- The police had no interaction with either subject or their wider family; there was no apparent reason for the police to become involved in this situation prior to the murder. Health Services had no interaction, other than routine, with either subject or their wider family; there was no apparent reason for them to become involved in this situation prior to the murder.
- There was no involvement from Children’s or Adults Social Services, nor any apparent need that there should be.
- There were no reports, no meetings and no apparent reason to call them so joints services such as MARAC and the relevant information sharing protocols play no part in this case.
- Local agencies have for a number of years acted together through the CSP and through ADVA to raise awareness of domestic abuse and of the availability of support. There has been less action at local level to signpost help for substance misuse, and nothing directed at families of cocaine users.
- The mutual aid groups, Narcotics Anonymous and Alcoholics Anonymous, clearly played an important role for Subject A in her attempts to address her previous substance misuse and related problems; she was able to support others going through the process. Given the confidential nature of their work, it is not known if they have any safeguarding policies or similar. It has not proven possible to have any effective engagement with NA/AA at policy level.
- The homicide could not have been predicted. There is nothing in the history of Subjects A or B that would have made any agency intervention appropriate.
- Agencies were not in a position to see any risk that Subject B posed to Subject A as they had no contact with either about either domestic abuse or substance misuse. So far as can be known, Subject A had not previously been the victim of violence from Subject B. While there were levels of coercive control in the relationship, there is no indication that this was at the level that would attract intervention from any agency. Friends who knew the couple saw nothing that gave them reason to intervene, to seek the intervention of others or to fear for the safety of subject A. Subject A did not appear to have any such concerns herself.
Prevention – on the day
- There was nothing on the day that would have led to any intervention that might have prevented the murder. It might have been helpful if Subject A had brought a friend with her to the meeting with Subject B. However Subject A had no reason to fear harm to herself and may have wished to maintain a degree of confidentiality. There is no Devon policy or advice on participants in divorce proceedings bringing a friend or supporter to meetings with estranged partners.
Prevention – through victim awareness of risk
- Agencies had no opportunity or reason to assess any risk posed to Subject A by Subject B. There had been no previous agency interaction and while divorce and separation is a known risk factor in domestic abuse, it alone would be insufficient reason to trigger any agencies involvement. Although here was a degree of hostility from Subject B to Subject A, this appeared to be no more than might be expected in a divorce case.
- There is no indication that Subject A perceived herself to be at risk, and her relationship with her estranged husband was perceived by family and friends to be difficult during their divorce, but not one based on fear. It is unlikely, therefore, that the initiatives taken in South Devon and Dartmoor to raise awareness of domestic abuse would have come to the attention of Subject A.
- Subject A was seeking a new life; separate from Subject B and from her own old ways. So far as is known she did not seek any professional advice on this, or contact with others facing similar problems. The mutual aid groups helping Subject B, NA and AA, do not, as a matter of policy, pass on information about other services.
Prevention – through interventions with Subject B
- On the available facts, there would have been no reason for Subject B to attend any perpetrator programme or other course. Had he done so, it might have prevented the homicide. Such programmes have some success in changing attitudes and behaviour but he had no history of violence and would only have entered such a program through self-referral.
WHAT CAN BE LEARNED TO IMPROVE FUTURE PRACTICE?
- This review has not identified errors in the work of the agencies who might have been engaged. Given the history demonstrated in this review neither subject would have met the thresholds for accessing services for Domestic Abuse.
- While in theory at least, given the situation as it was in January 2015, either Subject A or Subject B could have accessed support, there was no evident reason why they would have done. Their behaviour did not indicate that there was a perception of risk of domestic abuse. Subject B’s actions in the final stages do appear to have elements of pre planning and had he engaged support at that stage, from a friend, counsellor or agency, he may have been able to change the course of events.
- Subject A had disclosed sexual grooming and abuse that occurred in her life when she was 15. This may have had an impact on her later life and her ability to form relationships. It may also have had an impact on her use and abuse of drink and drugs. There is no record that she reported this earlier abuse or sought any help in dealing with it.
- Ensuring that people know of and are able to access the services which are in place to help needs continued effort. While advice and support groups would have been available to Subject A, she did not appear to consider that she had any need to do so
- The mutual support groups Alcoholics Anonymous and Narcotics Anonymous played an important role for Subject A in her attempts to sort out her life. She was receiving almost daily support from these bodies. No other services to address his substance misuse were offered nor sought, nor appeared necessary. The philosophy of these groups prevents them from contributing to the learning from untoward events. Engagement on this has been sought, but their tradition of anonymity and lack of any infrastructure makes this difficult to achieve. That these groups do not engage with other services to support individuals appears to be a significant weakness, but it is not possible to know if or how they signpost members to other agencies.
- Because the review found almost no interaction between Subject A or Subject B with public sector agencies, or with voluntary agencies, there is no indication of good practice. There is through a very positive sense of community in the area of Subject A’s home and active support to her by NA and AA.
- Because of the absence of contact between the subjects of the review and the relevant agencies there are only limited recommendations in this case.
- R1 During divorce proceedings where there is any risk of domestic abuse, whether involving physical abuse or the exercise of inappropriate control or coercion any partner at risk of victimisation should be advised to bring another person with them to meetings, as a supporter or advocate.
- R2 Ensure effective communication to front line professionals regarding what services are available addressing alcohol misuse, drug misuse and domestic abuse and how to refer or signpost clients to them.
- R3 Make information about support groups for families of substance misusers more widely available, recognising that not all will be in contact with treatment services.
- R4 (National – Public Health England) Encourage Public Health England to work with Narcotics Anonymous and Alcoholics Anonymous, though their national bodies, to review their Safeguarding processes and protocols to assist in responding to serious incidents involving anyone attending one of their groups.
A PDF of this page is available here – Domestic Homicide Review Case 6 – Executive Summary