Domestic Homicide Review Case 7 – Executive Summary

Executive Summary October 2018 – Arising from the death of Mrs Y, May 2015

Introduction

Review Process

1. This is a summary of the Safer Devon Partnership domestic homicide review into the death of Mrs Y, undertaken on behalf of East and Mid Devon Community Safety Partnership in whose area she lived. Pseudonyms have been used for the victim and perpetrator and members of their family to protect their identities.  
2. Mrs Y, aged 59 was killed in May 2015 by Mr Y, her estranged husband, aged 63, who took his own life in the same event. Inquests into both deaths were held in November 2016, with verdicts of unlawful killing for Mrs Y and suicide for Mr Y. 
3. The multi-agency Executive Group accountable to Safer Devon Partnership for oversight of domestic homicide reviews decided at a meeting in May 2015 to hold a domestic homicide review. All agencies that potentially had contact with Mr or Mrs Y prior to their deaths were asked for details. Five of the 15 agencies asked had had some form of contact and were asked to secure their files.

Contributors to the Review

1. Chronologies were provided by Northern Devon Healthcare Trust (which runs community hospitals in the area) and the Royal Devon and Exeter NHS Foundation Trust. New Devon Clinical Commissioning Group, in consultation with the couple’s GP, briefed the panel on relevant aspects of primary care records. Devon & Cornwall Police provided summary information from their investigation of the homicide and their records of an earlier burglary at the house in which Mrs Y was living and the homicide occurred (House G). East Devon DC reviewed their contact with the couple on a planning issue relating to their former marital home (House F) in which Mr Y continued to live, and provided information on domestic abuse awareness campaigns in the area. 
2. The insights of people who had known Mrs Y and Mr Y were invited. The Panel appreciates the contribution of relatives, friends or colleagues who offered views, or whose accounts informed the police investigation.  Where references are made to the views of family and 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. 

Review Panel

1. The Review Panel met four times, also conferring by electronic means. Panel members were from Devon & Cornwall Police (Serious Case Review Team), Devon County Council (Public Health), New Devon Clinical Commissioning Group (Safeguarding Adults Nurse), East Devon District Council (Community Safety Manager) and the Royal Devon and Exeter NHS Foundation Trust (Senior Safeguarding Nurse). In addition, the Panel obtained comments on the draft report from the Devon manager of Splitz Support Service (provider of domestic abuse services in the area), and from the Devon County Council Principal Social Worker – Commissioning. The Panel had administrative support from the Safer Devon Partnership Co-ordinator for domestic homicide reviews, who is contactable at Devon County Council. 
2. The Panel’s Independent Chair and report author has no other connection with Safer Devon Partnership or East and Mid Devon Community Safety Partnership, has not been employed by any of the agencies concerned with this review, and has no personal connection to people involved in the case. She has a past career in public sector regulation, with extensive experience of assessing community safety and partnership working.
3. 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. This report is agreed by the Chairs of Safer Devon Partnership’s Executive DHR Group and East and Mid Devon Community Safety Partnership and has passed quality assurance by the Home Office. The family of Mr & Mrs Y have had an opportunity to comment on it.

Terms of Reference

1. The review considers agencies’ involvement with Mrs Y and Mr Y from 2013 to 2015. This was the period in which the relationship finally broke down and the couple separated. Earlier involvement by agencies was concerned with physical health problems only, with no indications of domestic abuse. Other evidence obtained during the police investigation of the deaths, covering this period and the history of the relationship, has therefore been a valuable source for the review.
2. The terms of reference reflect Home Office guidance on domestic homicide reviews and the particular context for this homicide. In summary they were to invite the involvement of family and friends, review agency contact with the victim and perpetrator for opportunities to identify or prevent domestic abuse, and report on lessons for improving services. The Panel agreed, in the light of initial information available, that questions should include whether Mr Y received an appropriate response on contacting primary care services and any learning about preventing domestic violence among older people.

Findings

Summary Chronology

The Homicide

1. At the time of the homicide, Mrs Y and Mr Y each lived alone in East Devon, about 10 miles apart. Mrs Y had left their home (House F in Town N) the previous August, initially renting, then moving into her late father’s home, House G, after his death in November 2014. Their son SY lives in a neighbouring town, and saw his parents fairly frequently. Their daughter DY was living in the south east at the time of the homicide, and her wedding there the week before was a major gathering of the wider family. 
2. The deaths were discovered in May 2015 by prospective buyers of House G. Mrs Y was last seen alive the previous afternoon, and had cancelled an evening out with a friend as she had a cold. The subsequent police investigation established that Mr Y stabbed Mrs Y with a kitchen knife, then carefully sealed the room and placed his car to pump exhaust gases in at a level sufficient to kill them both. He had brought some of the materials he used (eg sealing tape and tubing) from House F, and left his papers there in order. Mr Y posted a form of suicide note to SY, intended to prevent the deaths being discovered accidentally by family, and including the phrase “just could not stand the humiliation anymore”.  

History prior to 2013

1. Prior to the separation Mr & Mrs Y had lived together for nearly 40 years, mainly in Devon and Somerset. They married in about 1978. Both were British citizens of White British ethnicity, and had spent part of their childhood abroad. Each had several siblings with whom they kept in touch, some living in south west England and some overseas. 
2. Mr Y, after a few years active service in the Army, trained as a car mechanic, and for a number of years owned and ran a garage. He was unable to sustain the business due to problems with crime and staffing. After it closed (around 2004) he did some work for other garages until around 2011. In retirement he continued to work with specialist cars as a hobby, finding respect and friendships among other enthusiasts. 
3. Mrs Y had a career as an accountant, and had worked for a large organisation in Exeter for the past 12 years. She was looking forward to retirement later in 2015, and planning to take up new interests. She was a governor of a local secondary school. 
4. Friends and family recognise that, although there were many good times, there were strains in the relationship between Mr & Mrs Y from the start. Examples include: 
   • several episodes of partial separation within the home while the children were growing up, with Mr Y withdrawing into silence;
   • Mr Y telling Mrs Y’s parents in around 1990 of (unsubstantiated) suspicions of an affair, and appearing obsessed with the issue, but wanting to keep the matter within the family; 
   • Mrs Y seriously considering separation around 2003/ 2004 due to difficulty dealing with Mr Y’s moods and depression about his business but staying in the hope that things would improve;
   • increasing arguments about money once Mrs Y became the main earner. 
5. There is no indication that there was any physical violence between the couple prior to the homicide. Family and friends think Mrs Y would have told them if this had occurred. They were aware that Mr Y had been subject to variable depressive moods for much of his life. Some, including his father-in-law, had urged him on several occasions to seek medical attention. Mrs Y told friends that Mr Y was not managing his health well and this caused her stress and that in 2013 he had threatened to take his own life as he did not feel needed.

Relevant contact with agencies since 2013

1. Mrs Y had health treatment for medical conditions which were not relevant to domestic abuse. In the course of several consultations with her GP between 2013 and 2015 she did not discuss her home situation or report anything indicating possible domestic abuse. Her final call to the GP was in February 2015.
2. Mrs Y was referred to the community hospital run by Northern Devon Healthcare Trust for a hand X-ray in 2014. This concerned degenerative disease rather than injury. She attended the Royal Devon and Exeter NHS Foundation Trust for day case endoscopy to investigate a digestive problem 11 days before the homicide. 
3. Mr Y was diagnosed in 2010 with hyperthyroidism, but had not attended the clinic for follow up monitoring. In 2013 he saw the GP on three occasions, for physical conditions and a medication and general health review. No concerns relevant to this review were raised. 
4. The next contacts with the GP were in 2014:
   • In August, two days after Mrs Y had moved out, Mr Y presented with stomach cramps and a skin condition, for which he was prescribed a palliative cream.
   • The next day SY left a message for a GP to telephone him about concerns over his father’s mental health, which could not wait for the usual GP to return from leave. When a GP phoned SY the following day, he explained he was concerned about his father’s depression as his mother had left him. The GP, noting that Mr Y’s previous Thyroid Function Test was raised as was his blood pressure, advised SY that he would try to get Mr Y to come in for a blood test and blood pressure check and a review and then carefully ask about his mood at the appointment. 
   • Three weeks after this, in September 2014, Mr Y attended the surgery and had routine bloods and blood pressure taken. A week later he was seen by his regular GP and a depression questionnaire was completed, in which he scored 3/27. (Anything above 4 indicates a depressive illness.) Mr Y did not disclose the separation to the GP and spoke of being socially isolated because his wife was out at work.  He agreed to a hospital referral about his hyperthyroidism as he recognised he was tired and irritable but denied having depression.  
   • In November 2014 Mr Y attended the surgery and admitted that there had been family concerns about his mental health. He advised the GP that he had been looking after his terminally ill father-in-law and the stress had been affecting him. He reported that his father-in-law had since died, he felt better and was back with his wife. (The last point was untrue.) The GP recorded no mental health issues.
5. In October 2014 Mr Y was seen at the Royal Devon & Exeter NHS Trust thyroid clinic. Blood tests showed him to have sub clinical hyperthyroidism, so the recommendation to the GP was for annual blood test to monitor. The letter to the GP commented that ‘he does not feel frankly depressed but his wife has noticed that he is not his usual self more often’. (Mr Y told the clinic that he lived with his wife, not disclosing the separation.)
6. In October 2014 a planning officer from East Devon DC met Mr Y and Mrs Y at House F to agree a resolution to the problem of a previous owner having installed UPVC windows in a listed building without permission. While anxious about the effect of this on their ability to sell the property, there was no indication of any animosity between them.  
7. At the end of November 2014 Mrs Y reported an attempted burglary at House G. Police attending found Mr Y with Mrs Y (not knowing what their relationship was). He appeared to be encouraging her concern about the crime. The same officer later saw Mr Y present with a glazier overseeing repair of the broken window. 

Events since 2013 not involving agency contact

1. Mrs Y moved out of House F in August 2014. Earlier in the year she had told some friends and family she might do this. She said she was unable to deal with Mr Y’s moods and depression as he would not seek help, but she wanted to remain friends with him. SY assisted her with the move and his concern about Mr Y’s mood led him to stay the night and phone the GP as noted above. Mr Y tried to conceal the separation from all but close family, for example sending Christmas cards in joint names. 
2. Mr Y and Mrs Y then had approximately weekly contact, when she collected post from House F or he assisted with maintenance of House G. They also both attended some family social events. The indications are that he hoped she would return, but she, by January 2015 at least, had made up her mind not to. During April 2015 Mr Y appears to have realised this. His reactions included an initial refusal to attend DY’s wedding, and rejection of attempts by family and friends to get him to look forwards. She had become more cautious, and told friends she was avoiding being alone with him. 
3. Towards the end of April there were two long email exchanges with each other, prompted by Mrs Y’s request to Mr Y to progress the sale of House F so they can reach a financial settlement. These include three times as many emails from him as from her. Hers, while showing growing annoyance, used reasoned language, contained factual statements, and attempted to explain her position and reassure him. His made generic allegations, using a hectoring or threatening tone. He either ignored her factual responses or rejected them as not credible, and so justifying his suspicion. He urged her to see their situation as her fault. He used commands, insults and reminders of (unspecified) past events. He held out the prospect of punishing her non-compliance:  initially vague, then a definite threat to send their friends and family details of her supposed past wrongdoing.  She asked him to stop the insults, but gave no indication as to whether she took this threat seriously.
4. Mr Y copied some of these emails to his son and daughter, and Mrs Y admitted being upset by them. Mr Y does not appear to have fulfilled his threat to send widespread emails, but did send allegations about her to one of her siblings. In this he used the phrase “remember the dog and its day”. The family interpreted this as a threat to cause financial, reputational or possibly property damage to Mrs Y, but not of violence. 
5. Mrs Y saw a solicitor for the first time at the start of May. She focused on a plan for a financial settlement, and did not discuss legal action to restrict Mr Y’s contact with her. 
6. Mrs Y appeared confident and happy at DY’s wedding.  Mr Y, persuaded by SY, did attend the ceremony, but avoided conversation with adult relatives and did not stay for the reception. A factor in his departure may have been a guest expressing sympathy about the break up, thus revealing that it was widely known. In the following week he attended several social or car related events with friends, appearing normal in his behaviour right up to the morning of the homicide.

Key Issues Arising

The relationship between Mr Y and Mrs Y

1. This was the tragic ending of a marriage which had experienced difficulties from the start, but nevertheless had good times, and survived previous rifts. The couple had pursued their own career interests, and had both individual and joint friendships outside the home. Mrs Y maintained contact with her siblings as well as both her and Mr Y’s parents. She had control of her income, communication tools and transport. She had responsible work and voluntary roles, and was able to be appropriately assertive. While she sometimes found Mr Y difficult to live with, he did not exercise control over her activities, income or choices. 
2. Mr Y’s behaviour in the final weeks before the homicide amounted to domestic abuse, although the coercive control he attempted did not reach the level of a criminal offence. For example he attempted to put all the blame on her, made unreasonable accusations, and threatened to shame her. While he did not threaten physical violence directly, his language grew more strident until she cut off email communication the week before the homicide.
3. While the events on the day of the homicide cannot be known for certain, the evidence suggests Mr Y turned up at House G without an invitation, and had retained a key or persuaded Mrs Y to let him in. He may have made a last attempt to persuade her to change her mind before attacking her. After the initial assault he took a methodical approach, using his engineering skills, to completing the murder/suicide. It is highly likely that he came equipped and intending this as a probable outcome. 
4. At some point over the previous couple of months Mr Y had moved from denial that the relationship was over to a realisation that it was. In his pride he was unwilling to face public acknowledgement. Although not in any financial difficulty, he opposed the division of their assets, and refused to trust Mrs Y’s statements about money. Rejecting the efforts of family and friends to help him make a future life without her, he allowed suspicion and anger to brood to the point where he deliberately ended both their lives. 
5. Elements of Mr Y’s behaviour before the separation includes elements which could be interpreted either as a deliberate attempt to control his wife, or as selfish lack of consideration for her. He complained about her cooking and housework while leaving these as her areas of responsibility. After his own opportunities for earning ended, he felt uncomfortable with her bringing in the main income. He responded to arguments by extended periods of refusal to communicate, which affected their children.  His depressive moods affected them both, yet he was reluctant to seek help. He would change his behaviour to win her back after rifts, but did not sustain this. 

Agency knowledge and response

1. The only agencies to see Mr & Mrs Y together were police following a burglary at House G, and East Devon DC about a planning issue at House F.  In neither case did the behaviour observed show indications of domestic abuse.  
2. While Mrs Y had a number of contacts with health services in the two years prior to her death, these arose from physical conditions, and she showed no signs that should have prompted further questions. Her last contact with health services was a day case endoscopy at the Royal Devon & Exeter NHS Trust, between the first and second bouts of email aggression from Mr Y.  At that time not all day case unit staff were trained in recognising domestic abuse, though they since have been. Day case admission paperwork does not routinely ask about domestic abuse. While it is unlikely that Mrs Y would have been inclined to talk to staff after a procedure on her throat, her presence in the hospital provided an opportunity for her to see information signposted. 
3. Mr Y also had a number of contacts with health services over this period. Some were related to long term physical conditions, but some prompted by his family’s concerns about his moods. In none of them did he disclose any hostility to his wife, or intention to harm her or himself. Rather, he covered up the timing and extent of their separation when talking to the GP. The GP practice made a prompt and sensitive response when SY contacted them to tell them of his concerns about his father’s depression. This led to Mr Y completing a depression questionnaire and referral for further tests on his thyroid.  On attending the thyroid clinic, the condition was found to be at sub-clinical level, meaning no treatment was needed.
4. The level of Mr Y’s score for depression in September 2014 was below the threshold for diagnosis. Given feelings he expressed to his family shortly before the homicide, it could be that he did not complete the survey honestly, or that his condition deteriorated as the separation continued, or both. Mr Y appears to have wanted to deny family concerns about his mental health rather than allow them to contribute to his assessment. In his last contact with his GP, in November 2014, he claimed that the difficulties had passed and that he was now back with his wife. 

Preventative action

1. There is no indication that Mrs Y thought of herself as experiencing domestic abuse, either while living with Mr Y or during the separation. Had she done so, there would have been advice available to her. The domestic abuse service in the area includes a telephone helpline and one to one support and accepts self-referral. Their promotional leaflet includes “feeling unsafe even if you’ve separated?” as a reason to get in touch. Over a number of years, the East and Mid Devon Community Safety Partnership has run campaigns raising awareness of domestic abuse, and it is likely that Mrs Y would have seen some of the materials, for example at a GP surgery or as a school governor.
2. The organisation which employed Mrs Y did not have a policy on domestic abuse, so she is unlikely to have seen information there about its nature or the availability of support. The Human Resources policy would have led to exploration of home issues in the context of concern about performance, but this did not arise. She informed her line manager of the separation, but did not give any indication that she felt herself at risk.  
3. Mr Y’s actions can be viewed as a planned suicide as well as a homicide. There are links between male suicide and domestic abuse^[1]. Devon has a multi-agency Suicide Prevention Strategy Steering Group, which oversees actions based on the National Suicide Prevention Strategy. The actions most relevant to Mr Y’s situation are those encouraging people, especially men, to talk about suicide risk. Some training and information distribution had started before the homicide, but the main effort has taken place since. Mr Y, aged 63, was not among the “young and middle aged men” high risk group recognised in the national strategy, but his lifestyle and self-image (though not employment status) probably had more features in common with that age group than with “older people” as a whole. 

Conclusions

1. In this family tragedy a man who sought to protect his reputation and keep the failure of his marriage private chose a path which ended two lives amid inevitable publicity. The woman who had gained new confidence on leaving him and was looking forward to the freedom of retirement had her newly independent life cut short by his fear of shame. The Review Panel recognises the pain of the friends and family who were trying to help each of them move forward and to whom this violent outcome was totally unexpected.
2. Public services had no opportunity to recognise the problems or risks in this relationship. Nevertheless there are lessons for public services to take from these sad events, which can help people facing similar situations in the future. 

Lessons Learned

1. The period during which Mr Y acted towards Mrs Y in a way that was clearly domestic abuse was relatively short – perhaps only 6 weeks. While there are indications that she recognised the escalating threat, and took steps to protect herself, she does not seem to have seen herself as a victim of domestic abuse. This illustrates that the window for recognition may be small. Services which could have helped Mrs Y plan her safety during the separation had been available in the area for many years, and there had been regular awareness raising campaigns. While Mrs Y could have found information online had she sought it, a nudge from publicity during the crucial period – at her workplace, a hospital, public transport or a solicitor’s office – might have reminded her of the option. However, while she would have received advice, it is uncertain whether, even on disclosing a full history, she would have been assessed as at high risk.
2. Nationally the year after separation accounts for a significant proportion of partner / ex- partner homicides, but the Review is not aware of any research into how many of these involve perpetrators using discussion of asset settlements as an excuse to meet the victim in private. While Mrs Y had a clear intention not meet Mr Y alone, and had told him by email, she had not yet initiated legal or physical steps to prevent him coming to her home.
3. It is possible that Mr Y did suffer from depression at a level where clinical intervention would have helped, but if so he was unwilling to report the symptoms.  He concealed the state of the marriage from both doctors and friends. National analysis of domestic homicide reviews notes depression affecting a number of the perpetrators.  This underlines the importance of encouraging men to seek help with their mental health. While health services acted appropriately on the information available to them, this illustrates the challenge of overcoming stigma, particularly for men who want to be seen as the strong member of in the family. 
4. While Devon’s Suicide Prevention Strategy rightly follows the national one in recognising young and middle aged men as a risk group, the risks for older men like Mr Y who see themselves as active and skilled should not be overlooked, or conflated with those of the frail elderly. Demographics make this a particular issue for Devon. Programmes aimed at the younger group may well be suitable for many older men, so should be inclusive in their scope. 
5. The organisation which employed Mrs Y now has an externally run Employee Assistance Programme covering a range of issues including domestic abuse. Had this been in place in 2015 it is possible that Mrs Y might have used it to explore the type of advice available to her. It is disappointing that one of Devon’s major institutions does not yet have an overall policy on domestic abuse. Devon’s current Domestic and Sexual Violence and Abuse Strategy includes the aim that “employers, schools and organisations support their staff through the impacts of DSVA”. 
6. Royal Devon and Exeter NHS Foundation Trust now has a programme to ensure all clinical staff receive training on domestic abuse. As part of the learning from this review, a special training session has been held for the endoscopy unit. 

Recommendations from the Review

1. These recommendations are developed in more detail in the separate action plan. 
   • R1 Build capability in the workforces of all Safer Devon Partnership member agencies to respond in a timely and appropriate way to victims and perpetrators of domestic abuse. 
   • R2 Develop a multi-agency communication strategy and plan that includes public facing awareness raising campaigns on domestic abuse. 
   • R3 (National) In a future analysis of domestic homicide review reports, draw out any patterns in the location and circumstances of intimate partner homicides where the couple had separated. 
   • R4 Scope suicide prevention initiatives targeted at men in a way that reaches men around the time of retirement as well as younger age groups.  
   • R5 (National) Encourage major employers in all sectors to develop a policy on preventing and responding to domestic abuse affecting staff. 

^[1] See eg ““Men, Suicide and Society” (The Samaritans, 2012)

A PDF of this page is available here – Domestic Homicide Review Case 7 – Executive Summary