Domestic Homicide Review Case 8 – Executive Summary

Executive Summary January 2019 – Arising from the death of “Mrs J”, December 2015


Review process

  1. This is a summary of the Safer Devon Partnership domestic homicide review into the death of Mrs J, 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 to protect their identities and those of their family members.  
  2. Mrs J, aged 71, was killed in December 2015 by her fiancé Mr F, then aged age 66. Both were widowed, of White British ethnicity, and had been living together, at his family home in Town N, for most of the year. Mr F reported the killing to the police but took his own life in prison shortly before the case came to trial. The Review Panel offers condolences to all those affected by these deaths.
  3. As required by law, Safer Devon Partnership set up a domestic homicide review and asked local agencies to check whether either Mrs J or Mr F had contacted them. At the request of the Coroner, the main work of the Review was deferred until after the inquest into Mrs J’s death, which in January 2017 ruled that it was an unlawful killing. 
  4. The following agencies had contact and provided information for the Review: 
    • Devon and Cornwall Police (based on the criminal investigation);
    • Devon Partnership NHS Trust (chronology and Internal Management Review[1]);
    • Royal Devon and Exeter NHS Hospitals Trust (chronology and Internal Management Review);
    • South Western Ambulance Services NHS Trust (chronology); and
    • Town N Surgery (statements from and interviews with relevant general practitioners (GPs)).

      In addition, Relate (a counselling charity), Splitz Support Service (the main provider of domestic abuse services in the area at the time) and East Devon District Council provided information on relevant policies.
  5. The insights of people who had known Mrs J and Mr F have been mainly drawn from statements given during the police investigation, as only one of those contacted, a friend of Mr F, took up the offer of further discussion. Mrs J had no close relatives. The Panel offered sight of the draft report to Mr F’s sons. 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.

Review Panel

  1. The Panel met four times and also conferred by electronic means. Panel members were from Devon and Cornwall Police (Serious Case Review Team), Devon County Council (Adult Social Care), East Devon District Council (Community Safety Manager), Devon Partnership Trust (Practice Lead: Safety and Risk); NEW Devon Clinical Commissioning Group (Lead Nurse, Adult Safeguarding[2]), Royal Devon and Exeter NHS Trust (Senior Safeguarding Nurse) and Splitz Support Service (Devon manager), The Panel was supported by 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 knowledge of community safety, partnerships and domestic abuse and experience of previous domestic homicide reviews. She has a past career in public sector regulation, 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.
  3. The Review Panel operated collaboratively to reach agreed conclusions. These have been agreed by the Chairs of Safer Devon Partnership and East and Mid Devon Community Safety Partnership and quality assurance by the Home Office. 

Terms of reference

  1. The Review focuses on agencies’ involvement with Mrs J during 2015, and with Mr F between 2013 and 2015. This covers the period following the death of Mr F’s wife Mrs F, during which the relationship between Mrs J and Mr F, who had known each other for many years, became close. 
  2. The terms of reference reflect Home Office guidance on domestic homicide reviews and the context for this death. In summary they were to review agency contact with the victim and perpetrator for opportunities to identify or prevent domestic abuse, invite the involvement of those who have known them, and report on lessons for improving services. The Panel agreed, in the light of initial information available, that questions should include whether there were indications of domestic abuse by either of the couple prior to the homicide, and any learning about recognising domestic abuse among older people.


Summary chronology

  1. At the time of the homicide Mrs J had lived in Devon for just over 10 months, having moved from another county to join Mr F, who had lived in Town N for most of his life. They had known each other for over 30 years, initially as neighbours in Town N when she lived there with her late husband Mr J, but only formed a romantic relationship after both being widowed. This developed rapidly: within a few months they announced their engagement and Mrs J sold her home and moved into Mr F’s home, House M, in which he had brought up his now adult sons with his late wife. 
  2. From information Mrs J and Mr F shared with friends or family, and later with GPs, it is clear that the relationship soon became fraught. There is no indication of violence between them prior to the homicide, but they both used harsh words when they argued. While she continued to wear an engagement ring, no wedding plans were made.
  3. Mrs J sold her own house in June 2015. While she retained the capital in her own name, relative property values meant it would have been insufficient to buy a home of any form in Devon. She and Mr F set up a joint account for household spending, but otherwise retained control of their own income and savings. 
  4. Mrs J expected that Mr F would sell House M and they would buy a new home together in the area, but there was little progress with this. Tensions arose about changes she wanted to furnishings at House M. She appeared to Mr F’s family and local friends to decline opportunities to join social activities, and discourage visits, despite past connections.  Mr F probably knew that her late husband Mr J had lost contact with his children (from an earlier marriage) after marrying Mrs J, which may have added to the concern this caused.  However there had been stresses within his family before Mrs J’s arrival. 
  5. In telephone conversations with friends in the area she had moved from, Mrs J shared disappointment that Mr F did not spend more time at home with her, as he continued to work nearly full time and pursue a long term hobby with a local group. Mr F was concerned that Mrs J discouraged him from normal social contact with women friends. She found it hard to trust him. He referred to her as “a nag” and too “needy”. While Mrs J’s health problems were not serious enough to make her dependent on Mr F’s care, she started to refer to him as her “carer” and he worried that this might become a reality. He had found coping with Mrs F’s final illness difficult. 
  6. Mrs J had several physical health problems, some long term, which led to contacts with health services during her brief residence in Devon. She registered at Town N Surgery in February 2015 and gave a clear account of her health needs. At Royal Devon and Exeter NHS Hospitals Trust she had treatment as a medical inpatient in March and June 2015, and day surgery in November, with outpatient visits in June, July and November, and associated GP contacts in between. Her last contact with health services was an outpatient clinic only a few days before the homicide. No domestic abuse was disclosed or observed in these visits. Records show that Mr F assisted Mrs J by calling ambulances or collecting her from hospital. 
  7. Mr F was in good physical health but had attended Town N Surgery a number of times, from 1991 onwards, with issues, in the family or at work, causing him stress or anxiety. In the autumn of 2014 he told a GP about difficulty adjusting to the death of Mrs F, which led to an assessment from Devon Partnership Trust’s Older People’s Mental Health Team.  While he spoke of problems in his marriage, he did not express any thoughts of violence. He was offered medication or counselling for depression and anxiety, but declined, and in November told his GP that he was more positive and had plans. In these consultations he did not mention any new relationship, although it must have been developing at this point. 
  8. Mr F had three contacts with Town N Surgery after Mrs J had moved in with him, seeing a different GP each time. In June 2015 he reported significant stress affecting his digestion, ascribing this to a new relationship and (potentially) buying a new home, and said he thought he might be depressed at times. In July, he arranged a joint appointment with Mrs J at which they disclosed strains in their relationship. In November 2015, he talked about being unhappy in the relationship and appeared to be trying to decide whether to leave it. The GP gave him a questionnaire measuring depression to take away, expecting to re-refer him to Devon Partnership Trust when he returned with it. Mr F told police he thought he would have shown most of the indicators of depression. However, he had not yet completed the survey when the homicide occurred just 8 days later. In none of these contacts did Mr F show any sign that he might harm himself or others.
  9. GPs advised Mr F, and Mrs J on their joint visit, to seek help from Relate in talking through their future. Neither did, although the charity offers regular sessions in Town N, and can offer help even if only one partner wants engagement. Mr F told police that Mrs J thought they should sort things out without involving others. 

Key issues arising

Nature of the relationship

  1. The relationship between Mr F and Mrs J progressed from a long term acquaintance to engagement and living together at a rate which surprised those who knew them. While they had shared memories of Mrs F, it is unlikely that Mrs J knew of the marriage problems Mr F had described to his GP, or that he was fully aware of her state of health. They had mismatched expectations, and had not found a way of resolving the resulting strains.
  2. Mrs J responded with jealousy and attempts at control, refusing Mr F’s suggestion of seeking counselling or mediation. Mr F tried to hold on to his previous pattern of life, resenting Mrs J’s demands, but not reaching the point of ending the relationship. Her ill health and limited options for finding an alternative home both constrained and frustrated him. 
  3. There are no indications that Mr F was physically abusive to Mrs J before the homicide, nor that he neglected her welfare, or attempted to control her movement, communications or finances. While Mrs J was less fit and mobile than Mr F, she was able leave the house without assistance, walk and drive. Both appear to have been verbally abusive during arguments.
  4. Mrs J showed some low level controlling behaviour towards Mr F, just exceeding the reasonable expectation that a new partner will adapt their routines. She may have been trying to get reassurance that Mr F valued her, but he spoke to friends of her trying to control him. 

Cause of the homicide

  1. The homicide appears to have been an extreme response by Mr F in the context of a quarrel that was otherwise typical of many earlier ones. Killing is the ultimate form of domestic abuse, but there is no indication that this was an escalation of previous abuse in any form.  It was a violent assault, using tools he had in the vehicle for his trade, in a field to which she often accompanied him when he went to feed cattle.  He told police that they were arguing about proposed Christmas visits by members of his family, and that “in a shaking frenzy” he decided to kill Mrs J. He handed himself in to police later that day. His account is consistent with other evidence, and there is no reason to think he planned the homicide. 

Role of agencies

  1. Mr F sought and received advice from health services in dealing with anxiety and depression. Town N Surgery provided a context in which he felt able to talk about his mental health and relationships, and referred him to Devon Partnership Trust’s Older People’s Mental Health Team. Mr F found the assessment helpful but declined the offer of medication and of psychological therapies. With hindsight the offer of re-referral to this team could have been made in July 2015 rather than November. While it is not possible to know how far his feelings of depression arose from, or contributed to, the strains in his relationship with Mrs J, he might then have been ready to access the depression and anxiety service and explore this.
  2. On several occasions GPs drew Mr F’s attention to relationship advice available from Relate. This was appropriate to the information they had. Counselling, or if Mrs J had agreed, mediation, could perhaps have enabled them to address not only their current conflict but the influence of past marriages on their hopes and fears. While Relate require potential clients to initiate contact, the Surgery could perhaps have helped him and saved resources overall by helping him make an initial call on the spot.
  3. Mrs J had several episodes of health care for physical conditions during her time in Devon. During some of these she had the opportunity to raise concerns about her safety at home, for example through standard questions used by the Royal Devon and Exeter NHS Hospitals Trust on inpatient admission. Staff are trained to look out for signs of domestic abuse. There is no indication that she felt herself at risk or that staff attending her missed any warning of the homicide.
  4. Other services were available which could have helped the couple to safely end their relationship. Mr F was still in touch with a solicitor setting the estate of Mrs F. East Devon District Council would have helped Mrs J to find rented accommodation if Mr F had required her to leave House M. Splitz Support Service provides a telephone helpline which both men and women concerned about domestic abuse can contact. 


  1. This tragedy concerns two widowed people who started a relationship in later life. This decision unfortunately made them both unhappy, as they had differing expectations of their new life together but were unable to resolve them or to agree to seek help. A single act of deliberate but unplanned violence by Mr F during one of their quarrels caused the death of Mrs J and his subsequent suicide in prison.  
  2. Mr F had no record of violence or prior domestic abuse, and none has been identified since the homicide. Some of Mrs J’s behaviour towards Mr F could be regarded as attempts at low level control. Neither contacted any agency about domestic abuse, nor would they, on the available facts, have been judged to be at risk if they had. Both were signposted by GPs to Relate, but neither made contact. 
  3. Health services acted appropriately on the information they had and provided Mrs J with opportunities to disclose had she felt at risk. Mr F had given no indication of intention to harm others or himself, and at the time of the homicide was on course to be re-referred to Devon Partnership Trust for help with depression and anxiety. It seems likely that his feelings of despair at his situation contributed to the homicide, but there is no evidence that clinicians missed signs of risk, or that their diagnosis was wrong.  

Lessons to be learned

  1. This tragedy illustrates that the health and wellbeing of older people should include healthy relationships. It has contributed to increased recognition, both within Devon and nationally, that domestic abuse is as much a risk for older people as for younger adults.  Insufficient attention has yet been given to presenting the services available in ways that older men and women can understand and match to their own experience. 
  2. The story also illustrates the importance of health services as a point of contact with older people, reaching many who do not need social care or housing services. Devon County Council, with other partners, has obtained government funding to pilot in 2018 a programme aimed at GP practices in Devon and Torbay. This uses the national IRIS (identification and referral to improve safety) scheme to aid recognition of and response to domestic abuse. While not targeted at older people, it has the potential to increase recognition of older victims, given Devon’s higher than average proportion of older people in the population. 
  3. Royal Devon and Exeter NHS Hospitals Trust is well advanced in its programme of training all staff in recognising indications of domestic abuse and knowing when to ask about it. Within this it is now raising awareness about how to help older people in Devon to recognise domestic abuse and seek or signpost appropriate support. Devon Partnership Trust, while offering timely mental health support in this case, had not at the time developed a training programme on domestic abuse to ensure its staff are able to play an equivalent role. It now includes training on domestic abuse within a two-day mandatory safeguarding course introduced in 2017, aiming at 95% compliance by October 2018. 
  4. The available facts point to this homicide being the dramatically violent end of a relationship in which there had been little or no abusive behaviour by either party, or violence to others. The Panel recognises that this is unusual among domestic homicides, but thinks it important that this is recognised as something that can happen.


Recommendations from the Review

  1. These recommendations are developed in more detail in a separate action plan overseen by Safer Devon Partnership. 
    • R1 Promote awareness among older people in Devon of the availability of local advice and support with relationship problems, including domestic abuse. 
    • R2 Identify and share good practice in primary care settings in connecting patients who report relationship concerns or domestic abuse with appropriate sources of support. 
    • R3 (National) In future national analysis of domestic homicide review reports, check the prevalence of domestic homicides in which no evidence of prior domestic abuse (fitting the proposed statutory definition[3]) can be found after the event. 

[1] An Internal Management Review is an internal report whose author was not involved in the events.

[2] Due to staffing changes, this panel position was left vacant by the CCG from January 2018.

[3] Government consultation “Transforming the Response to Domestic Abuse” March 2018)

A PDF of this page is available here – Domestic Homicide Review Case 8 – Executive Summary