Domestic Homicide Review Case 9 – Executive Summary

Executive Summary July 2018 – Arising from the death of victim M – December 2015


Review Process

  1. This is a summary of the Safer Devon Partnership domestic homicide review into the death of Victim M[1], undertaken on behalf of Torridge 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.  Victim M, aged 83 was killed in December 2015 by Mr T, her long-term partner, then aged 73. He was convicted of murder in June 2016 and sentenced to life imprisonment with a tariff of 20 years. 
  2. The multi-agency Executive Group accountable to Safer Devon Partnership for oversight of domestic homicide reviews decided at a meeting in May 2016 to hold a Review. All agencies that potentially had contact with Victim M or Mr T prior to their deaths were asked for details. Five of the 16 agencies asked had had some form of contact.

Contributors to the Review

  1. The insights of people who had known Victim M and Mr T were invited. The Panel appreciates the contribution of Victim M’s son Mr L and niece Ms J, and several friends who offered views[2].  
  2. Devon and Cornwall Police provided a summary of statements made by Mr T after his arrest, and information about details of household arrangements relevant to the terms of reference. Mr T agreed to be interviewed in prison by the Independent Chair and to allow information from his medical records to be used in the review. 
  3. The NHS Northern Eastern and Western Devon Clinical Commissioning Group representative on the Panel obtained the views of Mr T’s General Practitioner through telephone and correspondence. Devon Partnership Trust provided a summary of his contact with their service, which ended in 2008. Regrettably, attempts to consult another branch of the same practice about Victim M were unsuccessful.  
  4. and South Western Ambulance Service Trust each provided an Independent Management Review, listing and reflecting on their contacts with the couple.

Review Panel

  1. The Panel met four times and also conferred by electronic means. Panel members were from Devon & Cornwall Police (Serious Case Review Team), Devon County Council (Public Health and Adult Social Care), Northern, Eastern and Western Devon Clinical Commissioning Group (Safeguarding Adults Nurse), Northern Devon Healthcare NHS Trust (Head of Quality and Safety), Splitz Support Service (Devon Service Manager) and Torridge District Council (Community Safety Manager). 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 Torridge 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, and took account of helpful comments from Victim M’s family on a draft report.  This report is agreed by the Chairs of Safer Devon Partnership and Torridge Community Safety Partnership and has been through quality assurance by the Home Office. 

Terms of Reference

  1. The Review considers agencies’ involvement with Victim M and Mr T from 2008 to 2015. There was no earlier agency contact indicating domestic abuse.  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 there were indications of domestic abuse prior to the homicide, and any learning about recognising domestic violence among older people.


Summary Chronology

  1. The homicide occurred in the middle of the night at the bedroom the couple shared in their house in Town F.  Mr T’s account is that, waking in the night, after a brief verbal exchange with Victim M, he fetched a hammer and killed her. He then attempted to gas himself, but failing, called the police. He has no explanation for his actions, and does not link them to anything Victim M said or did. There was no alcohol in his blood. The question of whether his mental health was a factor was tested at the trial and found not to “substantially affect his ability to think rationally or to exercise self-control”.  
  2. The couple had moved to Devon from the south east around 1999, when Mr T took early retirement from a senior research post in the pharmaceutical industry.  Victim M had already retired from a career with a utility company. They had met around 1975, when she was recovering from a brief second marriage which family recall was abusive. She had one son, Mr L, by her first marriage. Mr T never married and had no children. 
  3. Mr T had had a long history of mental health problems, with treatment starting in his student days. He had a history of ruminating depression and suicidal ideation, and an obsessive personality. On coming to Devon he was treated by Devon Partnership Trust until 2008, when he was discharged to the care of his GP, on long term medication. He saw his GP several times a year, and while sometimes disclosing general thoughts of self-harm, never gave any indication of intent to harm others. His last contact with the GP was a few days before the homicide, to discuss continuing pain from a recent fall, revealing anxiety about his health but nothing else untoward.
  4. Mr T was an alcoholic, and in mid-life had attended Alcoholics Anonymous. In later life he switched from spirits to canned beer, attempting to conceal his purchase and use of it. By 2015 he had reduced his consumption, but still had bouts of binge drinking which affected his physical health. His contacts with Northern Devon Healthcare NHS Trust and South Western Ambulance Service NHS Foundation Trust in the period under review arose from an arm injury and shoulder surgery in 2013, wrist injury in 2014, and four attendances at emergency units in 2015, two with signs of alcohol misuse. He sometimes injured himself when doing house maintenance, as he preferred doing things himself to allowing others onto the property, which he and Victim M owned jointly.
  5. Victim M had a medical condition affecting her balance, so used a stick. Her contacts with Northern Devon Healthcare NHS Trust and South Western Ambulance Service NHS Foundation Trust arose from planned hand surgery in 2010, a fall in 2011, another in 2012, two falls and further hand treatment in 2013. There were no indications that any of these arose from violence. She enjoyed gardening, and their home had large grounds and steep steps for access, accounting for some of the falls. 
  6. During their time in Devon, Victim M, described by friends as caring and sensible with a real interest in people, had built friendships and interests. For example she continued to enjoy Pilates and U3A[3]meetings to the end of her life. She visited Mr L, who lived less than 20 miles away, most weeks, and, often with him but without Mr T, took several trips each year to visit Ms J and other relatives. She controlled her own pensions and had some capital from an inheritance. She had her own car and phone (not a smartphone), but did not use a computer. 
  7. Mr T, by contrast became more withdrawn, neither maintaining relationships with former colleagues nor making new friendships or joining local organisations. While there were activities the couple had enjoyed together, including photography, walking and holidays abroad, these diminished over the years, and Mr T increasingly avoided contact with Victim M’s friends and relatives. His desire for privacy extended beyond rejecting Victim M’s suggestions of engaging a decorator or window cleaner, to refusing to have the boiler serviced. He could become fixated on a problem to the point where it consumed all his thinking, and small issues were magnified. A written query to Torridge District Council on a planning matter in 2013 illustrated disproportionate effort and attention to a minor issue. Victim M told friends shortly before the homicide about his worry over ordering a new computer. 
  8. Victim M found Mr T’s moods and behaviour a constraint on her ability to continue the activities she enjoyed outside the home, compounding the limitations she faced through increasing age. While he did not overtly prevent her going out, he made his displeasure clear, so that she worried as to what she would find on her return. Friends admired her for keeping her spirits up in the face of this. By 2015 she no longer felt able to leave Mr T overnight except for visits to her family. She told friends that he was increasingly being “nasty” or “vile” in what he said to her, using his verbal skill to hurt her, including comments on her family, but she confirmed there was no physical violence. 
  9. In mid-December 2015 Victim M was due to go away with Mr L for three nights to visit Ms J. This trip did occur, but was nearly disrupted by Mr T having a fall two days earlier, under the influence of alcohol, which she interpreted an attempt to prevent it. Looking back, family see a pattern in the timing of his health incidents prior to her planned holidays. In reporting the fall to relatives she said, sounding distressed, “I can’t cope with this anymore”. She enjoyed the holiday but did not want to talk about her home situation.
  10. Over the Christmas period Victim M had several contacts with friends and family, and did not report any change in her situation. In a long telephone conversation with Ms J days before the homicide they discussed her concerns about future housing and finances. Mr T had told Victim M that if he had another fall he would go into a care home and this would take all his money and all of hers. He had, the previous year, told her they would not be able to afford to move to a safer property locally. (These assessments were incorrect.) Ms J encouraged her aunt to look at options for moving either with or without Mr T and suggested contacting Citizens Advice.  At the time of the call Mr T was in bed. He is not thought to have overheard the conversation, but it is impossible to be sure. 

Key Issues Arising

Nature of the relationship

  1. Aspects of Mr T’s treatment of Victim M in recent years could be described as domestic abuse, though not meeting the threshold of the criminal offence of coercive control. He could be domineering in his conversation, and she appeared to accept his view of himself as her intellectual superior. While she had less formal education, family and friends valued her astuteness and warmth. Through moodiness, asking her to abandon plans, and self-neglect, Mr T attempted to reduce the time she spent outside the home and get her to focus on his perceived needs. Her age, and genuine concern for his welfare, made her increasingly vulnerable to this exploitation, although there is no indication of threatened or actual violence before the homicide.
  2. Victim M did not think of this behaviour as domestic abuse. She and her friends would use terms such as “being a pain”, “making things difficult”, or “selfishness” to describe it. She retained independence of income, travel and communication, and would stand up to Mr T on occasion. Friends describe her as stoical. However the intensity was increasing and she was weary of it.

Agency knowledge and response

  1. Over the period considered by the review, each of the couple had several planned and emergency attendances at local hospitals. Assessments were carried out appropriately each time, with the reason for any falls or injuries checked, and safeguarding checklists filled in. Mr T’s history of anxiety and depression was noted, as was his alcohol use. Some enquiries were made about the home situation. Ambulance clinicians are aware of the signs and risks around domestic abuse and when to report. There is no reason to think that any of the admissions was precipitated by domestic violence, so in that sense no opportunities to intervene were missed. 
  2. No reasons for concern about the primary care received by Mr T have arisen. His character and professional background made him an informed but probably difficult patient, who was on medication for long term mental health problems. The GP discussed risk of harm with him, but found no signs that he had any intention to harm others. 
  3. Victim M’s GP was at another branch of the same practice. Family recall that, although not reporting abuse, she had talked of concerns about how Mr T used his medication to her GP, asking that his GP be informed. Regrettably, the Review Panel was unable to check this. However Mr T’s GP did not receive any message by this or other means about her concerns. As they were within a single practice there would have been no barrier to the information being shared.

Availability of advice

  1. Some of Victim M’s family and friends encouraged her to consider leaving Mr T, not because they considered her in immediate danger, but because they could see that his behaviour was making her unhappy. She had offers of a place to stay while she made further plans. It is not clear whether she had reached the point of seriously considering this, but she was ready to look, despite Mr T’s objections, at options for leaving their house, which was no longer suitable for either of them.
  2. There is no evidence Victim M had already sought external advice on her options for dealing with her increasingly difficult home situation. This would have been a big step for her, as she was unused to making major decisions separately from Mr T, and had no internet access. 
  3. There is no indication that Victim M thought of herself as a victim of domestic abuse. If she had, there was a local specialist advice available to support her in understanding her situation and considering her options, although on the basis of information available prior to the homicide the risk to her would have been judged low.  There had been annual campaigns to raise awareness on domestic abuse in the area while she lived there.
  4. It seems more likely that the type of advice Victim M would have sought, had she lived, would have been on her options for moving, either to live independently of Mr T, or with him in somewhere easier to manage. Information on care and housing was available through a mix of voluntary and public agencies which either had an office in Town F or offer telephone advice, and which are alert to the possibility of domestic abuse. However, unless she had already reported domestic abuse, she would not have been eligible for any practical support in initiating a move against his will.


  1. The murder of a friendly, intelligent woman who still had much to live for by the man who had shared her life for 40 years could not have been anticipated. There was some domestic abuse through low level controlling behaviour, but no previous violence or identifiable trigger for it.  Victim M and those who cared about her did not use the language of domestic abuse in discussing the increasing difficulties Mr T’s behaviour caused her. She was starting to consider her future options, but he is unlikely to have known this, though it is possible she revealed it in a moment of frustration. Nothing in the couple’s contacts with health services indicated that she might be at risk. However, the growing misery of both with their life together was not perceived. 
  2. Lessons can be learned from this tragedy about recognising and responding to domestic abuse among older people.

Lessons Learned

  1. The prevalence and under-reporting of domestic violence and abuse among older people is starting to be recognised nationally, and is borne out by the pattern of contact in Devon. Of relevance to this case is that those over 60 who do access services are more likely than those under 60 to have a current partner as the perpetrator, and less likely to have attempted to leave them. It is likely that a domestic abuse advisor could have helped Victim M reflect on her situation and plan a safe way forward. Services were available, but she was of a generation accustomed to thinking of domestic violence as “battered wives”, and did not see herself as a victim.
  2. Devon County Council is planning to undertake further research into the nature of domestic abuse among older residents, and the appropriate service response. Learning from Victim M’s tragic death, and those of other older victims, will help inform this. 
  3. Like many people over 70, both Victim M and Mr T had several contacts with health services in typical year. Both primary and secondary care provide an opportunity to invite older people to recognise and seek help with domestic abuse in a setting that may be more acceptable to them than involving the police or approaching  a specialist service. 
  4. Health services in Devon have continued to improve the processes and training they use to enable front line staff to recognise and respond to domestic abuse. Both Northern Devon Healthcare NHS Trust and South Western Ambulance Service NHS Foundation Trust have appropriate arrangements for training staff and enabling them to report concerns. Relevant patients presenting to the emergency department and minor injury units are now asked whether they feel safe at home. This review has, however, highlighted the challenges of identification of subtle safeguarding signs especially with the elderly group.
  5. Victim M’s situation illustrates some of the ways in which older people may find it particularly hard to end abusive relationships. She faced a worsening situation at home, as Mr T’s behaviour became more demanding and both of them became frailer. In planning her future, and deciding whether to leave him, she faced challenges which are less common for younger women, including the prospect of living alone for almost the first time in over 80 years, and lack of experience of email or the internet. She may have been concerned that Mr T would be unsafe living alone without some form of monitoring, given his record of falls and lack of other friends and family. In helping older victims of domestic abuse it is important to recognise the additional limitations they may face in accessing information and finance for housing, and the validity of concerns they may feel for the perpetrator’s welfare. 

Recommendations from the Review

  1. These recommendations are developed in more detail in the separate action plan. 
    • R1 Promote awareness among older people in Devon of the range of forms domestic abuse can take, and the availability of local advice and support.
    • R2 Ensure that domestic abuse training for front line staff recognises the particular risks and challenges for elderly victims.

[1] Pseudonyms agreed with the family have been used. 

[2] 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.

[3] University of the Third Age – peer led education for older people.

A PDF of this page is available here – Domestic Homicide Review Case 9 – Executive Summary