Domestic Homicide Review into the death of 'Alina'
Approved for publication in August 2019
Summary: Unlawful killing of ‘Alina’ by ‘David’. Reported incidents of stalking and harassment escalated and culminated in the domestic homicide of Alina. A Domestic Homicide Review was undertaken in 2016 and found that whilst most services have provided appropriate response, there were also significant learning points that would lead to review and redevelopment of policy, procedure and practice for the agencies involved, when responding to incidence of stalking and harassment.
Issues identified: The review took place in 2016, and since this time agencies involved have taken proactive steps to change policy, procedure and practice to improve response.
At the time, the review found that across agencies, and within the community that could support Alina, there was a lack of recognition of the dangers of stalking.
There were also issues identified about use of language between victims and services; observations that the different ways an incident can be described and identified with by the victim and services could potentially lead to misunderstanding on the part of the victim. The panel also identified issues with regard to victim consent and the effect on timely intervention/contact (where a case is not assessed as high risk) for onward referral to support services.
The panel raised concerns about whether communication with young people was effective; particularly in reaching young women who are experiencing stalking and harassment, either proactively through education to help early identification and reporting, or in responding to reports of incidents with successful engagement with services. It asked ‘Are agencies cognisant of the different ways in which young women engage with services which may not ‘fit’ the current structures?’ The panel also acknowledged the impact of the existing culture and narrative in society, that creates an environment in which stalking and harassment is minimised, normalised or even rationalised as ‘romance’.
The panel identified the necessity of quality ‘sex and relationships’ education in schools.
The panel identified failure to follow procedures during its review. There were a number of instances where existing policy and procedure were not followed by Sussex Police. This has been the subject of a parallel review by the IOPC.
A range of lessons learned were identified, in particular relating to:
- Developing recognition and understanding of stalking and harassment and the characteristics, behaviours and motivations behind this; and how service response to such crimes and incidents must be specific to those circumstances.
- Effective risk assessment: reliant on the right risk indicators for stalking and harassment being in place and these being confidently assessed
- Victim perception of services and the subsequent impact on victim’s perceived ability to report concerns.
- Services and the general public allowing perpetrator stalking behaviours to be down played
- A need for publicity to raise awareness amongst the general public of the following issues:
- Coercive control and the risks associated with it
- Stalking behaviours and the help available
- Opportunities for family and friends to report their concerns and the use of schemes like Domestic Violence Disclosure Scheme with particular emphasis on the range of people who have the ‘right to ask’.
- Actions that friends and family members of victims can take to protect and support their friend / family member
Actions We Are Taking: A range of recommendations were made with implications for individual agencies and the wider partnership around practice, training, partnership working and commissioning. These recommendations will be discharged into a city wide ‘combined action plan’ which manages the response to any common recommendations arising from local reviews.
Domestic Homicide Review into the death of Mrs A
Approved for publication in February 2014
Summary: Unlawful killing of Mrs A by her husband. The panel concluded that the homicide was not predictable on the basis of the information available at the time and it does not appear that there were any specific weaknesses or errors that might have affected the likelihood of the homicide occurring.
Issues identified: The review only had limited information about Mrs and Mr A, and there was an absence of information from Mrs A herself. As a result the panel was unable to rule in or out the presence of domestic violence or abuse, but did identify broader learning relating to older women and their experience of domestic abuse.
Lessons learned: The importance of ensuring that local residents have information about support services so they are able to access these when appropriate; the challenge of working with individuals where help is not sought, particularly where there is no other information at the time that might have lead to a safeguarding referral or concern; the importance of timely discharge notifications to ensure that health needs are managed appropriately; better understanding of the issues for older women who experience, or may be at risk of, domestic violence or abuse, including barriers to disclosure and service responses; the importance of professional curiosity so that professionals have a sense of service users as ‘real people’ to inform their engagement with services.
Actions we are taking: Reviewing how to raise awareness about elder abuse or domestic violence or abuse among older residents; Ensuring professionals know how to identify and assess older people at risk, have adequate training to do so, in relation to domestic violence and abuse and safeguarding adults; Reviewing provision by specialist domestic abuse services so they are able to consistently address the needs of older people where appropriate; Ensuring that discharge notifications from Hospital to General Practitioners are timely.
Domestic Homicide Review into the death of Mrs B
Approved for publication in June 2014
Summary: Unlawful killing of Mrs B by her husband Mr B, who was tried and found guilty of murder. The panel concluded that there was nothing to indicate that Mr B might kill a partner as he did. There is no evidence that leads to a view that this event might have been predicted.
Issues identified: The review identified that neither person was well known to services, and nor were the strains within their relationship well known. Mr B had sought psychological support in the past and in the months before this act for his low mood in relation to bereavements he had suffered. He was identified as having a moderately severe depression. Mr B was offered a psychological intervention, but this was not taken up as it appears he did not see the appointment letter and, when discussed with his GP, he had expressed some concern about accessing the service.
Lessons learned: Lessons learnt from this case are limited because the engagement of this couple was itself limited with statutory services, and there was no contact with any specific domestic abuse agencies. However, some specific practice issues were identified in relation to accurate record keeping, as well as how information on psychological interventions is made available to members of the public. Broader lessons learnt linked to the importance of ensuring that there is clear, accessible information available to victim/survivors, that there are clear referral pathways to ensure that help and support are available (in particular, from health) and the importance of wider societal awareness and understanding of domestic abuse.
Actions we are taking: Ensuring practice around recording is fit for purpose; Developing a referral pathway for victims of a domestic abuse incident; Ensuring the information available to victims of domestic abuse at or following an incident is fit for purpose; Ensuring that there is a consistent DHR process across Sussex, in both the commission and dissemination of reviews; Developing a consistent response to victims of domestic abuse in primary care settings; Ensuring the information on psychological interventions are fit for purpose; Developing a consistent response to victims of emergency care; Ensuring that businesses are better informed and supported in relation to domestic abuse; Ensuring that the communities are better informed about domestic abuse.
Domestic Homicide Review into the death of Mr C
Approved for publication in December 2014
Summary: Unlawful killing of Mr C by his partner. The panel concluded that Mr C had been assaulted at least over a period of months and probably years. He was physically, emotionally and financially abused. The panel identified a key practice episode when Mr C did disclose, but professionals did not respond pro-actively, addressing his immediate health needs but not prioritizing his safety.
Issues identified: Mr C’s family knew of some of the abuse but were unable to convince Mr C to seek help or leave Mr Y. It may be that being an older gay man may have made it more difficult for Mr C to seek help and for professionals to identify the assault as domestic abuse. Mr C’s problematic alcohol use appears to have been allowed to mask the signs of abuse, even when he disclosed. The many health professionals that Mr C saw in the last year of his life did not pick up the signs of abuse or ask about it.
Lessons learned: A range of lessons were identified, including ensuring that there is an improved understanding about domestic violence and abuse amoung: victim/survivors (so they are able to name the abuse), family (particularly on where to go for advice and information) and employers and unions (particularly on how to respond to concerns or a disclosure and offer proactive support). Additional lessons related to the need to improve: health and social care responses to patients and employees, commissioned services’ responses and communication between agencies and services.
Actions we are taking: A range of recommendations were made, with implications for individual agencies and the wider partnership around practice, training, partnership working and commissioning. These recommendations will be discharged into a city wide ‘combined action plan’ which manages the response to any common recommendations arising from local reviews.
Near Miss Review relating to the attempted suicide of Ms D
Approved for publication in September 2014
Summary: Near fatal overdose by Ms D, who had experienced domestic violence & abuse (DVA) from two partners and also had a complex and chaotic lifestyle, with a range of needs including mental health problems, alcohol misuse and other health problems. A Near Miss Review (NMR) was conducted because this was a life changing incident and it was apparent that she had extensive contact with local services. The panel concluded that services mostly provided appropriate responses, were all familiar and experienced in dealing with her vulnerabilities and it seems they provided a good service in this respect. While the panel concluded that there did not appear to be any specific weaknesses or errors in professional practice or service response(s) that might have affected the likelihood of this life changing incident occurring, a range of issues were identified.
Issues identified: Agencies struggled to retain Ms D in services as, like many other victim/survivors of DVA, she would resort to a number of strategies to minimise the difficulties she was facing. This prompted some services to discharge her, rather than to make greater efforts to uncover the reality of her problems and to work together in order to ensure that she had a suite of services around her with effective oversight and governance to ensure she did not fall through the net. This led to an ‘event’ based approach; the services she received were unconnected in many ways and no agency or professional took the initiative to step up and provide a central role in overseeing the care that Ms D needed and was receiving. In addition, there were some specific practice issues identified, for example where information was not shared fully and the case management of Ms D was more ‘process centric’ rather than ‘client centric’. This included practice at Multi-Agency Risk Assessment Conferences (MARACs), which did not construct sufficiently robust or focused action plans, as well as a key practice episode managing a response to an overdose in July 2013
Lessons learned: A range of lessons were identified, with these relating to the response to complex cases by a range of services locally, with regard to risk assessment, information sharing and case management. There were also broader lessons learn relating to the conduct of reviews and commissioning of services.
Actions we are taking: A range of recommendations were made, with implications for individual agencies and the wider partnership around practice, training, partnership working and commissioning. Brighton & Hove City Council will work with West Sussex County Council to address shared recommendations, while a number of recommendations will be discharged into a city wide ‘combined action plan’ which manages the response to any common recommendations arising from local reviews.
- Executive Summary
- An Overview Report has been shared within the partnership, however it will not be published in order to respect Ms D's privacy and because this was not a statutory review.