Lessons learned from domestic homicide reviews

This brief is based on the findings from a Domestic Homicide Review (DHR). It was undertaken by Safer Leeds The purpose of a DHR is to learn lessons and improve future responses to domestic violence and abuse. This review is described as a Fatal Incident Review (FIR) as the death was by suicide; there was a history of domestic abuse and so it met the DHR criteria and was conducted as a DHR. We hope to demonstrate respect and compassion to victims and their families and, where possible, to represent the victim’s voice through these briefings.     

What happened

Luke* was in a relationship with a woman, which ended several months before his death; both parties had made reports of domestic abuse (including online abuse) to the police including after the relationship ended. Luke had a history of mental health issues including suicidal thoughts. He was accessing support for his mental health for several months and until he died. He was found dead in his family home. He had been accessing websites and social media to research methods of suicide; this was not known until after his death.     

*Luke is the pseudonym that was chosen by his family and agreed upon by the Review Panel.     

What did the review tell us?

The victim was a vulnerable young man with ongoing mental health issues and suicidal ideation. He disclosed ongoing domestic abuse (via social media) to clinicians who did not signpost or refer him to specialist services. There is a need for those services who are providing support to people with mental health issues or suicidal thoughts to consider the impact of domestic abuse on their mental state.     

The victim was male. Although the services involved recognise male victims of domestic abuse, the learning from this review is that more needs to be done to raise awareness of this issue and how it impacts on men.     

The victim was able to access information about ways of carrying out suicide and the means to do it online. Practitioners need to be more aware of the potential for this activity and to explore the possibility that people may be accessing this information as part of ongoing management of risk.     

The post-separation abuse was carried out via social media. The review found that greater emphasis and understanding of this form of abuse is required.     

What can we do now?

Signpost or refer to specialist services

Where a disclosure is made, services should ensure that either the person is signposted to local, specialist services such as Leeds Domestic Violence Service Home - LDVS or that a direct referral is made. This should be followed up in ongoing contact with the person concerned. This is related to services being “professionally curious”.     

Recognising and responding to male victims

Services should make sure that there is a broad understanding that victims of domestic violence and abuse can be any gender and that responses are tailored to the individuals circumstances. LDVS has two male workers that can be accessed via the helpline on 0113 246 0401.     

Technology Facilitated Domestic Abuse

This is a newer form of abuse that needs to better understood across the workforce. Staff need to be able to recognise and proactively identify this form of abuse, and respond appropriately.     

Recognising DVA as a risk factor for mental health and suicide

The impact of domestic violence and abuse on a person’s mental health and wellbeing can not be over-estimated. Those services that are working with people in mental distress need to have an awareness of the potential for DVA and where DVA is known to fully explore how this is impacting on their mental health.     

Local support for suicide prevention

Ensuring staff have access to resources, including but not limited to Suicide Prevention (leeds.gov.uk) to signpost people to suicide prevention services and to recognise the links between suicide and domestic violence and abuse.     

This brief is based on the findings from a Joint Strategic Review (JSR) undertaken by Safer Leeds, Leeds Safeguarding Adult Board and Leeds Safeguarding Children Partnership. It was conducted based on the prescribed methodology for a Domestic Homicide Review (DHR) though with additionality to inform the learning. The purpose of a DHR is to learn lessons and improve future responses to domestic violence and abuse.     

What happened

Jake (not his real name) was an 18-year-old White British male and the persons found guilty of his manslaughter were his mother and grandmother, sentenced to 4 years and 3 years imprisonment, respectively. His elder sister was convicted of allowing the death of a vulnerable adult and sentenced to 18 months imprisonment. They are all White British women.     

Jake died of malnourishment which had occurred over a number of months prior to his death. The exact reason for this is unknown, however medical help had not been sought either by himself or his family members. On the day he died his mother called for an ambulance on the 999 system and said he was unwell. The ambulance arrived, and paramedics found Jake lying on a mattress on the living room floor. He had a Glasgow Coma Scale score of 3 (totally unresponsive). His life was pronounced extinct shortly afterwards. At the time of his death he weighed 37 kg (5 stone 11 pounds).     

What did the review tell us?

In his early years, concerns were raised in relation to Jake’s developmental delay and risk of neglect both pre and during his primary school education. As a result, Children’s Social Care became involved, and assessment processes were undertaken. The family received further support and as a result, in part because Jake and his mother were then living with his grandparents, it was felt that there had been improvements so there was no ongoing involvement from Children’s Social Care. For the remainder of his time in mainstream education there do not appear to have been further concerns identified by any agency.     

By the end of his second term at secondary school his mother decided that he would be educated at home. This continued until his 16th birthday when he reached the age whereby the requirement for statutory education ceased. He did not go into further education or employment.     

Although a family who tended to keep themselves to themselves, at points there were professionals who visited their home or met with the family including workmen, housing officers, and Elective Home Education Officers. However at differing points throughout Jake’s life there was a pattern of missed health appointments and not seeking medical help     

What can we do now?

The review acknowledged that over the course of time local and national guidance and practice has changed and highlighted the importance of building upon and strengthening existing safeguarding approaches and work practices. The following summarises those key approaches/practice:     

Think family, work family

The needs of one individual within a family may impact on another, including their ability to care for or meet the needs of another, which may in term place that person at risk of harm, abuse, or neglect either intentionally or otherwise.     

A 'Think family, work family' approach helps to understand the unique circumstances of an adult or child, and the strengths and resources within the family to provide for their needs, but also identifies where additional support may be required.     

Early intervention

Intervening early as issues arise can positively improve the outcomes for an individual and their family.     

Within children’s services this approach is known as Early Help and is based on the following principles:     

• early in the life of the problem – whatever the age of the child
• early to respond when problems emerge or remerge
• help to prevent concerns getting worse and avoid the need for statutory intervention
• support in school, home and community through a graduated approach

Within adult services this is referred to as the early intervention and prevention approach undertaken by Adult Social Care which enables individuals to access advice, guidance and information about the services and support that is available to prevent entry into and reliance on services.     

Non-attendance at appointments or meetings

Many children and adults are reliant on someone else to take them to meetings or appointments that relate to their welfare, care, or health and as a result they are sometimes not taken to them, or appointments are not made or cancelled. Over time this may have an implication for that person’s health or welfare.     

Changing how non-attendance is recorded, and consideration for the implications of not attending is known as the “Was Not Brought Approach”      

Neglect

Neglect is a form of abuse. Neglect with regards to children and young people is defined as “the persistent failure to meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development” (Working Together to Safeguard Children 2018).     

The Care Act 2014 describes this as:     

• ignoring medical, emotional, or physical care needs
• failure to provide access to appropriate health, care and support or educational services
• the withholding of the necessities of life, such as medication, adequate nutrition, and heating

Neglect may be intentional or unintentional and can be caused by anyone with a responsibility to provide care, including relatives and paid carers. It rarely occurs as a one-off incident rather than a cumulative effect which can take place over a period of time.     

Professional curiosity

Professional curiosity is where a practitioner explores and understands what is happening within a family or for an individual rather than making assumptions or taking a single source of information and accepting it at face value. It means:     

• testing out your professional assumptions about different types of families.
• triangulating information from different sources to gain a better understanding of family functioning which, in turn, helps to make predictions about what is likely to happen in the future.
• seeing past the obvious.
• questioning what you observe

It is a combination of looking, listening, asking direct questions, checking out and reflecting on ALL the information you receive.     

Safeguarding awareness

Safeguarding is everybody’s responsibility, and everyone has a part to play.     

Safeguarding is an umbrella term which refers to any activity that ensures the safety and welfare of an individual.     

There are specific definitions as to what constitutes abuse and neglect for children and young people and for adults with care and support needs, and associated legislation with regards to how abuse and neglect of individuals is responded to.     

Being alert to the signs and indicators of abuse and neglect and knowing how to raise these / respond may enable a person to get the support and care that they need.     

This brief is based on the findings from a Domestic Homicide Review (DHR) undertaken by Safer Stronger Communities Team Leeds. The purpose of a DHR is to learn lessons and improve future responses to domestic violence and abuse. We aim to demonstrate respect and compassion to victims and their families in these briefs and, where possible, to represent the victim’s voice.      

What happened

Edward was a white British male aged 44. On the night he died, they had been involved in an altercation which resulted in Edward being pushed by Jane which lead to the head injury that caused his death. She was later acquitted of manslaughter.     

They had been in a relationship for approximately 5 years.     

There was a history of physical abuse, mental health issues, substance and alcohol misuse for both parties.     

Edward suffered from severe anxiety and was opioid dependant. He had little contact with services.     

What did the review tell us?

In the period of the review, there were several domestic abuse incidents reported to the police where either Jane or Edward were the aggressor; these were dealt with appropriately with both parties denying that offences had taken place. They were discussed at MARAC, with Edward as the alleged perpetrator towards Jane though no support was accepted by either party.     

What can we do now?

Recognising and responding to ongoing DVA

In this review, there was ongoing arguing and fighting between this couple. This review reminds us that when we become familiar with the dynamics of relationships (as we need to do if we’re building a meaningful rapport with people), this can obscure the potential for risk. She told others she had given him a black eye, she herself described the relationship as mutually abusive yet he was not identified as vulnerable, and he was not recorded as a victim of domestic abuse during the period of the review.T his review prompts us to think regularly about risk in ongoing relationships.     

Flexible responses are needed to address complex needs

The question of the need to balance independence and empowerment with the identified safeguarding risk is especially pertinent. Best outcomes are achieved when service users engage with support. This might mean a long-term pattern of resistance and disengagement is accepted and managed by services. Empathetic, non-judgmental approaches needed.     

Accurate and timely recording should be the bedrock of effective daily practice

The review found several examples of missed or incomplete information so prompted a recommendation around the need for good record keeping. This is to ensure that good practice is documented and evidencing the work that has been undertaken.     

This brief is based on the findings from a Domestic Homicide Review (DHR) undertaken by Safer Leeds. The purpose of DHR’s is to learn lessons and improve future responses to domestic violence and abuse. We aim to demonstrate respect and compassion to victims and their families in these briefs and, where possible, to represent the victim’s voice.     

What happened

Victim was a 55 year old woman who had been in a relationship with her male partner for 33 years. They lived in their own home in Leeds. The DHR process established that in the period prior, the couple had been experiencing financial difficulties in relation to the payment of their mortgage. As a result of this they were facing eviction from their home and this was due to happen just three days after she was found dead. The Victim was not aware of the financial difficulties that she and her partner were facing or the impending eviction. They were a private couple and little is known about them, although they reported to have been a couple that were happy together. Police attended their home and signs indicated that she had been deceased for some days and died as a result of stab wounds. When the police attended they found the suspect intoxicated, and with cuts to his wrists, which they believed may have been an attempt by him to end his own life.     

The incident that led to the death was the first occasion in which domestic abuse or violence had occurred and the couple had not come to the attention of local statutory services.     

What did the review tell us?

Neither victim or suspect known to services other than health related services.     

There was no evidence of domestic abuse in the relationship but the DHR panel concluded that routine enquiry should have been undertaken in health related contacts.     

It appears that the suspect was under considerable stress in relation to the financial problems and the impending loss of the couple’s home. According to the court reports it is understood that the perpetrator had not told the victim about the impending repossession prior to the incident. What role this played in the incident occurring is not clear.     

The perpetrator did not appear to have sought any specific help in relation to his financial difficulties and had kept them to himself. What effect this level of stress had on his mental health is not clear, though he sought no support from health professionals or others.     

The overriding conclusion of the DHR panel was that it was a particularly sad case. The circumstances surrounding the lead up the incident appear to centre on the financial difficulties and impending loss of the house. There was very limited contact with statutory services, but that which was reviewed showed good standards of care and treatment.     

What can we do now?

Routine enquiry

The use of routine enquiry was lacking in this case. GP practices, including those that have undertaken domestic abuse training should be reminded of the necessity of using routine enquiry. Those that require additional training or support should be offered it. An audit of understanding and use of routine enquiry should be undertaken with an appropriate sample of Leeds GP practices before April 2020.     

Financial pressures

The review uncovered issues around financial pressures the victim and suspect were facing. Services should consider the impact of these situations and the potential for them to trigger or play a part in domestic violence and abuse.     

Signs and indicators

This DHR revealed that there may be no indicators of Domestic Violence and Abuse, but that does not mean the possibilty or potential for it to be present or to occur should be discounted by services.     

This brief is based on the findings from a Domestic Homicide Review (DHR) undertaken by Safer Leeds Executive. The purpose of DHR's is to learn lessons and improve future responses to domestic violence and abuse. We aim to demonstrate respect and compassion to victims and their families in these briefs and, where possible, to represent the victim's voice. In this instance the family requested the victim's real name, Poppy, should be used.     

What happened

Poppy was aged 24 years old at the time she was murdered. She was of white European ethnicity. She lived in Leeds in a shared flat with her ex-boyfriend John, who she had recently split from some months before. They stayed in the flat due to financial convenience, until a new flat became available.     

She was due to move to another apartment in the same block just three days after she was murdered. She died as a result of stab wounds inflicted by the perpetrator.      

John pleaded guilty to Poppy's murder at Leeds Crown Court and was sentenced to life imprisonment and told that he must serve a minimum of 16 years and two months.     

What did the review tell us?

Neither victim or suspect were known to any agencies, therefore the review has gathered information from family and friends to inform the learning.     

There was no known domestic abuse prior to her death.     

None of the witnesses interviewed ever considered the perpetrator to be a risk to Poppy.     

It is clear that the ending of the relationship was a period of heightened risk to Poppy and proved to be the catalyst, or trigger, for the fatal attack upon her.     

In particular the review highlights the importance of picking up on behavioural cues and emotional warning signs. These could take the form of emotional instability, evidence of a refusal to accept the end of the relationship, evidence of self-worth being too connected with the maintenance of the relationship, seemingly isolated instances of violence,and stalking type behaviours.     

What can we do now?

Post-separation risk

There were a number of incidents reported by friends and family after her murder which, reviewed in hindsight demonstrate the risks posed to Poppy. There is significant research to highlight the fact that the risk to women, from their male partners, rises significantly when there is a withdrawal of commitment to the relationship or a separation. Expert in the field of Domestic Homicide, Dr Jane Monckton Smith, identifies the eight-stage relationship progression to Domestic Abuse Homicides, which include many coercive or controlling behaviours.     

Awareness of risk

Learning from the review highlights the importance of routine enquiry and the need for practitioners to be alert to the sometimes-subtle signs that individuals pose an increasing risk of harm to partners and ex-partners, or signs that they are indeed already causing harm.     

Poppy was a young woman, in her first serious relationship. This means she may have had very little to compare her relationship with. Whilst Poppy bears no responsibility for not recognising any potential risk, she may not have been aware that behaviours being exhibited by the perpetrator were coercive, abusive and indicated she was in danger of harm. The review indicated the need for continuing healthy relationship awareness to be available in schools and education settings. Also, for wider knowledge across society around risky behaviours such as coercive control and stalking.     

Signs and indicators

Many practitioners working across services, engage with men and women who move in and out of relationships and thus have the ability to pick up on concerning behaviours and take appropriate action. Professionals need to be alert to the potentially subtle signs of abuse and the changing dynamics of inter-personal relationships.

This brief is based on the findings from a Domestic Homicide Review (DHR) undertaken by Safer Leeds. The purpose of DHRs is to learn lessons and improve future responses to domestic violence and abuse. We aim to demonstrate respect and compassion to victims and their families in these briefs and, where possible, to represent the victim’s voice.     

What happened

The victim was a 40-year-old white female resident of Leeds who was found dead in her flat. The inquest identified that the cause of her death was blunt force head trauma and neck compression. Her ex-partner an immigrant from Tanzania who still lived at her address following a separation, admitted murder at a pre-trial hearing. There appears to have been no reported history of domestic violence in the relationship although the perpetrator was known to abuse alcohol and suffer mental health difficulties engaging in self-harm and suicide attempts. The victim’s family, friends and work colleagues were all concerned about the relationship and the stress and unhappiness the perpetrator's behaviour was causing but did not feel that they had any concerns for her safety or felt at risk. Similarly, none of the agencies who had contact with them identified any risk or reported any concerns. Following the murder, the perpetrator walked some distance to a motorway loop where he jumped off a footbridge resulting in serious injuries, including multiple spinal and shoulder fractures and a head injury.     

What did the review tell us?

The review uncovered instances of the perpetrator engaging in financial abuse and controlling behaviour through the threatening of suicide and acts of self-harm. The perpetrator was also found to regularly mis-use alcohol. Friends and family felt they recognised evidence of emotional control throughout the relationship and that he was very manipulative but not using aggression, rather using his perceived vulnerability to make the victim respond to him in the way he wanted. The review also found he had put spyware on her phone and that there was a perceived build-up of behaviours as the relationship had come to an end. The review found the perpetrator created an un-real world to serve his own narcissistic needs and he used ‘gaslighting’ as an extremely effective form of emotional abuse that caused the victim to question their own instincts and feelings. The victim was not found to fear the perpetrator in any way but was seen to often have a ‘mothering’ role. Financial abuse was a factor with the perpetrator stealing money from bank accounts right up to the point of her death. The review did uncover that the perpetrator had stated ‘he would never let her go, ever’ and it was known that the victim had made concrete plans to leave Leeds at the time of her death. Panel discussions highlight that no failings were identified in service provision and the perpetrator was offered a range of support on several occasions. There is however a balance of clinical practice with professional curiosity in terms of repeat questioning; and professional curiosity was identified as a learning point and recommendation.     

What can we do now?

Barriers to professional disclosure

There are additional barriers for those who are aware that disclosure of abuse will have a specific and far-reaching impact on the employment of the perpetrator, for example the police, social care, voluntary sector or where the perpetrator is working with children. Reporting domestic abuse may result in the person losing their job and this will be a significant factor for the family income, and for future employment. If a perpetrator works in a childcare setting any disclosure or report to the police could lead to LADO investigations and this may result in victims being less willing to disclose abuse.     

Non-violent forms of controlling behaviour

Fear is only one method of control. The victim did not report any threat or fear of violence in her relationship, yet he was still able to establish an imbalance of power and control within their relationship. Emotional and psychological coercion and control leaves no easily observed evidence, and this highlights the need to reinforce professional curiosity, “respectful scepticism” and to use every opportunity to evaluate risk.     

Homicide/Suicide Incidents

These instances are relatively rare; however the victim of the homicide is most frequently their intimate partner. Studies highlight masculine possession and control as a dominant theme alongside mental ill-health, previous suicide attempts and fears around financial security; themes which have been present in this review. Perpetrators can first externalise blame through killing a loved one. Unable to cope with the loss of the victim, who may also be their primary source of nurturing. Without a viable “other” to blame, the offender commits suicide as a form of self-punishment.     

Assessing risk

The merged chronology and agency reports highlighted that this review was characterised by the lack of any apparent history of domestic abuse. This review highlights the importance of considering potential signs and indicators even when no disclosure has been made, and there is no obvious use of violence. Although some of this information was available to professionals the extent of his controlling behaviour was not fully apparent until the events that led to the victims death. This review highlights the specific risk associated with separation, planning to leave and where the couple continue to cohabit and how safely.