The analysis of this tragic incident will draw on the chronology presented in section 2 above, the management IMRs provided by involved agencies, and information gained from the Chair's meetings with Mrs B's mother, with [redacted] with Mr B and with Mrs B's employer.
The analysis will focus in turn on the engagement of involved agencies, and then in how they worked together.
3.1 Contact with Bedfordshire Police
3.1.1
The only contact with Mrs B and Mr B where domestic abuse was a directly identified issue was with Bedfordshire Police in April 2011.
3.1.2
The IMR details the contact made by Mr B in a 999 call, the incident itself and the follow up. The Review Officer comments that:
"From the documentation available, this incident turned out to be a minor domestic situation and by the time the officers arrived there was no indication that it had developed into anything more serious than a verbal dispute.
However the initial call received by Bedfordshire Police would seem to indicate that this was not a straightforward case. According to the 'crime report', the aggrieved party was recorded as being (Mrs B , then girlfriend not wife) whereas the incident log identifies the male party as being the aggrieved and the person responsible for calling the police."
3.1.3
The IMR comment continues:
''At 12.45 hours that day, (a police constable) from the Public Protection Support Team reviewed the incident checked for any background history and completed a Domestic Abuse Incident Report. Although the Domestic Incident Crime Report categorized (Mrs B) as being the complainant and (Mr B) as being the accused, no offences were revealed, and therefore it was considered not appropriate to send a follow-up letter to either individual.
Due to the SPECCS risk assessment: scoring no points, (the police constable) assessed the risk as 'Standard', and concluded there was no further role for the Domestic Abuse Investigation Unit I Child Abuse Investigation Unit (DAIU/CAIU) at this time".
3.1.4
In completing the IMR the Review Officer interviewed one of the officers who attended the house on this call and completed the 'Domestic Incident Crime Report'; they also completed the 'SPECCS risk assessment form' in line with Bedfordshire Police Force policy. However, the officer was unable to recall the incident so was unable to clarify the questions that arose about the nature of the call and the respective roles of Mrs B and Mr B. This is commented on in the Effective Practice/Lessons Learned section of the IMR as follows:
"It is always difficult to predict the outcome of a relationship even with first-hand knowledge of the family dynamics. As far as Bedfordshire Police are concerned this one incident would not have given any cause to predict that homicide would be the eventual outcome. The incident referred to in this review would appear to have taken place when both parties were heavily intoxicated with alcohol, and there are no other incidents that came to the notice of the police to suggest that this behaviour was typical.
However, the unfortunate situation with the response officer ... being unable to recall this event and the period of time the officers spent at the scene leaves the Review Officer concerned that possibly, more could have been done in this case. The comments on the crime report and domestic violence report do not rationalize either the initial call to the police or the background conversation overheard by the call taken. Although the DVIU officers (were) compliant with Force Policy, more time spent at the scene and a more enquiring mind may have identified a pattern of behavior unknown to the relevant agencies. This may have been a missed opportunity. The Review Officer fully accepts that the DVIU has only limited resources and their reliance on response officers acting effectively in the first instance is obvious. This ambiguity may easily be explained but should have been identified and clarified with further enquiries by DVIU staff."
Panel Comment
3.1.5
The Panel endorses the Review Officers comments. Follow up questions were also put to Bedfordshire Police in relation to:
- The duration of engagement by officers on the scene in April 2011 and why they were called away;
- The categorization of the incident as "verbal only" when it was evident that there was a degree of physical restraint;
- The differences between the call log and the officer's record;
- Whether the incident should have been referred to a specialist domestic abuse support agency; and
- If the change from SPECCS to DASH (Domestic Abuse, Stalking and Honour Based Violence (DASH 2009) Risk Identification, Assessment and Management Model.) risk assessment might lead to a different risk categorization?
3.1.6
Bedfordshire Police responded to all these questions. The Panel was satisfied with the explanation for the officers being redeployed as there was a serious 'High Priority Incident' taking place requiring more police presence in the town centre.
3.1.7
The incident was recorded as a "verbal only domestic", and the risk assessment as being 'standard risk'. This decision was questioned within the OHR Panel. There was consensus from representatives with a specialist domestic abuse background that while the information would not have necessarily meant that the case should have been graded as high risk, it did appear to indicate that the case should have been investigated further. In particular, this reflects the facts of the incident that were disclosed to the Force Control Room Operator (that Mr had restrained his partner by sitting on her; that Mrs B may have been attacking Mr B; and both had been drinking).
3.1.8
While there was a review of the case later that day, in line with normal procedure, a decision was made not to follow up. This decision was questioned by the Panel. While no crime had been reported, given that both parties were under the influence of alcohol, and officers were only on the scene for a short period of time, a follow up would have been appropriate. In addition, there is no indication that the parties were spoken to separately. The Panel felt this was particularly significant given the incident was left unresolved, including a lack of clarity as to the identification of the complainant.
3.1.9
Concerns were noted regarding the process of recording events/actions. It is recognised in the IMR quoted extensively above that the recording of the event was inconsistent, with differences between the original incident log and the subsequent crime report being unresolved. The lack of clarity as to the identification of the complainant (i.e. which party was the victim and which the perpetrator or indeed whether this was a situation where both Mrs B and Mr B were physically and verbally abusing each other) was not followed through. There is no indication that the parties were spoken to separately. It is unknown if the records were reconciled in discussion but there is no indication that this did happen on the available records.
3.1.10
It was noted that recording the incident differently could have caused a trigger point and therefore further investigation. However, the view given by Bedfordshire Police in response to the question about the different risk assessment processes of SPECCS and DASH indicated that on both measures this incident was regarded as 'Low risk'.
3.1.11
As noted in 2.26, there was no onward referral to a specialist domestic abuse service as this incident was not recorded as a crime. The Panel noted that this may have been a missed opportunity to offer support, although accepted that this reflects policy at the time and the referral of all incidents (in addition to crimes as is currently the case) would have resource implications.
3.1.12
Overall the Panel noted that there were a number of issues relating to the recording of the incident and these were unresolved; it is not clear if either party were spoken to separately at the time, nor was there any follow up in which they may have been spoken to subsequently; also, no referral was made to specialist agencies as this incident was not recorded as a crime.
3.1.13
Consideration of these issues leads to the following recommendation:
Recommendation 1
Records should be consistently completed, in order to provide:
- An accurate record of an incident
- The actions of officers at the time
- What was known to police officers at the time of the incident
Where there are discrepancies between the Incident Log and Domestic Incident Crime Report, these are resolved to ensure a full understanding of the current situation and any further action.
Recommendation 2
That all domestic abuse incidents (not just crimes) are offered a referral to a specialist domestic abuse service.
3.1.14
This incident illustrates the complexity of identifying relatively minor situations that may occur often, but have the possibility of becoming, or indicating, something more serious. A parallel with medical practice was discussed in the Panel where the presenting symptoms might be relatively low level but could also be the early manifestation of a serious condition not immediately detectable. General Practice in medicine has a "safety-netting"' process whereby patients are advised when to seek further advice if their symptoms resolve or evolve
3.1.15
Drawing on this model of targeted advice provided at a time when people are most likely to be receptive, and therefore most likely to be take note and act on it. The Panel recommends:
Recommendation 3
That information is provided directly to victims of domestic abuse at or following an incident (where it is safe to do so) that might encourage them to identify ongoing abuse in the relationship and know where to seek help.
3.2 Sussex Police
3.2.1
There was some involvement with Mr B as a juvenile in 2002 when [redacted]
3.2.2
In January 2010 the police records show awareness of who was living in the family home at that time: [redacted] and [redacted], [redacted] and Mr B and his then girlfriend (it is not clear who this was).
3.2.3
There was contact in February 2013 (see 2.45 and 2.46) when a routine Neighbourhood Policing Team foot patrol came across the group of people including Mrs B and Mr B in a verbal dispute. The officers appeared to have a placating effect on the dispute and offered Mr B the opportunity to meet with local officers when he felt low. Mrs B had by then left the scene with the friend who was accompanying her.
3.2.4
The only other contact was at the time of the murder when the police responded promptly to the 999 call and apprehended Mr B.
Panel comment
3.2.5
The Panel endorses the analysis of involvement by Sussex Police in their IMR, which identifies the engagement with Mr B in February 2013 (when he was spoken to as part of the group in [redacted]) was a positive example of
community policing. The officers offered the opportunity to Mr B to speak with them further and advice (and possibly help) to contact Relate.
3.2.6
At the time of his arrest the police response is correctly described in the IMR as "prompt and effective", administering first aid to the victim prior to the paramedics attending, securing the crime scene, gaining the details of witnesses, arresting Mr B and ensuring that he received the necessary medical attention to the intentional injuries he had made to himself.
3.2.7
On a broader point relating to the IMR process, there was a degree of caution in sharing all relevant police information as the criminal trial was impending. The effect of this was that the Panel received information in a somewhat piecemeal manner, including a witness statement from a former partner of Mr B. This is a genuine dilemma when the two processes of the OHR and the criminal trial converge that will affect a number of DHRs.
3.2.8
This OHR was a learning opportunity as it was the first OHR undertaken locally while a criminal process was imminent. Reflecting this, and learning in neighboring authorities, the pan Sussex Domestic Abuse Steering Group has established a OHR working group. It is proposed that this group develop a pan Sussex protocol to ensure that there is a consistent process across the higher tier local authorities and statutory and voluntary sector partners in order to share learning and good practice from across Sussex and nationally. Additionally, it is intended that this group will identify the parameters of what information can be shared (and when) in the context of an imminent or ongoing criminal trial.
The Panel recommends:
Recommendation 4
That the proposed DHR working group, under the auspices of the Pan Sussex Domestic Abuse Steering Group, is established with a view to developing a protocol to ensure a consistent DHR process across Sussex, including information sharing. This would also promote sharing learning and recommendations locally, regionally and nationally.
3.4 High Weald Lewes Havens Clinical Commissioning Group, Sussex Partnership NHS Foundation Trust and Health in Mind (HiM)
These IMRs are being considered together as there is a connection between them in relation to the GP's engagement with Mr B and subsequent referral to HiM. HiM is provided by Sussex Partnership Trust, who are commissioned by the High Weald Lewes Havens Clinical Commissioning Group to provide mental health services in the area.
Both Mrs B and Mr B were registered with, and seen by, the same Primary Care practice.
3.4.1
In relation to Mrs B: Mrs B attended the practice once [redacted]. She also accompanied Mr B in January 2013 when he saw the GP in relation to his insomnia and irritability.
3.4.2
When Mrs B saw the GP in December 2011 this was also her registration with the practice, so she was previously unknown to them. The IMR notes that on neither occasion did the GP note any concerns relating to Mrs B's home situation or safety. The IMR also notes that the practice received her medical notes from her previous practice in Luton on 2nd February 2012, and these were subsequently entered onto the electronic records system at the practice on 30th March 2012.
Panel comment
3.4.3
The GP made a narrative entry onto the electronic system. It is not possible to confirm if this was based on a New Patient Questionnaire, which may have been completed in line with normal procedure. If this is the case, there would have been an original paper form that was shredded once the electronic entry had been made.
3.4.4
There is no evidence to indicate that Mrs B made any disclosures in relation to domestic abuse.
3.4.5
In regard to Mrs B's [redacted]. This was her only consultation with the GP.
3.4.6
[redacted]. A Discharge Summary to the GP was made and she was advised to follow up with the GP if she had further symptoms. The IMR states that:
"There appears to be no signposting on from [redacted] as to whether leaflets or support services are available should people require them. The (GP) practice manager gave assurances that when [redacted] this was done (provision of information) but since they moved into another practice there were 'gaps' in the service for follow up." The IMR says that this is being "looked into as part of (the) action plan" from this IMR.
3.4.7
Although there is no evidence that Mrs B made any disclosures of domestic abuse to either her GP or the [redacted] the Panel was mindful of the importance of ensuring that health practitioners are aware of domestic abuse. In particular the panel felt that it was important that professionals are aware of the range of health impacts and therefore potential clinical indicators that they may encounter in their practice, so that they are in a position to routinely consider the possibility of domestic abuse. The Panel recommends:
Recommendation 5
The NHS England local Area Team works with the relevant Clinical Commissioning Groups to develop a consistent process to support practitioners' awareness of domestic abuse, including access to an appropriate specialist service, in a primary care setting. Examples include the domestic abuse health advocate/educator within the IRIS model (Identification and Referral to Improve Safety' in General Practice.)
3.4.8
In relation to Mr B: The CCG IMR documents Mr B's engagement with the GP practice:
"(Mr B) visited the GP practice on more than 8 occasions in the time frame given for this /MR. He was experiencing low mood. During these visits there was no recorded indication of any violence issues. He was described as withdrawn. The practice GP's did assess (him) using tools such as the Depression Screening Form (PHQ9). (Mr B) had an initial scored of 16 then proceeded to score 13 (seven months later).
Antidepressants were prescribed and reviewed. There had been some improvement with his condition with medication alone. Bloods were taken for any underlying organic disorders. On one occasion this was acted upon (there was a deficiency in folic acid) medication was prescribed to alter this deficit. On two occasions the GP referred AM to Health in Mind (HiM) via a referral form... faxed to HiM (on 21 December 2012).
The mental health service responded to these referrals via a letter. Even the GP contacted (him) on one occasion via a letter for him to engage with the mental health service. In October of 2012 it was documented that he no longer wanted talking therapy indicating there would be a problem with transport.
3.4.9
It is helpful to factor in at this stage the IMR supplied by the Sussex Partnership NHS Foundation Trust (who provide the Health in Mind service). The IMR included information provided by HiM, including a copy of the referral fax.
3.4.10
This IMR describes Mr B's referral to HiM in November 2009 with the commentary noting that he "had previously been referred to the Mental Health in Primary Care Service. He was invited to attend an assessment but had declined to attend". From the IMR this would appear to be on 1st December 2009. He was subsequently recorded as a Did Not Attend referral, the GP was notified and the case closed.
3.4.11
However, Mr B and [redacted] describe a significant engagement with a counselling service from June 2009 to December 2009 which Mr B found helpful. There is no reference to this in either IMR.
3.4.12
The IMR records when Mr B saw the GP on 1ylh October 2012 he was "not wanting Talking therapy" and that "transport would be a problem for him with HiM services". There is however, no reference to the session that Mr B says he had with a trainee counselor. There is no reason to doubt that this session took place. It is probable, from the information given by Mr B to the Chair of the OHR, that Mr B did not want an isolated session of "talking therapy" (as he described the counselor as offering) but wanted a more substantial series of engagement similar to that he described as beneficial in 2009.
3.4.13
In December 2012 and January 2013 the HiM record confirms the faxed referral by the GP describing Mr B's clinical presentation as "Low mood and insomnia for months. On Citalopram (medication) since May. Losing jobs because of drowsiness". The referral contained the PHQ-9 assessment score of 10 and Generalised Axiety Disorder (GAD-7) assessment with a score of 8. Both these scores are relatively low and, in the words used in the IMR, "identify the patient as being of a mild presentation, and further confirm low risk. "
3.4.14
HiM assessed this referral on 4 January 2013. The case was referred onto a Psychological Wellbeing Practitioner within the service who wrote to Mr B on 1ot January 2013 saying that he had been referred by his GP and asking Mr B to make contact with them, and set out the various ways he could make contact. The letter made it clear that if HiM did not hear by the 31st January 2013 "we will close our file to Health in Mind on this occasion". The Chair understands [redacted] that there were some difficulties with postal delivery/opening of post in the household at that time.
3.4.15
There is a reference in the reports of both the psychiatrists who saw Mr B in relation to the criminal process that he made contact with the primary care 'Out Of Hours' service on the 19th January; this is presumed to be self reported by Mr B to them. However, there is no reference to this in the CCG IMR or in the GP's records from when Mr B saw the GP two days later. Mr B saw his GP during the month of January; this was the occasion that he was accompanied by Mrs B. The GP asked Mr B to respond to the HiM letter but he did not do so.
3.4.16
The GP next saw Mr B on 4th February when he was accompanied by his [redacted]. This is recorded as a "long consultation" in the CCG IMR when the focus was his low mood, the loss he had suffered with the death of his daughter a year previously, continuing sleep difficulties and irritability. Mr B- [redacted] was "very low, withdrawn, not eating or sleeping': and [redacted] difficulties between Mrs B and Mr B were also discussed. Mr B's medication was changed from Citalopram to Mirtazapine with the intention of improving his sleeping. The IMR states that there were "no suicidal thoughts" on this consultation.
3.4.17
There was no further contact after this date and the incident a few days later.
3.4.18
The CCG IMR identified three recommendations from their work on this IMR. They are:
"1) The CCG will review its service for young adults (18+) particularly those trying to cope with loss, bereavement and depression.
2) The CCG will look at the service specification of Health in Mind (HiM); the referral system, correspondence and engagement process.
3) The GP practice to review their leaflets on sleep hygiene to ensure they are age appropriate.
Additionally, the practice manager is looking into reviewing follow up for those patients being health screened post registration by the practice nurses. She is also looking at follow up for those having had a miscarriage and signposting them on. Trying to forge a closer relationship with the midwives now they are no longer on site."
3.4.19
There were no recommendations from the Partnership Trust in regard to the provision of Health in Mind.
Panel Comment
3.4.20
The Panel was very conscious of the difficulties there are in working with people with low mood who are reluctant or inconsistent in their engagement with services. This may have been exacerbated by Mr B's use of alcohol in the later part of 2012 when he acknowledged an unusually higher level of drinking than what was his normal (self-reported) unexceptional level of alcohol consumption. From reviewing the information in regard to Mr B's consumption of alcohol the level of consumption would not have merited specific action by way of a referral to an alcohol misuse service.
3.4.21
The Panel chair has had the advantage of talking with [redacted] Mr B to gain their perspectives on Mr B's state of mind and engagement with services. From discussion with Mr B's [redacted] and with him it does seem clear that Mr B did receive a counseling service in 2009 which he found positive and helpful.
3.4.22
There is no record of this in the IMR from the CCG, Partnership Trust or the HiM paperwork. Indeed to the contrary, the record in the IMR states that he did not attend when previously referred in November 2009. However, the Primary Care Practice did have its own counselors in 2009 and it seems probable that it was one of these counselors that engaged with Mr Bin 2009. There is reference in the reports of the criminal process psychiatrists to "Anger Management" as being part of the focus of this psychological intervention. It seems that Mr B relates this reference to a specific argument he had with a former partner rather than a sustained difficulty with managing his feelings of anger.
3.4.23
As described to the Panel chair [redacted], Mr B was referred for counselling support in May 2012 and, after a wait, he was seen in August or September 2012. However he had not appreciated that, rather than the beginning of a block of appointments offering a period of counseling support, this was an assessment appointment only. As indicated above, there is no indication of this engagement in any of the IMRs, so it is not possible to verify the purpose or focus of the session. Apparently Mr B was very disappointed at this and it had a detrimental effect on his mood and he felt badly let down.
3.4.24
This may be an issue that other people experience too, meaning that they are unclear about the purpose of their appointment, which may affect their commitment to attending. There is merit in considering if the correspondence is sufficiently clear about both the process and the purpose of the appointment they are awaiting. This has to be balanced against a form of words that might become either too complex or off-putting for people awaiting such counseling.
The Panel makes the following recommendation:
Recommendation 6
Where people are contacted offering them a psychological intervention, it is made very clear what the contact arrangements are, where the service might be offered and the nature of the contact, i.e., as an initial session in a series of sessions, or as an initial assessment, or as a one off session.
3.4.25
During discussion within the Panel questions were raised about the difficulties in securing service for people with relatively low level mental health needs who may also misuse alcohol and drugs to some level, and who may benefit from the availability of a psychological intervention.
3.4.26
While not making a recommendation in regard to this the Panel refers this issue onto the local CCGs for consideration on the basis of their service demand information for such support.
3.4.27
In relation to Mr B's former partner (Ms C), a request for information was made to SECAmb and BSUH. Both agencies were identified as having come into contact with Ms C after she self injured following an argument with Mr B in June 2009. However, there was no record of contact with this previous partner in South East Coast Ambulance Service records. This is likely to relate to the record showing the call address rather than the name of the person.
3.4.28
The Panel has taken the view not to pursue this as we have seen the record of the A & E engagement which shows what happened at the time, Ms C's own health circumstances, the severity of the argument with her partner (Mr B) and the actions Ms C was to progress the following day.
3.4.29
Although this specific incident in 2009 might have been further followed up, the Panel noted that at that time there was no Health Independent Domestic Violence Advisor service available. However, the incident does emphasize the
importance of staff in such a setting having a good awareness of the risk of domestic abuse and of the steps to take should they have concerns.
The Panel makes the following recommendation:
Recommendation 7
Develop a consistent process to support practitioners having access to an appropriate specialist service in Accident and Emergency, for example, a Health Independent Domestic Violence Advisor (HIDVA)
3.5 Luton NHS Clinical Commissioning Group
3.5.1
The Luton CCG prepared an IMR which showed that Mrs B had been registered with a GP surgery between 2007 and 2011. The IMR was unable to provide greater detail than this as her records had, appropriately, been sent via the Practitioner Services Unit to Sussex when she registered with the [redacted] practice.
3.5.2
A check was made with the local Out of Hours service records and Walk-In Centre but they contained no reference to her.
3.5.3
Mr B was not registered with any primary care services in the Luton area.
Panel Comment
3.5.4
The absence of information is understandable. The IMR did moot a recommendation in relation to the records of people who move away from the area: "The main recommendation would be that primary care retain a copy of the patient records via the Practitioner Services Unit as an electronic copy for those patients who have leff the local area so that a more accurate foot print is traceable as to who they were registered with and any encounters they had with general practice. "
3.5.5
The Panel noted this recommendation but did not feel it was sufficiently competent to determine whether this was practicable or appropriate. The OHR panel therefore refers this issue onto the local CCGs for consideration.
3.6 Luton Borough Council Children's Services
3.6.1
This was an appropriately brief IMR derived from the Luton Borough Council Children Services Care First Electronic System which showed some child protection work with Mrs B's half sibling in 2009.
Panel Comment
3.6.2
This information supports the view of the OHR Chair when he visited Mrs B's family home that the house was very crowded and with people living there with a network of relationships.
3.7 Brighton & Hove Adult Social Care
3.7.1
There was no contact with either Mr or Mrs B by this service. [redacted]
3.8 Mrs B's employer
3.8.1
Mrs B was killed outside the premises of her employer, although there is no indication that this location was specifically chosen by Mr B for that reason. Mrs B was accompanied at the time by a work colleague. While no formal IMR was requested, the Chair of the Panel met with her employer. This was after the conclusions of the trial, as both the Regional Manager and Mrs B work colleague were called as witnesses. The meeting was with the Regional Manager and the Human Resources (HR) Manager, and the information gained from this meeting is described below. The Panel chose not to speak to the work colleague who was present with Mrs B at the time of her death, or to other employees. This was because, from the discussions with the employer, it was clear that this individual, and other employees, were still distressed and receiving ongoing support from the company. In addition, it appeared unlikely that they had any further information that was not already known to the Panel. The Chair therefore decided against further meetings on the basis that these may increase distress when there was little to gain.
3.8.2
Mrs B worked in a large organisation but within a team structure. She had a relatively small number of colleagues with whom she worked closely. Neither of the people interviewed knew her personally, but they had come to understand her situation after the event. There were no disclosures made to her employer in relation to domestic abuse. There were also no ongoing issues around Mrs B's employment that might have indicated, in hindsight, that there were concerns around domestic abuse (for example, unexplained absences, lack of concentration at work).
3.8.3
On the Monday after the event, as described by her employer, the organization took a number of actions to support staff. This included briefing staff within their teams, as well as offering access to counseling which the employer sourced independently of local provision. Over the following period of time, access was provided to further counseling where this was required; in particular ongoing support to the employee had been with her at the time of the attack. The regional manager was in dialogue with his national counterparts/managers during this period and the company closed earlier than usual given the impact on staff.
3.8.4
Although the company does not have a formal policy or procedure for dealing with such incidents it was clear that they were proactive in their response in offering collective and individual support to staff.
3.8.5
The Regional Manager particularly welcomed the discussions he had with the senior police officer who took time to talk through the importance of support within the organisation and the impact of incidents involving the loss of a member of staff on teams, including those who did not know her directly. However, the Regional Manager observed "the individuals [in contact with the employer, specifically the senior police officer] were great but I didn't feel [this support was] anything else than those guys taking their own personal time to help". This perception may be a reflection on the skill and style of the police officer, but it is worth the local police considering if the support offered was provided within a formal protocol or dependent on the actions of an individual.
3.8.6
There are some lessons to emerge from this locally, Specifically, following the incident, the employer was not aware of how to access any specific information on services locally. No contact was made by any Brighton & Hove or East Sussex based victim support agencies, or by the local authority Partnership Community Safety Team.
3.8.7
The HR Manager welcomed the suggestion that local information could be made available, tailored to the needs of employers.
The Panel makes the following recommendation:
Recommendation 8
That the Community Safety Partnership identifies how to support local businesses in regard to domestic violence and abuse, including raising awareness of this issue among staff, ensuring that employers know how to respond to domestic violence and abuse, and having the capacity to offer proactive support in the event of a serious incident or homicide.
3.9 Meetings with Mrs B's family and with Mr B and, separately, with his [redacted]
3.9.1
The Chair has met with Mrs B's mother and her partner. They gave a helpful description of Mrs B, describing her independence, energy and initiative. Mrs B's mother had no inkling of the extent of the difficulty in the relationship at the time, and was unaware that they had broken up. Her partner said that Mr B had contacted him as he was looking for Mrs B and thought that she was in a new relationship and that Mr B pestered him with phone calls and texts asking where she was.
3.9.2
They said that the family knew nothing about any threats or had any concerns for her wellbeing or that she might suffer harm. They said that various friends had seen his messages posted on Facebook at the time immediately before the incident, but nobody could make contact with him because his phone contract had ceased and he had his [redacted] phone with him and nobody knew at the time.
3.9.3
[redacted] spoke at length about [redacted], his relationship with his wife and state of mind.
3.9.4
The chair met with Mr B at Lewes Prison. He spoke candidly about his past, the relationship with Mrs B, his state of mind and engagement with services.
3.9.5
The impressions, discussions and intelligence gained from these discussions has been incorporated into this report.