Preface
The purpose of this review is to examine the circumstances surrounding the sudden unexpected death of Mrs A in Brighton and Hove, as well as the engagement and support offered by relevant agencies to Mrs A (the victim of the homicide) and Mr A (the alleged offender), jointly and separately prior to December 2012. The review will consider the issues identified in the Multi Agency Statutory Guidance for the Conduct of Domestic Homicide Reviews (DHRs) (section 5.11). Section 3.3 of the Statutory Guidance defines the purpose of a OHR as to:
- establish what lessons are to be learned from the domestic homicide regarding the way in which local professionals and organisations work individually and together to safeguard victims
- identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result
- apply these lessons to service responses including changes to policies and procedures as appropriate
- prevent domestic violence homicide and improve service responses for all domestic violence victims and their children through improved intra and inter-agency working
Although family members chose not to participate in this review, the OHR panel wish to acknowledge their loss, and offer their sincerest sympathies.
Timescales
This review began on 26th February 2013 and was concluded on the 11th July 2013. Following the submission of the initial report, in September 2013 the Home Office Quality Assurance Panel judged it to be inadequate. A revised report was resubmitted in October 2014, along with a request for clarification on some of the feedback provided . The Home Office Quality Assurance Panel subsequently approved the revised report for publication in February 2014.
Confidentiality
The findings of each review are confidential. Information is available only to participating officers/professionals and their line managers.
Dissemination
The following recipients have received copies of this report:
- the anonymised Executive Summary and Overview Report has been presented to the Brighton and Hove Community Safety Partnership ('Safe in the City Partnership') & the Home Office Quality Assurance Group
- the anonymised Executive Summary and Recommendations have been presented to the Brighton and Hove Safeguarding Adults Board, Domestic Violence Forum, and the newly established Violence against Women and Girls Partnership Board
Executive Summary
Introduction
The purpose of this review is to examine the circumstances surrounding the sudden unexpected death on the - November 2012 of Mrs A in Brighton and Hove, as well as the engagement and support offered by relevant agencies to Mrs A (the victim of the homicide) and Mr A (the alleged offender), jointly and separately prior to December 2012.
The review process
This summary outlines the process undertaken by the OHR panel (hereafter 'the panel') convened by the Safe in the City Partnership in reviewing the death of Mrs A.
The alleged offender (Mr A) subsequently died on the - December 2012 as a result of his pre-existing condition of -The CPS was unable to provide definitive guidance in relation to what, if any, criminal charges would have been pursued had Mr A lived.
The process began with an initial meeting on the 22nd January 2013 to review the Statutory Guidance for the Conduct of DHRs and consider the options available, before agreeing the next course of action. Subsequently, the first meeting of the panel was convened on the 26th February 2013.
The agencies that participated in this case review were:
- Brighton and Hove City Council (Adult Services, Benefits Team Finance & Resources and the Partnership Community Safety Team)
- Brighton and Sussex University Hospitals NHS Trust
- NHS Brighton and Hove
- RISE - a charity working in Brighton & Hove and West Sussex, and is the local specialist domestic violence and abuse service
- Community NHS Trust
- Sussex Police
- Western Sussex Hospitals NHS Foundation Trust
The methodology used was to request proportionate Individual Management Reviews (IMRs) from those agencies identified by the panel as having had contact with Mrs and Mr A. This totalled 6 agencies. The agencies were provided with guidance for the completion of a proportionate IMR, based on the Home Office Guidance and were asked to provide a written report regarding their chronological accounts of their contact with the victim prior to her death. In particular, they were asked to:
- looking openly and critically at individual and organisational practice and the context within which people were working to see whether the homicide indicates that changes could and should be made
- identify how those changes will be brought about
- identify examples of good practice within agencies
Where there was no involvement or insignificant involvement, agencies advised the panel accordingly. In addition, the report writer attended the Coroner's Inquest.
The accounts of involvement from agencies cover different periods of time prior to the death of Mrs A. Some of the accounts have more significance than others, although a common feature of all information shared was the limited information known to agencies about Mrs and Mr A.
All of the agencies asked to complete a proportionate IMR did so. No other agencies in the local area, either at the initial or subsequent meetings, were identified as having had contact with either Mrs or Mr A.
The panel also sought to encourage the participation of, or a contribution from, the family of Mrs A and Mr A. Members of the family were identified with the assistance of Police Family Liaison Officers (FLOs). They were offered the opportunity to participate at any time and to be notified of the outcome, although the family members contacted declined to participate.
Terms of Reference
- To examine the engagement and the support offered by relevant agencies to Mrs A (victim) and Mr A (alleged perpetrator), jointly and separately to December 2012, considering the issues identified in the Statutory Guidance (section 5.11).
- To take account of a Coroner's inquiry (if relevant) and any criminal investigations related to the homicide.
- To take into account whether either the victim or the alleged perpetrator was a 'vulnerable adult' and identify appropriate assistance in the conduct of the DVHR as required.
- To agree how friends, family members and other support networks should contribute to the review, and who should be responsible for facilitating their involvement.
- To seek independent expert advice where necessary, including advice from an independent domestic violence agency.
- To commission (if required), review and analyse agency Individual Management Reviews (IMRs) as appropriate, including expectations around who conducts IMRs, how they will be quality assured internally and staff will receive feedback and debriefing in advance of the completion of the Overview Report.
- To examine the adequacy of the operational policies and procedures applicable to engagement with either party and whether staff complied with them.
- To examine the adequacy of collaboration, communication and information sharing between all of the agencies involved, including across regional boundaries.
- To form a view on practice and procedural issues that emerge in considering the circumstances of this case and any lessons from this engagement that can be generalised to other situations where domestic violence is known of or suspected.
- To agree the key points to be included in the Overview Report and Executive Summary, along with SMART recommendations for an action plan.
- To agree which body will monitor the implementation of the action plan.
- To prepare an anonymised Overview Report and Executive Summary and agree arrangements for publicising the findings if appropriate.
- To consider media arrangements if necessary for the publication of the Overview Report and Executive Summary.
- As this is the first DVHR to be undertaken in Brighton and Hove with reference to the Statutory Guidance, identify how to engage with a wider group of interested agencies to ensure that learning from the process is available to interested agencies but who are not involved in the detailed DVHR panel in the particular circumstances of this case.
- Decide whether it is necessary to develop a DVHR protocol, including provision for Chairing any future reviews.
- Timetable - the precise timetable will be dependent on a number of factors including the need to collate and cross reference information.
- The process should be completed within six months of the decision to proceed.
Key issues arising from the review
Key issues have been identified in the Analysis section of the Overview Report. In the absence of information to indicate that agencies had any knowledge of domestic violence or abuse, or indeed that that either had occurred in the relationship, there are few specific issues (and therefore lessons learned) in relation to the case itself. However, the panel identified broader issues for further consideration which have implications for services in the city.
Specifically, the issues that the panel considered were:
- contact by both Mrs and Mr A with agencies
- Mr A's role as a 'Carer'
- inter-agency working
- social isolation
- vulnerability and capacity
- evidence of domestic violence or abuse
- the nature of the incident (whether it was a suicide pact or a homicide / suicide)
- the limitations that constrained the work of the panel (in particular the limited information available about Mrs and Mr A, and the absence of informationfrom Mrs A herself)
- the importance of professional curiosity, particularly with an awareness of the potential presence of elder abuse or domestic violence or abuse
As part of the analysis of these issues, which informed the final recommendations, the panel identified the following lessons to learn:
The importance of ensuring that local residents are aware of (information about) support services, so that 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
- understanding of the broader issues in relation to older women and domestic violence or abuse, including barriers to disclosure and service responses
- the importance of professional curiosity (particularly with an awareness of the potential presence of elder abuse or domestic violence or abuse), so that professionals have a sense of service users as 'real people' in order to give a broader context to their engagement with services
Conclusions and recommendations from the review
While the death of Mrs A was tragic, the first and most important conclusion from the review is that there is no indication from the evidence provided that any agency had any knowledge of domestic violence or abuse between Mrs A and Mr A.
Secondly, the panel concluded that Mrs A and Mr A had not sought help from services, with the exception of medical care for Mr A and ongoing, routine medical care for Mrs A.
Thirdly, while Mrs A was 'vulnerable' in the broadest sense of the term by virtue of her social isolation, there was no information known to the professionals involved that might or should have triggered a safeguarding referral or concern. Furthermore, the limited information available to professionals meant that more proactive enquiry was not appropriate.
Moreover, it was unlikely that any referral, if made, would have met the safeguarding threshold.
As the homicide did meet the criteria for a domestic homicide review, the panel has examined the circumstances of Mrs A's death. The panel concluded that the homicide was not predictable on the basis of the information available to practitioners at the time. Furthermore, on the basis of the available evidence, it does not appear that there were any specific weaknesses or errors in professional practice or service response(s) that might have affected the likelihood of the homicide occurring.
However, the review was significantly constrained by the limited information available to the panel about Mrs and Mr A, and the absence of information from Mrs A herself. This meant it was impossible to gain an understanding of the lived experience of Mrs A, whose voice in the report is consequently limited. It was therefore impossible to fully understand the incident that led to the death of Mrs A or the dynamics of the relationship. This is relevant because if domestic violence or abuse were present but not known (in particular if Mr A had used coercion and isolation as a tool of control), the panel's understandingof Mrs A's experiences, options and decisions would be fundamentally changed. The same is true if it was possible to be certain that there no domestic violence or abuse in the relationship. Either circumstance would have informed the panel's view of this incident. Consequently, as the panel was unable to rule in or out the presence of domestic violence and abuse, it was also unable to make a conclusive determination as to whether this incident was a suicide pact or a suicide/homicide
As it was unable to resolve these questions in the absence of information, the panel sought to identify broader learning relating to older women and domestic abuse. The panel therefore concluded that the death of Mrs A highlighted some broader issues for further consideration with implications for services in the city. The panel felt that, given the specific nature of the case, a detailed action plan arising from this review was not appropriate. However, it agreed that the Brighton & Hove Safeguarding Adults Board, with support from the Violence against Women and Girls Partnership Board, were the most appropriate forums through which statutory and voluntary and community partners could work together. The action plan developed reflects this decision. The aim of this work should be to ensure that domestic violence and abuse as an issue for older people is embedded through governance, service planning, and workforce development. The panel also concluded that 'professional curiosity' (particularly with an awareness of the potential presence of elder abuse or domestic violence and abuse) was essential to ensure that the potential for these issues is considered in day to day practice.
The panel therefore made the following recommendations.
Recommendation 1 - for all professionals:
- To remind professionals through workforce development to be mindful of the importance of 'professionalcuriosity', particularly with an awareness of the potential presence of elder abuse or domestic violence or abuse.
Recommendation 2 - for the Brighton and Hove Safeguarding Adults Board:
- to review existing priorities within the Safeguarding Adults Board Action Plan to ensure these address domestic abuse, in particular with reference to raised awareness about this issue among older residents
- to review workforce development to ensure that professionals are aware of domestic abuse, know how to identify and assess older people at risk, have adequate training to do so (including the use of the CAADA DASH risk identification checklist) and understand what services are available locally
Recommendation 3 - for the Brighton and Hove Violence against Women and Girls Board:
- to review care pathways to ensure that the planned Violence against Womenand Girls Action Plan addresses safeguarding adults, in particular with reference to older people, and that this encompasses commissioning as well as delivery of specialist domestic abuse services
- to review workforce development to ensure that professionals are aware of safeguarding adults arrangements, how to identifyand assess older people at risk, and understand what services are available locally
Recommendation 4 - for Western Sussex Hospitals NHS Trust:
- to review the timeliness of discharge notifications