Review into the death of Sarah in December 2020
Report Author: Allison Standiford
June 2022
Contents
- The Review Process
- Summary Chronology
- Brief Background (The Facts)
- Lessons Learned
- Conclusions
- Good Practice
- Developments Since the Scoping period
- Recommendations
- Appendix 1: Terms of Reference and Project Plan
- Appendix 2: Single Agency Recommendations
The Review Process
Domestic Homicide Reviews (DHRs) were established on a statutory basis under the Domestic Violence, Crime and Victims Act 2004.
The purposes of a DHR is 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 inform national and local policies and procedures as appropriate.
- prevent domestic violence and homicide and improve service responses for all domestic violence and abuse victims and their children by developing a co-ordinated multi-agency approach to ensure that domestic abuse is identified and responded to effectively at the earliest opportunity.
- contribute to a better understanding of the nature of domestic violence and abuse; and
- highlight good practice.
DHRs are not enquiries into how the victim died or into who is culpable; that is a matter for coroners and criminal courts, respectively, to determine as appropriate. DHRs are not specifically part of any disciplinary enquiry or process.
Part of the rationale for the review is to ensure that agencies are responding appropriately to victims of domestic abuse by offering and putting in place appropriate support mechanisms, procedures, resources, and interventions with an aim to avoid future incidents of domestic homicide and violence. The review also assesses whether agencies have sufficient and robust procedures and protocols in place which were understood and adhered to by their staff.
The findings of each review are confidential. Information is available only to participating professionals and their line managers. To ensure confidentiality, the victim of the homicide subject to this review is referred to as Sarah, and her husband as Andrew. Sarah and Andrew have a child who is referred to as Tom. The pseudonyms were chosen by the review panel in lieu of family members.
The Review Chair, Review Author and domestic homicide review panel send their condolences to Sarah’s family.
The report will examine agency involvement but will also examine the past to identify any relevant background, or trail of abuse, before Sarah’s death. It will also examine whether support was accessed within the community and/or if there were any barriers to accessing support. By taking a holistic approach, the review seeks to identify if there are appropriate solutions to make the future safer.
The brief circumstances of this domestic homicide review are that Sarah was found deceased at her home address by her husband, Andrew. There was a history of domestic abuse in Sarah and Andrew’s relationship and initially the circumstances were thought to be suspicious but subsequent enquiries, and the Coroner’s findings have concluded that Sarah died by suicide. (The Coroner ‘s Inquest concluded prior to this review and therefore the Coroner did not have access to this report.) Toxicology shows the existence of numerous drugs in her system, sufficient to have caused her death.
The key purpose for undertaking DHRs is to enable lessons to be learned from homicides where a person is killed as a result of domestic violence and abuse. In order for these lessons to be learned as widely and thoroughly as possible, professionals need to be able to understand fully what happened in each homicide, and most importantly, what needs to change in order to reduce the risk of such tragedies happening in the future. This review is seeking to examine the role of agencies who came into contact with the victim, Sarah and her husband, Andrew, to establish if there are any lessons to be learned as a result of engagement with the family or to identify missed opportunities for agency engagement. The review also seeks to understand the family’s ability to be aware of, and access, services they may have needed.
At the time of the fatal incident, both Sarah and Andrew were 50 years old. Both identify as White British.
This review commenced on the 7th of April 2021 and concluded in June 2022.
Terms of Reference for the Review
The Project Plan appears at Appendix 1 and details the purpose, framework, agency reports to be commissioned, and the particular areas for consideration for this review. For effective learning, it was agreed that the scoping period for this review will be from the 13th of December 2019 until the date of death. There are, however, incidents that occurred in the past, prior to the review period, which have significance, and these will also be included where they provide learning.
The review was asked to consider:
- What was known about the circumstances of Sarah’s living/family arrangements and dynamics within the family.
- How did any physical health and/or mental health (issues including substance issues) and/or financial issues affect Sarah’s vulnerabilities/dependencies upon Andrew? Was a Carer’s Assessment offered/completed and what was the outcome.
- How accessible and responsive were support services that may have been available to the family. How well known were these services to the public or silent victims.
- How well understood was the family’s/community’s approach to/recognition of domestic violence, coercive control and/or risk of suicide. What support was offered to Andrew to manage his violence.
- Were there any barriers to accessing support.
- Could communication and information sharing within and between agencies have been improved during the scoping period. What opportunities existed for multi-agency referrals for vulnerability and/or risk management meetings.
- Were there missed opportunities to exercise professional curiosity.
- What support is offered to living relatives and is enough consideration given to any future risk.
- How has the Covid Pandemic impacted upon the family and support offered.
- Identify examples of good practice, both single and multi-agency.
Methodology
The Review sub-group of the Bassetlaw, Newark and Sherwood Community Safety Partnership recommended the circumstances of this case as fulfilling the criteria for a statutory domestic homicide review and this was approved by the Chair. The Serious Incident Learning Process (SILP) model of review was commissioned to be used within the domestic homicide review process.
SILP is a learning model, tried and tested in safeguarding reviews for both children’s and adult’s cases, including domestic homicide reviews, and takes account of principles enshrined in government guidance. The process seeks to engage front line staff and their managers in reviewing cases to focus on why those involved acted in a certain way at the time.
An initial scoping meeting and first panel meeting was held on the 25th of June 2021, where agency representation, terms of reference, the scoping period and the project plan were agreed. This was followed by a full day’s learning event on the 29th of September 2021.
Whilst applying the principles of the SILP methodology, the independent chair and author have followed the Multi-Agency Statutory Guidance for the Conduct of Domestic Homicide Reviews, as amended in December 2016. Importantly, the model has incorporated 4 review panel meetings, a sufficient number of meetings in this case for the panel to effectively support the review and to discharge their duties.
Contributors to the Review
| Agency | Contribution |
|---|---|
| Nottinghamshire Police |
|
| Nottinghamshire County Council Children's Social Care |
|
| General Practitioner x2 |
|
| Nottinghamshire Healthcare Trust |
|
| Nottingham County Council - Adult Social Care |
|
| Bassetlaw Clinical Commissioning Group |
|
| Doncaster and Bassetlaw Teaching Hospitals |
|
| The Probation Service |
|
| Bassetlaw District Council - Benefits Unit |
|
| Bassetlaw District Council - Housing Team |
|
| Nottinghamshire Women's Aid |
|
The Review Panel Members
- Carolyn Carson - Independent Chair, Review Consulting. Attended and Chaired panel meetings and the Learning Event. Attended the Recall Event
- Allison Sandiford – Independent Author, Review Consulting. Attended all panel meetings and the Learning Event. Chaired the Recall Event.
- Nicolette Richards – Domestic Abuse Coordinator*, Bassetlaw, Newark and Sherwood Community Safety Partnership.
- Gareth Harding/Claire Dean – Detective Inspector/Detective Chief Inspector, Nottinghamshire Police
- Mandy Green – Head of Services, Nottinghamshire Women’s Aid
- Cathy Burke – Designated Safeguarding Nurse, Bassetlaw Clinical Commissioning Group
- Elizabeth Boyle – Designated Safeguarding Nurse, Doncaster, and Bassetlaw Teaching Hospital.
- Richard Wright – Team Manager, Nottinghamshire County Council, Adult Social Care.
- Tracey Tapley – Senior Benefits Officer, Bassetlaw District Council.
- Martyn Hudson – Bassetlaw District Council
- Gerald Connor/Nikala Elliot-Carter – Community Safety and Safeguarding Manager, Bassetlaw District Council
- Julie McGarry – Domestic Abuse Lead, Nottinghamshire Healthcare Trust
- Lisa Adkins-Young – Deputy Head of Nottinghamshire Probation.
*The Domestic Abuse Coordinator’s role includes coordinating the DHR’s meetings, administration to assist the DHR chair and author and working in partnership with the other agencies.
Chair and Author of the Overview Report
The review commissioned Carolyn Carson, to act as Independent Chair. Carolyn is an independent safeguarding reviewer. She is a retired Police Superintendent who specialised in Safeguarding, retiring whilst holding the post of Safeguarding Lead at Her Majesty’s Inspectorate of Constabulary, (HMIC), in 2011. Post retirement from 2012, Carolyn has conducted adults safeguarding reviews, domestic homicide reviews and SILP, independently. Carolyn has no links to Bassetlaw, Newark and Sherwood Community Safety Partnership or any of its partner agencies.
The report has been authored by Allison Sandiford. Allison is an independent safeguarding consultant with no links to Bassetlaw, Newark and Sherwood Community Safety Partnership or any of its partner agencies. Allison gained experience in safeguarding whilst working for a police service. Since 2019 Allison has conducted serious case reviews in both children’s and adults safeguarding, and domestic homicide reviews, both independently and with SILP.
Whilst applying the principles of the SILP methodology, the independent chair and author have considered the nine protected characteristics under the Equality Act 2010 (age, disability; gender reassignment; marriage and civil partnership; pregnancy and maternity; race; religion or belief; sex; sexual orientation).
Sarah was female, and Andrew is male. Sarah and Andrew were married to each other, although separated. Both identify as White British. Sarah was 50 years old at the time of her death as was Andrew.
Whilst the review understands that domestic abuse can affect anyone, regardless of age, disability, gender identity, gender reassignment, race, religion or belief, sex, or sexual orientation, it is recognised that in the year ending March 2020, an estimated 1.6 million females aged 16 to 74 years experienced domestic abuse. This is in comparison to an estimated 757,000 males. More women are killed as a result of domestic abuse than men.
Sarah suffered with her health but was not identified and registered as disabled by agencies despite numerous debilitating health issues. However, under the Equality Act 2010, you are disabled if you have a physical or mental impairment that has a ‘substantial’ and ‘long term’ negative effect on your ability to do normal daily activities. Substantial is more than minor or trivia and long-term means 12 months or more. Sarah suffered from extensive health issues and as a consequence, she lived with long-term poor mobility and required assistance with aspects of her care.
Parallel Reviews
There have been two parallel reviews, namely a police criminal investigation and the Coroner’s Inquest. The criminal investigation concluded with no further criminal action to be taken, but both have been updated concerning this review. In particular the Independent Author observed the inquest into Sarah’s death and ascertained information as shared by the Coroner. The Coroner’s finding was death by suicide.
Summary Chronology
Brief Background (The Facts)
Sarah started a relationship with Andrew when she was around 17 years old, and they married 5 years later. In 1991 they had a child, Tom. At the time of Sarah’s death, Tom was estranged from both parents. There is a history of domestic violence in Sarah’s and Andrew’s relationship from 2001, as reported to agencies and detailed further in this report.
Domestic abuse always has a significant impact upon children. In regard to physical abuse, even if the children are not exposed to the domestic abuse directly, they can hear it from another room, and may notice injuries and/or damage around the home. In regard to the outcome of childhood exposure to coercive control abuse, the voices of children who have lived in households where there is coercive control is limited (Callaghan et al. 2015). However, Callaghan et al. found (in their interviews with 12 girls and 9 boys in the United Kingdom) that children are significantly affected by coercive control. This is echoed in an Australian study - recently published in January 2023 which found that children are often used as tools to enact coercive control. The study reports that the evidence suggests similar impacts on children exposed to coercive control as those exposed to other forms of domestic abuse.
The psychological effects of experiencing domestic abuse are compound. It can result in behavioural changes including challenging behaviour, withdrawal, and can cause a child to struggle to interact with other individuals, including their parents. A child who has experienced domestic abuse may become fearful of conflict, worried, anxious, and depressed. Experiencing domestic abuse can impact a child’s ongoing development and lead to overactive stress responses.
Post the scoping period of this review, the Domestic Abuse Act 2021(which came into force on the 31st of January 2022) has recognised that children who experience domestic abuse are victims in their own right whether they have been present during incidents. The incident leading to this DHR occurred pre this legislation coming into force but the effect of ongoing abuse on Tom was still recognised by the professionals involved with this review. As mentioned, Tom did not wish to contribute to this review and his decision is respected, however, in the absence of his voice, the review would reference the adverse childhood experiences (described at 7.1) that Tom has been subject to.
Sarah suffered from extensive health issues that included Chronic Obstructive Pulmonary Disease, Spondylitis, Sciatica and Fibromyalgia. As a consequence, she suffered poor mobility and required assistance with aspects of her care. She often described Andrew to professionals as her carer, but he was not registered as such. Prior to her death in 2020, Sarah had also started to report suffering memory problems and was waiting assessment.
Andrew has a medical history of depression, anxiety, substance misuse and significant alcohol use (from age 16). In 2005 he disclosed his abuse towards Sarah to his GP and as a result was referred for anger management; but the referral was declined as it was felt that he needed to address his alcohol issues first. In 2011Andrew reported to have stopped drinking alcohol and was concentrating on his physical fitness. It is known that he returned to drinking alcohol and using substances, but it is unclear exactly when. The first report indicating such was July 2019.
Sarah and Andrew separated several times throughout their marriage. In 2011, following a marital breakdown, Andrew attempted suicide. The exact dates of separation are unknown, and it is not clear from agency records exactly at which points Andrew was living at the home address. Although it is known that even when the couple were separated, Andrew would still spend time with Sarah at her home and sometimes stay overnight.
Sarah had reported to be separated from Andrew at the time of her death, but she was allowing him to stay as she needed his help with her care. Sadly, he was her only source of support.
The evening before Sarah’s death Andrew attended hospital with a head injury, having fallen over whilst intoxicated. Upon discharge in the early hours of the morning, he attended Sarah’s address and found her deceased in her bedroom.
Police attended and found Andrew to be calm and cooperative, although the ambulance service reported that he had been aggressive when they had arrived beforehand. Andrew attended the police station voluntarily.
There were no signs of disturbance at the address. The post-mortem revealed a few old bruises on Sarah but no recent physical injuries or internal injuries that could be contributory to her death. Sarah’s death was identified to have been a result of mixed drug toxicity. The Coroner ruled that this was at her hand and returned a verdict of death by suicide.
Chronological Agency Interaction Prior to the Key Lines of Enquiry (pre-2004)
Between 1993 and 1996, Children’s Social Care received 14 referrals in relation to Sarah. Full details are unavailable as the paper records are no longer accessible, but Children’s Social Care note that they were requests for support with either furniture or finances.
In 2001, Sarah first reported a domestic incident to the police. Andrew was banging on the door in a drunken state. No offences were disclosed.
In 2003 Andrew was arrested for drugs offences. He said that he was a regular user and would continue to be so because he believed that it controlled his alcohol problem.
For reasons that cannot now be confirmed, Andrew was referred to psychiatry in 2003 but he did not attend appointments.
Key Historical Events Prior to the Scoping Period (2004 - 2012)
In 2004, police received a report of Andrew having punched Sarah to the face and head before stabbing her thigh several times. Tom, who was 13 years at the time, was present.
Police records show that Police attended the incident. Sarah had wounds to her leg and identified that she had been stabbed by Andrew. Andrew was arrested that same evening near to the scene and charged with Actual Bodily Harm. Andrew was not convicted and due to the records now being on a legacy system, this review has been unable to establish why. But it would appear that Sarah withdrew her statement hence the prosecution was not continued.
A referral was made to Children’s Social Care, but no strategy meeting convened. An initial assessment was completed but cannot now be located.
In 2006, incidents began to be reported again. Police report that following the first post-stabbing domestic incident in February 2006, a referral was sent to Children’s Social Care. Children’s Social Care has no record of this. Within weeks of the incident, education contacted Children’s Social Care enquiring whether Tom could have contact with his father. Children’s Social Care concluded that given Tom’s age (14 years) he was able to decide for himself.
In March 2006 Tom disclosed to school that he felt suicidal and was suffering emotional and physical abuse from Andrew. When Tom was seen by a social worker, some 5 weeks later, he retracted his disclosure and said that everything was fine. Nevertheless, Children’s Social Care undertook an Initial Assessment which concluded with a Child in Need plan. The Child in Need plan was discharged the same month with Children’s Social Care not establishing further contact.
Following a further verbal incident being reported in July 2006, Tom wrote to Children’s Social Care stating that he was in fear for his and his mother’s safety as Andrew was drinking heavily and making threats towards them both. Police and Children’s Social Care conducted a joint visit but failed to make contact. Due to capacity, police did not re-attend, but Children’s Social Care completed a visit 6 days later. Tom was seen on his own, but he now retracted the content of the letter and minimised the situation. A Child in Need plan was initiated in August 2006 whilst section 47 enquiries were completed but it was discharged the following month.
*When children's social care receives a referral and information has been gathered during an assessment, in the course of which a concern arises that a child maybe suffering, or likely to suffer, significant harm, the local authority is required by Section 47 of the Children Act 1989 to make enquiries.
In December 2006, police received a further report of Andrew banging on the windows of Sarah’s address after she had told him to leave. As Tom was present, the police made a referral for which Children’s Social Care took no further action. Police received 2 further domestic incident reports whilst Tom was under the age of 18, one in 2007 and one in 2009 (Tom was not recorded as present at this incident).
In 2010, Andrew was charged with assaulting Sarah (Common Assault). He was also found to be in possession of a lock knife. At court he was found guilty of the assault whilst the bladed article was allowed to lie on file*. Andrew was sentenced to a 12-month Community Order on the 25th of August 2010, with conditions of Supervision, an Alcohol Treatment Requirement and Unpaid work hour.
*In English law, applicable to England and Wales, a criminal charge is allowed to lie on file when the presiding judge agrees that there is enough evidence for a case to be made, but that it is not in the public interest for prosecution to proceed.
In 2011 Andrew received a Community Order for a Public Order offence. As per standard practice, a Domestic Violence call-out check was conducted by The Probation Service when completing his pre-sentence report. This was returned by the police with no recorded incidents during the preceding 12 months as the last reported incident had dated from 15 months ago.
Andrew’s community order was concluded early on the 3rd of May 2012, on the grounds of good progress. The revocation report stated that his offence had been committed within the context of a long standing and problematic relationship with alcohol, and although not a mandated action through probation, Andrew had self-referred to the Community Alcohol Team for support. He had been discharged from that service following a period of nine months of abstinence. At that time Andrew was reporting that he had also removed himself from the influence of negative peers and had been concentrating on his physical fitness.
Events Leading to a Crisis for Sarah (July 2019 to 23rd November 2020)
There are no interim reported domestic incidents until a verbal incident in July 2019, during which Andrew was recorded to be heavily intoxicated. Officers dealt with this incident as a Breach of the Peace to prevent any further offences being committed.
In October 2019, Sarah declared on an application form to the Benefits Office that Andrew had left the address and she was now the sole occupier of the property. Around the same time, she also disputed with housing their assessment that she didn’t need the extra bedroom in her property. She said that she needed it for Andrew who still stayed overnight sometimes as her carer. In January 2020 Sarah referred to the separation again when because she was struggling to push herself in her manual chair alone, she requested a wheelchair assessment during her asthma consultation with her GP.
Also, in January 2020 after reporting Andrew being drunk in her shed and being verbally abusive making conditional threats to kill her, Sarah told the police that she and Andrew had separated. Attending officers completed a DASH* which assessed a standard risk.
*The Domestic Abuse, Stalking and Honour Based Violence (DASH 2009) Risk Identification, Assessment and Management Model
On the 12th of February 2020 Sarah attended the hospital emergency department with a wrist injury. She said that she had fallen in her kitchen. Following an X-Ray, Sarah was discharged with observed mobility issues, and advice to follow up with her GP if needed.
In March 2020 Sarah contacted the Council Tax department by telephone as she was struggling to meet payments. The officer who spoke with Sarah recorded her as being very vulnerable but did not refer her for any further support.
Health concerns continued with Sarah reporting back pain and memory issues at the beginning of March 2020 to her GP. Consequently, Sarah was referred to the memory services for review. This referral wasn’t accepted but that information was not relayed to Sarah.
On the 13th of March Sarah requested a MED3 certificate* for depression. Upon receipt of this request, a GP referral was completed for a powered wheelchair, but Sarah was subsequently assessed as not meeting the criteria.
*The MED3 form is a now retired Statement of Fitness for Work filled out by a patient’s GP to certify that the patient is unfit for work.
On the 23rd of March 2020, the beginning of the Coronavirus pandemic, Sarah being vulnerable was advised to shield. Up until this time Sarah had been working as a teaching assistant and now had to stop. The lockdown also affected Sarah’s physical access to her GP. Contacts regarding growths on her face that she had attempted to razor off, and back pain, were via the telephone and she did not attend her asthma reviews.
On the 10th of July 2020 Andrew was arrested for being drunk and disorderly and committing criminal damage to a police vehicle. Despite the known risks associated with Covid, he spat in the direction of a police officer during the incident.
On the 6th of November 2020 Sarah reported that Andrew was banging on the front door and had kicked their car. Officers took him to his mother’s address. Because Sarah suffered with numerous ailments and answered yes to the DASH question; do you feel depressed or suicidal, she was noted as vulnerable. The incident was risk assessed as medium and shared appropriately.
The following afternoon, Sarah reported another verbal argument. Officers attended and completed a further DASH which was assessed as a medium risk. Sarah had initially reported to the police that Andrew had threatened to kill her, but she retracted this when she spoke with attending officers. No further offences were disclosed.
Events Surrounding Sarah's Death (24th November 2020 - 17th December 2020)
On the 24th of November 2020 Andrew was arrested on suspicion of ‘Possession of Controlled Drugs with Intent to Supply’. He told officers that Sarah’s disability had caused him to drink and experiment with drugs to help with his depression. He provided her address as his current abode.
Between 17:44 hours and 18:05 hours on the same day, police conducted a search of Sarah’s address*. Sarah was present and assisted officers to find a small amount of vegetable matter. Andrew was charged with possession of Class A and B controlled drugs.
*Under Section 18 Police and Criminal Evidence Act 1984.
The officers conducting the search referenced Sarah’s vulnerabilities in their documentation. Within 35 minutes of the officers concluding their search Sarah had contacted the Crisis team, disclosed that she had overdosed and been taken to A&E in an ambulance. Sarah told the paramedics that she was scared of Andrew and that he was verbally abusive. Consequently, the ambulance service made a referral to the Multi-Agency Safeguarding Hub.
Upon attendance at hospital, Sarah continued to disclose domestic abuse. She told staff that in the past when Andrew had been involved with the police, he had returned angry, and his violence had increased. She spoke of being intimidated by him and explained that she had sent him away in the past but had allowed him back because he is her carer. She said that if she had a formal carer, she could send him away.
As Sarah had taken an overdose, A&E referred her to their mental health team for immediate assessment. During the subsequent review with a mental health rapid response nurse, Sarah discussed the abuse she was suffering, and her isolation, openly.
The clinician referred Sarah to the Crisis Resolution and Home Treatment Team, Multi-Agency Safeguarding Hub and, with Sarah’s consent, reported the disclosed offences to the police via 999. He also requested that a colleague, able to do so on a day shift, make a referral to Adult Social Care.
Sarah was discharged from the Emergency Department* on the 25th of November at 00:08 hours. Andrew was released from police custody to the Magistrates’ Court later that day. A remand in custody application requested by the prosecution was refused by the Court and Andrew was allowed to return to Sarah’s address. Sarah did not consent or agree to this.
*Sarah was keen to return home and there was no medical or statutory reason to stop her.
The Crisis Resolution Home Treatment Team contacted Sarah the same day by telephone. Andrew was heard to be present at the home address during this phone call and so Sarah was offered a face-to-face appointment with a psychiatrist for the next day. She accepted the appointment and attended. However, Andrew attended with her, and it was not recorded whether the health professional saw Sarah alone. Following the assessment Sarah was offered a change to her medication and her risk level was reduced to amber which effected required contact every 48 hours.
During the next telephone contact on the 27th of November 2020, Sarah declined a face-to-face meeting. On this occasion, the Crisis Resolution Home Treatment Team worker also spoke with Andrew and after he reported difficulties in managing Sarah’s needs, he was offered carers information. This was delivered to the house, together with Sarah’s medication, by the clinician later that day.
The Multi-Agency Safeguarding Hub received the referral from the mental health rapid response nurse on the 25th of November. The decision was made at triage to pass the referral to the Adult Social Care Bassetlaw Living Well Team for Section 42 enquiry*.
*The Care Act 2014 (Section 42) requires that each local authority must make enquiries, or cause others to do so, if it believes an adult is experiencing, or is at risk of, abuse or neglect. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect, and if so, by whom.
The Crisis Home Resolution Team attempted to contact Sarah on the 28th, 29th and 30th November but were unsuccessful. On the 1st of December 2020, after the Crisis Resolution Home Treatment team had texted, Sarah telephoned to say that she no longer felt suicidal or needed the team’s support.
The Adult Social Care Living well Team was delayed in engaging with Sarah due to struggling to make direct contact with her, and due to delays in information sharing which resulted in Adult Social Care not obtaining the relevant information to progress their referral for some days.
On the 7th of December 2020 Sarah was told that her long awaited upcoming appointment scheduled with the memory team was to be rearranged due to an urgent case taking priority.
On the 9th of December 2020 a Social Worker was allocated Sarah’s case. On the 12th of December 2020, after falling whilst intoxicated, Andrew was taken to A&E in an ambulance with head injuries. He had fallen outside Sarah’s address whilst shouting abuse to her. Andrew was discharged from hospital around 03:00 hours the following morning. At 04:53 hours, Andrew phoned the ambulance service having found Sarah deceased in her bedroom.
Unaware of the situation, Adult Social Care continued to attempt to contact Sarah unsuccessfully and, in consequence, Adult Social Care made a visit on the 17th of December to Sarah’s home address. Sadly, Sarah had died prior to the visit.
Lessons Learned
Management of Risk
Lesson 1
Ineffective Children’s Social Care management of referrals and ineffective information sharing from partner agencies prevented key agencies being aware of valuable safeguarding information on which to base future assessments.
Lesson 2
The lack of risk assessment regarding the potential risk that Andrew posed to Tom impacted upon Tom’s welfare.
Lesson 3
The police effectively used the Domestic Abuse Public Protection Notice but did not complete a Public Protection Notice when vulnerability was identified. This was a missed opportunity for Sarah to be assessed for additional support.
Lesson 4
The DASH is being used by the police routinely, but not yet by practitioners in other agencies. This is preventing effective risk identification and management of domestic abuse, at a critical point of disclosure, thereby enhancing the future risk for victims of domestic abuse.
Lesson 5
Police Officers did not consider the Domestic Violence Protection Notice/Domestic Violence Protection Order process as a proactive response when Sarah reported domestic incidents and requested Andrew’s removal. This was a missed opportunity to support Sarah to access services to help her manage without Andrew.
Lesson 6
Currently, very few agencies other than the police are aware of Domestic Abuse Protection Notice/Orders and this is a missed opportunity to understand a potentially effective domestic abuse management tool.
Lesson 7
Police did not consider the full range of options available to them to protect Sarah when they attended repeat domestic incidents and requests for help. The lack of use of options, other than completion of DASH, reflect the findings of the national report; Her Majesty’s Inspectorate of Constabulary and Fire & Rescue Services; A progress report on the police response to domestic abuse.
Lesson 8
An adult safeguarding referral which lacked relevant information prevented support being offered to Sarah in a timely way where there was an opportunity to do so. This prevented Sarah receiving support at a point when she was clearly asking for help and left her no further forward and still reliant on Andrew.
Lesson 9
Opportunities to engage Sarah with domestic abuse support services were prevented as a result of domestic abuse referrals not being made, and by the absence of a specialist hospital Independent Domestic Violence Advisor.
Lesson 10
Information sharing processes within the Multi-Agency Safeguarding Hub were ineffective causing an unnecessary delay in support being allocated to Sarah.
Lesson 11
A multi-agency opportunity to share information was missed when a strategy meeting did not convene after Sarah had been referred to the Adult Social Care Multi-Agency Safeguarding Hub. This prevented risk identification and management at a critical point for Sarah.
Lesson 12
Information known by professionals historically, did not get carried forward into later assessments or shared in professionals meetings, thereby preventing effective risk management.
Application of Professional Curiosity
Lesson 13
Practitioners did not consistently apply curiosity to practice and as a result no single professional gained a greater understanding of Sarah’s situation. This impacted on support offered to Sarah.
Lesson 14
Local domestic abuse and safeguarding training should sufficiently incorporate and reinforce the need to be professionally curious.
Effects of the Covid Pandemic on the support offered to Sarah
Lesson 15
National research outlining the increase of hardship and risk faced by those with disabilities or suffering domestic abuse is reflected in Sarah’s covid situation.
Understanding Sarah's Living Experience
Lesson 16
As a result of agencies not sharing information, or of understanding Sarah’s lived experience, no professional or agency gained a vital understanding of Sarah’s lived experiences or barriers to engagement.
Lesson 17
It is important that domestic abuse training for professionals includes a thorough understanding of how to identify coercive and controlling behaviour and its effect on service provision and include strategies to support victims.
Conclusions
Sarah and Andrew were in a relationship from the age of 17. Reports of domestic abuse commenced in 2001. Opportunities for agency interventions existed from 2004 due to reports of domestic abuse which included a serious assault on Sarah by Andrew, and repeat concerns raised by their child, Tom.
Early opportunities for multi-agency support for Sarah and Tom did not materialise due to ineffective information sharing and case management. This prevented important background information being recorded to inform future risk management and support.
Through the scoping period, it was known that Sarah’s health had deteriorated. Andrew and Sarah were still married, but Sarah had been trying to separate. Sarah reported further domestic abuse by Andrew but told agencies she allowed him to return home because she needed him to act as her carer. She also felt powerless because Andrew always returned home in any case.
Agencies predominantly managed their interactions with Sarah as they presented but on a single agency basis. There is no evidence of professional curiosity being applied which impacted on no agency understanding the true lived experience for Sarah or her wishes and needs. This prevented effective positive action being taken in support of Sarah making the break from Andrew or receiving appropriate support plans for her disabilities.
For Sarah, this lack of understanding and support was critical at a point when, in despair at Andrew being arrested, and in her opinion likely to be more abusive as a result, she took an overdose. This was a moment of great opportunity to work with Sarah because she asked for help immediately after overdosing, by contacting the Crisis care team that she clearly knew existed. At hospital she bravely disclosed her situation and supported the abuse being reported to the police, via 999, but no action was taken.
Consequently, referrals were made by professionals who obviously cared, but they were ineffective due to poor information being provided, poor information sharing and time delays in actioning. There was no multi-agency information sharing or domestic abuse risk planning considered. In November 2020 Andrew was supported to act as her carer, acknowledging his concerns about ‘managing’ her disabilities; but there was no consideration of the impact on Sarah of Andrew being her sole carer.
This left Sarah unsupported and isolated yet again after overtly seeking help, leaving her with only Andrew, an abuser, as support. At the point that he had to go to hospital having sustained an injury through intoxication, and prior to support being offered by adult services, Sarah took a further overdose. This time, however, Sarah took much more medication and did not reach out to services, as she knew how to do, and she sadly died by suicide.
Good Practice
Sarah was offered a face-to-face appointment rather than a virtual one by the Crisis Resolution and Home Treatment team following discharge from the Emergency Department.
The mental health clinician’s referral to Multi-Agency Safeguarding Hub was described as excellent.
Police demonstrated a clear understanding of when to use the DASH risk assessment tool.
Adult Social Care attended the home address of Sarah during Covid, in an attempt to make successful contact.
Developments Since the Scoping Period
Since the scoping period of this review, agencies have already made some important amendments to practice:
Doncaster and Bassetlaw Teaching Hospitals have arranged domestic abuse training sessions for staff in the Emergency Department to improve their awareness of domestic abuse.
Nottinghamshire Healthcare NHS Foundation Trust are piloting a safeguarding template for adult mental health records with a few adult services within the Trust. The pilot began on the 1st of November 2021 and will last three months. The template has links to the Domestic Abuse, Stalking and Harassment and ‘Honour’-based violence Risk Indicator Checklist, referrals to other agencies including Adult Social care and links to the Trust’s intranet pages for further guidance on a variety of subjects. Safeguarding advice and supervision can also be recorded within the safeguarding template. After the pilot any feedback and amendments will be made before it is rolled out to all adult mental health services that use Rio (the electronic recording system).
Guidance has now been issued to staff in the Council Tax Team at Bassetlaw District Council Benefits Unit regarding the welfare of claimants and in a situation where a claimant is flagged as vulnerable, there is an expectation that a referral will be made or at least raised with a manager. The Council has recently approved a Vulnerability Strategy, aimed at increasing staff understanding and improving linkages.
Bassetlaw District Council have booked frontline staff on to Domestic Abuse training, and ongoing safeguarding refresher training is being identified.
Bassetlaw District Council is establishing a new internal Safeguarding Group, taking account of a number of key staff changes.
Bassetlaw District Council are setting up a process which involves visiting Council tenants who have had major adaptation works completed, to check how the work has affected the tenant, and the suitability of the works.
A new specialist safeguarding member of staff has been introduced to Bassetlaw Hospital who has a focus on Domestic Abuse domestic violence.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust has started an audit of Emergency Department attendances for demographics/outcomes for domestic abuse victims and will re-audit following training input.
There is an instruction to digitise all of the Lloyd George notes.
During Covid the Social Care team at the Multi Agency Safeguarding Hub were instructed to work from home which meant that usual face to face interaction and communication with partners had to be adjusted through IT solutions. As restrictions have been raised, the team are now back in the office and developing relationships with partners again. As a result, the team have reviewed information sharing process to ensure appropriate information is shared in a timely manner. There have been targeted sessions with the team, dip sampling to ensure quality and monthly quality assurance sessions with health. This is also to be developed with the Police in Autumn 2022.
An independent safeguarding adult pathway review has been undertaken by Adult Social Care in the Multi Agency Safeguarding Hub. The actions from the review are ongoing - one of which focuses on positive and fulfilled outcomes. The team have already begun to develop the service offer and now undertake end to end enquires, working with people at risk or their representatives to support them to achieve their outcomes. The team have reviewed pathways too to reduce ‘hand-offs’ to other departments within adult social care and this will continue to grow and develop.
Recommendations
The review would like to thank agencies for their single agency learning outlined within their reports (see Appendix 2) and draw attention to the following single agency recommendations further identified during the course of this review.
Nottinghamshire police should consider the HMIC report; Her Majesty’s Inspectorate of Constabulary and Fire & Rescue Services; A progress report on the police response to domestic abuse and ensure that their training includes all options for protective factors including revised Domestic Violence Protection Order guidance.
The Hospital Trust should explore and consider the benefits of having an IDVA on site.
Nottinghamshire County Council should review the information sharing protocols within the Multi-Agency Safeguarding Hub to ensure that they are effective, and that staff are aware of what is required and the agreed time scales for the sharing of information.
NHS Bassetlaw Clinical Commissioning Group should ensure that the HARKS assessment tool is incorporated into their health training packages.
The following multi-agency recommendations are made to Bassetlaw, Newark and Sherwood Community Safety Partnership:
Recommendation 1
Bassetlaw, Newark and Sherwood Community Safety Partnership should assure itself that domestic abuse victims are protected through agencies demonstrating an effective domestic abuse policy and that practitioners who come into contact with potential domestic abuse victims are trained and use the DASH risk assessment tool.
Recommendation 2
Bassetlaw, Newark and Sherwood Community Safety Partnership should satisfy itself that partner agencies demonstrate effective adult safeguarding policies, and that practitioners and staff make appropriate, effective adult safeguarding referrals.
Recommendation 3
Bassetlaw, Newark and Sherwood Community Safety Partnership should satisfy itself that multi-agency domestic abuse training is up-to-date and provides an awareness of new legislation, research and initiatives, including professional curiosity that it is able to provide practitioners with a holistic oversight of good practice and tools available to identify and manage domestic abuse.
Recommendation 4
Bassetlaw, Newark and Sherwood Community Safety Partnership should consider raising awareness of the risks of domestic abuse for disabled people within agencies, and the community, to better identify and protect vulnerable victims.
Recommendation 5
Bassetlaw, Newark and Sherwood Community Safety Partnership should assure themselves and that agencies are aware of and undertake their responsibilities under The Equalities Act 2010.
Recommendation 6
Bassetlaw, Newark and Sherwood Community Safety Partnership should share this domestic homicide review with the Health and Wellbeing Board, the Multi Agency Risk Assessment Conference Steering Group and the ALIG (County Assurance Learning and Implementation Group which looks at DHRs).
Appendix 1: Terms of Reference and Project Plan
DOMESTIC HOMICIDE REVIEW
TERMS OF REFERENCE & PROJECT PLAN
SUBJECT: Bassetlaw DHR
Victim: Sarah
Date of birth: [Redacted]
Date of death: [Redacted]
Introduction:
This Domestic Homicide Review was commissioned by Bassetlaw, Newark & Sherwood Community Safety Partnership in response to the death of Sarah. The circumstances are that on X date, Sarah was found deceased in circumstances initially thought to be suspicious. However, subsequent enquiries have concluded that Sarah died by suicide.
Toxicology shows the existence of numerous drugs in Sarah’s system, sufficient to have caused her death.
Sarah was married to Andrew, although separated at the time of death and at times during the relationship. There is a history of domestic violence to the extent of Andrew having stabbed Sarah in 2006. On the evening before Sarah’s death, Andrew had been drunk and sustained a head injury, having fallen, that necessitated hospital treatment. On his return, in the early hours of the following morning, he found Sarah deceased, with a quantity of empty blister packs evident.
Sarah had extensive health issues that included COPD, Spondylitis, sciatica, F Myalgia and was being diagnosed for early onset dementia. In consequence, Sarah was in receipt of numerous prescription drugs.
The DHR referral from the Police was received by the CSP on the 11th of March 2021 once the cause of death had been established.
The case details were considered by the CSP on the 7th of April 2021. The CSP agreed a recommendation to the Chair that the case details met the criteria for a DHR to be commenced.
The scoping period was agreed to be from the 13th of December 2019 to the 13th December 2020.
Legal Framework:
A Domestic Homicide Review (DHR) must be undertaken when the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse, or neglect by-
(a) a person to whom he was related or with whom he was or had been in an intimate personal relationship, or
(b) a member of the same household as himself, held with a view to identifying the lessons to be learnt from the death.
The purpose of the DHR is 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; and
- prevent domestic violence and abuse homicide and improve service responses for all domestic violence and abuse victims and their children by developing a co-ordinated multi-agency approach to ensure that domestic abuse is identified and responded to effectively at the earliest opportunity.
- contribute to a better understanding of the nature of domestic violence and abuse; and
- highlight good practice.
Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews (December 2016).
Methodology
This Domestic Homicide Review will be conducted using the Significant Incident Learning Process (SILP) methodology, which reflects on multi-agency work systemically and aims to answer the question of why things happened. Importantly it recognises good practice and strengths that can be built on, as well as things that need to be done differently to encourage improvements. The SILP learning model engages frontline practitioners and their managers in the review of the case, focussing on why those involved acted in a certain way at that time. It is a collaborative and analytical process which combines written Agency Reports with Learning Events.
This model is based on the expectation that Case Reviews are conducted in a way that recognises the complex circumstances in which professionals work together and seeks to understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight.
The SILP model of review adheres to the principles of,
- Proportionality
- Learning from good practice
- Active engagement of practitioners
- Engagement with families
- Systems methodology
Scope of Case Review
Subject: Sarah
Date of birth: [Redacted]
Scoping period: 13.12.2019 - 13.12.2020
In addition agencies are asked to provide a brief background of any significant events and safeguarding issues prior to the scoping period, including an account of what is known about behavioural, social, or emotional difficulties of family members where relevant. This will include any significant event that falls outside the timeframe if agencies consider that it would add value and learning to the review.
Agency Reports
Agency Reports will be requested from:
- Police
- Adult Social Care
- GP via Bassetlaw CCG
- Bassetlaw Partnership Trust
- CCG: Crisis Home Treatment Team/Mental Health Liaison Trust
- Ambulance
- Doncaster Bassetlaw Hospital Trust
- Bassetlaw District Council
- Women’s Aid
- Change Grow Live
- Housing
Agencies are requested to use the attached Report Template.
Summary reports requested from - if relevant:
- Education
- Children’s Social Care
- National Probation Service
Areas for consideration
The review was asked to consider:
- What was known about the circumstances of Sarah’s living/family arrangements and dynamics within the family.
- How did any physical health and/or mental health (issues including substance issues) and/or financial issues affect Sarah’s vulnerabilities/dependencies upon Andrew? Was a Carer’s Assessment offered/completed and what was the outcome.
- How accessible and responsive were support services that may have been available to the family. How well known were these services to the public or silent victims.
- How well understood was the family’s/community’s approach to/recognition of domestic violence, coercive control and/or risk of suicide. What support was offered to Andrew to manage his violence.
- Were there any barriers to accessing support.
- Could communication and information sharing within and between agencies have been improved during the scoping period. What opportunities existed for multi-agency referrals for vulnerability and/or risk management meetings.
- Were there missed opportunities to exercise professional curiosity.
- What support is offered to living relatives and is enough consideration given to any future risk.
- How has the Covid Pandemic impacted upon the family and support offered.
- Identify examples of good practice, both single and multi-agency.
Engagement with the family
A key element of SILP is engagement with family members, to ensure their views are sought and integrated into the Review and the learning. The family will be notified of the DHR by a letter from the Chair. The independent lead reviewer will follow up by making contact with the family, and ensure they are consulted on the terms of reference for the review.
Further contact will be made to invite participation in the review by a personal interview, correspondence, or telephone conversation prior to the Learning Event. Contributions will be woven into the text of the Overview Report and the family will be given feedback at the end of the process.
Timetable of Domestic Homicide Review
Table for Case Review:
- Scoping Meeting and Panel 1: 25th June 2021
- Letters to Agencies: 5th July 2021
- Engagement with family: Begin once authorised
- Author's briefing: 12th July 2021, 1:30pm
- Agency IMR's completed, quality assured and submitted to Chair: 16th August 2021
- Agency Reports quality assured by Chair and Author: 16th August - 23rd August
- Agency Reports Distributed: 23rd August 2021
- Learning Event inc Panel 2: 29th September
- First draft of Overview Report to: 27th October 2021
- Recall Event inc Panel 3: 17th November 2021
- Second draft of Overview Report to: TBA
- Presentation and Sign-Off: TBA
Appendix 2: Single Agency Recommendations
Sing agency recommendations identified by agencies within their reports:
Doncaster and Bassetlaw Teaching Hospitals
- The organisation will raise the importance of detailed and accurate record keeping and documentation.
Improve staff knowledge on professional curiosity. - Ensure domestic abuse services are updated and promoted across all areas within the trust.
GP Surgery
- To consider ways into which to highlight those registered patients who are a victim/survivor of domestic abuse.
- Those adults at risk of being vulnerable may need an enhanced Did Not Attend process in place.
- To enhance Professional curiosity across the practice
- To review and digitalise Lloyd George records.
Bassetlaw District Council
- Ensure that staff of aware of the importance of making referrals where a customer has indicated that they are struggling financially or are vulnerable.
Last Updated on Wednesday, May 8, 2024