Domestic Homicide Review Report - Sarah

Review into the death of Sarah in December 2020

Report Author: Alison Standiford, August 2022 

Contents

 

• Introduction
  • Timescales
  • Confidentiality
  • Terms of Reference
  • Methodology
    
    
• Involvement of Family and Wider Community
  
  • Contributors to the Review
  • The Review Panel members
  • Parallel Reviews
  • Dissemination
    
    
• Equality and Diversity
  
• Background and Information (The Facts)
  
  
• Chronological Agency Interaction Prior to the Key Lines of Enquiry (pre-2004)
  
  
• Overview of Key Practice Episodes
  
  • Key Historical Events Prior to the Scoping Period (2004-2012)
  • Events Leading to a Crisis for Sarah (July 2019 - 23rd November 2020)
  • Events Surrounding Sarah's Death (24th November 2020 - 17th December 2020)
    
    
• Overview of the Voice of Sarah
  
  
• Analysis by Theme
  • Management of Risk
  • Application of Professional Curiosity
  • Effects of the Covid Pandemic on the Support afforded to Sarah
  • Understanding Sarah's Lived Experiences
    
    
• Conclusions
  
  
• Lessons to be Learnt
  
  
• Lessons to be Learnt from Good Practice
  
  
• Recommendations
  
  
• Appendices
  • Appendix 1
  • Appendix 2

 

Introduction

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:

a) 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.

b) 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.

c) apply these lessons to service responses including changes to inform national and local policies and procedures as appropriate.

d) 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.

e) contribute to a better understanding of the nature of domestic violence and abuse; and

f) 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 subject of this DHR is Sarah. 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 her 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.

Timescales 

This review commenced on the 7th of April 2021 and concluded in June 2022.

Confidentiality

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.

Terms of Reference

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 effect 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.

Involvement of Family and Wider Community

Initial communications, which included the Home Office DHR leaflet for family members, have been made with family members via personal contact by Nottinghamshire police. In consequence, Sarah’s sister initially advised that she would contribute to the review. However, following initial introductions and explanations, Sarah’s sister made the decision not to make any further contact. The review respects and understands this decision and the review panel send their condolences.

Sarah and Andrew’s son made the decision not to contribute to this review and his decision is respected and understood.

Nottinghamshire police also made personal contact with Andrew and his parents to inform of the review and offer the opportunity to contribute. All parties made the decision not to contribute, and their decision is respected and understood.

Sadly, the review has not been able to speak to any other family members, friends, or wider community.

Contributors to the review 

Agency	Contribution
Nottinghamshire Police	Individual Management Review provided by an Independent Review Officer. Attended Learning and Recall Event.
Nottinghamshire County Council - Children's Social Care	Individual Management Review provided from an Independent Service Manager. Attended Learning and Recall Event.
General Practitioner x2	Individual Management Review provided from GPs.
Nottinghamshire Healthcare Trust	Individual Management Review provided from an Independent Safeguarding Lead. Attended Learning and Recall Event.
Nottingham County Council - Adult Social Care	Individual Management Review provided from an Independent Service Manager. Attended Learning and Recall Event.
Bassetlaw Clinical Commissioning Group	Individual Management Review provided from an Independent Safeguarding Lead. Attended Learning and Recall Event.
Doncaster and Bassetlaw Teaching Hospitals	Individual Management Review provided from an Independent Safeguarding Lead. Attended Learning and Recall Event.
The Probation Service	Report provided from an Independent Manager.
Bassetlaw District Council – Housing Team	Attended Learning and Recall Event.
Nottinghamshire Women’s Aid	Attended Learning Event and Recall Event.

 

 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, 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 – Housing Management, 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.

 

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 adult 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 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.

 

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.

 

Dissemination 

The report will be disseminated by the CSP by notifying agencies when the report is published. 

 

Equality and Diversity 

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.

Background Information (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 as reported to agencies and detailed further in this report, from 2001.

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 or not. 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*.

*Sarah never received her memory tests, due to Covid restrictions on appointments, and was therefore undiagnosed as to her cognitive abilities and potential for dementia.

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.

 

Overview of Key Practice Episodes 

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 a 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. 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.

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 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 2020 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 Nottinghamshire Customer Service Centre.

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 101. 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.

 

Overview of the Voice of Sarah

Sadly, as outlined in section 2 of the report, the review has not had the opportunity to engage with family members.

In the absence of the voice of the family the review has ensured that Sarah’s voice has been woven into the body of the report where possible using professionals’ recorded references to what has been said.

 

Analysis by Theme

The analysis section of the review will examine information gained from Agency Chronologies and Reports, the Learning Event, and the Recall Event, thematically. The themes to be addressed are:

• Management of Risk
• Application of Professional Curiosity
• Effects of the Covid Pandemic on the support afforded to Sarah
• Understanding Sarah’s Lived Experience

Within each section of analysis, the lesson learned will be stated, along with a recommendation where required. These will be reiterated in the specific sections towards the end of the report.

 

Management of Risk

The processes for managing risk have changed considerably since Tom was a child. At the time, there was poor information sharing and a lack of professional curiosity but if the incident during which Andrew stabbed Sarah occurred now, current practice would be to convene a strategy meeting. A section 47 enquiry would follow to decide what action was required to safeguard Tom. In the absence of such action taking place, a vital opportunity was missed in 2004 to work with Sarah and Tom to support them with the domestic abuse they had already suffered and help them to safety plan for their future.

In 2004 when this incident took place, the Children’s Act 1989, which placed a duty on the local authority to undertake enquiries where it believed a child suffered significant harm, was in place. The Children’s Act 2004, which sought to strengthen the duties on other agencies, specifically the police, to safeguard children, had not yet been put into practice. It may be that had the new Act been embedded into practice at the point of this incident, more emphasis and focus would have been placed on holding a multi-agency meeting with partners and this would have allowed for safety planning.

When Children’s Social Care was approached in March 2006 regarding Tom having contact with his father, their response was to allow Tom to decide for himself. This was due to ‘Gillick competence*’ being applied to Tom as Children’s Social Care was of the opinion at the time that he was old enough at 14 to make his own decisions.

*Gillick competence is the principle we use to judge capacity in children. When practitioners are trying to decide whether a child is mature enough to make decisions about things that affect them, they often talk about whether the child is 'Gillick competent' or whether they meet the 'Fraser guidelines'. Although the two terms are frequently used together and originate from the same legal case, there are distinct differences between them. The Fraser guidelines still apply to advice and treatment relating to contraception and sexual health. But Gillick competency is often used in a wider context to help assess whether a child has the maturity to make their own decisions and to understand the implications of those decisions.

If this situation were to arise now, Children’s Social Care have assured the review that current social work practice would see Children’s Social Care assessing the contact by ascertaining the views of Tom and Sarah. Consideration would include an assessment of Andrew and the level of risk he may pose.

In the absence of such intervention, Tom clearly struggled as in March 2006 he bravely reported to school that he was suicidal and suffering physical harm. Following his disclosure, it was requested that Children’s Social Care did not visit Tom at his home address, as per Tom’s request. However, owing to school holidays and a health appointment* of Tom’s, he was subsequently not seen until May 2006 when he informed Children’s Social Care that the situation had improved, and he did not now wish to speak with a Social Worker. The delay prevented Children’s Social Care’s window of opportunity to hear from Tom at a time when he had felt ready to talk.

*It has not been possible to identify what the health appointment was concerning.

Around this time, Tom was supported by Children’s Social Care through two Child in Need plans. The first commenced in May 2006 and was discharged within weeks due to not establishing engagement with him. The second commenced in August 2006 and was discharged the subsequent month following completion of the section 47 enquiries. Both plans should have ensured multi-agency meetings, preferably to include the family. Any reluctance to engage by Sarah and Andrew should have been assessed at the time and prompted consideration of why, and how lack of engagement impacted on Tom.

Child in Need should have ensured support was available and identified the roles and responsibilities of the professionals around the family. Instead, the first plan was very quickly discharged as it was assessed that Tom was not providing any information of concern. The second plan’s only actions were to provide Tom with Children’s Social Care contact details, request that school monitor Tom and ask that the police inform Children’s Social Care of any further domestic incidents. No referrals were made to Women’s Aid and neither the GP, the school nurse, nor the Health Visitor are recorded to have been informed. Crucially, no support was offered to help Sarah understand the effects of domestic violence upon Tom by way of a Domestic Abuse Link Worker*.

*In 2006 Bassetlaw introduced Domestic Abuse Link Workers (funded by Children’s Social Care and Women’s Aid) to work with mothers to help them to recognise how domestic abuse effects children.

There is evidence to indicate that Tom would have been receptive to working with professionals had they persevered: In July 2006, following a reported verbal incident between his parents, Tom wrote to Children’s Social Care disclosing his fear of Andrew. Sadly, the opportunity to engage with him was once again missed owing to initial contact attempts being unsuccessful. When Children’s Social Care did manage to speak with him, 6 days later, he retracted his disclosure. Although it is recognised that having withdrawn Tom may not have engaged, a referral to Women’s Aid could have been made at this time in an attempt to provide Tom support in his own right. 

In 2006 little was understood about the impact of coercive control* within domestic abuse. Accordingly, it was not considered that Tom’s retraction, and Sarah’s minimisation of the situation could have been the result of Andrew’s control over the family. Professionals now have a greater understanding of coercive control, and this is discussed in more detail when the report considers Sarah’s lived experiences.

*Coercive control involves an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse by a perpetrator that is used to harm, punish or frighten their victim. Section 76 of the Serious Crime Act 2015 created a new offence of controlling or coercive behaviour in an intimate or family relationship.

Children’s Social Care report that a further domestic incident in July 2006 contributed to the second Child in Need plan but did not, as it should have, ensure escalation to an Initial Child Protection Conference and a higher level of support.

Better practice around this time would have seen Children’s Social Care applying Think Family* approach. Think Family is pertinent when more than one family member needs support, as was here with Tom and Sarah requiring support around the abuse and Andrew requiring support with his mental health issues and substance misuse as described in paragraph 5.3. The circumstances provided an opportunity for a professionals meeting to obtain more information and to identify those best to engage with the family members.

*The Think Family initiative was introduced by the Department for Children, Schools and Families in 2008 following the Cabinet Office’s 'Families at Risk' Review. It is an approach to help practitioners consider the parent, the child and the family as a whole when assessing the needs of and planning care packages.

Lesson 1
Ineffective CSC 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.

Although referrals to Children’s Social Care had ceased because Tom was now an adult, at the beginning of the review’s scoping period (December 2019) agencies were in possession of risk information that Andrew was a perpetrator of domestic abuse and had stabbed Sarah during one such incident; that he had history of poor mental health, anger and substance misuse; and following a report of a domestic incident in July 2019 in which he was heavily intoxicated, that he had returned to drinking alcohol and being abusive to Sarah.

In addition, Housing knew from Sarah’s application forms that she had recently separated from Andrew, but that Andrew still attended the home address and stayed overnight as Sarah needed him to assist her with her care. Also, very early in the scoping period in January 2020, the GP surgery learned that Sarah was struggling physically on her own and was asking for an electric wheelchair to improve her independence.

One of the most dangerous times in an abusive relationship for the victim is at the point of separation. At this point there is a huge likelihood of violence; 41% (37 of 91) of women killed by a male partner/former partner in England, Wales, and Northern Ireland in 2018, had separated or taken steps to separate from them. Eleven of these thirty-seven women were killed within the first month of separation and 24 were killed within the first year* (Femicide Census 2020).

Consequently, thorough risk management and safeguarding was crucial at the time Sarah separated from Andrew. Each organisation is responsible for its own internal guidance and procedures for staff to implement when they are faced with an adult for whom there is a safeguarding concern. Likewise, organisations must ensure that all staff (paid and volunteers) understand that they have a duty to act immediately to refer or to inform the person within their organisation responsible for ‘referring to the local authority’ where there are concerns that an adult is at risk of significant harm.

The core definition of ‘vulnerable adult’ from the 1997 Consultation ‘Who Decides?’ issued by the Lord Chancellor’s Department, is a person: ‘Who is or may be in need of community care services by reason of disability, age or illness; and is or may be unable to take care of, or unable to protect him or herself against significant harm or exploitation’.

Several professionals encountering Sarah noted her vulnerabilities in respect of both the domestic violence and her health issues. Some agencies, such as the Benefits Office, ensured that their identified concerns were visible within their notes. Others, such as the police and the mental health team, risk assessed and referred her onwards for consideration of further support.

The Housing team stated at the Learning Event that better practice when they first recognised and recorded Sarah’s vulnerability in March 2020, would have seen a referral to the Council’s Welfare Team who could have contacted Sarah to see if they could provide with her any further assistance. Such an offer of support is not just for financial matters but also for consideration of referral to other agencies who could help with health and well-being. Further guidance has now been issued to staff 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 following safeguarding referrals were made with regard to Sarah during the scoping period (13.12.2019 - 13.12.2020) of this review:

Date	Referred by:	Referred to:	Concern
06/01/20	Police Officer	Police Domestic Abuse Support Unit	Domestic Incident
06/11/20	Police Officer	Police Domestic Abuse Support Unit	Domestic incident
07.11.20	Police Officer	Police Domestic Abuse Support Unit	Domestic incident
25.11.20	Mental Health Liaison Team	Multi-Agency Safeguarding Hub*	Sarah had disclosed abuse from Andrew to a consultant
27.11.20	East Midlands Ambulance Service	Multi Agency Safeguarding Hub	Sarah had disclosed that she was scared of Andrew to a paramedic

 *The Multi Agency Safeguarding Hub (MASH) is a multi-agency team which identifies risks to vulnerable adults and children. 

The Domestic Abuse, Stalking and Harassment and Honour-based violence (DASH) risk assessment was endorsed by National Policing leads in 2009 to support and improve professional responses to cases of domestic abuse. It is a risk assessment tool, linked to the Duluth Power and Control Wheel. Its purpose is to ensure professionals employ a proactive response to a domestic situation by asking direct questions to assess risk.

*The Power and Control Wheel is an earlier tool that helps explain the different ways an abusive partner can use power and control to manipulate a relationship.

A DASH should be completed for every domestic abuse and stalking, and harassment incident attended, and on 3 occasions during the scoping period of this review, the police completed a DASH which met the threshold of risk for referral of Sarah to the police Domestic Abuse Support Unit for consideration of further support. The police complete an electronic version of the DASH which is known within forces as a Domestic Abuse Public Protection Notice*.

*This notice referred to is purely an internal mechanism for forwarding on an electronic DASH.

The DASH assessment risk level directs the level at which further support thresholds are met. The first two completed regarding Sarah were assessed as reaching the threshold for a standard risk and consequently, in line with the local referral pathway, no further referral was made to Women’s Aid. The third was assessed as a medium risk, the threshold for referral to Women’s Aid. As a result, a Women’s Aid worker attempted to contact Sarah on 4 occasions between the 19th of November and the 30th of November 2020, but a case was never opened as none of the contacts were successful. Had contact been successful, Women’s Aid would have been able to offer a wide range of commissioned services to Sarah as a female survivor.

A Domestic Abuse Public Protection Notice completed by the police, does not act as a referral into wider safeguarding processes via the Multi-Agency Safeguarding Hub. Where other vulnerabilities are identified the attending officer should also complete a Public Protection Notice for a vulnerable adult. Although one of the police Domestic Abuse Public Protection Notices refers to clear identification of vulnerability observed in relation to Sarah’s poor physical health and dementia, no Vulnerable Adult Public Protection Notices were ever completed with regard to Sarah. This was explained at the Recall Event to be because she was not seen to be living in poor living conditions or suffering self-neglect.

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.

Did officers rely too much on the DASH to risk assess and not consider Sarah’s wider vulnerabilities? Although the DASH is an essential tool when considering thresholds for referrals, a review (Robinson of three police forces has suggested that it does not always present a clear indication of the risk of harm, and it should therefore be used with caution. Professionals must make a conscious effort not to over-rely on its findings and should not hesitate to make further safeguarding referrals where there is evidence of other vulnerabilities. 

The DASH is not a risk assessment tool exclusively for the police. As stated on the DASH form for use in Nottingham and Nottinghamshire* it is for all staff and volunteers working with an individual or family at risk from domestic abuse or violence. As such, a DASH should have been completed by the practitioners to whom Sarah disclosed domestic abuse whilst at the Emergency Department of the hospital on the 24th of November 2020. This omission was discussed with practitioners and professionals at the Learning Event, and it was established that although the DASH has been introduced to hospital staff, there is a lack of ongoing training and a consequent inconsistent use by practitioners. This needs to be addressed to protect future victims.

*OPERATING PROTOCOL (nottswa.org)

Lesson 4
The DASH is being used by the police routinely, but not yet by practitioners from 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.

DASH training is included within the Multi Agency Risk Assessment Conference* Training which has been delivered by Nottinghamshire Women's Aid. The training was commissioned by Nottinghamshire County Council, Public Health, and the Office of the Police Crime Commissioner as part of the 2015 Domestic Abuse North Nottinghamshire contract, jointly with the sub-contractor Equation, to demonstrate ongoing and embedded commitment to working with other agencies. The purpose is to promote, support and improve the response to domestic abuse. The training seeks to ensure:

• All agencies are using the Nottinghamshire DASH risk assessment which increases the likelihood that domestic abuse will be identified as early as possible.
• Explains the process of Multi Agency Risk Assessment Conference and how specialist domestic abuse services operate.
• Ensures that agencies are aware of how the Multi Agency Risk Assessment Conference operates and how to refer to Multi Agency Risk Assessment Conference.
• Clarifies the role of professionals in regard to the Multi Agency Risk Assessment Conference.
• Develops a higher state of awareness in relation to which services are available in the area to support both female and male domestic abuse survivors; and
• Ensures an understanding of how domestic abuse sits within the safeguarding adult’s framework, clarifying how safeguarding adult’s procedures and domestic abuse procedures work in unison under the Care Act.

*A Multi Agency Risk Assessment Conference, or multi-agency risk assessment conference, is a meeting where information is shared on the highest risk domestic abuse cases between representatives of local police, probation, health, child protection, housing practitioners, Independent Domestic Violence Advisors (IDVAs) and other specialists from the statutory and voluntary sectors. After sharing all relevant information about a victim, representatives discuss options for increasing safety for the victim and turn these options into a co-ordinated action plan. The primary focus of the Multi Agency Risk Assessment Conference is to safeguard the adult victim.

Two sessions have been delivered every year in North Nottinghamshire free of charge for professionals to attend. The training is delivered as part of a multiagency event. In 2020 Equation were commissioned to deliver the training that continues to be delivered across the county.

NHS Bassetlaw CCG is supportive of the HARKS model and advocate for its inclusion in agency training. Work is currently ongoing to explore how this can be embedded, and the Clinical Commissioning Group is working to identify resource or funding to support Nottingham City and Nottinghamshire to utilise the model HARKS denotes five questions:

• Humiliation - Within the last year, have you been humiliated or emotionally abused in other ways by your partner or your ex-partner?
• Afraid - Within the last year, have you been afraid of your partner or ex-partner?
• Rape - Within the last year, have you been raped or forced to have any kind of sexual activity by your partner or ex-partner?
• Kick - Within the last year, have you been kicked, hit, slapped or otherwise physically hurt by your partner or ex-partner?
• Stalking and Coercive Control - Have they harassed you, including loitering, following, unannounced contact or has your property been vandalised or destroyed?

*Neighbouring CCG areas (Barnsley and Rotherham) have adopted the use of a modified HARK model (Sohal, Eldridge & Feder, 2007), this model is also currently under consideration in the Doncaster CCG area.

If any question is answered in the affirmative, a referral will be made for completion of the DASH risk assessment.

In addition to making referrals, Police Officers have a duty to take or initiate steps to make a victim as safe as possible and are required to take positive action at the scene of domestic incidents. Arrest may not always be an option where the grounds for doing so are not met. However, where there is domestic abuse and the victim is at risk of harm, positive action requires officers to consider and implement proportionate alternative measures to protect the victim, regardless of the victim’s consent.

During the scoping period, officers attended Sarah as follows:

Date	Circumstances	Police Response
06.01.2020	Andrew was refusing to leave the shed. He was drunk and shouted abuse including conditional threats to kill. Sarah later said that she had not felt in fear.	Andrew left and a Domestic Abuse Public Protection Notice was completed. Sarah given safety advice to re-call 999 if he returned.
06.11.2020	Sarah reported that Andrew was drunk banging on the door. He had kicked their car but hadn’t damaged it.	Andrew was taken to his mother’s address to avoid a Breach of the Peace and a Domestic Abuse Public Protection Notice was completed. Sarah said she wouldn’t provide a statement if and when she reported criminal matters.
07.11.2020	Sarah reported a verbal altercation. She initially reported threats to kill but then minimised this to no threats being made that day.	The incident was considered by officers to be a domestic argument involving alcohol on Andrew’s part. A Domestic Abuse Public Protection Notice was completed but no further action taken.

On the 6th of November 2020, when attending a report of domestic incident, the police removed Andrew to his mothers to prevent a breach of the peace. Whilst providing some space, the review would like to highlight one study* which has raised concerns that using a lesser power, such as an arrest for a breach of the peace, could give a victim a negative view of policing and send them a false message that the police have not taken their situation seriously. This in turn could influence a victim to trivialise their own abuse, which is a serious issue, as that perception can deter victims from seeking help because they may feel that the effort expended in engaging with the criminal justice system has reaped very little reward. This little reward is reflected in Sarah’s comments made to staff in the hospital Emergency Department, when she stated that when she reported Andrew to the police, he just returned home later. 

*Enhancing the Experience of Procedural Justice for Domestic Abuse Survivors by Improving the Policing Response A Mixed Method Study Utilising Interpretative Phenomenological Analysis Alison Claire Heydari.

The option of removing Andrew was repeated the very next day, on the 7th of November 2020 when police took positive action and ensured Andrew was removed from the property again. Having reviewed their actions, the police are satisfied that they did not have grounds for an arrest on this occasion; Sarah was not seen with injuries, there was no evidence of criminal damage, and although Sarah initially reported a specific threat, upon police attendance she retracted that he had threatened her on that day and did not agree to support any investigation with a statement. Neighbours were spoken to, and none were forthcoming with any evidence of a crime having occurred. Therefore, an arrest was not utilised on this occasion due to lack of evidence that a crime had been committed. The presenting situation was resolved by Andrew agreeing to leave the premises, and he was advised to stay away, which did give the benefit of providing space.

Overall, despite Sarah being encouraged to call the police for help and making repeat requests for Andrew to be removed, simply moving him to an alternative location was an ineffective measure as he always returned. Similarly, on another occasion (6th of January 2020), police attended, and Andrew left of his own accord but later returned. As such it is apparent that Andrew always kept control of the situation, leaving Sarah powerless to prevent his return. A more proactive response to the incidents that would have provided an opportunity for extra space for Sarah in lieu of an arrest and ability to prosecute, as the legislation intended, would have been consideration of a Domestic Violence Protection Notice* to ensure Andrew could not return whilst Sarah accessed support.

*A two-stage process involving both the police and the magistrates’ court. Once the police have served a Domestic Violence Protection Notice on the suspect, an application must be made to the magistrates’ court for a Domestic Violence Protection Order within 48 hours of the Domestic Violence Protection Notice being served. In order for a Domestic Violence Protection Notice to be available:

• the suspect must be over 18.
• there must be reasonable grounds for believing that the suspect has been violent or has threatened violence towards an associated person, and
• that the Domestic Violence Protection Notice is necessary to protect the associated person from violence or threat of violence by the suspect.

Much discussion was had during the Learning Event about why a Domestic Violence Protection Notice wasn’t ever considered to prevent Andrew returning to Sarah’s address. The Domestic Violence Protection Notice process is designed to grant victims a temporary respite from their abuser and allow referral to support services without interference.

The College of Policing advises that a Domestic Violence Protection Notice and a Domestic Violence Protection Order may be used in situations like Sarah’s where, following a domestic incident, an arrest has not been made, but positive action is needed (or where an arrest has taken place, but the investigation is in progress).

The Domestic Violence Protection Order application requires reasonable grounds for believing that the suspect has been violent or has threatened violence towards an associated person. Whilst violence is not defined by the Home Office guidance on Domestic Violence Protection Notice’s and Domestic Violence Protection Order's or the Crime and Security Act 2010, the Oxford English Dictionary indicates that violence is characterised by a person aiming physical force at either a person or property:

• behaviour involving physical force intended to hurt, damage, or kill someone or something.
• strength of emotion or of a destructive natural force.

Although during the scoping period of the review, Sarah minimised Andrew’s threats of violence after she had reported the incidents to the police, she had initially reported threats on every occasion, to herself and property, and specifically asked for his removal. Andrew’s abusive nature was also witnessed directly by the police when they were dealing with him on other occasions and had resulted in separate prosecutions. Also, given that the Domestic Violence Protection Notice process can be pursued without the victim’s active support, or even against their wishes, it should have been considered to protect Sarah from Andrew’s violence or threats of violence.

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.

This review has been assured that to aid compliance:

• Nottinghamshire Police have increased training in the use of Domestic Violence Protection Notice/Orders across the force and bespoke training has been given to frontline officers to refresh their knowledge.
• All new police officers now receive direct training on the use of Domestic Violence Protection Notice/Orders as part of their core training.
• Additional training has been provided to departments more usually involved in prisoner processing.
• The need to consider the use of Domestic Violence Protection Notice/Orders as a proactive measure, has been reinforced through senior officer posts on the force intranet, and a full page has been embedded which offers guidance for all staff.
• An officer is now in post to review Domestic Violence Protection Notice/Orders use and to identify any potential opportunities for use that may have been missed. This proactive approach has seen an increase in orders and since February 2021 Women’s Aid report an increased use of Domestic Violence Protection Notice/Orders in the local area.

It became clear at the Learning Event and Recall Day that very few agencies understand the Domestic Violence Protection Notice/Order processes. However, it must now be noted that the new Domestic Abuse Bill 2020 has repealed existing Domestic Violence Protection Orders and introduced a new civil Domestic Abuse Protection Notice and a new Domestic Abuse Protection Order. Like the current Domestic Violence Protection Notice, a Domestic Abuse Protection Notice will give victims immediate protection following an incident and the police can make an application for a Domestic Abuse Protection Order to a Magistrates’ Court. Both prohibitions and positive requirements will be imposable on perpetrators subject to a Domestic Abuse Protection Order. The government is to produce detailed statutory guidance and a programme of training and toolkits for professionals to embed understanding of the new orders and will work with both the Judicial College and HM Courts and Tribunal Service to introduce training into their ongoing training programmes. The review would go further and recommend that all agencies engaged with safeguarding incorporate knowledge of the revised Domestic Abuse Protection Notices/Orders into their domestic abuse training.

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.

Attending officers could also have advised Sarah about the existence of non-molestation orders* and could have made a referral to, or signpost Sarah to, the National Centre for Domestic Abuse for direct support, if she so wished. A non-molestation order can protect a person against behaviour that itself may not be a criminal offence, or in situations where the police have responded to a 999 call, but there has been insufficient evidence to charge the abuser with any criminal offence. Where a victim obtains such an order, this provides the police with an additional power of arrest should it be breached.  

*A non-molestation order can be granted by the court under section 42 of the Family Law and is typically issued to prohibit an abuser from using or threatening physical violence, intimidating, harassing, pestering, or communicating with you. An order could prevent the abuser coming within a certain distance of you, your home address or even attending your place of work.

However, because Sarah relied upon Andrew for many aspects of her day-to-day care and owing to her isolation with no one other than Andrew to support her, it is acknowledged that she may not have felt able to pursue a non-molestation order, or indeed any order against Andrew, given she was reluctant, after the event, to support a police prosecution. However, this should not prevent officers providing victims with advice, especially where there is a raised risk identified through DASH, as there was for Sarah. If officers do not consider all options for positive action, they are inappropriately assigning responsibility to a victim to protect his or herself without help.

Women’s Aid rely upon police and all agencies to promote domestic abuse services and to encourage victims to contact them to engage. Similarly routine enquiry at appointments, promotion of helplines in public places and public campaigns such as White Ribbon UK*, are all necessary to help victims of abuse to become aware of what options exist for them. Nottinghamshire utilises the White Ribbon promotion and also continue to raise their profile internally and to promote other services.

*White Ribbon UK is part of the global White Ribbon movement to end men’s violence against women.

Despite it being incumbent upon officers to protect victims of domestic abuse and to consider the tools and referral options available to them, a recent report* jointly conducted by the HM Inspectorate of Constabulary and Fire and Rescue Services, the Independent Office for Police Conduct and the College of Policing has found a lack of understanding within police forces over how and when to use protective measures. It has therefore included within its recommendations that Chief Constables should ensure their officers understand all the protective measures available.

*Her Majesty’s Inspectorate of Constabulary and Fire & Rescue Services; A progress report on the police response to domestic abuse.

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.

Sarah’s attendance at the hospital, on the 24th of November 2020, was the only contact she had with health professionals during which she freely disclosed the current abuse she was enduring from Andrew. Positively, having overdosed, Sarah immediately contacted the Crisis Team for help who arranged an ambulance. On the telephone Sarah disclosed that Andrew treated her badly. This was a real opportunity to engage with her.

Upon presenting at the hospital Sarah bravely continued to disclose the abuse to staff in the Emergency Department. In consequence, because Sarah said that she had taken an overdose of medication due to frustration and that she had ‘had enough of life’, an immediate referral was made to the mental health services.

Records indicate that no safeguarding referral was made by the Emergency Department, and this has been determined to be because there was an expectation that the mental health team would make the referral. However, this didn’t happen. Despite Sarah having disclosed her abuse on the phone to the Crisis team, and to staff at the Emergency Department, no safeguarding issues were documented. At the Learning Event, the hospital outlined that the Emergency Department records are kept electronically and that there is a specific question within the system that asks, “Are there any safeguarding concerns?” Before any patients can be discharged this question needs to be completed. On Sarah’s record, on the 24th of November it is recorded that there are “no safeguarding issue”. This was a missed opportunity, given the disclosures, for a specific domestic abuse referral for Sarah.

Doncaster and Bassetlaw Teaching Hospitals have informed this review that in response to these omissions, domestic abuse training sessions have been arranged for staff in the Emergency Department to improve their awareness of domestic abuse.

During the subsequent assessment with mental health services, Sarah discussed the abuse openly. The clinician responded professionally and:

• ensured a Multi-Agency Safeguarding Hub referral was completed.
• reported domestic abuse offences to the police via 101 with specific consent from Sarah; and
• diarised a referral to adult social care via a colleague the following day – it was not possible to complete immediately due to the time of night.
  However, there was no power to prevent Sarah from leaving the hospital and staff had to respect Sarah’s decision to return to her home address at 00:08 hours on the 25th of November 2020.

As mentioned, the clinician had contacted the police via 101at 23:48 hours and reported the abuse. As a result, officers spoke with Sarah at 02:41 hours but she did not want to disclose any further information and made no disclosures to the officer. At this time, Andrew was still in custody and Sarah indicated that she did not want him returning to the address. Sarah was advised that if he returned, she could call the police who would attend, and the information was relayed back to the officers in the custody suite.

As Andrew’s arrest was not for domestic matters or crimes against Sarah, there were no powers to stop Andrew returning to the family home. The Bail Act would not allow bail conditions to be placed on Andrew returning to his home address as Sarah was not a victim of the offences, nor a witness/suspect in the offence.

The Adult Social Care referral request was reviewed by a colleague the next day, but there was insufficient information provided to action. Upon learning of this during his next shift, the clinician to whom Sarah had made her disclosure, requested that the psychiatrist pass Sarah the details of Adult Social Care for self-referral. However, the review has learnt that by this time, Andrew had returned to the home address and as such the window of opportunity to engage was closing. Accordingly, it is reasonable to assume that Sarah would now have decreased ability to self-refer to Adult Social Care. Asking Sarah to self-refer, however well intentioned, places the responsibility to protect herself and seek support back on her shoulders. This is especially so given the request was made due to insufficient information being available in her records for the clinician to complete the referral.

This highlights the cruciality of professionals identifying and supporting vulnerability and getting the safeguarding referral process right. To ensure referrals are completed accurately with sufficient information, professionals have access to a checklist, produced by Nottinghamshire Safeguarding Adults Board and Nottingham City Safeguarding Adults Board. The referral checklist is contained within the ‘Nottingham and Nottinghamshire Multi-Agency Adult Safeguarding Procedure for Raising a Concern and Referring’. Adherence to the checklist would prevent a delay in important referrals being made and maximise opportunities to support vulnerable people.

A failed referral is a missed opportunity to refer effectively. Because as mentioned earlier in the report, the time following a victim having taken steps to separate from their abuser, such as when they have disclosed abuse, can be a dangerous one, consideration should have been had to action the referral even in the absence of all of the information.

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.

Neither A&E nor the mental health team made any domestic abuse referrals to support Sarah. This oversight was discussed at the Recall Day, and it was noted that if the hospital had a hospital Independent Domestic Violence Advisor* as many other hospitals do, staff could have turned to them for advice and would have been informed of procedures including DASH and referrals. The role of hospital Independent Domestic Violence Advisor not only provides professionals with a specialist on site who they can engage with for support, but also provides the survivor with a skilled person that they can talk to and, importantly, can ensure the completion of a DASH risk assessment at the time. The Trust has told this review that The Doncaster partnership Domestic Abuse strategy 2022-2025 is looking at suggesting an Independent Domestic Violence Advisor in acute hospitals, and it is something that may be considered in the future. In addition, the Trust confirmed that they do now have a safeguarding nurse specialist in post whose focus is domestic abuse.

*An IDVA (Independent Domestic Violence Advisor) is a trained specialist who provides a professional service to victims of domestic violence who are at high risk of serious harm.

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.

The review panel concur that Sarah’s overdose at this point was a clear cry for help. Sarah sought immediate help when she overdosed and was really brave when she disclosed her abuse. However, although her disclosure was a positive step towards seeking support to address her situation, it didn’t provide the help she so badly needed. Disclosure was the beginning of a chapter, not the end of her abuse and sadly Sarah saw no effects of change as a result of her disclosure. Andrew was still released from police custody and the Magistrates’ Court and returned to her address. Sarah’s physical needs remained unmet, and her abusive situation remained.

The Multi-Agency Safeguarding Hub team began to process the referral made by the mental health clinician, after Sarah’s return to the home address on the 25th of November 2020. They requested information from the police to assist their enquiry; but despite information sharing protocols within the Multi-agency Safeguarding Hub being in place, there was confusion regarding what information the police could disclose, causing repeat requests and escalation to supervisors. In consequence, despite all staff working within the Multi-Agency Safeguarding Hub, the police did not share their information with Adult Social Care until the 3rd of December 2020. This created an unnecessary delay of some 8 days. A Social Worker was finally allocated on the 9th of December 2020.

Adult Social Care attempted to contact Sarah on the 25th of November 2020 as outlined in section 7.3 of the report but were unsuccessful. Whilst it is recognised that this, and the delays in receiving the police information, hindered Adult Social Care, given the known history, consideration could have been had to refer to Women’s Aid in the meantime.

Lesson 10
Information sharing processes within the Multi-Agency Safeguarding Hub were ineffective causing an unnecessary delay in support being allocated to Sarah.

A clear barrier to effective agency practice and management of risk throughout this scoping period has been the poor nature of information sharing between agencies. A key mechanism for information exchange is to use policy and practice guidance that is already in place and to think widely about who needs to know what and/or what is needed to be sought. There were opportunities to do this. For example, consideration could have been had to convene a strategy meeting when Multi-Agency Safeguarding Hub received the clinician’s referral on the 25th of November. A strategy meeting could have been used to establish what other agencies knew about Sarah and Andrew. Given the fact the review has established that significant background information existed, this would have promoted the sharing of such information and the identification of risk, both for domestic abuse and for Sarah’s vulnerabilities.

The previously mentioned Think Family approach is again relevant here as both Sarah and Andrew were in receipt of services.

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.

Multi-agency information sharing was pertinent upon Sarah’s disengagement from the Crisis Resolution and Home Treatment on the 1st of December 2020. Adult Social Care had been proactive in contacting Crisis Resolution and Home Treatment for information and had been told that Sarah had reassured the worker that she no longer had thoughts of self-harm; but Housing information was not requested by Adult Social Care and the role of the Benefits Team was overlooked. Housing could have provided relevant information as the Benefits Team and Council Tax Team collectively knew that Sarah had separated from Andrew but that he still stayed at the address as Sarah perceived him as her carer. This information would have highlighted Sarah’s dependency upon her abuser to Adult Social Care.

However, information sharing is a two-way street and upon recognising Sarah’s vulnerability when she told them that she needed Andrew to stay at her address overnight to help with her care, Housing could have asked her consent to refer her to Adult Social Care. It is recognised that Housing did not know of the domestic abuse but given that she had told them that she had separated from Andrew, professional curiosity into her situation and proper assessment of her needs could have proven beneficial and may have provided Sarah with an opportunity to talk about her situation and expedite her disclosure.

Historically poor assessment of the risk Andrew posed, proved particularly detrimental. Had there been effective referrals and better information sharing at this time, there would have been an informed assessment of the risks to Tom and Sarah much earlier.

It is also notable that historic multi-agency information that was known to Sarah’s GP, where Andrew had disclosed being abusive, was not transferred to their electronic records during the digitalisation process. This impacted their assessment of future interactions with Sarah and is discussed later in the report.

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.

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, and that it is able to provide practitioners with a holistic oversight of good practice and tools available to identify and manage domestic abuse.

 

Application of Professional Curiosity

Practice to include application of professional curiosity is embedded in safeguarding adult policies and the Care Act 2014, the main statutory framework which guides safeguarding adult practice. There is no clear definition of professional curiosity, but it is expected within the British Association of Social Work Professional Capabilities Framework* that those entering social work education and the profession will: ‘apply imagination, creatively and curiosity to practice’. Practitioners are required to question and challenge the information they receive, identify concerns, and make connections to enable a greater understanding of a person’s situation. Professional curiosity is an essential pre-cursor to identifying and managing risk.

*(PCF, 6) (British Association of Social Workers, 2018 p.26)

Highlighted at the Learning Event by professionals partaking in this review is a notable lack of professional curiosity historically when Tom was a child. This lack of professional curiosity contributed to a poor response when he reached out for help by disclosing his suicidal thoughts to school and writing to Children’s Social Care exposing his fear of his father. Professionals did not appropriately consider his needs and there was little understanding of how the abuse he was witnessing was affecting him. This resulted in missed opportunities for further assessment and intervention.

Perhaps most concerning was a lack of professional curiosity when Children’s Social Care were approached regarding whether Tom should have contact with his father. There was no curiosity whether domestic incidents were continuing and no consideration of whether Tom had maintained a relationship with his father in recent years or exploration of Tom’s views.

Children’s Social Care have examined their response and their view is that the response to referrals and to Tom was not robust enough and was not holistic. Children’s Social Care agrees that it required more professional curiosity and that no professional listened to Tom’s voice or sought to understand his daily lived experience. Importantly, although school offered Tom counselling, Children’s Social Care did not explore whether he required the support of any other service for his mental health and the records do not show any consideration being had of Sarah’s or Andrew’s mental health.

Perhaps the most significant barrier for professionals to demonstrate professional curiosity pre-2014, were the delays in contacting Tom and Sarah following Tom’s disclosures. Had timelier visits been undertaken, Tom may have repeated his disclosures, and this may have provoked more professional curiosity, and of course, identification of risk.

There were opportunities for agencies to demonstrate professional curiosity throughout the scoping period of this review. For example, Sarah failed to attend some of her appointments at the GP surgery towards the end of 2019. Although the practice did apply their policy on failed appointments and attempted to contact Sarah, her missed appointments could have stimulated professional curiosity whether she was starting to struggle with her health situation.

Sarah did not respond to the surgery’s telephone calls but she did attend a subsequent asthma review appointment in January 2020. During this visit she explained that having separated from Andrew, she was struggling to push her manual wheelchair and asked for a wheelchair assessment to obtain an electric one she could self-propel. The impact of this for Sarah would be more independence. Could more curiosity have been shown at this appointment as to why she separated and whether she needed any other help following the separation and how she was managing?

Similarly, when Sarah presented at A&E with a wrist injury in March 2020 there is no documentation that indicates that the cause of the injury was explored or that a social care assessment was considered on the grounds that she had poor mobility. It is recognised that routine enquiry regarding domestic abuse would not be appropriate for all attendees of the Emergency Department but active questioning in a presentation such as this one could have been undertaken to explore how Sarah suffered the injury and whether there was any form of abuse.

Discussions at the Learning Event highlighted that currently professional curiosity is included within safeguarding training delivered to all staff within the Healthcare Trust, and professional curiosity has recently been promoted in an article published in both the hospital weekly bulletin and staff quarterly newsletter.

Following the wrist injury, Bassetlaw Healthcare Trust forwarded a discharge summary to Sarah’s GP, affecting a second chance of curiosity. The GP practice has told this review that the event would have been followed up if there had been any safeguarding concerns, or if A&E had raised any suspicions of domestic abuse. However as highlighted earlier in this report, no previous referrals or concerns had been shared with the practice and they had no knowledge of previous domestic violence because for unknown reasons the historic stab wound had not been transferred across onto their records from the old Lloyd George* notes when the records had been digitalised. In addition, no organisation or partner agency had contacted the practice highlighting any concerns that Sarah had shared regarding Andrew. And although Andrew had disclosed abuse and anger to his GP historically, because he and Sarah attended different surgeries, and due to separate information systems, nothing had been shared with Sarah’s GP. This is of concern. If historical information had been known, Sarah would have been flagged as a patient at risk of being vulnerable which is crucial for effective risk management and, besides prompting extra curiosity, would have had an impact on future encounters.

*Handwritten envelope patient records

In November 2020 when the GP surgery was informed of Sarah’s attempted overdose, they did attempt to follow up by means of a telephone call, but it was a failed contact as the line would not connect. There is no explanation as to why this was not re attempted despite this being a critical time for Sarah.

Sarah’s overdose was, according to Professor Williams(1*) a ‘cry of pain’ more likely where feelings of defeat and entrapment exist alongside beliefs that neither rescue nor escape are possible(2*). This theory examples the great psychological pain it is reasonable to assume that Sarah was now suffering and highlights the need for professional curiosity into her situation. A key finding, observed across a number of studies, is that previous suicidal behaviour, regardless of cause, is one of the most robust predictors of future suicide(3*), with some research indicating that a completed attempt often follows an uncompleted attempt within an average of one year(4*). The review would assert that this knowledge is encompassed within domestic abuse and safeguarding training.

1* Williams, J. M. G. (1997). The Cry of Pain. London: Penguin

2* Rasmussen, S.A., Fraser, L., Gotz, M., MacHale, S., Mackie, R., Masterton, G., McConachie, S & O’Connor, R.C. (2010) ‘Elaborating the Cry of Pain model of suicidality: Testing a psychological model in a sample of first-time and repeat self-harm patients.’ British Journal of Clinical Psychology 49: 15–30.

3* World Health Organisation (2016) Practice manual for establishing and maintaining surveillance systems for suicide attempts and self-harm.

4* Bostwick, M, Pabbati, C., Geske, J., & McKean, A (2016) ‘Suicide Attempt as a Risk Factor for Completed Suicide: Even More Lethal Than We Knew.’ Am J Psychiatry 173(11): 1094–1100. 

Professional curiosity needs to be encouraged within the Benefits Unit. Changes to benefits applications and council tax payments can be indicators of a person’s struggles. In March 2020, the officer dealing with Sarah’s queries regarding her council tax payments noted that she was very vulnerable. Professional curiosity into her situation could have identified further areas of her life where she needed support, for example, when she disclosed her struggles with independence and her reliance on Andrew to stay overnight, this could have been explored much further.

If at the point of discharge, the Crisis Resolution and Home Treatment team had been more professionally curious and explored Sarah’s circumstances and vulnerability in more depth, they may have identified that the domestic abuse was not being addressed and could have identified further beneficial support systems for Sarah. Lack of professional curiosity resulted in the mental health team closing Sarah’s case without any understanding of why she had disengaged and without ensuring that her disclosure of abuse was being addressed by other agencies, this being reinforced by no domestic abuse referral having been made by them, or consideration of a multi-agency professionals meeting within Think Family. The Trust records note that Andrew lived at his mother’s address and sofa surfed, despite him answering the phone and attending appointments with her. Therefore, this should not have created any presumption that Sarah was no longer suffering domestic abuse from Andrew.

There was a missed opportunity to add a domestic abuse marker to Sarah’s hospital notes. Any staff member could have completed this task following her disclosure and it would have prompted professionals to be curious and helped prevent them from losing sight of the abuse disclosed earlier.

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.

It is difficult to conclude whether Adult Social Care missed any opportunity to demonstrate further professional curiosity as besides the fact that at the time that they became involved home visits were being discouraged due to Covid, approaching a victim of domestic violence in their home environment is always a difficult decision where there is fear of putting the victim at higher risk. Adult Social Care told this review the dilemma facing us with domestic violence referrals is how best to establish contact. The perpetrator will often control their victim’s means of communication, whether that is by phone calls, texts, emails, or letters; and in attempting contact we are acutely aware not to raise too much suspicion so as not to increase risk.

In order to avoid increasing the risk to Sarah, Adult Social Care left the initiative to Sarah to contact them when safe and ready. The cold call to Sarah’s address was undertaken on the 17th of December 2020 after it was concluded that the initiative had been left to Sarah long enough and a home visit was needed. This was very true and appropriate, however, sadly by this time, Sarah was deceased, and Adult Social Care did not now have a chance to demonstrate professional curiosity and ascertain Sarah’s feelings.

Lesson 14
Local domestic abuse and safeguarding training should sufficiently incorporate and reinforce the need to be professionally curious.

Professional curiosity is known to be an essential component of safeguarding procedures so why, after years of this good practice permeating safeguarding practice are we still finding examples of it not being considered?

A 'Research in Practice' briefing* has identified that the structure and service values of an organisation or partnership will have a deep impact on the likelihood that curiosity will thrive. The briefing examines eight key areas that leaders could focus on to develop the conditions for professional curiosity to flourish:

• Involving people who use services – adapting practice to meet people’s needs and outcomes.
• Time and capacity – creating space for professionals to reflect.
• Structure and working practices – maximise opportunities for managers to use strength-based practice frameworks to encourage professionals to focus on the individual and their situation.
• Supervision and support – provide good quality supervision which offers reflection, critical analysis, and respectful challenge.
• Legal and safeguarding literacy – enable practitioners to make connections between legal rules and professional practice.
• Learning and development – provide programmes of learning and development.
• Open culture – encourage challenge from frontline practitioners and promote innovative practice.
• Partnership working – share information, bring together different perspectives, manage difficulties between professionals.

*The importance of professional curiosity in safeguarding adults. Helen Thacker, Dr Ann Anka and Bridget Penhale Published 9.12.2020

 

Effects of the Covid Pandemic on the Support afforded to Sarah

To reduce the risk of transmission of the coronavirus, the national lockdown in March 2020 saw many professionals who worked in safeguarding organisations being required to leave the office and work from home.

Professionals have told this review of the difficulties that came from working from home when trying to support survivors of abuse. They have described their work as being even harder because personal interactions are vital in such circumstances, and it is very difficult during telecommunications and video calls to know if a perpetrator is in the address or listening to the conversation.

Face to face communication with other professionals within the same organisation or within another, was also affected and was replaced with virtual communication. Platforms such as Zoom and Microsoft Teams started to be utilised but at first, different sectors used different virtual platforms; for example, the police were unable to use Microsoft Teams, the primary tool for local authority organisations, and this stilted inter-agency discussions. Professionals at the Learning Event spoke of further problems that not everyone had access to computer stations or all of the equipment that they needed. They explained that rollout of equipment took time and those that did have equipment weren’t always familiar with the communication tools and had to rapidly learn how to use them.

Team managers spoke of difficulties in managing their teams remotely from home and reported that even with technology it was hard to monitor the work that was coming in. They said that possibly as a result, morale dipped and was hard to rebuild. This was a very difficult time for many professionals.

 

Agencies in the Multi-Agency Safeguarding Hub, a team which was built upon the principle of co-locating organisations together, lost the ability to easily engage with partner agencies and forwent the advantage of soft intelligence being shared. In theory, a virtual Multi-Agency Safeguarding Hub model should work and prove as effective as one with co-location; but in reality, bringing practitioners together is thought to improve their understanding of each other’s roles and give them greater confidence to share information. Although not conclusive, the difficulties that Adult Social Care encountered when trying to obtain police information in November 2020 may have been more effectively resolved had everyone still been physically co-located in the Multi-Agency Safeguarding Hub.

Not everyone had a role whereby working from home was a possibility and those that could not, for example, hospital staff, ambulance staff and response police officers, were at risk of contracting the disease. The risk of such professionals being exposed to the disease by members of the public is highlighted when we remember that Andrew spat at officers during an incident in July 2020. Hand in hand with the contamination risks came low staffing levels for these agencies as:

• Staff who had been exposed to the virus had to self-isolate
• Staff who had been unfortunate enough to contract Covid-19 were off work.

Certainly, the pandemic put the NHS under extreme pressure. The covid pandemic had a significant impact upon Sarah’s ability to access a memory assessment. The team had to stop accessing new referrals at the beginning of the pandemic and when Sarah was re-referred there was a backlog which meant she had to wait even longer for an assessment. She was then cancelled, and priority given to another patient.  This was devastating for Sarah coming so close to her death.

Certainly, the pandemic put the NHS under extreme pressure. The covid pandemic had a significant impact upon Sarah’s ability to access a memory assessment. The team had to stop accessing new referrals at the beginning of the pandemic and when Sarah was re-referred there was a backlog which meant she had to wait even longer for an assessment. She was then cancelled, and priority given to another patient.  This was devastating for Sarah coming so close to her death.

In addition, Sarah had telephone consultations with her GP instead of seeing a doctor in a face-to-face setting. Telephone consultations have been the subject of national debate throughout the pandemic. For example, a clinical director of commissioning for NHS Salford CCG has described to his local newspaper his experience of telephone consultations with family doctors, as 'inefficient' and has said that the majority of his colleagues in the profession would agree with him*. Sadly, the review is unable to confirm whether Sarah felt that her telephone consultations were sufficient or not.

*GP says doctors want face-to-face appointments to return - but not just yet (Manchester Evening News).

It is commendable that despite staffing problems the pandemic had no noticeable impact upon the police or the ambulance service in terms of their response times to Sarah’s incidents. 

A major issue for Sarah regarding the pandemic, and possibly the most significant, appears to have been its personal effects. She told the Crisis team that shielding had left her isolated from friends. Sarah said that she was looking forward to going back to work, but she was still being advised to shield in October. This was sensible and appropriate advice, but it must have been frustrating and disappointing for Sarah, increasing her isolation and potential reliance on Andrew.

The Opinions and Lifestyle Survey, Coronavirus and the social impacts on disabled people in Great Britain: February 2021, shows that Sarah’s worries and frustrations with the pandemic are echoed by other disabled* people living in Great Britain. The survey evidenced that around this time, disabled people tended to be less optimistic than non-disabled people about life returning to normal in the short term: 20% of disabled people compared with 27% of non-disabled people thought that life will return to normal in less than six months.

*For the purposes of the analysis, a person was considered to be disabled if they had a self-reported long-standing illness, condition or impairment that reduced their ability to carry out day-to-day activities.

The survey looked at the ways in which coronavirus had affected lives and demonstrated how the effects varied between disabled and non-disabled people. The largest differences being in the areas of health (35% for disabled people, compared with 12% for non-disabled people) access to healthcare for non-coronavirus related issues (40% compared with 19%) well-being (65% compared with 50%) access to groceries, medication, and essentials (27% compared with 12%)

In addition, disabled people indicated that the coronavirus was affecting their well-being because:

• it made their mental health worse (46% for disabled people and 29% for non-disabled people)
• they felt like a burden on others (25% and 10%)
• they felt stressed and anxious (67% and 54%)
• they felt lonely (49% and 37%)
• they spent too much time alone (42% and 31%)
• they had no one to talk to about their worries (24% and 16%)

These results align with Sarah’s life, but she also had the domestic abuse to contend with. When the first ‘lockdown’ was announced in March 2020, charities, such as Women’s Aid, highlighted the increased risk of harm and isolation for those affected by domestic abuse.

The Crime Survey for England and Wales showed that 1.6 million women and 757,000 men had experienced domestic abuse between March 2019 and March 2020, with a 7% growth in police recorded domestic abuse crimes. Although there is limited official data so far on the impact of lockdown on domestic abuse, the Office for National Statistics report that in mid-May 2020, there was a 12% increase in the number of domestic abuse cases referred to victim support. Between April and June 2020, there was a 65% increase in calls to the National Domestic Abuse Helpline, when compared to the first three months of that year.

Women’s Aid reflected on the impact of the Covid lockdown on disabled women in their report; ‘A Perfect Storm – The impact of the Covid-19 pandemic on domestic abuse survivors and the services supporting them’ and stated that disability or healthcare needs could be used by perpetrators who also acted as “carers” as part of their abuse. In the April survivor survey, Women’s Aid heard from four women that their abuser had withheld medication from them and from three that their abuser had blamed them for being unable to get hold of required medication. “I am reliant upon my abuser to get food and medication as shielding for 12 weeks. This is being used against me.”

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 Lived Experience

At the beginning of the scoping period, it was known by health professionals that Sarah suffered significantly with her health and that her health issues had a substantial effect upon her mobility. Occupational Therapy was also aware of this as between 2009 and 2018 there had been 6 referrals describing issues with bathing/personal care and requesting adaptations to the home address. The adaptations included a request for a downstairs toilet/shower, a stairlift and most recently, an electric wheelchair. The review is pleased to acknowledge that by May 2019, some adaptations had been undertaken but it is unclear what had and had not been provided. Sarah’s case was closed in July 2020 and, although the review has been unable to establish the details as to why, Sarah is reported to have been very unhappy about that, at that time.

It was also known by police and Children’s Social Care, at the beginning of the scoping period, that Sarah had been subject to domestic abuse from Andrew. The GP should have known but as mentioned previously, the old paper records had not been correctly transferred to the electronic records during the digitalisation process and consequently this valuable risk information was lost.

Sarah had declared to Housing in October 2019 that Andrew had left the marital home on the 22nd of October 2020 with no forwarding address, and that she was now the sole occupier of the home. In December 2019 she told Housing that she required the extra bedroom in her address for Andrew as he stayed to assist her with her care. It wasn’t until March 2020, when Sarah raised council tax queries, that any vulnerabilities were formally noted and recorded, albeit not referred.

On the 2nd of March 2020 Sarah reached out for help with her mobility issues when she requested a wheelchair assessment. At the same time, she also confided that she was suffering memory loss. It was good practice that she was referred to memory services for a review, but the DHR understands the review wasn’t forthcoming due to Covid, and Sarah’s memory loss remained unassessed. On the 13th of March 2020 Sarah told the GP surgery that she was suffering depression and requested a MED3.

It is known that later in March 2020, owing to her health problems, Sarah had to shield and had to stop working indefinitely. Andrew, who was reportedly sometimes staying overnight at the address, could have now become the only person that Sarah came into physical contact with. Consequently, Sarah was shielding in her home address, whilst suffering memory loss and depression, with limited mobility, with Andrew, who since 2001 she had reported for being abusive and seriously physically assaulting her. Andrew was known to misuse substances and alcohol, and to have had anger issues that have not been addressed.

To add to Sarah’s hardship, in July 2020 her back pain became so severe that she had to ask her GP to prescribe painkillers.

As time passed, the police became aware of the domestic abuse continuing. Following an incident on the 7th of November 2020, Women’s Aid were also informed of the abuse, but their contact with Sarah was unsuccessful. The DASH assessments completed at the domestic incidents during the scoping period should have helped professionals, amongst other vulnerabilities, to understand Sarah’s fear of Andrew and her isolation from her family and friends.

By November 2020, Sarah had spent 8 months shielding, hadn’t been able to return to work, hadn’t had her memory loss assessed, and hadn’t been awarded an electric wheelchair to assist with her mobility. Early in November 2020, Sarah reported a domestic incident with Andrew. Officers removed him to his mother’s address, but he returned the following day and Sarah had to call the police again.

When professionals spoke with Sarah alone, they were very good at managing any immediate apparent concerns; for example, the benefits office supported her to obtain the financial assistance she was eligible for, the police removed Andrew away from the property when he was abusive, albeit temporarily, the health practitioners addressed her physical health. But did agencies understand how she really lived? Were opportunities to explore her lived experience maximised?

Because Sarah was unable to engage with agencies following disclosures of abuse, these contacts that professionals had with Sarah when she requested support were immediate opportunities for them to ask her how she preferred to engage, whether she felt safe and to consider what professional support was available to her. Unsuccessful follow-up contacts by Women’s Aid and Adult Social Care and Sarah’s reluctance to support police prosecutions, evidence how she had to retreat soon after her disclosures.

Professionals had individual snapshots into Sarah’s life, but no single agency held the full picture. As such there was no understanding as to Sarah’s lived experience on which to base referrals and decision-making. For example, had housing been aware of the history of domestic abuse, Sarah’s report of Andrew being her carer would have generated concern. Had the police understood Sarah’s dependency better and her struggles to get help with her mobility, a Vulnerable Adult Public Protection Notice may have been completed affecting an Adult Social Care needs assessment. Had the GP known of Andrew’s abusive behaviour and substance misuse, Sarah’s disclosure of depression may have been considered differently.

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.

On November 24th when the police searched Sarah’s home for drugs and drug paraphernalia, the officers identified Sarah as vulnerable. Sarah was in despair following this search and as she reported, due to Andrew’s arrest, very worried about enhanced abuse. Sarah, having taken an overdose, very bravely disclosed to several professionals, namely the Crisis team, staff at the hospital Emergency Department and the clinician in the mental health team, the abuse she was suffering. As referred to earlier in the report, Sarah first reported domestic abuse in 2001. Hence Sarah had been a victim of Andrew’s abuse for at least nineteen years when she made her disclosure at this point.

On their website Women’s Aid explain why disclosures can take so long. They explain how victims often feel ashamed, and how they have been humiliated and their confidence and self-esteem has been challenged.

Sadly, as already identified, following Sarah’s brave disclosure nothing changed for her. Andrew was released from the Magistrates’ Court back to her home, and for life to continue as before.

It is clear that Sarah, despite trying to separate from Andrew and disclosing abuse to professionals, struggled to manage her safety and continue with her path of estrangement because Andrew always regained entry to her house and her life. Why? Because Sarah’s physical needs for someone to assist her with her daily life overcame her determination when faced with Andrew’s attempts to reconcile. She depended upon him as the only person of contact for her care.

Dr Justin Varney’s report on disability and domestic violence published by Public Health England in 2015 (external PDF) confirms that disabled people experience disproportionately higher rates of domestic abuse. It also highlights that they experience domestic abuse for longer periods of time. The report explains that there is a wide range of abuse that may be experienced by a person with a disability which includes coercion and control from the person who is acting as their carer. For example, abuse can happen when someone withholds, destroys, or manipulates medical equipment, access to communication, medication, personal care, and transportation. People with disabilities have also reported abuse through the form of intrusion and lack of privacy.

Sarah was clearly vulnerable to this type of carer’s abuse. Her disability decreased her ability to physically defend herself and also to escape.

In 2016, the Office of National Statistics published a report on Intimate Personal Violence and Partner Abuse. The report found that:

• 16% of women with a long-term illness or disability had experienced domestic abuse compared to 6.8% of non-disabled women.
• Victims with a disability were more likely to experience other effects as a result of their abuse, including mental or emotional problems, difficulty in other relationships and attempted suicide.

These figures highlight that undoubtedly more needs to be done to alert professionals to the heightened risks of domestic abuse that people with disabilities face. Disabled victims of domestic abuse are protected under the Equality Act (2010)* which legally protects people from discrimination in the wider society. As such it is imperative that support available to others, such as from an Independent Domestic Violence Advocate, is equally accessible to those with impairments. It is a legal requirement of the Act that public bodies undertake an equality analysis to take account of the needs of those with impairments when planning, delivering, and commissioning services.

*The Equality Act 2010 protects you from discrimination by: employers’ businesses and organisations which provide goods or services like banks, shops and utility companies health and care providers like hospitals and care homes. 

Nottinghamshire has taken steps to support disabled victims of abuse by ensuring that there is disabled access to all service buildings and that staff are fully trained to be able to support people with disabilities. And although it is recognised that not all of the local refuges are accessible to disabled people, the review has been reassured that there is available refuge provision for victims with disabilities across the Country. There is provision available across the County. Bassetlaw Refuge could be accessible but possibly not safe for a Bassetlaw resident.

Professionals need to also be aware of how abusive carers may attempt to portray themselves as heroical. On the 27th of November 2020, when Andrew spoke with the Crisis Resolution and Home Treatment team, he informed them that he was having difficulties in managing Sarah’s needs. This switched any focus on him as the abuser, to carer. Dr Ravi K. Thiara is a principal research fellow at the Centre for the Study of Safety and Wellbeing at the University of Warwick. On the Safe Lives practice blog she refers to a study undertaken at the centre, a disabled woman spoke about how abusive partner-carers presented themselves as ‘caring heroes’ to outsiders but in fact used this to exert greater damage, also making it harder for women to ‘name’ abuse and to do anything about it. Another woman described the collusion of agencies and professionals thus: “People pity him because he is taking care of you… people are reluctant to criticise this saint or to think he could be doing these terrible things.”

As mentioned, because Sarah relied upon Andrew for care, Andrew had increased opportunity to control her and the criminal offence of ‘controlling or coercive behaviour in intimate or familial relationships’ is particularly pertinent.

Coercive control is now recognised as the behaviour that underpins domestic abuse. It is a pattern of behaviour which seeks to take away the victim’s sense of self, minimising their freedom of action and violating their human rights. Coercive control can be hard to recognise as the abuser will exert power over a victim through intimidation or humiliation. Only Sarah and Andrew truly know the extent of control that Andrew potentially had over Sarah but her dependency on him for her care served to dramatically reduce her ability to seek support, as evidenced through this report. It could also be argued that agencies contributed to his ability to control when giving him the power to come and go as he pleased from Sarah’s home and trustingly accepting his need for support to ‘manage’ Sarah.

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.

Understanding Sarah’s lived experience was crucial as without it, professionals were unable to take any difficulties that Sarah had breaking away from her relationship with Andrew into consideration within their support plans. Listening to her and understanding her situation was the only way to understand any barriers to engagement. This realisation serves as a further reminder as to how important professional curiosity is when working with vulnerable adults and victims of domestic abuse.

It was apparent that Women’s Aid and Adult Social Care failed to make successful contact with Sarah and that Sarah felt unable to support police prosecution, but no agency understood why because they didn’t enquire with her. Practitioners and professionals at the Learning Event used the term ‘golden opportunities’ to describe the windows of opportunities they had to speak to Sarah alone. They recognised how important these occasions were and how such junctures needed to be utilised to their maximum potential and used to ask Sarah about her personal experience within the relationship and understand what support she needed. The review endorses this awareness.

Such opportunities may be infrequent for some victims because a domestic abuser may often rely on isolating a victim and reducing his or her contact with the outside world. This can be a feature of an abuser’s coercive control.

The review does not have the information to understand how Sarah came to be isolated from her family. Sarah disclosed to A&E in November 2020 that her child had refused to have any contact with her whilst Andrew was still alive, but the timeline of their child leaving home and their relationship fully breaking down cannot be established. Likewise, the review has learned that Sarah had family members who she no longer maintained contact with; but again, the review has been unable to establish the details. However, it becomes clear that in the absence of her child and family, Sarah was very dependent upon Andrew.

Sarah had been in a relationship with Andrew from being a teenager and their relationship had steadily moved to one of dependency for Sarah. Andrew, as a perpetrator of abuse, would have been able to consolidate his power and control due to Sarah’s need for a carer and being so isolated, despite Sarah clearly wishing to break that chain. In Sarah’s case, post her disclosure in hospital of the abuse she was suffering, professionals were all unable to speak to her alone either by the telephone or in person as Andrew was always present. The importance of professionals making the most of solo contact and ensuring that as much information as possible is obtained when it can be, cannot be articulated enough.

Sarah’s desperation of her circumstances is reflected in research undertaken by Ruth Aitken, a Chartered Psychologist and Policy Consultant for Refuge, and Vanessa Munro, a Professor of Law at the University of Warwick, in 2018, which opens with the strong statement; Those trapped by domestic abuse can feel so hopeless that they believe the only way out is suicide. The research indicates that suicidality is more prevalent amongst domestically abused women than their non-abused counterparts*.

*Domestic abuse and suicide. Exploring the links with Refuge’s client base and work force. Domestic-Abuse-and-Suicide.pdf (refuge.org.uk) (External link)

This review hopes that its reflection upon professionals understanding of Sarah’s lived experience will serve as a driver of change moving forward and that her history will lead us to better practice.

Lesson 18
Understanding Sarah’s lived experiences would have identified the level of dependency on Andrew and the risks of domestic abuse and suicide faced by Sarah.

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 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).

 

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, 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.

There is no doubt that Sarah was failed by agencies and unless the recommendations of this review are implemented, the same outcome will be apparent for future victims of domestic abuse in Sarah’s situation.

Lessons to be Learnt

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 of 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 11
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.

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.

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.

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.

Lesson 18
Understanding Sarah’s lived experiences would have identified the level of dependency on Andrew and the risks of domestic abuse and suicide faced by Sarah.

Lessons to be Learnt from Good Practice

There is evidence of much good practice within several agencies who supported Sarah and it is equally important to develop learning from this good practice as it is from any shortcomings.

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.

The Hospital Mental Health Liaison Team now has a link nurse. The link nurse will have a specific responsibility for domestic violence abuse. They will link with local specialist domestic violence abuse services and share information within the team about best practice.

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.

1. 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.

2. The Hospital Trust should explore and consider the benefits of having an IDVA on site.

3. 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.

4. 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).

Appendices

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:

a) 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.
b) 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.
c) apply these lessons to service responses including changes to policies and procedures as appropriate; and
d) 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.
e) contribute to a better understanding of the nature of domestic violence and abuse; and
f) 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 the 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 for Domestic Homicide Review

Timetable for Case Review:

• Scoping Meeting and Panel 1 - 25th June 2023
• 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 - 27th October 2021
• Recall Event inc Panel 3 - 17th November 2021
• Second draft of Overview Report - TBA
• Presentation and Sign-off - TBA
  
  

Appendix 2: Single Agency Recommendations

Single 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.
  
  

Appendix 3: Domestic Violence Abuse Local Service Offer

Domestic Abuse Services in Bassetlaw

Name	Contact Details
Juno Women's Aid	W: https://junowomensaid.org.uk/ T: 0808 800 0340
National Domestic Violence Helpline (Female)	T: 0808 200 0247
Men's Advice Line (Males)	T: 0808 801 0325
National LGBT Domestic Violence Helpline (Same-sex relationships)	T: 0800 999 5428
Nottinghamshire Women's Aid	W: www.nottswa.org T: 01909 533 610
Nottinghamshire Police	Emergencies: 999 Non-emergencies: 101
Nottinghamshire County Council	W: www.nottinghamshire.gov.uk T: 0300 500 80 80
Citizens Advice Bureau	Website T: 0300 456 83 69
Bassetlaw District Council	W: www.bassetlaw.gov.uk T: 01909 533 533
Universal Credit Helpline	T: 0800 328 56 44
Turn2Us	W: www.turn2us.org.uk
Centreplace	W: www.centreplace.org.uk T:  01909 479 191
HOPE	W: www.hopeservices.org.uk
North Notts Support Partnership	W: www.bassetlawactioncentre.org.uk
Refuge	W: https://www.refuge.org.uk/
National Women's Aid	W: https://www.womensaid.org.uk/
Nottinghamshire Rape Crisis	W: https://nottssvss.org.uk/
Equation - support available for men and women	W: https://www.equation.org.uk/
Notts Help Yourself	W: www.nottshelpyourself.org.uk
Safe Spaces	W: https://uksaysnomore.org/safespaces/

 

Housing

Seeking help for domestic abuse does NOT automatically mean you will have to leave your home, all situations are different, we can help & advise:

Staying in your home:

If you are subjected to domestic abuse but want to stay in your home, there are a number of options that may be available to you:

• Apply for a court order (known as an injunction) against the person who is abusing you. The injunction can protect you or your child from being harmed or threatened by the person who has abused you (a ‘non-molestation order’) or decide who can live in the family home or enter the surrounding area (an ‘occupation order’).  Even if you do not own or rent the property you are living in, you can still apply for an injunction. (see website gov.uk for more details).  If your income is low, you may be entitled to ‘legal aid’ to help with the costs of this.
• Apply for a Domestic Violence Protection Notice/Order against the person who is abusing you; this can prevent them from returning to the home and grants the police and magistrates’ courts time to put protective measures in place. This can be done in the immediate aftermath of a domestic violence incident, where there is insufficient evidence to charge a perpetrator and provide protection to a victim via bail conditions.
• Request a referral to the Council’s Sanctuary Scheme. If your referral is accepted, you could get measures installed at your address such as additional lighting and locks, fire-proof letterbox or external door, secure gates/fencing etc. to make your home safer internally and externally.
• Contact domestic abuse charities who can provide someone to talk to, support and access to legal advice such as Nottinghamshire Women’s Aid (nottswa.org) National Domestic Violence Helpline or Men’s Advice Line
• Visit the Council’s website https://www.bassetlaw.gov.uk/community-and-living/domestic-violence-and-abuse/

Moving Out Of Your Home - Staying Safe

If you are subjected to domestic abuse and need to move out of your home to a safer place, there are a number of options that may be available to you:

• Contact local support organisation’s such as Nottinghamshire Women’s Aid or the National Domestic Violence Helpline who can help you plan your move safely. They can advise of your rights and options and find a space in a specialist refuge in another part of the country where you can live safely and be supported to settle.
• Contact your landlord to see if they can offer a move to an alternative property (Council’s and Registered Providers will have a policy in place to deal with this type of situation).
• Apply as a homeless person to any Council in England. If it is not reasonable for you to remain in your present home and you have nowhere else to go, if you are in priority need, the Council can provide you with emergency accommodation in a safe area whilst they try to work with you to find more settled accommodation elsewhere.  You will be in priority need if you have children or are pregnant, the Council may also consider you to be in priority need if you are vulnerable because of your circumstances and needs.
• If the Council accepts you are homeless, you will be owed what is called “a relief duty” and you will be given a ‘Personalised Housing Plan’ which will outline the steps that both you and the Council are required to take to relieve your homeless situation.  The Council will work with you for a period of 56 days, or until you secure a new home.  If it is not possible to find a new home during this ‘relief period’, you may be accepted as homeless and owed a full housing duty.
• If you need to leave your home quickly, try to make sure you have essentials with you such as a change of clothes, toiletries, medication and important items such as your passport, bank and credit cards and mobile phone. You do not have to make any decisions about giving up your home permanently until you have obtained advice about your rights from a Solicitor, the Council or specialist advice agency such as Nottinghamshire Women’s Aid.

Last Updated on Tuesday, March 8th 2022. 

 

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Last Updated on Wednesday, May 8, 2024