Lessons learned from domestic homicide reviews

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

What happened

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

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

What did the review tell us?

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

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

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

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

What can we do now?

Signpost or refer to specialist services

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

Recognising and responding to male victims

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

Technology Facilitated Domestic Abuse

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

Recognising DVA as a risk factor for mental health and suicide

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

Local support for suicide prevention

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

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

What happened

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

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

What did the review tell us?

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

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

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

What can we do now?

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

Think family, work family

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

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

Early intervention

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

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

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

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

Non-attendance at appointments or meetings

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

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

Neglect

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

The Care Act 2014 describes this as: 

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

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

Professional curiosity

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

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

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

Safeguarding awareness

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

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

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

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

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

What happened

Victim A was a 50-year-old woman of Afghani origin who was found dead by police after her 62 year old estranged husband phoned 999. The cause of death was found to be stabbing and strangulation. The victim's estranged husband was arrested, subsequently convicted of manslaughter and sentenced to life imprisonment. 

The perpetrator had come to England from Afghanistan in 2001 after seeking Asylum. Victim A and 3 sons then joined him in England in 2006. The couple had been married for 30 years but separated 3 years before the death when the victim and her 3 sons moved out to another address. There was regular contact between the couple after separation with on-going conflict over financial issues. At one stage, the perpetrator presented to a service as a victim and asked for help after a domestic related incident. This resulted in the victim being served with a Harassment Notice. An interpreter was not used in this instance so the victim did not get an opportunity to disclose what was happening. 

What did the review tell us?

The victim was extremely isolated and known to very few services. She had some health issues, very limited income and experienced ongoing domestic abuse from her ex-partner. Both the victim and perpetrator experienced significant language barriers. Services did not always use interpreters and sometimes one of the sons interpreted. A telephone interpreting service was used by some health workers but was not always found to be of a high standard or effective in helping communication. The victim had attended her GP Surgery on a number of occasions and disclosed domestic abuse on at least two occasions. She also presented with an unexplained injury. There were limited notes and no flagging on GP systems so records did not tell us what the victim wanted or how GPs responded. 

The perpetrator had also consulted his GP on health issues and made repeated requests for help with mental health problems. It was initially thought that he was experiencing Post Traumatic Stress Disorder (PTSD) due to his experiences in Afghanistan. Mental health assessments deemed him not to be in need of PTSD services but he was not offered an alternative treatment.  

It is thought that cultural issues caused barriers in how his symptoms were expressed and interpreted by services. 

What can we do now?

Ask sensitively but directly about domestic abuse if you have the slightest suspicion but only when the person is alone. Record that you have asked and capture the response and any desired outcomes or actions. Find a way to flag disclosures of domestic violence on your systems, especially if you think it is a high-risk case. Share information with appropriate colleagues, other professionals and services. Some practitioners such as midwives, health visitors or social workers routinely ask every female about domestic abuse. 

Make efforts to improve your own and your organisation's awareness of the barriers people face when experiencing domestic abuse. Demonstrate your understanding of the different levels of isolation someone might be affected by and make contact, whenever possible, to break down isolation and / or identify other support. 

If someone is experiencing domestic abuse, always think about the level of risk to the victim, children or adults at risk. Undertake a DASH risk assessment and support the victim to access another appropriate service to be assessed. Talk to your manager, safeguarding or domestic violence lead about any concerns you have. 

Wherever possible, use professional interpreters and be especially mindful of confidentiality issues. If you do use a family member, do not ask about domestic abuse and ensure you ask another time. 

Anyone can experience domestic abuse; however, government reports indicate that most victims tend to be women. In this case, the perpetrator presented to a service as victim and was dealt with accordingly. If men are victims, they need the right support and help but we also need to assess who else may be at risk. View more information on how to assess male victims.

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

What happened

Victim B was a 21 year old British woman of Asian heritage who was in a relationship with a 24 year old British man of Asian heritage. They had separated and reconciled several times over a period of years and were separated at the time of the murder. The perpetrator had a history of drug misuse and violence. Victim B's family did not approve of the relationship and she was subjected to a forced marriage abroad. She fled this marriage and, on her return to Britain, reported that her husband had been abusive. Victim B resumed her relationship with the perpetrator and became pregnant. Her family's disapproval intensified and she was forced to leave the family home and live in a hostel. She told the police that she and her partner received threats from her family. She was in contact with many agencies and would engage and disengage over the years. 

Following a serious assault on victim B and her daughter, the perpetrator was arrested. There was an interim care order and a MARAC referral at this time. The perpetrator was released on bail and Victim B retracted her statement. 

Criminal charges were then dropped but the child was placed for adoption. A year later, Victim B died after sustaining a knife wound inflicted by the perpetrator. He called 999 immediately after inflicting the wound. He later received a Life sentence after being convicted for Murder. 

What did the review tell us?

This young woman was extremely vulnerable and had experienced multiple forms of abuse throughout her life. She found it hard to trust services and was perceived by agency staff as aggressive and able to take care of herself. She was at risk of multiple forms of abuse, sometimes from her own family and other times from her partner/ex-partner. 

The victim's complex needs and presentation meant that no one service alone was able to offer her the support she needed. At times, referrals were made without her understanding or consent. This young woman made repeated presentations to multiple services but also disengaged regularly. Agencies did not always explore this with her or appear to understand the reasons for disengagement. They did not regularly assess risk, critically question or persist in offering suitable help. 

What can we do now?

Risk assessment

This should take account of family members who are supportive and those who pose a risk. Family networks can be a protective factor however they can also be a source of risk in some cases. If we use presentation solely to assess vulnerability, we may miss risk factors and it is critical to include service users in assessing risk and needs. Consider the impact of experiencing multiple forms of abuse over years as well as recent incidents. Long term abuse may have a significant effect on self-esteem, coping strategies and trust in services. Assess risk regularly, take advice from safeguarding leads and follow safeguarding procedures. If you are concerned about the level of risk, check whether a risk assessment has been undertaken by another service involved and if not, ensure that you or someone else addresses this.  

Restorative practice

Working with someone who is vulnerable rather than doing things to or for them should mean gaining consent for referrals wherever possible. If risk is high, this is not always possible. In cases where action is taken without consent, we should explain our reasons to the service user. It is particularly important to work in this way when someone has multiple and complex needs. 

Asking the question

If you are concerned about someone and think they may be experiencing abuse, ask direct questions without showing discomfort or judgement. If you are part of a universal service such as health services or housing, this is particularly important as many victims will not attend specialist domestic violence services. 

Needs and experiences of BME communities

Be mindful of and responsive to the many diverse communities in Leeds and educate yourself and your staff about the issues that may affect them. Consider the barriers to seeking help such as the impact of Honour Based Violence and how this might increase the risk and isolation for the victim. Try to communicate this understanding without making assumptions when speaking to an individual. Ask respectful questions about someone's culture and / or religion to help you understand how to best support them. 

Engagement

Keep the door open, consider why someone may resist or disengage. This does not necessarily reflect their needs or risk levels and could depend on many things e.g. how safe they feel to be in touch with services and whether risk has increased or reduced. Agencies need to develop disengagement procedures to ensure those most at risk do not fall through the net and that staff do not have to make decisions to accept service user disengagement based solely on availability of time or resources

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

What happened

Victim C was a 51-year-old woman of Black British heritage who was killed by her ex-partner who was also Black British. The victim had been in an abusive relationship with her ex-partner for nearly 25 years and had separated from him 4 years before her death. After the relationship ended, she was subjected to ongoing stalking, harassment and abusive incidents including theft, criminal damage and threats. She died after sustaining knife wounds inflicted by her ex-partner who was convicted of Murder and received a life sentence. 

Victim C was in contact with a wide range of agencies over a long period of time with differing levels of engagement. Her needs were met to varying degrees, but she was not always seen as being at risk by services and this affected the help she received. 

What did the review tell us?

Victim C made repeated reports to the police however incidents were seen as isolated events rather than part of a pattern of abuse. She also repeatedly expressed to a range of services how terrified she was and said she thought her ex-partner was going to kill her. 

It appears that, because Victim C presented to services as outspoken and angry, the level of her vulnerability was often under-estimated. There was a lack of understanding of the effects of domestic violence on her. 

There was also limited recognition of the barriers facing some black and minority ethnic victims when seeking help such as racial stereotyping. 

Risk assessments with Victim C tended to focus on current risk status and overlooked the combined impact of historical, long-term abuse and oppression. Risk factors such as coercive control, previous experience of violence and threats to kill were missed at some points and some opportunities to intervene further were not pursued. 

The effects of living with fear and ongoing abuse meant that Victim C experienced low mood and depression. She used alcohol as a coping strategy and, because of this, was refused access to the mental health therapy she needed. 

Over recent years, the perpetrator had been arrested several times and, at one stage, was given a Community Order with two years supervision. He attended a DV programme however continued his denial and lack of engagement throughout. This did not result in any consequences or further work with him. 

What can we do now?

Working restoratively and safely with complex needs

Work with victims should be empowering and respect the victim's choices as far as is possible and reasonable however the safety of the victim and any others at risk should be paramount. People with complex needs may be unwilling or unable to access services they need and we may have to take action to draw attention to that and mobilise any services to work flexibly to reduce risk. 

Needs and experiences of Black and minority ethnic communities

Be mindful and responsive to the many diverse communities of Leeds and educate yourself and your staff about the issues and concerns affecting them. Consider the barriers to seeking help and how previous negative experiences with services or experiences of racism can increase risk and isolation for victims. Try to communicate this understanding without making assumptions when speaking to an individual. 

Engagement

Keep the door open, consider why someone may resist or disengage. This does not necessarily reflect their needs or risk levels and could depend on many things e.g. how safe they feel to be in touch with services and whether risk has increased or reduced. Agencies need to develop disengagement procedures to ensure those most at risk do not fall through the net and that staff do not have to make decisions to accept service user disengagement based solely on availability of time or resources. 

Controlling behaviour and separation

Ensure controlling behaviour is considered in relation to other risk factors, especially separation. Controlling behaviour coupled with separation can be a more significant predictor of homicide than the escalation of physical violence. 

Stalking and coercive control

Be alert to the risk inherent in long term stalking and controlling behaviour and take account of the potential state of mind of the perpetrator. Be aware of the impact of this behaviour on the victim, their level of fear and how terrifying small incidents might be when they are part of an ongoing pattern of abusive behaviour. 

Work with abusive men: 

If you are working with a man who is abusive, ensure that any assessment you make about his level of engagement, ability to take responsibility and motivation to change is informed by feedback from and risk assessment of the victim. Keep regular contact with the man to assess the risk he poses and any changes in his circumstances. Where appropriate, share concerns with other services.

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

What happened

Victim D was an 87 year old white British woman and was a carer for her white British husband who suffered from Alzheimer's disease. Victim D's daughter-in-law found Victim D dead at her home along with the husband who sustained self-inflicted stab wounds. The victim was allegedly killed by her husband. The husband was arrested and subsequently detained under Section 2 of the Mental Health Act. He was deemed unfit for interview due to advanced dementia. As a consequence of this, a decision was made not to prosecute him.  

The couple, who had been married for 60 years, had a daughter and a son. There was no known history of domestic abuse. 

Both the victim and her husband were in poor health. They had some contact with services in relation to this and were actively supported by their family.

What did the review tell us?

A Community Care Assessment was carried out by Adult Social Care with both parties present. This meant that there was no opportunity for the victim to raise any concerns or issues she may have had about her husband or about her role as a carer without him being present. Equally, the husband was not offered the opportunity to be seen alone. The Social Worker appears to have responded to the couple jointly rather than as individuals despite both parties having care and support needs of their own. 

At one point, the Social Worker in this case was unable to complete a full assessment as the victim asked her to leave her home. Had the couple been responded to individually, this request might not have resulted in an incomplete assessment, at least of the husband's mental health needs. This could have led to a better understanding of how to support both parties and identify any risk factors. 

The couple had support from their family and were attempting to live as independently as possible. They were reluctant to accept help from statutory agencies and rejected services on more than one occasion. Although Victim D had the capacity and right to refuse services, this rejection had an impact on her husband and his wellbeing. 

What can we do now?

When referrals are received from service users who are living together, there needs to be sufficient rigour in assessing each of the service user's needs individually, especially where the same worker is assessing both parties. 

Ideally, when responding to couples, separate workers should be allocated to each individual. In addition, the Care Act 2014 requires local authorities to consider undertaking a Carer's Assessment in appropriate cases. An effective assessment should involve seeing the Carer alone unless there is good reason not to. 

Where it is not possible to allocate separate workers, each person should be assessed separately so that the needs of each person have been considered thoroughly and each person has been given an opportunity to discuss any concerns in private.

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

What happened

Victim E was a 34-year-old White British woman who died after sustaining head injuries. Her partner, a 47-year-old White British man, will be referred to as 'the perpetrator' in this brief. He had a long history of perpetrating domestic violence against Victim E although he was found not guilty of manslaughter when Victim E died. The perpetrator died within a year of the victim's death due to a drugs overdose.

The couple were known to services because of their substance misuse issues. Victim E had known the perpetrator since her childhood as he had been a friend of her elder brother. Although Victim E was using drugs herself when she met the perpetrator, this increased when the relationship started.

There were many incidents of violence, separations, and reconciliations in this relationship. It appears that the perpetrator used self-harm and suicide threats to manipulate and control Victim E. After four years together and shortly after Victim E's mother died, the couple had a daughter. This child however was removed by social care services and placed with a member of the victim's family. In the two months prior to her death, emergency services were called out 27 times to Victim E's address. On the last occasion, Victim E reported an assault to the police and was taken to hospital later that day due to head injuries. She remained in hospital and died two weeks later as a result of these injuries.  

What did the review tell us?

Numerous agencies were aware of the domestic violence but it was not addressed effectively. Victim E was never referred to specialist domestic violence support services and the abuse appears to have been accepted as part of couple's problematic substance misuse and chaotic lifestyle.

Although Victim E received specialist care relating to her drug and alcohol use during pregnancy, the domestic violence was not addressed. After the birth of her child, services stipulated that Victim E should abstain from using drugs and alcohol and separate from the perpetrator however there was no extra support offered to help her achieve this. Victim E lost custody of her child, continued the relationship with the perpetrator, and seemingly lost all hope and motivation to make positive changes.

The absence of information sharing between the emergency services involved with the couple meant that no one agency was aware of the full extent of the abuse and escalating pattern of incidents. There was a huge increase in the calls to emergency services in the two months prior to Victim E's death. This covered a period of time when she was trying to separate from the perpetrator. Given the separation, history of abuse, escalation of incidents and other high risk factors, a MARAC referral should have been made. A MARAC could have potentially provided some multi-agency oversight, a safety plan and helped to engage the victim with specialist domestic violence support services.

What can we do now?

Assessment of risk

When assessing risk, be aware of the multiple and complex factors affecting an individual's risk status. Consider historic abuse, the effects of bereavement and the impact of controlling behaviour on a victim's decision making ability. Assess risk regularly; identify changes and escalation and increased vulnerability. When you have concerns, take advice and discuss issues with your manager, Safeguarding Lead or specialist services. Complete a DASH risk assessment and consider a referral to MARAC.  

Drugs, alcohol and domestic violence

Working with people who have long standing addictions is a complex task. Many victims of domestic violence use alcohol and drugs as part of their coping mechanism. Equally, many perpetrators report that their abuse is worse when they use alcohol and/or drugs. Victims and perpetrators should be supported to access specialist domestic violence services. Addressing substance misuse issues without addressing domestic abuse will limit the effectiveness of interventions. 

Coercive control

This can be difficult to identify and often relies on the victim reporting patterns of controlling behaviour in their relationship. Look out for indicators of coercive control and remember that this is a high-risk indicator. Someone in a controlling relationship is often at significant risk when attempting to separate from the abuser. Safety plans or referrals to services should always include information on this. Talk to the victim about your concerns and support them to take action that will reduce the risk. 

Information sharing

When domestic violence is identified, check all sources of information on the victim, children and perpetrator. Consider what other services need to know and who may be able to give you information to build a fuller picture of the situation and develop an informed safety plan.

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

What happened

Victim F was a 61-year-old white British woman who died in April 2014 after being stabbed by her ex-husband. They had been married for over 30 years and had three adult children. The relationship appears to have been characterized by financial control. The perpetrator dealt with all financial matters and, when the couple separated, the victim struggled to manage even paying bills as she was unused to any involvement in the family finances. The victim had disclosed to friends that she was unhappy in her marriage and that she and her husband lived separate lives within the same house. The perpetrator tended to go to the pub every night by himself and mix with other regulars there.  

Victim F had moved out of their joint home in the weeks prior to her death to a property that the couple had bought as an investment. She was subjected to ongoing harassment by her husband who regularly turned up at her new address uninvited. Victim F was at her new home on the day of her death when the perpetrator called. Whilst it is unclear specifically what occurred, neighbours reported hearing a dispute.  

There was no reported history of domestic violence and little contact with agencies. 

What did the review tell us?

The review explored whether services could have identified the presence of domestic abuse had they worked differently and considered whether there were any interventions that might have helped prevent the death. 

Four high risk factors were present in the relationship: 

• controlling behavior by the perpetrator
• financial change
• recent separation
• regular use of alcohol by the perpetrator above recommended levels (though alcohol abuse is not believed to have been a factor on the day of the offence)
  

Although the victim and perpetrator were not in contact with many services, had mainstream agencies, such as health services, recognised risk factors or identified them through routine enquiry, the victim could have been signposted to help and received information or support. 

What can we do now?

Remember that an absence of physical violence does not mean that someone is not experiencing domestic abuse. It is important to recognise that coercive control and separation are domestic violence and abuse risk indicators. A history of controlling behaviour (including financial control) and separation can be a high-risk time for some victims. 

It is everybody's responsibility to develop understanding across services and communities about the risk of controlling behaviour in relationships, particularly at the point of separation. Victims should be signposted to help and advice.

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

What happened

Victim G was a 47 year old White British woman who was in the process of separating from her husband, a 48 year old White British man. The couple were living together and had 2 teenage sons. 

Shortly before Victim G's death, she told her husband she wanted to end the marriage. Following this, he attempted suicide and, as a result, was detained under the Mental Health Act. After being discharged from hospital, the husband returned to the family home. There was an escalation in controlling and difficult behaviour which the victim reported to the police. On the day of her death, Victim G returned home from work and was stabbed by her husband who then set fire to the home and died as a result of his injuries. 

What did the review tell us?

There was a failure by services to understand the significance of Victim G challenging a 25 year long established dynamic in a relationship which was characterised by coercive control. When Victim G made it clear she wished to separate, the risk increased hugely and this risk was not recognised by services. 

The absence of known physical violence appears to have been interpreted by services as an indication that there was less risk (at the point of separation) than if there had been a history of physical violence. 

In addition, the perpetrator was risk assessed in relation to self harm but not with respect to the risk he potentially posed to others. This meant that he was not offered any help to address his controlling behaviour. 

There was a delay between Victim G disclosing domestic abuse to services and being signposted to specialist domestic violence services. Had she had contact with specialist services at an earlier point, she could have talked through the risks and options and had longer to appraise her circumstances. 

The combination of a history of controlling behaviour, separation and the perpetrator's suicide attempt should have triggered a DASH risk assessment. Had a risk assessment been undertaken, the risk factors may have been considered in more depth by services. In addition, the victim may have understood the risks to herself and considered her situation differently. 

What can we do now?

Risk factors

Ensure staff are trained in recognising and assessing risk in abusive relationships and specifically that they recognise that long term coercive control, combined with separation could drastically escalate the risk of homicide. 

Referral pathways

Check that your understanding of a referral is the same as the agency to which you are referring. Make sure other agencies are clear about how to make a referral to you. 

Safety planning

Support staff to become more confident having conversations with service users about the risks they perceive. Support early intervention to address issues in relationships. 

Victim and perpetrator presentation

Just because a victim presents as capable and confident, it does not mean they are not vulnerable or at risk. Equally, just because someone is vulnerable and has attempted suicide, it does not mean they are not a risk to others. 

Coercive control

This can be difficult to identify and often relies on the victim reporting patterns of controlling behaviour in their relationship. Look out for indicators of coercive control and remember that this is a high risk indicator. Someone in a controlling relationship is often at significant risk when attempting to separate from the abuser. Safety plans or referrals to services should always include information on this.

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

What happened

Victim H was a white British woman who died on her 38th birthday as a result of head injury inflicted by her 52 year old white British partner. He was convicted of her murder in December 2014. On the day of her death, Victim H had travelled to Leeds city centre and was seen leaving Leeds train station with the perpetrator. Police were called after receiving reports of a woman being assaulted on the Leeds-Liverpool canal towpath. She was admitted to hospital and died later that day. The perpetrator was sentenced to life imprisonment for Murder. 

Victim H frequently changed addresses and often had no fixed abode. She presented as homeless regularly and suffered abuse in several relationships. She struggled with alcohol and drug addiction and engaged and disengaged with detoxification programmes over the years. At the time of her death, Victim H was estranged from all of her family members. She had begun a relationship with the perpetrator and had moved to Leeds to live with him. 

What did the review tell us?

A critical issue in this review was the lack of multi agency oversight in the management of the perpetrator, especially given his known history of domestic violence and abuse. 

The review highlighted that the perpetrator's risk to others was not managed effectively. His sustained history of violent offending against vulnerable women and his controlling and emotionally abusive behaviour should have involved multi-agency oversight which would have ensured key information and intelligence was shared about him. At one point, there was a reduction in his risk of harm level from 'high' to 'medium' which should not have happened. It was only two-weeks after his move into independent accommodation, before he had been visited at that address and before his response to independent living had been tested. There was no prior discussion between the offender manager and his supervisor, and there was no review of the risk assessment or risk management plan. 

In addition, there was a missed opportunity to recognise that the perpetrator posed a serious threat to vulnerable women when the police were called to an incident. A search of police databases should have revealed the perpetrator's licence conditions, but a combination of human error and information 'overload' meant the opportunity was lost. 

The review also illustrated the way in which many victims of domestic violence use alcohol and drugs as a means of coping with difficult life events and experiences of abuse. 

Victim H found it particularly hard to beat her substance addictions as the only people she associated with were those in similar positions to her. 

What can we do now?

Domestic violence enquiry

Services such as health visitors, social workers and midwives routinely ask women about domestic abuse. Consider if this approach is appropriate in your service area however it should only be introduced with staff training. Always ask directly and sensitively about domestic abuse if you have any concerns. Indicators of domestic violence could include injuries, low mood, self harm, substance misuse and depression. 

Homelessness

Be aware of the law regarding homelessness and help your service users to understand their rights regarding priority accommodation. Advocate for them if necessary and support them to disclose issues that might make them particularly vulnerable. 

Working with individuals who have Multiple Complex Needs

People with complex needs may be unwilling or unable to access the services they need. Consider how your service can be flexible and creative to ensure your provision is as accessible as possible. 

Recording information

Record all contact, professional or otherwise and maintain comprehensive records. It is especially important to record if you have asked about domestic violence, your response and any action agreed. 

Managing risk and information sharing

Identifying the risk a service user poses is central to preventing them from harming others. A service user's history should be considered in full and background checks made before determining appropriate action plans for them. Service users should be regularly re-assessed to identify any changes to the risk they pose; with any such changes being recorded and shared with all agencies involved with the individual. 

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

What happened

'Elaine' was discovered by police at her home following a call from her husband 'Paul' who admitted her murder. She had severe head injuries and was pronounced dead at the scene. The following day, the body of 'Paul' was found having fallen from a height. Notes apparently written by 'Paul' were found at the scene and indicated that this was a murder-suicide. 

The couple were dealing with some stressful life events, in particular 'Paul's' bankruptcy and his being reprimanded by his professional body and ordered to pay a fine, following allegations of professional misconduct being proved in November 2013. He experienced low mood and depression at times and had expressed thoughts of self-harm and suicide. 

What did the review tell us?

The DHR did not found any evidence of domestic violence or abuse in this review, either from the IMRs received or the wider work of the panel. 

Neither 'Elaine' or 'Paul' were known to the services in relation to domestic abuse, neither had ever sought any assistance from the police, or any statutory or voluntary sector agency in relation to allegations or incidents of domestic abuse. 

Following a minor incident involving the police, the LYPFT crisis team had limited involvement with Paul. The review found that the actions of both agencies were appropriate. 

What can we do now?

LYPFT to ensure that all its mental health services, both in patient and community based have information regarding domestic violence and abuse and are able to inform them when conducting assessments and reviews. 

The processes that GPs have in place for the use of PHQ-9s should be reviewed and, if necessary, amended to ensure that following completion PHQ-9s are reviewed and any appropriate action is taken.  

(PHQ-9 is a type of assessment tool. It is designed to facilitate the recognition and diagnosis of depression. For patients with a depressive disorder, a PHQ-9 can be calculated and repeated over time to monitor change.) 

This brief is based on the findings from a Domestic Homicide Review (DHR). It was undertaken by Safer Leeds in partnership with Leeds Safeguarding Children’s Partnership and Wakefield Community Safety Partnership. The purpose of a DHR is to learn lessons and improve future responses to domestic violence and abuse. We hope to demonstrate respect and compassion to victims and their families and, where possible, to represent the victim’s voice through these briefings. 

What happened

The victims were a 51 year old White British woman and her two children who were killed in their home by their husband/father, a 42 year old White British male. This occured shortly after the victim had told him the relationship was over. The children were their 11 year old daughter and 8 year old son. Subsequent to the killings, the perpetrator travelled to a remote location and killed himself. 

Two and a half years previous to these homicides, there had been one reported violent incident to the police. The perpetrator admitted the assault and was jailed for 16 weeks. After his release, the couple gradually reconciled though the perpetrator continued to display controlling and coercive behaviour. 

The assault was the subject of a multi-agency review and, although professional support was offered, the victim did not access specialist domestic violence and abuse services. Her family have suggested that this was likely to have been as a consequence of her not wanting to expose the family’s problems. 

What did the review tell us?

The victim was a high achieving manager within the retail trade who took a reduction in position and salary to spend more time with her family. She was the sole earner in the household whilst her husband remained at home as the primary carer for their children. He had been undergoing medical tests and being treated for back pain for several months. Through the review process, it became clear that controlling, coercive behaviour by the suspect had been a feature throughout their relationship. One example of this was that he convinced the victim that the side effects of his pain medication was the reason for his previous violent assault on her. 

The victim was still receiving emotional support at the time of her death having undergone a variety of therapies with third sector providers following the earlier assault. She was assessed as suffering from Post Traumatic Stress Disorder shortly before her death. 

The review author stated: 

“The review has highlighted some learning from some organisations, but generally professionals that had been involved in the delivery of services to Mandy and Trevor (pseudonyms) were experienced, reflective, qualified, embracing and supportive.” 

What can we do now?

Children are not a protective factor

Services should ensure that children and the potential impact of domestic abuse on them is explored as early as possible in contact with the perpetrator and/or victim. This includes joint working with agencies to ensure all known information is utilised in risk assessment and safety planning. Those safety plans and risk management plans must be monitored to ensure they take account of the children. 

Update your training

Services should refresh training on risk assessments and the requirement to ensure there are no gaps in information on their case management system. Good practice would be to ensure that every domestic abuse case is reviewed by a senior manager before closure. 

Be responsible

Staff should be aware of their responsibilities in respect of the safeguarding of children and vulnerable others. This includes information sharing, their responsibility in relation to it and the expectations that their duty of care is exercised in a timely and appropriate manner. 

Think family

Staff supervision notes should record any history of violence and patterns of abuse as well as the specifics of incidents. It is difficult to assess risk without having such information. Safeguarding children should form a key element of the supervision process; developing a ‘Think Family” culture and approach to working with and supporting families. 

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

What happened

The victim was a 26 year old White British female and the perpetrator, the victim’s partner at the time of her death, was a 26 year old British Asian male. They had 2 children together, and the victim had 2 children from a previous relationship. 

In the days leading up to her death, the victim had made contact with several agencies disclosing domestic abuse and her increased fear of her partner. After a final call to the police stating that she was afraid to go home in case the perpetrator was waiting for her, the police made several attempts to contact the victim without success; the perpetrator claimed she had gone missing. The victim had been killed and her body was discovered four days after she had died. The perpetrator was convicted of murder along with a female friend of his, he was sentenced to 22 years imprisonment.  

What did the review tell us?

Throughout the relationship, the perpetrator displayed controlling behaviour and had made numerous calls to agencies including the police and the Children’s Social Work Service often claiming the victim was drunk and aggressive, in a direct attempt to discredit her. In addition, there were a large number of calls by neighbours to the Anti-Social Behaviour Team for noise nuisance. Neighbours also described how they had heard the victim asking the male not to hurt her in at least one report. 

This young woman had experienced significant neglect and inconsistent care in her childhood. She had moved to Leeds having left a violent and abusive relationship with the father of her two eldest children. The two significant intimate relationships in her life were characterised by abuse and violence. 

The victims was killed by a man who successfully presented himself as a source of help and protection to outside agencies. He was not identified as a perpetrator of domestic violence and abuse until after he had murdered her. Friends described his ability to exploit her emotional volatility and her fear of people in authority. They witnessed how he would engineer confrontations, particularly when she was in drink and less able to control her emotions, and then call the police and present himself as the calm and responsible partner. Agencies had been unaware that she was a victim of domestic violence and abuse until the weeks leading up to her murder. 

What can we do now?

Engaging with victims

Traumatic experiences in childhood can contribute to a multitude of personal, emotional, psychological and behavioral issues which can include mental health, misuse of alcohol and emotional management. Victims may present to services as resistant to intervention, however, it is important to try to understand this is likely to be as a result of previous life experiences and the possibility of past unhelpful service responses. Professionals need to be reassuring and honest about their involvement and their remit with a victim and should always seek to adopt a trauma informed approach. 

Understanding and recognising coercive control

Perpetrators who control their partners will seek to influence and manage how information is presented to professionals and is processed by them; this includes controlling the narrative about who is victim and who is the perpetrator. It is an extension of their control over the victim and isolates them from advice and help. It is essential that professionals receive adequate training around the power dynamics that are present within an abusive relationship to ensure that the risk to the victim is not lost within the story presented by the perpetrator. 

Professional curiosity

Routine contacts may provide valuable opportunities to identify safeguarding issues. Reports of anti-social behaviour or noise disturbances for example could present a chance to ask about domestic violence and abuse. Annual tenancy visits such as for maintenance and repair can also provide important opportunities for identifying risk and vulnerability. 

Understanding the correlation between fear and risk

A victim’s fear is often a pre-requisite for escalating risk in the context of domestic violence and abuse and professionals should ensure that, where fear is a factor, a DASH Risk Assessment is completed and a subsequent referral into MARAC is made for high risk cases. 

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

What happened

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

They had been in a relationship for approximately 5 years. 

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

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

What did the review tell us?

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

What can we do now?

Recognising and responding to ongoing DVA

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

Flexible responses are needed to address complex needs

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

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

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

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

What happened

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

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

What did the review tell us?

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

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

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

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

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

What can we do now?

Routine enquiry

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

Financial pressures

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

Signs and indicators

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

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

What happened

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

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

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

What did the review tell us?

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

There was no known domestic abuse prior to her death. 

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

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

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

What can we do now?

Post-separation risk

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

Awareness of risk

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

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

Signs and indicators

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

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

What happened

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

What did the review tell us?

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

What can we do now?

Barriers to professional disclosure

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

Non-violent forms of controlling behaviour

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

Homicide/Suicide Incidents

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

Assessing risk

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