Police contact with woman before her death – Suffolk Constabulary, January 2020
On 16 January 2020 at 10.32pm, police attended a woman’s address following a distressed call from her housemate. On arrival, police officers found the woman unresponsive with serious injuries after being stabbed multiple times by her ex-partner. An ambulance arrived but the woman was pronounced dead at the scene. The police arrested the ex-partner, and he was subsequently found guilty of murder.
Police records showed that the woman contacted Suffolk and Cambridgeshire Constabulary to report domestic incidents involving her ex-partner on three occasions in the weeks preceding her death. These incidents included allegations that she had been assaulted by the ex-partner and he was abusive towards her and made threats against her.
Suffolk Constabulary made a mandatory referral and we launched an investigation to examine the response from Suffolk Constabulary and Cambridgeshire Constabulary to all reported incidents involving the woman and her ex-partner. Specifically, we investigated whether appropriate risk assessments and safety plans were implemented; whether the police response was in accordance with local and national police policy and guidance; the complaints made by the woman’s family.
During our investigation, we obtained statements from several officers involved in the reported incidents. We viewed body worn video footage, police records, call recordings and relevant police policies and procedures.
Our investigation concluded in November 2021. We waited for all associated proceedings to be complete before publishing our findings.
We determined there was no indication that a person serving with Suffolk Constabulary or Cambridgeshire Constabulary committed a criminal offence or behaved in a manner justifying the bringing of disciplinary proceedings.
We upheld one complaint in relation to a significant delay in the victim’s family being notified of her death and a delay in the police family liaison officers updating the father.
The ex-partner was convicted and sentenced to life imprisonment in 2021.
An inquest was held in May 2022. The jury concluded that the woman had been unlawfully killed by her ex-partner. The jury highlighted, "insufficient evidence-gathering in a timely manner to progress the investigation" into the ex-partner "may have contributed to her death".
The jury recorded other areas of policing, including the completion of certain forms with risk assessments, were completed correctly and the force made repeated attempts to contact the woman.
We carefully considered whether there were any organisational learning opportunities arising from the investigation. We issue recommendations to improve policing and public confidence in the police complaints system and prevent a recurrence of similar incidents.
In this case, we identified various areas for improvement for Suffolk Constabulary. We issued recommendations that related to allocating cases from sergeant work trays and the force’s approach to supporting student officers under performance review. In addition, we recommended that Suffolk Constabulary amend force training and guidance on a risk assessment to highlight the importance of probing certain questions. This information will assist officers in assessing whether a disclosure under the Domestic Violence Disclosure Scheme is required.
Suffolk Constabulary accepted our recommendations and outlined their approach to improve these areas in their response.
IOPC reference
Recommendations
The IOPC recommends that Suffolk Constabulary review the process for allocating cases from sergeant work trays and develop appropriate policy and/or standard operating procedure (SOP). This should include targets for case allocation (i.e., within that shift, within 48 hours etc.), and ensure that there is a clear line of delegation if those responsible for the various work trays are on leave and are unable to allocate cases. This is particularly important in cases where there are risks to the victim.
Do you accept the recommendation?
Yes
Accepted action:
The crime allocation policy has been reviewed. It was noted that whilst the crime allocation policy and systems in place are clear around allocation of investigations from IMU to Sgts Work trays, the requirements around allocation from Sgts work trays to officers were not clear.
Different approaches to allocation from the trays exist across the different policing areas within the force area (based on different SNT structures for example), and so the attached SOP guidance has been drawn up, circulated to staff, and will be included in the allocation policy – this puts a clear onus on Local Policing Inspectors or Detective Inspectors to ensure the allocation processes for their policing area are robust and that relevant staff and in place and aware of their responsibilities.
The IOPC recommends that Suffolk Constabulary amend force training and guidance on the DASH risk assessment to highlight the importance of probing Q27 of the DASH: “Do you know if (Name of Abuser(s)) has ever been in trouble with the police or has a criminal history? (If yes, please specify)”. Further probing may help to establish the source of the information, the extent of the victim’s knowledge of the perpetrator’s offending history and whether this correlates with the information on police systems. This information will assist officers in assessing whether a disclosure under the Domestic Violence Disclosure Scheme (DVDS) is required. The purpose of the DVDS is to enable victims to make informed choices about continuing an abusive relationship and/or about their personal safety if they are no longer in the relationship.
Do you accept the recommendation?
Yes
Accepted action:
The Constabulary has an ongoing project to implement DARA (domestic abuse risk assessment) as a new replacement risk assessment for the current DASH (domestic abuse stalking harassment) system; the aim is for this to be introduced by the end of 2022.
DARA has been evaluated and approved by the college of policing as an improved risk assessment tool for forces to adopt.
DASH has 27 questions, followed by 11 stalking questions.
DARA has 16 questions, followed by the same 11 stalking questions.
DASH is formed of yes/no responses, whereas DARA is a narrative approach to questions and responses leading to a better-informed risk assessment.
The current question 27, “Do you know if (Name of Abuser(s)) has ever been in trouble with the police or has a criminal history? (If yes, please specify)”, is not included within DARA, however, there is a large section in relation to whether there is relevant information held on police systems and records which should be included.
DARA includes a specific question requiring the officer completing the records to research and consider, “Previous Domestic abuse/violence incidents (including against other victims) call outs/previous convictions – for defendant and victim/witnesses.”
Within the 11 stalking questions is the following: “Is (insert name of abuser) known to have been violent in the past? (This could be physical or psychological.)
The introduction of DARA will include updated training with key emphasis to ensure each risk assessment is victim focussed, not victim led.
This will include consideration around the victim’s knowledge of the perpetrator’s history, and whether a “Claire’s law” domestic violence disclosure scheme disclosure should be made to the victim.
The IOPC recommends that Suffolk Constabulary takes steps to ensure that response and domestic abuse officers consider a victim’s previous DV history when assessing risk, even if the previous reported domestic abuse was with a different partner and not recent. This will provide a complete picture of the victim’s history and lived experience of domestic abuse and possible risks. The force should consider issuing communications to officers on this matter, ensuring that it is covered in appropriate training and amending any relevant policies and guidance.
Do you accept the recommendation?
Yes
Accepted action:
The Constabulary has an ongoing project to implement DARA (domestic abuse risk assessment) as a new replacement risk assessment for the current DASH (domestic abuse stalking harassment) system; the aim if for this to be introduced by the end of 2022.
DARA has been evaluated and approved by the college of policing as an improved risk assessment tool which forces should adopt.
DASH currently has 27 questions, followed by 11 stalking questions.
DARA has 16 questions, followed by the same 11 stalking questions.
DASH is formed of yes/no responses, whereas DARA is a narrative approach to questions and responses leading to a better-informed risk assessment.
The introduction of DARA will include updated training with key emphasis to ensure each risk assessment is victim focussed, not victim led.
The training to officers will include highlighting that a victim’s past experiences of domestic abuse at the hands of ANY previous partner may present as the victim normalising the offender’s behaviour towards them. Risk assessment levels should not be reduced just because a victim is less scared by such behaviour – risk assessments should be victim focussed and not victim led.
The IOPC recommends that Suffolk Constabulary reviews its approach to the support provided to student officers under performance review. There should be a more rigorous approach to the supervision and guidance given on any cases they are leading whilst they are under performance review. In cases where a student officer is moved to a different team, be it temporarily or permanently, it should be clear who is responsible for the officer’s case supervision, and this should be documented in writing and communicated to all parties involved.
Do you accept the recommendation?
Yes
Accepted action:
The probationer development unit (PDU) has developed the attached document to utilise as a documented handover of responsibilities and expectations for the supervisors who receive student officers from other teams, whether the student is subject to a performance review or otherwise.
This document includes a specific time/date when responsibility is passed from one supervisor to another, and the expectations around workload supervision, scrutiny, and support.
The IOPC recommends that Suffolk Constabulary reviews current practice around 'Protect a Vulnerable Person' (PVP) referrals and updates the welfare/mental health policies and procedures as appropriate. Current practice and policies provide conflicting advice. The force should consider issuing communications to officers on this matter, ensuring that it is covered in appropriate training and amending any relevant policies and guidance.
Do you accept the recommendation?
Yes
Accepted action:
The Constabulary will be making additions to existing policies to overcome any ambiguities around required responses from officers – the proposed additions are as underlined below and will take a number of weeks to process due to the policy update procedures (consultation across different commands) that are in place.
1) Joint Suffolk/Norfolk Missing policy changes to include:
a) Submit an API (Norfolk) or PVP (Suffolk) to the MASH where there is (or was) a specific welfare or safeguarding concerns for a missing vulnerable adult immediately and this includes once the missing person has been located. If there is any immediate safeguarding concerns, contact the MASH Duty Detective Sergeant.
b) Where mental health concerns exist the telephone numbers for the professional’s advice line to NSFT and the telephone line for the public in crisis should be utlised – a PVP submission WILL NOT initiate contact to achieve Mental Health support so officers must make additional contact via this system and consider also utilising the MH nurses in the CCR.
2) Suffolk Welfare check policy changes to include:
a) (section 5.7 of policy) On conducting a welfare check and where there is (or was) suggestion of vulnerability or concern, then officers should submit an appropriate safeguarding referral and consult with a supervisor as appropriate. This referral will usually be in the form of an Athena ‘protecting vulnerable people’ (PVP) entry.
b) Where mental health concerns exist the telephone numbers for the professional’s advise line to NSFT and the telephone line for the public in crisis should be utilised – a PVP submission WILL NOT initiate contact to achieve Mental Health support so officers must make additional contact via this system and consider also utilising the MH nurses in the CCR.
The IOPC recommends that Suffolk Constabulary review its approach to concern for welfare reports where there is also an element of domestic abuse. In cases where a concern for welfare report is received regarding a known DV perpetrator or victim, once basic intelligence searches on the person’s name or DOB have been conducted (in line with Suffolk Constabulary Welfare Checks policy), and if there are any open investigations or a history of DV, the details of the concern for welfare report and any relevant material should be shared with the OIC and the OIC ought to consider contacting the victim to establish their welfare. If there is a history of DV or an open investigation, the concern for welfare report should be recorded on Athena and linked to any ongoing DV investigation and victim.
Do you accept the recommendation?
Yes
Accepted action:
The Constabulary will be making additions to existing policies to overcome any ambiguities around required responses from officers – the proposed additions are as underlined below and will take a number of weeks to process due to the policy update procedures (consultation across different commands) that are in place.
1) Suffolk Welfare check policy changes to include:
a) (section 5.14) Where welfare checks have been undertaken in relation to domestic abuse, or a known domestic abuse perpetrator or victim, attending officers must review previous and live/ongoing domestic cases and ensure that the OIC(s) for those cases are updated of the detail around the most recent welfare check visit so as to re-assess the risk to the ongoing cases.
b) Any current or recent partners of the person subject to the welfare should be identified and consideration be made around contacting that person to establish their welfare.
2) Suffolk Domestic Abuse Policy changes to include:
The domestic abuse policy will be updated to cross refer to the above proposed additions to the welfare check policy.