Domestic Homicide Review Overview Report Report into the death of Adult A Report produced by Mark Reed Strategic Director, Guildford Borough Council Chair of Domestic Homicide Review Panel Date: 5 March 2013 1 CONTENTS 1. Introduction ……………………………………… 4 Purpose of Review ……………………………………… 4 Subjects of Review ……………………………………… 4 Conduct of Review ……………………………………… 5 Timescale for Review ……………………………………… 6 Terms of Reference of Review ……………………………………… 7 2. Background and Chronology ……………………………………… 8 Adult A (up to February 2008) ……………………………………… 8 Adult B (up to February 2008) ……………………………………… 10 Adult A and Adult B (February 2008 to March 2012) ……………………………………… 11 3. Surrey Police ……………………………………… 19 Review of Involvement ……………………………………… 19 Analysis of Involvement ……………………………………… 32 Effective Practice/Lessons Learnt ……………………………………… 38 Recommendations ……………………………………… 38 4. Hampshire Police ……………………………………… 40 Review of Involvement ……………………………………… 40 Analysis of Involvement ……………………………………… 45 Effective Practice/Lessons Learnt ……………………………………… 49 Recommendations ……………………………………… 50 5. Frimley Park Hospital NHS Foundation Trust ……………………………………… 51 Review of Involvement ……………………………………… 51 Analysis of Involvement ……………………………………… 55 Effective Practice/Lessons Learnt ……………………………………… 56 Recommendations ……………………………………… 57 6. South East Coast Ambulance Service NHS Foundation Trust ……………………………………… 58 Review of Involvement ……………………………………… 58 Analysis of Involvement ……………………………………… 61 Effective Practice/Lessons Learnt ……………………………………… 62 Recommendations ……………………………………… 63 7. General Practice ……………………………………… 64 Review of Involvement (Adult A) ……………………………………… 64 Review of Involvement (Adult B) ……………………………………… 66 Analysis of Involvement ……………………………………… 67 Effective Practice/Lessons Learnt ……………………………………… 67 Recommendations ……………………………………… 67 8. Surrey County Council ……………………………………… 68 Review of Involvement ……………………………………… 68 Analysis of Involvement ……………………………………… 69 Effective Practice/Lessons Learnt ……………………………………… 69 Recommendations ……………………………………… 70 2 9. South West Surrey Domestic Abuse Outreach Service ……………………………………… 71 Review of Involvement ……………………………………… 71 Analysis of Involvement ……………………………………… 71 Effective Practice/Lessons Learnt ……………………………………… 71 10. Rushmoor Borough Council ……………………………………… 72 Review of Involvement ……………………………………… 72 Analysis of Involvement ……………………………………… 73 Effective Practice/Lessons Learnt ……………………………………… 74 11. Guildford Borough Council ……………………………………… 75 Review of Involvement ……………………………………… 75 Analysis of Involvement ……………………………………… 76 Effective Practice/Lessons Learnt ……………………………………… 76 12. Surrey and Borders Partnership NHS Foundation Trust ……………………………………… 77 Review of Involvement (Adult B) ……………………………………… 77 Analysis of Involvement ……………………………………… 79 Effective Practice/Lessons Learnt ……………………………………… 79 Recommendations ……………………………………… 79 13. Hampshire Probation Trust ……………………………………… 80 Review of Involvement ……………………………………… 80 Analysis of Involvement ……………………………………… 84 Effective Practice/Lessons Learnt ……………………………………… 84 14. Involvement of Other Agencies ……………………………………… 86 Hampshire County Council ……………………………………… 86 Surrey and Sussex Probation Trust ……………………………………… 86 Southern Health NHS Foundation Trust ……………………………………… 86 South Central Ambulance Service NHS Foundation Trust ……………………………………… 86 15. Conclusions ……………………………………… 87 16. Recommendations ……………………………………… 91 17. Action Plan ……………………………………… 94 3 1. INTRODUCTION 1.1 This domestic homicide review follows the death of Adult A on 2 March 2012 at his home in Ash. South East Coast Ambulance Service attended the address on that date in response to a telephone call from his partner, Adult B. A paramedic pronounced Adult A dead at the scene at 03:44. 1.2 A post‐mortem examination conducted by a Consultant Forensic Pathologist on 2 March 2012 concluded that Adult A had died of severe abdominal, head and chest injuries, including traumatic sheering damage to the brain, bowel haemorrhage bleeding, ruptured liver and abdominal tears. There were no defence injuries. The pathologist was of the view that Adult A would not have been able to move after sustaining the injuries, indicating that he was assaulted and subsequently died at his home. 1.3 Adult B was found guilty of the murder of Adult A at Guildford Crown Court on 30 October 2012 and sentenced to life imprisonment, with a minimum tariff of 17½ years. A history of domestic abuse and Adult A’s disability and vulnerability were cited as aggravating factors in the sentencing. Purpose of Review 1.4 Domestic homicide reviews were established on a statutory basis under Section 9 of the Domestic Violence, Crime and Adults Act 2004 and came into force on 13 April 2011. The Act requires a review “of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by a person to whom he was related or with whom he was or had been in an intimate personal relationship or a member of the same household as himself”. 1.5 The Home Office’s multi‐agency statutory guidance for the conduct of domestic homicide reviews states the purpose as being to: establish what lessons are to be learned from the domestic homicide regarding the way in which local professionals and organisations work individually and together to safeguard victims; identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; apply those lessons to service responses, including changes to policies and procedures as appropriate; and prevent domestic violence homicide and improve service responses for all domestic violence victims and their children through improved intra and inter‐agency working. Subjects of Review 1.6 The subjects of this review are as follows: Adult A: Date of Birth ‐ 3 December 1974 (Male) Date of Death ‐ 2 March 2012 Adult B: Date of Birth ‐ 12 October 1967 (Female) 4 1.7 Adult A was and Adult B is White British. They had no children together, although research indicates that Adult A had children with previous partners. No children are directly involved in this case or review. Conduct of Review 1.8 Following notification by Surrey Police of the death of Adult A and consultation with partners, the Chairman of the Safer Guildford Partnership confirmed that the circumstances met the criteria set out in the statutory guidance for a domestic homicide review on 1 May 2012. The Home Office was informed of the intention to conduct a review on the same day. 1.9 A Panel comprising senior representatives of relevant partner organisations was convened to oversee the review. Following consultation with partners, Mark Reed, a Strategic Director at Guildford Borough Council, was appointed by the Chairman of the Safer Guildford Partnership to chair the review. Mark’s background as an environmental health officer has provided him with extensive experience in regulation, enforcement, investigative procedures and joint agency and partnership working. Full membership of the Panel is set out below: Pauline Disley, Manager, South West Surrey Domestic Abuse Outreach Service Caroline Jones, Senior Manager, Adult Social Care, Surrey County Council Susan Lawes, Associate Director of Quality and Safeguarding Children, NHS Hampshire DCI Colin Matthews, Head of Northern Area Public Protection Department, Hampshire Police Lin Pedrick, Service Director, Surrey and Sussex Probation Trust Mark Reed, Strategic Director, Guildford Borough Council DS Jon Savell, Head of Public Protection, Surrey Police Diane Woods, Associate Director Commissioning, Mental Health & Learning Disabilities, NHS Surrey 1.10 Stephen Benbough, Policy and Partnerships Officer at Guildford Borough Council, acted as assistant to the Chair of the Panel throughout the review and provided advice and support to the organisations involved. 1.11 The Panel agreed that an Individual Management Review (IMR) should be conducted by each agency in accordance with the statutory guidance. As the review progressed and further possible contacts with Adult A and Adult B by various agencies emerged, IMRs were also commissioned from the following additional organisations: Frimley Park Hospital NHS Foundation Trust Hampshire County Council Hampshire Probation Trust Rushmoor Borough Council South Central Ambulance Service NHS Foundation Trust South East Coast Ambulance Service NHS Foundation Trust Southern Health NHS Foundation Trust Surrey and Borders Partnership NHS Foundation Trust 1.12 The Panel has given detailed consideration to and challenged robustly the IMRs submitted by individual agencies and the final documents have contributed significantly to this report. This documentation has been supplemented by: information provided by the general practices attended by Adult A and Adult B; 5 discussions with and information provided by Surrey Police’s Senior Investigating Officer in relation to the murder of Adult A; discussions with members of Surrey Police’s Ash Neighbourhood Team; and attendance at the trial of Adult B and review of the evidence given, including by neighbours and acquaintances. 1.13 The Panel recognised that the family might have detailed knowledge about the victim’s experiences that could support the review process. The Chair wrote to Adult A’s parents after the initial Panel meeting to inform them that a formal review had commenced and to seek their involvement following completion of the criminal proceedings against Adult B. The