ROCHDALE SAFER COMMUNITIES
PARTNERSHIP
DOMESTIC HOMICIDE REVIEW
OVERVIEW REPORT
03.12.2012
Victim FEMALE A
DECEMBER 2012
This report is the property of Rochdale Safer Communities Partnership. It must not
be distributed or published without the express permission of the Chair.
Page 1 of 44
CONTENTS
SECTION
PAGE
1.
Introduction
3
2.
Establishing the Domestic Homicide Review
3-7
3.
Definition of Domestic Violence
8
4.
Family Background
9 - 10
5.
Key Events Analysis
11 - 31
6.
Terms of Reference Analysis
32 - 39
7.
Lessons Learned
40
8.
Conclusions
41 - 42
9.
Recommendations
43 - 44
Page 2 of 44
1.
INTRODUCTION
1.1
On 07.05.2012 the body of Female A was discovered at her house by neighbours.
They had been altered by her son, Child A, who found her lying in the kitchen. A post
mortem established she died from multiple stabs wounds.
1.2
In the early hours of 08.05.2012, Male A called 999 and admitted stabbing Female A.
He was arrested by Greater Manchester Police [GMP] and charged with murder.
1.3
On 15.10.2012 Male A pleaded guilty at Crown Court to the murder of Female A and
received life imprisonment with a minimum tariff of 21 years.
1.4
The trial judge is reported as saying: “It was a merciless and sustained attack on a
young woman in her own home who was 18 or 19 weeks pregnant, while her ... son
was in the house."
2.
ESTABLISHING THE DOMESTIC HOMICIDE REVIEW
Decision Making
2.1
Rochdale Safer Communities Partnership (RSCP) Domestic Homicide Review
Screening Panel met on 18.06.2012 and decided that the death of Female A met the
criteria for a domestic homicide review (DHR) as defined in the Multi-Agency
Statutory Guidance for the Conduct of Domestic Homicide Reviews April 2011 (the
Guidance).
2.2
Section 6.2 of the Guidance states that a decision to hold a DHR should be taken
within one month of the homicide coming to the attention of the Community Safety
Partnership. Section 6.4 states it should be completed within a further six months.
In this case the time between the homicide and the decision to hold a DHR was
about six weeks. The completion date was set as 18.12.2012; six months from the
screening panel meeting.
DHR Panel
2.3
David Hunter was appointed as the Independent Chair and Author on 20.06.2012.
He is a self employed independent practitioner with professional knowledge of
investigating and reviewing domestic violence and honour based violence. He has
never been employed by any of the agencies involved with this DHR and was judged
to have the experience and skills for the task. The first of five panel meetings was
held on 20.07.2012. Attendance was good and all members freely contributed to the
analysis, thereby ensuring the issues were considered from several perspectives and
disciplines. Between meetings additional work was undertaken via e-mail and
telephone.
Page 3 of 44
The Panel comprised of:
 Ian Halliday
Principal Community Safety Officer Rochdale
Metropolitan Borough Council [RMBC]
 Hazel Chamberlain
Designated Nurse Safeguarding (Children and
Adults) Heywood, Middleton and Rochdale PCT
 Rachel Dodge
Care & Support Manager, Adult Care RMBC
 Michelle Ward
Service Delivery Manager, Victim Support
 Jane Curran
Detective Inspector GMP Public Protection
Investigation Unit [PPIU]
 Gary Cropper
Review Officer GMP Major Crime Review Unit
 Caroline McCann
Pennine Care NHS Foundation Trust [PCFT]
 Ann Christopher
Named Nurse Safeguarding Adults Pennine
Acute Hospitals Trust [PAHT]
 Joanne Hodgkinson
Safeguarding Children [PCFT]
 Lana Shannon
RMBC Children’s Social Care
 Louise Ashurst
Rochdale Boroughwide Housing[RBH]
The Panel took cultural advice from Shupee Begum Anti-Social-Behaviour Project
Worker, Victim Support. She has professional knowledge of domestic violence and
honour based violence and attended the DHR Panel meetings.
Agencies Submitting Individual Management Reviews (IMRs)
2.4
The following agencies submitted IMRs.
 Greater Manchester Police
 Rochdale Boroughwide Housing
 Pennine Acute Hospitals Trust [Accident and Emergency]
 Pennine Care NHS Foundation Trust [Mental Health] [Health Visiting]
[School Health]
 General Practitioner: for Female A only
 Homelessness Advice and prevention Service RMBC
 Victim Support
Note: Enquiries were made with Child C’s school. The staff had no relevant
information.
Page 4 of 44
Notification/Involvement of Families
2.5
Key members of Female 1 and Male 1’s families were written to, informing them that
a DHR was taking place and inviting them to contribute after the trial. Female A’s
family members were approached using the services of a Family Liaison Officer [FLO]
from GMP. The Independent Chair/Author established which language the families
wanted the Home Office Domestic Violence leaflets in and arranged for one to be
translated into Urdu. The FLO delivered the leaflets to the victim’s family.
Thereafter, David HUNTER visited the families in their homes and on one occasion
was accompanied by the FLO when he saw the victim’s sisters. The following people
engaged with the DHR process and their views are reflected in the report.
 Females B, E and G [Female A’s Sisters]
 Male B: Female A’s former husband
 Female C:
 Male F: Male A’s Father
 Male A: He was seen in prison on 12.12.2012 by David HUNTER who was
accompanied by Male A’s Offender Manager from Greater Manchester
Probation Trust.
Terms of Reference
Purpose of a DHR
2.6
The purpose of a Domestic Homicide Review (DHR) is to:
 Establish what lessons are to be learned from the domestic homicide
regarding the way in which local professionals and organisations work
individually and together to safeguard victims;
 Identify clearly what those lessons are both within and between
agencies, how and within what timescales they will be acted on, and
what is expected to change as a result;
 Apply these lessons to service responses including changes to policies
and procedures as appropriate; and
 Prevent domestic violence homicide and improve service responses for
all domestic violence victims and their children through improved intra
and inter-agency working.
Source: Paragraph 3.3 The Guidance.
Page 5 of 44
Specific Terms of Reference
2.7
1. Were the risk indicators of domestic abuse present in this case recognised;
appropriately assessed and responded to in providing services to Female A and
Male A and where applicable Child A, B, C and D ?
2. Were the services provided for Female A and Male A timely, proportionate and ‘fit
for purpose’ in relation to the levels of risk and need that were identified? Was
there sufficient focus on reducing the impact of Male A’s abusive behaviours
towards Female A and were the reasons for Male A’s abusive behaviour properly
understood and addressed?
3. Were arrangements made to determine the wishes and feelings of Female A
about her circumstances and were these taken into account in the provision of
services and support?
4. Were single and multi-agency policies and procedures adhered to in the
management of this case? Are single agency policies and procedures ‘fit for
purpose’ in safeguarding and promoting the welfare of victims of domestic abuse
and is there evidence that they are embedded in practice?
5. Was information sharing and communication with other agencies regarding
Female A, Male A and Child A effective? Is there evidence of inter-agency cooperation and joint working in the management of this case?
6. Did practitioners working with Female A, Male A and Child A receive appropriate
supervision and support? Was there adequate management oversight and control
in this case?
7. Were there any racial, cultural, linguistic, faith or disability issues that needed to
be taken into account in the assessment and provision of services to Female A,
Male A and Child A? How were these issues managed within your agency?
8. Were there any issues in relation to capacity or resources within your agency that
affected the ability to provide services to Female A, Male A or any of the children
or to work with other agencies?
Subjects of Review
2.8
Female A
20+ years
Victim
Asian-British, Pakistani
Male
30 +
Offender
Asian-British, Pakistani
mixed heritage
A
Page 6 of 44
Other People
Female C
>30
Wife of Offender
Male
B
>30
Former husband of Asian-British, Pakistani
Female A and father
Child A
Child
A
< 10 years
Child of victim
and Male B
Child
B
< 10 years
Child of Female B
and Male A
Asian-British, Pakistani
Child
C
< 10 years
Child of Female B
and Male A
Asian-British, Pakistani
Child of Female B
and Male A
Asian-British, Pakistani
Females B, E and G
Female A’s sisters
Asian-British, Pakistani
Male F
Male A’s Father
Asian-British, Pakistani
Child
D
< 10 years
>60 years
Asian-British, Pakistani
Asian-British, Pakistani
Time Period
2.9
2.10
The time period under review is from 08.08.2008 to 2350 hours on 07.05.2012.
Agencies were asked to exercise their professional judgement and include any
information relevant to the terms of reference that pre-dated 08.08.2008 to help with
the context.
The target date for completing the review was 18.12. 2012.
Page 7 of 44
3.
DEFINITIONS
DOMESTIC VIOLENCE
3.1
The Government definition of domestic violence against both men and women
(agreed in 2004) is:
“Any incident of threatening behaviour, violence or abuse [psychological, physical,
sexual, financial or emotional] between adults who are or have been intimate
partners or family members, regardless of gender or sexuality”
3.2
An adult is any person aged 18 years and over and family members are defined as
mother, father, son, daughter, brother, sister and grandparents, whether directly
related, in-laws or step-family.
3.3
The definition and advice on Rochdale Metropolitan Borough’s web site is:
“Domestic abuse is any kind of violence or other abuse between family members.
This can be violent behaviour by a husband, wife, boyfriend, girlfriend, partner, expartner, father, mother, son or daughter who lives with you or lives elsewhere. It
may include physical, sexual, emotional or financial abuse. It can also affect the
health and wellbeing of children in the family.
No one should have to put up with any kind of violence or abuse. Everyone has the
right to personal safety - so if you are worried then ask for help. If it has happened
once it is likely to happen again. Even if it has been happening for years it is never
too late to seek help”.
3.4
GMPT definition of domestic violence is:
“Domestic violence covers a wide range of abusive behaviours within intimate and
family relationships. The government defines domestic violence as:
“Any incident of threatening behaviour, violence or abuse (psychological, physical,
sexual, financial or emotional) between adults who are or have been intimate
partners or family members, regardless of gender or sexuality”
3.5
Therefore, the experiences of Female A easily fall within the various descriptions of
domestic violence/abuse.
Honour Based Violence
3.6
The Crown Prosecution Service and the Association of Chief Police Officers have a
common definition of Honour Based Violence [HBV]:
"Honour Based Violence" is a crime or incident, which has or may have been
committed to protect or defend the honour of the family and/or community'.
Page 8 of 44
4.
FAMILY BACKGROUND
4.1
Introduction
4.1.1 The sources of information in the following paragraphs are from GMP’s IMR and the
families of Female A and Male A.
4.2
Female A
4.2.1 Female A is the eldest of eight siblings and was born and educated in England. In
2000 Female A’s father took her and two of her siblings to Pakistan to arrange their
marriages. Female A was introduced to her cousin Male B and stayed in touch with
him after her return to England. Female A returned to Pakistan in 2003 and willingly
married Male B in August that year. The couple remained in Pakistan whilst Male B
finished his professional training. Female A returned to England in 2004 and her
husband followed a few months later after his visa was granted. Child A was their
only offspring. The anecdotal evidence suggests that the family was a happy,
cohesive unit. However this changed once Male A reformed the relationship with
Female A. This eventually led to her husband [Male B] leaving the family home in the
spring of 2010.
4.2.2 Female A’s family described her as quiet person who cared very much for her child.
Professionally she worked with children with learning difficulties and found the
experience very rewarding. She was also a warm and loving person who wanted the
same in return from those she loved, in particular Male A.
4.3
Male A
4.3.1 Male A was born and educated in England and has at least one sibling. His father
was Asian and his mother white British. He was brought up in the Islamic faith. In
the late 1980’s Male A spent some time in Pakistan with his sibling in order to
accommodate family needs. They returned to the South of England a few years later
from where they moved to the North West in the early 1990’s.
4.3.2 Male A completed his education and in the years before the murder he worked as a
taxi driver. Male A married Female C in 2001 and they had three children together;
Child B, Child C and Child D. Male A purchased his house in 2007 under the Right to
Buy Scheme.
4.4
Female A and Male A
4.4.1 It appears that Female A first met Male A [who is about four years older than her]
when she visited his house to play with his sister. It is believed they began an
intimate relationship during the last year of her schooling. It is thought that when
Female A returned from Pakistan in 2000 having pledged her future to Male B, the
intimate relationship between her and Male A re-ignited and then ceased when Male
A’s family moved to another area of town.
Page 9 of 44
4.4.2 However, about a year later, the relationship resumed but was short-lived. The
families disapproved of the liaison and successfully pressurised Female A and Male A
to ending it. Shortly afterwards Male A married Female C in an arranged marriage. A
few years later Female A married Male B.
4.4.3 It is now clear that in the years after their marriages Female A and Male A
recommenced their relationship. Male B left the family home and divorced Female A
following his discovery of the affair. Thereafter, Male A struggled to persuade Female
C to accept his relationship with Female A. Male A told the independent chair/author
that Female A accepted his marriage to Female C and wanted Female C to adopt the
same attitude, where by the three could live in harmony. Male A said Female C was
not willing to do this. This resulted in turmoil and in defiance of Female C’s wishes.
Male A took Female A as a second wife, in July 2007, in line with his faith. The
covert way in which that was achieved, set up further tensions between the two
women and the families. Male A had effectively put himself in the middle of a
chaotic and at times unpleasant situation, culminating in the death of Female A.
Male A acknowledged that he was sometimes violent to both women.
4.4.4 Female A’s family recall that Male A was very much a controlling figure who wanted
Female A to be compliant with his wishes. They report he controlled the finances
which left Female A short of money; they supplemented her income at times. It is
known that Female A was struggling to pay her rent and was offered advice by
Rochdale Boroughwide Housing [November 2010 to September 2011].
4.4.5 The family recall that Male A regularly inflicted physical violence on Female A as
evidenced by her complaints to them and their observations of the bruising. Male A
minimised the extent of the violence when he was seen in prison. The family
respected Female A’s wishes not to report the violence to the police. Female A
believed Male A would change. The family discussed going to the police without
Female A’s permission but held back, fearing it would make the situation worse for
her when Male A found out. Male F and Female C were not aware that Male A was
violent to Female A, save for the one occasion in May 2008. Female C told the
independent chair/author that Male A was not violent to her. This was supported by
Male F but later contradicted by Male A when he spoke to the independent
chair/author and admitted hitting Female C. The chair/author subsequently saw
Male F and Female C but they again denied Male A hit Female C.
Page 10 of 44
5.
KEY EVENTS ANALYSIS
5.1
Introduction
5.1.1 Set out below in date order is a list of important events, which illustrate the
dynamics between Female A and Male A, and on occasions Female C. The ones in
italics are designated “Key Events” because of the opportunities they presented for
agencies to respond to domestic issues/abuse. The Key Events are dealt with in two
parts. The first is a factual narrative immediately followed by a critical analysis drawn
from the IMRs, the deliberations of Panel members and information from the
families. Male A subjected Female A to emotional domestic abuse and on one
reported occasion [GMP] physical violence. Overall the involvement of services with
Female A and Male A resulting from domestic abuse was limited.
5.1.2
The important events are preceded by a synopsis covering 2003 [when Female A
reached 18 years of age] to 07.08.2008.
5.2
Synopsis: 2003 to 07.08.2008
5.2.1
During this period Female A visited Pakistan with other family members and she
married Male B; returning to England alone while he finished his professional
training. Male B was settled and working in Rochdale. There is no information from
his period which is directly relevant to the DHR.
5.3
Important Events
Date
Event
08.08.2008
Female C calls GMP saying Male A not seen for 12 hours after
argument. He returned soon after the call.
April 2009
Female A ends relationship with Male A after he refused to leave
Female C.
15.02.2010
Male B moves to Lincolnshire for work; Female A declines to go and
stays in home with Child A.
23.04.2010
Male A attends A&E having taken 32 paracetamol. He reported being
stressed out after arguments with his wife and family over his
relationship with Female A. Psychiatric assessment completed no
mental health needs.
21.05.2010
Female A reported to GMP that Male A assaulted her.
27.05.2010
Victim Support provided services to Female A.
21.06.2010
Services offered to Female A by RMBC Homelessness Advice and
Prevention Officer after referral from Victim Support.
23.06.2010
Female a contacted Victim Support saying Male A was harassing her.
Page 11 of 44
25.06.2010
Female A visits A&E, anxious and depressed after family dispute. Her
ribs were tender.
04.08.2010
Female A tells GMP she was followed by Asian male.
10.10.2010
Female A and her sister tell GMP Male A had threatened Female A,
saying her would shoot her and kidnap her son [Child A].
15.10.2010
Female C tells GMP that Female A has threatened her children
15.10.2010
GMP refer Female A to Victim Support for 10.10.2012 incident.
06.11.2010
Male A tells GMP that Male B threatened to kill him.
June - July
2011
Female C is reported as discovering Male A was planning to marry
Female A in accordance with his Islamic faith [Nikah ceremony]
17.10.2011
Male A tells GMP that someone is smashing his windows.
Dec
2011
Female A and Male A believed married in Nikah ceremony. Female A
is now regarded as Male A’s second wife.
20.12.2011
Male A seen by psychiatric services; he did not want help and wishes
his wife and family would stop nagging him. No mental health needs
identified.
16.01.2012
Female A tells GP she is trying for a baby.
Jan/March
Male A told Female A he was divorcing her in accordance Sharia law.
28.02.2012
Female A tells midwife she was victim of domestic violence by Male A
about two years ago but nothing since.
04.05.2012
Female C discovers Male A married Female A and is
pregnant with his child. Female C is alleged to have told Female A she
hoped her and the baby would die.
06.05.2012
Female C calls GMP to report marital problems.
06.05.2012
Male A reports to GMP that Female C had bitten him and torn his
clothes.
07.05.2012
Female A tells Male A he has to choose between her and Female C.
Female A added if he chose Female C she would end the relationship
and divorce him.
07.05.2012
Female C telephoned Female A’s mother saying she intended to get
Female A killed.
07.05.2012
A sister of Female A, confronted Female C over her behaviour towards
Female A given she had agreed to Male A marrying Female A.
Page 12 of 44
07.05.2012
5.4
Neighbours alert GMP to disturbance at Female A’s house. Emergency
services attend and find Female A dead.
Key Event: Male A takes 32 Paracetamol Tablet
5.4.1 On 23.04.2010 Male A was taken by ambulance to A&E accompanied by Male F [his
father]. Male A reported taking 32 paracetamol tablets by mistake. He was admitted
and was reluctant to answer most questions. A&E staff were aware from the
Ambulance staff that he lived with his family, including his wife and father. The
Ambulance staff did not raise any concerns about the welfare of any children. He
was seen the next day by a qualified mental health professional and was more
forthcoming. Male A acknowledged taking the tablets in response to what was
described as personal social stressors in his relationship with his wife [Female A]. He
disclosed having an extra-marital affair and was being pressurised by his family to
end it. The mental health professional noted the names of his children and that his
wife was pregnant. The details of Female A and her family composition were not
identified.
5.4.2 Male A was assessed as not posing a risk to himself or others, or of being exploited.
He had good insight into his situation and declined the offer of psychological
therapies. He was discharged and a letter sent to his GP. Information about his
admission was not shared with Children’s Services.
Analysis:
5.4.3 At the time of this incident Female A’s husband [Male B] had left the marital home
after “discovering” the relationship between Female A and Male A. It is now known,
but not reported to the police at the time, that one of Female A’s sisters went with a
cousin to see Female C and confronted her with the information that her husband
[Male A] was still in a relationship with Female A. Male A’s attempting to commit
suicide in response to domestic turmoil can easily be view as a form of emotional
abuse through which he attempted to regain control over the person who rejected
him. It is not known who Male A was trying to control; his wife, Female A or both.
5.4.4 Male A was dealt with appropriately by A&E and psychiatric services. He was judged
competent to make his decision to decline services.
5.4.5 The DHR Panel debated whether Children’s Services should have been told of the
incident and concluded that on balance, it was not necessary to share the
information. The reasons were; staff completed a risk assessment judging him to be
a low risk of harming himself or others; or of being exploited. This was a single
incident with no recorded history and a child protection issue was not apparent. If
Children’s Services had been told about the admission to hospital the most likely
response would have been a telephone call to the family to see if they needed any
support. It could be argued that Female C might have used this opportunity to share
additional information with Children’s Services. However, that is speculation.
5.4.6 In an ideal world Male A’s circumstances would have been referred to Children’s
Services, but the presentation and assessment of this case were unremarkable.
Sharing such low level information with Children’s Services would probably
overwhelm them. However, Pennine Care NHS Foundation Trust will open
Page 13 of 44
discussions with Children’s Services to examine whether the current thresholds for
sharing information are robust and to check that desensitisation [an inadvertent
raising of information sharing thresholds] has not occurred. The DHR Panel thought
that was a proportionate and responsible response.
Note: The desensitisation issue is a general point applicable to all agencies and is
picked up in Lessons Learned and Recommendations.
5.5
Key Event: Female A reports being Assaulted by Male A
5.5.1 On 21.05.2010, Female A [and two female friends] were driving away from a fast
food shop and noticed Male A following them in his car. He was harassing them.
Female A stopped the car and got out. Female A reported that Male A approached
her; hit her on the arms and legs with his fists and a shoe, before walking away.
5.5.2 Female A reported the assault in person at a police station and because it was late at
night it was agreed she would go home and be interviewed the next day. GMP
created an electronic log and coded it, “personal violence”. A secondary log was
created on Female A’s home address and coded, “Domestic Violence”. A crime of
“common assault” was also recorded, stating that Female A had not suffered physical
injury, but was shocked by the violence. Female A’s two friends did not want to
make a statement. A referral was made to Victim Support and Female A was sent a
standard domestic violence victims letter by GMP. Children’s Services were not
informed. The whole incident was closed with a “domestic violence between adults”
code.
5.5.3 At the time of this incident GMP risk assessed such incidents using the SPECSSVO
risk assessment.
S – Separation or child contact issues;
P – Pregnancy or new birth;
E – Escalation in violence;
C – Cultural awareness/isolation;
S – Stalking;
S – Sexual assault;
V - Vulnerable adult (including mental health issues);
O – Other factors.
5.5.4 Officers were required to complete a mandatory minimum data set (1 – 12) that
encapsulated all the information it was believed necessary for specialist domestic
violence investigators to undertake an informed evaluation. The attending officers
completed the minimum data set.
5.5.5 GMP expect response officers to apply common sense and experience when
completing risk assessments, recognising they do not have the same level of
knowledge as specialists. A closing incident code of domestic violence enabled the
log to be identified by GMP Public Protection Investigation Unit [PPIU] where it was
risk assessed as Standard by a domestic abuse specialist and an appropriate letter
Page 14 of 44
was sent to Female A. The 1-12 data set did not identify Female A’s child [Child A]
but recorded there were no children born of Male A and Female A. It appears that
Female C and her children were not identified.
5.5.6 Male A was arrested on 24.06.2010 and denied the assault, saying that whilst he was
present, he was only trying to calm down Female A. In the early hours of 25.06.2010
he was released without charge after GMP discussed the case with CPS Direct [The
out of hours service of the Crown Prosecution Service] The reviewing lawyer noted
that “there is no supporting evidence to make one account more believable than the
other”.
Analysis:
5.5.7 GMP’s initial response to this incident was good and afforded Female A significant
protection from Male A. Referring the file to CPS ensured independent scrutiny of
the allegation. Female A’s family said that her friends who witnessed the incident did
not want to be involved because they thought the matter would blow over and she
would be back with Male A in a week or so. Looking at the incident from the
perspective of what else was happening in Female A’s life, it is apparent that Male A
was harassing Female A, because she had ended the relationship.
5.5.8 The GMP IMR author feels that sufficient risk factors were present to warrant contact
with Female A from a PPIU officer so that a more informed risk assessment could
take place. The PPIU officer simply did not view the material in the same way as the
IMR author who lists the risk factors as:
 The offender was a married man with children;
 The victim and offender had been engaged in an extra marital relationship for
5 years;
 The victim had ended the relationship a month prior to the incident;
 The offender was unable to accept the end of the relationship;
 The offender had been constantly bombarding the victim with telephone calls
during the previous month;
 The offender had slapped the victim 3 days earlier;
 The offender had followed the victim for about ten miles;
 The offender had not been processed as a suspect and therefore was not
subject of any legal restraints;
 Male A had potential mental health issues [paracetamol overdose]
5.5.9 The DHR Panel thought that PPIU should have assessed Female A as a medium risk
victim on the known facts. However, an increase of risk from standard to medium
would not have seen the case automatically referred to MARAC and the DHR Panel
thought it was very unlikely that a referral to MARAC using the overriding
“professional judgment” was necessary. Nevertheless, a medium outcome from the
risk assessment would have seen a PPIU member telephone Female A, thereby
providing an opportunity to discover additional information with which to inform the
Page 15 of 44
risk assessment. Since 2010 any domestic abuse incident which also has a crime
recorded against it will automatically have a minimum risk assessment of Medium.
5.5.10 It appears Male A would not accept that the relationship was over, despite being told
so by Female A in April 2010. It is known that the risk of harm to victims of domestic
abuse increases at the point of separation. In this case Female A had ended the
relationship with Male A who continued to harass her.
“Women are at greatest risk of homicide at the point of separation or after
leaving a violent partner: Source (Lees, 2000)”. www.womensaid.org.uk
5.5.11 This case should have been referred to Children’s Services. The attending officers
did not identify that Female A or Male A had children, albeit it with separate partners.
The reason for this appears to be that the incident happened outside of the home
and there were no children present. This lapse meant a referral to Children’s Services
was not made; thereby denying them the opportunity to offer support. The position
could have been rectified by Victim Support, and HAPS who both had direct contact
with Female A. It seems no active thought was given to the strong links between
domestic violence and child protection. Since these events in 2010, GMP has
increased the amount of domestic violence and stalking awareness training it delivers
to front line response officers.
5.5.12 During the interview with the independent chair/author, Male A acknowledged he
had assaulted Female A and thrown his shoe at her as an insult. He explained that
Female A’s friend was making mischief between him and Female A and therefore
throwing his shoe was meant to infer that if Female A chose to be influenced by her
friend rather than listen to Male A, then she deserved to be insulted in the method
chosen.
Note: Shoes are considered ritually unclean in the Muslim faith.
Source: bbc.co.uk when reporting on a shoe thrown at President Bush in Baghdad in
December 2008.
5.6
Key Event: Victim Support Contact with Female A After Assault
5.6.1 Victim Support received a referral from GMP on 27.05.2010 and contacted Female A
the same day. She requested support and an early appointment was made which
Female A cancelled on 01.06.2010. The meeting was rescheduled for 08.06.2010 and
Female A attended the Victim Support office and received emotional support together
with personal safety advice. There is no record that Victim Support knew that Female
A or Male A had any children. At the time Victim Support did not complete formal risk
assessments. They now undertake CAADA-DASH risk assessments which would
identify children. The referral from Victim Support to RMBC Homelessness Advice
and Prevention Service [HAPS] was date stamped 21.06.2010, suggesting it was
received on that date. This was 13 days after the Victim Support saw Female A on
08.06.2010. Victim Support did not keep a record of when the referral was passed to
HAPS. Referral dates are now recorded.
Analysis:
5.6.2 Female A must have welcomed the involvement of Victim Support given her positive
response to their contact. Their service was delivered within its standards, and as
Page 16 of 44
will be seen by a later key event [23.06.2010], instilled confidence in Female A and
helped her at a difficult time. There is no information to say whether Victim Support
indentified that Female A had a child or that Male A had children. This appears to be
because at that time [2010] Victim Support did not complete formal risk assessments
and consequently Children’s Services were not informed. Victim Support now use the
CAADA-DASH risk assessment model which, when applied competently, would
identify any children who might be at risk through exposure to domestic violence.
Additionally, a referral would now be made to Children’s Services. The reasons for
the apparent 13 days delay between Victim Support seeing Female A and HAPS
receiving the referral cannot be explained, but had the potential impact of leaving a
vulnerable person without the support available through HAPS.
5.7
Key Event: HAPS contact with Female A
5.7.1 On 21.06.2010 HAPS received a referral from Victim Support requesting a needs risk
assessment. HAPS contacted Female A the same day and concluded there was no
immediate risk to her. On 22.06.2012 a HAPS worker, accompanied by
representatives from the Home Improvement Agency and Domestic Violence Forum
visited Female A in her home and undertook an assessment of risk and in
conjunction with her agreed what physical security measures were needed. The work
was completed within the four day standard.
5.7.2 There is no information to say whether any of the three professionals who visited
Female A indentified Child A or that Male A had children. There was no referral to
Children’s Services.
Analysis:
5.7.3 The involvement of HAPS through a referral from Victim Support demonstrates that
local agencies have developed information sharing systems which support victims of
domestic violence. HAPS response was positive including immediately contacting
Female A and assessing her risk. This was swiftly followed by practical measures to
reduce the risk Female A faced from Male A. However, the assault on Female A
happened on 21.05.2012 and it took a month before physical security measures were
taken. The DHR Panel felt that was too long and identified the reason as the delay
in the reporting chain; Viz:
 21.05.2012
Assault on Female A
 27.05.2010
Victim Support notified by GMP
 01.06.2010
Broken appointment with Victim Support by Female A
 08.06.2010
Appointment with Victim Support kept by Female A
 21.06.2010
HAPS receive a referral from Victim Support
 22.06.2010
HAPS visit Female A
 25.06.2010
Security measures in place; work completed
 07.07.2010
Case signed off by haps manager
Page 17 of 44
5.7.4 Therefore it seems the significant delays occurred before the referral to HAPS on
21.06.2010 and in particular between Female A’s appointment on 08.06.2010 with
Victim Support and the 21.06.2010. Victim Support cannot explain the gap and say
that at the time its practice was not to record the date of onward referrals. They do
now and report that referrals are always made within a few days.
5.7.5 Perhaps more concerning is why HAPS and its partners did not identify Child A and
make a referral to Children’s Services. The DHR Panel thought that HAPS should
have recognised that Child A was potentially at risk from being exposed to domestic
violence and made a referral to Children’s Services. This recognition should have
been prompted by their actions in securing the house. At the time HAPS [including
the Home Improvement Agency] were not well trained in such recognition. HAPS is
currently going through a process of providing guidance on safeguarding and
referrals to Children’s Services, as part of a regular supervision programme with
staff, and are examining training needs for all staff in the service in terms of
domestic abuse and Safeguarding/Child Protection matters. Therefore a
recommendation is not necessary.
5.7.6 The Domestic Violence Forum no longer exists and the location of its archived paper
files is uncertain. The Domestic Violence Forum worker who attended has been
identified from HAPS records but cannot recall any details of the visit.
5.7.7 This event is another occasion when an agency [HAPS] missed an opportunity to
consider the welfare of a child and decide whether a referral to Children’s Service
was warranted. The current training should reduce the chances of it happening
again.
5.8
Key Event: Female A Complains to Victim Support of Male A Harassment
5.8.1 On 23.06.2010 Female A contacted Victim Support to say that her ex-partner
[Male A] was harassing her. She was advised to report it to GMP and to keep a log of
Male A’s activities. GMP has no record that Female A contacted them over the
harassment. On 25.06.2010 Victim Support contacted Female A who said Male A was
on bail not to contact her directly. That was not the case. He was arrested on
24.06.2010 and released without charge or bail in the early hours on 25.06.2010.
Analysis:
5.8.2 It is to Victim Support’s credit that Female A felt confident to approach them about
the harassment. Victim Support offered standard advice to Female A, but there is no
detail on what form the harassment took; its intensity or impact on Female A or Child
A. Victim Support acknowledges that it should have checked with GMP and/or
Female A that she had reported the matter. Equally Victim Support recognises it
could have made the referral to GMP on behalf of Female A, with her consent.
5.8.3 As stated previously, Victim Support did not use formal risk assessments and neither
did they refer the incident to GMP. This meant that the existing risk assessment was
missing an important piece of information which may have altered the level of risk
and denied GMP a response such as holding Male A to account under the Protection
from Harassment Act 1989.
Page 18 of 44
5.9
Key Event: Female A Visits A&E Anxious/Depressed
5.9.1 On 25.06.2010 Female A attended A&E on her own, complaining of chest pains. She
reported being single, saying she felt anxious and depressed and there had been a
family dispute earlier that day. She was examined and it was noted her ribs were
tender, but nothing else untoward was found. Female A was advised to visit her GP
if she continued to feel unwell.
Analysis:
5.9.2 The visit to A&E reveals a number of points. It was made at 9.30 pm and within 18
hours of Male A being released after his arrest for the alleged assault on Female A. It
is clear that there was domestic turmoil in Female A’s life as evidenced by her
disclosure to the attending clinician. What is not clear is whether A&E staff thought
to connect the tender ribs to Female A’s domestic situation. It is not known why the
possible link did not occur to them and there is no recorded diagnosis for the
tenderness. Their training includes the signs and symptoms of domestic abuse and
they have standard screening questions to be applied when judged appropriate.
Therefore the DHR Panel concluded this was a missed opportunity to help Female A.
5.10 Key Event: Female A reports to GMP being followed
5.10.1 During the evening of 04.08.2010 Female A called GMP using the emergency
number. She reported that a taxi driven by an Asian male had followed her and her
son [Child A] to her sister’s home. When Female A approached the male querying
what he wanted, he took a photograph of her and the car saying, “You’ll see what
happens in a week”.
5.10.2 The incident was recorded and coded as “Suspicious Circumstances”. Female A was
seen in her home later that evening but did not disclose the assaulted of 21.05.2010,
nor it appears the full extent of the harassment she was enduring.
Analysis:
5.10.3 It is very likely that the incident had something to do with Male A’s continued
harassment of Female A and offers a worrying insight into his attitude towards her.
It demonstrates his continuing campaign of harassment and persistence, given that
Female A had ended the relationship three months previously.
5.10.4 Female A’s actions around this episode appear contradictory. On one hand she was
concerned enough to call GMP via “999” and on the other hand does not appear to
have shared information with the response officers that would have enable them to
identify the underlying story of what was happening in her life. Has she done so the
officers would probably have acted differently and considered offences under the
Protection from Harassment Act 1989. However, Female A’s apparent mixed
messages may have stemmed from her general weariness of the situation and
according to her family, her underlying, and apparently contradictory feelings of
attraction to, and fear of, Male A.
5.10.5 GMP held information on Female A which would have enabled them to probe her
account and reveal some of her background, including the alleged assault by Male A
in May 2010. The GMP IMR author believes that without additional disclosures from
Page 19 of 44
Female A, the officers acted reasonably and given the nature of what appeared to be
a single incident would not necessarily be expected to check further. The DHR Panel
felt the officers’ decisions were defensible.
5.11 Key Event: Female A reports to GMP Male A threats to kill/kidnap
5.11.1 On 10.10.2010 Female A and her sister attended a GMP police station reporting that
Male A had threatened to shoot Female A and kidnap her son. The incident was not
coded as domestic related, nor was the child protection element recognised. Female
A asked to be seen at home. When they left the police station Male A was outside
and followed them for about five minutes. Female A’s sister telephoned GMP with
the information.
5.11.2 GMP were unable to contact Female A during the next 24 hours and at 5.0 pm on
11.10.2010 she re-contacted GMP to report that Male A had accosted her outside a
Mosque and threatened to kidnap her. GMP tried to contact Female A during the
following 24 hours, including a home visit, but was unsuccessful. Female A was
contacted about 8.0 am on 12.1.2010 and GMP officers saw her about 10.0 am that
day. They completed a 1-12 minimum data set, but Female A did not have enough
time to make a statement and agreed to deal with the matter by appointment
through the Customer Service Desk [CSD]. An appointment was made for
14.10.2012.
5.11.3 At that appointment Female A made a statement, setting out a fairly comprehensive
history of the relationship between herself and Male A. She included her fear of Male
A and that she had told him to leave her alone. The officer assessed that the risk of
Female A coming to further harm was medium. The matter was never looked at by
the domestic violence specialists in PPIU because the incident was coded incorrectly
as “Other Crime” and also lacked a “Concern for Child” code, either of which would
have drawn the issues to PPIU’s attention. However, a referral was made by GMP to
Victim Support on 15.10.2010 but despite making six telephone calls Victim Support
was unable to make contact with Female A and GMP were informed accordingly,
albeit GMP cannot find a record of that notification. GMP or Victim Support did not
inform Children’s Services whose clear expectation is that a referral should have been
made to them following the threat to kidnap Child A.
5.11.4 Male A was arrested on 13.10.2010 and charged with Section 4 Harassment [Fear of
Violence] Protection from Harassment Act 1997 and Section 39 [Common Assault]
Offences Against the Person Act 1861. He was kept in custody and appeared at court
on 14.10.2010. CPS judged he posed a medium risk to Female A and the court set
the following bail conditions.
 Live and sleep at his home address
 Not to contact Female A directly or indirectly
 Not to enter or go to the street where Female a lived
There was a note on the Police National Computer that should he be arrested
for breaching the conditions, the CID should be told.
Page 20 of 44
5.11.5 On 02.04.2011 Female A made a statement withdrawing her cooperation from the
prosecution. On 08.06.2011 Male A appeared at Manchester Crown Court where the
judge directed the jury to find him not guilty.
Analysis:
5.11.6 Overall the incident took 95 hours [almost four days] from the first report, to taking
a statement. The incident was originally recognised as domestic abuse as evidenced
by the officers completing the 1-12 minimum dataset. The four days it took to
finalise the report of domestic abuse was too long because it left Female A exposed
to risks which were not assessed by a PPIU specialist and the threat to kidnap Child
A seems to have been completely overlooked. The delay was in part due to Female
A’s availability and her agreement to an inappropriate suggestion that it could be
dealt with by the CSD. It was inappropriate because CSD deal with matters in slow
time, a response not desirable for domestic violence victims who should be seen and
assessed as soon as practicable.
5.11.7 The incorrect final closing code applied to the incident, [“other crime” instead of
domestic abuse and “concern for child”] meant that PPIU specialists were not aware
of the report and therefore could not use their expertise in risk assessing the matter
and making the necessary referrals to other agencies. The constable closing the log
had supervisory authority to do so and readily acknowledged the mistake. Staff
working on CSDs do not usually deal with domestic violence/child protection and
their unfamiliarity with the subjects probably contributed to the error.
The GMP IMR Author believes that had PPIU seen the incident and applied
reasonable judgement it would have identified Male A as posing high risk of causing
serious harm to Female A, with a “mandatory” referral to a Multi Agency Risk
Assessment Conference [MARAC] and offers the following as evidence.
 The victim was frightened of the offender
 She was a repeat victim
 The offender was a married man with children
 The victim and offender had been engaged in an extra marital relationship
 The victim had ended the relationship
 The offender was unable to accept the end of the relationship
 The offender had been constantly bombarding the victim with telephone calls
and text messages
 The offender visited her home and sat outside for long periods trying to
contact her
 Despite the previous allegation he had continued to harass the victim
 The offender had been following her
Page 21 of 44
 The offender had threatened her life
 The offender had threatened to kidnap and harm her son
 The offender persistently asked the victim to marry him despite the fact that
he was already married with children
 The offender had not been arrested and therefore was not subject to any
legal constraints.
5.11.8 Victim Support’s six calls to Female A were not answered by her. It is not known
why. Evidence from the combined chronology shows Female A was in contact with
two other agencies at that time. The unanswered calls meant that Victim Support did
not have the opportunity to support Female A or make referrals to other agencies.
5.11.9 No cognisance seems to have been taken of the child protection issue [threat to
kidnap and exposure to domestic abuse] by GMP which compounds the mistake that
prevented PPIU from examining a significant case. The report of 10.10.2010
provided GMP an opportunity to support Female A, which was missed, and to build
up an intelligence picture of Male A’s behaviour. A full history of Male A would have
meant that any risk assessments completed on him would be far better informed.
The converse is true. GMP was in the prime position to identify the child protection
aspect and did not. Neither did any other agency who knew of the matter.
5.11.10 Female A’s family believe that the motive for Male A wanting to take Female A as a
second wife was to persuade her to “drop” the charges against him. The family also
believe that Female C only “agreed” to the marriage on this basis. It is not clear
when the marriage took place as the evidence is conflicting. Female A’s family think
it was about April 2011, whereas GMP believes it to be later in 2011. However it is
the agreement to marry in exchange for dropping the charges that is significant.
Female C and Male F [her father-in-law] told the independent chair/author that they
did not know exactly when the marriage took place and had no notice of it. Male A
told the independent author/chair that the marriage happened on 07.07.2011 and
named the two witnesses. Female C also distanced herself from the suggestion that
she agreed to the marriage as a means of persuading Female A to drop the charges
against Male A. Female C wanted an exclusive relationship with Male A. Male A
described in detail how in the early months of 2011 he actively encouraged Female C
to make friends with Female A. He claimed the motive was to see if exposure to
Female A would alter Female C’s attitude, whereby Female C would accept Female A
into the relationship. Male A claimed that a by-product might be a softening of
Female A’s approach to the charges.
5.11.11 The DHR Panel felt there was a missed opportunity for Female A’s case to be
referred to MARAC and Children’s Services. For MARAC to be successful Female A
would have needed to fully engage with their plan. It is known that at this time
Female A felt her future lay with Male A and she may have been reluctant to distance
herself from him. However, a domestic violence professional could well have
provided her with sufficient information, insight and support to moderate or sever
her association with Male A. The involvement of Children’s Services would also have
provided Female A with information to assist her in making choices and decisions
which would protect Child A.
Page 22 of 44
5.12 Key Event: Female C makes Allegations Against Female A
5.12.1 On 15.10.2010 Female C [Male A’s first wife] reported to GMP that Female A had
threatened her and her children. Female C said she did not feel threatened and just
wanted the calls stopping. Female C was seen the following day and described how
over the last six months Female A had made many annoying and threatening
telephone calls the nature of which escalated. For example about the 08.10.2010
Female C alleged that Female A called saying,” If I see you out anywhere I’m going
to run you and your daughter over “, and the next day called to say, “ I will burn the
house and kill everyone including the kids. Female C claimed that Female A was
pursuing her husband and wanted to marry him.
5.12.2 GMP recorded a “Threats to Kill” crime and coded the incident as “Personal Violence”
a non-domestic abuse code, as the incident did not meet GMP’s domestic Violence
policy. Therefore a 1-12 dataset was not required. GMP’s protocol for non- domestic
violence, but domestic related incidents, is for the information to be disseminated to
interested parties [e.g. PPIU] using the Force Intelligence system. GMP did not
identify the child protection aspect of the call and should, in addition to a domestic
violence code, have included a “Concern for Child” code which would have routed the
incident log to PPIU.
5.12.3 Female A was arrested and described how her husband [Male B] left in February
2010 because of her relationship with Male A. Female A acknowledged the
relationship with Male A was intimate and that she had regular contact with
Female C. However, Female A denied making any threats, claiming Female C’s
allegations were motivated by jealousy.
5.12.4 The Custody Officer determined there was no evidence to support the allegation
made by Female C and that some parts were inaccurate. Therefore s/he decided
there should be no further action against Female A and she was released.
5.12.5 The officer submitted an intelligence report which following evaluation was placed on
Female A’s intelligence profile. There is no information on whether the allegation was
referred to Victim Support or if the potential child protection issues were considered.
Children’s Services told the DHR Panel that this incident should have been referred to
them.
Analysis:
5.12.6 Female C’s allegation was taken seriously and investigated resulting in the arrest of
Female A. While in strict terms the incident did not fit the definition of domestic
violence; it nevertheless had its roots in the complicated world of Female A,
Female C and Male A. The incident was not looked at by PPIU because it fell outside
their remit but would perhaps have benefitted from the scrutiny of a domestic
violence expert see whether it impacted on the risk faced by Female A.
5.12.7 The non-application of a domestic violence code, whilst correct, did not allow GMP to
fully consider all aspects of the report. The application of a “Concern for Child” code
would have flagged the matter to PPIU. A PPIU officer should then have spotted the
potential increase in risk to Female A and the child protection concerns.
5.12.8 The GMP IMR author felt the intelligence dissemination was limited and should have
extended from Female A’s intelligence profile to that of Male A, Female C and their
Page 23 of 44
respective addresses. Addition it was felt that PPIU should have been on the
intelligence circulation list, adding to the view that this incident should have been
assessed by them.
5.12.9 The DHR Panel felt this was a lesson learned: i.e. That some incidents relevant to
ongoing domestic violence situations which do not fall within the definition of
domestic violence, and therefore do not attract a domestic violence code, should
nevertheless be brought to the attention of PPIU, so that risk assessments can be
updated an victims protected. In this case the application of a “Concern for Child”
code would have rescued the situation. However, that code may not be applicable to
all non-definition domestic violence. GMP’s recommendations pick up this point.
5.13
Key Event:
Male A tells GMP that Male B threatened to kill him
5.13.1 On 06.11.2010 Male A contacted GMP via “999” to report that Male B [Female A’s
former husband] and threatened to kill him. It appears they met by coincidence on a
petrol forecourt where it is alleged that Male B said, “If you have anything to do with
[Female A] I will rip you up”. The incident was coded, “Anti-Social behaviour”.
5.13.2 Male B was interviewed denied the allegation. Given the lack of supporting evidence
no further action was taken and the circumstances did not amount to a notifiable
crime. The officers did not submit an intelligence report.
Analysis:
5.13.3 GMP dealt with the incident effectively and perhaps should have submitted an
intelligence log for PPIU given this event was part of an ongoing domestic dispute
between the families. However, it is not known what background information the
officers extracted from Males A and B. Nevertheless, the incident would have
contributed to the overall picture of the relationship between Female A and Male A.
This is another example of a non-domestic violence which would have benefited from
examination by PPIU to see if it impacted on the risk assessment
5.14 Key Event: Female C Discovers Male A is planning to Marry Female A
5.14.1 In June or July 2011 Female C found out that her husband [Male A] was planning to
marry Female A at a local Mosque in accordance with Islamic tradition. Female C
confronted Female A in the presence of Male A and other family members, and
threatened to kill Female A if she did not stop seeing her husband [Male A]. The
meeting became abusive and when Female A turned to Male A for support it is
alleged he assaulted her.
Analysis:
5.14.2 This matter was not reported to the police at the time. It emerged during GMP’s
investigation into Female A’s death. It is however, illustrative of the continuing
volatile relationship between Female A, Female C and Male A, and the involvement of
the families in the situation. Male A “confirmed” the involvement of the families in
trying to get him to end his relationship with Female A.
5.15 Key Event: Male A reports Threats to Smashed Windows
5.15.1 On 17.10.2011 Male A reported to GMP that a male known to him was threatening to
smash his windows. He agreed there was no immediate threat and the matter was
Page 24 of 44
passed to CSD to deal with. GMP was unable to contact Male A and the log was
closed as no further action.
Analysis
5.15.2 This event was included because it might relevant to what was happening in Male A’s
life. He reported knowing who made the threat but did not follow up the matter
when GMP could not contact him. Therefore the motive for the threat and whether it
was executed are unknown. The DHR Panel felt it was likely to be part of the
continuing tensions between Female A and Male A’s families. Male A declined to
expand on this when he was seen in prison.
5.16 Key Event: Male A’s 2nd contact with Mental Health Services
5.16.1 On 06.12.2011 the out of hours GP service referred Male A to mental health following
his presentation with symptoms he attributed to his marital problems.
5.16.2 He was seen on 21.12.2011 by the same mental health practitioner who saw him in
April 2010. He spoke of his significant domestic issues and just wanted his wife to
stop nagging him. He said he had no thoughts of either self harm or hurting others
and declined help. Male A was judged to have the capacity to make informed
decisions and was referred back to his GP. There is no information from Male A’s GP
whether he attended and what services might have been offered or taken up,
because access to his medical records was refused.
Analysis:
5.16.3 It is not known if Male A was referring to Female A or Female C when he spoke of his
wife. In many ways it matters little because the event demonstrates the continuing
turmoil in Male A’s domestic life, the depth of which was significant enough for him
to attend an out of hours GP service. Male A presented as the victim and perhaps
that is how he viewed himself. However, Female A’s family contend he was a
perpetrator and Female A the victim; a position now known to be true. Male A told
the independent chair/author that he did have trouble coping with the stress of the
situation.
5.17 Key Event: Female A tells GP she is trying for a Baby
5.17.1 On 16.01.2012 Female A saw her GP and queried whether she was pregnant,
revealing she had been trying for a baby. The GP made an appropriate referral to
obstetric services.
Analysis:
5.17.2 The basis for this analysis comes from the meeting with Female A’s family. Female
A’s family was not aware that she wanted to become pregnant and felt it was an
attempt to bind Male A to her. It is not known if Male A was aware of Female A’s
desire to conceive. The DHR Panel thought that Female A’s wish to have a child
probably reflected her view that she wanted an enduring future with Male A and that
perhaps a child would also increase her status in the relationship, particularly with
respect to Female C; her rival for Male A’s affection. Male A said the child was
planned by both of them and was part of his wish to have a family with both women.
Page 25 of 44
5.18 Key Event: Female A tells Midwife of Historic Domestic Violence
5.18.1 On 28.02.2012 Female A had her first ante-natal assessment. She told the midwife
she was married [and named Male A as her partner albeit she referred to him by a
different surname] and lived with her husband. Interestingly gave her mother as
next-of-kin.
5.18.2 Female A revealed to the midwife that she had been the victim of domestic violence
two years ago by her present partner but did not want any referrals as there had
been no violence since. See added that the police had been involved at the time. A
“special circumstances” form was submitted to the hospital’s safeguarding team and
GP. It should have been passed to the health visitor but there is no record of it going
or being received. The electronic midwifery database [Euroking] was updated
thereby enabling other midwifery staff to be aware of the previous domestic
violence. The Special Circumstances Form alerts health professionals that a pregnant
woman had been subject to historical domestic abuse. It is known that pregnancy
increases the risk of domestic violence and therefore staff should be more vigilant.
The information was not shared with Children’s Services.
Analysis:
5.18.3 Female A disclosed the domestic violence following a routine screening question. The
disclosure was limited to the domestic situation between Female A and Male A; and
the fact that Male A had another wife and three children. It is not known why
Female A did not expand on her position. Again her family felt it was about
protecting Male A in the hope that she would become his only wife. They thought
she wanted him to return her love.
5.18.4 The Special Circumstances form records her “husband” inflicted domestic violence
two years ago. This very likely refers to the May 2010 incident when the perpetrator
was Male A, who at that time was not her husband. Her partners name is given as
Male A but his date of birth as required by the form is not present. Additionally Male
A’s name as recorded on the screening document is not one that the DHR Panel has
seen him referred to by. It appears Female A was limiting the information she gave
midwifery and may have intentionally mislead them about the identity of Male A. This
trait was seen in one of her dealings with GMP. Her family believe she was subject of
domestic violence at the time of booking her pregnancy; February 2012.
5.18.5 The disclosure by Female A is another example of a piece of information that might
be relevant to Children’s Services, particularly if they were providing services or
undertaking assessments. The DHR Panel felt midwifery faced a fine judgement on
whether to share the information with Children’s Services. It has parallels to the
decision made by mental health professionals not to share the 2008 overdose
information with Children’s Services. [Paragraph 5.4] However, on this occasion a
majority of the DHR Panel thought on balance the information should have been
shared with Children’s Services, believing that midwifery’s actions in raising a Special
Circumstances Form and including the health visitor on the circulation list was
sufficient justification to do so.
Page 26 of 44
5.19 Key Event: Male A “divorces” Female A
5.19.1 At some point in early 2012 [January-March] Male A had a heated argument with
Female A on the telephone and was heard to say, “Talaq, Talaq, Talaq”, meaning “I
divorce you in accordance with his faith.
Analysis:
5.19.2 This event was discovered by GMP during the murder investigation and provides yet
more evidence of the domestic strive between Female A and Male A, and if true
might suggest that Female C was winning the battle for Male A’s sole affections. It
also reflects the controlling nature of Male A and the see-saw situation of his own
making. Male A reflected the call was in response to Female C’s continuing pressure
for him to end the relationship with Female A. He thought it would take the pressure
off him.
Note: Obtaining a divorce under Sharia Law is not as simple as uttering the word
“Talaq” three times. There is an extensive process to follow part of which includes
attempting reconciliation.
5.20 Key Event: Female C tells GMP about her Marital Problems
5.20.1 At 1.0 pm on Sunday 06.05.2012 Female C telephoned GMP via “999” to report
marital problems. She complained that her husband [Male A] was having an affair
with another woman [believed to be Female A]. He was not aggressive to her but
she wanted a divorce. GMP suggested she saw a solicitor. It is known from GMP’s
murder investigation that Female C found out two days before [04.05.2012] that
Female A was pregnant. Female C telephoned Female A and made some very
unpleasant remarks. Male A recalls the incident. The matter was not reported to
GMP.
Analysis:
5.20.2 This event shows a glimpse of the apparent frustration felt by Female C and that she
saw her husband [Male A] as having an affair, a position substantially different from
his view that Female A was his second wife. Female C appears not to have accepted
Female A’s position. GMP’s response was appropriate.
5.20.3 The DHR Panel could not find any independent evidence that Male A was abusive to
Female C which given his controlling nature and known physical violence against
Female A might appear remarkable. Female C’s remark to GMP that he was not
aggressive to her suggests Male A treated the women differently or maybe that their
tolerance levels and acceptance of his behaviour were different. Female C was not
tolerant of his relationship with Female A and brought sustained pressure on him to
end it. However, in interview with the independent chair/author, Male A accepted
that on occasions he did assault Female C because, according to him, she would not
leave him in peace.
5.21 Key Event: Male A tells GMP that Female C has Assaulted Him
5.21.1 At 1.02 pm on Sunday 06.05.2012 Male A telephone [“999”] GMP to report he was
having a domestic with his wife [Female C] and that she had assaulted him by biting
his arm and tearing his clothes; adding there were children and other adults present.
An electronic log was opened and a domestic violence code assigned. As there was
Page 27 of 44
no immediate threat GMP proposed dealing with it later so that resources could be
directed to higher priority calls. GMP kept in touch with Male A by telephone and
officers attended his address about three hours later. When they arrived Male A was
asleep on the settee and Female C was present in the kitchen with her sister. It is
not recorded where the children were or if they were seen. Male A said he learned
later that the child had been taken from the house by his father so they would not be
there when the police came.
5.21.2 The officers saw the protagonists separately and perceived Female C to be the
victim, describing the incident as, “six of one and half a dozen of the other”. They
elicited that the issue was Male A’s continuing relationship with Female A and the
fact that she was now pregnant with his child. Female C said she intended leaving
Male A with their three children to go and live with Male A’s father. When Male A
learned of this he agreed to leave the address and stay with a friend, believing it was
the easiest solution at the time.
5.21.3 The officers did not establish the identity of Female A or the name and address of
the friend. [It is now known that the friend was Female A.] There is no evidence that
they consider the child protection issues for Male A’s own children or the “pregnant
other woman”. They completed a DASH risk assessment judging that Male A posed a
standard risk of harming Female C and the log was closed with a domestic incident
code, thereby enabling it to be picked up by PPIU. The incident was not reviewed by
PPIU staff on Sunday 06.05.2010 because it was submitted after the triage staff
finished work at 5.0 pm. On Monday 07.05.2012 abstractions meant there was a
limited number of staff on duty in PPIU who prioritised their work to deal with high
then medium risk cases. The case was looked at on Tuesday 08.05.2012 by which
time staff knew that Female A had been killed.
Analysis:
5.21.4 The incident described above took place about 32 hours before Female A’s death.
Male A’s call came just two minutes after his wife’s telephone call and attracted an
appropriate response from GMP. The attending officers gather limited information
and dealt with the incident in isolation of the full history. The GMP IMR author
thought that the officers should have considered HBV given the circumstances of the
incident. It is not known why they did not. Despite the fact that children were
reported to have been present during the actual incident no consideration seems to
have been given to where they were or the impact on them. Male A had reported
being assault and having his property damaged by Female C yet somehow the
attending officers identified Female C as the victim; concluding Male A posed her a
standard risk of causing harm; that was probably the right conclusion but over
looked Male A’s victimisation and more importantly did not consider Female A’s
position or that of any children.
5.21.5 GMP’s IMR notes, “The risk assessment did not include Male A’s history of violence
with Female A, nor did it address the issue of “the other woman”, her pregnancy and
how that third party dynamic might affect a risk assessment of the potential for any
of the parties concerned coming to harm, nor did it address the potential issue of
HBV and whether there was a heightened risk because of the family’s perception of
‘honour’ and how it should be upheld”. It is known from research that pregnancy
increases the risk of domestic violence as demonstrated in case.
Page 28 of 44
Lewis, Gwynneth, Drife, James, et al. (2001) and (2005) Why mothers die: Report(s)
from the confidential enquiries into maternal deaths in the UK 1997-9 and 2000-2002
5.21.6 The DHR Panel felt that the officers did not identify the underlying key issues,
thereby restricting their ability to make informed risk assessments on the relevant
people. The real person at risk, as evidenced by the known history, was Female A.
The officers failed to recognise the importance of “the other woman” and never
establish her identity, hence no risk assessment on her. The staffing levels in PPIU
did not provide the safety net to rectify the situation. Abstractions from specialist
services are a normal every day event brought about by higher priority demands
from other parts of the Force. Had the incident with Female C been risked assessed
by a domestic abuse specialist in PPIU on Monday 07.05.2012, using all the
information known to GMP, it is likely that Female A would have been identified as
the person at real risk and that risk would have been high. This would have
prompted contact with Female A, a referral to Children’s Services and MARAC. As it
was, that opportunity was missed because the standard risk assessment assigned to
the incident by the attending officers meant the case never reached the top of the
PPIU’s “in tray” on Monday 07.05.2012. Thereafter, events were overtaken by the
death of Female A.
5.21.7 The DHR panel has observed that the attending officers dealt with the immediate
domestic problem between Male A and Female C adequately, albeit they selected the
wrong person as the victim. However, they failed to recognise the significance of
what they were told them about the cause of the incident and consequently failed to
identify three significant risk indicators, viz:
1. They did not identify Female A as ‘the other woman.’
2. They did not identify Child A and the fact that Male A had previously
threatened him.
3. They failed to identify that it was to Female A that Male A intended to go.
5.21.8 This was considered a weakness in their thought processes, resulting in no steps
being taken to safeguard Female A and Child A.
5.21.9 The overlooked historical evidence clearly indicated that Female A and Child A were
the individuals to whom Male A really posed a risk. The panel felt that the recorded
incidents of domestic violence between them in 2010 placed that risk in the ‘high’
category.
5.21.10 The panel also considered that the absence of PPIU staff to triage the incident in
live time on that Sunday evening effectively removed the safety net that may have
rectified the situation and that abstractions from the PPIU staffing levels on the
following morning compounded the issue.
5.21.11 The DHR panel felt that had the responding officers identified, Female A and Child A
and the history of domestic abuse, they would have judged the situation to be a high
risk, thereby ensuring it received attention from PPIU on Monday. This would have
allowed a specialist within that department to carry out a fully informed risk
assessment with the likely outcome that Female A would have been contacted by
specialist staff that day [Monday] and referrals made to Children’s Services and
MARAC. However, staffing levels within PPIU on the Monday meant that only High
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and Medium cases were re-assessed by specialist staff. The standard cases were
deemed a lower priority.
5.21.12 The DHR panel do not believe that, the attending officer’s oversights and the
associated missed opportunities as detailed above, contributed to the death of
Female A. It was considered that GMP’s recommendations, to review the DASH risk
assessment check list, to help busy front line response officers gather all the relevant
material and to review its domestic violence awareness training program, were a
sensible response to the identified weaknesses.
5.22 Other Points of Note
5.22.1 GMP recorded statements during the murder investigation in which they were told
that at noon on Monday 07.05.2012 Female C telephoned Female A’s mother telling
her she intended to get Female A killed. If true it is illustrative of the mounting
tensions and was not known to any agency in real time.
5.22.2 At an unknown time on 07.05.2012, one of Female A’s sisters confronted Female C in
her house asking why she was behaving inappropriately when she had previously
agreed to her husband [Male A] marrying Female A.
5.22.3 The sister contended it was to ensure Female A dropped the charges against Male A.
Male F and his wife were present. Male F said he was with Male A when he made the
“divorce” telephone call to Female A, adding the divorce could not be recognised as it
had been done in anger.
5.22.4 Female C was very concerned about the date of Female A’s conception, wanting to
know was it before or after the “divorce” telephone call. Female A’s sister said it
could only have occurred after that telephone call; the inference being Male A had
been intimate with Female A after the “divorce”. Female C is alleged to have said
that if her brothers had been present both Male A and Female A would be dead. It is
not known who the “brothers” are.
5.22.5 It is known that Female A was 18-19 weeks pregnant at the time of her death. That
fixes conception between the 26.12.2011 and the 02.01.2012. The date of the
“divorce” is judged to be between January and March 2012. Therefore it is more
likely than not, that conception took place before the “divorce”.
5.22.6 When the DHR independent chair/author saw Female C and Male F it was apparent
that they felt Male A was behaving inappropriately to Female A and Female C by
continuing a simultaneous relationship. His Father believed he should have made a
choice between the two women and reflected that many people in similar situations
do so.
5.23 Motive for the Murder of Female A
5.23.1 It is not a specific purpose of domestic homicide reviews to determine the
perpetrator’s motive. However, the DHR Panel felt that knowing why Male A killed
Female A would inform its work. Male A pleaded guilty to murder, saying in court
that he had a “fight” with Female A and just snapped. Male A told the independent
chair/author that in the weeks leading up the death, he was under intense pressure
from his extended family to end the relationship with Female A. He recalled several
visits from family members who travelled from other areas of the country to speak
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with him. He also remembers talking with a well respected senior member of his
family in Pakistan who urged him to finish the relationship with Female A. Male A
added this was the only time in his life he failed to follow that person’s advice.
5.23.2 In a call to police before giving himself up, the court heard Male A told officers: "We
had a fight. She picked a knife up and she told me she was going to kill my baby or
I'll kill you. "We ended up having a fight and I ended up grabbing the knife and
shoving it in her - that's what I did." Female A suffered 15 stab wounds, including
two punctures to her heart and wounds which went through her body and injured
her spine. Source: www.bbc.co.uk This is suggestive of a sustained attack.
5.23.3 The DHR Panel did not know why Male A’s violence escalated to a grave level.
However, it is known what events had and were happening in his life, and it is
reasonable to say he was probably influenced by them. These events include:
 His history of domestic abuse against Female A
 His history of largely getting his own way
 Pressure from his family to end the relationship
 Recent and significant pressure from Female C to end the relationship
 Female C’s very recent refusal to allow him to attend his son’s birthday
celebrations
 Recent confrontation between Female A’s family and his family
 Female A’s pregnancy
 His history of being unable to cope adequately with his chosen lifestyle
5.23.4. When Male A’s history and escalating pressures are considered alongside the high
risk he posed to Female A, there begins to emerge the framework within which he
committed the fatal act. It might be that Female A had finally decided to end the
relationship for good, thereby wrestling control and dominance from Male A.
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6.
ANALYSIS AGAINST TERMS OF REFERENCE
6.1
Introduction
6.1.1 Each term of reference is commented on from material in the IMRs, the debates of
the DHR Panel and the views of family members. Some commentary could fit into
more than one term and the decision on where it appears was made on a best fit
basis.
6.1.2
The terms appear in bold italics followed by an analysis.
6.2.
Term 1
Were the risk indicators of domestic abuse present in this case recognised;
appropriately assessed and responded to in providing services to Female A
and Male A and where applicable Child A, B, C and D ?
6.2.1 The following agencies had opportunities to recognise and respond to risk indicators:
GMP, Victim Support, Mental Health, GP, Homelessness Advice and Prevention
Service and Midwifery.
6.2.2 GMP had three opportunities; May 2010, October 2010 and May 2012. Their
response was mixed. The incident in August 2010 where Female A was followed by
a taxi driver was not dealt with as a domestic incident, a decision the DHR Panel
judged defensible. Therefore it does not appear in this “opportunities” list.
6.2.3 The May 2010 incident was the only one reported to GMP where Male A had been
physically violent to Female A. They recognised it as domestic abuse and took
positive action, including referring Female A to Victim Support. The risk assessment
as determined by a specialist domestic violence officer from PPIU revealed that
Male A posed a standard risk of harming Female A. The GMP IMR Author felt that
even at this stage there were enough indicators to assess the risk as high. The DHR
Panel thought that on balance a risk assessment of medium rather than standard or
high was appropriate. The risk indicators were:
 The offender was a married man with children;
 The victim and offender had been engaged in an extra marital relationship for
5 years;
 The victim had ended the relationship a month prior to the incident;
 The offender was unable to accept the end of the relationship;
 The offender had been constantly bombarding the victim with telephone calls
during the previous month;
 The offender had slapped the victim 3 days earlier;
 The offender had followed the victim for about ten miles;
 The offender had not been processed as a suspect and therefore was not
subject of any legal restraints.
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6.2.4 Had Female A been assessed as being at high risk of harm from Male A additional
services would have been offered and actions taken. These might include, personal
attack alarms, flagging of her address and access to support networks. A referral to
MARAC would have been made. The incident should have been referred to
Children’s Services. The GMP IMR author believes that specialist assessors within
PPIU failed to recognise the significance of the above indicators, resulting in a
standard risk assessment response. It has not been possible to identify the staff
concerned and obtain their views, because the practice at that time did not require
their names to be recorded on the database.
6.2.5 There is no evidence that PPIU staff referred, or thought to refer, this incident to
Children’s Services. It clearly should have been, but the flaw in not doing so lay in
the poor collection and assessment of information by GMP.
6.2.6 The second opportunity for GMP came in October 2010 when Female A attended a
police station to report that Male A had threatened to shoot her and kidnap her son
[Child A]. This is a serious allegation from a known victim of domestic abuse and
should have had a priority response. GMP’s assessment of the initial report failed to
identify the seriousness of the situation or recognise Female A as a repeat victim.
The incident was then allocated to the CSD for a slower time response. It took GMP
almost four days to obtain a statement. The reasons for the lengthy delay are
explored in detail in its IMR. The attending officer assessed the risk to Female A as
“medium”. The incident log was closed with a non-domestic violence code, meaning
that the specialist domestic violence assessors in PPIU were denied the opportunity
to review the risk. The alternative code of “Concern for Child” could have been used,
resulting in the incident log being routed to PPIU.
6.2.7 The GMP IMR author lists multiple points arising from the incident which should have
been spotted by a PPIU domestic violence assessor, resulting in Female A being
assessed as facing a high risk of harm from Male A and referred to MARAC.
6.2.8 On a positive note, GMP arrested Male A and charged him with two offences. He was
granted bail by the court with restrictions on contacting Female A. This provided
some level of protection for her, but the more comprehensive package of protection
available for high risk victims was absent.
6.2.9 The third and final opportunity for GMP to assess the risk to Female A came on
06.05.2012, the day before her death. GMP attended at Male A’s address after he
reported being assaulted by Female C [his first wife]. The officers dealt with the
incident but did not make the link between Male A and Female A despite discovering
that the domestic argument between Male A and Female C had been over, “another
woman” who was pregnant. It appears it just did not occur to them to ask. The
officers were partly wrong footed because Male A’s history of domestic abuse was
not flagged on his intelligence record or the Police National Computer because he
was not assessed as being high risk. The consequence of this was that Female A’s
risk was not assessed. Additionally, the officers recorded Female C as the victim
despite the allegation of assault coming from Male A.
6.2.10 The officers used a domestic violence code to close the log, enabling it to be
identified by PPIU specialist assessors. The PPIU staff left work at 5.0 pm on Sunday
06.05.2012 before the log was submitted. The standard assessment assigned to it
by the attending officers meant that on Monday 07.05.2012, the log did not reach
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the top of the priority queue because of the limited number of assessors working in
PPIU that day and consequently was not assessed.
6.2.11 The DHR Panel thought that GMP’s initial response to the domestic incident between
Male A and Female C on Sunday 06.05.2012 would have been better if they identified
the link between Male A and Female A and taken account of their history when
completing the immediate risk assessment. Identifying Female C as the victim
appears to contradict the original call from Male A saying he had been assaulted. The
DHR Panel concluded that the risk to Female A was high and not standard as
assessed by the attending officers.
6.2.12 If the initial response officers had assessed the risk as high or medium the incident
would have been re-assessed by PPIU staff before the death of Female A. It is likely
that referrals would have been made to MARAC and Children’s Services. However,
there was no indication in either the incident on Sunday 06.05.2012 or the more
distant history, that the treat of serious harm to Female A by Male A was imminent.
Therefore, cause and effect between GMP’s assessment of events on Sunday and
Female A’s death on Monday cannot reasonably be made out.
6.2.13 Victim Support received a referral for the May 2010 incident with the risk indicators
identified and referred the case to HAPS. At that time Victim Support did not use a
risk assessment model, whereas now they employ CAADA/DASH. This would identify
the link between domestic abuse and child protection, resulting in a referral to
Children’s Services. Victim Support also received a referral for the 10.10.2010
incident but was unable to contact Female A and closed the file after notifying GMP.
6.2.14 The same Mental Health professional saw Male A on two occasions; April 2010 and
December 2011. Whilst he disclosed his “affair”, he withheld his history as a
perpetrator of domestic abuse. He was judged not to be suffering from mental illhealth, but needing better strategies to cope with the stressors in his life. He was
also judged not to be a danger to himself or others, nor susceptible to exploitation.
Ideally Children’s Services could have been informed but the DHR Panel felt the
decision not to do so was defensible.
6.2.15 HAPS received a referral from Victim Support in June 2010 requesting, “an
assessment for support” and “assessment of risk” on Female A and visited Female A
in her home They offered advice and installed physical security measures. No
consideration was given to the child protection issues, because at the time staff were
not trained beyond a basic degree.
6.2.16 At the end of February 2012 Female A disclosed to midwifery during routine
screening that she had been the victim of domestic violence two years previously but
not since. From what her family say that was a misleading statement. She said she
did not require a referral to agencies. A Special Circumstances form was completed
and passed to the hospital Safeguarding Team with a copy to the GP and health
visitor. It appears no consideration was given to sharing that information outside of
midwifery/GP/health visitor. The health visitor never received the form. The DHR
Panel felt that midwifery could have shared the information with Children’s Services
particularly as they felt it necessary to raise a Special Circumstances Form.
6.2.17 The GP IMR author notes that Female A presented to GP services on a number of
occasions with injuries which in hindsight may have indicated she was a victim of
Page 34 of 44
domestic abuse. She did not identify herself as a victim and the accounts she gave
appeared consistent with the injuries.
6.2.18 The GP received the Special Circumstances form from Midwifery. There is no
evidence within the GP record that further information was sought or that measures
were taken to ensure that a full risk assessment was made in relation to possible
harm befalling Female A or Child A; neither, it appears, did the GP ask any agency
for further information. Midwifery seemed to have been reassured by Female A that
the domestic violence was in the past and therefore no current action was needed.
Victims are not always best placed [albeit their views should always be sought and
considered] to assess the risk they face and professionals should factor this into their
decision making.
6.2.19 The GP refused to share information on Male A, a response which is not helpful to
learning lessons from domestic homicide reviews. For example it is not known
if Male A revealed any relevant material and whether the GP recognised it. Also, was
Male A given advice or offered services, and did he take them up?
6.2.20 No other agency who had contact with Female A or Male A had any information
which suggested Female A was at risk from Male A. In particular, school health did
not see any indicators of domestic abuse. It might be argued that when Female A
went to A&E with chest pains, the cause of her sore ribs should have been explored;
something caused the pain.
6.2.21 It is apparent that Female A’s family knew she was the victim of violence at the
hands of Male A and made the very difficult choice of not going to the police in
deference to her wishes and for fear of what Male A would do to her additional harm
when he found out.
6.2.22 Male B discussed his concerns for Child A’s safety with Female A who reassured him
that she would never let Male A touch him. The Royal College of Psychiatrists [2004]
identified a whole range of effects on children who witness domestic abuse;
depression; anxiety; nightmares and flashbacks; problems at school; lower sense of
self-worth adding, children may also feel angry, guilty, insecure, alone, frightened,
powerless or confused. They may have ambivalent feelings towards both the abuser
and the non-abusing parent. Male B says that Child A expressed relief and felt safe
after hearing of Male A’s sentence.
6.3
Term 2
Were the services provided for Female A and Male A timely, proportionate
and ‘fit for purpose’ in relation to the levels of risk and the need that was
identified? Was there sufficient focus on reducing the impact of Male A’s
abusive behaviours towards Female A and were the reasons for Male A’s
abusive behaviour properly understood and addressed?
6.3.1 The depth of the domestic abuse between Female A and Male A was not known to
any agency and therefore the services that were offered were limited to the assessed
risk, which never got beyond standard until the day before her death. It is known
from the preceding paragraph [6.2] that the standard risk assessments were
inaccurate.
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6.3.2 As a standard risk victim Female A received the following services:
 In May/June 2010 and October 2010 GMP investigated her allegations and
arrested Male A. He was charged with offences following the October
incident and given conditional bail which provided a protective factor for
Female A.
 Victim Support provided emotional support, personal safety advice, including
the provision of a personal alarm and a referral to HAPS, a specialist domestic
abuse service for the May 2010 incident. Their response was proportionate.
 HAPS provided additional security measures for Female A’s property in line
with their assessed low risk; therefore the services were proportionate and fit
for purpose.
 Midwifery provided an opportunity to Female A to talk about domestic
violence but received reassurances from her that what happened was a one
off, two years ago.
6.3.3 It is very unusual, if not rare, for agencies to offer, non-convicted perpetrators of
domestic violence, services to address their offending behaviour. This was the case
for Male A. Therefore it is not known why he was abusive and no agency engaged
with him to identify a solution. There was no requirement for them to do so. Male A
told the independent chair/author that he became frustrated with the situation and
felt that Female C should have accepted Female A into the relationship and was not
reasonable in opposing it.
6.3.4 Even if Female A’s case had been referred to MARAC, the focus of its work would
have been to protect the victim by making it difficult for Male A to harm her. He
would not have received services to address his offending behaviour.
6.3.5 The DHR Panel felt the lack of services for non-convicted perpetrators of domestic
violence was woeful, leaving agencies to tackle the problem from the victims’ side
only.
6.3.6 Male A was offered services to help him cope with the stressors brought about by the
domestic turmoil he placed himself in, but that is significantly different to addressing
his offending behaviour. In the event he even declined that offer.
6.4
Term 3
Were arrangements made to determine the wishes and feelings of Female
A about her circumstances and were these taken into account in the
provision of services and support?
6.4.1 There is substantial evidence that agencies asked Female A what she wanted, albeit
the substantive response by GMP to the October 2010 incident took four days. This
has to be balanced by some extensive notes made by GMP officers when detailing
the history of domestic abuse between Female A and Male A.
6.4.2 GMP, Victim Support, RABS, and Midwifery have evidenced in their IMR’s that they
actively sought Female A’s thoughts and took these into account when offering or
delivering services. For example Midwifery noted and acted on Female A’s wish not
to be referred to services.
Page 36 of 44
6.4.3 Female A made very limited disclosures to agencies on the extent of the physical
violence she suffered. Her family believed this was because she saw her future with
Male A and did not want to get him into trouble. It seems Female A tolerated the
abuse in an attempt to win him over, an approach all too common in domestic
violence relationships.
6.4.4 No agency seems to have considered what Female A thought about her son living in
a situation where it was likely he was exposed to domestic violence. This is a
significant oversight by all.
6.5
Term 4
Were single and multi-agency policies and procedures adhered to in the
management of this case? Are single agency policies and procedures ‘fit
for purpose’ in safeguarding and promoting the welfare of victims of
domestic abuse and is there evidence that they are embedded in practice?
6.5.1 All agencies, contributing to this DHR, including Rochdale Safer Communities
Partnership have domestic violence policies and all, with the occasional exception of
GMP, followed them. Some agencies report that their domestic violence policies
have been amended as part of a continuous improvement regime. For example
Pennine Care NHS Foundation Trust is harmonising its domestic abuse policies.
6.5.2 Victim Support followed its policy and reflects that when Female A reported she was
still being harassed by Male A in June 2010 it could have referred the matter to GMP,
instead of offering advice to her. Additionally it thought it should have checked with
GMP that Female A had contacted them. Both of those points are within the scope of
the existing policy. Victim Support’s self-reflection is evidence of an organisation
willing to learn from practice.
6.5.3 GMP domestic violence policies are fit for purpose, albeit there were compliance
lapses by some staff. These lapses were around call handling, prioritisation and
closing codes on domestic violence logs. The GMP IMR makes two recommendations
for policies to be reviewed; “Incident Response Policy” and “GMP DASH Risk
Assessment Check List”. Additionally it recommends that the PPIU Handbook is
reviewed to help staff understand the role of “intelligence” and “The Role and
Responsibilities of Staff”
6.6
Term 5
Was information sharing and communication with other agencies
regarding Female A, Male A and Child A effective? Is there evidence of
inter-agency co-operation and joint working in the management of this
case?
6.6.1 There was good liaison between Victim Support and RABS, including checks to
ensure agreed actions had been completed. The systems for referring cases from
GMP to Victim Support worked well.
6.6.2 Midwifery raised a Special Circumstances Form and shared it with the GP [and
wanted to share it with the health visitor] but not with any other agency.
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6.6.3 The evidence of joint working was limited and information sharing was limited. HAPS
conducted a joint visit to Female A’s house in 2010. There was no inter-agency
management of the case, because the risk assessments wrongly judged that the case
did not meet the threshold for referring to MARAC.
6.6.4 The DHR Panel believed that several opportunities were missed to share information
with Children’s Services; some of these were marginal others not. The marginal ones
include: Mental Health following his overdose of paracetamol tablets, midwifery’s
knowledge of historical domestic abuse. The clearer examples of where referrals
should have been made include: GMP after the May 2010 assault on Female A and
the threats to kidnap Child A in October 2010. However, it is not believed that these
lapses contributed to Female A’s death.
6.7
Term 6
Did practitioners working with Female A, Male A and Child A receive
appropriate supervision and support? Was there adequate management
oversight and control in this case?
6.7.1 No agency [GMP apart] reported any issues with the supervision or management of
staff.
6.7.2 The GMP IMR author comments that its supervision of the closing codes of incident
logs [FWIN – Force Wide Incident Number] did not pick up on the errors made by
staff and makes a recommendation that the Incident Response Policy be reviewed.
6.8
Term 7
Were there any racial, cultural, linguistic, faith or disability issues that
needed to be taken into account in the assessment and provision of
services to Female A, Male A and Child A? How were these issues managed
within your agency?
6.8.1 Female A, Male A and Child A are all Asian-British Pakistani, living and, where
applicable, working in the same community. The Local Authority says that 20% of
the people are from the Black and Minority Ethnic Group [BME] with the majority
being Pakistani. It is known from family members that Female A, Male A and Child A
are Muslims.
6.8.2 The DHR Panel members reported that their agencies were very familiar working
with people from a diverse background and that their dealings with Female A, Male A
and Child A did not pose any problems caused by their ethnicity or faith.
6.8.3 The DHR Panel considered whether there was an element of HBV associated with the
death and concluded they saw no evidence that Male A’s actions were connected
with HBV.
6.8.4 The DHR Chair/Author discussed HBV with the families, including Male B, and asked
them directly whether they thought it was an issue in this case. The families
rejected the notion, believing the matter was simply domestic violence set against
the difficulties of a complex relationship between two adults who each wanted
different outcomes. Male B and Male F independently thought that the explanation
offered by Male A for the homicide did not seem credible, but could not identify a
motive or reason for it.
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6.9
Term 8
Were there any issues in relation to capacity or resources within your
agency that affected the ability to provide services to Female A, Male A or
any of the children or to work with other agencies?
6.9.1 On Monday 07.05.2012 the number of specialist staff on duty in PPIU was limited in
because of shortages caused through abstractions, and the standard priority
assigned to the incident from 06.05.2012 meant it was not processed on the
07.05.2012.
6.9.2 The Customer Service Desk officer who closed the October 2010 log without
endorsing it with a domestic violence code openly reflected that she was not used to
dealing with domestic violence incidents as they should normally be dealt with in real
time. This lack of experience coupled with the constant pressure faced to keep open
logs to a minimum, contributed to her closing the log without a domestic violence
code.
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7.
LESSONS LEARNED
7.1
Introduction
7.1.
Only two agencies reported under the term Lessons Learned; GMP and the GP. The
DHR Panel identified a number of other lessons which appear below.
7.2
DHR Panel
1. Professionals, who omit to collect, record and consider all information
relevant to victims of domestic violence, are more likely to produce inaccurate
assessments or underplay the risks faced by the victim; leading to the
provision of inappropriate, or no services.
2. Fine judgements often have to be made when deciding whether to refer a
family to Children’s Services. This can lead alternatively to overloading
Children’s Services with inappropriate detail or denying them the opportunity
to support families.
3. Nearly all the professionals involved in this case overlooked, or did not
recognise, the link between domestic violence and child protection, and given
that the events were relevantly contemporary [April 2010 to May 2012] The
DHR Panel thought it surprising, but could not identify a reason. The lesson is
for professionals to remain vigilant and recognise the child protection issues
when dealing with domestic violence.
7.3
GMP
1. That a domestic violence incident is not suitable for response by the
Customer Service Desk which deals with incidents in slow time, because of
the dynamic nature of domestic abuse.
2. That incorrect closing codes applied to domestic violence incidents can inhibit
the identification of domestic incidents by PPIU and in this case the
supervisory check failed to spot the error.
3. That officers in this case did not actively consider HBV when dealing with the
incidents and the DASH risk assessment does not specifically deal with the
point or prompt an officer to consider it.
4. That the Handbook used by PPIU officers may not contain sufficient guidance
for Specialist Domestic Violence investigators or their supervisors, meaning
that in some cases relevant risk assessment factors could be overlooked.
7.4
GP
1. The lack of awareness of domestic violence and the need to complete risk
assessments did not support Female A who was the victim of domestic
violence.
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8.
CONCLUSIONS
8.1
Female A and Male A knew each other since childhood and the relationship became
intimate around the time Female A left school. They married separate partners, but
continued the intimacy, with some breakdowns in the relationship, until Female A’s
death.
8.2
Neither of their families approved of their liaison and Female A’s husband [Male B]
divorced her when he discovered her infidelity. It was reported by Male A, that his
wife [Female C] was opposed to the situation which caused a high degree of
animosity between all concerned.
8.3
Female A was in the middle of an extremely complex domestic situation. She was
caught between her love for Male A as evidenced by her becoming his second wife
and wanting a child together and, what her family believed to be his attitude of
“stringing her along”, with no intention of leaving his first wife. Male A reports that
Female A was very willing to “share” him with Female C, a notion she appears to
have strongly rejected.
8.4
The history of domestic violence between Female A [victim] and Male A [perpetrator]
known to GMP was limited to two incidents in 2010; one involved physical violence,
the other harassment. Some other agencies knew of both matters but only as a
result of referrals from GMP. In 2012 Female A disclosed to midwifery that she had
been a victim of domestic violence two years earlier but not since. That was untrue
according to her family.
8.5
After Female A’s death her family and Male B, described a far greater level of
violence, both in intensity and frequency, than was ever disclosed to any agency.
The family reluctantly respected Female A’s wishes not to report the violence to the
police. They knew she aspired to a life with Male A, and understood from her that
reporting the violence would prejudice her chances of success. The family was also
fearful that Male A would inflict greater violence on her as a reaction to police
involvement. Male A acknowledged that he also perpetrated domestic abuse on
Female C.
8.6
GMP’s assessment of the risk faced by Female A was understated. The reasons for
the understatement arose because staff did not fully recognise the risk factors,
combined with the harassment case not being routed to a specialist domestic
violence assessor. The case was never referred to MARAC and the agencies to which
it was referred did not challenge GMP’s assessment. No agency adequately
considered the child protection aspects of the case and consequently no referral was
made to Children’s Services.
8.7
Female A was provided with safety advice and practical measures to make her home
more secure. Male A was charged with harassment and common assault and his bail
conditions provided protection for Female A. However, it appears Male A frequently
broke the conditions and Female A did not report him. The fact that Female A
wanted the relationship to end, suggests that Male A’s account of Female A being
content with her role in the affair may be overstated. However, there is evidence
that Female A fluctuated in her resolve and kept falling under his control and
influence.
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8.8
This influence extended to such a degree that Male A persuaded Female A to be his
second wife and they were married in a Mosque in accordance with their faith. It is
not known whether Female C knew of the marriage at the time. Female A’s family
firmly believe that the marriage was engineered simply to pressure her into dropping
the charges against him. Female A made a statement withdrawing her support for
the prosecution and Male A was formally found not guilty in June 2011. This formal
finding of not guilty indicates that the prosecution was halted fairly late in the
process, perhaps suggesting that Female A finally succumbed to Male A’s pressure on
the promise of marriage which Male A reports as taking place in July 2011.
8.9
Thereafter, the relationship openly resumed and the turmoil between Female A, and
Male A continued. Female C was unhappy with the situation and there is evidence
captured by GMP post Female A’s death that the two families were very unhappy
about the continuing relationship between Female A and Male A, and solicited them
to stop. Male A states that significant family pressure was placed on him to end the
relationship. He claimed to have resisted; even denying a request to end the
relationship by a favoured relative in Pakistan.
8.10
Female C was incensed when she discovered that Female A was pregnant to Male A
and the pressure increased on Male A. Very unpleasant verbal exchanges took place
between the families and on the day before Female A’s death, Male A reported to
GMP he was the victim of domestic abuse, committed by Female C as a result of his
relationship with “another woman”. GMP dealt with the matter by way of advice
and an agreement that Male A would leave the property for the night. GMP did not
identify the “other woman” [Female A] and missed a final opportunity to undertake a
risk assessment on here.
8.11
The DHR Panel discussed whether the case had an element of HBV and note that
there is no evidence that it was considered by GMP or any other agency who knew of
the situation between Female A and Male A. HBV was not an issue at trial [Male A
pleaded guilty to murder]. The families do not believe her death was connected with
HBV.
8.12
The DHR Panel concluded that Female A’s pregnancy was seen by Female C as a
significant threat to her marriage as evidenced by her reaction when she found out.
It cause a domestic argument between Female C and Male A and two days before
the death he stayed with Female A who asked her sister to leave to make room for
him. On the day of the death Female C declined Male A’s request to attend his son’s
birthday. The reason for Male A killing Female A still remains unknown but is very
likely to be bound up with his inability to find or accept a solution to his marital maze
and his tendency to control the two women in his life.
8.13
An opportunity was missed to assess Female A as being at high or medium risk of
serious harm on the day she died. However, there was nothing to indicate that the
risk was imminent and the level of violence would be fatal. The DHR Panel
concluded that the errors and oversights identified in this review did not contribute to
the death of Female A or that it could have been reasonably foreseen or prevented.
Male A alone is responsible, a fact supported by his conviction for her murder.
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9.
RECOMMENDATIONS
9.1
Single Agency
9.1.1 GMP
1.
For the Operational Communications Branch Commander to commission a review of
the organisation’s policy document entitled “Incident Response Policy” with the
specific objective of ensuring that it contains a detailed description of the requisite
supervisory and quality assurance processes that must be applied before an
electronic incident, regardless of from where it is being managed, can be finalised,
closed and archived. Once completed for the document to be published and
forwarded to all stakeholders to ensure compliance.
2.
That the Public Protection Division Commander commissions the development of a
mandatory refresher course for tackling, Domestic Violence, HBV and Stalking /
Harassment with an emphasis on the content of the DASH risk assessment check list,
the use of the FIS, the importance of identifying all risk indicators including HBV
regardless of who the potential victim might be and highlighting the services that can
be supplied by other agencies. To be delivered to front line officers during the
monthly scheduled training days.
3.
That the Public Protection Division Commander considers the content of this IMR
with a view to commissioning an amendment to the GMP DASH risk assessment
check list so that item 28 also specifically asks the following questions:
Is the perpetrator involved in any other intimate relationships?
Is there a pregnancy or any other children involved?
And, if the response to either of the two questions is in the affirmative,
How do the victim and / or their family feel about it?
4.
That the Public Protection Division Commander considers commissioning a review of
the PPIU handbook with a view to including brief overview of using intelligence to
identify risk to third parties and guidance to identify risk indicators for HBV.
5.
That the PPB Commander considers commissioning a review of the PPIU handbook
and PPIU induction document with a view to including a description of the Specialist
Domestic Violence Investigators investigative, supervisory and quality assurance
responsibilities with emphasis placed on the Triage Desk role and enhanced risk
assessment process.
9.1.2 GP
1.
GPs must undertake training in domestic violence in order to understand the role
which they play in early identification and response
2.
There is a need for single agency domestic violence policy for GPS. This must include
recognition and response, risk assessments and the need to consider children and
other vulnerable people.
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3.
The Clinical Commissioning Group must take action to ensure that GPs are aware of
their duties to share information for statutory reviews.
9.2
DHR Panel
1.
That Rochdale Safer Communities Partnership reinforce with it member agencies the
well established link between domestic violence and child protection and the need to
share information to safeguard and promote the welfare of children.
END OF REPORT
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