Domestic homicide review relating to the death of Alina - executive summary

The Review Panel members and the Safe in the City Partnership (the Brighton & Hove Community Safety Partnership) offer their deepest sympathy to Alina’s parents for the sudden loss of their daughter.

We further extend our condolences to all those who have been affected by the death of Alina, and thank them, together with the others who have contributed to the deliberations of the Review, for their participation, generosity of spirit and patience. It is clear that Alina is greatly missed.

1.1

Domestic Homicide Reviews (DHRs) were established on a statutory basis under Section 9 of the Domestic Violence, Crime and Victims Act (2004).

1.2

The purpose of a 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 identify what needs to change in order to reduce the risk of such tragedies happening in the future to prevent domestic homicide and improve service responses for all domestic violence victims (including stalking victims) and their children through improved intra- and inter-agency working.

1.3.

This Domestic Homicide Review (DHR) examines the circumstances leading up to the death of Alina (not her real name) who was murdered in August 2016 by David (not his real name). The decision to undertake a DHR was made by the Safe in the City Partnership (Brighton & Hove’s Community Safety Partnership) in consultation with local specialists. The Home Office was duly informed on 28th August 2016, with a further update provided in January 2017 regarding timescales. An independent Chair was appointed at the end of October 2016 and the Panel met for the first time in January 2017 where IMRs were commissioned and agencies advised to implement any early learning without delay. In consultation with the Senior Investigating Officer, it was decided to delay some aspects of the DHR, such as meeting with family members and other witnesses, until the criminal investigation had concluded. Three further meetings of the Panel were subsequently held in March, June and July 2017. The timing was arranged to reduce the burden on partners as there were other DHRs, commissioned by a neighbouring local authority area, which overlapped with this Review. This enabled attendance at Panel meetings.

2.1.

Persons involved in this DHR:

Name: Alina 

Gender: Female

Age at time of murder: 19

Relationship to victim: Victim

Ethnicity: White UK 

Name: David 

Gender: Male

Age at time of murder: 27

Relationship to victim: Perpetrator / on-off boyfriend

Ethnicity: White UK 

Name: Andy

Gender: Male

Relationship to victim: Occasional intimate partner

Name: Simon

Gender: Male

Relationship to victim: Boyfriend 

Name: Kevin

Gender: Male

Relationship to victim: Work colleague and close friend

Name: Jane

Gender: Female

Relationship to victim: David's mother

2.1.1.

Neither Alina nor David had children.

2.1.2.

Initially this case was known as Adult H in Brighton & Hove but subsequently the name ‘Alina’ was chosen as a pseudonym. The family were offered the option of choosing a name but decided not to do so.

2.1.3.

This report also includes examination of a number of instances where David was reported to the police by women and girls although it should be noted that almost all of these were not reported to any professional until after the murder of Alina.

2.2.

Summary of the case

2.2.1.

Alina was 19 years old and shared a bungalow with two friends near Brighton. Alina’s bedroom was on the ground floor at the rear of the property.

2.2.2.

Alina had a boyfriend called Simon. They had been seeing each other for about four years but after Alina started a new job in July 2015, she was approached by an older work colleague called David who took an immediate interest in her. Within weeks they began seeing each other. Approximately ten weeks before the murder, Alina and Simon split up but got back together again about a month later. Alina continued to see David throughout this period.

2.2.3.

Between 8 February 2016 and 12 July 2016, Sussex Police were contacted five times by Alina and other members of the public, with concerns about David’s behaviour towards Alina. Simon also reported damage to his car and a note that had been left on his windscreen stating “Dear Simon, Alina has and always will cheat on you. Happy New Year.”

2.2.4.

From the outset, Alina said that she believed that David was stalking her, and that she felt frightened of him. On the first occasion, David was spoken to by police officers; on the second he was interviewed and on the third occasion he was arrested. Throughout their contact with Alina, Sussex Police consistently assessed that Alina was at ‘medium’ risk of serious harm, using the DASH RIC. (DASH RIC is the Domestic Abuse, Stalking and Honour based violence Risk identification checklist)

2.2.5.

Towards the end of August 2016, Sussex Police received a call from Simon’s sister who had gone to Alina’s address to check on her as she had not arrived at work that morning. On arriving at the address she saw there was a bloody footprint on the doorstep of the property. Simon’s sister also called her father who arrived within minutes.

2.2.6.

Whilst attempting to gain entry, he became aware that he could smell smoke. He eventually gained entry to the house, together with his sister-in-law who had arrived to help, and managed to get to Alina’s bedroom. Through the hazy smoke they were able to see a body lying face down on the bed. Although they could not see the person’s face they were able to see long blond hair that looked like Alina’s. It was apparent to them that she was dead. They ran from the bungalow to find that the police and ambulance had arrived. A paramedic pronounced Alina dead at 10.03am.

2.2.7.

David was subsequently arrested and interviewed. Throughout seven interviews, he either gave no comment responses or protested his innocence, although changing his story each time evidence proved that he was lying. In early March 2017 he was convicted of murder and sentenced to a minimum tariff of 25 years. David has subsequently admitted that he is guilty of murdering Alina.

3.1.

As mentioned immediately above, there was a criminal trial.

3.2.

The day after the murder a post mortem was conducted by Dr Biedrzycki at Brighton Mortuary. He made a provisional finding regarding the cause of death as being an incised wound to the neck (her throat was slit). The wound measured 10.5 cm in length. There were no defensive injuries to her upper limbs.

3.3.

An inquest was opened by Her Majesty’s Coroner, and was adjourned pending the outcome of the criminal trial. Communication channels were established with the Coroner who at the time of writing this report is deciding whether to re-open the inquest. To aid in this process, it was agreed that a confidential copy of this report will be provided to her prior to Home Office approval.

3.4.

Due to Alina’s contacts with the Police, the Independent Police Complaints Commission (IPCC) also undertook a review of the involvement of Sussex Police with Alina and David. This DHR endorses the quick-time recommendations that the IPCC have made ahead of the completion of their investigation. These are included in full in the main DHR report.
 

The DHR Panel was comprised of the following agencies:

• Brighton & Hove City Council (BHCC) Adult Social Care
• BHCC Children's Safeguarding & Care
• BHCC Partnership Community Safety Team / Joint Domestic, Sexual Violence & Abuse and Violence against Women & Girls (VAWG) Unit – Brighton & Hove and East Sussex
• Brighton & Hove Clinical Commissioning Group (CCG)
• Brighton and Sussex University Hospitals NHS Trust (BSUH)
• Office of the Sussex Police & Crime Commissioner (OSPCC)
• RISE / The Portal (local specialists)
• Sussex Partnership NHS Foundation Trust (SPFT)
• Sussex Police Crime Review Team
• Sussex Police Safeguarding Investigation Unit
• Veritas Justice

At the start of the review process, the Suzy Lamplugh Trust (national) and Veritas Justice (local) were contacted to consider representation on the Review Panel. As the Suzy Lamplugh Trust was supporting Sussex Police to review their response to this case, it was agreed that Veritas Justice would be the specialist stalking service representative on the Review Panel.

All Panel members were of sufficient seniority to agree to changes in their agency.

Panel meetings were also attended by the IPCC (now IOPC).

In accordance with the statutory guidance, the DHR Panel sought to engage with the IOPC who were undertaking a parallel investigation to agree how to manage this process. Both the DHR Panel and the IOPC engaged with each other in good faith and sought to identify how the two parallel processes would work together. This included, for example, addressing this in the Terms of Reference. Unfortunately there was a misunderstanding about this working relationship in practice. This misunderstanding was held by all parties. It did not become apparent until the latter part of the process.

The Chair and author of this report, Davina James-Hanman, is independent of all agencies involved and had no prior contact with any family members. Davina James-Hanman is an experienced DHR Chair and is also nationally recognised as an expert in domestic violence having been active in this area of work for over three decades. These have included roles at local, regional and national levels in both the voluntary and statutory sector. She has devised a wide variety of original resources for survivors, written innumerable articles, toolkits and manuals for practitioners, is the author of three book chapters and among a variety of other national roles, acted as the Specialist Adviser to the Home Affairs Select Committee Inquiry into domestic violence, forced marriage and ‘honour’ based violence.

All Panel members and IMR authors were independent of any direct contact with the subjects of this DHR and nor were they the immediate line managers of anyone who had had direct contact.

6.1.

The full terms of reference can be found in the main overview report at appendix A. The key lines of enquiry for the DHR were as follows:

1. Each agency’s involvement with the victim Alina from October 2014 to August 2016.

2. Each agency’s involvement with the perpetrator David, including his contact with:

• Alina from October 2014 to August 2016
• Any other female from 2003

3. Whether, in relation to the either Alina or David, an improvement in communication between services might have led to a different outcome for Alina.

4. Whether the work undertaken by services in this case was consistent with each organisation’s professional standards.

5. Whether the work undertaken by services in this case was consistent with each organisation’s domestic violence policy, procedures and protocols, and in light of the features of this case, whether the organisation’s policy, procedures and protocols adequately address stalking and harassment.

6. The response of the relevant agencies to any referrals relating to Alina, concerning domestic violence, stalking and harassment or other significant harm from David until the point of the death, including identification of the key opportunities for assessment, risk assessments, decision making and effective intervention; whether any actions taken were timely and effective and in accordance with assessments and whether appropriate services were offered/provided.

7. The response of the relevant agencies to any referrals relating to David, covering the same areas as outlined above.

8. The training provided to adult-focussed services to ensure that, when the focus is on meeting the needs of an adult, this is done so as to safeguard and promote the welfare of children or vice-versa.

9. Whether thresholds for intervention were appropriately calibrated, and applied correctly, in this case.

10. Whether practices by all agencies were sensitive to the ethnic, cultural, linguistic and religious identity of the respective family members and whether any special needs on the part of either adult were explored, shared appropriately and recorded.

11. Whether issues were escalated to senior management or other organisations and professionals, if appropriate, and in a timely manner.

12. Whether the impact of organisational change over the period covered by the review had been communicated well enough between partners and whether that impacted in any way on partnership agencies’ ability to respond effectively.

13. Were there any concerns amongst family / friends / colleagues or within the community and if so how could such concerns have been harnessed to enable intervention and support?

6.2.

Agencies were asked to search their records from October 2014 for Alina since at the start of the process the Panel was unsure of when her relationship with David began and from 2003 for David to capture the complaints made by other women who came forward after the murder. It later became clear that the relationship between Alina and David began at some point in the summer of 2015.

7.1.

The findings of this Overview Report are restricted. Information is available only to participating officers/professionals and their line managers, until after the Review has been approved for publication by the Home Office Quality Assurance Panel.

7.2

As recommended within the ‘Multi-Agency Statutory Guidance for the Conduct of Domestic Homicide Reviews’ to protect the identities of those involved, pseudonyms have been used and precise dates obscured.

7.3

This has not prevented agencies taking action on the findings of this Review in advance of publication.

7.4

Subsequent to permission being granted by the Home Office to publish, this report will be widely disseminated including, but not limited to:

• Members of the Brighton & Hove Safer Communities Partnership Board, the Local Safeguarding Children Board and the Safeguarding Adults Board, for consideration and dissemination by members of these groups within their own organisations
• The Pan Sussex Domestic Abuse Management Group

7.5

A number of learning events have been planned to ensure that the lessons are disseminated as widely as possible; the first of these will be a confidential briefing to key local partners which will share critical learning from this DHR (and other DHRs in Sussex) which is taking place in Autumn 2017. Once permission is granted by the Home Office to publish, this report will be more widely disseminated to the local professional networks.

8.1. Individual Management Reviews (IMRs)

8.1.1.

The agencies listed below submitted an IMR:

• Brighton & Sussex University Hospitals Trust
• David’s GP
• RISE/The Portal
• Sussex Partnership NHS Foundation Trust
• Sussex Police
• Victim Support

Alina’s GP returned a chronology and based on this, the Panel decided that an IMR would not be required.

The Scout Association also returned a chronology and after seeking clarity over some points, it was decided that a full IMR would not be needed.

14 witness statements were shared by either Sussex Police or the IPCC. In some cases, these statements were supplemented with individual meetings with the Chair.

A further ten agencies advised they had not had any contact with either Alina or David.

8.1.2.

Agencies completing IMRs and reports were asked to provide chronological accounts of their contact with Alina and/or David prior to the homicide. The DHR has focused on the contacts of agencies from October 2014 for Alina and from 2003 for David. The recommendations to address lessons learned are listed in section 13 of this report and action plans to implement those recommendations have been developed.
Each IMR / report was scrutinised by the Panel and in some instances redrafted to take account of questions raised.

8.1.3.

This report is an anthology of information and facts gathered from:

• The Individual Management Reviews (IMRs), chronologies and short reports
• The Police Senior Investigating Officer
• Witness statements from the criminal trial and associated press articles.
• Witness statements gathered by the IPCC
• Alina’s Facebook page
• DHR Panel discussions
• Information from friends, family members and the perpetrator
• The collective expertise of the Panel which included stalking specialists
• Electronic communications made via text, email or voicemail which were recovered from Alina and David’s phones. These were in excess of 25,000 over a 12 month period
• Electronic communications made via text or email between Alina and Simon
• The Crown Prosecution Service whose assistance was sought to clarify several evidential matters raised by the family

The Brighton & Hove Community Safety Partnership is responsible for monitoring the implementation of the action plans that have been developed.

8.2. Involvement of family and friends

8.2.1.

The family of the victim were informed about the commencement of the DHR and invited to participate. This was initially via a family friend which allowed them an opportunity to comment on the Terms of Reference. Information was provided about Advocacy After Fatal Domestic Abuse (AAFDA). Once the trial had concluded, the family communicated that they wished to continue their involvement only through the family friend which was duly done with them receiving regular updates from the Chair. A copy of the draft report was sent to the family prior to submission to the Home Office and extensive efforts were made to include their comments, views and recommendations. However, towards the end of the process, the Chair received a short email from the family friend stating that his role as an intermediary had ceased. Subsequent to that, the Chair communicated directly with the parents who repeatedly stated their dissatisfaction with the report but were unable to provide any specifics beyond their sense that the report was unfair to their daughter. During this communication, Alina’s parents asked that the information they had previously provided to the review not be used. The Chair, with the agreement of the CSP, agreed to respect the family’s wishes as far as it was possible to do so. This report therefore does not include either a family impact statement or a pen portrait of Alina. Where amendments have been made to the report in relation to factual accuracy or clarity, based on feedback from the family or family representatives about specific issues, these have been left in the report, as these changes are not identifiable to the reader.

8.2.3.

David’s mother, a former colleague and an off-on intimate partner also participated in the Review. Information from them has also been integrated into this report. Others were invited to participate but either declined or did not respond.

8.3. Involvement of the perpetrator

8.3.1.

Post-conviction, the perpetrator was contacted through his Offender Manager and agreed to participate. The Chair duly met with him in prison. Notes of this meeting were provided to Alina’s parents at their request. Information provided by David has been integrated into the narrative below.

9.1. 2005 - 2012

9.1.2.

David used youth movements, which appealed to young women and girls, to allow him access to victims and to attempt to meet sexual partners. David’s behaviour towards other women was largely unreported until after the murder and as such, there were no opportunities for partnership intervention. There was only one exception to this where the father and a Guide Leader were involved. At 2006, David attempted to kiss and cuddle a 16 year old girl but she pushed him away and he then acted as if it had not happened. When she was 18 (2008) she started to drink at the same pub and came into contact with David again as it was also his local. She then started receiving explicit photos from him and offers to pay her for sex. These incidents were not reported to the police until after the murder. In 2008 he sent text messages of a sexual nature to another teenage Girl Guide, which also went unreported. In 2010 he was arrested on suspicion of grooming a 14 year old girl whilst working as a Scout volunteer leader. He was not charged or prosecuted but a marker was put on his police record. David resigned from the Scouts.

9.1.3.

In 2009, David’s Grandfather died. They were very close and his death affected David enormously. A pattern begins to emerge where David reacts to any loss as a major catastrophe, often resulting in him threatening or even attempting suicide although it is clear that he also used suicide threats as a form of manipulation.

9.3. 2013

9.3.1.

By 2013, David was involved in a Drum Corps and in June he met Elsa who he began dating in November of the same year. Elsa stated that David was nice to begin with but became very controlling, demanding she text him constantly and tell him who she was with. Elsa lived in Essex and David in Sussex so they were often apart but he still tried to control her. Elsa would comply to avoid arguments.

9.3.2.

Alina left school this year (she was 16). Whilst at school she met and began a relationship with Simon which continued (with some break-ups and reconciliations) until her death.

9.4. 2014

9.4.1.

Elsa went to a dance competition in Stoke in April and was accompanied by David. David became jealous during the day and assaulted Elsa. This was not reported to the police until after Alina’s murder.

9.4.2.

David became friends with another young woman aged 17. When she told him that they would never be more than friends, she was then bombarded with texts telling her to cut herself or with David threatening suicide. He also parked up near her home or school on numerous occasions. This stopped when a family member warned him about his behaviour and was not reported to the police until after Alina’s murder.

9.4.3.

In October Elsa went with friends to Tenerife for a long weekend. David did not want her to go and both bombarded her with texts and threatened suicide. Elsa ended the relationship that same month.

9.4.4.

The following day, David went to his GP and disclosed his suicidal ideation which he said was due to depression over the death of his Grandfather and the ending of his relationship. He received a diagnosis of severe depression and severe anxiety. He was prescribed antidepressants, a crisis plan was discussed and information given about a cognitive behavioural therapy website along with an ‘unfit to work’ certificate. This was subsequently lifted in November after David was reassessed and scored for moderate depression and moderate anxiety. He was seen by the GP at two week intervals until the end of the year and his medication adjusted slightly.

9.5. 2015

9.5.1.

Although his relationship with Elsa had ended the previous year, David turned up unannounced at her place of work in March and again threatened suicide. Elsa called the police and David's mother. The following day, his mother contacted their GP who arranged for David to come to surgery later that day for assessment. At this appointment, David continued to express suicidal thoughts stating he did not want to carry on living if he was not able to continue his relationship with Elsa. He was referred to Brighton Urgent Response Service (BURS) (Now the Mental Health Rapid Response Service – MHRRS) and risk planning was put in place. The BURS worker called David who agreed that he would benefit from mental health services. He did not present with any overt mental health symptoms and displayed good concentration and was warm and friendly with the ability to make jokes. However, David said he would not be able to attend an appointment immediately and asked if he could ring BURS in a few days.

9.5.2.

The following month, David sent a Snapchat message to another young woman offering her £500 if she would spend the night at a hotel with him and let him doing anything he wanted to her. She ignored this. David also sent an image of the front of her house saying that he could see her. Subsequent to this, chance meetings in the local pub would often lead to unsolicited messages being sent to her from David suggesting that they should be together when it was obvious to all that she had a boyfriend.

9.5.3.

In June, Alina started work at the same company as David. By the following month they were exchanging text messages and by the autumn, the relationship had progressed to a sexual one. By the time of her death, there were in excess of 25,000 media messages between them in the form of text, WhatsApp, Facebook Messenger and Snapchat. These show an obsessive and complicated relationship with a number of messages being highly sexualised in content. David appeared to pressure Alina into ending the relationship with Simon.

9.5.4.

In July, David applied for membership of Scouts and he was not recognised as a past resigned member. This meant that the previous information was not considered. He began volunteering again as an Assistant Section Leader but was subsequently described as unenthusiastic and resigned in February 2016.

9.5.5.

In August, David sent a friend request on Facebook to a woman he knew from school. She accepted the request and then received an email from David asking if she lived at a specific address. She realised that his work brought him into the area and that he must have seen her coming and going. She then began to notice David’s van parked up outside of her home address several times, even on days he was not due to be working there. She began to feel harassed by him and took steps to avoid seeing him. This was not reported to the police until after Alina’s murder.

9.5.6.

In September, Alina’s car had a flat tyre. David helped her to fix it.

9.5.7.

In October, David sent an unsolicited text to a neighbour asking her for a date; this was followed by another text saying he was all alone in his house. She consulted her mother and they decided on an appropriate form of reply expressing a lack of interest which they did. This was not reported to the police until after Alina’s murder.

9.5.8.

In December, two young women reported harassing encounters with David in the local pub. Both subsequently received Facebook messages from him. One of these stating that ‘she wanted it’ and the other outlining David’s desire to perform oral sex on her and detailing what he would do. These incidents were not reported to the police until after Alina’s murder.

9.5.10.

At the company Christmas party, David was moody and scowling at any man who spoke to Alina but this did not stop Alina from enjoying herself. David went outside and was refused re-entry due to being drunk. Alina stayed at the party.

9.5.11.

In mid-December, David’s step father called the Mental Health Rapid Response Service (formally BURS) reporting that he was worried as David seemed to be depressed again. He reported that David had stated that he ‘can’t do it anymore’ after attending a work’s Christmas event. When the family tried to contact David they were unable to locate him for some time before eventually finding him in a corner behind a warehouse. He refused to talk to the MHRRS worker but said that he would call them back later. The family were instructed to call the MHRRS team again if they were concerned about David’s safety.

9.5.12.

David did later call the MHRRS team. He could not articulate why it had all got too much for him but he said that there was ‘other stuff going on’ but would not elaborate. He told the MHRRS worker that he had been on antidepressants for over a year and they had initially worked for him. He reported suicidal thoughts for a few years on and off but that he had been feeling more suicidal recently. He denied any current plan to end his life but stated he did just want it to end. He reported that he had taken paracetamol in the past and had not told anybody, having most recently done this two months ago.

9.5.13.

David was advised to go to his GP to discuss either an increase or a change in his antidepressant medication and to ask his GP to refer him for counselling. He was also given contact numbers for other agencies which David did not contact. He did visit his GP for a series of appointments for the rest of December during which time his medication was slowly reduced without further incident. David would later reflect that he should have accessed counselling and not just relied on medication.

9.5.14.

On New Year’s Eve, Simon found a handwritten note on his windscreen which read: ‘Alina has and always will cheat on you. Happy New Year’.

9.6. 2016

9.6.1.

In mid-January, Alina received flowers at work with an unsigned card that read ‘Have a nice day. Love you’. Alina called the florist and was told that they had been paid for with a credit card owned by David. Alina spoke to a work colleague and disclosed that David had been ‘bumping into her’ on a regular basis on her route to and from work. She also disclosed that she had been having a series of flat tyres on her car which had started occurring since last September. This was reported to her manager who contacted HR. David’s company van tracker was studied and it was revealed that there were several occasions when the van had been near Alina’s house or her mother’s house during work time when it should have been elsewhere.

9.6.2.

Shortly after this, Alina’s tyres were slashed. Simon’s car was similarly damaged as well as being scratched down one side.

9.6.3.

In February, Alina made the first report to the police. She shared the information detailed above and described David as a colleague and friend. She was told that her case would be allocated for further investigation. A Domestic Abuse Stalking and Harassment Risk Identification Checklist (DASH RIC) was completed and Alina was assessed as medium risk.

9.6.4.

The police spoke to the HR manager at Alina’s workplace, flagged her address and her mobile number, referred Alina to RISE and advised Alina to keep a record of any further incidents. The officer also gave Alina contact details for the National Stalking Helpline.

9.6.5.

David was spoken to and denied everything. The case was filed due to insufficient evidence. This appears to have sent the message to Alina that incidents were not worth reporting if she did not have proof that David was the culprit as she subsequently mentioned her lack of evidence to several friends and colleagues when explaining why she was not reporting an incident.

9.6.6.

As the case was a Medium Risk Crime RISE received a referral from the Police and tried to make telephone contact with Alina. There was no response so a safe voice message was left.

9.6.7.

Towards the end of March, Alina returned to her home address after being at the pub when her two housemates returned home with David and some other friends. Alina was unhappy about this and had a verbal argument with David before packing to go to stay with Simon. David chased her down the street and ran up behind her while she was on the phone to Simon. David tried to grab the phone from her and pulled her hair, causing pain but no injury. A passing car stopped and asked her if she was OK. Alina accepted a lift from them to Simon’s house where his mother insisted on calling the police.

9.6.8.

David was interviewed and disclosed that Alina and he had been having a secret affair since the previous year. He shared text messages on his phone including one from the previous day from Alina saying she still wanted him. Alina admitted to the police officers that they were much more than friends. She was advised that wasting police time was a criminal offence and issued with a Penalty Notice for Disorder (PND). The matter was then filed.

9.6.9.

Four days later Alina left her job citing David as the reason. She was unemployed for a few weeks during which time David was visiting her at home during work hours as revealed by the monitoring that his employer was still undertaking of his whereabouts. David was later told that he was to attend a meeting at work to discuss this evidence.

9.6.10.

Meanwhile, Victim Support received a referral about Alina experiencing assault occasioning actual bodily harm for the incident described above. However, there was no domestic abuse flag on it. Also at this time, Rise was still trying to establish contact for the report made in February but always got voice mail. On the third attempt, in line with policy, they left a message saying they would not try again but including the number of the helpline if she would like to call.

9.6.11.

In mid-April, David took an overdose; a combination of Paracetamol, Ibuprofen and alcohol. He was accompanied to A&E by his mother where he was seen by the Mental Health Liaison Team. David stated that he was feeling low in mood as it was 7 years since his grandfather died and he was worried about his job. He had drunk alcohol which led to an impulsive overdose. He said he regretted his actions and felt positive about getting another job. He said the counselling he had received was helpful (no record can be found of David ever accessing counselling) and denied he had any intention of harming himself or others.
9.6.12.

Three days later, David resigned from his job in advance of the meeting where he would have been challenged with the evidence of his company vehicle being near Alina’s home on work time and a witness who saw him entering and leaving Alina’s house.

9.6.13.

At some point, David purchased and fitted a tracker to Alina’s car and kept appearing wherever she was. On several occasions when he was spotted, he was confronted (usually by whoever Alina was with) and he always passed it off as mere coincidence. From around this time onwards, however, different people would later describe how David always seemed to be lurking around. At the same time, however, it is clear that Alina and David were still conducting a secret on-off relationship.

9.6.14.

In May, David sent yet another woman an image of him masturbating on a bed via Snapchat. She was shocked and deleted the image immediately. The following morning she messaged him and said ‘What the fuck?’ David responded by saying it was sent in error.

However he subsequently sent another message asking her if she liked it. She replied that she did not. When reporting this incident to the police after Alina’s murder, she also mentioned that when she was 15 or 16 years old (in 2009) David would send her messages detailing what he would like to do to her sexually.

9.6.15.

Also in May, David went on holiday to Turkey and contacted Elsa again threatening to kill himself as he was so unhappy without her. He informed Elsa that he had previously tried to overdose two months earlier. Elsa later went on to block David from all social media to avoid further contact with him.

9.6.16.

Elsa was contacted via Facebook by Alina in June even though the two did not know each other but were connected through a mutual friend. Alina asked Elsa what her relationship with David was like and stated that he was pestering her and she didn’t want to be with him. Elsa told her not to let him stop her doing what she wanted to do.

9.6.17.

Alina started a new job. She was currently on a break-up from Simon and, whilst David was away on holiday for two weeks, spent time with Andy with whom she had been having a sexual relationship over the previous ten months. David returned from his holiday three days early. Alina found her tyres slashed and suspected David. A couple of days later, Alina was staying with Andy when David turned up at his house, pushed his way inside and confronted Andy. Andy denied having a sexual relationship with Alina.

9.6.18.

At some point Alina and David reconciled and they were ‘officially’ in a relationship from 4 June to early July at which point Alina resumed her relationship with Simon but continued to see David in secret. Numerous text messages were exchanged between them with both emphasising the secret nature of their liaison.

9.6.19.

Alongside this David sexually assaulted another woman and bombarded another with text messages including one with a picture of his penis. These events were not reported to the police until after Alina’s death.

9.6.20.

In July, David went to Alina’s house to collect some of his belongings. Whilst he was there he stole the back door key and returned to Alina’s house early the following morning when she was still in bed. She woke when he let himself into the house but pretended to still be asleep and hid her head under the covers. She would subsequently describe herself as being ‘very scared’. David stood at the foot of her bed for a few moments and then left. Once she heard the door close, Alina got out of bed and was able to identify that it was David walking away from the house. After discussing this with her housemates, she decided to call David and confront him. She recorded this call so that she would have evidence to give to the police.

9.6.21.

Alina reported the incident to Sussex Police and David was arrested. He admitted his actions and was cautioned for theft from a dwelling. A PIN was also issued and he was told to stay away from Alina.

9.6.22.

The following day Alina called the police again over a series of four calls. She stated that she had received six or seven missed calls; one from a landline and the others from a withheld number. She was wondering if it was the police trying to contact her but it was quickly established that it was not. One call was answered and she could hear heavy breathing. Alina described herself as ‘worried and ‘really scared’. She was advised not to answer calls from withheld numbers. Record keeping of these calls was poor. An enquiry was made eight days later which resulted in the landline being identified as originating from David’s address. No action was taken.

9.6.23.

A few days after the key incident, Alina called Simon saying she did not feel safe in the house. Simon stayed for the weekend. Over the next week, David was seen several times following Alina to work. This was reported to the police but as there was no direct approach made, it was determined that the risk was low. No action was taken. Alina told a work colleague that she was too afraid to go to her kitchen at night as she felt someone was in the garden watching her. David continued to appear ‘coincidentally’ wherever Alina went. Simon received a text messages from a ‘John Smith’ reporting on Alina’s behaviour when she was out without him.

9.6.24.

A referral was made to Victim Support but after three attempts to contact Alina (from a withheld number), they sent an email to Sussex Police informing them that contact attempts had been unsuccessful and thus no DASH risk identification checklist had been completed.

9.6.25.

David called Sussex Police stating that he needed to get in touch with Alina with regard to monies owed and he was seeking advice on how to do this without getting himself into trouble as he has been ordered to stay away from her. He asked if contact by letter was allowed and was told that his message would be passed to the officer in charge to make contact with him. The call-taker states that they relayed the message but there is no mention on the NICHE record that the officer in charge received or acted on this information.

9.6.26.

A referral was made to RISE using a SCARF (the Single Combined Assessment Referral Form used by Sussex Police) with a ‘medium’ risk assessment attached. The SCARF/DASH RIC was reviewed in line with policy and it was deemed appropriate to contact Alina and offer a service. A week later, a RISE worker made the first attempt to contact Alina (from a withheld number). The call was not answered so a safe voice message was left.

9.6.27.

David continued to be spotted in the vicinity of Alina’s house and although a friend urged her to report this to the police, Alina said she was reluctant to do so as she thought the police would think she was ‘blowing it out of proportion’.

9.6.28.

In early August, a RISE worker made two further attempts to contact Alina. In both instances, the call was not answered so a safe voice message was left and the case closed.

9.6.29.

A couple of days later, David told one of his friends that Alina had dumped him and gone back to her ex. He said he was depressed. As he was parting from his friend, he whispered in her ear 'she'll pay for what she's done'.

9.6.30.

Three days later, via a series of text messages, Alina arranged to meet David at a nearby hotel. He would later describe this as being for ‘one last fling’. Around this time, Simon told Alina that he wanted to break up with her although he stayed the night at her home the following day.

9.6.31.

A neighbour would later give evidence that they heard a raised woman’s voice from Alina’s home shortly after 7.30am. About 30 minutes later, David was caught on CCTV at a cash machine. £60 was withdrawn from Alina’s account at the same time. He then returned to Alina’s home with a water bottle, believed to contain petrol. CCTV would later reveal David purchasing petrol in a can the previous day. This suggests planning and intent on his part.

9.6.32.

After Alina failed to turn up at work, Alina’s manager called Simon who in turn called his sister who went to Alina’s house. On arriving at the address she saw there was a bloody footprint on the doorstep of the property. Simon’s sister phoned the police as well as her father who arrived at the address within a matter of minutes. He began banging on the doors and windows calling Alina’s name.

9.6.33.

He attempted to gain entry by going to the back of the property but failed (he assumed the front door would be locked). He returned to the front of the house and opened the letter box to see in. At this point he could smell smoke. Neighbours heard the commotion and tried to help gain access. They also went to the back of the property and were discussing breaking a window but felt that this could cause an explosion with the fire.

9.6.34.

Simon’s father tried the handle of the front door and it opened. He entered the property and became aware of the extent of the smoke. He was struggling to breathe and had to come back out of the house.

9.6.35.

On exiting the house he became aware that his sister in law had arrived to help. Both of them entered the bungalow and managed to get to Alina’s bedroom. Through the hazy smoke they were able to see a body lying face down on the bed. Although they could not see the person’s face they were able to see long blond hair that looked like Alina’s. It was apparent to them that she was dead. They ran from the bungalow to find that the police and ambulance had arrived. A paramedic pronounced Alina dead at 10.03am.

All nine protected characteristics in the 2010 Equality Act were considered by the DHR Panel. Two protected characteristics were found to have relevance to this DHR. These were:

Ethnicity: Alina and David were both of white British origin and this was not felt to be a factor.

Sex: Sex is relevant as there is extensive research to support that in the context of domestic violence, females are at a greater risk of being victimised, injured or killed. Latest published figures show that just over half of female victims of homicide in the UK aged 16 or over had been killed by their partner, ex-partner or lover (54%). In contrast, only 5% of male victims aged 16 or over were killed by their partner, ex-partner or lover.

According to the Crime Survey for England and Wales 2015/16, 4.6% of women and 2.7 % of men aged 16 to 59 self-identified themselves as having been victims of stalking. Stalking can be perpetrated by both men and women but women are more likely to be victims, and 80% of stalkers are male (Osteryemer et al. 2016). Women are found to be more likely to suffer serious harm and homicide when they are stalked, especially where there is a previous intimate relationship with the stalker (McFarlane et at 2002). Stalking and domestic abuse are highly correlated and there is a suggestion that coercive control and stalking are often simultaneously present (Norris et al. 2011).

Age: Alina was only 19 when she was so brutally murdered placing her squarely in the age category which experiences the highest rates of domestic abuse (16-24 years old).

With respect to the agencies involved in this review, the Panel concluded that age was the only protected characteristic which potentially impacted on the services delivered. Recommendations have been made relating to this.