Domestic homicide review relating to the death of Mr C - overview report

1. Introduction

• 1.1 Outline of the lncident
• 1.8 The review process
• 1.23 Methodology
• 1.35 Contact with family and friends
• 1.42 Equalities

2. The facts

• 2.1 The death of Mr C 
• 2.8 Background
• 2.10 The relationship between Mr C and Mr Y
• 2.14 Information from Mr C's family
• 2.22 Information from agencies
• 2.60 Concerns of Mr C's family

3. Analysis

• 3.3 Abuse over a period of time that was not stopped
• 3.5 Who might have helped?
• 3.33 Responses to disclosures - 14 May 2012
• 3.81 Recording and transmission of information between professionals
• 3.85 Equality and diversity
• 3.93 Good practice

4. Conclusions

• 4.8 Preventability
• 4.10 Recommendations
• 4.11 To improve health and social care responses to patients and employees
• 4.17 To improve the community's understanding and response
• 4.19 To improve commissioned services' responses
• 4.20 To improve the communication between agencies and services

Appendix 1 - Terms of Reference

Appendix 2 - Panel Members and Agencies Represented

Appendix 3 - Home Office Letter

Outline of the incident

1.1

On Monday, 16 July 2012, AC, Mr C's older sister who lives in - rang Sussex Police saying that they had not heard from her brother, Mr C (60-64) for two months. Mr Chad spoken to one of his sisters, BC, on 14 May 2012 and was last seen alive by a friend, LM, on 23 May 2012.

1.2

Police attended Mr C's home and found Mr C's decomposed remains on his bed and covered with a sheet. There was no evidence of a forced entry, burglary or a violent altercation.

1.3

Initially, the death was not treated as suspicious.

This report addresses activity with services up to the time of Mr C's death. However, it is worth noting that, as it is difficult to ascertain the cause of death of a decomposing body, police might consider such a death suspicious from the outset.

The Coroner's preliminary enquiries into Mr C's medical history identified that he had been taken by ambulance to the Royal Sussex County Hospital (part of Brighton and Sussex University Hospital Trust (BSUH)) on 14 May 2012 after collapsing in a store and telling staff there that he had been assaulted by his boyfriend. This information was passed to the Sussex CID and then to the Major Crime Team.

1.4

Post mortem: A post mortem concluded that Mr Chad died from blunt force trauma to his body and a homicide investigation commenced on 21 July 2012.

1.5

Criminal prosecution: Mr Y, Mr C's flatmate, was sought but not found until 7 May 2013, when he was arrested.

1.6

Mr Y was indicted for murder. When the jury were sent out to consider their verdict they were told that they could consider both murder and manslaughter by the Judge. Subsequently, Mr Y was convicted of manslaughter, causing actual bodily harm, and preventing a decent lawful burial on REDACTED 1111 and sentenced to 18 and a half years. A deportation order was also made. During this OHR, Mr Y has requested leave to appeal his conviction and his sentence. He has been given leave to appeal his sentence, but not his conviction.

1.7

The Panel would like to express its sympathy to the family of Mr C for their loss and to thank them for their contributions and support for this process.

The review process

1.8    

This Domestic Homicide Review (OHR) was commissioned by the Safe in the City Partnership, Brighton & Hove's community safety partnership, in accordance statutory with the Revised Statutory Guidance for the conduct of Domestic Homicide Reviews published by the Home Office in March 2013.

1.9  

Sussex Police notified the Safe in the City Partnership on the 29 May 2013 that the case should be considered as a OHR (the reason for the time delay is outlined in 1.4 and 1.5). The Safe in the City Partnership made a decision to conduct a OHR, and having agreed to undertake a review, the Home Office was notified of the decision on the 11 July 2013. An initial meeting was held on the 19 August between  representatives from the  Safe in the  City Partnership and Sussex Police to establish the scope of the OHR, as well as to identify how it would dovetail with the then ongoing criminal investigation. At this time it was agreed that the review was not to be fully commenced until the conclusion of criminal proceedings.

1.10    

The purpose of this review 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 those lessons to service responses including changes to policies and procedures as appropriate
• prevent domestic homicide and improve service responses for all domestic violence victims and their children through improved intra and inter-agency working

1.11

This review process does not take the place of the criminal or coroners courts nor does it take the form of a disciplinary process.

1.12    

The initial Panel meeting was held on 21 October 2013 to consider the circumstances leading up to this death, with subsequent Panel meetings on 22 January 2014, 9 April 2014 and 20 May 2014.

1.13    

The Executive Summary and Overview Report, as well as recommendations in response to the findings, were presented Violence against Women and Girls (VAWG) Programme Board in September 2014. The Safe in the City Partnership Board also received a report on these recommendations in in the same month as part of the city's combined action plan. They were submitted to the Home Office in September 2014 and were considered at the November meeting of the Home Office Quality Assurance Panel. The report was judged 'adequate', with the Home Office providing notification and approval for publication in December 2014 (see Appendix Three).

1.14    

Once published, the final report will be shared with the governance boards and committees of participating statutory agencies; in addition an Executive Summary will be shared with the Violence against Women and Girls Forum in Brighton & Hove.

Terms of Reference

1.15    

The full Terms of Reference are included at Appendix 1. The purpose of this review is to establish how well the agencies worked both independently and together and to examine what lessons can be learnt for the future.

1.16  

This OHR was conducted in Brighton & Hove as that is where Mr C was killed in May-June 2012. Mr C and Mr Y had moved to Brighton in October 2011, so the Terms of Reference looked at the time that Mr C and Mr Y lived in Brighton.  However summary of involvement forms were sent to those agencies that might have been involved with Mr C or Mr Y in -· This was in order to identify if more information could be gathered from their time in - and to understand what, if any, information was transferred from agencies to - to agencies in Brighton & Hove at the time of their relocation. The results of that exercise are below.

1.17    

Throughout this report, the term 'domestic abuse' is used to identify incidents or a pattern of threatening behavior, violence or abuse (psychological, physical, sexual, financial or emotional), between adults who are or have been intimate partners or family members.

Parallel and related processes: The Coroner

1.18    

On - , Her Majesty's Coroner for Brighton & Hove held an inquest into the death of Mr C and concluded: 'So, taking everything that I've heard into consideration, I am satisfied beyond reasonable doubt that [Mr CJ was unlawfully killed and that's the verdict that I am recording.'

1.19    

The criminal trial of Mr Y was concluded on REDACTED.

1.20    

There were no parallel reviews undertaken in the course of this review.

Panel membership

1.21    

The Panel members were:

• Brighton and Sussex University Hospital NHS Trust (BSUH)
• Sussex Police, Crime Review Tearn
• RISE - local specialist domestic abuse service, with representation from the LGBTQl (Lesbian, Gay, Bi-sexual, Transgender, Queer, or lntersex) service within the organisation
• Brighton & Hove Clinical Commissioning Group
• Sussex Partnership Foundation Trust, with substance misuse and mental health responsibilities
• Brighton & Hove City Council, Safeguarding Adults and Partnership Community Safety Team (including the Head of Community Safety and the Violence against Women & Girls Commissioner)

Independence

1.22

The Independent Chair of the OHR is Laura Croom, an associate of Standing Together Against Domestic Violence, an organisation dedicated to developing and delivering a coordinated response to domestic abuse through multi­ agency partnerships. She has conducted domestic abuse partnership reviews for the Home Office as part of the Standing Together team that created the Home Office guidance on domestic violence (DV) partnerships, 'In Search of Excellence'. She undertook the Home Office accredited training for OHR Chairs and has worked in domestic abuse for over 10 years. She has no connection with the Brighton & Hove City Council or any of the agencies involved in this case.

Methodology

1.23    

Mr C and Mr Y had recently moved to Brighton from -· They had moved into their Brighton flat in October 2011.

1.24    

In addition, Mr Y used a number of aliases and, even when convicted, his real name had not been established beyond doubt.

1.25    

Consequently, information was sought from agencies both in -    and in Brighton & Hove. Initial enquiries were made with a request for a 'Summary of Involvement' (SOI) to the following agencies. Where agencies checked their files and found no contact with Mr C or Mr Y, it is noted as 'nil return'.

1.26    

Based on the response in the SOI, Individual Management Reviews (IMRs) were requested from those organisations and agencies that had contact with Mr C or Mr Y. It was also considered helpful to involve those agencies that could have had a bearing on the circumstances of this case, even if they had not been previously aware of the individuals involved. This would include those agencies that, if the response to this type of incident were completely effective, would have had some contact with either party.

1.27    

It is worth noting that there are no recent records for Mr Y.
 
1.28    

IMRs were provided by:

• GP in Brighton
• Brighton and Sussex University Hospital NHS Trust - this was revised in the course of the process following new information being revealed through the criminal justice process
• South East Coast Ambulance Service NHS Foundation Trust - no chronology
• Sussex Police

1.29    

Additional information was sought from and contributed by:

• Mr C's GP surgery in REDACTED Medical Centre REDACTED
• REDACTED NHS Trust - Mr C's employer from 29 April 1996 to 6 April 2011 - a letter of thanks was sent by the Chair of the Safe in the City Partnership to REDACTED with this OHR as it was outside their area to acknowledge their help with this OHR as it was outside their area

1.30    

The Panel understood through the trial that Mr C had disclosed to the staff at a local store that he had been assaulted when he collapsed there on 14 May 2012. Seeking further clarification, a letter was sent to the manager of the store; followed by several phone calls over a period of months. The manager of the store has not wished to be involved in this review. The Panel itself has also identified recommendations in relation to developing work with employers.

1.31    

The Panel would like to thank everyone who contributed their time and expertise to this review.

1.32    

The trial of Mr Y had begun at the time of the first OHR meeting and so there was a delay in the early stages as the Panel waited for the trial to complete so that those interviewed for this process would have discharged their responsibilities as witnesses.

1.33    

The IMRs were undertaken by agency members not directly involved with the perpetrator, victim or family members and who did not have line responsibility for those who did.
 

1.34    

Medical evidence gathered for the trial was also made available to the Chair to understand the link, if such existed, between Mr C's trips to the hospital and the injuries that eventually led to his death. The Chair excerpted medical information regarding the time of death for the Panel and added pertinent information to the combined chronology.

1.34    

During this process, Mr Y requested leave to appeal his conviction and his sentence. He has been granted leave to appeal his sentence. Further questions were asked of witnesses through Sussex Police where clarity was required.

Contact with family and friends

1.35    

In accordance with the Statutory Guidance, the panel sought to engage with Mr C's family. The Family Liaison Officer (FLO) passed the Chair's letter explaining the purpose of the OHR to a member of Mr C's family. Subsequently, members of the family agreed to meet with the Chair and FLO in early January 2014.

1.36    

The Chair and the FLO met with 7 members of Mr C's family in January 2014. A number of them had given evidence in the trial and had attended the trial to its conclusion. A brother who was unable to attend sent an email with his observations and further questions.

1.37    

The CPS asked that we not interview those who were likely to be called as witnesses in an appeal so we did not interview friends of Mr C's. We asked several questions through the Police about Mr C's contact with local agencies.

1.38    

Subsequently, the Chair met with 4 members of Mr C's family in early September to review and comment on the draft report the draft report before it was sent to the VAWG Programme Board, the Safe in the City Partnership Board or the Home Office. Their responses are included in the body of the report.

1.39    

Contact with friends of Mr C was not sought as they were witnesses in the criminal justice proceedings throughout the course of this review.

1.40    

Contact with members of Mr C's wider network was also attempted, specifically with his former employer.

1.41    

Contact with the perpetrator has not been sought as he was the subject of criminal justice proceedings throughout the course of this review, first with his trial and then an appeal.

Equalities

1.42    

Mr C was 60-64, gay, with problematic alcohol misuse and suffered from osteoporosis. According to his family, he had moved to Brighton in order to live a more openly gay life. The Panel included members with specialisms in work with the LGBTQI clients and vulnerable adults, and those with substance misuse issues. The Panel considered all the protected characteristics when analysing the facts of this case.

The death of Mr C

2.1    

On Monday, 16 July 2012, AC, Mr C's older sister who lives in-·rang the Sussex Police saying that they had not heard from her brother, Mr C (60- 64) for two months.  Mr Chad spoken to another of his sisters on 14 May 2012 and was last seen alive by a friend on 23 May 2012.

2.2    

Police attended Mr C's home in Brighton and found Mr C's decomposed remains on his bed and covered with a sheet. There was no evidence of a forced entry or burglary or of a violent altercation.

2.3  

Initially, the death was not treated as suspicious, but the Coroner's preliminary enquiries into his medical history identified that he had been taken by ambulance to Brighton and Sussex University Hospital (BSUH) on 14 May 2012 after collapsing in the store and telling staff there that he had been assaulted by his boyfriend. This information was passed to the Sussex CID and then to the Major Crime Team.

2.4    

A post mortem concluded that Mr C had died from blunt force trauma to his body and a homicide investigation commenced on 21 July 2012.

2.5    

Mr Y knew that the Sussex Police were interested in him. As a result, the police were unable to locate him until 7 May 2013 when he was arrested in Southampton.

2.6

Mr Y was tried for murder and convicted on REDACTED mansIaughter, causing actual bodily harm, and preventing a lawful and decent burial of a dead body. He was sentenced to 18 and a half years. A deportation order was also made. During the OHR process, Mr Y requested leave to appeal his conviction and his sentence and was granted leave to appeal the sentence.

2.7    

The Judge, in his summing up (! REDACTED), said that by the time Mr C was overdrawn by £20,000, Mr Y saw no further use for him. 'As he became less of an asset to you, you treated him with disdain, with violence. It was the only way he would do what he was told. When he was lying there weak you told him he was faking it. The relationship was violent and abusive and set in a domestic relationship because you were unable or unwilling to earn your own living. You were obsessed with your own self-interest. You left him to rot3.'

Background

2.8 Mr C

2.8.1 Mr C was one of a large family (7 sisters and 3 brothers) who grew up in REDACTED. He left REDACTED in the 1970s (first GP entry in August 1974) and moved to REDACTED with his long-time partner, DE, where he lived until October 2011. DE died in 2001. There are no reports or any evidence to suggest that that relationship was abusive.

2.8.2 Mr C was employed by REDACTED Trust as a healthcare assistant from 29 April 1996 to 6 April 2011 when he was dismissed for unauthorised absences and general misconduct.

2.8.3 Mr C owned his house in REDACTED, where he had a long-term lodger (18 to 19 years), GH. In 2008, he gave GH 30% of the house in recognition of the financial support GH had provided over a period of time. Mr C had a number of debts and in 2011 he sold the remaining 70% to GH and moved to Brighton with Mr Y and JK, another friend.

2.8.4 In Brighton they rented a flat and Mr C paid a year's rent in advance. JK lived at the Brighton flat address until April 2012.

2.9 MrY

2.9.1 Mr Y's background and personal history are unclear. He used a number of aliases while in this country.

2.9.2 uring the trial, it was disclosed that Mr Y had absconded from jail in   in 2001 where he was serving a sentence for drug and extortion offences.

2.9.3 Mr Y at some point was registered with a GP surgery in REDACTED. His date of birth was recorded then as 18 June 1977, making him 35 to 39 at the time of Mr C's death. He recorded that he was single, and worked as a chef. This information does not match that found by the police who identified that he had been married and was REDACTED.

The relationship between Mr C and Mr Y

2.10

In 2009, Mr C answered an ad posted by Mr Y in a gay magazine REDACTED. The two began an on - off relationship from that time. Mr Y lived with Mr C on an occasional basis. It appears that Mr Y did not contribute any money to the household. Soon after they met, Mr C told his brother-in-law, CC, that he had been assaulted by Mr Y.

2.11    

Mr C had a lodger in REDACTED. GH, who recalled Mr C falling several times while he lived in REDACTED several times down the stairs and another time in snow and ice not far from the house.

2.12    

The relationship between Mr C and Mr Y was ambiguous. Mr C told his family that he and Mr Y were partners, that Mr Y wanted to marry him and that they were talking of going to   to get married. Mr Y described himself to hospital staff as Mr C's friend at the February admission and as his carer at the May admission.

2.13    

Risk assessment: A CAADA DASH - Domestic Abuse, Stalking and Harassment (DASH) risk indicator checklist is an evidence-based tool used by staff in many agencies to assess whether a person is at risk of serious injury or death as a result of domestic abuse, stalking or harassment. If the checklist indicates that a victim is at high risk of such harm, she or he is referred to an Individual Domestic Violence Advisor (IDVA) for personal advocacy and support and also to the Multi-Agency Risk Assessment Conference (MARAC) where a multi-agency group gathers information about the victim's situation and plans a coordinated response to address and mitigate the risk.

Risk indicator checklist was completed in the course of this Review and shows Mr Casa firm 8 ticks with 4 further questions unknown. In Brighton & Hove, a high risk case (i.e. one that should be referred to the local Multi-Agency Risk Assessment Conference (MARAC)) is 14 ticks, or on the basis of professional judgement. Mr C was vulnerable through his health problems, his problematic alcohol misuse and his sexual orientation - all of which may have made it more difficult for him to ask for help. He denied or minimised the abuse until his trip to hospital in May 2012. There is no record of him contacting services to seek help for the abuse.

Information from Mr C's family

2.14  

His family described Mr Casa gentle man who avoided conflict. They described him as innocent, pleasant and helpful. He kept in regular contact with his family. Mr C was a healthcare assistant REDACTED Hospital from 29 April 1996 to 6 April 2011. His family say that he enjoyed his job but that his problematic alcohol misuse may have contributed to his forced departure from that role in April 2011. They felt that Mr C's health and wellbeing deteriorated after he left his job and his drinking increased.

2.15    

Mr C had moved to Brighton in October 2011. His family felt that he had moved to Brighton in order to live a more openly gay life.

2.16    

Mr C's and Mr Y's relationship: Mr C's family knew that Mr Y had lived with Mr C on and off for a number of years, though their relationship was not clear to everyone in the family. They think that Mr C might have been ashamed of the abuse and therefore did not want to talk to them about it. When the family expressed concerns about Mr Y's behaviour and his financial dependence on Mr C, Mr C was defensive. They say that towards the end of Mr C's life, he seemed to be changing his SIM card and phone regularly. They thought that A CAADA Domestic Abuse, Stalking and Harassment (DASH) risk indicator checklist is an evidence-based tool used by staff in many agencies to assess whether a person is at risk of serious injury or death as a result of domestic abuse, stalking or harassment. If the checklist indicates that a victim is at high risk of such harm, she or he is referred to an Individual Domestic Violence Advisor (IDVA) for personal advocacy and support and also to the Multi-Agency Risk Assessment Conference (MARAC) where a multi-agency group gathers information about the victim's situation and plans a coordinated response to address and mitigate the risk. Mr Y was eventually in control of the phone. This made it very difficult to stay in touch with Mr C as they had to wait for him to ring them.

2.17    

Problematic alcohol misuse: The family knew that Mr C had a drinking problem and over the years encouraged him to reduce his drinking. They recalled that Mr Y had helped Mr C cut down his drinking at one point. Mr C's drinking was the cause of arguments with family members from time to time. They expressed concern to the Chair that Mr C's many falls were attributed by medical professionals to his drinking when the falls and injuries may have been the result of abuse.  They asked whether professionals asked Mr C about his falls. They also wondered whether Mr C's reports of abuse were discounted because of his problematic alcohol misuse.

2.18    

Nature of abuse: The family were aware that Mr Y was physically abusive to Mr C. Mr C reported an occasion in REDACTED when Mr Y sat on Mr C's chest and poured something into his eyes. Mr C told them that Mr Y was only 'like that' when he smoked dope. Mr C's family felt that they could not be friendly to Mr Y after that, so did not visit Mr C again but continued to communicate, with some difficulty, by phone.

2.19    

Mr C's family knew that Mr Y was exploiting Mr C financially. In particular, on 14 May 2012 Mr C spoke to one of his sisters on the phone and she heard Mr Y telling Mr C to ask for more money from her. Mr Y then took the phone and told the sister to send more money. The family assumed that Mr Y would leave Mr C when the money ran out and that that would be the time when they could act to get Mr C back on his feet.

2.20    

When they expressed concerns about Mr Y's treatment of him, Mr C would change the subject.

2.21  

In particular, Mr C avoided conversations about his drinking, his money and MrY.

Information from agencies Police

2.22 Mr C

2.21.1 There were police records of contact with Mr C; these were considered by the Panel as relevant as they provided additional information

2.21.2 There were no police records of assaults on Mr C.

2.23 MrY

2.22.1 There are no reports of violent offences by Mr Y before Mr C's death.

2.22.2 On 7 May 2013 Mr Y was arrested.

REDACTED NHS Trust

2.24 

Mr C worked for the REDACTED NHS Trust in REDACTED from 29 April 1996 to 6 April 2011 as a healthcare assistant. Between 1996 and 2001 there were no concerns about his behaviour.

2.25 

Mr C had a long period of absence from work after his partner of 30 years died in 2001.  Following his return to work, Mr C continued to have a high level of sickness and unauthorised absence. The Trust dealt with this through their Sickness Absence Management and Disciplinary Procedures.

2.26

Disciplinary action was begun several times due to Mr C's attendances at work under the influence of alcohol and unauthorised absences.
 
2.27 

Mr C was offered support from the Trust's Occupational Health Department for his health issues in the course of his employment. He did not attend the appointments scheduled for him.

2.28 

Further disciplinary actions were begun that led to his dismissal in April 2011. Mr C did not attend the final hearing and was dismissed in his absence.

2.29 

The Trust noted that Mr C provided 3 different next of kin during his employment there, but Mr Y was not one of the names supplied to them.  He did not disclose domestic abuse during his employment at the Trust.

REDACTED GP -1 October 2011 to 16 July 2012

2.30 

Mr C was registered at the   Medical Centre from 1973 to 2011. The GP records provide a summary of issues from August 1974 to March 2011 and detailed entries for 5 January 2011 to 2 August 2012. They reviewed their notes and provided a list of problems he presented with over that time with more detail for the time period under review. They noted that he suffered from a number of chronic health problems, occupational stress and depression. He had a history of problematic alcohol misuse (first identified in 1990) and health problems that may have been related to that. These records show Mr C attended the surgery 8 times between Jan 2011 and July 2011 for tests, prescriptions and blood pressure readings. He took medications for hypertension that were reviewed regularly.

2.31 

In March 2011, Mr C told the GP that 'he'd been on a bender' and admitted to drinking close to a bottle of vodka daily but that he had reduced his consumption. There is no note of a conversation as to why Mr Chad been consuming so much alcohol or of a referral to alcohol services.   The GP records advice to limit consumption further and check liver function tests and review.

2.32 

Mr C had suffered some trauma related to accidental falls that he reported on 16 November and 7 December 2010, 26 January and 21 February 2011.
 
When attending for the fall in January 2011, the GP observed that the falls were 'all slips and trips, no collapses', and noted 'falls clinic if any further falls'.

2.33 

The surgery reports that there was no evidence to indicate domestic abuse or any disclosure of domestic abuse.

Brighton GP

2.34 The GP in Brighton records show only that Mr C registered with the practice on 29 March 2012.  He did not identify domestic abuse when registering at the practice.

Summary of relevant medical evidence given at trial

2.35 

The pathologist noted that the friend and lodger in Brighton reported that he never saw Mr C fall. He records 5 medically-recorded episodes of accidental falls from 16 November 2010 to 21 February 2011.

2.36 

The bone pathologist noted injuries of various ages, also noting that most happened within 12 hours of Mr C's death. He recorded 23 rib fractures, as well as others to the right clavicle and to the sternum. He dated three episodes of fractures:

• within 12 hours of death
• 5 to 10 days prior to death
• 5 to 10 weeks prior to death

2.37 

The dating of the time of death is uncertain due to the state of decomposition of Mr C's body, but estimates range from the first week of June to the end of June. One estimate suggests that the hospital visit on 14 May (see below) is likely to correlate to the assault 5 to 10 days before his death.

2.38

The pathologist also identified a possible fourth episode of fracture which might have been 8 weeks old at the time of death or possibly much older.

2.39 

The pathologist noted Mr C's osteoporosis, possibly as a result of excessive alcohol ingestion, and recorded that though this would have weakened the bone, significant force would have had to have been applied to cause these fractures.

The store

2.40 

We know from the trial that Mr C collapsed at the store on 14 May 2012 and that staff there called for an ambulance. When Mr C collapsed in the store, staff noticed he had recent injuries that were not caused by the collapse and enquired about these. Mr C told them these injuries were the result of being beaten by his boyfriend and that his boyfriend had kicked him in the ribs.

2.41 

Staff rang for an ambulance. The first aider noted that he had felt Mr C's disclosure of abuse by his boyfriend was too personal to put on a form and was not relevant to their accident report.

South East Coast Ambulance Service

2.42 

30 October 2011 - An ambulance was called to Mr C's home address in Brighton with the original report that the patient was unresponsive after fainting. The patient regained consciousness during the call and declined to have the ambulance attend and the caller reported that the person who had fainted felt better. It is not possible to identify the patient from the information gained during the call.

2.43 

20 February 2012 - An ambulance was called to Mr C's flat following a possible fit. The call indicated that Mr Chad appeared to black out and fall, sustaining a head injury. The attending crew found Mr C sitting up with an injury to his right eyebrow. He had had a nose bleed which had stopped before they arrived. He appeared slightly confused but responsive. The attending crew had the impression that the person with Mr Cat the time was possibly a carer as he was 'fussing' around Mr C, but his identity is unknown.

2.44

The PCR5 (Patient Clinical Record) notes that Mr C was alcohol dependent and had voluntarily ceased his alcohol consumption over the previous couple of days. It is not clear from the notes who supplied this information. The PCR records significantly raised blood pressure. Given Mr C's presentation and the history given, the attending crew concluded that it was quite likely that he had suffered an alcohol withdrawal seizure.

2.45 

Mr C was taken to hospital by ambulance for further investigations.

2.46 

14 May 2012 - The ambulance was called on this date to attend a store for a patient who had fallen. The call log notes the patient, Mr C, had sustained a cut to his head earlier in the day following an assault by his boyfriend. The PCR notes that he had sustained a head injury and complained of having been kicked in the ribs, causing pain on breathing. He said he'd also been hit on the nose.  He had felt unsteady on his feet at the supermarket and the store had called for an ambulance. The PCR notes Mr C's slightly raised blood pressure.

2.47 

One of the ambulance crew that attended that day has since left the Trust, but the other crewmember does recall that Mr C made a disclosure about having been assaulted earlier in the day, stating that he said he had 'had a fight with my boyfriend this morning, it's fine, it's nothing'. The crew asked if he had reported it and he had responded,'/ don't want anything done about it'. The crew felt that he had the capacity to make a decision about making an onward report to police about the assault, and consequently took no further action.

2.48    

Mr C was then taken to hospital for monitoring for his head injury and blood pressure. The PCR records that the cause of the head injury was an assault, but does not record that Mr C had identified his boyfriend as the perpetrator.

Royal Sussex County Hospital - part of BSUH

2.49    

20 February 2012 - Mr C arrived by ambulance, having been found by an unidentified friend collapsed in his flat. Mr C said that he went into the living 5 Supplied.room and felt faint. He said that though he did not lose consciousness, he did not remember falling. His friend reported waking to find him gasping on the floor and asked the people in the shop above to call the paramedics. Mr C's long-term alcohol dependence is noted. Mr C presented with a laceration above his right eye and evidence of a nosebleed, but no obvious nose fracture. (The following x-ray revealed a fracture, described at 2.54 below.)

2.50    

Contact was made for Mr C with the Community Alcohol Team and Mr C agreed to be seen when medically fit. He had a facial x-ray and CT scan and was admitted to the Acute Medical Unit.

2.51    

He was assessed and the doctor notes that Mr C was a poor historian with a varying story. In this conversation, Mr C denied being alcohol dependent and the doctor documents that this aspect of his history was taken from the ambulance crew and friend. The doctor spoke to Mr C further and gathered more information, including that Mr Chad moved to Brighton with a friend, was a smoker and was consuming a bottle of vodka daily.

2.52    

During this visit, Mr C said he was registered with the REDACTED Medical Centre. REDACTED The pharmacy contacted REDACTED to confirm this and they replied that he was not a current or past patient of theirs. (This may be due to the confusion we found over Mr C's name. His name had been misspelled, presumably as a result of a mis-hearing). The source of information about Mr C's current medications is unclear, as a history is usually taken from the patient and confirmed with the GP. Despite being told that they were not Mr C's GP, all the discharge letters from this admission were sent to REDACTED.

2.53    

The next day, 21 February 2012, Mr C was seen by hospital alcohol liaison. In this conversation, Mr C admitted to drinking ¼ to ½ bottle of vodka daily but that he had cut down with his partner's help. Initially he said he was not worried about his alcohol consumption but changed his mind when prompted and agreed to take information home about safe drinking and the drop-in clinic. Information was also left for his partner.
 
2.54    

Mr C was also seen by the maxillary facial team for treatment of a depressed fracture to his right maxillary sinus and nasal fracture. He was seen also by the Digestive Disease Team as Mr Chad described symptoms of vomiting. He was discharged home following investigations and treatment with a review appointment on 29 Feb 2012 at the eye hospital and a follow-up appointment at the AMU clinic on 9 March and a CT scan on 7 March 2012. Before discharging him, the nurse tried to contact his friend who had visited earlier, identified later as Mr Y. A message was left on his phone and Mr C was discharged to make his own way home.

2.55    

Mr C attended the appointment on 9 March and reported that he was feeling well and the bruising had significantly reduced. He did not attend the other appointments.

2.56    

14 May 2012 - Mr C was admitted to A&E by ambulance. The initial hospital assessment reports, 'fell whilst shopping legs gave way - hit head on floor, sustained laceration wound to scalp no loss of consciousness'. This does not align with the information in the PCR and is returned to in 3.54 below. Mr C was then transferred to the minors department to wait fqr a doctor's assessment.

2.57    

The triage nurse, in an interview conducted as part of the IMR, reported that it was a busy evening and that the handover from the ambulance crew did not mention that Mr C had been assaulted (though it was noted in the PCR).  Mr C was seen briefly when a history was taken. He did not check Mr C for signs of visible injury. He reports that Mr C was assessed as not being an emergency.

2.58    

The triage nurse says that Mr C was reluctant to say what had happened but remembers that Mr Y arrived during this conversation and introduced himself as Mr C's carer. Mr C said, 'He beats me up' and Mr Y replied, 'You know I don't beat you up'. He said that Mr C did not react to this and did not show signs of being anxious. The triage nurse noted that Mr C was under the influence of alcohol. (He was the only person to identify this.) He also says that he did not include Mr C's accusation in his notes as he did not know if it was true. He observed that-Mr Y appeared very caring and asked on about 3 occasions how long the wait would be before Mr C was seen by a doctor.

2.59    

Mr C, with Mr Y, was sent to the waiting room to wait to be seen by a doctor. After approximately 2 hours, Mr C was called for treatment and did not attend. He was called 3 more times and did not attend whereupon it was assumed he had left the department. There is no record that he informed anyone that he was discharging himself and there is no policy on following up self-discharges from A&E.

Concerns of Mr C's family ·

2.60    

Members of Mr C's family attended the trial and some gave evidence. They had questions as a result of what they had heard.

2.61    

They felt that there were several times that others might have intervened to help Mr C: when he was dismissed from his job in -    and when he was taken to A&E in February 2012 and again in May 2012.

2.62    

The family also had concerns that Mr C might have been treated less well because he was a man, because he was gay and because of his problematic alcohol misuse. They thought that perhaps some of his falls might have been the result of assaults whereas they were attributed to trips and slips, perhaps as a result of his drinking. They knew that his drinking made him vulnerable and want to know if he was offered help. They also want to know if his medical records linked up so that the medical professionals in Brighton knew his medical history from -    and whether those records would have shown a pattern of abuse.

2.63

The family want to know why the medical professionals did not respond to Mr C's disclosure that his boyfriend beat him up and why they did not examine him for injuries. Some of the family also want to know why agencies did not take the extra step to find out what was wrong when Mr C, a person who presented as so vulnerable and walked with a stick, did not attend appointments.

2.64

There was particular concern in Mr C's family that when professionals looked at Mr C, they saw only "an alcoholic and not the man he was".

2.65  

The family have discussed their concerns and made recommendations to the Chair, who is also the report writer. These are included below.

3.1    

Mr C was a man in his sixties with problematic alcohol use that led to the loss of his job. He had a number of additional and chronic health concerns including depression. His problematic alcohol misuse, which increased after losing his long-term partner, made him vulnerable to abuse. Mr Y had a criminal past and some of his offending behaviour related to exploitation of others. Mr Y appears to have exploited Mr C's vulnerability to financially, emotionally and physically abuse Mr C.

3.2    

Mr C presented as quite vulnerable. He was very thin and walked with a stick and was described by some of the professionals as 'elderly' at the age of 60 to 64. Some professionals reported that he smelled of drink and Mr C acknowledged his problematic alcohol misuse.

Abuse over a period of time that was not stopped

3.3    

The Coroner reported that Mr C died from blunt force trauma and the bone expert at the trial found evidence of 3, and perhaps 4, separate episodes of injury, indicating that he was assaulted a number of times in the last 3 or 4 months of his life. In addition, his family knew of an assault back in 2009 or 2010, soon after Mr Y entered Mr C's life, so it is likely that Mr C was physically abused for a number of years.

3.4

Mr C told his family about some of the abuse but they were not successful in getting Mr C to cut his ties to Mr Y, and their access to him became more and more limited. Mr C did not disclose the abuse to agencies he came into contact with until the end of his life. The professionals did not ask Mr C about his situation and when he did disclose little or no help was offered. He was not protected from further abuse and was not given information to help him protect himself.

Who might have helped?

3.5    

Anyorie and everyone can help another identify that they are suffering abuse and assist them.  Friends, family, employers and professionals need to be able to identify signs of abuse, be confident to 'ask the question', and respond sensitively and effectively. To do this, family and friends need to understand domestic abuse and where to go for help and information. Employers and professionals need training and information. All need to understand how domestic abuse might present itself, the dynamics of abuse that make it hard for victims to identify what is happening and act to protect themselves, and to understand how perpetrators often present themselves, and then how to respond (referral and support). The link to specialist support can come from family and friends, employers, statutory agencies and health professionals. Below we review the engagement of family, employers and health professionals.

3.6    

Family: Over the course of Mr C's relationship with Mr Y, he talked to his family about the relationship. The family reported various aspects of Mr C's situation that are common in cases of domestic abuse: physical assault, Mr C's vulnerability through his problematic alcohol misuse and Mr Y's regular drug use; Mr C's minimisation of Mr Y's actions saying that Mr Y was only like that when he smoked dope; increasing isolation through the move to Brighton and Mr Y's control of Mr C's phone; and the financial abuse when Mr Y demanded money from Mr C.

3.7    

Mr C's family attempted to talk to him about the dangers but he changed the subject or ended the conversation. Mr C's family did not seek help from professionals as they thought that Mr Y would eventually leave Mr C when the money ran out. Mr C did not seek help for the abuse until near the end of his life.

3.8    

In this case, Mr C's family and Mr C himself might have benefitted from public information that described the different types of abuse and that abuse tends to get worse without an intervention of some type. The public should also understand that addressing a perpetrator's mental health or drug and problematic drug or alcohol misuse will not reduce their abusive behaviour alone as it does not address the power and control dynamics that underpin domestic abuse. We do not know what information Mr C had access to or whether he knew that there was a specialist service for LGBTQI people suffering domestic abuse. Mr C's family did not know about RISE, the domestic abuse service in Brighton.

3.9    

Analysis: the Panel identified the importance of ensuring that local information for victims/survivors is tailored for specific communities of interest, so that they are able to name the abuse they are experiencing and to access appropriate help and support. In addition, the Panel found there was a need for information aimed at family and friends of victims/survivors, so that they know where they can go for advice and to talk through their options when supporting those suffering abuse.

3.10  

Employer REDACTED Trust noted a change in Mr C's behaviour following the death of his long-term partner in 2001. His unauthorised absences and attendance at work under the influence of alcohol led to the Trust starting disciplinary procedures that resulted in a disciplinary warning in February 2006 which was extended following another incident in November that year. There were no more concerns until disciplinary actions were begun again in November 2010 for unauthorised absences and general misconduct. Occupational health services were offered to Mr C that might have provided an opportunity to him to disclose the abuse he was suffering, but Mr C did not attend the appointments arranged for him. The Panel were concerned that Mr C's non-attendance could have been due to injuries he was suffering, but the Trust noted that the misconduct noted included appearing at work when he was off sick to talk to fellow employees and sit in the staff canteen.

3.11    

Absences from work and increased alcohol consumption can be indicators of abuse, but the Trust saw these behaviours in Mr C before he began his relationship with Mr Y.    Mr C's employers offered him a number of opportunities to talk to the occupational health service and appointments and hearings were rescheduled a number of times to accommodate him. The appointments with the occupational health professionals would have been the obvious place for Mr C to discuss his personal circumstances and difficulties and to have disclosed abuse, but he did not attend. If he had spoken to the occupational health team and disclosed abuse, a link might have been made, through his GP, to the symptoms he was exhibiting and he might have been given information and support to protect himself.

3.12    

The Trust followed its procedures and rearranged meetings and appointments several times to accommodate Mr C. He did not appear to be engaging in this formal process. The Trust might have drawn on an understanding of problematic alcohol use and its link to domestic abuse to initiate an informal conversation with Mr C, when he was in work or on the ward, to ask about his home life and abuse. The training for health professionals to improve their response to patients suffering abuse should also be used to inform their employment practices.

3.13    

Analysis: As victims of domestic violence try to cope with the abuse they experience, their employers may see that they are late for work, have unexplained absences and find it difficult to concentrate. The Panel identified that employers and unions should be supported in relation to domestic violence and abuse, including raising awareness of this issue among staff and members, ensuring that employers and unions know how to respond to concerns or a disclosure and are able to offer proactive support in these cases.

3.14    

REDACTED GP: Mr C's GP in REDACTED saw him regularly for tests, review of medications, and blood pressure readings. A number of Mr C's symptoms are related to his problematic alcohol misuse, but are also health symptoms of domestic abuse.  The Royal College of General Practitioners provide guidance on the role of the GP that includes a list of presenting problems that should prompt an enquiry about domestic abuse from the GP. It suggests that GPs ask about abuse where a review of the medical record reveals that a patient has presented with repeated 'accidental' injuries, a history of psychiatric illness, alcohol or drug dependence in patient or partner, and a history of depression, anxiety, failure to cope, social withdrawal, with underlying sense of helplessness. Further, a recent review of sources on intimate partner violence and health among men who have sex with men (MSM -  abbreviation used in the review) concluded that MSM victims of abuse are, among other things, more likely to engage in substance use and suffer from depressive symptoms, though they note that little is known about this client group and more research is needed into effective interventions.

3.15    

The GP records 4 or 5 - GP hand-written notes show 4 episodes and Pathologist's recounting shows 5 - incidents where Mr C fell and noted that they were all slips and trips, not collapses. He noted that he would recommend the falls clinic if there any further falls.  It is not possible to tell at this distance if the falls Mr C had in REDACTED were related to abuse from Mr Y, to his problematic alcohol misuse, or to his general health that made him unsteady. But the combination of his alcohol use, depression, and 5 falls in 3 months might have prompted a question about abuse, or at least about his living situation and any help he might have had at home.

3.16    

Mr C obviously felt comfortable at the GP surgery and trusted his GP enough to admit to his period of heavy drinking in March 2011. Evidence of Mr C's problematic alcohol misuse had many of the same characteristics as symptoms of abuse. There are some studies that look at the relationship of criminal behaviour to domestic abuse, but the studies found focus on women's offending REDACTED shoplifting may have been another indicator. Some of these pre-dated Mr Y's entry into Mr C's life and Mr C's pre-existing problematic alcohol misuse may have obscured any other cause.

3.17  

The GP might have had a conversation with Mr C about why his alcohol consumption had increased and might have referred him to an alcohol service to support him in his efforts to reduce his drinking.

3.18    

The GP reports that there were no signs of domestic abuse. There were symptoms, as noted above, that could have indicated abuse and an enquiry at this time by his GP might have led to a disclosure, as might a referral to an alcohol service.

3.19    

IRIS, Identification & Referral to Improve Safety is a GP practice-based training and support and referral programme that has been evaluated in a randomised controlled trial. Core areas of the programme are training and education, clinical enquiry, care pathways and enhanced referral pathway to specialist domestic violence services. The Panel noted that implementation of such a programme would provide the opportunity for those suffering abuse to disclose and get help.

3.20    

Analysis: The Panel identified the importance of ensuring that there is a consistent response to domestic violence and abuse within General Practice. This would require staff to be trained so they have the confidence to recognise the indicators of domestic violence and abuse and can ask relevant questions to help people disclose their past or current experiences of such violence or abuse. Staff would also need to be aware of the services, policies and procedures locally and have access to a formal referral pathway to support a response to a disclosure.

3.21    

Health professionals on 20 February 2012: Mr C was picked up by ambulance and taken to hospital for an apparent fall. The ambulance crew worked from the information they were given - the source is unclear - and concluded that Mr C was an alcoholic who had suffered an alcohol withdrawal seizure. From Mr Y's behaviour, they assumed Mr Y was Mr C's carer, but they did not confirm this with Mr C.

3.22    

At the hospital, Mr C was seen by a number of professionals: he was assessed by a doctor, talked to the alcohol liaison, had x-rays (for a nasal fracture) and a CT scan, and was seen by the maxillary facial team for fractures, and by the digestive disease team for vomiting. The doctor notes that Mr C was a poor historian and that the history was taken from the ambulance crew and 'his friend'. Some of the background information was confirmed by Mr C in his consultation with the doctor. Mr C was seen by the alcohol liaison person and said that his partner had helped him to cut down on his drinking.

3.23    

None of these professionals noted anything amiss in Mr C's story - apart from him being a poor historian - that prompted them to ask further questions. The ostensible presenting problem, a fall as a result of his problematic alcohol misuse, seems to have provided a realistic, if not necessarily accurate, diagnosis of the cause of his injuries which they were prepared to accept rather than delving more deeply into other possible social factors.

3.24    

Health responses that focus solely on the presenting health problem will miss the social factors that may be the cause of that problem. Understanding the dynamics of domestic abuse requires a wider view to ask and get to the real source of the presenting health problem. For instance, being a 'poor historian' can also be evidence of abuse as a victim may feel he or she needs to change the story to hide the fact of the abuse due to anxiety about the results of a disclosure.

3.25    

None of the health professionals in particular the REDACTED GP or the alcohol liaison service (who met Mr Con 21 February 2012) REDACTED noted asking Mr C about his home situation or about abuse. The professionals may have been further dissuaded from such questioning by Mr C's praise of the support (to the alcohol service) he had received from Mr Yin his efforts to decrease his drinking.

3.26    

The hospital alcohol liaison service in the hospital does not ask a question about abuse routinely, instead making a decision on a case-by-case basis. In this case, Mr C's positive reference to Mr Y's support is likely to have dissuaded the service from asking Mr C about abuse.

3.27  

The local DV service note that the hospital alcohol liaison service are, at the time of writing this report, one of the highest referrers to the hospital IDVA, the HIDVA. The alcohol liaison service is now working with domestic abuse and mental health colleagues to develop training for professionals working with clients experiencing substance misuse, mental health problems and domestic abuse.

3.28    

Because of the difficulty of identifying indicators and signs of domestic abuse in the lives of those who have substance misuse or mental health problems, NICE Guidance recommends routine enquiry for a number of services that work with such vulnerable people.

National Institute for Health and Care Excellence public health guidance 50, 'Domestic violence and abuse: how health services, social care aAd the organisations they work with can respond effectively', February 2014, Recommendation 6.

The guidance states, 'This should be a routine part of good clinical practice, even where there are no indicators of such violence and abuse.' Mr C's combination of health problems and, in particular his vulnerability as a result of his problematic alcohol misuse should have prompted questions from the GP, the hospital and the alcohol liaison service.

3.29    

Analysis: The Panel identified the importance of ensuring that there is a consistent response to domestic violence and abuse within Secondary Care (in particular in this case, Accident & Emergency). This would require staff to be trained so they have the confidence to recognise the indicators of domestic violence and abuse and can ask relevant questions to help people disclose their past or current experiences of such violence or abuse. Staff would also need to be aware of the services, policies and procedures locally and have access to a formal referral pathway to support a response to a disclosure.

3.30    

The Panel also noted the need for staff in mental health, children's and vulnerable adults' services, sexual health, alcohol or drug misuse, antenatal, postnatal, reproductive care, to ask service users whether they have experienced domestic violence and abuse. These services work with people with particular risks and vulnerabilities that may make it hard for them to disclose, whose symptoms of abuse may be masked by other issues or mistakenly attributed to another cause. This should be a routine part of gooD clinical practice, even where there are no indicators of such violence and abuse.

3.31    

As part of the commissioning process for substance misuse services from 2015 in Brighton & Hove, routine screening is included in the service specification. In the meantime and to accompany the new specification, alcohol services will need to start moving towards this approach now. The city has previously developed Service Level Outcomes for domestic violence and abuse that were extended in 2014 to include Violence against Women & Girls.

3.32    

Analysis: There is a need to ensure that there is a consistent response to domestic violence and abuse within both health care and substance misuse settings. In addition, the Panel felt that there is an opportunity to support an effective response to domestic violence and abuse in all commissioned services by ensuring that Commissioners are aware of the city's Service Level Outcomes for VAWG and that these are reflected in service specifications.

Responses to disclosures - 14 May 2012

3.33    

There were a number of health professionals involved with Mr C in the last few years of his life. Mr Conly disclosed the physical abuse on 14 May 2012, but on that occasion he disclosed to 3 people, two being healthcare professionals. All remembered the disclosure, but the healthcare professionals did not record the information or pass it on to the next person in the chain of care that night.

3.34    

The store. When Mr C fell in the store, he disclosed to staff that he had been assaulted by his boyfriend that morning. The staff summoned an ambulance and the call log notes the assault by Mr C's boyfriend. The staff recommended Mr C report this to the police.

3.35    

The response of the staff reflects a common and limited understanding of the dynamics of domestic abuse and the options for someone suffering abuse. However, they properly fulfilled their obligations by providing immediate first aid to Mr C and responded to his disclosure of assault by advising him to report it to the police.

3.36    

Ambulance crew. Mr C also told the ambulance crew that he had been assaulted by his boyfriend. They too recommended that he tell the police, but Mr C said that he did not want anything done about it. The ambulance crew then assessed that Mr C had 'capacity' to make decisions and felt they were respecting his wishes to not take further action. They recorded that he had been assaulted - 'kicked, hit in nose and kicked in L ribs (PCR seen) but did not record that it was his boyfriend who had assaulted him.

3.38    

The ambulance service's review states that best practice would have required the crew to note that Mr C's boyfriend had assaulted him, but suggests that they were respecting his wishes and that recording this information would not have had an impact on his treatment.

3.39    

We know now that Mr Y had assaulted Mr C a number of times by this point. Mr Chad not sought help before but had disclosed twice so far on the evening of 14 May.

3.40    

The ambulance crew's response suggests a limited understanding of domestic abuse, of their responsibilities in these situations and of the care pathway for victims of abuse. We know that domestic abuse victims are likely to have suffered repeated assaults - approximately 42% of domestic abuse victims have been victimised more than once. The British Crime Survey indicates that victims experience an average of 20 incidents of domestic abuse in a year, which can often increase in severity each time. [Walby, S. and Allen, J. (2004) www.avaproject.org.uk - by the time they disclose, but the ambulance staff responded as if this were an isolated incident with no further threat likely. Their apparent understanding of the care pathway for victims of abuse, as enacted here, only includes a referral to the police or acting on their safeguarding responsibilities if the patient is vulnerable and lacks capacity. They did not offer a referral to a specialist domestic abuse service to talk his options through, discuss how he might keep himself safe and they took no steps to protect him - such as passing on information about who the threat came from so that other professionals could understand the situation more fully and be better able to protect him and help him to protect himself.

3.41    

A clear indication that the patient had alleged that the assault had been carried out by his boyfriend on the PCR would have reflected best practice.

3.42    

The NICE guidance recommends (Recommendation 8) that healthcare staff should prioritise people's safety, refer people to domestic abuse services if they need additional support and regularly assess what type of service someone needs- immediately and in the longer term. To move from their present understanding to the approach that NICE recommends will require training on dynamics, health indicators (in addition to risk factors}, information collection and sharing, the care pathway and targeted enquiry, as well as training on older people's, LGBTQI people and men's experience of domestic abuse. As ambulance crews will be the first professionals at many scenes of domestic abuse, it is very important that this training begins as soon as possible and does not wait for this report to be published.

3.43    

Further, the Panel were concerned about lost opportunities to get help to victims in situations where the ambulance service attends, the crew or operator suspect domestic abuse, but the victim does not disclose. The Panel was particularly concerned about such situations when children might have been present.

3.44    

The ambulance service will need to have policies and practices and accountability mechanisms to ensure that the training is effective and supported by agency expectations and support.

3.45    

It may be that the ambulance crew's limited view of their responsibilities around domestic abuse is an unintended consequence of domestic abuse training being part of safeguarding adult training. The result may be that practitioners think of domestic abuse as a responsibility under their safeguarding obligations and do not understand their role in helping those who are not statutorily vulnerable or 'adults at risk'. Most victims do not fit the statutory definition of vulnerable adult.

3.46    

After this incident, in March 2013, South East Coast Ambulance Service employed a specialist domestic abuse support coordinator, on secondment from RISE, the local domestic abuse charity in Brighton, to lead on a domestic abuse (DA) referral project. This project, funded by the Department of Health, aimed to investigate how the ambulance service nationally can play a more effective role in the early identification of violence and provide care and support for victims.

3.47    

The project targeted incidents where a patient or person at the scene reported that they were being abused or concerns were raised by a SECAmb staff member. It ran over a period of 10 months and in 14 ambulance stations in Brighton & Hove and West Sussex. The project trained Champions and provided a toolkit for selective screening for those who disclosed or showed signs and symptoms of abuse. It worked only with those who were referred to safeguarding (the ambulance service took a wide view of 'vulnerability' for this), who consented and who then provided safe contacts details.

3.48    

Domestic abuse referrals increased across all SECAmb areas during the pilot period.

3.49    

Findings from that pilot that are particularly relevant to this OHR are:

• increased awareness of DA amongst crews and an increase in DA referrals
• increase in onward referrals to DA support pathways
• detailed information base of DA support networks in the region
• the need for greater understanding about how to increase the number of victims consenting to contact

3.50

That report supports the findings of this OHR but our findings would urge SECAmb to expand its efforts to encourage early identification and onward referral for those who are not statutorily 'vulnerable' (so that a wide view of 'vulnerability' is used) and for whom a safeguarding alert would not normally be raised.

3.51    

The greater understanding of how to gain consent for a referral would be particularly important to engage this group as, unless they were assessed as at high risk, information-sharing would require consent. Staff will also need to be trained on how to record enquiries and disclosures as part of a chain of care to support gaining consent as a result of cumulative asking, that is, that all health professionals will be asking the question, ensuring that victims/survivors are given a number of opportunities to engage with services that can support them.

3.52    

A&E department. On the night of 14 May 2012, Mr C then arrived at the A&E department of the Royal Sussex County Hospital (part of the BSUH).

3.53    

It is important to note that A&E is always a busy department and there is a high intensity to the work as many people who arrive there need immediate emergency attention. The point of the triage process is to prioritise those who are acutely ill and injured. Members of staff are often required to analyse complex presentations of patients' medical needs, further complicated by the patient's alcohol or substance use.

3.54    

On 14 May 2012, the notes suggest that the ambulance crew left Mr C in A&E and left the notes about him with reception. The ambulance crew's notes detail an assault. There does not appear to have been a verbal hand-over between the ambulance crew and the A&E staff and the triage nurse does not recall being told that Mr Chad been assaulted, though it is noted in the PCR.

3.55

This practice has now changed and building works have been undertaken to ensure that patients have privacy and dignity in A&E. Now, all arrivals by ambulance are handed over to hospital staff more formally and when there are sensitive circumstances the handover is completed face-to-face. These new facilities and practices will greatly assist health professionals to enquire about domestic abuse. If they had been in place on the night of 14 May, it may be that the ambulance crew would have highlighted that the injuries were as a result of the assault earlier in the day that Mr C had told them about. This might have informed the triage nurse's response to the following conversation.

3.56    

During his brief assessment by the triage nurse, Mr Y arrived and Mr C said, 'He beats me up' and Mr Y contradicted him, saying, 'You know I don't beat you up'.

3.60    

The triage nurse discounted Mr C's disclosure based on his own observations of the two of them and he did not record the information because he said he did not know if it were true. Mr Y introduced himself as Mr C's carer and the triage nurse observed that he behaved in a very caring way and that Mr C did not appear frightened. Mr Y then wheeled Mr C into the waiting room, but came to ask 3 times when Mr C would be seen. When Mr C was called, some two hours later, he was no longer in the waiting area.

3.61    

This is the third person that Mr C disclosed to that night and he made this third and final disclosure in front of Mr Y, thereby increasing his risk considerably. When victims of abuse disclose or seek to leave the relationship, their risk increases significantly because they are threatening the control that the abuser has over them.

3.62    

On this and the previous hospital trip, professionals readily accepted or concluded that Mr Y was Mr C's carer from Mr C's obvious vulnerability and from Mr Y's behaviour. Being identified as Mr C's carer also gave Mr Y authority in health situations. No doubt it was easier to gather and give information to Mr Y than it was to give or get information from Mr C who was described as 'confused' and 'a poor historian' and who changed his story about how much he drank. Mr C even attributed his reduction in consumption to the support of Mr Y, supporting a positive view of Mr Y and their relationship.

3.63    

In May, the triage nurse said that, as Mr Y had identified himself as Mr C's carer, he did not consider that this situation might be about domestic abuse. However, he did know that a person who had self-identified as Mr C's carer had been accused by Mr C of assaulting him. A carer is in a position of trust and has an authority that can be abused. The cared-for person's dependency can put them at risk. It is surprising that the triage nurse did not see this as a safeguarding alert even if he felt - and this is not documented - that Mr C had capacity.

3.64    

Leaving Mr C with Mr Y in the waiting room would have allowed Mr Y time to influence and threaten Mr Cover this recent disclosure.  We cannot know what happened between the two of them while they waited, but it would not be surprising if Mr Y's control over Mr C resulted in their leaving before Mr C could be examined and, once again, tell someone that he'd been assaulted by Mr Y.  Having told 3 people that he had been assaulted by Mr Y and getting no response, he was unlikely to believe that the next person would help him.

3.65    

Even without identifying this as domestic abuse, it would have been good practice to separate both parties and have a further discussion with Mr C about his situation to understand what was happening. If he had had fuller notes or a fuller conversation with the ambulance team, the triage nurse may have been better alerted to the risk to Mr C. He may have questioned Mr Y's self-identification in the role of 'carer' and been more sceptical of what he saw. He says now that with the benefit of hindsight he would have separated the two.

3.66    

There are several aspects of this situation that are familiar to those working in domestic abuse: the abused person did not act like the triage nurse would have expected - he did not appear frightened; the abuser assumed a role of responsibility and authority in front of professionals and was believable in that role; professionals did not respond to what they were told, but instead allowed their own judgment to override the victim's, that is, they did not believe the victim. The Panel was also surprised that Mr C was not examined during the triage session. The fact that he had collapsed some time after the attack might have suggested internal injuries.

3.67    

As part of the new process at A&E outlined above, all patients' notes are handed by the ambulance team to a nurse. As a result, triage is much tighter and any information on an assault or domestic abuse would be noted separately and addressed at a later assessment. There are 3 lead nurses for domestic abuse in A&E now as well as the hospital IDVA.

3.68    

The BSUH report that their new nursing documentation for A&E has a question that asks people if they feel safe at home. That is a good step forward but, as Mr Chad disclosed, was unnecessary in this situation because they already knew that he was not safe, whether Mr Y was his partner or his carer.

3.69    

Forty per cent of nursing staff have had domestic violence training at BSUH and there is a schedule of rolling training for all staff.  Each ward in the hospital has a file with guidance on what to do when domestic abuse is disclosed. There are particular steps that healthcare professionals are trained to implement in the event of a disclosure.

3.70    

The Royal Sussex County Hospital (part of the BSUH) A&E IDVA is provided by RISE, a specialist domestic abuse service. As part of local agreement to develop an integrated care pathway for male victims of domestic abuse, RISE has agreed that in 'universal' settings (like A&E) the HIDVA there will talk to male victims, risk-assess them, and provide them with safety planning and onward referral. This means there will be help in A&E for all victims of abuse, with heterosexual men due to be referred to Victim Support and gay, bisexual and trans men being referred to the specialist LGBTQI service provided by RISE.  The value of such specialist staff in A&E is that they can provide advice to professionals as well as to victims. When the IDVA is not on duty, staff would now make contact with one of the Lead Nurses for domestic abuse in A&E. Where allegations of abuse are made, staff should know how to respond and encouraged to ask the domestic abuse leads, the safeguarding lead (if unclear about the relationship), or the HIDVA for advice and assistance when needed.

3.71    

None of the people to whom Mr C disclosed that night considered contacting the police themselves.

3.72    

The duty of confidentiality is an important one and encourages and facilitates trust between patients and the professionals involved in their care. Simple questions often help a victim take that next step to disclosure: 'Is there anything I can do?', 'What are you concerned about?' Often taking the time to talk through someone's options will help dispel concerns about engagement with other agencies. In this way, staff can support people to make their own decisions to access help. When specialist workers discuss options and put a support plan in place, victims often feel more confident and comfortable involving services such as the police.

3.73    

With this understanding, health professionals need to see the potential for serious harm and murder in domestic abuse and re-consider their policies and processes around disclosures of crimes. Policies should provide for a swift, patient-centred response to the risk of a serious crime, as was committed soon after this contact with services.

3.74    

In some areas, particular services have adopted an 'opt out' approach where patients or service users are told that they will be referred to a specialist domestic abuse service unless they state that they do not want to be referred. This, or an 'assumed consent' approach, has been successful with some services such as the police.  It can be effective in raising referrals, but must be monitored to ensure that referrals lead to engagement and the process does not disaffect and distance victims.

3.75    

Finally, the reports from the BSUH and from the ambulance service suggest that BSUH and the ambulance service are satisfied with the response to Mr C. They do not challenge the assumptions made by staff that their observations overruled the patient's disclosure, or that recording the full disclosure would not have had an impact on his treatment. They appear to agree with the limited view of responsibilities acted on here.

3.75    

Yet staff did not act as part of a care pathway for those experiencing abuse, whether from his boyfriend or his carer, depending on the information theY. had. They did not recognise a duty of care in relation to Mr C's safety beyond his immediate health needs. They did not respond fully to Mr C's disclosure by providing links to specialist support or acting to keep him safe, nor did they provide full and accurate information to the next professional to enable them to do their job better. The analysis in the IMRs supports the view that their organisations do not understand their role in the care pathway or expect any other response. These organisations and their staff need to understand the vital role they play in responding to domestic abuse and acting to keep victims safe.

3.76    

The organisations need clear policies and practices, supported by institutional responsibility and accountability structures. As a result, clients will get a consistently effective response regardless of the healthcare agency they approach.

3.77    

Analysis: The Panel identified the importance of ensuring that there is a consistent response to domestic violence and abuse within Accident & Emergency.

3.78    

The Panel also identified the importance of ensuring that there is a consistent response to domestic violence and abuse within the Ambulance Service. This would require staff to be trained so they have the confidence to recognise the indicators of domestic violence and abuse and can ask relevant questions to help people disclose their past or current experiences of such violence or abuse. Staff would also need to be aware of the services, policies and procedures locally and have access to a formal referral pathway to support a response to a disclosure.

3.79    

The Panel noted that a pilot programme has been developed by South East Coast Ambulance Service and should be built on.

3.80

The Panel further identified issues with the recording and sharing of information disclosed to staff in this case. In particular the Panel felt that this case identified the importance of checking personal details when meeting a client, the recording of third party information (noting who provided the information recorded), disclosures of abuse, and the patient's responses and wishes (including the role of consent where a patient asks that 'nothing be done'), and the sharing of that information.

Recording and transmission of information between professionals

3.81    

In February 2012, the hospital contacted the REDACTED GP for confirmation that Mr C was a patient and was told that he was not registered with them. This as likely due to the misspelling of Mr C's name in the hospital file. The recording of the name appears to be based on the ambulance record and was not checked by any of the many medical professionals Mr C saw in the course of his care that evening. Despite the REDACTED GP's response, discharge notices continued to be sent to that surgery.

3.82    

The REDACTED GP had noted a number of falls and an intention to refer Mr C to the falls clinic if there were more of them. Mr C had not registered with a Brighton GP when he fell in February. (He registered with a Brighton GP on 29 March 2012.) Because the connection was not made between the hospital and the GP, the record of Mr C's falls and the suggested referral to the falls clinic did not inform further medical interventions.

3.83    

Throughout the account of Mr C's collapse in May, a marked discomfort is shown by the professionals dealing with Mr C, as though him being assaulted was a personal matter. This is reflected in how his disclosures were recorded, leading to incomplete information being passed from one agency to the next. The ambulance service did not record that it was Mr C's partner that assaulted him and they felt they were respecting Mr C's wishes by not recording this. The triage nurse did not record Mr C's accusation that Mr Y had beaten him because he was not sure that it was true, based on his own observations. If the ambulance crew had recorded that Mr C had said he had been assaulted by his partner, the triage nurse might have put that together with Mr C's accusation of Mr Y and realised this was an incident of domestic abuse.  The process of separation and asking about the disclosure might have been started then.

3.84    

Analysis: The Panel noted an overarching theme, reflected across a number of services, related to information-sharing and the confidence of professionals both to explore issues relating to disclosures made by Mr C and to share information. It was of note that, although Mr C was in contact with a range of professionals, there was little psychosocial information recorded that would have provided a context for his presenting problems and may have Jed to further questions.

Equality and diversity

3.85

The Panel considered Mr C's single status, his race and religion and concluded that these had no impact on the response he received. The protected characteristics of pregnancy and gender reassignment are not pertinent in this case.

3.86    

The Panel considered the protected characteristics that were apparent in this case. Mr C was an older white gay man in a relationship with a younger Black African man, though that relationship was unclear to the professionals and was described differently by Mr C and by Mr Y.  Mr C was not disabled, but had significant health problems, including problematic alcohol misuse, that made him more vulnerable within the context of his life.

3.87    

Mr C's family wondered if Mr C would have had the same response to his disclosures if he had been a woman.

3.88    

The Panel considered that it was likely that, despite the training, professionals did not identify this as domestic abuse - Mr C was male, gay, and older, and Mr Y was younger - and the presentation may have been more familiar to them in a carer relationship. When Mr Y confirmed that, they asked no further questions.

3.89

So it is likely that the fact that Mr C did not fit the more common picture for domestic abuse - of a woman abused by a man - meant that the extensive training was not triggered. It was felt that the combination of his sex, race (i.e. as different from Mr Y), sexual orientation and his problematic alcohol misuse may have affected the care he received.

3.90    

This is particularly a concern in Brighton & Hove where it is estimated that between 35,000 to 40,000 (13 - 14.5%) of the local population is Lesbian, Gay, Bisexual or Transsexual. It may be that the professionals in contact with Mr C responded less well to him because he was gay. Indirect discrimination is difficult to identify and counter without specific training.

3.91    

It also may be that Mr Chad suffered discrimination in the past because he was gay.  It is common for victims of domestic abuse to be ashamed of what is happening to them and for gay people to feel shame about their sexual orientation.  The combination may have made it much more difficult for Mr C to disclose abuse. Such barriers to getting help make it vital that the professionals whom they tell - and for professionals who suspect abuse - to be pro-active in their response. A poor response may end a victim's efforts to get help at all.

3.92  

Analysis: the Panel identified the importance of ensuring that training on domestic violence and abuse addresses issues for specific communities of interest, so that professionals are aware of whom this may affect and any unique needs or barriers to accessing help. This should include ensuring that introductory training on domestic abuse has information on these communities and, where appropriate, more advanced training is developed to further develop practice responses.

Good practice

3.93    

There are a number of initiatives in Brighton and Hove to improve the response to domestic abuse:

3.94    

RISE, the specialist domestic abuse service in Brighton & Hove, is funded by the Partnership Community Safety Team to provide an LGBTQI service.

3.95    

The South East Coast Ambulance Service NHS Foundation Trust Domestic Abuse Referral Pilot has been undertaken to improve the response of the SECAmb service so that it can become a model of good practice. The
 
findings and recommendations are compelling and the service is seeking funding to implement them.

3.96    

Each ward in the Royal Sussex County Hospital (part of BSUH) has a folder with information about responses to domestic abuse to help staff respond effectively.

3.97    

There are steps already being taken to improve the response to domestic abuse in Brighton & Hove and, if they had been in place, may have made a difference in this case.

3.97.1 The HIDVA that works at A&E is now working with both women and men, as part of an integrated care pathway.

3.97.2 Substance misuse services commissioned by the local authority will be required to ask routinely about domestic abuse from 2015.

3.97.3 BSUH reports that their new nursing documentation for A&E has a question that asks people if they feel safe at home. With training, staff will be able to engage victims during this initial interview and connect them to services.

4.1    

Every professional that Mr C saw had the opportunity to ask him about his home life and the abuse that he suffered.   In a coordinated community response (CCR), all parties are aware of domestic abuse and its dynamics. They know the indicators of abuse and the risk factors, their role in the coordinated effort, and act to help victims. The CCR closes the gaps between services.  The professionals who dealt with Mr C each did their specific job, but without an understanding of their role in the coordinated response - in the care pathway to help - and without a broader understanding of health to include safety.

4.2    

As communications between health agencies is a key theme here, Brighton & Hove may find it useful for senior health professionals to work through the recommendations together to ensure the CCR is developed between them.

4.3  

Mr Chad been assaulted at least over a period of months and probably years. He was physically, emotionally and financially abused. His family knew of some of the abuse but were unable to convince Mr C to seek help or leave Mr
Y. The many health professionals that Mr C saw in the last year of his life did not pick up the signs of abuse or ask about it. Mr C's problematic alcohol use appears to have been allowed to mask the signs of abuse, even when he disclosed.

4.4    

It also may be that being an older gay man may have made it more difficult for Mr C to seek help and for professionals to identify the assault as domestic abuse.

4.5

When Mr C did disclose, the professionals did not honour that disclosure by responding pro-actively. They responded with a narrow set of options or discounted what he said and did not take pro-active steps to help him. They addressed his immediate health needs but did not prioritise his safety as required in Recommendation 8 of the Nice Guidance: Domestic violence and abuse; how health services, social care and the organisations they work with can respond effectively.

4.6    

Mr C's REDACTED GP and the healthcare professionals involved with him during his February 2012 admission may have identified domestic abuse if they had asked. They all focused on the presenting health problems without asking questions about the wider context. We cannot tell if the 'falls' recorded over the last year of his life were the result of increasing poor health, increased problematic alcohol misuse, or assaults. Mr C may have not disclosed but a failure to ask means that he was not given the opportunity to get help.

4.7    

Mr C did disclose, repeatedly, on the night of 14 May 2012 and no one responded effectively to those disclosures. He was left with his abuser and, after 2 hours, left A&E without having seen the doctor.

Preventability

4.8    

Mr C's reluctance to talk about the abuse limited the opportunities to help. Such reluctance - which is common in victims of abuse - heightens the importance of the responses when Mr C did disclose. As Mr C finally named the abuse to health professionals  in May 2012 even risking confronting Mr Y in front of others, it appears that he was ready to get help. The only advice he was given was that he talk to the police. If the professionals that night had responded more appropriately to his disclosures, if they had recorded and shared key information so that Mr C was separated from Mr Y and had the opportunity to make a safety plan and talk to someone about his options, it may be that he would have survived. In these circumstances, there is a clear possibility that this death could have been prevented.

4.9

The NICE guidelines are wide-ranging and their implementation is likely to address some of the other concerns raised by this review of services that worked with Mr C. However, the frontline response needs to be addressed as a matter of urgency and therefore recommendations related to that are listed separately.

Recommendations

4.10    

The response to domestic and sexual violence and abuse, as well as a range of other crime types, is overseen by the Violence against Women and Girls (VAWG) Programme Board. Representatives include:   the Local Authority (Adult Services, Children's Services, Environment, Development and Housing, Public Health), Health (Brighton & Hove Clinical Commissioning Group, Brighton and Sussex University Hospital, NHS England and Sussex Partnership Foundation Trust), Police, Probation, University of Sussex, University of Brighton, Voluntary and Community Sector representatives and the Local Safeguarding Children Board (LSCB). It is chaired by the Assistant Chief Executive of Brighton & Hove City Council. The Board has responsibility for a VAWG Strategy, with a particular focus on women and girls, but with actions as appropriate to address the needs of men as victims, perpetrators, boys and allies. It reports to the Safe in the City Partnership, which is responsible for this review and the actions taken in response to the recommendations.

To improve health and social care responses to patients and employees

4.11    

Recommendation 1: Implement the NICE guidance on Domestic violence and abuse: how health services, social care and the organisation they work with can respond effectively.

4.12    

Recommendation 2: Review training for health care professionals on domestic violence and abuse and ensure it is available to all frontline staff. Training should include the following key messages:

• health symptoms that correlate to domestic abuse
• dynamics and indicators of domestic abuse, especially how an abusive situation and an abuser may present to them in the course of their work. Highlight particular issues with older people, with carers, and with those who are LGBTQI
• how to undertake targeted and routine enquiry, and the appropriate responses to any disclosure of abuse or assault
• indirect discrimination and the need for a pro-active response
• clarify that staff should respond to all victims, not just those who meet the vulnerable adult criteria: the care pathway for domestic abuse victims requires all professionals to act - to provide an emergency response when required (ambulance, A&E, police); to provide a statutory response (for vulnerable adults and children); and an empowering response for all: to listen, believe, ask what the victim wants and what they can do, record and share, and provide a specialist to talk about their situation and options)

4.13    

Recommendation 3: Primary Care Providers, and NHS England commissioners, support primary care providers and staff to respond to domestic violence and abuse by adopting Recommendation 16 of NICE Guidance and by commissioning the IRIS project locally. (This is in order to ensure that staff undertake targeted enquiry, and are supported by policies and procedures locally and that staff have access to a formal referral pathway to support a response to a disclosure).

4.15    

Recommendation 4: Secondary Care Providers, and local Health Commissioners, to support Secondary Care providers and staff to respond to domestic violence and abuse, specifically by ensuring that staff undertake targeted or routine enquiry as appropriate. (Staff should be supported by local policies and procedures that include a formal referral pathway. They should be able to access advice when they require it either from specialist agencies or champions within their organisation).

4.16    

Recommendation 5: South East Coast Ambulance Service and the service's commissioners support a response to domestic violence and abuse, by ensuring that staff undertake targeted enquiry as appropriate. (Staff should be supported by local policies and procedures that include a formal referral pathway. They should be able to access advice when they require it either from specialist agencies or champions within their organisation).

To improve the community's understanding and response

4.17

Recommendation 6: Launch publicity and awareness-raising for family, friends and victims, to include:

• information about where victims, family and friends can go for advice and to talk about their options
• tailored information for specific communities of interest, including gay men and their family and friends to name the abuse they are experiencing

4.18    

Recommendation 7: Provide guidance and support for employers and unions to develop employment policies that address domestic abuse, ensuring that employees are asked about domestic abuse and supported to address this before instigating disciplinary actions. (Work could be prioritised with health providers so that their awareness of the link between mental health and substance misuse problems and domestic abuse when working with patients is reflected in their own employment practices).

To improve commissioned services' responses

4.19    

Recommendation 8: The specifications for all services commissioned locally include provisions in relation to domestic violence and abuse, reflecting the City wide VAWG outcomes.

To improve the communication between agencies and services

4.20

Recommendation 9: NHS England (Surrey and Sussex) and the local Clinical Commissioning Group to provide guidance and training for health professionals on recording and sharing information, particularly in regard to domestic violence and abuse. (This case might be used to develop that guidance).

4.21    

Recommendation 10: The ambulance service should develop their response to patients who disclose domestic abuse and those cases where staff suspect there has been domestic abuse. (A model has already been piloted for this and the pilot should be built on. Key areas for development are training for targeted enquiry, the role of consent, a full understanding of the care pathway for victims of abuse, recording of information and patient's wishes and sharing information with other agencies).

4.22    

Recommendation 11: Learning is disseminated from this review to ensure staff are aware of the importance of their responses to disclosures or concerns, the value of good communication with patients, and the need for information-sharing. (The understanding gained through this exercise should be used to develop responses and processes from all healthcare agencies. Work could be prioritised with Ambulance crews, A&E staff, GPs and Police using the review of this death as a case study).

This Domestic Homicide Review is being completed to consider agency involvement with Mr C, and Mr Y, following Mr C's death before 16 July 2012. The Domestic Homicide Review is being conducted in accordance with Section 9(3) of the Domestic Violence Crime and Victims Act 2004.

Purpose

1. Domestic Homicide Reviews (DHRs) place a statutory responsibility on organisation to share information. Information shared for the purpose of the OHR will remain confidential to the Panel, until the Panel agree what information should be shared in the final report when published.
2. To review the involvement of each individual agency, statutory and non­ statutory, with Mr C and Mr Y during the relevant period of time: 1 October 2011 to REDACTED 2012.
3. To summarise agency involvement prior to that date, where relevant.
4. To establish whether there are lessons to be learned from the case about the way in which local professionals and agencies work together to identify and respond to disclosures of domestic abuse.
5. To identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result and as a consequence.
6. To improve inter-agency working and better safeguard adults experiencing domestic abuse and not to seek to apportion blame to individuals or agencies.
7. To commission a suitably experienced and independent person to chair the Domestic Homicide Review Panel, co-ordinate the review process, quality assure the approach and challenge agencies where necessary, produce the Overview Report and Executive Summary by critically analysing each agency involvement in the context of the established terms of reference.
8. To conduct the process as swiftly as possible, to comply with any disclosure requirements, and on completion, present the full report to the Brighton & Hove Safer in the City Partnership.
9. Membership - The following agencies are to be involved: RISE, local domestic abuse service, Local authority: Safeguarding Adults, Health Authorities, Sussex Partnership Trust (mental health and substance misuse services), Brighton and Hove Safer in the City Partnership, Sussex Police.
10. Where the need for an independent expert arises, for example, a representative from a specialist LGBTQI organisation, the chair will liaise with and if appropriate ask the organisation to join the Panel.
11. If there are other investigations or inquests into the death, the Panel will agree to either: run the review in parallel to the other investigations, or conduct a coordinated or jointly commissioned review - where a separate investigation will result in duplication of activities.
12. Collating evidence: each agency to search all their records outside the identified time periods to ensure no relevant information was omitted, and secure all relevant records.
13. Each agency must provide a chronology of their involvement with Mr C and Mr Y during the relevant time period.
14. Each agency is to prepare an Individual Management Review (IMR), which: sets out the facts of their involvement with Mr C and/or Mr Y, critically analyses the service they provided in line with the specific terms of reference, identifies any recommendations for practice or policy in relation to their agency, and considers issues of agency activity in other boroughs and reviews the impact in this specific case.
15. Agencies that have had no contact should attempt to develop an understanding of why this is the case and how procedures could be changed within the partnership which could have brought Mr C or Mr Y in contact with their agency.
16. Analysis of findings: in order to critically analyse the incident and the agencies' responses to the family, this review should specifically consider the following six points: analyse the communication, procedures and discussions, which took place between·agencies, analyse the co-operation between different agencies involved with the victim, alleged perpetrator, and wider family, analyse the opportunity for agencies to identify and assess domestic abuse risk, analyse agency responses to any identification of domestic abuse issues, analyse organisations access to specialist domestic abuse agencies, analyse the training available to the agencies involved on domestic abuse issues.
17. Liaison with the victim's and alleged perpetrator's family - sensitively involve the family of Mr C in the review, if it is appropriate to do so in the context of on-going criminal proceedings. Also to explore the possibility of contact with any of the alleged perpetrator's family who may be able to add value to this process. The chair will lead on family engagement with the support of the senior investigating officer and the family liaison officer.
18. Coordinate with any other review process concerned with the child/ren of the victim and/or alleged perpetrator.
19. Development of an action plan - establish a clear action plan for individual agency implementation as a consequence of any recommendations.
20. Establish a multi-agency action plan as a consequence of any issues arising out of the Overview Report.
21. Media handUng - any enquiries from the media and family should be forwarded to the chair who will liaise with the CSP. Panel members are asked not to comment if requested. The chair will make no comment apart from stating that a review is underway and will report in due course.
22. The CSP is responsible for the final publication of the report and for all feedback to staff, family members and the media.
23. Confidentiality - all information discussed is strictly confidential and must not be disclosed to third parties without the agreement of the responsible agency's representative. That is, no material that states or discusses activity relating to specific agencies can be disclosed without the prior consent of those agencies.
24. All agency representatives are personally responsible for the safe keeping of all documentation that they possess in relation to this OHR and for the secure retention and disposal of that information in a confidential manner.
25. It is recommended that all members of the Review Panel set up a secure email system, e.g. registering for criminal justice secure mail, nhs.net, gsi.gov.uk, pnn or GCSX. Confidential information must not be sent through any other email system. Documents can be password protected.

Safeguarding & Vulnerable People, Unit 2 Marsham Street, London, SW1P4DF
Phone: 020 7035 4848
Mobile: 020 7035 4745
Web: www.homeoffice.gov.uk
 

Mr James Rowlands,

Partnership Community Safety Team Brighton & Hove City Council
Room 419, 4th Floor King's House, Grand Avenue, Hove, BN3 2LS

8 December 2014

Dear Mr Rowlands,

Thank you for submitting the Domestic Homicide Review (OHR) overview report for Brighton to the Home Office Quality Assurance (QA) Panel. The review was considered at the November Panel meeting.

The QA Panel would like to thank you for conducting this review and for providing them with the final overview report. In terms of the assessment of reports, the QA Panel judges them as either adequate or inadequate. It is clear that a lot of effort has gone into producing this report and I am pleased to tell you that it has been judged as adequate by the QA Panel.

The QA Panel would like to commend you on your approach taken to monitoring and implementing the actions that have come out of this and other DHRs through a centralised action plan holding information from different reviews. The QA Panel felt that it appeared to strengthen oversight by getting the VAWG Programme Board to monitor the plan. They also felt this would help to embed the learning from this and other OHR reports conducted by this Community Safety Partnership.

The QA Panel also commented that the report appeared open and thorough, and demonstrated a sound knowledge of domestic violence and coercive control.

• there were some issues that the QA Panel felt might benefit from more detail and/ or consideration which you may wish to consider before you publish the final report:The QA Panel felt that it would be helpful if you included more text to clarify why the conviction was for manslaughter rather than murder
• additional text to clarify the rationale behind not engaging with family, friends or wider networks in accordance with the Statutory Guidance
• consider reviewing the wording at paragraph 3.71, which the QA Panel felt could be misconstrued as blaming those around the victim to whom he disclosed that night. Consider if the commentary is appropriate
• consider whether the wording in paragraph 3.61 which implies close proximity between the victim leaving the hospital and being killed, is appropriate

The Panel does not need to see another version of the report, but we would ask you to include our letter when you publish the report.
I would like to thank you once again for submitting this thorough report for consideration by the Home Office Domestic Homicide Review Quality Assurance Panel.

Yours sincerely,

Christian Papaleontiou, Chair of the Home Office Quality Assurance Panel

Head of the Interpersonal Violence Team, Safeguarding & Vulnerable People Unit