Domestic homicide review relating to the death of Mrs A - overview report

The purpose of this review is to examine the circumstances surrounding the sudden unexpected death of Mrs A in Brighton & Hove, as well as the engagement and support offered by relevant agencies to Mrs A (the victim of the homicide) and Mr A (the alleged offender), jointly and separately prior to December 2012. The review will consider the issues identified in the Multi Agency Statutory Guidance for the Conduct of Domestic Homicide Reviews (DHRs) (section 5.11). Section 3.3 of the Statutory Guidance defines the purpose of a DHR as to:

• Establish what lessons are to be learned from the domestic homicide regarding the way in which local professionals and organisations work individually and together to safeguard victims;
• Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result;
• Apply these lessons to service responses including changes to policies and procedures as appropriate; and
• Prevent domestic violence homicide and improve service responses for all domestic violence victims and their children through improved intra and inter-agency

Although family members chose not to participate in this review, the DHR panel wish to acknowledge their loss, and offer their sincerest sympathies.

Timescales

This review began on 26th February 2013 and was concluded on the 11th July 2013. Following the submission of the initial report, in September 2013 the Home Office Quality Assurance Panel judged it to be inadequate. A revised report was resubmitted in October 2014, along with a request for clarification on some of the feedback provided. The Home Office Quality Assurance Panel subsequently approved the revised report for publication in February 2014 (see appendix two).

Confidentiality

The findings of each review are confidential. Information is available only to participating officers/professionals and their line managers.

Dissemination

The following recipients have received copies of this report:

• The anonymised Executive Summary and Overview Report has been presented to the Brighton & Hove Community Safety Partnership ('Safe in the City Partnership') and the Home Office Quality Assurance Group; and
• The anonymised Executive Summary and Recommendations have been presented to the Brighton & Hove Safeguarding Adults Board, Domestic Violence Forum, and the newly established Violence against Women and Girls Partnership Board

1.1 Circumstances that led to the DHR

On the REDACTED November 2012 Mr A contacted the South East Coast Ambulance Service (SECAmbs) and stated that his wife was dead. Statements by Mr A to the ambulance operator, first responders, police officers and two notes left at the scene indicated that Mr A had killed Mrs A, before attempting to take his own life. Although his attempts were unsuccessful, Mr A subsequently died on the REDACTED December 2012 as a result of a pre-existing medical condition.

The Coroner's Inquest was held on 3rd April 2013 and recorded a verdict of unlawful killing of Mrs A.

1.2 Commissioning the DHR, Terms of Reference and Methodology

This summary outlines the process undertaken by the OHR panel (hereafter 'the panel') in reviewing the death of Mrs A

The Chair of the Safe in the City Partnership was notified by the police on the REDACTED December 2012 of the homicide. As this was the first domestic homicide in the city since the introduction of the Guidance for the Conduct of DHRs, a Multi-Agency Panel was convened on 22nd January 2013. The purpose of the meeting was to review the Statutory Guidance for the Conduct of DHRs and consider the options available, before agreeing the next course of action following consultation with the Home Office.

The Safe in the City Partnership subsequently made the decision the case would be subject to a OHR in line with Section 9 of the Domestic Violence, Crime and Victims Act. The Home Office was notified of this decision on the 15th February 2013. The first meeting of the panel was convened on the 25th February 2013. A subsequent meeting was held on the 23rd April 2013.

The Terms of Reference were agreed at the meeting on the 25th February 2013, with reference to the Statutory Guidance. They are included in Appendix One.

The methodology used was to request proportionate Individual Management Reviews (IMRs) from those agencies identified by the panel as having had contact with Mr and Mrs A. This totalled 5 agencies. The agencies were provided with guidance for the completion of a proportionate IMR, based on the Home Office Guidance and were asked to provide a written report regarding their chronological accounts of their contact with the victim prior to her death. In particular, they were asked to:

Where there was no involvement or insignificant involvement, agencies advised the panel accordingly. In addition, the report writer attended the Coroner's Inquest.

The panel sought to encourage the participation of, or a contribution from, the family of Mrs A and Mr A. Members of the family were identified with the assistance of Police Family Liaison Officers (FLOs). They were offered the opportunity to participate at any time and to be notified of the outcome, although the family members contacted declined to participate.  No friends of Mrs or Mr A could be  identified,  with the information  from the family  provided to the Police and from the Coroner's Inquest indicating Mrs and Mr A had been an intensely private couple. In addition, no information on friends was obtained during house to house inquiries as part of the police investigation.

It was agreed that the anonymised Executive Summary and Overview Report would be presented to Safe in the City Partnership. It was agreed that anonymised Executive Summary and Recommendations would be  considered by the Brighton & Hove Safeguarding Adults Board and the newly established Violence against Women and Girls Partnership Board, as these were likely to be the most appropriate forums to enable statutory and voluntary and community partners to work together to ensure that violence and abuse as they affect older people are considered. The anonymised Executive Summary and Recommendations would also be shared with the Domestic Violence Forum.

1.3 Contributors to the review

Proportionate IMRs were requested from those agencies identified by the panel as having had contact with Mr and Mrs A, specifically:

• Brighton & Hove City Council (Benefits Team Finance & Resources);
• Brighton and Sussex University Hospitals NHS Trust;
• NHS Brighton and Hove;
• Sussex Community NHS Trust;
• Sussex Police; and
• Western Sussex Hospitals NHS Foundation

The agencies that participated were represented on the panel were:

• Brighton & Hove City Council (Adult Services, Benefits Team Finance & Resources and the Partnership Community Safety Team);
• Brighton and Sussex University Hospitals NHS Trust;
• NHS Brighton & Hove;
• RISE (RISE is a charity working in Brighton & Hove and West Sussex, and is the local specialist domestic violence and abuse service)
• Sussex Community NHS Trust;
• Sussex Police; and
• Western Sussex Hospitals NHS Foundation Trust.

1.4  Panel members, chair and overview report writer

The Panel was made up of senior representatives from the agencies from within the Safe in the City Partnership, as well as a representative from the local specialist domestic violence and abuse service.

Administrative support for the panel was provided by Charlotte Farrell, Partnership Support Officer at Brighton & Hove City Council (Partnership Community Safety Team).

The panel was chaired by the Chief Executive of Brighton & Hove City Council. This approach was agreed at the first meeting of the panel in February 2013, where it was felt that this decision was proportionate, while also consistent with the Statutory Guidance (Section 5.8-5.10). The rationale for this decision was:

• The information gathering process had already begun following the meeting of the Multi-Agency Panel on the 22" January 2013 and identifying and appointing an external Chair would have further delayed the DHR; and
• This would be a proportionate use of resources, given the limited engagement of Mrs and Mr A with agencies

In relation to the role of the Chair, the Chief Executive was considered to be independent in this specific case, as the local authority had no direct involvement with either Mrs or Mr A outside of benefit payments. Furthermore, the Chief Executive had had no prior involvement with the local authority having joined it in December 2012. She also otherwise met the 'skills' identified within the Statutory Guidance for a chair (5.10). Approval to this decision was subsequently sought from the Home Office; the Home Office indicated that the appointment of an appropriate chair was a matter for the local area to decide.

The Overview Report was prepared by a report writer, specifically the Violence against Women and Girls Commissioner for Brighton and Hove. Report writing was completed under the direction of the panel chair, who identified the key themes in this report with the assistance of panel members. The post holder was considered to be independent in this case, as the local authority had no direct involvement with either Mrs or Mr A outside of benefit payments. Furthermore, the Violence against Women and Girls Commissioner had had no prior involvement with the local authority having joined it in February 2013. He was also able to support the Chair, having the 'skills' identified within the Statutory Guidance (5.10), in particular relevant knowledge of domestic violence and abuse, an understanding of the role and context of the main agencies likely to be involved and having completed the E-Learning Training Package on DHRs.

2.1 Synopsis of the Homicide

On the morning of REDACTED November 2012 Mr A contacted the South East Coast Ambulance Service (SECAmbs) to state that his wife was dead in the bedroom at their home address and that she had been dead since the previous Sunday (the REDACTED November 2012). Mr A said that his wife had initially placed a plastic bag over her head and tightened it. This bag had been subsequently removed and he then suffocated Mrs A with a pillow. The Coroner subsequently concluded that Mrs A died as a result of asphyxia due to an obstruction of upper airways by a pillow on that Sunday.

Mr A informed the call handler and first responders from SECAmbs that he had taken an overdose of tablets, following the death of Mrs A. He had also cut his wrists. He had remained in the home before calling 999 four days later.

Mr A was arrested on suspicion of Mrs A's murder on the REDACTED November 2012. He was taken to Royal Sussex County Hospital for medical treatment given his self inflicted injuries and because he had REDACTED.

Two letters were discovered at the home address. Both were written by Mr A and indicated that Mrs and Mr A had entered into a suicide pact because of Mr A's REDACTED REDACTED, Mrs A's own health and because neither wished to become a burden to others. Only one letter was available to the panel.

On REDACTED November 2012 the Senior Investigation officer made a decision to de-arrest Mr A. The Crown Prosecution Service (CPS) was contacted and appraised of the circumstances of the case. Mr A subsequently died on the REDACTED December 2012 as a result of his pre-existing condition of REDACTED. The CPS was unable to provide definitive guidance in relation to what, if any, criminal charges would have been pursued had Mr A lived.

2.2  Details of the Coroner's Inquest

An Inquest was held on the 3rd April 2013. Evidence was provided in person by the Coroner's Officer, the police and two pathologists. Written evidence included the transcript of calls and dispatch by the ambulance service and the police, the patient clinical record completed by paramedics, a statement from a family member, as well as a report from Mrs and Mr A's doctor and a District Nurse who had visited the property shortly before the homicide. The Coroner concluded that Mrs A had died as a result of asphyxia due to an obstruction of upper airways by a pillow on the REDACTED November 2012 and that this was an unlawful killing.

The information used in this report is based on a contemporaneous record. It was not possible to obtain a transcript of the Coroner's Verdict, despite an approach being made, as the author was not considered a 'Properly Interested Person' in this case.

The Coroner provided the following summary in her summing up

• Mrs A "increasingly seemed" to have no friends and had no Specifically, Mrs A and Mr A saw family infrequently and were not in the habit of contacting them. In addition, Mrs A had become more socially isolated since the death of her sister in July 201O;
• Mrs A was "dependent and very happy for him [Mr A] to take control"; and
• Mrs A and Mr A, reflecting written statements from the family, appeared to be devoted to each

The Coroner noted that she was inclined to believe the explanation given by Mr A, specifically:

• The couple had been thinking of a suicide pact, probably for several months;
• No one else was involved;
• The choice of dates was influenced by the increasing weakness of Mr A due to his REDACTED
• The rationale for the suicide pact was that Mrs A felt she could not manage without her husband and he had a limited time to live; and

The Coroner also noted that she was inclined to believe the account given by Mr A, specifically that a bag was initially placed over Mrs A's head, that this was then removed and thereafter a pillow was applied to Mrs A's face.

The medical evidence considered by the Coroner included a post-mortem on Mrs A and an external examination of Mr A. This indicated that there was no evidence that Mrs A has been drugged or injured in order to render her incapable of resistance. It further indicated that Mr A was extremely frail and had Mrs A resisted the application of a pillow, it was unlikely that he would have been able to smother her.

The Coroner was also satisfied that Mr A had made attempts to commit suicide. Although the medical evidence indicated that neither the overdose nor cuts to his wrists would have been sufficient to bring about his death, she was satisfied that he took what he thought would be suitable steps to achieve this end given his lack of medical training. Other evidence available to the Coroner from the police, including cancellation of contracts (i.e. Sky subscription and car insurance), and payments to family members and a donation to charity were considered to be evidence of an intention to die.

The Coroner noted that she had no evidence from Mrs A. The Coroner also noted that while Mr A stated to the police in interviews after his arrest that Mrs A was 'insistent' as the course of action he had described, there is no way of knowing whether this is the case. Nonetheless, as noted above, the Coroner found there was no reason to disbelieve Mr A's explanation.

2.3 Members of the Household and Family

At the time of her death, Mrs A was living with Mr A in Brighton & Hove. Mrs and Mr A had no children.

Mrs A had no living siblings at the time of her death, her sister having died in July 2010. She had two living nephews, only one of whom resides in the UK. The nephew who was resident in the UK would phone and visit. His last contact was with Mr A on the 19th September 2012 when he visited him in hospital. In his statement to the police, he said that Mr A "did everything... " and "she [Mrs A] was happy for him to take control". He described their relationship as very loving.

Mr A had a brother (resident REDACTED) and a sister (resident REDACTED).  The brother had last seen Mr A four years previously, when they attended a family funeral. They had last spoken two years previously by phone. Mr A's sister visited her brother in hospital prior to his death, but it was not possible to determine the frequency of contact prior to this incident.

2.4  History of the relationship

Mrs and Mr A had been married for REDACTED years. In the account given by both Mrs A's nephew and Mr A's brother, there is no indication of separation during the relationship. They had lived together in the area since October REDACTED, initially in another property in the block before they moved in October REDACTED. into the property in which Mrs A died. The most recent property was privately rented and they claimed Housing Benefit.

Of the small number of agencies who knew Mrs and Mr A prior to the incident that prompted the review (principally NHS Brighton & Hove (REDACTED Medical Centre), Sussex Community NHS Trust, Western Sussex Hospitals NHS Foundation Trust, as well as Brighton & Hove City Council (Finance & Resources, Benefits), none reported that they were aware of any history of domestic abuse in the relationship. Mrs and Mr A were not known to the police. During house to house enquiries following the killing of Mrs A, there was a report that there had been raised voices in the vicinity of their residence. Subsequent police investigations determined that although the report had been made good faith, it could not have involved Mrs or Mr A. These house to house enquiries did not identify any friends of the couple.

Given the length of the relationship, the panel considered it unlikely that there would have been a prior relationship of relevance for either Mrs or Mr A. No agency who knew Mrs and Mr A had any evidence that Mr A has been abusive in any previous relationships, or any evidence that Mrs A had experienced abuse in any previous relationships.

2.5 Voice of the victim

A significant challenge in undertaking the review was the limited information available to the panel about Mrs and Mr A, and the absence of information from Mrs A herself. This reflects Mrs A's limited contact with agencies, although it is important to note that the panel concluded that this also reflected the restricted understanding that agencies had of Mrs or Mr A as 'real people' (see 3.8).

The single most important source of information about Mrs A was the Coroner's Inquest (see 2.2), which provided information from family members (who had chosen not to participate in the review itself). Consequently the panel's ability to accurately give voice to Mrs A's experience is heavily constrained. It, like the Coroner, is largely dependent on accounts given about and by Mr A. The panel has attempted to manage this by noting where Mr A is the only source of information. It has also sought to avoid assuming that the absence of any other evidence is sufficient to allow it to reach a conclusive determination (see 3.10). In particular, the limited information available has meant it was impossible to fully understand the incident that led to the death of Mrs A or the dynamics of the relationship. For example, the panel was unable to rule in or out the presence of domestic violence and abuse (see 3.9).

What was known about Mrs A is summarised here, largely reflecting information from the Coroner and her GP:

• Mrs A seemed to have no friends, had no children and only saw family infrequently and had become more socially isolated since the death of her sister in July 2010 (see 2.2);
• The only other significant contact that any agency had with Mrs A was via her GP during her annual consultations at the surgery (see 2.6.3). During these visits no concerns were identified about Mrs A's capacity, health or potential vulnerability, and she attended these consultations independently;
• Reflecting these consultations, Mrs A had no identified health needs with the exception of her managed REDACTED and an earlier REACTED; and
• The last agency contact with Mrs A was during the home visit the week before her death (see 2.6.4), although she was not spoken with directly

2.6 Chronology of contact

The following services are known to have provided services to Mr A. No agencies have reported that they were aware of domestic abuse, or that any disclosures had been made:

2.6.1 Brighton & Hove Council (Finance & Benefits): Mrs and Mr A were in receipt of Housing and Council Tax Benefit, with Housing Benefit paid to Mr A and Tax Benefit credited directly to the Council Tax account.

They were in receipt of Pension Credit Guaranteed Credit. Following a review of correspondence in the two years prior to the killing of Mrs A, no disclosures were made by either party to indicate that they might be entitled to other benefits that they were not claiming. There were no claims being made for Carer's Allowance under the name of Mr A, with this confirmed by Carers' Allowance Direct. No disclosures were made to the Benefits Team indirectly or directly to indicate that there was a risk of harm to either party.

2.6.2 Brighton and Sussex University Hospitals NHS Trust: Mr A had no inpatient hospital stays in recent years, with the exception of his admission in November 2012 the incident that promoted the DHR. He died during this admission on the REDACTED December 2012.

Prior to this, he had attended the hospital for 2 appointments at the REDACTED clinic in August 2012. The case notes reveal that he was seen on the 10 August 2012 where a proforma was completed. In the social history section of the case notes it is documented that Mr A lives with his wife (Mrs A) who has  REDACTED. It is documented that he has no outside help and is independent with activities of daily living. There was no risk assessment about Mr A social circumstances during this admission. This is usual practice, as having completed the relevant proforma, no concerns were highlighted.

Mr A was also seen in the REDACTED outpatient clinic on 17.07.12 where he was given some antibiotics. There was no record made relating to any social concerns.

2.6.3 NHS Brighton & Hove (REDACTED Medical Centre): Mrs and Mr A were patients of Dr A1 from 2006. Over the six and a half years, both were independent of the other and accessed pre-booked consultations at the As with all patients who are independent, mobile and self-caring there had never been cause to visit them at home. At no point did either of the patients ever request a home visit.

Dr A1 met with Mrs A five times in total to perform an annual review of her medications and her REDACTED which had started in 2001 but has been well controlled. Mrs A always attended alone and independently. She never voiced any concerns regarding her relationship with Mr A nor did she give any verbal or non-verbal indications as to possible underlying anxiety or depression . Other than a REDACTED in 2007 there was nothing of note in her medical records. There was no history of domestic abuse, alcohol or drug misuse.

Mrs A was not classed as a 'vulnerable' adult as she was independent with no significant mental, educational or physical disabilities or symptoms. Therefore the GP's inputs were limited to annual reviews. There were no dealings with external agencies such as district nurses or social services.

Dr A1 saw Mr A over the last few years following a diagnosis with REDACTED in 2009. H e was receiving three-monthly REDACTION injections to counter the spread of his REDACTION. These were administered by practice nurses. The practice nurses never raised any concerns regarding the welfare of the patient during his visits to the surgery. Mr A was never confrontational to staff. There is nothing in his records regarding aggression, drug or alcohol problems, violent conduct or domestic abuse. He was not classed as a 'carer' for his wife. He always attended the surgery independently.

The most recent meeting with Mr A was in September of 2012, as his health was deteriorating. Dr A1 arranged an urgent outpatient review by the REDACTED team at REDACTED Hospital (part of Western Sussex Hospitals NHS Foundation Trust). Mr A attended this appointment independently, were he was offered an operation to REDACTED caused by his REDACTED. The subsequent clinic letter states that Mr A was his wife's carer. It also states that he wanted to discuss his options with his wife before committing to the operation, suggesting that she had an input into the couple's decision making.

Dr A1 received a short discharge summary from REDACTED Hospital stating that Mr A underwent the operation on the 24th September 2012. Mr A then attended s ndently the following week for a dressing change and his regular REDACTED injection. The nurse attending him raised no concerns as to his ability to cope or care. REDACTED Medical Centre received a more detailed letter from the REDACTED department on the 10th October 2012 with details of the operation and that the patient was to have a district nurse attend at home for dressing changes. However, by the time this letter was received Mr A had already been coming to the surgery for the dressing changes.

A multi-disciplinary discharge form was received from REDACTED Hospital (Western Sussex Hospitals NHS Foundation Trust) on 24th October 2012, one month after the patient's discharge, stating that the patient was felt to have no problems with self care upon discharge. He was deemed not to need the input of occupational therapists, social workers or any other external agency other than the local district nurse for the purpose of medical care (specifically dressing changes). Dr A1's subsequent understanding was that the district nursing team did not feel he warranted home nursing as he was mobile and able to attend the surgery.

It was not until his final attendance at the surgery's nursing clinic on the 19th November that the patient mentioned that he was finding it difficult to attend the surgery. At that point the practice nurse referred back to the district nurses who agreed to home visit. No feedback was received from the district nurse regarding their visit.

2.6.4 Sussex Community NHS Trust: Mr A was a patient of a local Integrated Primary Care Team Cluster. The practice nurse had asked the team to visit Mr A at home because he had felt too weak to attend the surgery for

This visit took place a week before the death of Mrs A. Prior to this the team had not known him. During the home visit by Staff Nurse A2, Mr A said that his wife (Mrs A) was in the other room and he appeared calm and sensible, and did not say or do anything that caused Staff Nurse A2 to become concerned. This was the last contact that any agency had with Mrs A, and also the last contact any agency had with Mr A until the incident itself. Staff Nurse A2 and Mr A agreed that if he felt well enough he would attend the Practice for future dressings, and if he felt unwell he would ring the team for another home visit. The team did not hear from him again.

2.6.5 Sussex Police: Mrs and Mr A were not known to Sussex Police until the incident that led to this The involvement of the police is summarised in 2.1.

2.6.6 Western Sussex Hospitals NHS Foundation Trust: Mr A had a diagnosis of advanced REDACTED of the REDACTED. He had been under the care of the REDACTED at the trust since REDACTED. The first reference to Mrs A was made in the clinical notes from a REDACTED outpatient appointment on 7th June 2012 (and included in the clinic letter dated 18th June 2012) which stated that Mr A and his wife "are coping very well".

By the 3rd September 2012, Mr A's condition had deteriorated. A course of treatment was proposed to REDACTED caused by his REDACTED. Mr A stated he would like to discuss the plan with his wife later that day. During this appointment it was noted that Mr A was the carer for his wife but no further detail was recorded.

This treatment was planned for 10th September 2012. The correspondence section of the health records include a letter from Mr A (not dated) stating that he wished to "thank [staff] for their efforts... but as the REDACTED  was now so advanced, he did not think the treatment would be of any great benefit to him".

Mr A then attended the Medical Day Case Unit (MDCU) on REDACTED September 2012. Although the reason for this attendance is not clear, it appears that this was a planned appointment in preparation for a planned clinical intervention, despite the letter requesting that the appointment for the 10th September be cancelled. It appears likely that a new date was offered and Mr A agreed, although this cannot be confirmed.

Mr A's blood results indicated worsening REDACTED failure and he was admitted for further clinical treatment, which was done on 19th September 2012.  During this admission, there is only one reference made regarding Mrs A. This is an entry in the medical notes, dated 17th September 2012, stating that Mr A had informed his wife [of his admission].

A nursing assessment was completed, but no reference was made to Mr A being the carer for his wife. The specific carer question was not asked and on the discharge risk assessment, Mr A is not identified as having a caring responsibility.

Mr A remained an inpatient after the clinical treatment and was not discharged home until 24th September 2012. The plan was for follow up by the GP and ongoing dressing changes to be done by the district nurses. A nursing discharge summary was completed and this states that referral was faxed to the community nurses on 19th September 2012.

A letter filed in the health records from Mr A dated the REDACTED October 2012 stated that he had not had his dressing changed since he was discharged on 24th October 2012 (he was discharged on 24th September 2012), and asked for the dressings to be changed. It appears that despite the referral to the community team, the follow up care did not commence following discharge.

This analysis will draw on the chronology presented in section 2 above, the information provided by involved agencies, and the perceptions and information gained from information with the family. The analysis will focus in turn on the engagement of involved agencies, and then in how they worked together.

During the initial panel meeting on the 26th February 2013, the panel identified the following themes to be considered:

• The concept of what 'being a carer' meant to Mr A and whether this could have been explored;
• The importance of 'professional curiosity, particularly with an awareness of the potential presence of elder abuse or domestic violence or abuse;
• The issue of a potential delays in the feedback from secondary to primary care; and
• Lack of involvement with external support agencies / lack of signs of concern.

At the subsequent panel meeting on the 23rd April 2013, in light of the information obtained from the proportionate IMRs, the Coroner's Inquest, as well as information from Brighton & Hove City Council (Finance & Resources, Benefits), the panel analysed these issues and identified the following lessons to learn:

3.1 Contact by Mrs A with agencies

With the exception of her GP at the REDACTED Medical Centre, Mrs A had no contact with any agencies. There was no evidence to indicate that Mrs A had approached any other services.

The panel noted that Mrs A is reported to have felt that she could not manage without Mr A, with this information summarised in the Coroner's Inquest (see 2.2). However, the evidence from the GP indicated that she was able to access health services independently.

Analysis: the panel concluded that Mrs A had not sought help from any agencies. However, informed by the Coroner's verdict, the panel concluded that she had become increasingly dependent on Mr A, with this likely to have been social rather than a physical need. The panel noted that this raised issues about Mrs A's (and other local residents') awareness of and access to information about support services. The panel further concluded that there was no other information at the time that might have led to a safeguarding referral or concern.

3.2  Contact by Mr A with agencies

Mr A did have contact with a range of agencies, as noted in 2.6 above. During his involvement with services, there is no evidence that he sought additional assistance beyond a request for assistance in changing his dressings following his discharge. There is no evidence to indicate that Mr A did not receive the appropriate medical support, based on the information he provided to practitioners. Issues have been noted in the delay in the discharge notification (see 3.4 below).

Following the last visit to Mr A, and the last known contact with Mrs A, there was no feedback from the district nurse following their home visit suggesting that they had no cause for concern.

Analysis: the panel concluded that Mr A had not sought help from any agencies, other than in relation to his health needs. The panel further concluded that there was no other information at the time that might have led to a safeguarding referral or concern.

3.3   Mr A role as a 'Carer'

Mr A made a single disclosure about his role as a 'carer' in September 2012, which is around the time when his medical condition started to deteriorate.

This is the one record (from a clinic appointment dated on the 3rd September 2012) that states that Mr A is the carer for his wife. A previous entry, made in June 2012 had recorded "he and his wife are coping". A further entry on the same date, in relation to a possible hospital admission records that Mr A said that he will be unable to leave his wife for very long as she is not very mobile. This was communicated to the GP in a follow up letter. However, when Mr A was admitted to hospital, he did not express any concerns with regards to his wife or her ability to manage at home alone. Mr A made no request for assistance or support for himself or Mrs A.

The panel noted that the concept of what 'being a carer' meant to Mr A might have been explored further by the health professionals involved. This may have helped to determine the care that Mr A provided to his wife and whether she would have been able to manage without this help for a specified period of time. However, there was only one reference made within the health records (made at an outpatient's appointment and reported in the clinic letter) regarding Mr A's role as a carer, and this did not indicate that further clarification was required because no disclosures were made. The absence of any disclosures also meant that no further questions about social circumstances were asked this admission. This is usual practice, as having completed the proforma, no concerns were highlighted.

It was also noted that in his contact with Brighton & Hove City Council (Finance & Resources, Benefits), Mr A did not make any disclosures which indicated that he or Mrs A would be entitled to any benefits, including Carer's Allowance.

Analysis: the panel concluded that there while Mr A may have been caring for Mrs A, he had provided inconsistent information with regard to his caring role. In particular, there appears to have been only one occasion when Mr A explicitly presented himself as a carer. In addition he had not accessed services in the city that might have initiated a carer's needs assessment to consider his ability to provide care and any help that he may need to do so.

The panel further concluded that there was no other information at the time that might have led to a safeguarding referral or concern.

The panel also noted that it was possible that a presentation as a 'carer' might have been a means by which Mr A exerted control or isolated Mrs A. However, it was noted that there was no evidence to indicate that Mr A made any attempt to limit, monitor or restrict during Mrs A's contact with the one service she accessed directly (her GP) (see 2.6.3). Nonetheless, this needs to be considered  in  light of the potential  for domestic violence and abuse (see 3.7).

3.4  Inter-agency working

The panel noted the delay between Mr A's discharge (from REDACTED Hospital, Western Sussex Hospitals NHS Foundation Trust) and notification being received by his GP (NHS Brighton and Hove, REDACTED Medical Centre). It was also noted that the original referral to Community Nursing did not result in a home visit, until this was requested by Mr A.

Analysis: the panel noted that there was a delay in transferring the discharge notification. However, the panel concluded that this did not have an impact on the provision of services to Mr A as he was seen promptly by his GP on his discharge from hospital. The panel also concluded that although Mr A did not initially receive a home visit, this was because he was deemed to be able to attend the surgery independently. A home visit was subsequently provided when he requested it.

3.5  Social isolation

The panel noted the evidence, with this information summarised in the Coroner's Inquest (see 2.2), that Mr and Mrs A were an intensely private couple with limited contact with their family, no identifiable friends and limited engagement with agencies.

Analysis: the panel concluded that the evidence indicated that Mrs and Mr A consciously excluded themselves from social networks and services. As noted in 3.1 and 3.2, in light of this exclusion, there was no information at the time that might have led to a safeguarding referral or concern. Nonetheless,  this needs to be considered in light of the potential for domestic violence and abuse (see 3.7).

3.6 Vulnerability and capacity

The panel noted the evidence relating to Mrs A's limited engagement, which was principally with her GP, which did not raise any issues around vulnerability, capacity or indeed any other health needs. The panel also noted that while in receipt of healthcare, there were no broader concerns raised about Mr A's vulnerability or capacity.

Analysis: the panel concluded that on the basis of the available evidence, Mrs A would not have met the safeguarding threshold to be considered a vulnerable adult. Nor was there any evidence that Mrs A did not have capacity. The panel concluded the same for Mr A. However, this needs to be considered in light of the potential for domestic violence and abuse (see 3.7).

3.7   Evidence of domestic abuse

In relation to the incident that led to Mrs A's death, the reports from pathologists to the Coroner's Inquest appeared to indicate that Mrs A was a participant in this suicide attempt and there was no evidence of force or that she had been rendered incapable. However, it was noted that, as the Coroner had recognised, that there was no evidence directly from Mrs A in relation to the incident.

In relation to the context of the incident, there is no evidence that domestic violence and abuse was a feature of the relationship between Mrs and Mr A, with the information provided during the Coroner's Inquest (see 2.2) indicating that the couple were "devoted to each other".

Analysis: the panel concluded that there was no evidence that domestic violence abuse had occurred in the relationship. However, the panel noted that it was not explicitly possible to rule in or out the existence of domestic violence and abuse (in particular the use of coercion or isolation as a tactic of control), given the limited information available. This is of particular relevance given (as noted by the Coroner) there was no evidence directly from Mrs A.

Consequently, as it was unable to resolve these questions in the absence of information, the panel sought to identify broader learning relating to older women and domestic abuse. Without prejudice to the case, the panel noted issues relating to older women and domestic violence and abuse.   See Women's Aid. Older women and domestic violence: an overview. [Accessed 27th June 2013)

• Older women may experience more barriers to disclosure than younger women: they may have a different understanding of domestic abuse which means they are less likely to identify their experience(s) as abuse; they may be more reluctant to report violence or abuse; or they may have a lack of knowledge about the resources available; and
• Service responses may not be appropriate for older women: professionals may not identify domestic abuse as an issue for older women; they may lack the lack the skills and knowledge to deal confidently with cases where older women are abused; or services may not be designed for victims of this age group.

3.8  Professional curiosity

The panel noted the limited information known to agencies about Mrs and Mr A. Although the panel felt that there was no information that might have led to a safeguarding referral or concern, it was of note that in their contact, albeit limited, with a range of professionals, no one had any sense of Mr and Mrs A as real people. For example, no one was aware of their likes, history or interests or a broader context to their engagement with services.

Analysis: Without prejudice to the case, the panel noted as a broader issue in relation to 3.1 - 3.7 the importance of 'professional curiosity', particularly with an awareness of the potential presence of elder abuse or domestic violence or abuse.

Analysis: The panel has attempted to manage this by noting where Mr A is the only source of information. It has also sought to avoid assuming that the absence of any other evidence is sufficient to allow it to reach a conclusive determination, for example in relation to domestic violence or abuse (see 3.10).

The panel therefore made the following recommendations:

Recommendation 1: For all professionals:

• To remind professionals through workforce development to be mindful of the importance of 'professional curiosity', particularly with an awareness of the potential presence of elder abuse or domestic violence or abuse.

Recommendation 2: For the Brighton & Hove Safeguarding Adults Board:

• To review existing priorities within the Safeguarding Adults Board Action Plan to ensure these address domestic abuse, in particular with reference to raised awareness about this issue among older residents; and
• To review workforce development to ensure that professionals are aware of domestic abuse, know how to identify and assess older people at risk, have adequate training to do so (including the use of the CAADA DASH risk identification checklist) and understand what services are available locally.

Recommendation 3: For the Brighton & Hove Violence against Women and Girls Board:

• To review care pathways to ensure that the planned Violence against Women and Girls Action Plan addresses safeguarding adults, in particular with reference to older people, and that this encompasses commissioning as well as delivery of specialist domestic abuse services; and
• To review workforce development to ensure that professionals are aware of safeguarding adults arrangements, how to identify and assess older people at risk, and understand what services are available locally.

Recommendation 4: For Western Sussex Hospitals NHS Trust:

• To review the timeliness of discharge notifications.

13. To consider media arrangements if necessary for the publication of the Overview Report and Executive Summary.
     
14. As this is the first DVHR to be undertaken in Brighton & Hove with reference to the Statutory Guidance, identify how to engage with a wider group of interested agencies to ensure that learning from the process is available to interested agencies but who are not involved in the detailed DVHR panel in the particular circumstances of this case.
     
15. Decide whether it is necessary to develop a DVHR protocol, including provision for Chairing any future reviews.

Timetable

16. The precise timetable will be dependent on a number of factors including the need to collate and cross reference information.
     
17. The process should be completed within six months of the decision to proceed.

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