Transcription
Report of the Domestic Homicide Review Panel into the death ofSusanCommissioned by the Epping Forest Community Safety PartnershipPanel Chair Elizabeth HanlonReport Author John GilbertMAIN REPORTApril 2018Page 1 of 2216 November 2018
Definition of Domestic ViolenceIn March 2013, the government introduced a cross-government definition of domesticviolence and abuse, which was designed to ensure a common approach to tackling domesticviolence and abuse by different agencies. This definition states that domestic violence is:“Any incident or pattern of incidents of controlling, coercive or threatening behaviour,violence or abuse between those aged 16 or over who are or have been intimate partners orfamily members regardless of gender or sexuality. This can encompass, but is not limited to,the following types of abuse: olling behaviour is: a range of acts designed to make a person subordinate and/ordependent by isolating them from sources of support, exploiting their resources andcapacities for personal gain, depriving them of the means needed for independence,resistance and escape and regulating their everyday behaviour.Coercive behaviour is: a continuing act or a pattern of acts of assault, threats, humiliationand intimidation or other abuse that is used to harm, punish or frighten their victim.”This definition, which is not a legal definition, includes so called honour-based violence,female genital mutilation and forced marriage.Page 2 of 2216 November 2018
ContentsSectionPageThe Review Process4The Facts12Key Issues and Analysis15Conclusions / Recommendations18AppendicesAppendix A – Participants in the Review20Appendix B – Action Plan22Appendix C – Letter from Home Office Quality Assurance Group23Page 3 of 2216 November 2018
1.The Review ProcessThroughout the Review Report the following names are used to maintain the confidentialityof those persons referred to within the report. The terms mother, father, child, children,brother, sister, aunt and uncle are used where confidentiality is not compromised:Perpetrator: PeterVictim:SusanPurpose1.1The purpose of a Domestic Homicide Review (DHR) is to:(a)(b)(c)(d)(e)(f)establish what lessons are to be learned from domestic homicide regardingthe way in which local professionals and organisations work individually andtogether to safeguard victims;identify clearly what those lessons are both within and between agencies,how and within what timescales they will be acted upon, and what isexpected to change as a result;apply these lessons to service responses including changes to inform nationaland local policies and procedures as appropriate;prevent domestic violence and homicide and improve service responses forall domestic violence and abuse victims and their children by developing a coordinated multi-agency approach to ensure that domestic abuse is identifiedand responded to effectively at the earliest opportunity;contribute to a better understanding of the nature of domestic violence andabuse; andhighlight good practice.1.2This review arises from a death within the area of the Epping Forest DistrictCommunity Safety Partnership. The victim, a female aged 35 years, died in early2016 as a result of an assault by her husband. The circumstances of the deaththerefore fulfil the criteria of section 9(3)(a) of the Domestic Violence, Crime andVictims Act 2004 in that the violence appeared to be perpetrated by a person withwhom the victim had an intimate personal relationship1.3This DHR has been conducted in accordance with statutory guidance under section 9of the Domestic Violence, Crime and Victims Act 2004. The review examines agencyresponses and any support provided to the victim prior to her death. The reviewconsiders agencies’ involvement and contact with the victim and perpetrator for theperiod 1 May 2015 until the victim’s death in February 2016.1.4Having considered all the evidence available to it, the Panel is of the view that therewere no obvious ethnicity, culture, faith, sexual orientation, disability, gender orother diversity issues that had a bearing on the death of the victim or any agencyinvolvement with the victim or perpetrator.Page 4 of 2216 November 2018
1.5The Review Panel members would take this opportunity to extend the Panel’scondolences to the family and friends of Susan and to all others who have beenaffected by her tragic death.Panel Membership1.6The membership of the Review Panel was as follows:NamePanelElizabeth HanlonThe late CouncillorGary WallerAlan HallCaroline WigginsRuth RoseJoanne MajauskisMohammedShofiuzzamanIan CummingsVal BillingsNon PanelJohn GilbertJulie ChandlerColin RowellPosition / RepresentingChairFormer Chair, Epping Forest District Community SafetyPartnershipDirector of Communities, Epping Forest District CouncilCommunity Safety Manager, Epping Forest District CouncilSenior Legal Officer, Epping Forest District CouncilProgramme & Practice Manager, Safer PlacesAdult Safeguarding Manager, West Essex ClinicalCommissioning GroupDCI, Essex PoliceEssex Domestic Abuse Officer, Essex Safeguarding AdultsBoardReview Report AuthorAssistant Director (Community Services and Safety), EppingForest District CouncilVoluntary Action Epping Forest (Administration)In addition, at the invitation of the Panel Chair, the Essex Police Senior InvestigatingOfficer, DI Stephen Jennings, attended a number of meetings to advise the Panelfollowing the conclusion of the investigation and criminal proceedings.Timetable1.7The Review commenced on 2 March 2016 when the late Councillor Gary Waller, theformer Chair of the Epping Forest District Community Safety Partnership, notified theHome Office of the intention to establish a Domestic Homicide Review Panel. Theinitial meeting of the Review Panel took place on 3 May 2016. At this meeting acommunications strategy was produced in relation to the DHR. This will be amendedprior to any publication.1.8In view of the ongoing criminal proceedings, and the request of the SeniorInvestigating Officer from Essex Police that no contact be made with family andfriends of the victim and perpetrator during the criminal investigation, the ReviewPanel decided that whilst a scoping exercise of relevant agencies should becommenced, the Review Panel would not meet substantively again until such time asPage 5 of 2216 November 2018
the criminal proceedings had concluded. In view of lengthy delays in bringing thematter to court, it became evident that the Home Office requirement for the finalreport to be submitted within six months of the death could not be met, andtherefore the Review Panel agreed to seek an extension of time from the EppingForest District Community Safety Partnership (CSP). The CSP was requested to agreea time delay of either:(a)(b)1.9six months from the date of a guilty plea in July 2016 by the perpetrator; orsix months from the date of the court hearing in November 2016 in the eventof a not guilty plea.The CSP agreed to this request. The perpetrator, Peter pleaded not guilty to murderand therefore the completion deadline for the Review Report was extended until 31July 2017, and the Home Office was duly informed of this extension by the Chair ofthe CSP.Confidentiality1.10All information received by this Review Panel has been treated in the strictestconfidence. All Review Panel members were made aware of the strict requirementnot to disclose or discuss any information provided to the Review Panel without theexpress consent of the Review Panel.1.11The findings and conclusions of this review remained confidential during the reviewprocess. Information was only available to Panel members until such time as thePanel Review Report was approved for publication by the Home Office QualityAssurance Group. The Home Office Quality Assurance Group letter of approval isattached as Appendix C and any suggested amendments referred to in that letterhave been considered and incorporated within this final Review Report whereconsidered appropriate.Epping Forest District Community Safety Partnership (CSP)1.12In February 2016 the death of Susan was reported to the late Councillor Gary Waller,the former Chair of the CSP, by Essex Police, stating that the death had occurredwithin the administrative district of the CSP. Following discussions with Essex Policeand the Essex Domestic Violence Co-ordinator, Councillor Waller concluded that thedeath should be treated as a domestic homicide and on 2 March 2016 the HomeOffice was informed that a Domestic Homicide Review Panel would be established.Review Panel Chair1.13Mrs Elizabeth Hanlon is a former Detective Chief Inspector with the HertfordshireConstabulary. In that role she had been a member of an earlier Domestic HomicideReview Panel within the administrative district of the CSP and had also been involvedwith a number of Domestic Homicide Reviews elsewhere in the region. On leavingthe Hertfordshire Constabulary, Mrs Hanlon was appointed as the Chair of thePage 6 of 2216 November 2018
Hertfordshire Safeguarding Adults Board, and given her all round experience ofdomestic abuse and related issues, Councillor Waller formed the view that sheshould be asked to chair this Review Panel. Mrs Hanlon has no direct links with theEpping Forest District Council or Epping Forest CSP. Mrs Hanlon was appointed tothat role at the first meeting of this Review Panel on 3 May 2016.Report Author1.14The Review Report was authored by Mr John Gilbert who is a former Director ofEnvironment and Street Scene at Epping Forest District Council. In that role he was aReview Panel member and report author for a number of Domestic HomicideReviews. Mr Gilbert retired from Epping Forest District Council in May 2014 and nolonger has links with either the Council or Epping Forest CSP. Mr Gilbert wasappointed to this role at the first meeting of the Review Panel on 3 May 2016.The Coroner’s Inquest1.15The Coroner for Essex was informed that the CSP had established a DomesticHomicide Review Panel to review the death of Susan. Given the outcome of thecriminal investigation and the perpetrator being found guilty of murder, no inquestwas held and the coroner therefore closed the case.Scope of the Review1.16At the first Review Panel meeting on 3 May 2016, it was agreed that until furtherinformation was received, the draft Terms of Reference should reflect those of otherreviews. It was further agreed to reconsider the draft Terms of Reference at the nextReview Panel meeting. It was considered that despite there being no final Terms ofReference in place, this should not prevent the commencement of the scopingexercise whilst the criminal process was proceeding.1.17At the Review Panel meeting held on 6 January 2017 the draft Terms of Referencewere considered and amendments suggested. The final Terms of Reference wereconsidered by the Review Panel at its meeting on 31 March 2017 and agreed asfollows:(1)(a)(b)In conducting the Domestic Homicide Review into the death of Susan, thePanel shall have regard to:The Home Office Multi-agency Statutory Guidance for the Conduct ofDomestic Homicide Reviews1 and the recommended Home Office securityprovisions2; andThe Essex Domestic Abuse Strategy Group - Domestic Homicide ReviewsGuidance3 .1Home Office “Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews” (December 2016)Full personal details to be provided to the Review Panel, but published documents will be redacted or anonymised3Safer Essex “Domestic Homicide Review Guidance” (May 2015)2Page 7 of 2216 November 2018
(2)The Panel shall conduct the review on the basis that Susan was murdered inearly 2016 by her husband Peter at the couple’s home address.(3)The Panel will seek to establish the nature of the relationship between Susanand her husband Peter prior to her death, and the manner of her death will beconfirmed.(4)The Panel will review the outcome of the scoping exercise in order todetermine which agencies, organisations and individuals should be requestedto submit an IMR4. Based upon that review, the Panel will issue a request forIMRs and upon their return consider their content to determine the extent oftheir knowledge of Susan and Peter prior to her death, and any actions takenor offered in relation to them. IMRs will be required to cover the timespanning at least between the 1st of May 2015 (i.e. around the time that Petercommenced an affair with another female) and the date of her death and ifagencies, organisations or individuals consider that events outside of this timeframe are significant and of relevance to the review, then they should includethat information setting out the dates involved.(5)In the light of information arising from (4) above, the Panel shall considerwhether such practitioners or agencies:(a)(b)(c)4need to increase their own levels of awareness and informationgathering;were appreciative of and sensitive to the needs of Susan; andwere knowledgeable about potential indicators of domestic abuse andaware of actions they could take if such concerns had arisen.(6)The Panel shall consider the role of any practitioners or agencies that had notcome into contact with Susan and/or Peter that might reasonably have beenexpected to do so.(7)The Panel shall seek to co-ordinate its work with that of HM Coroner for Essexand any inquest that is underway. The Panel shall remain cognisant of theoutcome of the trial of Peter and any subsequent legal process that mayfollow his conviction for the murder of Susan. The Panel shall also seekrelevant information from the Crown Prosecution Service, the police andPeter’s defence counsel in relation to the court case.(8)The Panel shall consider which members of Susan’s and Peter’s family orfriends should be asked to contribute to information gathering, and how thatwould then be managed. The Panel will particularly seek to establishwhether:(a)Susan had made any disclosures to family or friends in respect of thestate of her marital relationship with Peter;IMR – “Individual Management Review”Page 8 of 2216 November 2018
(b)(c)(d)Peter had exhibited any tendency towards domestic violence towardsSusan;Peter had made any disclosures to family or friends in respect of thestate of his marital relationship with Susan; andPeter had expressed any intention to bring the relationship to an endor to harm Susan.(9)The Panel shall seek information in respect of the background and anyprevious convictions of Peter and whether or not he had ever been subject toMulti- Agency Public Protection (MAPPA) Arrangements or Domestic ViolencePerpetrator Programmes (DVPP).(10)The Overview Report shall be written by the nominated Review Panel ReportAuthor who shall, subject to the agreement of the Panel Chair, submit a draftto the Panel for its consideration. The Report shall set out the extent to whichthe homicide could have been anticipated and possibly prevented, andwhether, from the findings of the review, there are improvements that couldbe made in the way in which relevant agencies and organisations can workindividually or together to safeguard future potential victims. The Panel shallalso consider whether further information should be made available in thepublic domain for the benefit of family or friends who have concerns relatingto potential abusive relationships.(11)Subject to (10) above, the Panel will identify any changes in policies andprocedures arising from the lessons learnt, make recommendations and will,through an agreed Action Plan, establish timescales for their implementationand identify what is likely to change as a result.(12)The Panel shall, once it has agreed the final report, submit it to the EppingForest District Community Safety Partnership for its consideration. ThePartnership will be requested to consider the content of the report, therecommendations and the associated Action Plan. If the Partnership issatisfied with the report, it shall be requested to:(a)(b)(c)(13)Page 9 of 22submit the report to the Home Office;consider whether, prior to the Home Office response, there are issuesthat should be brought to the immediate attention of Safer Essex; andconsider which agencies, organisations or individuals should receive acopy of the report and the degree to which its findings should be madepublic, following the approval of the report by the Home Office.The Panel shall seek to complete its work before the 31st of July 2017, thatbeing the date before which the Epping Forest District Community SafetyPartnership should submit the final report to the Home Office. Should thePanel consider that this date cannot be achieved it shall take immediate stepsto seek the consent of the Epping Forest District Community SafetyPartnership to seek an extension of time.16 November 2018
Review Methodology1.18This Domestic Homicide Review (DHR) has followed the statutory guidance issued bythe Home Office1 for the conduct of such reviews. The Review Panel undertook ascoping exercise in order to gather information about the victim Susan and theperpetrator Peter. In accordance with the agreed Terms of Reference, the scopingexercise sought information covering the period from 1 May 2015 until the date ofher death in early 2016. The selection of the start of May reflects this being the timewhen it is believed that Peter commenced an affair with another female, and whenSusan identified difficulties in their marriage and started to challenge Peter aroundthose difficulties. A total of 51 agencies, organisations and individuals wereapproached, of which 6 responded with information. The Review Panel consideredall of the responses to the scoping exercise, but, in view of the relative lack ofrelevant information on the victim and the perpetrator, it was decided that formalIMRs were not required and were therefore not sought. The information from theagencies was presented to the Review Panel by representatives of those agenciesand the Panel members had an opportunity to seek additional information throughquestioning.1.19More detailed information was sought, and by the conclusion of the Reviewinformation had been received from:(a)(b)(c)(d)(e)(f)The General Practitioners to Susan and Peter;Princess Alexandra Hospital (Harlow) regarding Peter;The Head Teacher of the school attended by the children of Susan and Peter;The Crown Prosecution Service;The East of England Ambulance Service; andThe Essex Fire and Rescue Service.1.20At the outset of the Panel inquiry process, Susan’s parents were contacted to informthem that a DHR Review had been established and that once the criminalproceedings had been concluded, they would be invited to contribute to the reviewprocess.1.21Once the criminal proceedings against Peter had concluded, the Review Panel soughtto gather information from the family and friends of Susan. Throughout the period ofthe review numerous attempts were made to engage with Susan’s family includingwriting to them and making requests for engagement via the police Family LiaisonOfficer. Unfortunately, at that time, all these attempts did not result in Susan’sfamily directly engaging with the Panel. Similar attempts were made to engage withSusan’s friends, but with the same negative outcome. The Panel also consideredapproaching Susan’s work colleagues to obtain background information, but sinceshe had only been in that particular employment for a very short period (threeweeks), it was considered unlikely that any useful information would be obtained. Itwas later established through information received from Susan’s family that Susanhad gone to work with a family friend in their pub.Page 10 of 2216 November 2018
1.22Some information was made available to the Panel Chair by Essex Police, whoreleased statements provided to them by Susan’s family and friends as part of thecriminal case against Peter. That information provided the Review Panel with helpfulinsights into the relationship between Susan and Peter. Although, at this time,Susan’s parents declined to engage directly with the Panel, Susan’s mother took partin a radio interview soon after the completion of the criminal process and Peter’sconviction for murder. This interview was recorded for the benefit of the Panel andprovided some useful insight into her views and Susan’s personal circumstanceswithin her marriage.1.23Susan had attended her general practitioner’s surgery on numerous occasions in theperiod covered by the Terms of Reference. The surgery provided full details ofattendances after 13 February 2013 to the Review Panel that were reviewed by theClinical Commissioning Group’s representative on the Review Panel.1.24There was no information available from Peter’s GP, but there was informationprovided by the Princess Alexandra Hospital, Harlow, following his involvement in aroad traffic accident in early 2014.1.25The Panel attempted to obtain information from the female with whom Peter was ina relationship outside the marriage. Despite making approaches via the Police FamilyLiaison Officer, the female chose not to engage.1.26Attempts were also made to seek information from Peter’s parents and his formeremployers. Neither were prepared to engage with the Panel. Consideration wasgiven to meeting Peter whilst he was in prison, but the advice from the Police wasthat this was unlikely to be of assistance due to Peter’s inability to accept that he hadcommitted a crime and because there remained a possibility of an appeal againstconviction and sentence. However, a letter was written to Peter, in prison, to notifyhim that a Domestic Homicide Review was taking place.1.27At the conclusion of the review process, the Panel Chair wrote once more to Susan’sparents asking for their comments and seeking a meeting to determine whether theycould provide further insight into their daughter’s relationship with Peter. Familymembers of Susan felt that they were unable to speak about the death of Susan atthat time however contact has since been made with Susan’s family who very kindlyagreed to talk about Susan and Peter and their relationship. The family met with theCSP Community Safety lead and the chair of the panel Elizabeth Hanlon. We wouldlike to acknowledge how difficult this must have been for the family and we wouldlike to thank them for their time.1.28The Panel also gave consideration as to the benefits of attempting to speak to Peter,in prison. However, given Susan’s mother’s views on Peter’s inability to accept thathe was in any way at fault for the tensions within their marriage, coupled with hisfailure to demonstrate any remorse for his actions during his trial, it was concludedthat it would be inappropriate to arrange such a visit.Page 11 of 2216 November 2018
2.The Facts2.1On a day in early 2016 at around 15:30 the ambulance service received a call fromPeter stating that he had just found his wife Susan collapsed at home, along withsigns of a fire. He gave his home address and was given advice on how to administerCardiac Pulmonary Resuscitation (CPR).2.2The first paramedic to arrive at the scene described finding a female lying on thefloor in the kitchen, burnt. At 15:40 the paramedic recognised that the female wasdeceased and that the body was not warm to the touch, suggesting that death hadoccurred sometime earlier.2.3The police were called to the scene by the ambulance service at 15:45. On arrival atthe scene the police officers were informed by the paramedic that a deceased femalewas inside the house with severe burns. The paramedic could not explain how theburns could have arisen. The duty police inspector formed the view that the deathwas “unexplained” and that a full investigation and post-mortem examination wouldbe required. A Detective Chief Inspector (DCI) was informed of the circumstancesand attended the scene. The DCI agreed that the circumstances of the deathappeared suspicious and a crime scene was established.2.4The post-mortem examination indicated that there was no evidence of naturalcauses for the death, but there was extensive burning to Susan’s head and trunk andbruising to the right side of her face and left side of her head, consistent with someform of assault and subsequent fire. Furthermore, traces of white spirit were foundon Susan’s clothing suggesting that, following the assault, Susan’s body had been seton fire by the perpetrator. Contrary expert evidence was given in the subsequentmurder trial as to the cause of death. However, the victim’s death certificate states‘death by immolation with an accelerant.2.5On the basis of the evidence, Peter was charged with the murder of Susan, and hewas subsequently found guilty of murder and arson, resulting in a life sentence with aminimum period of 24 years before parole.Susan2.6Susan was born in December 1980. At the time of her death she was 35 years of ageand living in a semi-detached house within the Epping Forest District. She had beenmarried to Peter for 8 years and they had two children, aged 6 and 4. She was anonly child. Her parents described her as someone who “lived for her family and hertwo darling children”. She had no previous police or related agency involvement orrecord.2.7Friends and family described Susan as a worrier who could often become anxious.However, no friend or relative ever considered Susan to be at risk in her personal life.Family members have since reflected on the relationship Susan had with Peter andPage 12 of 2216 November 2018
believe that he was controlling Susan throughout their relationship and that Peterwas not happy unless he had Susan’s full attention and that she was doing what hebelieved was his priorities. They reflected that these observations are in hindsightand at the time of their relationship they believed that Peter was ‘selfish’ and ‘spoilt’but that they did not have any concerns in relation to Susan’s wellbeing. Susan hadkept written notes of her relationship with Peter which indicated her concerns abouthis potential adultery. However, she felt that she should do nothing that might bringthe relationship to an end, despite the fact that the stresses in their relationshipwere, in her opinion, of his making, not hers.2.8In statements made to the police during their criminal investigation, her friendsvariously described her as a “wonderful mother and wife”, who was very organisedaround the home. They said that when with her friends she was relaxed and open,but was always considerably more reserved when her husband Peter was present.However, no friend indicated that Susan had expressed any concerns regarding hersafety or had suggested that she was being subjected to any form of domestic abuse.2.9Susan’s family described Susan as being loving, loyal, kind and beautiful, both insideand out. She was extremely conscientious in everything that she undertook.2.10 The family stated that Susan met Peter at work and that she was swept off of her feet.Peter was described as being charming and very confident and that he did everythingpossible to please Susan, showering her with gifts and attention, going to greatlengths to please her. It was described as a whirl wind romance and that they quicklymoved in together and soon afterwards got married. After the birth of their first childthey decided that they would move to live nearer Peters parents but later changedtheir mind and brought their house. They had their second child within 21 months.2.11The family described the relationship between Susan and Peter as changing shortlyafter the children were born. Peter appeared to be jealous of all the attention thatSusan was giving the children and stated that he wasn’t being given enoughattention. They believe that Peter started blaming Susan for everything that wentwrong including why he lost his job. He had tried to get Susan to put some pressureon her friends and family to get Peter another job and when this didn’t happen Susanwas blamed for not trying hard enough2.12 Six weeks before the murder, Susan told her family that Peter had threatened her thatif she didn’t improve and become more attentive towards him then he would seek adivorce and sell the family home.2.13During this period Susan found out that Peter had secretly consulted a divorce lawyerand that he had a file on his computer titled ‘Susan’ where he had listed all hermisdemeanours. Susan was desperate to make the relationship work as she did notwant her children to grow up in a divorced family.2.14In May 2015, Susan discovered flirtatious text messages on Peters phone. Susan hadconfronted Peter and the female regarding an affair but had been told that it was allPage 13 of 2216 November 2018
in her mind and that she was imagining things. Family describe the relationship asgoing downhill afterwards.2.15Her medical history was relatively unremarkable with the majority of attendancesbeing related to contraception. In December 2015 she consulted her GP regarding‘difficulties at home’, although there were no details in her record. In December2015 she confided in her GP that her husband had admitted adultery and that as aresult they were attending counselling as a couple. However, Susan felt that thecounselling sessions were actually making matters between her and Peter worserather than better. Following a similar conversation with her GP in January 2016Susan was prescribed an anti-depressant for her anxiousness.2.16The family describe Peter as being controlling and that he would try and get Susan todo things his way. They described instances when Peter would come homedeliberately late if he knew that Susan was going out and that he would deliberatelymake things difficult for her.2.17 Family members were not aware of any incidents of violence towards Susan, howeverthey did quote an occasion where Peter deliberately made Susan fear for her life i.e.driving up the motorway 100 MPH eating and drinking. Family felt that Peter usedinstances like this as a controlling mechanism.Peter2.18Peter was born in June 1976. At t
(1) In conducting the Domestic Homicide Review into the death of Susan, the Panel shall have regard to: (a) The Home Office Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews1 and the recommended Home Office security provisions2; and (b) The Essex Domestic Abuse Strategy Group - Domestic Homicide Reviews Guidance3.
