1 May 2026 Natasha Hill · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Failure to formally review safeguarding, domestic violence or controlling or coercive behaviour risks affecting teenagers approaching 18 View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Department for Education
Conduct an urgent review of adult safeguarding powers and duties, including consultation on updated safeguarding guidance and consideration of transition safeguards.
View source
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AI-generated summary
Natasha Hill · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Natasha Hill, who had been in care and was experiencing grooming, exploitation, self-harm, substance misuse and domestic violence, was pronounced dead at her abuser’s home in the early hours of 15 April 2018. The jury concluded that she was unlawfully killed by her abuser. The report raised concerns about safeguarding during the transition to adulthood, protection from exploitation and domestic abuse, and coordination of relevant policing and safeguarding policies.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to formally review safeguarding, domestic violence or controlling or coercive behaviour risks affecting teenagers approaching 18
Wider context from the report “• Anyone requiring/needing/suffering
o Safeguarding
o Domestic violence
o Controlling/ coercive behaviour
And incurring the consequential risks, as a teenager approaching 18 should be formally reviewed by an adult safeguarding team ad the independent reviewing officer .
” Source location Natasha Hill · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct an urgent review of adult safeguarding powers and duties, including consultation on updated safeguarding guidance and consideration of transition safeguards.
Verbatim wording from the response “• The National Adult Safeguarding Board will be conducting an urgent review of adult safeguarding powers and duties. The first part of that work will be to consult on updating the safeguarding chapter of Care and support statutory guidance (CASSG). As part of this update, we will consider what guidance can be provided to strengthen safeguarding in the context of the transition of young people to adult services. In that process we will take the learning from this PFD report and consider the recommendation that when a teenager with care and support needs approaches 18 they should be reviewed formally by an adult safeguarding team and the independent reviewing officer.” Source location Response from Department for Education
Open published response
5 Mar 2026 Joanna HILLARD · Prevention of Future Deaths report Somerset
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Concerns raised 1
Lack of understanding of the effects of controlling and coercive behaviour on decision-making capacity View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
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AI-generated summary
Joanna HILLARD · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joanna Hillard was discovered at her home on 25 February 2021 and could not be revived despite CPR. The inquest concluded that her death was suicide contributed to by coercive and controlling behaviour. The principal concern was that the effects of coercive and controlling behaviour on a person's decision-making ability may not be adequately recognised under the Mental Capacity Act 2005 and current capacity law.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of understanding of the effects of controlling and coercive behaviour on decision-making capacity
Wider context from the report “I am concerned that there is a lack of understanding of the effects of controlling and coercive behaviour on a person’s ability to make a decision in their best interests . I am concerned that people who live in a level of fear (resultant from coercive and controlling behaviour) may have their decision-making abilities negatively affected and the law surrounding capacity, as currently drafted, does not recognise this.
” Source location Joanna HILLARD · Prevention of Future Deaths report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The MCA need not override unsafe or unwise decisions where capacity exists because safeguarding, civil and criminal routes are available.
Verbatim wording from the response “Although section 76 Serious Crime Act 2015 offence post-dates the MCA, it was developed and updated alongside the modern adult safeguarding framework (including the Care Act 2014 and the Domestic Abuse Act 2021) and is supported by statutory guidance: Controlling or coercive behaviour: statutory guidance framework - GOV.UK. The MCA remains relevant where coercion or undue influence interacts with an impairment or disturbance of the mind or brain so that the person cannot make the specific decision, in such cases, practitioners should complete and record a decision-specific capacity assessment. Where an adult has capacity, the MCA is not a general route to override unsafe or unwise decisions, and other safeguarding, civil and criminal routes may be more appropriate.” Source location 2026-0128 - Response from Department of Health and Social Care
Open published response
19 Sep 2025 Rebekah Arter · Prevention of Future Deaths report South London
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Concerns raised 1
Failure of investigations to identify victims of domestic abuse and coercive control View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Rebekah Arter · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Rebekah Arter, aged 47, died in a hotel room in Barbados on 28 June 2024 in circumstances involving likely intoxication; the medical cause of death was unascertained and the inquest conclusion was open. The principal concern was that missed opportunities by the IOPC and Metropolitan Police Service may have prevented identification of Rebekah as a victim of domestic abuse and coercive control, and prevented protective action.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of investigations to identify victims of domestic abuse and coercive control
Wider context from the report “That there may have been missed opportunities for the IOPC and Metropolitan Police Service from their investigations to identify that Rebekah was a victim of domestic abuse and coercive control , which would have enabled her to be protected. This is illustrated by these facts:
• That Rebekah had met her husband initially as a victim of a crime.
• That police investigations uncovered a large number of women with whom he had inappropriate relationships and that he misused his police powers.
• That he was dismissed from the police for drug offences in May 2023, but the risk to Rebekah was not apparently considered at that time.
• A witness has alleged that a video was sent by him of Rebekah ████████ which the family allege was used to shame and enforce control over her, allegedly in 2023.
• A history of her having unexplained repeated bruises and injuries was available in 2024 to anyone who enquired about the risk of domestic abuse .
• ████████
• That in retrospect it is recognised by a Detective Chief Inspector that he was an exceptionally persistent and damaging offender against women, but no charges in relation to that had ever been brought.
The coroner did not accept submissions from the family that the inquest engaged Article 2 of the European Convention on Human Rights and ruled that details of the seven years of conduct investigations were beyond the scope of the inquest.
” Source location Rebekah Arter · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and operate the Domestic Abuse and Sexual Offences Investigation Unit with specialist investigation teams and victim-support capacity.
Verbatim wording from the response “DASO – this was created in early 2022 in response to the cases relating to former Police Constables ████████ and ████████, a unique reactive department committed to investigating Police-Perpetrated Domestic Abuse (PPDA) and Sexual” Source location Response from Metropolitan Police
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £13.1 million to establish a National Centre for VAWG and Public Protection.
Verbatim wording from the response “I am very sorry to hear about the experiences Rebekah went through as a victim of domestic and sexual abuse, as noted in your report. I recognise the devastating impact these awful crimes can have on their victims. I would like to reassure you that this Government is committed to tackling all forms of violence against women and girls (VAWG), including domestic and sexual abuse. We have set out an unprecedented mission to halve VAWG in a decade. Improving policing practice is a key part of this, and we have provided £13.1m this year to establish a new National Centre for VAWG and Public Protection which will help drive consistency nationally, including through the development of specialist training on VAWG to ensure that officers are well equipped to manage offences and provide consistent support to victims.” Source location Response from Home Office
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No specific risk to Rebekah was apparent because no domestic abuse allegations or concerning evidence had been reported to or identified by the IOPC.
Verbatim wording from the response “Prior to Rebekah’s death, the IOPC was not on notice of any allegations of controlling or coercive behaviour or any other domestic abuse allegation in respect of Mr ████████. When in” Source location Response from Independent Office for Police Complaints
Open published response
13 Aug 2024 Angela · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 2
Insufficient frontline staff understanding of domestic abuse and coercive and controlling behaviour View source Failure of the domestic abuse risk assessment form to clearly include psychological harm from coercive and controlling behaviour within serious harm View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
National Police Chiefs’ Council Thames Valley Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 11
Thames Valley Police
Review and improve frontline training inputs on domestic abuse and coercive and controlling behaviour.
View source
Thames Valley Police
Deliver DA Matters training, including coercive-control content, to all frontline officers.
View source
Thames Valley Police
Develop a new Contact Management training package covering coercive control and using Angela’s death as a case study.
View source
Thames Valley Police
Review and refresh the specialist domestic abuse officer training programme with coercive-control content throughout.
View source
National Police Chiefs’ Council
Provide learning materials and classroom training content on coercive and controlling behaviour and its legislation.
View source
National Police Chiefs’ Council
Establish and license the DA Matters training course for first responders and domestic-abuse champions, with specialist-provider delivery and trainer development.
View source
National Police Chiefs’ Council
Embed domestic-abuse learning, including risk assessment and protective-order responses, within all entry routes into policing.
View source
Thames Valley Police
Add the College of Policing serious-harm definition to the current domestic abuse risk assessment form.
View source
Thames Valley Police
Explore an interim solution for incorporating DARA questions and the serious-harm definition into the current crime-recording system.
View source
National Police Chiefs’ Council
Review the policing implementation of the DASH risk-assessment tool.
View source
National Police Chiefs’ Council
Develop, pilot and evaluate the DARA risk-assessment tool and aligned training for identifying coercive-control patterns.
View source See 8 more actions
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AI-generated summary
Angela · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Angela was murdered by her husband at their home on 26 December 2018, aged 41. Before her death, she reported assault and elements of coercive control to Thames Valley Police, but the reported crimes were not recorded or investigated, relevant information was not considered in the risk assessment, and the risk was graded as standard rather than medium. The report raises concerns about frontline understanding of domestic abuse and coercive control, the clarity of the DOM5 risk assessment form, and the non-adoption of a newer domestic abuse risk-assessment tool.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient frontline staff understanding of domestic abuse and coercive and controlling behaviour
Wider context from the report “1. Whether sufficient steps have been taken to ensure that frontline staff have a clear understanding of domestic abuse and coercive and controlling behaviour – to think not just about physical abuse, but also about controlling behaviour and how that may escalate .
” Source location Angela · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the domestic abuse risk assessment form to clearly include psychological harm from coercive and controlling behaviour within serious harm
Wider context from the report “2. I am concerned that Thames Valley Police’s DASH risk assessment form (called a DOM5) does not make it sufficiently clear that the definition of “serious harm” can include psychological harm from coercive and controlling behaviour . It may be that other formulations of this document nationally do make this clear – I have looked only at the form used by Thames Valley Police.
” Source location Angela · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and improve frontline training inputs on domestic abuse and coercive and controlling behaviour.
Verbatim wording from the response “We are always seeking to improve our training. Changes to training practice and content can be brought about in a number of ways. The training of new recruits is mandated through the College of Policing and delivered through a number of courses, collectively known as Foundation Training. All our training inputs have been reviewed and in some cases improved by an independent domestic abuse training consultancy. I am satisfied” Source location Response from Thames Valley Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver DA Matters training, including coercive-control content, to all frontline officers.
Verbatim wording from the response “Thames Valley Police have commissioned the Safe Lives charity to deliver its ‘DA Matters’ training to all front-line officers since January 2020. This includes sessions on coercive and controlling behaviour. This training also includes an input known as ‘Crime Data Integrity’. This is essentially training officers to identify and accurately record crime and to that end specific videos have been produced covering behavioural crimes such as harassment, stalking and coercive and controlling behaviour.” Source location Response from Thames Valley Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a new Contact Management training package covering coercive control and using Angela’s death as a case study.
Verbatim wording from the response “In 2024 Contact Management leaders commissioned an external training provider to develop a new training package (including Coercive Control) and asked for the circumstances of Angela’s death to be included as a case study.” Source location Response from Thames Valley Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and refresh the specialist domestic abuse officer training programme with coercive-control content throughout.
Verbatim wording from the response “The training course designed for specialist domestic abuse officers has also recently been reviewed and refreshed. Inputs on coercive and controlling behaviour run throughout the programme.” Source location Response from Thames Valley Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide learning materials and classroom training content on coercive and controlling behaviour and its legislation.
Verbatim wording from the response “A programme of work was developed to improve the policing response to DA, including a project to examine existing risk assessment processes for victims of DA, a review of the existing training curriculum and the development of APP for this area of work. In 2015 with the inception of new legislation for the offence of coercive and controlling behaviour, several products were made available on the College learning network (College Learn) aimed at embedding knowledge of the legislation. Using a video briefing, two victims provide an insight of their lived experience of controlling and coercive behaviour, while advice and guidance is also given on the legislation. In addition, forces were provided with a new training guide and content for a half-day classroom session so that there was an option for face-to-face inputs.” Source location Response from NPCC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and license the DA Matters training course for first responders and domestic-abuse champions, with specialist-provider delivery and trainer development.
Verbatim wording from the response “responding to coercive and controlling behaviour, the impact of such behaviours on victims, including the clear links to victim suicide and the heightened risk posed by suspects who use coercion and control in their abuse of victims. This consists of a one-day course for responders and a two-day course for ‘champions,’ those with a more involved, mentoring role. DA Matters was developed with the support of ‘Safelives,’ (a national service for victims of DA), and other key stakeholders including Women’s Aid, Suzy Lamplugh Trust, and other specialist support services. The course was piloted and evaluated in 2016 and a model of delivery, (which included co-delivery with a DA specialist) is promoted through the licensing of the product (essentially outlining the conditions by which forces must use the training course).” Source location Response from NPCC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed domestic-abuse learning, including risk assessment and protective-order responses, within all entry routes into policing.
Verbatim wording from the response “More broadly DA is embedded in the curriculum for all entry routes into policing with various supporting products available to deliver against the curriculum (for example, areas such as Domestic Violence Disclosure Scheme (DVDS), Domestic Violence Protection Orders (DVPOs), response to DA /Stalking (Abusive Relationship digital learning, Domestic Abuse Risk Assessment (DARA/DASH) are catered for).” Source location Response from NPCC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add the College of Policing serious-harm definition to the current domestic abuse risk assessment form.
Verbatim wording from the response “You are right to point out that the current TVP Domestic Abuse risk assessment form (Dom5) does not define the term ‘serious harm’. The College of Policing defines the risk of serious harm as follows - ‘A risk which is life threatening and/or traumatic, and from which recovery, whether physical or psychological, can be expected to be difficult or impossible.’ This definition is included in the risk assessment model known as the DARA. I have asked Detective Superintendent ████████ to include this definition on our current risk assessment form.” Source location Response from Thames Valley Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore an interim solution for incorporating DARA questions and the serious-harm definition into the current crime-recording system.
Verbatim wording from the response “There are challenges to implementing the DARA risk assessment model within our current version of the NICHE crime recording system. In the future TVP will be looking to adopt an updated NICHE safeguarding and vulnerability module when available. In the mean time I have asked Detective Superintendent ████████ to explore an interim solution. This will include the replacement of the current questions in the DOM5 with the questions contained within the DARA and include clear reference to the College of Policing definition of serious harm which can include psychological harm from coercive and controlling behaviour. This will be attached to the crime recording system in the form of a template. The DARA includes a number of questions designed to assess the level of coercive and controlling behaviour and the level of risk posed.” Source location Response from Thames Valley Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the policing implementation of the DASH risk-assessment tool.
Verbatim wording from the response “Simultaneous to the learning products, the College carried out a review of the implementation of domestic abuse, stalking and honour based crime (DASH) risk assessment ‘tool’ introduced into policing in 2009. Working alongside Cardiff University the review findings and report prompted the development of a new tool for use by initial responders, more focused on patterns of behaviour with a focus on coercion and control rather than incidences of specific behaviours. The Domestic Abuse Risk Assessment (DARA) and aligned training was piloted and evaluated in three forces, with subsequent testing in further forces to ensure effectiveness The evaluation found that the DARA uncovered more cases of coercive and controlling behaviour (CCB), and gave officers more accurate information to use professional judgement to assess and respond to risk.” Source location Response from NPCC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop, pilot and evaluate the DARA risk-assessment tool and aligned training for identifying coercive-control patterns.
Verbatim wording from the response “Simultaneous to the learning products, the College carried out a review of the implementation of domestic abuse, stalking and honour based crime (DASH) risk assessment ‘tool’ introduced into policing in 2009. Working alongside Cardiff University the review findings and report prompted the development of a new tool for use by initial responders, more focused on patterns of behaviour with a focus on coercion and control rather than incidences of specific behaviours. The Domestic Abuse Risk Assessment (DARA) and aligned training was piloted and evaluated in three forces, with subsequent testing in further forces to ensure effectiveness The evaluation found that the DARA uncovered more cases of coercive and controlling behaviour (CCB), and gave officers more accurate information to use professional judgement to assess and respond to risk.” Source location Response from NPCC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing training and guidance sufficiently equip frontline staff to understand domestic abuse and coercive and controlling behaviour.
Verbatim wording from the response “I am satisfied frontline staff are equipped with sufficient training to understand domestic abuse and coercive and controlling behaviour. Thames Valley Police is committed to providing ongoing and updated training in these important areas.” Source location Response from Thames Valley Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Delivery of the national domestic-abuse training curriculum was not centrally undertaken; individual police forces were responsible for delivering it.
Verbatim wording from the response “Although this was not centrally delivered forces were encouraged to deliver against the national curriculum using the specific products available.” Source location Response from NPCC
Open published response
20 Jun 2024 Lee-Ann Sarah INCE · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to recognise coercive and controlling relationship behaviours and their impact on victims’ mental health View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Lee-Ann Sarah INCE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lee-Ann Sarah Ince was a victim of domestic abuse in a coercive and controlling relationship and was found unresponsive attached to a ligature on 9 May 2023. The inquest identified concerns that agencies did not fully recognise coercive control, the impact of “love bombing” on her mental health, information shared by her children, or her physical-health-related vulnerability and dependence on the perpetrator.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise coercive and controlling relationship behaviours and their impact on victims’ mental health
Wider context from the report “The inquest heard evidence that agencies involved in supporting her in the months leading up to her death had a limited understanding of how behaviours could be twisted in a coercive and controlling relationship to make it appear as if the victim was part of the problem . In this situation it was clear that Lee-Ann was the victim of so called “love bombing” which meant that she was barraged with messages from the perpetrator. The impact of that on a victim’s mental health was not recognised .
” Source location Lee-Ann Sarah INCE · Prevention of Future Deaths report
Open source report
Concerns raised 1
Lack of understanding of controlling and coercive behaviour and its impact on victims View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Hertfordshire Constabulary
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Hertfordshire Constabulary
Deliver recurring domestic abuse training covering coercive control, stalking, investigations, risk assessment and safeguarding.
View source
Hertfordshire Constabulary
Establish a dedicated domestic abuse training role to increase frontline knowledge of coercive control, civil orders and safeguarding processes.
View source
Hertfordshire Constabulary
Deliver sudden-death and domestic-abuse training highlighting the link between domestic abuse and suicide, professional curiosity and evidence-led investigation.
View source
Hertfordshire Constabulary
Provide new DAISU staff with a regularly updated guidance manual covering domestic abuse, coercive control, civil orders, evidence-led prosecution and safeguarding.
View source
Hertfordshire Constabulary
Deliver specialist domestic-abuse training inputs to detectives, supervisors, Police Now officers and PCSOs, including evidence gathering, protective orders, DARA and safeguarding.
View source
Hertfordshire Constabulary
Deliver booked frontline training on stalking and coercive and controlling behaviour in August 2024.
View source
Hertfordshire Constabulary
Establish and roll out a DA Influencers initiative training officers across ranks and areas to share and champion coercive-control knowledge.
View source See 4 more actions
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AI-generated summary
Kellie Marie SUTTON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kellie Sutton died in hospital on 26 August 2017 after suffering irreversible brain injury following a hanging on 23 August 2017. She had been subjected to controlling and coercive behaviour and domestic abuse by her partner. The principal concerns were inadequate understanding of controlling and coercive behaviour, insufficient awareness of the link between domestic abuse and suicide, and uncertainty among frontline officers about the use of DVPNs and DAISU referrals.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of understanding of controlling and coercive behaviour and its impact on victims
Wider context from the report “1. There was a lack of understanding of controlling and coercive behaviour, what it is, and the impact on victims .
” Source location Kellie Marie SUTTON · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver recurring domestic abuse training covering coercive control, stalking, investigations, risk assessment and safeguarding.
Verbatim wording from the response “████████ report also documents DA training delivered within Hertfordshire Constabulary relative to the inquest of Kellie Sutton. Coercive Control was a relatively new offence in 2017, only introduced as legislation on the 29th December 2015. The report documents coercive control training packages that were delivered to front line officers in 2016. In April 2017, further training was provided to front line responders on coercive control, including how to recognise and investigate it.” Source location Response from Hertfordshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a dedicated domestic abuse training role to increase frontline knowledge of coercive control, civil orders and safeguarding processes.
Verbatim wording from the response “A DAISU Detective Sergeant moved to a dedicated training role in September 2022 and was tasked with providing training to increase knowledge to frontline officers on a wide variety of domestic abuse subjects. This included an update on processes, how to identify and investigate coercive and controlling behaviour, how to seek civil orders (including DVPN/DVPO’s) as well as other safeguarding measures including reinforcing the Clare’s Law process.” Source location Response from Hertfordshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver sudden-death and domestic-abuse training highlighting the link between domestic abuse and suicide, professional curiosity and evidence-led investigation.
Verbatim wording from the response “Training regarding this policy has been delivered to all front-line officers and Neighbourhood Policing Teams (NPT) within the last 6-8 weeks. Student officers, Detectives (including sergeants and Inspectors) are captured by the Bedfordshire Police, Cambridgeshire and Hertfordshire Constabularies collaborated Learning and Development team. Further plans are being drafted to deliver wider training to capture the remaining relevant staff. The sudden death training also focuses on the failings identified from the Stephen Port investigation and critically emphasises the need for professional curiosity at unexpected deaths, the risk of categorising a sudden death without a global understanding of the circumstances and the risks of prejudice and bias.” Source location Response from Hertfordshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide new DAISU staff with a regularly updated guidance manual covering domestic abuse, coercive control, civil orders, evidence-led prosecution and safeguarding.
Verbatim wording from the response “DAISU have designed and regularly update a guidance manual which they provide to all officers and staff who newly join the unit. This is a comprehensive guide providing information on all areas of domestic abuse including definitions, civil orders, ‘Evidence Led’ Prosecution guidance and safeguarding advice. This manual includes the definition of coercive control and evidential ‘points to prove’ for the offence to be made out, as well as links to the Domestic Abuse Bill and the Hertfordshire Constabulary Vulnerability Handbook.” Source location Response from Hertfordshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver specialist domestic-abuse training inputs to detectives, supervisors, Police Now officers and PCSOs, including evidence gathering, protective orders, DARA and safeguarding.
Verbatim wording from the response “Input has been provided to ‘Police Now’ detectives, PCSO’s and sergeants/first line supervisors from across the constabulary including the following:” Source location Response from Hertfordshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver booked frontline training on stalking and coercive and controlling behaviour in August 2024.
Verbatim wording from the response “• In August 2024, frontline training days have been booked to deliver an input on stalking and coercive & controlling behaviours.” Source location Response from Hertfordshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and roll out a DA Influencers initiative training officers across ranks and areas to share and champion coercive-control knowledge.
Verbatim wording from the response “• A new DA Influencers initiative has started in which officers from a variety of areas within the force and of all ranks are trained in coercive and controlling behaviour and the expectation is that they will share and champion their knowledge and provide advice and training across the force. This is in the early stages of delivery and guest speakers with lived experience will feature within this process.” Source location Response from Hertfordshire Constabulary
Open published response
18 Nov 2020 Alfie Gildea · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2
Limited police training and capability to identify coercive and controlling behaviour View source Limited health visitor understanding of coercive and controlling behaviour View source
This report raised 20 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care Greater Manchester Police Home Office NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Home Office
Continue considering how to work with police forces to improve understanding and enforcement of the coercive and controlling behaviour offence.
View source
Greater Manchester Police
Deliver rolling virtual continuing professional development covering domestic abuse, coercive control, stalking, risk assessment, DASH, strangulation and related safeguarding topics.
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Greater Manchester Police
Review vulnerability training and design, establish and test a new force-wide vulnerability training offer.
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Greater Manchester Police
Establish a safeguarding course for officers and staff who evaluate risk and provide formal training on identifying risk factors.
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Department of Health and Social Care
Publish domestic-abuse guidance for health professionals, including responsibilities for responding to victims and practical guidance on perpetrators.
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AI-generated summary
Alfie Gildea · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alfie Gildea sustained catastrophic injuries consistent with being shaken with force while in his father's care on 12 September 2018 and died from his injuries on 14 September 2018. The report identifies concerns about failures by police, children's services, health visiting services and the CPS to recognise, assess, share and act on domestic abuse risks, including coercive and controlling behaviour.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Limited police training and capability to identify coercive and controlling behaviour
Wider context from the report “5. Evidence at the inquest suggested that the majority of officers had received very limited training in relation to DA and in particular coercive and controlling behaviour . Understanding of how coercive and controlling behaviour in a relationship could be identified was limited .
” Source location Alfie Gildea · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Limited health visitor understanding of coercive and controlling behaviour
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself . Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” Source location Alfie Gildea · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue considering how to work with police forces to improve understanding and enforcement of the coercive and controlling behaviour offence.
Verbatim wording from the response “The coercive and controlling behaviour offence is increasingly being used by police, but we continue to consider how best to work with forces to ensure they understand it and enforce the laws with maximum effect.” Source location 2020-0242-Response-from-Home-Office-Redacted.pdf
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver rolling virtual continuing professional development covering domestic abuse, coercive control, stalking, risk assessment, DASH, strangulation and related safeguarding topics.
Verbatim wording from the response “Between 2015 and 2020, 2773 PCs completed the Safeguarding for Constables course at Sedgley Park which incorporated coercive and controlling behaviours within a relationship. Further CPD was due to be delivered in 2020 but, owing to the COVID-19 pandemic, this has not been achieved. Virtual CPD is taking place from early 2021 on a rolling programme and will cover: domestic abuse definition and typology; the ‘murdered by my boyfriend’ film; coercion and control; stalking and harassment; identifying, assessing, and managing risk; DASH reports; non-fatal strangulation; voice of the child; and incident closing codes.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review vulnerability training and design, establish and test a new force-wide vulnerability training offer.
Verbatim wording from the response “DCI ████████ from the Public Protection Governance Unit has been seconded to the People and Development Branch to review all GMP vulnerability training in the first instance. Following initial scoping, she will design, establish, and test a new vulnerability training offer for the force.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a safeguarding course for officers and staff who evaluate risk and provide formal training on identifying risk factors.
Verbatim wording from the response “This Unit is also working with the People and Development Branch to support a newly designed course which is aimed at officers and staff in the organisation who work in a safeguarding role where they need to evaluate risk and provide formal training to support those staff in understanding risk factors and identifying them at the earliest opportunity.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish domestic-abuse guidance for health professionals, including responsibilities for responding to victims and practical guidance on perpetrators.
Verbatim wording from the response “In March 2017, the Department published a resource for health professionals, Responding to domestic abuse[1], an update to a handbook for healthcare professionals published in 2005.” Source location 2020-0242-Response-from-Dept.-of-Health-and-Social-Care-Redacted.pdf
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Other named respondents are responsible for addressing the coroner’s concerns; this response covers only broader learning-sharing issues within its remit.
Verbatim wording from the response “I have noted that your Regulation 28 letter has also been sent to Greater Manchester Police, Trafford Metropolitan Borough Council, Greater Manchester Mental Health NHS Foundation Trust, Pennine Care NHS Foundation Trust, The Crown Prosecution Service, the Home Office and the Department of Health and Social Care and I will leave it to the named respondents to address the concerns which you have expressed. My letter therefore addresses the issues that fall within the remit of GMHSCP more widely around how we can share the learning from this case.” Source location 2020-0242-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted.pdf
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.