Recurring concern

Unreliable domestic abuse investigations

First to latest report 18 Nov 2020 — 19 Sep 2025

Reports that mention this concern
4
Times this concern has been raised
7
Stated actions linked to this concern
11

What this concern includes

Includes failures of the dedicated domestic abuse investigation process, including investigation capacity, recognition of domestic abuse or coercive control, investigation quality, safeguarding or investigation planning, implementation, monitoring and audit where these controls directly concern domestic abuse investigations.

What is not included
  • Excludes generic police staffing, training, supervision or auditing deficiencies that are not directly tied to domestic abuse investigations.
  • Excludes domestic abuse risk-assessment, protective-measure or safeguarding failures where no deficiency in the domestic abuse investigation process is identified.
  • Excludes failures concerning general criminal investigations or investigations of other hazards without a direct domestic abuse investigation connection.
  • Excludes outcomes or missed opportunities where no unsafe domestic abuse investigation control is asserted.

Reports and published responses 4 reports

See individual reports that have raised this concern, and the actions taken in response

  1. South London

    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
    Page 2 · concerns

    Open source report

    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
    Page 4 · response
    Published 3 July 2026

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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
    Page 1 · response
    Published 3 July 2026

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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
    Page 6 · response
    Published 3 July 2026

    Open published response

  2. Birmingham and Solihull

    AI-generated summary

    Raneem Oudeh and Khaola Saleem · 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

    Raneem Oudeh and her mother, Khaola Saleem, were murdered outside Khaola’s home address just after midnight following an incident at a Birmingham shisha lounge. Both women died from multiple stab wounds. The report raises a concern that serious staff shortages in the domestic abuse team led to cases not being effectively investigated, placing repeat victims of domestic abuse and coercive control at serious risk.

    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 staffing and resources for domestic abuse investigations

    Wider context from the report

    “1. The inquest heard evidence that the domestic abuse team within the Public Protection Unit were seriously short staffed. The inquest was told that in Raneem's case the officer reviewing her case on 28/04/18 understood that more needed to be done however he filed the report due to having no staff to investigate the case. The officer stated that this problem continues. The inquest was told that cases are not being investigated due to lack of resources in the department. This leaves a very real and immediate concern that women like Raneem, who was a repeat victim of domestic violence and controlling and coercive control from a man who had made threats to kill her, are at serious risk due to a lack of effective investigation by the department responsible for investigating domestic abuse. ”

    Source location

    Raneem Oudeh and Khaola Saleem · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Recruit an additional 20,000 police officers through the Police Uplift Programme by March 2023.

    Verbatim wording from the response

    “Alongside implementing the commitments set out in the Tackling Domestic Abuse Plan, the Government are providing policing and law enforcement agencies with everything they need to bring murderers to justice. The Government is on track to deliver its commitment of recruiting an additional 20,000 police officers by March 2023. As of 30th September 2022, 15,343 additional uplift officers have been recruited in England and Wales through the Police Uplift Programme, 77% of the target of 20,000 additional officers by March 2023. As part of this commitment, West Midlands Police have benefitted from up to £40m of additional funding this year alone. As at the end of September, the force has recruited an additional 944 officers towards its overall Uplift allocation of 1,218.”

    Source location

    Response from Home Office
    Page 2 · response
    Published 7 November 2022

    Open published response

    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

    Maintain the restructured investigation arrangements, including Review and Allocation Team processing, Adult Complex teams and dedicated supervisory responsibilities.

    Verbatim wording from the response

    “In our response dated the 28th December 2022, we detailed the work of the Review and Allocation Team (R&A) that was set up in the Public Protection Unit (PPU) department restructure in February 2019. The R&A team removes a significant proportion of the inbox management work that used to be completed by the Domestic Abuse Team supervisors, alongside their other duties. The R&A team currently manage 40-50% of the DA crime that in 2018, the investigation supervisors would have had to review and process.”

    Source location

    Response from West Midlands Police (2)
    Page 2 · response
    Published 7 November 2022

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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

    Restructure domestic abuse investigations into Adult Investigation Teams and Adult Complex Investigation Teams.

    Verbatim wording from the response

    “The Public Protection Department (PPU) was restructured in 2019. One of the reasons the new structure was put in place, was because it was identified that the Domestic Abuse Teams found it difficult to manage complex investigations alongside high volume DA reports and individuals in custody with the associated statutory time constraints.”

    Source location

    Response from West Midlands Police
    Page 1 · response
    Published 7 November 2022

    Open published response

    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

    Increase staffing allocated to domestic abuse management and investigation across the West Midlands and Eastern area.

    Verbatim wording from the response

    “The number of staff allocated to DA investigation has increased since August 2018. The strength of the Domestic Abuse Teams in August 2018 was 308 full time equivalent officers and police staff. The police staff included our Police Staff Investigating Officers (PSIO) and police staff within the Safeguarding Teams. For the Coventry and Solihull team it was 53 officers and staff.”

    Source location

    Response from West Midlands Police
    Page 1 · response
    Published 7 November 2022

    Open published response

    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

    Operate a Review and Allocation Team to assess domestic abuse reports, verify risk grading, and allocate cases for investigation.

    Verbatim wording from the response

    “Review and Allocation Team”

    Source location

    Response from West Midlands Police
    Page 2 · response
    Published 7 November 2022

    Open published response

    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

    Require Adult Investigation Team Sergeants to review, triage, set actions for, and allocate incoming crime reports each shift.

    Verbatim wording from the response

    “Initial Investigative Reviews”

    Source location

    Response from West Midlands Police
    Page 3 · response
    Published 7 November 2022

    Open published response

    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

    Insufficient police staffing and funding prevent West Midlands Police from fully addressing domestic abuse demand and improving operational practice.

    Verbatim wording from the response

    “As set out in Chief Constable Guildford's response, the influx of new Officers into policing since 2020 is relevant to the ability of West Midlands Police to respond to Domestic Abuse cases. Whilst the increase is welcome, it remains the case that by March 2023, West Midlands Police will have approximately 1,000 fewer Officers than it did in 2010, while forces in lower crime, lower demand areas now have more Officers than at any time in their history. That is entirely perverse and irrational. In addition, flaws in the implementation of the government's policing funding formula, mean that West Midlands Police is further disadvantaged and does not receive its full funding allocation, costing our area £40m a year in lost police funding. On 14 December 2022, the government announced that West Midlands is to receive the fifth worst Police Grant Settlement in the country.”

    Source location

    Response from West Midlands Police and Crime Commissioner
    Page 4 · response
    Published 7 November 2022

    Open published response

    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

    Officer deployment, including staffing decisions, is a local responsibility for Chief Constables because police forces are operationally independent.

    Verbatim wording from the response

    “It is important to note, however, that forces are operationally independent, and the deployment of officers remains a local decision for Chief Constables.”

    Source location

    Response from Home Office
    Page 2 · response
    Published 7 November 2022

    Open published response

    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 new structure, resourcing, information technology and organisational processes manage domestic abuse demand in a controlled and safe manner.

    Verbatim wording from the response

    “The new DA policy gives guidance to supervisors on what actions are expected for DA investigations and includes the investigative checklist that has already been mentioned. Whilst DA investigation remains a busy and complex area of work, the new structure, additional resourcing, improved IT and daily organisational means that the demand is managed in a controlled and safe manner.”

    Source location

    Response from West Midlands Police (2)
    Page 3 · response
    Published 7 November 2022

    Open published response

    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

    Current domestic abuse investigation staffing has increased substantially, and the relevant team’s workload is considered manageable.

    Verbatim wording from the response

    “The number of staff allocated to DA investigation has increased since August 2018. The strength of the Domestic Abuse Teams in August 2018 was 308 full time equivalent officers and police staff. The police staff included our Police Staff Investigating Officers (PSIO) and police staff within the Safeguarding Teams. For the Coventry and Solihull team it was 53 officers and staff.”

    Source location

    Response from West Midlands Police
    Page 1 · response
    Published 7 November 2022

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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

    Investigation team staffing capacity is not a determining factor in decisions to file domestic abuse reports or pursue further action.

    Verbatim wording from the response

    “The R&A team is made up of three teams that review each crime and use a bespoke template to determine the progress of the investigation. If there are further lines of investigation the report is allocated to one of the investigation teams to progress. In some cases, further information is required from the victim in order to inform the decision and the R&A team will facilitate this. The R&A team will check the Domestic Abuse Risk Assessment (DARA) grading and any history of previous incidents. This is to ensure the correct risk grade has been determined before a report is filed or allocated for further investigation. In addition, the R&A team can re-grade the risk where appropriate to do so.”

    Source location

    Response from West Midlands Police
    Page 2 · response
    Published 7 November 2022

    Open published response

  3. Surrey

    AI-generated summary

    Aliny Godinho · 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

    On 8 February 2019, Aliny Godinho was attacked and repeatedly stabbed in Ewell, Surrey, and died at the scene despite emergency medical attention. The report states that Surrey Police’s handling of earlier and same-day domestic abuse reports included failures in risk assessment, safeguarding, investigation, supervision, monitoring, call-centre handling and consideration of cultural risk; the inquest found that her death was probably more than minimally contributed to by Surrey Police.

    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 systematic monitoring and auditing of domestic abuse investigations

    Wider context from the report

    “CONCERN 4 Monitoring and Auditing: I was told that there is no system in place to monitor and audit the performance and effectiveness of the Domestic Abuse Team. Data from the “PowerBI” system is used to monitor matters such as case load, but there is no systematic monitoring or auditing (whether by use of Key Performance Indicators or otherwise) of the conduct of the investigations, including (for example) whether and when safeguarding and investigation plans have been made and implemented. ”

    Source location

    Aliny Godinho · Prevention of Future Deaths report
    Page 5 · concerns

    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

    Lack of call-handler training on managing reports relating to ongoing domestic abuse investigations

    Wider context from the report

    “CONCERN 5 Call Centre Training: The evidence at the inquest revealed that, on three occasions, reports made to Surrey Police concerning the perpetrator’s conduct were incorrectly passed to the Metropolitan Police, and without sufficient information first being adduced and risk assessed. I found that, on the third occasion in particular, the error contributed to Aliny Godinho’s death. I was told by the Contact Centre Performance Manager for Surrey Police that these errors had not been appreciated until the inquest hearing and that there were important lessons to be learned concerning the proper management by the Call Centre of reports relating to an ongoing Surrey domestic abuse investigation, when the victim is currently living outside Surrey. It was acknowledged that training for call handlers in respect of this learning is required but has not yet been provided. ”

    Source location

    Aliny Godinho · Prevention of Future Deaths report
    Page 5 · concerns

    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

    Lack of timely effective supervision of domestic abuse investigations

    Wider context from the report

    “CONCERN 3 Supervision of the Domestic Abuse Team: I found that Aliny Godinho’s death was contributed to not only by the failures of the Officer in the Case, but also by those of her supervising sergeant. At that time, there was an expectation that the sergeant would ensure that safeguarding and investigation plans were in place and were implemented, but there was no system in place to ensure that happened and, in relation to the investigation of Aliny Godinho’s complaint, it did not happen. There continues to be no system in place to ensure, through supervision, that the steps which the Officer in the Case must take from the start of the investigation, including in relation to the initial risk assessment and the setting of safeguarding and investigation plans, have been taken in a timely manner. I was told that a supervisory review every 28 days is now included on “niche” as a task for the sergeant but, in my view, this will not ensure that there is effective supervision at any earlier stage of the investigation. ”

    Source location

    Aliny Godinho · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  4. Manchester South

    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.

    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

    Reduced specialist support and oversight for low and medium risk domestic abuse cases

    Wider context from the report

    “9. The inquest heard that since the death of Alfie GMP had restructured and removed the PPIU units. However the inquest heard that as a result the limited specialist support and oversight offered to neighbourhood/response officers had further reduced in low/medium risk DA cases. ”

    Source location

    Alfie Gildea · Prevention of Future Deaths report
    Page 3 · concerns

    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 to pursue further enquiries supporting victimless domestic abuse prosecutions

    Wider context from the report

    “8. The limited training and understanding of GMP officers meant that lines of further enquiry that would allow for a victimless prosecution were not followed. ”

    Source location

    Alfie Gildea · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    Use the revised domestic abuse policy to define responsibilities for considering evidence-led prosecutions.

    Verbatim wording from the response

    “It is recognised that GMP's previous domestic abuse policy did not fully explore or explain 'victimless' or evidence-led prosecutions. The revised domestic abuse policy provides clear definitions and responsibilities for officers investigating domestic abuse offences to consider evidence-led prosecutions where appropriate to do so.”

    Source location

    2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
    Page 5 · response
    Published 24 December 2020

    Open published response

    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

    Attend CPS evidence-led prosecution training and develop comparable training for the wider GMP workforce.

    Verbatim wording from the response

    “GMP recognise that this area needs further development and are currently in discussions with the CPS who are delivering training to prosecutors on this topic. It is intended that GMP will attend this training with a view to delivering something similar to the wider GMP workforce. By having a joint training event, this will ensure that the CPS and police are aligned in the delivery and expectations of evidence-led prosecutions.”

    Source location

    2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
    Page 5 · response
    Published 24 December 2020

    Open published response

    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

    Invite GMP domestic abuse investigators to CPS training so aligned evidence-led prosecution training can be delivered across GMP.

    Verbatim wording from the response

    “Analysis and Strategy training, focusing on the importance of case-building domestic abuse cases from the very start to ensure that it could proceed without the victim. GMP has confirmed with Deputy Chief Crown Prosecutor ████████ that a number of GMP officers involved in domestic investigations will be invited to attend this training so that similar training can be delivered across GMP.”

    Source location

    2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
    Page 7 · response
    Published 24 December 2020

    Open published response

    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
    Page 1 · response
    Published 24 December 2020

    Open published response

    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

    Prosecutors have no power to formally direct police to undertake reasonable lines of enquiry; their role is advisory.

    Verbatim wording from the response

    “Finally, although not a formal recommendation, I would like to comment on the reference within Section 4 paragraph 7 concerning reasonable lines of enquiry especially in the light of the newly issued Director Guidance 6 which comes into force on 31 December 2020.”

    Source location

    2020-0242-Response-from-CPS-Redacted.pdf
    Page 3 · response
    Published 24 December 2020

    Open published response

    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 police are responsible for complying with prosecutor action plans and providing further evidence, material or information within agreed periods.

    Verbatim wording from the response

    “Paragraph 3.1 (concerning the responsibility of the police):”

    Source location

    2020-0242-Response-from-CPS-Redacted.pdf
    Page 3 · response
    Published 24 December 2020

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026