Recurring concern

Failure to reliably recognise and assess domestic abuse risks

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First reported 30 Oct 2013•Latest report 19 Sep 2025

Definition

What this concern includes

Includes failures in domestic-abuse policies, flowcharts and operational risk-assessment arrangements to identify, understand or assess material abuse risks and risk factors, including non-fatal strangulation, cultural risk, coercive control and other indicators, where the deficiency affects safeguarding or protective action.

Not included

  • Excludes the existing DASH-specific risk-assessment process when the assertion is confined to DASH forms, training or operation.
  • Excludes general domestic-abuse investigation, victim support or protective-order failures where risk recognition or assessment is not the unsafe condition.
  • Excludes generic police or healthcare training, communication or information-sharing deficiencies without a direct domestic-abuse risk-assessment connection.
  • Excludes isolated domestic-abuse incidents or outcomes where no continuing deficiency in risk recognition or assessment is asserted.
Reports
12

Distinct published reports

Individual concerns
17

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
30

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Home Office4
Ministry of Justice3
National Police Chiefs’ Council3
Department of Health and Social Care2
Greater Manchester Police2
College of Policing1
Crown Prosecution Service1
Greater Manchester Health and Social Care Partnership1
Greater Manchester Mental Health NHS Foundation Trust1
HM Prison and Probation Service1
Independent Office for Police Conduct1
Lancashire Constabulary1
Metropolitan Police Service1
Midlands Partnership University NHS Foundation Trust1
National Offender Management Service Equality, Rights and Decency Group1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  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.

    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 consider domestic abuse risk at police dismissal

    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

    Update and strengthen safeguarding procedures.

    Verbatim wording from the response

    “While we do not think a specific risk to Rebekah was apparent from the information available to the IOPC, we wish to reassure you that the IOPC has robust safeguarding procedures in place, which were updated and strengthened in 2024. We will take this opportunity to review whether any additional content to this guidance would be appropriate in respect of risk assessments for spouses and intimate partners.”

    Source location

    Response from Independent Office for Police Complaints
    Page 7 · 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

    Review whether guidance needs additional content on risk assessments for spouses and intimate partners.

    Verbatim wording from the response

    “While we do not think a specific risk to Rebekah was apparent from the information available to the IOPC, we wish to reassure you that the IOPC has robust safeguarding procedures in place, which were updated and strengthened in 2024. We will take this opportunity to review whether any additional content to this guidance would be appropriate in respect of risk assessments for spouses and intimate partners.”

    Source location

    Response from Independent Office for Police Complaints
    Page 7 · response
    Published 3 July 2026

    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 the Integrity Assurance Unit to risk-assess personnel with adverse judicial findings or adverse information and impose risk-management measures where necessary.

    Verbatim wording from the response

    “The Integrity Assurance Unit (IAU) manages officers or staff who are the subject of an Adverse Judicial Finding (AJF), evidentially tainted by virtue of a criminal or misconduct outcome or in respect of whom adverse information is held. The IAU will ensure that such officers or staff are risk assessed and handled fairly to protect both the individual, the public and the organisation. This is achieved by holistically reviewing all known information and, where applicable convening a management meeting to decide on whether Risk Management Measures need to be imposed to manage the risk presented by the taint, AJF or adverse information. The IAU oversees disclosure requirements associated with taint and maintains confidential records.”

    Source location

    Response from Metropolitan Police
    Page 8 · response
    Published 3 July 2026

    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

    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. Berkshire

    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

    Non-adoption of the new domestic abuse risk-assessment tool

    Wider context from the report

    “3. I heard evidence about a new tool for risk assessing domestic abuse, created by the College of Policing. Both the senior Thames Valley Police officer and the College of Policing witness gave evidence that this system is likely to result in better risk assessment for domestic abuse. As I understand it, this new tool has not been adopted by Thames Valley Police at this time, because of competing financial priorities, and an issue with compatibility with the Niche system. ”

    Source location

    Angela · Prevention of Future Deaths report
    Page 3 · concerns

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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
    Page 3 · response
    Published 13 August 2024

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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
    Page 2 · response
    Published 13 August 2024

    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

    Work with police forces and relevant IT providers to drive implementation of the nationally launched DARA risk-assessment process.

    Verbatim wording from the response

    “The DARA was launched nationally in November 2022. Unfortunately, implementation has not been as smooth as anticipated due to competing demands for amending the various IT systems used for recording the risk assessment process, however, the NPCC and the College have been working closely with forces and relevant IT providers to drive implementation.”

    Source location

    Response from NPCC
    Page 3 · response
    Published 13 August 2024

    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

    Competing financial priorities are not the reason DARA has not been adopted; compatibility and training challenges are the principal barriers.

    Verbatim wording from the response

    “I heard evidence about a new tool for risk assessing domestic abuse, created by the College of Policing. Both the senior Thames Valley Police officer and the College of Policing witness gave evidence that this system is likely to result in better risk assessment for domestic abuse. As I understand it, this new tool has not been adopted by Thames Valley Police at this time, because of competing financial priorities, and an issue with compatibility with the Niche system.”

    Source location

    Response from Thames Valley Police
    Page 3 · response
    Published 13 August 2024

    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

    DARA cannot currently be implemented because of NICHE compatibility, contractor, training and partner-agency integration challenges.

    Verbatim wording from the response

    “It is important to note that competing financial priorities are not the issue here. The principal challenges are compatibility with our NICHE crime recording system and the delivery of training to front line police and staff. Thames Valley Police require a contractor to initiate the changes on the NICHE system. The development of Electronic Case Files was prioritised over the implementation of DARA and that project has overrun. Any solution to this must also be compatible with other processes such as our ability to refer the information captured in our domestic abuse risk assessments in a timely fashion to other agencies with responsibilities for the protection of victims/survivors and their children, such as Children’s Social Care and colleagues in the health service. A change from DASH to DARA is a significant departure from the current process which has been in place for many years.”

    Source location

    Response from Thames Valley Police
    Page 3 · response
    Published 13 August 2024

    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

    DARA implementation was delayed by competing demands to amend police IT systems, limiting the speed of national implementation.

    Verbatim wording from the response

    “The DARA was launched nationally in November 2022. Unfortunately, implementation has not been as smooth as anticipated due to competing demands for amending the various IT systems used for recording the risk assessment process, however, the NPCC and the College have been working closely with forces and relevant IT providers to drive implementation.”

    Source location

    Response from NPCC
    Page 3 · response
    Published 13 August 2024

    Open published response
  3. Manchester South

    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 the additional vulnerability arising from physical health and dependence on a perpetrator for care

    Wider context from the report

    “A feature of her vulnerability was her physical health and how dependent she was, as a consequence, on the perpetrator to help care for her. The additional vulnerability and impact of this was not recognised by agencies involved in supporting her. The inquest was told that where vulnerability is not properly understood the risk presented to a victim of domestic abuse increases. ”

    Source location

    Lee-Ann Sarah INCE · Prevention of Future Deaths report
    Page 2 · concerns

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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 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
    Page 1 · concerns

    Open source report
  4. East Riding and Hull

    AI-generated summary

    Jessica Louise LAVERACK “Jessie” · 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

    Jessica Louise LAVERACK “Jessie” had a history of domestic abuse, anxiety and alcohol dependence, and reported suicidal ideation and self-harm before her death. She was found on 2 February 2018, and the medical cause of death was recorded as hanging. The report identified concerns about the lack of a coordinated approach and information sharing between agencies, including for vulnerable people who did not meet the MARAC high-risk threshold.

    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 of processes and policies to recognise the link between domestic abuse and suicide

    Wider context from the report

    “(1) The is a need for the recognition of the link between domestic abuse and suicide. Processes and policies do not seem to include this serious area to the extent that is required. ”

    Source location

    Jessica Louise LAVERACK “Jessie” · 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

    Continue funding the Domestic Homicide and Suspected Victim Suicides Project.

    Verbatim wording from the response

    “The commitments in the Tackling Domestic Abuse Plan include measures to update police guidance on suicide so that it explicitly includes references to domestic abuse and for the police to consider whether domestic abuse was a contributing factor in cases of unexplained deaths and suspected suicides. We also committed to continue to fund the Domestic Homicide and Suspected Victim Suicides Project, led by the National Police Chiefs’ Council, College of Policing (NPCC) and the National Policing Vulnerability Knowledge and Practice Programme (VKPP).”

    Source location

    Response from Home Office (2)
    Page 2 · response
    Published 3 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

    Update police suicide guidance to reference domestic abuse and prompt consideration of domestic abuse in unexplained deaths and suspected suicides.

    Verbatim wording from the response

    “The commitments in the Tackling Domestic Abuse Plan include measures to update police guidance on suicide so that it explicitly includes references to domestic abuse and for the police to consider whether domestic abuse was a contributing factor in cases of unexplained deaths and suspected suicides. We also committed to continue to fund the Domestic Homicide and Suspected Victim Suicides Project, led by the National Police Chiefs’ Council, College of Policing (NPCC) and the National Policing Vulnerability Knowledge and Practice Programme (VKPP).”

    Source location

    Response from Home Office (2)
    Page 2 · response
    Published 3 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

    Strengthen statutory guidance for Domestic Homicide Reviews involving suicide to clarify referral criteria and review processes.

    Verbatim wording from the response

    “We will also be strengthening the Domestic Homicide Review statutory guidance for suicide cases to improve clarity for cases which should be referred for a Domestic Homicide Review and how to review these complex cases.”

    Source location

    Response from Home Office (2)
    Page 2 · response
    Published 3 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

    Work with the Home Office to implement the Tackling Domestic Abuse Plan.

    Verbatim wording from the response

    “The Department recognises the links between domestic abuse and suicide. We are working closely with the Home Office on the implementation of its Tackling Domestic Abuse Plan. We will also continue to work closely with a range of partners across the suicide prevention sector to consider factors linked to suicide and actions that should be taken to address them as part of the recently announced national suicide prevention strategy. We expect this renewed strategy will include measures to tackle domestic abuse. Additionally, as near real time suspected suicide surveillance systems develop at a local and national level, the feasibility of improving data collection in relation to domestic abuse will be explored.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 3 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

    Work with suicide prevention partners to consider suicide-linked factors and actions for the national suicide prevention strategy.

    Verbatim wording from the response

    “The Department recognises the links between domestic abuse and suicide. We are working closely with the Home Office on the implementation of its Tackling Domestic Abuse Plan. We will also continue to work closely with a range of partners across the suicide prevention sector to consider factors linked to suicide and actions that should be taken to address them as part of the recently announced national suicide prevention strategy. We expect this renewed strategy will include measures to tackle domestic abuse. Additionally, as near real time suspected suicide surveillance systems develop at a local and national level, the feasibility of improving data collection in relation to domestic abuse will be explored.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 3 November 2022

    Open published response
  5. 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 accessible cultural risk information for domestic abuse risk assessment

    Wider context from the report

    “CONCERN 6 Cultural Risk: I found that there was a failure to take account of the risk arising from the fact that the perpetrator was from Brazil, where there is a considerably higher incidence of domestic homicide than in the United Kingdom. I was told that no national source of information concerning such cultural risks exists for the benefit of officers investigating domestic abuse who are required to assess and manage the risks arising. Although steps are being taken in Surrey to build knowledge of relevant cultural norms for local communities, I was told that a national data base of relevant and evidenced cultural information, whether based on statistical incidence of domestic violence or homicide, or otherwise, would assist in ensuring cultural risk is not overlooked. ”

    Source location

    Aliny Godinho · Prevention of Future Deaths report
    Page 5 · 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

    Provide domestic abuse knowledge products covering victim-focused risk assessment, vulnerability, cultural competence, coercive control and Honour Based Abuse.

    Verbatim wording from the response

    “In order to ensure officers are equipped to identify these risks and mitigate them the CoP have provided a range of knowledge products to be applied in domestic abuse cases.”

    Source location

    2022-0149-Response-from-NPCC-and-College-of-Policing_Published
    Page 4 · response
    Published 24 May 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

    There is no evidence that nationality or cultural background predicts involvement in domestic abuse or domestic homicide, and international rates are unreliable.

    Verbatim wording from the response

    “Crime recording practices vary very significantly between countries. Reported international domestic homicide rates are often of questionable value because of the fragility of the reporting regime on which they are based. We would be very cautious before drawing assumptions that individuals are violent based on their cultural background or nationality. We would fear that this could constitute unlawful stereotyping of particular communities.”

    Source location

    2022-0149-Response-from-NPCC-and-College-of-Policing_Published
    Page 2 · response
    Published 24 May 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

    Existing policies, guidance, professional curiosity, cultural competence and individualised risk assessment are considered sufficient; a nationality-based risk database is not supported.

    Verbatim wording from the response

    “In order to ensure officers are equipped to identify these risks and mitigate them the CoP have provided a range of knowledge products to be applied in domestic abuse cases.”

    Source location

    2022-0149-Response-from-NPCC-and-College-of-Policing_Published
    Page 4 · response
    Published 24 May 2022

    Open published response
  6. 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

    Inconsistent definitions and thresholds for serious or serial domestic abuse perpetrators

    Wider context from the report

    “2. The inquest was told that the GMP/CPS definitions of a serious/serial domestic abuser perpetrator were different. It was unclear why that was the case. However as a result there are different points at which an offender's background triggers the requirement to treat the suspect as a serial/serious DA perpetrator. ”

    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

    Highlight the disparity between police and CPS serial-perpetrator definitions to the national policy team for further consideration.

    Verbatim wording from the response

    “I confirm that the disparity between the definitions has been highlighted to the Crown Prosecution Service’s national policy team so that they may consider further.”

    Source location

    2020-0242-Response-from-CPS-Redacted.pdf
    Page 2 · 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

    Revise the domestic abuse policy to define and govern application of the serial domestic abuse perpetrator marker.

    Verbatim wording from the response

    “The GMP domestic abuse policy is currently being revised and will shortly be sent out for consultation. It will provide clear definitions on the application and use of the serial domestic abuse perpetrator marker. Guidance will be shared with police officers and police staff based in safeguarding units around the correct application of this information marker on a person’s record.”

    Source location

    2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
    Page 2 · 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

    Share guidance with safeguarding officers and staff on correctly applying the serial domestic abuse perpetrator marker.

    Verbatim wording from the response

    “The GMP domestic abuse policy is currently being revised and will shortly be sent out for consultation. It will provide clear definitions on the application and use of the serial domestic abuse perpetrator marker. Guidance will be shared with police officers and police staff based in safeguarding units around the correct application of this information marker on a person’s record.”

    Source location

    2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
    Page 2 · 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

    Explore automation of domestic abuse information markers and improve staff understanding of when and how markers should be applied.

    Verbatim wording from the response

    “The definitions for repeat and serial victims and perpetrators have been revised since Alfie’s death to simplify them. Where automation of markers can occur, this is being explored, however clear direction on the application and use of the serial domestic abuse perpetrator marker will be shared with police officers and staff when the domestic abuse policy is agreed. The Public Protection Governance Unit is currently working with iOPS and Capita to ensure visibility and understanding of when information markers should be applied and how to do this.”

    Source location

    2020-0242-Response-from-Greater-Manchester-Police-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

    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
  7. Dorset

    AI-generated summary

    Katrina Margaret Mary O’Hara · 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

    Katrina Margaret Mary O’Hara was stabbed by her ex-partner outside her place of work on 7 January 2016 and was pronounced deceased at the scene. The report raises concerns about police handling of non-emergency domestic abuse calls, recognition of a perpetrator’s suicide risk, provision of replacement phones when victims’ phones are seized, and the use and training of the Niche police software system.

    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 the perpetrator’s suicide risk as a significant domestic abuse risk factor for the victim

    Wider context from the report

    “ii. Dorset Police have changed their Domestic Abuse Investigation Policy and Procedure to include the suicide risk of the perpetrator of domestic abuse as a significant risk factor for the victim of domestic abuse. This is a recent change and reflects the growing understanding that the perpetrator who has “nothing left to lose” poses a significant risk to his or her victim. I am concerned that this change in policy in Dorset may not be reflected nationwide. ”

    Source location

    Katrina Margaret Mary O’Hara · 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

    Pilot and evaluate approaches for identifying and tackling high-risk offenders, including adding suicide indicators to potential risk indicators.

    Verbatim wording from the response

    “In respect of potential risk indicators in perpetrators, the Home Office is working with a number of police forces and the College of Policing to pilot and evaluate approaches to identifying and tackling high risk offenders. This work includes adding suicide indicators to the list of potential risk indicators. In parallel work is ongoing to review findings from domestic homicide reviews and academic research with a view to more accurately identifying key characteristics and risk factors for domestic homicides.”

    Source location

    2020-0051-Response-from-Crime-Policing-and-Fire-Service
    Page 1 · response
    Published 10 March 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

    Review domestic homicide review findings and academic research to improve identification of characteristics and risk factors for domestic homicides.

    Verbatim wording from the response

    “In respect of potential risk indicators in perpetrators, the Home Office is working with a number of police forces and the College of Policing to pilot and evaluate approaches to identifying and tackling high risk offenders. This work includes adding suicide indicators to the list of potential risk indicators. In parallel work is ongoing to review findings from domestic homicide reviews and academic research with a view to more accurately identifying key characteristics and risk factors for domestic homicides.”

    Source location

    2020-0051-Response-from-Crime-Policing-and-Fire-Service
    Page 1 · response
    Published 10 March 2020

    Open published response
  8. Lancashire and Blackburn with Darwen

    AI-generated summary

    Cherylee Yvette Shennan · 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

    Cherylee Yvette Shennan, a 40-year-old woman, was murdered on 17 March 2014 by a former offender who had subjected her to domestic abuse, including serious violence. The report raised concerns about inadequate inter-agency communication and management of the perpetrator, including the absence of a mandatory process for sharing information when an offender with a known history of domestic abuse was managed at MAPPA Level 1.

    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 allocate an appropriately protective MAPPA level for offenders with significant domestic abuse histories who have not been fully tested before release

    Wider context from the report

    “1) During the course of the inquest statistics regarding the nature of domestic abuse were repeatedly reviewed and accepted by senior member of both probation and police services. In particular domestic abuse features in about half of all cases managed by probation staff and that in the year to the end of 2018 of the 659 homicides 1 in 10 were committed by a partner. Evidence was heard of the MAPPA process, for the managing of risk of offenders to be released on licence, and for the interagency sharing of information regarding those offenders. During the course of the evidence it was made clear that the perpetrator in this instance was a very dangerous individual, who was described as controlling and manipulative, and who, it was accepted by the witnesses involved in his management, was likely to have controlled his meetings by his nature, and by partial disclosures of information. The underlying issue that arose from both the various reviews that took place after the death of Cherylee Shennan, and from the inquest was that there was no substantial interagency communication following the perpetrator's release on licence, which would, the jury found, have allowed the sharing of his licence conditions and action plans to be put in place by local police forces. The jury concluded that such a failing possibly contributed to the death on the 17th March 2014. At the inquest no evidence was heard regarding any changes to MAPPA or the guidance given. Whilst the evidence heard was that the MAPPA level allocated to an individual is fluid, and would be based upon their risks and presentation at that time, my concern centres on the issue that an offender who has served a significant sentence and accordingly has never been fully tested before release on licence, and who has a significant history of domestic abuse and violence, will still be released on MAPPA level 1. On the evidence that was heard there remains no mandated process for joined up inter-agency working or communication at the point of their release, or when they develop new personal relationships. ”

    Source location

    Cherylee Yvette Shennan · 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

    Implement a Pan-Lancashire MARAC protocol requiring immediate emergency referral and high-risk prioritisation for relevant life-licensed domestic-abuse homicide offenders.

    Verbatim wording from the response

    “Specifically, with regards to perpetrators with homicide convictions and urgent MARAC referral, a Pan-Lancashire MARAC Operating Protocol Document was agreed in April 2016 which referenced specifically the procedure relating to Emergency MARAC, and reflects a response to the DHR in question.”

    Source location

    2019-0244-Response-by-Lancashire-Constabulary_Redacted
    Page 2 · response
    Published 9 September 2019

    Open published response
  9. Manchester North

    AI-generated summary

    Anne-Marie Nield · 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

    Anne-Marie Nield was a repeat victim of domestic violence who died from multiple injuries after her partner inflicted a violent and sustained attack at her home on 8 May 2016. The report identifies concerns about inadequate police risk assessment, delays, failures to provide support and information, and insufficient understanding and application of domestic abuse policies. It also notes that not all recommendations addressing these shortcomings had been implemented two and a half years after her death.

    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

    Absence of non-fatal strangulation from the Domestic Abuse Policy

    Wider context from the report

    “3. There is no reference to ‘non-fatal strangulation’ within the current Domestic Abuse Policy. Furthermore, almost all of the Police Officers in this case failed to appreciate the significance of non-fatal strangulation as a specific risk factor for domestic homicide. ”

    Source location

    Anne-Marie Nield · Prevention of Future Deaths report
    Page 2 · 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 of police officers to recognise non-fatal strangulation as a domestic homicide risk factor

    Wider context from the report

    “3. There is no reference to ‘non-fatal strangulation’ within the current Domestic Abuse Policy. Furthermore, almost all of the Police Officers in this case failed to appreciate the significance of non-fatal strangulation as a specific risk factor for domestic homicide. ”

    Source location

    Anne-Marie Nield · Prevention of Future Deaths report
    Page 2 · 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 of police officers to understand and apply the Domestic Abuse Policy

    Wider context from the report

    “1. During the course of the evidence, it became apparent that almost all of the Police Officers involved in this case did not understand or apply the Domestic Abuse Policy properly. In particular, they did not understand the meaning of important terminology such as ‘repeat victim’, ‘repeat perpetrator’ and ‘serious and serial perpetrator. An understanding of and the ability to apply this policy are critical to the risk assessment process and the prevention of domestic homicide. ”

    Source location

    Anne-Marie Nield · Prevention of Future Deaths report
    Page 2 · 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

    Inadequate and non-dynamic domestic abuse risk assessment

    Wider context from the report

    “5. Risk assessment and the exercising of professional judgement in relation to the level of risk were inadequate and ongoing/dynamic risk assessment was not carried out. A referral to MARAC was not made and DVDS not offered to the deceased, again without expectation. ”

    Source location

    Anne-Marie Nield · 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

    Update the Domestic Abuse Policy to address non-fatal strangulation, public protection and iOPS changes.

    Verbatim wording from the response

    “The existence of the Domestic Abuse Policy and the content of it are discussed in the student officer training in the initial stages of training and during consolidation training. As was acknowledged by ████████ during the inquest, GMP’s Domestic Abuse Policy does require updating and will include non-fatal strangulation as a heightened risk factor for victims of domestic abuse. The policy will also need to include significant structural changes within GMP in relation to public protection and a new operating system called iOPS. The structural, procedural and IT changes need to be embedded before the new policy can be written to ensure it is meaningful and fit for purpose by enabling police officers and staff to effectively respond to, and reduce incidents of, reports of domestic abuse.”

    Source location

    2019-0477-Response-from-Greater-Manchester-Police-Redacted
    Page 1 · response
    Published 25 January 2019

    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

    Provide non-fatal-strangulation awareness training across frontline, student-officer and specialist adult-abuse investigator courses.

    Verbatim wording from the response

    “At the time of Anne Marie’s death non-fatal strangulation was not terminology widely known by officers and no training had been given on it, as relatively little was then known about the incidence of non-fatal strangulation in DA victims. The term gained greater recognition as a consequence of some work between GMP and ████████ initially looking at non-fatal strangulation in other contexts but soon recognising that there was a potentially significant link to domestic abuse. As a consequence, the one-day safe-guarding course, which has been delivered since May 2018 to frontline officers, now includes reference to non-fatal strangulation as a specific risk factor for domestic homicide.”

    Source location

    2019-0477-Response-from-Greater-Manchester-Police-Redacted
    Page 3 · response
    Published 25 January 2019

    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

    Deliver domestic-abuse terminology training through student-officer, consolidation and Safeguarding for Constables courses.

    Verbatim wording from the response

    “The existence of the Domestic Abuse Policy and the content of it are discussed in the student officer training in the initial stages of training and during consolidation training. As was acknowledged by ████████ during the inquest, GMP’s Domestic Abuse Policy does require updating and will include non-fatal strangulation as a heightened risk factor for victims of domestic abuse. The policy will also need to include significant structural changes within GMP in relation to public protection and a new operating system called iOPS. The structural, procedural and IT changes need to be embedded before the new policy can be written to ensure it is meaningful and fit for purpose by enabling police officers and staff to effectively respond to, and reduce incidents of, reports of domestic abuse.”

    Source location

    2019-0477-Response-from-Greater-Manchester-Police-Redacted
    Page 1 · response
    Published 25 January 2019

    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

    Provide training on DVDS, risk identification, DASH, RARA, risk levels and MARAC processes.

    Verbatim wording from the response

    “As indicated by ████████ in the course of her evidence to the inquest, there were grounds on which a MARAC referral could have been made in Anne-Marie’s case. It is further accepted that use of, and disclosures pursuant to, the DVDS scheme have improved significantly in the intervening period. As part of the IPLDP initial and consolidation training and the Specialist Adult Abuse Investigators Course, training is provided on the DVDS scheme, as well as on risk identification, assessment and management by means of structured teaching on DASH. This includes the explanation of the RARA model and the definitions of Standard, Medium and High Risk. At the conclusion of the IPLDP, student officers also receive a further four hours training around risk identification and assessment and are then qualified to finalise their own cases that they deem to be “Standard Risk”.”

    Source location

    2019-0477-Response-from-Greater-Manchester-Police-Redacted
    Page 4 · response
    Published 25 January 2019

    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 Domestic Abuse Policy cannot be rewritten until related structural, procedural and information-technology changes are embedded.

    Verbatim wording from the response

    “The existence of the Domestic Abuse Policy and the content of it are discussed in the student officer training in the initial stages of training and during consolidation training. As was acknowledged by ████████ during the inquest, GMP’s Domestic Abuse Policy does require updating and will include non-fatal strangulation as a heightened risk factor for victims of domestic abuse. The policy will also need to include significant structural changes within GMP in relation to public protection and a new operating system called iOPS. The structural, procedural and IT changes need to be embedded before the new policy can be written to ensure it is meaningful and fit for purpose by enabling police officers and staff to effectively respond to, and reduce incidents of, reports of domestic abuse.”

    Source location

    2019-0477-Response-from-Greater-Manchester-Police-Redacted
    Page 1 · response
    Published 25 January 2019

    Open published response
  10. Norfolk

    AI-generated summary

    MARGARET CAROLE ANN PEGNALL · 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 18 May 2015, Margaret Carole Ann Pegnall stepped into the path of a train at Stracey Arms, Norwich, and died from her injuries. Concerns included that the GP surgery’s domestic abuse response flowchart was vague, lacked a domestic abuse-specific questionnaire, and provided no method for staff to recognise when a patient’s call required immediate escalation.

    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 a domestic-abuse-specific questionnaire

    Wider context from the report

    “(3) There is no Questionnaire specific to Domestic Abuse to assist in recognising signs of abuse and standardising the Surgery’s GPs’ response to concerns raised. ”

    Source location

    MARGARET CAROLE ANN PEGNALL · Prevention of Future Deaths report
    Page 1 · 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 of the domestic abuse response flowchart to provide clear abuse-specific risk assessment

    Wider context from the report

    “(2) The Flowchart for Responding to Domestic Abuse is vague and uses an Assessment of Risk pertaining to depression and not to the risk of abuse ”

    Source location

    MARGARET CAROLE ANN PEGNALL · Prevention of Future Deaths report
    Page 1 · 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

    Incorporate a DASH-based domestic abuse questionnaire and assessment into the practice protocol.

    Verbatim wording from the response

    “• A DASH based questionnaire and assessment for Domestic Abuse is incorporated into our protocol”

    Source location

    Margaret-Pegnall-Response
    Page 1 · response
    Published 31 December 2015

    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

    Use the DASH scoring system to support timely escalation to other agencies.

    Verbatim wording from the response

    “• The DASH scoring system will help to ensure appropriate elevation to other agencies at the appropriate time”

    Source location

    Margaret-Pegnall-Response
    Page 1 · response
    Published 31 December 2015

    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

    Update and improve the domestic abuse flowchart within the practice protocol.

    Verbatim wording from the response

    “• The flow chart has been updated and improved within the protocol.”

    Source location

    Margaret-Pegnall-Response
    Page 1 · response
    Published 31 December 2015

    Open published response
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Data last updated 7 September 2026