Recurring concern

Inadequate professional training for recognising and responding to domestic abuse

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First reported 25 Jan 2019•Latest report 5 Mar 2026

Definition

What this concern includes

Includes failures to provide, maintain, refresh or verify training for healthcare, policing, social-care, probation or comparable professionals where the training is specifically intended to support recognition, risk assessment, safeguarding or response to domestic abuse.

Not included

  • Excludes generic safeguarding or professional training deficiencies where domestic abuse is not a material part of the training requirement.
  • Excludes failures in domestic-abuse investigation, referral, risk assessment or protective action when the training or competence-assurance process is not itself deficient.
  • Excludes training for unrelated hazards, clinical conditions or operational processes.
  • Excludes deficiencies in the substantive domestic-abuse policy or pathway where staff training is not the shared unsafe condition.
Reports
8

Distinct published reports

Individual concerns
9

A report can raise multiple concerns

Date range
2019–2026

First to latest report issue date

Stated actions
12

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 Office3
Ministry of Justice3
Department of Health and Social Care2
Greater Manchester Police2
Metropolitan Police Service2
Capita PLC1
Care Quality Commission1
Crown Prosecution Service1
Department for Work and Pensions1
Derbyshire Healthcare NHS Foundation Trust1
East London NHS Foundation Trust1
Greater Manchester Health and Social Care Partnership1
Greater Manchester Mental Health NHS Foundation Trust1
HM Courts & Tribunals Service1
National Police Chiefs’ Council1

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. East London

    AI-generated summary

    Caroline Adeyelu · 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

    Caroline Adeyelu died after suffering a fatal stab wound to her chest at home on 30 October 2022, inflicted by her son, who was under the care of community mental health services. The inquest identified inadequate risk assessment and management, insufficient safeguarding and family engagement, poor care coordination and information sharing, and ineffective communication between mental health services and the 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

    Insufficient safeguarding training on adult child to parent domestic abuse

    Wider context from the report

    “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided. ”

    Source location

    Caroline Adeyelu · 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

    Deliver revised Safeguarding Level 3 training with dedicated adult child-to-parent abuse content and case studies across the mandatory rolling programme.

    Verbatim wording from the response

    “In relation to the training that our staff are required to complete for safeguarding we are implementing the following:”

    Source location

    Response from North East London Foundation Trust
    Page 1 · response
    Published 9 March 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

    Explore inclusion of adult child-to-parent abuse content in national Safeguarding Levels 1 and 2 e-learning packages with Health Education England.

    Verbatim wording from the response

    “• Our Safeguarding lead has also contacted Health Education England to explore the inclusion of ACPA training within the national Safeguarding Levels 1 and 2 e-learning packages. These packages are available to all NHS bodies and therefore we await the outcome of these discussions and will be sharing the Regulation 28 report as part of the supporting evidence for inclusion.”

    Source location

    Response from North East London Foundation Trust
    Page 2 · response
    Published 9 March 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

    Develop and disseminate a seven-minute adult child-to-parent abuse briefing through Safeguarding Assurance reports across Trust services and teams.

    Verbatim wording from the response

    “• A 7-minute briefing on ACPA is now in development and will be incorporated into our Safeguarding Assurance reports for dissemination across all services and teams within the trust. This will support the dissemination of learning for all staff and will commence in May 2026.”

    Source location

    Response from North East London Foundation Trust
    Page 2 · response
    Published 9 March 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

    Include adult child-to-parent abuse in regular Domestic Abuse awareness sessions for all staff and safeguarding practitioners.

    Verbatim wording from the response

    “• The Trust safeguarding lead will be including ACPA in the regular Domestic Abuse awareness sessions at both the ‘All-staff webinar’ and the Trust Safeguarding Practitioners’ event. This will take place by the end of June 2026.”

    Source location

    Response from North East London Foundation Trust
    Page 2 · response
    Published 9 March 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

    Strengthen mandatory Level 3 safeguarding training to address intergenerational domestic abuse, parental vulnerability, and risks to family members.

    Verbatim wording from the response

    “• The Trust’s level three safeguarding training now highlights domestic abuse from children (with or without mental health needs) to parents.”

    Source location

    Response from East London Foundation Trust
    Page 2 · response
    Published 9 March 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

    Deliver an intergenerational domestic abuse training session through the annual safeguarding conference.

    Verbatim wording from the response

    “• An intergenerational domestic abuse training session was held virtually at the Trust’s annual safeguarding conference (delivered by the charity Hourglass).”

    Source location

    Response from East London Foundation Trust
    Page 3 · response
    Published 9 March 2026

    Open published response
  2. Derby and Derbyshire

    AI-generated summary

    Terri Liz Harris and 3 others · 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

    Terri Liz Harris, her children John-Paul Bennett and Lacey Bennett, and their friend Connie Gent were discovered deceased at Terri’s home on 19 September 2021. They had been murdered by Terri’s partner, Damien Bendall, who inflicted severe head injuries on all four; the report also states that he raped Lacey. The deaths were contributed to by acts and omissions in offender supervision and electronic monitoring, including concerns about risk-recording, domestic abuse and child-safeguarding checks, reporting of threats, and notification of missed treatment appointments.

    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 or untimely domestic abuse and child safeguarding training for probation practitioners

    Wider context from the report

    “A significant issue in the inquests was the fact that the very inexperienced staff who were (wrongly) allocated Damien Bendall’s case on transfer to the East Midlands PS region had insufficient DA and SG training. The PS states it has introduced more robust DA and SG training, but it is unclear whether PS practitioners are receiving this before cases are allocated to them to manage. ”

    Source location

    Terri Liz Harris and 3 others · 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

    Maintain pre-allocation safeguarding and domestic-abuse training requirements for practitioners managing cases with related concerns.

    Verbatim wording from the response

    “A significant issue in the inquests was the fact that very inexperienced staff who were (wrongly) allocated Damien Bendall’s case on transfer to the East Midlands PS region had insufficient DA and SG training. The PS states it has introduced more robust DA and SG training, but it is unclear whether PS practitioners are receiving this before cases are allocated to them to manage.”

    Source location

    Response from HM Prison and Probation Service
    Page 6 · response
    Published 29 November 2023

    Open published response
  3. 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

    Insufficient training and awareness of domestic abuse and suicide risk among front line police officers

    Wider context from the report

    “(5) There is a need to consider better training and awareness of both domestic abuse and risk of suicide for front line police officers. ”

    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

    Provide up to £3.3 million to support further rollout of domestic abuse and related policing training.

    Verbatim wording from the response

    “In terms of training, the College of Policing has developed the Policing Education Qualifications Framework which is an important step in raising standards in policing, including in tackling violence against women and girls. Additionally, the College have developed a range of other training products, including the Domestic Abuse Matters programme. We committed up to £3.3m to support further rollout of the training.”

    Source location

    Response from Home Office (2)
    Page 3 · response
    Published 3 November 2022

    Open published response
  4. 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 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 effective training on the Domestic Abuse Policy and Procedure

    Wider context from the report

    “CONCERN 1 Training of the Domestic Abuse Team: At the inquest I heard that, at the time of the death, not all members of the Surrey Police SIU were familiar with and were implementing the contents of its Domestic Abuse Policy and Procedure; this led directly to a number of the failings which, I found, contributed to Aliny Godinho’s death. I have been told that all members of its new Domestic Abuse Team have been required to read its amended Domestic Abuse Policy and Procedure, but that training on the same, which is still being written, has not yet been delivered. I am concerned that unless and until effective training is delivered, a risk will continue. ”

    Source location

    Aliny Godinho · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report
  5. Inner South London

    AI-generated summary

    Emma Day · 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

    Emma Day died in the street on 26 May 2017 from multiple stab wounds and was found to have been unlawfully killed. The report describes a history of domestic violence, coercive and controlling behaviour, threats to her life and protective orders that had expired shortly before her murder. Principal concerns included failures to share and record risk information, inadequate domestic-violence training and guidance, and a system failure in handling reports of domestic violence within the Child Maintenance Service.

    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

    Inadequate caseworker training on the wider domestic-violence risk context

    Wider context from the report

    “b) Training of caseworkers at the time on domestic violence was focused on domestic violence as a criterion to grant waiver of the fee and did not provide information about the wider definition, the reluctance to self-declare or the available services to be signposted. ”

    Source location

    Emma Day · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  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

    Limited police training in domestic abuse risk evaluation and scoring

    Wider context from the report

    “6. The inquest was told that the DASH risk assessment is a national tool. However training of GMP officers on understanding how to evaluate risk and score risk was limited. ”

    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

    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
    Page 4 · 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

    Provide clearer domestic abuse risk-grading guidance and disseminate it through continuous professional development and safeguarding training.

    Verbatim wording from the response

    “At the time of GMP’s involvement with Alfie’s parents, the force policy stipulated that officers should take into account the circumstances of the incident, the vulnerability of the victim, and the history of the perpetrator when making a risk assessment. The new force policy offers more guidance to officers around risk grading. It has specifically outlined a number of circumstances when certain risk gradings, such as standard risk, would not be appropriate. This includes:”

    Source location

    2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
    Page 4 · 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

    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
    Page 4 · 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. Cornwall and Isles of Scilly

    AI-generated summary

    Avis Mary Addison · 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

    Avis Mary Addison died on 22 February 2017 after being murdered by her late husband; the recorded medical cause of death included suffocation, and the inquest conclusion was unlawful killing. The substantive concerns included possible failures or delays in recognising domestic abuse and safeguarding issues, and whether GP practices had appropriate domestic violence and safeguarding policies, training, and early-warning processes.

    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 provide all GP practice staff with training on domestic violence and safeguarding policies

    Wider context from the report

    “Given CQC is the agency responsible for inspection of GP practices, one way to ensure GP practices have domestic violence and safeguarding policies in place, and to ensure that all staff have received training on their contents, is to include checks in this regard as part of your inspection regime. It is, of course, entirely possible that this is already part of the process. ”

    Source location

    Avis Mary Addison · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Training records are not routinely checked in every inspection because inspection checks depend on the service, inspection type and concerns raised.

    Verbatim wording from the response

    “CQC do not always routinely check all training records as part of an inspection. This will depend on the service; the type of inspection and what concerns have been raised.”

    Source location

    2020-0216-Response-from-CQC-Redacted.pdf
    Page 1 · response
    Published 8 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

    GP practices are responsible for determining mandatory and additional staff training and how it is delivered, rather than CQC prescribing a definitive list.

    Verbatim wording from the response

    “CQC does not provide a list of mandatory training expected members of the GP practice team. This is because training requirements will depend on the role and specific responsibilities of practices, and the needs of the people using the service. Ultimately, the practice is responsible for determining what mandatory and additional training staff need and how this is delivered. Although there is no definitive list of mandatory training. Examples of training CQC would expect to see evidence of include training to the appropriate level on safeguarding adults at risk and safeguarding children.”

    Source location

    2020-0216-Response-from-CQC-Redacted.pdf
    Page 2 · response
    Published 8 December 2020

    Open published response
  8. 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

    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 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
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Data last updated 7 September 2026