This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.
On 22/3/24, I concluded the inquest into the death of Michaela Hall.
I recorded the cause of death as 1a) Stab Wound to the Right Eye Socket and Brain
Circumstances of the death
Michaela was a 49-year-old mother of two who lived at ████████ Cornwall. In early 2018, she worked as a volunteer for an organisation providing support to prisoners to assist them in making a fresh start. She lost her role as a consequence of being unable to maintain professional boundaries. Later that year, she was employed by a charity providing support to vulnerable and at-risk individuals. That charity was not aware of the circumstances in which she lost her previous role. Michaela started a relationship with one of her clients, a prolific offender. He assaulted her on a number of occasions and was recalled to prison. Upon his release, their relationship continued as did the incidents of domestic violence. In April 2021, her partner pleaded guilty to two counts of common assault upon Michaela in respect of which he was sentenced to a Community Order. He was assessed as posing a medium risk of serious harm to Michaela and allocated to a Community Rehabilitation Company for offender management. On 31 May 2021, her partner stabbed Michaela through the eye. Acting upon information received, the police attended her home address but did not enter it. Michaela was found deceased the next day. Life was formally pronounced extinct at 22: 56 on 1 June 2021. Michaela's partner was subsequently convicted of her murder.
I recorded the following conclusion. Michaela Hall was unlawfully killed. Shortcomings in a recruitment process meant she was employed in a role she was known to be temperamentally unsuitable for, given an inability to respect and maintain professional boundaries. Subsequently, a pre-sentence report was wrongly completed by an individual who was insufficiently qualified or experienced to undertake the task. The risk of serious harm Michaela's partner posed to her was wrongly assessed as medium rather than high. This meant her partner's management in the community was inappropriately allocated to a Community Rehabilitation Company rather than the National Probation Service. Had the shortcomings and errors not occurred, it is more likely than not that Michaela would not have died when she did.
Coroner’s concerns
This was a particularly complex inquest with a wide range of agencies involved. I enclose a copy of my judgment which sets out the full position. In writing to you, I wish to draw your attention, in particular, the actions of Children and Adult Services. My findings of fact start from paragraph 260 of the judgment.
- do not delineate rigidly between adults and children but consider the family as a whole. Where appropriate and permitted in law, share information between services; - Record in writing a rationale for reaching a view that there are no eligible care and support needs; - Record in writing why a safeguarding (s42) enquiry may not be progressed on a statutory footing but on a non-statutory basis instead; - When considering a victim of domestic abuse, complete a needs assessment even when consent is not forthcoming; - If no eligible care and support needs are identified, take a step back and consider the exercise of discretion; - When relevant information is shared from a family member or health-related information is received, ensure this is acted upon and shared appropriately between Council services and wider agencies. - Be curious. There were multiple examples of potential mental impairment – a diagnosis of OCD, mentions of suicidality and depression, the Acton email, yet no health-related enquiries appear to have been undertaken.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised1
Failure to undertake health-related enquiries in response to potential mental impairment
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1
Action
Complete and implement the Adult Social Care Practice Framework requiring holistic, collaborative and enquiring practice.
Stated byCornwall CouncilStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
Other statements in published responses
These actions and other statements could not be clearly connected to one concern in this report.
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.40
1
Deliver the blended risk, OASys and SARA learning product with mandatory completion for PQIPs and new entrant PSOs.
Stated byHM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
2
Continue working with partner agencies to enhance services that safeguard and protect domestic abuse victims.
Stated byHM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
3
Provide monthly protected regional development days for mandatory training and identified learning activities.
Stated byHM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
4
Use the implemented digital allocation tool to consolidate court notifications, risk information and workload data for defensible community-case allocations.
Stated byHM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
5
Roll out the blended safeguarding and domestic abuse training package nationally, requiring completion by all staff.
Stated byHM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
6
Consult on and publish guidance clarifying which probation grades should prepare different pre-sentence reports.
Stated byHM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
7
Deliver a rolling South West practitioner training programme covering risk assessment, risk management, professional judgement, sentence planning and quality management.
Stated byHM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
8
Consider reducing the timeframe for comprehensive risk assessments during development of the replacement OASys system.
Stated byHM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 15 April 2024.
9
Consider how to improve working relationships and information-sharing arrangements with partner agencies.
Stated byHM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 15 April 2024.
10
Introduce an auto-transfer process so the resource and incident management officer receives incidents sooner.
Stated byDevon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
11
Develop a new Domestic Abuse Operational Procedure incorporating learning and guidance on key safeguarding measures.
Stated byDevon & Cornwall PoliceStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
12
Emphasize through partnership work that professionals should use 999 for emergency calls.
Stated byDevon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
13
Deliver additional immediate-call and prompt-call training to all CMCU staff, with continuing refresher training.
Stated byDevon & Cornwall PoliceStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
14
Continue exploring residential detox placements for appropriate offenders through the Integrated Offender Management team.
Stated byDevon & Cornwall PoliceStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
15
Roll out DA Champion training to support the DA champion network.
Stated byDevon & Cornwall PoliceStated plannedThe respondent said that this action was planned when they made their response on 15 April 2024.
16
Implement a priority-vulnerable grading and six-hour dispatch standard for qualifying domestic abuse incidents.
Stated byDevon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
17
Deliver additional Domestic Abuse training for Detective Sergeants alongside College of Policing requirements.
Stated byDevon & Cornwall PoliceStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
18
Operate a Rapid Video Response pilot through a dedicated team for eligible domestic abuse calls.
Stated byDevon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
19
Deliver and roll out a refresher course for all police officers on section 17 PACE powers and domestic abuse risks.
Stated byDevon & Cornwall PoliceStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
20
Produce a revised operational procedure supporting officers’ understanding and use of DVPNs and DVPOs.
Stated byDevon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
21
Introduce a code 5 timer requiring progress checks and challenge during delayed immediate responses.
Stated byDevon & Cornwall PoliceStated plannedThe respondent said that this action was planned when they made their response on 15 April 2024.
22
Circulate learning from the coronial process to Superintendents to support consistent safeguarding understanding with partner agencies.
Stated byDevon & Cornwall PoliceStated plannedThe respondent said that this action was planned when they made their response on 15 April 2024.
23
Oversee performance data and monitor early arrests of domestic abuse perpetrators through Force Tasking.
Stated byDevon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
24
Review Evidence Led Prosecution use and scrutinize outcome data to identify reasons cases do not proceed.
Stated byDevon & Cornwall PoliceStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
25
Produce enhanced Evidence Led Prosecution guidance for police officers.
Stated byDevon & Cornwall PoliceStated plannedThe respondent said that this action was planned when they made their response on 15 April 2024.
26
Deliver additional DA Matters training initially to Moonstone officers.
Stated byDevon & Cornwall PoliceStatus unclearThe respondent did not make the status of this action clear when they made their response on 15 April 2024.
27
Circulate relevant section 17 learning and supervisory-support information through force-wide communications.
Stated byDevon & Cornwall PoliceStated plannedThe respondent said that this action was planned when they made their response on 15 April 2024.
28
Review potential improvements to Public Protection Notice quality and assess adding a secondary risk assessment.
Stated byDevon & Cornwall PoliceStatus unclearThe respondent did not make the status of this action clear when they made their response on 15 April 2024.
29
Deliver communications to response officers clarifying that the CIM and response Sergeants review domestic incident logs.
Stated byDevon & Cornwall PoliceStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
30
Record MARAC actions in Halo for auditing and flag incomplete actions to the MARAC chair.
Stated byCornwall CouncilStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
31
Remind Children’s Services practitioners to consider and discuss appropriate adult safeguarding and MARAC referrals.
Stated byCornwall CouncilStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
32
Write practice guidance supporting practitioners’ understanding and awareness of coercive control.
Stated byCornwall CouncilStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
33
Produce eligibility-recording guidance and a safeguarding decision-making template requiring written rationales.
Stated byCornwall CouncilStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
34
Commission a Domestic Abuse outreach team with low caseloads and flexible support for people with multiple vulnerabilities.
Stated byCornwall CouncilStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
35
Work to integrate domestic abuse, drugs and alcohol, and homelessness outreach teams into one coordinated support system.
Stated byCornwall CouncilStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
36
Provide dedicated Adult Social Care representatives at MARAC and deliver Lunch and Learn sessions to improve MARAC awareness.
Stated byCornwall CouncilStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
37
Fund a full-time Family Domestic Abuse Support Advisor for each of nine Family Assessment and Support teams.
Stated byCornwall CouncilStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
38
Reinforce information-sharing expectations between Adult Social Care and Children’s Services practitioners.
Stated byCornwall CouncilStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
39
Audit 30 Adult Social Care cases monthly to assure practice quality and assess the impact of guidance and training.
Stated byCornwall CouncilStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
40
Remind operational managers and staff to consider all available information and prioritise safeguarding when starting work with an individual.
Stated byCornwall CouncilStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.6
1
MARAC and probation use different assessment tools and risk definitions, so their risk outcomes may legitimately differ in some circumstances.
Stated byHM Prison and Probation ServiceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
2
Risk management action can continue before comprehensive OASys assessment completion, so the assessment timeframe does not itself prevent responsive action.
Stated byHM Prison and Probation ServiceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
3
A shorter period for completing comprehensive risk assessments was historically not achievable without compromising the completeness of underlying information.
Stated byHM Prison and Probation ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
4
A different statutory threshold for domestic abuse-related use of section 17 powers cannot be applied without a national review of legislation and guidance.
Stated byDevon & Cornwall PoliceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
5
Residential detox placements are limited and outside police control, restricting the ability to facilitate placements for appropriate offenders.
Stated byDevon & Cornwall PoliceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
6
The limited scope and resource demands of additional domestic abuse needs assessments may divert resources without notable improvement for those affected.
Stated byCornwall CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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