Investigation and inquest
On 8ᵗʰ January 2016, an investigation was commenced into the death of Katrina Margaret Mary O’Hara, born on 14ᵗʰ April 1971.
The investigation concluded at the end of the Inquest on the 19ᵗʰ February 2020.
The Medical Cause of Death was:
Ia Stab Wounds to the Chest
The conclusion of the Inquest was as follows:
“The conclusion of the jury as to the death of Katrina O’Hara is that she was unlawfully killed. During his interviews with both police and mental health professional the ex partner cooperated fully, answering all questions and presenting as a plausible and reasonable individual giving no indication that he was likely to cause harm to Miss O’Hara. He was controlling and manipulative and Miss O’Hara’s actions were influenced by his attempts to control her. The ex partner used threats both to Miss O’Hara and her family to try to maintain his control and even his threats to commit suicide and his suicide attempt were more to exert influence on Miss O’Hara than real attempts to end his own life.”
Circumstances of the death
On the evening of 7ᵗʰ January 2016, Miss O’Hara was at her place of work, a barbershop in ████████. Miss O’Hara was outside of the shop when she was approached by ████████ also known as ████████ who was Miss O’Hara’s ex-partner. ████████ used a kitchen knife to stab Miss O’Hara, who was sadly pronounced deceased at the scene.
████████ was apprehended nearby, having cut his own wrist. He survived his self-inflicted injury and is now serving a life sentence, having been convicted of Miss O’Hara’s murder.
At the time of the offence, ████████ was on conditional police bail for offences of stalking, assault and threats to kill, with a condition that he was not to have contact either directly or indirectly with Miss O’Hara, having been arrested on 30ᵗʰ December 2016 for those offences and having been released pending further police investigations.
Coroner’s concerns
1. During the inquest evidence was heard that:
i. On 29ᵗʰ December 2015, Miss O’Hara telephoned 999 to report that ████████ was stalking and harassing her and that he had assaulted her and threatened to kill her. It was established by the call handler that Miss O’Hara’s call was not an emergency, so she was advised to call back on 101, the non-emergency line. Miss O’Hara did not telephone again, though her adult son, ████████ telephoned the police, without her knowledge, on 30ᵗʰ December 2015 to report what he had been told about ████████ behaviour. Although Dorset Police have now changed their policy, so that if Miss O’Hara’s call is received today the 999 call handler would have taken the details, that change has arisen out of investigations conducted into the circumstances surrounding Miss O’Hara’s death. A senior Dorset Police Officer who gave evidence regarding the changes made in Dorset was not able to provide an assurance that similar policies are being adopted by police forces nationwide.
ii. Miss O’Hara’s son, ████████ contacted the police on 30ᵗʰ December 2015 to report his concerns about the risk ████████ posed to his mother. ████████ also expressed concern about the risk posed to ████████ himself: ████████ had told others he was on the ninth page of his suicide note. In addition, in the preceding 6 weeks the police had been called at least four times to attend upon ████████ with regards to concerns for his welfare; he had made repeated threats to family and others that he would take his own life. A senior police officer with considerable domestic abuse experience that reviewed the incident log of 30ᵗʰ December 2015 created following ████████ call, recognised that the suicide risk ████████ posed to himself increased the risk that ████████ posed to Miss O’Hara. However, the recognition of suicide risk of a perpetrator as a particular and significant high risk factor for a victim, was not explicitly recognised in the Dorset Police Domestic Abuse Investigation Policy and Procedure until more recently. A senior Dorset Police Officer who gave evidence regarding the changes made in Dorset was not able to provide an assurance that similar policies are being adopted by police forces nationwide.
iii. After Miss O’Hara’s adult son, ████████ contacted the police on 30ᵗʰ December 2015, police made contact with Miss O’Hara. She confirmed the account provided by her son and attended a local police station to provide a statement to the police. When Miss O’Hara provided a statement to the police in support of the complaint made on 30ᵗʰ December 2015, Miss O’Hara’s mobile telephone was quite properly seized in order that it could be forensically analysed by police to retrieve evidence that would substantiate the allegations that she made. However, Miss O’Hara was not supplied with a replacement phone. When approached by ████████ on 7ᵗʰ January 2016, she had no means of contacting the emergency services. Dorset Police now have a large stock of “pay as you go” mobile phones to supply to the victims of crime who have had their phones seized for evidential purposes. This has arisen in Dorset from learning arising out of investigations into the circumstances surrounding Miss O’Hara’s death. I have not been assured that such phones are available to victims in similar circumstances across all police forces in England and Wales.
iv. Following the complaint that was made on 30ᵗʰ December 2015, ████████ was arrested and interviewed under caution the same day. ████████ was not charged with any offences as further enquiries were required before approaching the Crown Prosecution Service for a charging decision. Therefore, he was released on conditional bail to return to the police station. The condition attached to ████████ bail was that he was not to have any contact in any manner whatsoever either directly or indirectly with Katrina O’Hara. On 4ᵗʰ January 2020, ████████ was reported to the police breaching his bail conditions: he had instructed his daughter to send a text message to Miss O’Hara’s daughter, asking “will your mum drop the charges or not” (referring to the complaint of 30ᵗʰ December 2015), thereby having indirect contact. A statement was then taken from Miss O’Hara’s daughter by uniformed police officers. However, due to a lack of familiarity with what was, at the time, a new police software product associated with the police in managing information and tasks, “Niche”, the information relating to the breach of bail was not communicated to the officer in the case for the substantive matter. Therefore, no action was taken against ████████ in relation to the breach of bail conditions and no further investigation, beyond the taking of the statement, was conducted by police. Essentially, the “task” to obtain a statement to evidence the breach of bail conditions was not linked on Niche to the original “occurrence”, relating to the substantive occurrence. The net result was that no notification was sent to the officer in the case, when there was an expectation by all police involved on 4ᵗʰ January that such a message would be sent and that the officer in the case could review the breach of bail conditions and decide upon appropriate action. I heard evidence that all officers in Dorset Police have or will be receiving further training in relation to the functionality of Niche and that Dorset Police are exploring the possibility of an officer in a particular case receiving an automated notification through Niche if there is an addition to the occurrence log for that case.
2. I have concerns with regard to the following:
i. I am concerned that Police Forces across England and Wales may still be employing a policy similar to that previously employed by Dorset Police, with regard to non-emergency calls made to 999. Dorset Police have recognised the courage it takes a victim of domestic violence to make a call to the police so have now ensured that, depending on the risk level and whether police attendance will be required, the call will either be taken by the 999 call handler, or, where it is deemed that no police attendance at any time is likely required, the caller will be called back at a later convenient time. It is no longer left to the victim to make a subsequent call to the police in relation to the same complaint. The concern is that if similar policies are not in place across the police forces in England and Wales, victims of offences, who may have had to take a huge risk to themselves or others to make the call to the police, are being asked to call back on a different number if their call is not categorised as an emergency.
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.
iii. It is not unusual that the mobile phones of victims are seized by police as part of investigation into domestic abuse related allegations. Until the death of Miss O’Hara, Dorset Police did not provide replacement phones, leaving victims potentially without a means to communicate with others, including in an emergency. As stated above, Dorset Police now have a store of mobile phones available to supply to victims where their phones have been seized as evidence. I am concerned that this may not be in place across the police forces of England and Wales and that victims in some areas are being left without the means of contacting others, including the emergency services, when their phones have been seized by police during an investigation.
iv. “Niche” is a software program used by, I understand, 23 police forces across England and Wales. I do not know if more forces are due to adopt Niche in the future. I am concerned that appropriate training needs to be provided to police officers to ensure they have a good understanding of Niche and how to “link” events to an occurrence and to ensure that the appropriate individuals, for example the officer leading an investigation, are notified of any developments in a case.